T H E  S O L U T I O N  

      In New York City’s largest borough of Queens, the vast percentage of Acquired Immune Deficiency Syndrome (AIDS) cases derives from Intravenous Drug Users (IDUs).  Approximately 38% of all AIDS cases in Queens come from IDUs. [i] This is a highly significant number, but unfortunately little is being done about it.  In fact, the first needle-exchange program in Queens opened in 2004 after about 19,200 people acquired AIDS from 1981-2004. [ii] Queens is undeniably in a plea for help.  With the staggering numbers of IDU cases, my plan is to set up a mobile needle exchange program (NEP) in five locations of Queens where the AIDS cases are highest.  I also plan to promote the use of “middlemen” who will collect dirty needles from drug users and exchange them for new ones at the mobile NEP.  In turn, the “middlemen” can sell the clean needles for profit and the drug users can get clean needles.

      Needle exchange programs are relatively new programs to help in the decrease of IDUs acquiring AIDS.  The concept of these programs is quite simple; drug users exchange dirty needles for clean ones.  Because IDUs find it extremely difficult to stop drugs all together, many needle-exchange activists thought it was best to hand out clean needles in the hopes of stopping the rapid spread of AIDS among IDU.  Jon Parker, a former intravenous (IV) drug user himself, was a needle-exchange activist who started the first United States NEP in New Haven, Connecticut which is still very successful in their efforts to stop AIDS. [iii] By the late 1980s and 1990s legal and illegal NEPs were implemented, especially in the hardest hit areas of New York City. [iv]  The Center for Diseases Control (CDC) states that there are currently 200 NEPs in more than 36 states nationwide. [v] Not only do NEPs decrease the amount of IDU cases associated with AIDS, a study done by Brooner et al. (1998) showed that NEPs encouraged drug users to enter a drug treatment center/rehabilitation. [vi] This may be due to the fact that they receive counseling at the NEP which then initiates a positive response from the IDU who want to attend drug centers.  NEPs are also a cost-effective method of supporting safe injection practices because it does not require the latest technology.  All it requires are some helpful volunteers and people who are experienced in the field of counseling and medicine.  NEPs are also supported by the CDC.  Thus, the resources provided by NEPs are immense. 

     Many argue about the efficiency of NEPs claiming that it encourages drug use and that it increases the number of drug users.  Though this topic is controversial many studies have shown that it does not boost drug use.  A study conducted by Dennis Fisher (2003), stated that during the time intervals of 6, 12, and 18 months, researchers never saw an increase in drug use. [vii] Robert Hiemer, Professor at Yale University School of Medicine in New Haven, further supports the idea that NEPs do not encourage drug use stating that these programs actually decrease drug use when they are done right. [viii] Despite all the studies and proof regarding the efficiency and value of NEPs, the United States federal government is still the only government that bans the use of money for NEPs.  NEPs are currently funded by state and local governments and private non-private organizations. [ix]

           The use of mobile NEPs has been the source of many scientific studies.  In a study conducted by Kuo et al. (2003) showed that mobile van NEPs were effective.  This distinct drug treatment program operating out of a mobile van gave patients who were referred from a NEP levomethadyl acetate hydrochloride (LAAM)-- a drug that blocks the effect of heroin for up to 72 hours with minimal side effects.  Ninety-nine percent of the participants in the study were African American and most were men (68%) who reported to not have completed high school.  This study not only showed the effectiveness of LAAM, but it also showed the effectiveness of a mobile van in attracting drug users to obtain help.  Additionally, the study also supports the idea that the AIDS epidemic targets the African American male population as opposed to the white population.  [x]

 NEPs operating out of mobile vans also attract more frequent drug users.  Miller et al. (2002) conducted a research comparing pharmacies, fixed sites and mobile van needle exchanges in The Downtown Eastside (DTES), Vancouver’s poorest neighborhood.  The study showed that these three different sites catered and attracted different groups of people.  Nineteen percent out of 1,437 persons of mobile-exchange clients used drugs more often injecting at least four times a day. [xi] In another study performed by Riley et al. (2000), researchers compared participants of mobile-based NEPs to pharmacy-based NEPs in Baltimore, Maryland.  Forty-three percent of the 268 IDUs enrolled at the van-based site and most of them injected at least four times a day. [xii] The study by Riley et al., 2000 is consistent with the results from Miller et al.- drug users who visited the mobile sites were reported to be engaged in more high risk behavior including sex work, injected more frequently on the streets, and were less likely to be enrolled in a drug rehabilitation center.  The vans also attracted twice more high-frequency injectors than the pharmacy-based sites.  These studies also correlates with the results found by Schechter et al. (1998) where van-based clients were involved in activities that put them at a higher risk for AIDS. [xiii] All three studies proved the effectiveness of mobile NEPs and that van-based NEPs reaches more hard-core street IDUs.  These studies also suggest the need for more mobile NEPs in the prevention of high AIDS cases associated with IDUs. 

 Latkin et al. (2001), conducted a study to find patterns of needle acquisition.  The study revealed that 85% of participants obtained needles from street needle sellers in Baltimore, Maryland further suggesting the importance of having “middlemen” to encourage the use of safe injection practices. [xiv] The study involved eight mobile van sites and two fixed pharmacy sites.  Only about 4% of participants exclusively used NEPs for needles. Most of the 741 injectors were poor, African American, unemployed inner-city drug users and over half did not complete high school.  The study concluded that street needle sellers are an important source of needles for drug injectors, and few of them were able to distinguish between clean and dirty needles.  The study also showed the desperation of IDUs who cannot tell between the dirty and sterile needles. The research suggests the importance of the link between needle-sellers and buyers; needle-sellers are the prime sources for HIV prevention.  Needle sellers, as a result, turn to NEPs for clean needles furthering the significance of these programs as a basis for the prevention of HIV/AIDS. [xv]

Geographic proximity is also important.  According to a study conducted by Rockwell et al. (1994) in New York City, 81% of IDUs who lived within a 10-minute walking distance typically visited a Syringe Exchange Program (SEP) compared to 59% of those who lived further away.  This research concluded that locations of SEPs are very important and may be crucial to the prevention of AIDS cases involving IDUs. 

 Based on this research, my plan is to open a NEP out of a mobile van that will stop at five distinct locations in Queens where AIDS rate is highest.  I chose IDUs as my main target because based on previous research, IDUs account for the majority of the AIDS cases in Queens.  With a whopping 38% IDU cases, AIDS targets impoverished neighborhoods where the majority of people are African American.  Based on research from paper two, there was a direct correlation between the African American population and AIDS rate, thus reassuring the fact that the IDU problem needs to be solved in Queens.  Additionally, the research that was mentioned previously (Miller et al. (2002), Latkin et al. (2001), Fisher et al. (2003), Riley et al. (2000), etc.) all had a significant number of African American participants. 

Many NEPs and SEPs are located in the Bronx and Manhattan.  There are currently two SEPs in the Bronx, six in Manhattan, one in Brooklyn and one in Queens.  Each SEP has many different locations for syringe exchanging, and many are near churches where counseling takes place.  Easy access to NEPs is a vital component in the prevention of AIDS.  In addition to the mobile needle exchanges, I will educate five “middlemen” who will serve as an important link to the street sellers and the NEP officials.  My plan is to target the hardest hit neighborhoods and bring the program to them as geographic proximity is significant to IDUs.  The main office of this NEP will be in Elmhurst hospital because it has many useful AIDS resources. There will be two vans that stop at Springfield Gardens, (zip code 11413) in front of Wesleyan Church, East Elmhurst (zip code 11370) adjacent to Astoria Auto Service Center, Jackson Heights (zip code 11372) near Elmhurst Hospital, Jamaica (zip code 11436) next to Lemuel Haynes Congregational Church, and Queens Village (zip code 11429) near Maranatha Baptist Church.  These areas all have an AIDS rate of well over 1,000 and the locations of the NEPs are meant to be accessible to all IDUs in Queens.  Three out of the five mobile NEP locations will be in front of Churches because it might encourage IDUs to step into the churches and achieve counseling.  Elmhurst hospital is an ideal location because it has an AIDS center with extensive HIV/AIDS services including HIV testing, expert treatment and counseling.  The schedule is as follows:

Place	NEP Mobile Location	Date and Time
Lemuel Haynes Congregational Church	146-09 116th Avenue Jamaica, NY 11436	Tues, Thurs 11 AM- 4 PM
Maranatha Baptist Church	11246 Springfield Boulevard, Jamaica, NY 11429	Mon, Wed, Fri 11 AM- 4 PM
Wesleyan Church	13449 228th St Springfield Gardens, NY 11413	Tues, Thurs 11 AM-7 PM
Astoria Auto Service Center	49-05 Astoria Boulevard East Elmhurst, NY 11370	Mon, Wed, Fri 12 AM- 4 AM
Elmhurst Hospital	79-01 Broadway Elmhurst, Queens, NY 11373	Sat, Sun 5 PM-1 AM

The time slot is approximately five to six hours each, with the exception of the weekends which extends to eight hours, because after further research on NEP schedules in Queens, the average time for each stop is four. [xvi]

The mobile NEPs, each 19 feet long, will be equipped with a dispensing booth, an examination room and a lounge area for counseling.  The mobile NEP will be staffed with six volunteers; one outside of the van on a desk advertising protected sex, HIV/AIDS awareness, and safe syringe practices.  Two volunteers will deal with the actual disposal of syringes. One of the staff members will be a counselor, with at least a Master’s degree in psychology/counseling, who will be present if any IDUs need to talk or vent.  The last two volunteers will be in charge of oral HIV testing.  Thus, the mobile NEP will consist of oral HIV testing, disposal of syringes, and counseling.  It will be funded by the state and local governments and non-profit organizations, especially grants from the American Foundation for AIDS research (AmFAR), a private organization, and the New York State Department of Health. [xvii] It is expected that contributions from these organization will be about $600,000.  All three institutions have funded many NEPs including The Bronx-Harlem Needle Exchange Program and the Lower East Side Needle Exchange Program. [xviii] Upon further research, this mobile program will cost roughly about $250,000 with expected needle exchanges to hit about 280,000 and 20,000 visits in a year. [xix]  In summary the mobile NEP will consist of

1. providing clean needles and syringes, condoms, and educational pamphlets;
2. HIV counseling and testing;
3. referral/ recommendation to clinics for sexually transmitted diseases (STD).
 

      In addition to the mobile NEP, the five “middlemen”/street needle-sellers will be educated on the prevention of HIV/AIDS.  The counselor will give each of them a two day session about ways to practice safe sex and encourage them to spread the message around.  In order to convince these IDU volunteers to participate in these sessions, each will get a $25 food voucher funded for by the New York State government.  However, these five “middlemen” will not earn a profit for their deeds of spreading the message, but as the study in Baltimore showed, these street needle-sellers actually get their own profit by exchanging dirty needles for clean ones and in turn selling the new ones to the drug injectors. [xx] The “middlemen” will float around their neighborhoods and stop by the mobile NEP when they please or when they feel ready to.  Because the study determined that 85% of IDUs acquire their syringes from street needle-sellers, this may prevent the decrease in AIDS cases associated with IDUs if clean and safe needles are being utilized. [xxi] Furthermore, needle-sellers are frequently in contact with IDUs and they are the main sources of both needles and information. 

      The AIDS epidemic in Queens has been a problem since the beginning of its discovery.  In the beginning I guessed a much lower number of AIDS cases in my hometown of Queens, NY due to the lack of media attention.  Its impact was further researched when it was later discovered that there are some major correlations between median income, race, public assistance income, those under poverty level, household size, number of unmarried couples and surprisingly public transportation.  After astounding statistics, the question that needed to be asked was, “How do I solve this problem?”  Hopefully, this NEP mobile plan will shed some light on the profound effect of the AIDS epidemic not only on the medical world, but society as well.