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Rain or shine, six days a week, 200 or so people line up at sites around San Francisco to exchange dirty syringes for clean ones.

Needle exchange programs like the San Francisco AIDS Foundation's HIV Prevention Project (HPP) have been crucial in keeping HIV infection rates down among injection drug users.

Despite much controversy San Francisco has led the way from early underground efforts to established programs such as HPP, one of the longest running programs in the country.

"Needle exchange programs save lives," said Yana Wirengarde, HPP outreach director. Last year, HPP's volunteers gave out over 2 million clean needles.

The two-hour exchanges run in the Mission, SoMa, Civic Center, Bayview Hunters Point, the Tenderloin and the lower Haight. Counselors, outreach workers and doctors and nurses running min-medical clinics are often on duty as well.

"Needle exchanges prevent the spread of HIV and other blood-borne diseases such as hepatitis B and C among injection drug users and therefore their partners and children," said Alex Kral, assistant professor of epidemiology at the University of California San Francisco. "If you use needle exchange, you are less likely to share syringes. That's the goal

"Nothing about injection drug use gets you HIV or hepatitis, but if you are using syringe somebody else used first, you're at risk for a host of infectious diseases like HIV that are blood-borne."

Federally funded scientific studies have shown that needle exchange programs can reduce HIV infections by at least one-third and reduce risk behavior by as much as 80 percent.

In San Francisco, needle exchange, coupled with efforts at prenatal HIV intervention, has been credited with eliminating pediatric AIDS for the past two years.

According to Dr. William McFarland, director of seroepidemiology at the San Francisco Department of Health, HIV among injection drug users in San Francisco is currently at about 10 percent, compared with rates of 40 to 50 percent in other cities lacking organized needle exchange efforts.

"San Francisco has never suffered the burden of the disease seen in other cities in that have witnessed a much bigger contribution of injection drug users to the epidemic," said McFarland. "I think that San Francisco's early and well-supported needle exchange network was an important factor in that."

According to UCSF's Kral, studies have found that needle exchanges can also serve as a bridge to drug treatment.

"Injection drug users need access to medical services, employment and housing. Society tends to treat them very poorly, which helps to perpetuate some of the problems that they had to begin with," he said. "Needle exchanges treat injection drug users with dignity and respect that helps them in so many ways."

Opponents of needle exchange have long feared that such programs encourage drug use in general, and drug use at a younger age. Kral and his colleagues have conducted study after study on the subject. "People using needle exchanges are not using drugs any more than people not using needle exchanges. It's an aging population rather than a younger population - we're not seeing a rash of young users."

But according to a recent Department of Health study, San Francisco has seen an alarming resurgence in HIV rates of infection among gay men who are also injection drug users. The Department of Health, says McFarland, has found that patterns of infection indicate that unsafe sex, not needle sharing, is the cause for higher rates of infection.

Currently, at least 24 exchanges operating in California. These include HPP and another exchange program in San Francisco, and others in Oakland, Marin, Berkeley, Santa Cruz, San Jose, Sacramento, Redwood City, Santa Cruz and Monterey. Like other needle exchanges, HPP began as a grassroots organization in 1988. Although exchanges were illegal, law enforcement and city government tended tolook the other way. .

In 1993, when then Mayor Art Agnos declared a state of emergency, allowing though not legalizing exchanges, the San Francisco AIDS Foundation took the program under its wing.

Despite broad support for needle exchange - a 1999 Field Research Institute study found that 69 percent of Californians surveyed favored it- legalization of needle exchanges in California has been an issue for years. Unlike other states, where syringes are sold over the counter in pharmacies, California law forbids such sales.

In January 2001, however, a new law went into effect, protecting local jurisdictions such as cities from criminal prosecution for distributing syringes as part of a needle exchange program, as long as they declare a state of emergency. The law was a compromise cut by Gray Davis between needle exchange advocates and law enforcement.

While in San Francisco, the renewal process is done through the Board of Supervisors which meets frequently, in other cities, that's not the case - and the status can shift with the winds of the political tide, making programs much more tenuous.