Last year, San Francisco AIDS Foundation Syringe Access Services (SAS) provided 2.5 million syringes to people who inject drugs in San Francisco. SAS has 11 syringe exchange sites throughout the city—all mobile except one. At the heart of SAS’s services is the Sixth Street location—a simple storefront located in the SoMa/Tenderloin neighborhood in San Francisco. The clean, organized space—complete with a living room gathering space and cheery lemony-yellow walls—stands in stark contrast to the gritty street life just outside its doors.
Janelle Silvis, volunteer and logistics coordinator for SAS, took the time to introduce a typical needle exchange shift at the SAS Sixth Street location.
One of the first things she clarifies is that—strictly speaking—SAS is not a needle exchange program.
“We don’t exchange syringes one-for-one. We’re allowed to give out up to 20 syringes even if someone doesn’t bring any dirties [used syringes] back. There are a lot of reasons why someone may not be able to bring back dirties—like if you think a cop is following you, you might ditch your stuff. And shelters don’t allow people to have these supplies, so you might have to hide or get rid of them if you want to stay at a shelter. But any amount over 20 is exchanged one-for-one.”
A typical client coming to the Sixth Street location is one who lives nearby. The storefront is accessible—people can come in right off the street without having to buzz through a locked door or walk past a doorman. Many Sixth Street clients are homeless or marginally housed in nearby single resident occupancy (SRO) hotels. Most are poly drug users who use a mix of different drugs. The most commonly injected drugs are heroin, crystal, crack cocaine, and crushed prescription painkillers. Many clients also smoke crack.
“We see everything, in terms of age, race, class, gender and drug use,” says Janelle. Many are friendly—they make small talk with Janelle and the other volunteers during their visits—and many are regulars at the site. Almost all are recognized and greeted by Janelle and her staff by name. Everyone is treated with empathy, respect and autonomy—tenets of harm reduction that Janelle works hard to enforce.
“Needle exchange is based in harm reduction—it’s about preventing harms associated with risky behavior around drug use. But we interpret harm reduction to also include respecting people and the autonomy they have for their body. People have the right to make their own choices regardless of social standards or morals. There’s never an underlying agenda that we’re trying to push on people. We really just want to help people get what they need to stay healthy and safe.”
Clients entering the site first gravitate to the “bucket side” of the room, where they are greeted by two SAS volunteers. The volunteers take back clients’ used syringes first, if there are any, then offer new ones. All of the SAS volunteers are trained to help clients figure out the gauge and size of the syringe and needle they need based on vein health, planned injection site and what substance will be injected—but most clients know ahead of time the size they prefer, immediately requesting “two bags of longs,” or “20 bee stingers” as they approach the table where the volunteers sit.
Some clients bring back large biocontainers full of used syringes, taking with them hundreds (even thousands) of new syringes before leaving. These are “satellite exchangers” who bring clean syringes and other supplies to other people in their camps or SROs.
“It’s amazing,” says Janelle, when asked about how these satellite exchangers reach additional clients. “They’re reaching networks that we normally can’t get to. There are reasons that people can’t get to a syringe access site. Maybe they have mobility issues, or maybe it’s just the shame of coming to a needle exchange.”
One criticism of syringe access programs is that they increase the amount of syringes that wind up being discarded on the street or in other public locations. For this reason, SAS provides clients with biocontainers to safely store used syringes, and they have trained staff who do sweeps every week to safely pick up any littered syringes and supplies. SAS is also collaborating with the city to put up safe disposal boxes in places that are convenient for people to safely dispose of used works—with a total of seven already up around the city.
Also, says Janelle, “most participants are very conscious about littered syringes and do their best to bring back their dirties or safely pick up littered syringes themselves and dispose of them with us.”
After picking up new syringes, clients stop at the supply table, where another volunteer bags up other injection or safer drug using supplies.
“You need a lot of tools to inject drugs,” says Janelle. “We want people to have the safest tools possible.” She explains that HIV can live in a syringe’s “dead space”—that’s exposed to blood when people pull up on the syringe plunger to make sure they’ve hit a vein before they inject. While HIV transmission can be prevented with new syringes, hepatitis C prevention requires more precaution.
“Hepatitis C is a resilient virus, and it can live on surfaces even when there isn’t any visible blood for up to three weeks or longer. This means that sharing any piece of injection equipment can spread hep C.” That’s why SAS provides a variety of new injection equipment to clients at a supply table that clients visit after picking up their new syringes.
Clients pick up new tourniquets (to tie off arms/legs to make veins “pop” and reduce the likelihood of failed injection attempts), sterile water or saline ampules (to dissolve drugs prior to cooking), “cookers” (aluminum caps to hold drugs while they are cooked), twist-ties (to create cooker handles) in a variety of colors (so people injecting in groups can have different colored cooker handles so they remember whose cooker is whose), vitamin C packets (to dissolve crack rocks), cotton (to filter out chunks as the drug solution is drawn into the syringe) and alcohol wipes (to clean injection sites prior to injecting in order to prevent bacterial infections and skin abscesses).
Some clients also ask for safer crack smoking supplies—which Janelle explains help prevent people from getting mouth and throat sores that can facilitate HIV transmission during oral sex. Little rolls of brillo are provided to clients as a filter and barrier that can be used inside a crack pipe. It’s important for people to use new brillo, since old brillo, that’s been heated again and again, can break down into hot pieces of metal that may burn or cut the back of the throat when they’re inhaled. Spark plug covers are handed out as mouthpieces to cover pipes and prevent people from burning their lips on the glass pipes.
“We get a lot of people who think we’re ‘enabling’ people to use drugs. But we enable people to take care of their health. For a lot of people, needle exchange is an open door to the health care system,” says Janelle.
At the Sixth Street location, besides being able to pick up safer drug use supplies, clients can also access a number of additional services. Because Janelle has been working at the site for the past 2 years, she knows the vast majority of clients who visit the site, and is quick to inquire about clients’ ongoing health conditions or life events. Every Tuesday, a nurse provides basic wound care for abscesses and other skin conditions caused by injection drug use. DOPE Project staff provide drug overdose training and Narcan (an injected or inhaled drug that reverses an opioid overdose) to clients. A case manager comes a couple of times a week to help clients get connected to Medi-Cal or get into detox or treatment when requested. Staff from Magnet, the San Francisco AIDS Foundation sexual health clinic, provide HIV and hepatitis C testing every week.
The safer injection supplies, explains Janelle, “are a way to get people in the door, so we can hook them up with other services. We do a lot of referrals and a lot of peer counseling. Usually people who use our services here are not welcomed at other places. I just want this to be a place where they’ll be treated with respect and as normal human beings.”
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