Public Health Pioneers

Reunion sparks reflections on landmark intervention that continues to save lives

In the late 1980s the AIDS epidemic was spreading rapidly in the United States and the toll in human lives was growing. In New Haven, the Mayor’s Task Force on AIDS, a group of activists, and some young public health researchers at Yale were looking for ways to stem the disease. They put forth a bold—and at the time, radical—idea: start a government-run program to provide clean syringes to injection drug users.

While New Haven was an epicenter of the AIDS epidemic, and injection drug users and their sexual partners were heavily impacted, the idea was greeted with skepticism and, in many cases, outright opposition. The advocates persisted and through tenacious organizing and education they were able to eventually persuade the city to launch an official Needle Exchange Program (NEP) that was authorized by the Connecticut legislature in 1990. Today, nearly 25 years later, the program, now called the syringe exchange, is still active in New Haven and has been replicated by other cities around the United States.

In New Haven alone, nearly 50,000 clean syringes were distributed and the City Health Department collected an equal number of used syringes in 2013. It is a public health intervention that prevents the transmission of diseases and saves lives.

Some of the key figures involved in the program’s launch posed in 1991 with the city’s first NEP van, donated by Yale. Pictured from left to right are Edwin C. Cadman (now deceased), former chair of internal medicine at the Yale School of Medicine and chief of staff at Yale-New Haven Hospital; Elaine O’Keefe, M.S., former New Haven AIDS Director who managed the NEP and is now a lecturer at the Yale School of Public Health and executive director of the Center for Interdisciplinary Research on AIDS at Yale; Edward H. Kaplan, now a professor at the Yale School of Management who conducted the seminal evaluation of the New Haven NEP; George Edwards and Dominick Maldonado, both original NEP staff members; Robert Heimer, M.Sc. ’80, Ph.D. ’88, member of the NEP evaluation team and now a professor at YSPH; Chris Brewer and Sonia Lugo, both NEP staff members; Kaveh Khoshnood, M.P.H. ’89, Ph.D. ’95, member of the NEP evaluation team and now an associate professor at YSPH; and Alvin Novick (now deceased), chair of the New Haven Mayor’s Task Force on AIDS, a lifelong AIDS advocate and professor of biology at Yale College.

In the top photo, five members of the original team (four of whom are now affiliated with the Yale School of Public Health) reunited in late September 2014 with the New Haven Health Department’s new syringe exchange van as a backdrop. They are (from left to right) O’Keefe, Kaplan, Maldonado, Heimer and Khoshnood. Edwards, Brewer and Lugo, also pictured in the original photo, eventually left the program and were unavailable for the reunion.

As the 25th anniversary of the landmark intervention approaches, we posed questions to founders and evaluators of the program and the difference that it has made.

Q: Has the Needle Exchange Program here in New Haven and elsewhere saved lives?

A: There is no question that needle exchange programs have averted new HIV infections and saved lives, both in New Haven and, in much larger numbers, elsewhere. Our own research indicated that needle exchange reduced the rate of new HIV infections in New Haven by at least 33 percent, which translates to preventing between one and four infections per year. This might seem like a low number, but contrasting the expense of treating HIV infections against total program expenditures reveals that needle exchange in New Haven is extremely cost-effective. These results gain force when one considers the life-saving impact of needle exchange in a city like New York. With an estimated 200,000 drug injectors, needle exchange programs that reach only a quarter of this population would avert as many as 1,000 infections annually. These findings have been corroborated by studies conducted on behalf of the Centers for Disease Control, the General Accountability Office, and the National Academy of Sciences, in addition to other independent scholarly research on the topic. As one example, an article in The Lancet estimated that the failure to implement widespread needle exchanges in the United States between 1987 and 1995 resulted in an additional 4,400 to 9,700 HIV infections that could have been prevented by needle exchange, but were not. While needle exchange is but one of several programs available to combat the spread of HIV, it remains a very efficient and important approach to prevent HIV transmission among drug injectors

—Edward Kaplan, professor at the Yale schools of management, public health and engineering

Q: How receptive was the New Haven community and the state to the Needle Exchange Program in the early 1990s?

A: Needle exchange was very controversial back then. It took intense education and advocacy to build support to authorize and implement the demonstration program. There were vocal opponents in New Haven and in state government and the legislature. There were also community members and organizations that bravely took up the cause and reputable proponents from the fields of medicine, public health, and addictions. We launched the program with the visible support of the New Haven mayor, police chief and other recognized community leaders. We were in the midst of a public health crisis at a time when HIV transmission was largely unchecked and people were dying for lack of treatment. Our primary focus was creating a safe and nonjudgmental environment where addicts would feel secure, and staying attuned to concerns within neighborhoods where the program operated. There were always some detractors, but with time opposition subsided.

—Elaine O’Keefe,lecturer at the Yale School of Public Health and executive director of the Center for Interdisciplinary Research on AIDS at Yale

Q: Have public attitudes toward the Needle Exchange Program changed over the past quarter century?

A: In many parts of the world and within the international public health community, syringe exchange is now normalized. New and relaxed methods for syringe delivery are increasingly accepted, replacing the highly regulated programs that were initially approved and implemented. The research documenting both the effectiveness of the New Haven Needle Exchange Program and the need to loosen restrictions and expand the service delivery model has influenced acceptance for and growth of syringe exchange programs across the US and in many other parts of the world.

—Robert Heimer, professor at the Yale School of Public Health

Q: Why did you get involved in the Needle Exchange Program originally?

A: I first learned about the HIV/AIDS epidemic as a first year M.P.H. student at Yale in the late 1980s. I learned that in New Haven, and other cities of the northeast, the HIV epidemic was concentrated among injection drug users. I wanted to learn more. I recall reading a short article written by Paul Bass in the New Haven Advocate about a man named Jon Parker, a former injection drug user who would make the trip from his home in Boston to New Haven every week to distribute sterile syringes to injection dug users. At the time, the purchase and possession of syringes were illegal. I was fascinated and inspired by Jon’s bold intervention. As a budding public health professional, what he did made good sense to me. Give the severity of the epidemic, the response had to be direct, non-judgmental and bold, even if it required breaking the paraphernalia laws, restricting the sale and possession of sterile syringes. I first met Jon on a Friday afternoon at the corner of Chapel and College Street and asked him to tell me more about his work. I remember Jon telling me, “If you want to know what I do, come with me.” I hesitated a bit, but decided to join him that evening. We went to Dixwell Avenue and within minutes after Jon parked his van, several drug users came up to him, greeted him and took away sterile syringes, condoms and bleach. Jon had clearly gained the trust and respect of one of the most marginalized groups at the center of the HIV epidemic in New Haven. I was hooked.

—Kaveh Khoshnood, associate professor at the Yale School of Public Health

Q: How did drug users influence the creation of the NEP in New Haven?

A: The success of the syringe exchange program in New Haven, and later in the state, was due to substance users. From the beginning, they trusted and took ownership of the program. They not only protected the program but also protected, and respected all of us. I feel very honored to have been part of such an important public health prevention initiative. The program proved it could save the lives of people who are members of our society. Many of them have since entered treatment on their own initiative and today live productive, substance-free live with their families.

—Dominick Maldonado is retired and lives in Florida