Yesterday, more than 100 people walked through the parking lot of the Allegheny County Health Department, entered one of the building's narrow hallways, and got fresh supplies of the alcohol swabs, syringes and needles they need to inject illegal drugs into their bloodstream.

	Darrell Sapp, Post-Gazette The Prevention Point Pittsburgh program is headquartered at the Allegheny County Health Department offices in Oakland. Signs mark where condoms, needles and other items are distributed every Sunday. Click photo for larger image.

Proponents would say that Prevention Point Pittsburgh's needle exchange program is an example of a public health measure that has been successfully used around the country to limit the spread of dangerous infections like HIV and hepatitis C.

But some people worry that handing out needles and syringes to drug users flies in the face of state law that says people cannot possess drug paraphernalia without a prescription. Others fear that the program will encourage drug use.

The weekly service has operated with the Board of Health's authorization for four years.

Two weeks ago, the conundrum again entered the spotlight, when County Councilman Vince Gastgeb, R-Bethel Park, said the needle exchange program, which is privately funded, had been operating for too long without an ordinance and without numbers that showed that it had slowed the spread of HIV and hepatitis C infections.

"I just said, 'Enough is enough,'" Mr. Gastgeb said. "If we're going to do this, let's at least do it right, which is one issue. The second issue is, should we do it at all?"

Meanwhile, he added, the program can continue to provide services every Sunday afternoon at the Health Department's Oakland offices.

"No one is attempting to shut it down in any fashion, but we're attempting to craft a better ordinance," Mr. Gastgeb said. "At least I am."

But, he noted, after examining the issues, which likely will take months, County Council members still might not vote to support it.

Prevention Point's executive director, Renee Cox, is eager to provide council members with information about the program and its effectiveness.

"We're willing to cooperate and provide them with the overwhelming body of research that shows needle exchange is effective," she said. "I am optimistic that council will support us."

The only other needle exchange program in the state, Prevention Point Philadelphia, receives public funds and has operated officially since an HIV public health emergency was declared more than a decade ago by then-Mayor Ed Rendell. Pittsburgh's program was authorized under a similar emergency declared by the county health board.

According to a spokeswoman, the state pharmacy board recently gave its lawyers the go-ahead to draft a regulation that would allow the purchase of syringes and needles without a prescription. The multistep process has barely begun.

In the wake of the news media attention around County Council's concerns, Ms. Cox and her colleagues have heard from many program participants.

"People were really incredibly fearful at the mere mention of these services being terminated," she said.

That's because without the exchange, addicts would once again have to buy -- or find -- needles and syringes on the street, and take their chances.

"I don't think if they took the program away that it would cut down any drug use at all," said one exchanger, a college student who asked that his name not be used. "They would most likely keep using any way they could."

He has gone to Prevention Point for a couple of years, as long as he's injected drugs. He's never shared a "point" or a syringe, not even with his girlfriend, has never used the exchange to make connections and has recommended the program to friends who also inject.

His family thinks that he's off drugs, but he actually injects daily.

Another exchanger started using heroin in the 1960s. He's 72 years old now and hasn't become infected with HIV or hepatitis.

"There was a time when you could go to the drugstore and you could buy the needles" in Pennsylvania without a prescription, he said. They were intended for diabetic patients, and even now, insulin needles are sold on the black market.

Without the exchange, he'd cross his fingers and turn again to the street for points, although he would never buy anything that wasn't sealed in a package. Not everyone is so particular.

"I've seen people down there when they were all standing around looking for the drug man," he said. "They're walking through the alleys, kicking things over, looking to see if there's a needle stashed under something."

Anonymity for users

Many drug users went to the exchange for the first time on the Sunday after the controversy arose. It happens in a little-used corridor in one of the Health Department's Oakland buildings.

Stuck on the harvest gold brick walls are plain paper signs that mark where the boxes of "Blues (aka Browns)," "Pogos" and other needle-syringe combos would sit during the exchange's Sunday hours. There are also spots for condoms, cotton balls and containers to safely dispose of sharps, namely used needles.

There's a display shelf of brochures and notices about other services, including a rescue breathing poster that says: "You may be a friend's only chance."

New participants get a card with a unique identifier, so they can stay anonymous, Ms. Cox explained. The card also notifies police that the bearer got the drug paraphernalia in a legal program. More than 3,000 people are registered.

The new exchanger is taught about safe injection practices, proper needle and syringe disposal, and HIV and hepatitis C; told about services like drug overdose education, case management and treatment; and asked for demographic information and about amount of drug use and high-risk practices.

"The goal of the program is to provide them with enough syringes so they never have to share or reuse," Ms. Cox said. Testing for HIV and hepatitis is offered at the exchange.

Study after study has shown that programs like Prevention Point do a lot of good and no harm, said Samuel Friedman, an HIV and drug use senior researcher at National Development and Research Institutes Inc. in New York. His team estimated that there are about 12,000 injection drug users in Pittsburgh.

Before needle exchange began in New York in the early 1990s, he said, there was a time when half of all injection drug users were infected with HIV. Every year, 4 percent to 6 percent were becoming infected. After exchange services were established, the infection rates dropped to less than 1 percent.

People who use exchanges are less likely to get infected than those who don't, are more likely to inject safely and don't litter the streets with dirty syringes because they know where to dispose of them properly, Dr. Friedman said.

Concerns that needle exchange programs discourage drug users from seeking treatment are unfounded, said addiction medicine specialist Dr. Neil Capretto, medical director of Gateway Rehabilitation Center.

"It's the opposite," he said. "They're a big referral of people to treatment, here and around the country."

There are, however, not enough drug rehab slots to meet the demand. Gateway's beds are often full, with a waiting list, Dr. Capretto said.

Prevention Point has helped 550 people get into rehab during the past few years, Ms. Cox said.

"The demand exceeds the capacity," she said. "Treatment is pretty scarce right now, which makes needle exchange all that more important."

Nor does having access to clean needles turn people into heroin addicts, Dr. Capretto noted. Most started by taking pills, particularly OxyContin, and turned to heroin in a quest for a cheaper high. Often users snort today's very pure form of the drug before making the switch to injecting because of qualms about needles.

Then, "given a choice between using a clean needle and a dirty needle, they'll always use a clean needle," Dr. Capretto said. "Given a choice between using a dirty needle or not using at all, they'll use a dirty needle."

The college student said he'd like to think he would never inject with a used needle, but conceded that "when you can't use, you think different than when you can."

Dr. Capretto has rarely seen a patient who's used injection drugs for more than two years and doesn't have hepatitis C. Most of the uninfected tell him they're needle exchange participants.

According to the Health Department, there were 82 new HIV cases in 2003 and 100 in 2004. Those numbers might be revised and 2005 data is not yet available, said spokesman Guillermo Cole. New cases of hepatitis C went from 238 in 2004 to 393 last year.

He said that intravenous drug use was identified as a risk factor in 14 percent of HIV infections reported by the end of 2003.

Hepatitis C can linger for years without causing acute illness, so it's not possible to say for any new diagnosis when or how it was acquired, Mr. Cole said.

Heroin and hepatitis C

To Dr. Capretto, the rise in hepatitis C cases does not point to an inadequacy of the needle exchange program, but rather reflects a dramatic rise in heroin use and perhaps a lack of clean needles.

A decade ago, he'd treat perhaps five teenage heroin addicts annually. "Now we're seeing between 200 and 300 teenagers," Dr. Capretto said. "What's sad is I'm seeing 21-year-olds now who have been using for five years."

He has met people for whom access to needle exchange has made a difference, and is bemused by arguments that the service must prove its local value when there is ample evidence that it has many beneficial effects.

As Dr. Capretto put it: "If a new cancer drug came out and was tested and proven to be effective in Washington, D.C., I don't think people here would say, 'Gee, is it going to work in people in Pittsburgh?' "

Measuring the program's success at reducing the burden of infectious disease is not likely to be easy or cheap. A study in another city did it by looking for HIV in discarded needles, finding less virus after the exchange was established.

The assessment cost almost $1 million, so conducting similar research would be out of reach for Prevention Point, which has no public funding and an annual budget of $250,000 to run its exchange, overdose and case management services.

"That is nowhere near enough money to meet the need of this county," said Ms. Cox. "Since day one, it has been an enormous struggle to keep this program going."