There's a proposal in Tallahassee right now that could make it easier for injection drug users to trade dirty needles for fresh ones -- preventing the spread of HIV and Hepatitis C.
A trial project in Miami Dade County is the only legal needle exchange in Florida. The bill would let the other counties to create something similar.
There's a spot along 11th street in Overtown in Miami that's surrounded by a convergence of overpasses. And this time last year, a guy with heavy black arrows tattooed on his arms showed up there pretty regularly.
"I'm Arrow," he said, introducing himself. "Pleasure."
Arrow was a heroin user. And he came here a couple times a week to swap his used needles for clean ones at a mobile needle exchange—a big green van, really—belonging to the IDEA Exchange. The exchange takes used needles off the street, reducing the sharing of dirty needles, and the odds of spreading of HIV and hepatitis C.
Arrow was sleeping under a nearby overpass. He was wiry and a little twitchy. We're not using his full name because the program keeps its participants anonymous. He said he and every addict he knew always put the drugs first. Clean needles were an afterthought.
"If I didn't have any of my own I had to try to clean out the ones that I had. Every once in a while, I did use someone else's and that was a thrill ride. Wondering whether or not I was going to catch anything. But I'm blessed, I'm 57 and I don't have anything," said Arrow.
"Now I can shoot with a clean needle every time," he said.
The IDEA Exchange is a trial project in Miami-Dade County, and the only legal needle exchange in Florida. As Florida continues to have some of the highest new HIV rates in the country—in the middle of an opioid epidemic—Miami's needle exchange is the model for a legislative proposal this year that could jumpstart needle exchanges across the state.
"This is more than just a needle exchange," said State Senator Oscar Braynon from Miami Gardens, who introduced Senate Bill 366 to allow counties to authorize similar needle exchanges. "This has become a roving triage and health center."
THE MIAMI EXPERIMENT
In the three years it's been around, the IDEA Exchange has reported to the health department that it's pulled more than a quarter million used needles out of circulation. It hands out Narcan (the drug that reverses opioid overdoses)—and, according to the exchange, making this drug available has prevented more than a thousand overdoses. The program also offers testing for HIV and hepatitis C, which is how Arrow knew he was negative. And it connects people to medical care and drug rehab.
This is Braynon's second attempt in a row to expand the needle exchange outside Miami-Dade County. Last year, a similar bill sailed through its committees but never got scheduled for a final vote in the house.
In fact, it took four tries just to get permission for the program in Miami--and it's temporary.
"We have several things working against us, the first is it is an outside-of-the-box idea; it just sounds different," says Braynon. "We have traditionally attacked drugs of addiction from a criminal justice standpoint and attacking it this way--which is very health-centric—is completely new."
New to Florida, anyway.
According to the Centers for Disease Control and Prevention, needle exchanges do prevent the spread of viruses in injection drug users.
At the same time, carrying around loads of needles to hand out without prescriptions can break drug paraphernalia possession laws as interpreted in Florida. Many other states figured out how to legalize this particular public health intervention decades ago.
But it wasn't legal to operate exchanges in Florida until 2016. That's when the legislature gave Miami-Dade County a special dispensation to try it for five years.
It was a huge win for Dr. Hansel Tookes. He first brought the needle exchange proposal to Tallahassee as a med student six years ago. He's now head of the IDEA Exchange.
"We have made it so easy for people to get into HIV care now, and we have so many people who we never would have known were infected—and would have infected countless other people—who are on their medications," said Tookes.
At a recent meeting with officials from Miami-Dade County, the City of Miami, police, and public health agencies, Ron Book—who chairs the Miami-Dade County Homeless Trust—asked a question that comes up a lot about the needle exchange and heroin use:
"Doesn't that help encourage it?" he wanted to know.
"Nobody who used our program--and we collect a lot of data--was a first time user of opioids when they came there. Not one person," said Tookes, who frequently meets doubts with data. "What we initially wanted to do was stop the spread of HIV. We identified that there was a real problem with hepatitis C. In 2018 there were half the needles found on the streets of Miami through a systematic study."
The meeting was called following an investigation into new HIV cases found in homeless people using heroin and living under that overpass where the exchange swaps needles.
Last year, the IDEA Exchange discovered ten new cases—seven of which were new infections in people who had until recently been HIV negative—during routine testing. They reported the test results to the health department and worked with the CDC and epidemiologists to figure out what was happening.
Before the results were in, the City of Miami moved quickly to close the homeless encampment.
"The city, the county and the state has contributed millions of dollars in an attempt to bring that neighborhood back," said Miami's director of Human Services, Milton Vickers, who has been one of the most vocal officials pushing back against the needle exchange. "Our opioid encampment was a block away from a brand new housing project that we're attempting to bring families with children in."
"When a mother walks her child to school and comes across discarded needles… that's legitimate anger," said Vickers.
Tookes said that this situation is exactly what he's trying to prevent. That's why the exchange sent its mobile unit to the overpasses to begin with.
"We overlay the HIV data, with the hepatitis C data, with the drug arrest data," said Tookes. "And we also follow the zip code data that people report when they come into the program. So it's not like we go to this place and then all of a sudden everything occurs there—it's the opposite."
After the homeless people were cleared, results from the epidemiological study suggested the virus was introduced by people from outside the encampment. Possibly through sex work, possibly through shared needles.
By then, Tookes and health officials had scrambled to find shelters and hospital beds for the exchange patients so they wouldn't lose track of people who needed treatment. The crisis ultimately created more partnerships with social service agencies and led to more treatment options for homeless people.
These are the sorts of conflicts other counties may deal with if the expansion bill passes. Counties would have to opt in. It's up to them to sign off on any needle exchange, and the proposal bans the use of any state funds for needles. In Miami, the exchange gets support from private donors, the University of Miami, the drugmaker Gilead and other grants.
"For observers who are not used to this kind of collaboration, you may be seeing a bunch of people in conflict here, but the truth is we really work together really well," said Eldys Diaz, executive officer to the Miami Chief of Police.
He said that for him and other officers, it's a relief to know more injection drug users are keeping their syringes in special sharps containers, provided by the IDEA Exchange, to safely dispose of dirty needles.
"Now for our officers, when they're doing a pat down… that sharps container is really protecting you from a loose needle 100 percent of the time," said Diaz. "That's an extraordinary source of comfort for us."
If it weren't for the tattoos running down his arms, it would be hard to recognize Arrow as the man who once slept under the Overtown overpass. Clear skin, a little paunch around his midsection—he looks healthier.
"How've you been?" asked Dr. Tookes, greeting Arrow in his clinic.
"Wonderful, I feel good," said Arrow.
He looks and feels better, but it's been a rough year for Arrow.
Last May, his girlfriend died from a heart infection—that can happen to people who inject drugs. After that, Arrow says he overdosed, on purpose. Narcan from the needle exchange brought him back. He kept using—$400 worth of heroin and fentanyl a day. He says he paid for it by dealing.
Arrow says he doesn't remember a lot from this period, but he does remember using so much, he ran out of fresh needles between visits to the exchange. So he grabbed other people's used needles.
And then he tested positive for HIV and hep C.
Tookes and his colleagues threw Arrow one more life raft: they got him an in-patient drug treatment bed.
At Arrow's checkup with Tookes, a string of key chains from Narcotics Anonymous clicked at his waist:
"My chain of sobriety. I got 30 days, 60 days, and 90 days chips," he said.
"Thanks to this man right here," he added, nodding to Tookes.
Arrow's HIV is under control. And medication cured his hepatitis C. Now, he's focused on staying sober one day at a time. And he's starting to want new things—like a construction job.
Even if the needle exchange bill passes and Florida counties get to decide whether to create more of these programs—not every person who uses them will necessarily get this far.
The folks supporting it hope that more people will at least have a chance.