In the part of San Francisco’s Tenderloin that drops below Market down Sixth Street, The San Francisco HIV Prevention Project (HPP) has an exchange center. HPP has been in operation since the late eighties when it was organized in association with the SF AIDS Foundation in response to the spread of HIV through needle-sharing. It has been operating ever since in a quasi-legal manner. The overt purpose of the needle exchange is not to promote drug use, but to prevent disease and death. It is a testament to the failures of the War on Drugs that neighborhoods with large numbers of IV drug users have remained neighborhoods with large numbers of IV drug users since the program’s inception. It is, of course, possible to argue that the existence of something like the needle exchange has contributed to this constancy of a user population and I would agree. We have kept people alive longer.

I’ve been an on again/off again volunteer with HPP for at least seven or eight of the eleven years I’ve lived in San Francisco. It’s a way to get to know the community and experience life in all of its vital ugliness without the intermediary of the television screen or the printed page. I’ve done volunteer work in almost every so-called “transitional neighborhood” in the city, as well as the officially “non-residential” districts such as the Civic Center.

For some reason the exchangers who came in while I volunteered at the Sixth Street/ Civic Center location often seemed to be in greater disrepair than at other city sites. People would come in practically nodding out on their feet. Some of the exchangers had open sores on their mouths and tongues.
If someone overdoses on heroin or, as is often the case, overdoses on a toxic cocktail of substances, their lungs stop working. The way to revive an individual whose lungs are not working is to perform pulmonary resuscitation while a partner, if you have one, dials 911. This partner should tell the 911 dispatcher that someone has stopped breathing. You never mention that they’ve “OD-ed.” If you do, the police will probably come, too, and you are trying to help the exchangers not get them arrested. Because of the open sore situation, it is recommended that a $2 filter be employed before proceeding with mouth-to-mouth.

If someone overdoses on speed or cocaine, a different physiological problem occurs: their heart stops. In this case you have to do full CPR. If you get punctured or scratched by a dirty syringe or contact with similar bio-hazardous material, you run the risk of contracting any number of infections. If this happens, it is recommended, as a matter of caution, that you take an anti-HIV AZT cocktail for at least a couple of weeks during which time you will be chronically sick.

There are many health risks involved with IV drug use. In addition to AIDS and hepatitis there is also “flesh eating disease” – of which there was a minor epidemic among IV drug users in the-mid nineties. “Flesh eating disease,” or Necrotizing Facistis,  is an opportunistic virus described by one physician as “a localized gangrene.” FED destroys human tissue like wildfire. It’s a killer. Radical amputation is sometimes the only way to save a victim. One poor girl I knew, a really sweet lady, lost an arm and a leg in the space of twenty-four hours. Not that the procedure saved her; she died anyway.

Each site is set up in a similar way. Anywhere between two and five volunteers with a supervisor, or HPP employee, oversees several drop buckets, a cart with boxes of fresh insulin needles, and a table of supplies. These include alcohol prep pads, rubber tourniquets for “tying off,” bottle cap cookers to burn dope in so that users will not share spoons, sterile water, condoms, and information. Originally, exchangers got one point for every needle turned in, but now exchangers can receive up to twenty free needles. This has come about because the program has discouraged the use of bleach to sterilize needles since certain viruses, like hepatitis C, have a high resistance to bleach. When the plastic biohazard buckets are filled with needles, dried blood, pus, pubic hair and residue, they are sealed and incinerated at medical waste disposal sites. Sometimes the sight of the exchange is outdoors – as was the Mission exchange when it was located in front of the National Guard armory on Fourteenth St. Sometimes a community outreach office is employed – as is the case on Sixth Street or in Bayview where there is an adjoining clinic. Occasionally the locations are pleasant. That is to say, there are no gaps in the walls or door to let the freezing winds in during the winter months.

Alcohol prep pads are used to clean the skin for injection and prevent abscess formation. Abscesses happen when germs are forced under the epidermis through injection. Once inside the body, anaerobic bacteria flourishes. I’ve seen people with abscesses the size of footballs: swollen, discolored tissue filled with pus and invasive viral or bacterial RNA. Sometimes you see people walking around who’ve had abscesses removed. Individuals sporting huge meaty holes on their arms or legs, roughshod raw tissue surrounding a jagged gap in the flesh. Many users say that health practitioners in over-worked public hospitals perform such butcher surgery (rather than merely lancing and leaching the abscess) to “punish” chronic skin poppers.

The site volunteers vary. There are idealistic punk rock anarchists, musicians, college students, political activists, doctors, nurses, community activists, counselors, city employees, ex- and current users. Workers from the Department of Public Health and professional doctors will attend the exchange during the two-hour operating periods. These professionals can provide referrals to treatment programs if they are requested, but nothing is forced on anyone. The means of getting treatment is merely available. It is systemic policy within the organization not to judge anyone. In fact we don’t tell people that they need to get off dope; we just tell them how to stay healthy when they are on it. The only mission of the exchange is to prevent the spread of STDs.

The exchangers consist of all sorts of people as well: prostitutes, runaways, single-room-occupancy hotel-dwellers, hustlers, lawyers, college graduates, pimps, computer programmers, stylish yuppies, affluent, young, club-going hipsters. The needle exchange draws from all races, the concentration differing from neighborhood to neighborhood. If everyone did not, as the hippies of the sixties desired, achieve “better living through chemistry,” they at least achieved a kind of commonality. I’ve never seen any kind of racial antagonism at a needle exchange site. Nor have I seen any homophobia, obvious sexism, or contempt for drag queens, queer-boy punk kids or anything of the sort. I’ve seen macho gangster types and effete she-men waiting together and nobody pulls any kind of gender pecking order (if such a thing exists on the streets). If someone does act like an asshole then everybody else just rolls their eyes as if they were putting up with the tired antics of a spoiled brother. Most bad behavior consists of excessive whining or the one in a hundred who tries to steal needles or who will act surly toward a volunteer. Many exchangers humbly thank the volunteers for being there.

Exchangers can be entertaining and this is sometimes intentional and sometimes unintentional. Street hustlers have to be salesmen. Those that haven’t lost their minds are acutely aware of this. You get come-on lines from people who have been practicing them as a means to acquire change or at least to earn appreciation.

There was a couple who used to come into the Sixth Street site (maybe they still do). Young and punk rock, she was a beautiful girl in her early twenties who radiated a tropical sexuality. She was also dirty as hell and smelled like an outhouse. Her boyfriend was a suburban skater with baby fat. One time she came in with her rigs and her boyfriend came up behind her while she counted out her used needles on the table we provided for this purpose. The boyfriend, standing slightly to her side, ran his finger from where her outer labia would have been under her jeans up the cleavage of her buttocks to the base of her spine. In response she shook her head and her ass like a mare in heat and the wave of energy I felt coming off of the two of them would have been described as “inappropriate” in the office cubicle. Nobody noticed of course and she didn’t miss her count.

“I should hire you to be my secretary,” said an old exchanger to the girl.
“I was a secretary,” she said, in another world.

I volunteer now at the Hunter’s Point/ Bayview Needle Exchange sites down on Third Street where they are laying a light rail line that will probably alter this community forever. Hunter’s Point is perhaps the most ghettoized African American neighborhood in the city. Third Street is the dividing line between the peninsula of Hunter’s Point – a residential/industrial district that grew up around the naval shipyards during and after World War II – and the somewhat less socially chaotic Bayview District to the east. In the forties there was a main drive in HP where there were juke joints and soul food restaurants that catered to sailors and others who came to the neighborhood for a taste of lively African-American culture. Only the storefronts are left. To drive around HP or to hang out on Third Street you can get a sense of economic nakedness, of things in the lee side of a great American city being as arid and poor as a remote desert. If historical patterns hold, the predominantly African American local population will not benefit from the urban upgrade of the new light rail as much as suburban colonists seeking employment in the biotech industry being developed on the West Side.

The Hunter’s Point/ Bayview exchange site is, ironically, one of the more mellow exchanges. The percentage of people who come in is smaller and includes those who come in once or twice a month from out of town. These come to exchange needles for all their friends who live in homeless encampments in places as far away as the Sierra Nevada, or from small valley and foothill towns where there are no exchanges but apparently there is heroin, coke and speed.

At this site we give people Ensure. Ensure is a protein drink customarily given to hospital patients when they are off solid food. The popularity of the stuff is phenomenal. People beg for it, but everyone is entitled only to one. I let the HPP paid staff member I work with, Alicia, act as the Ensure lightning rod. She can handle it.

“I need a Strawberry Ensure.”
“I’m sorry you were here earlier and already got one.”
“That was my twin sister. We look just like each other. She got one but I didn’t.” This was said without sarcasm.
“Sorry you only get one.”
“I need an Ensure.”
“I’m sorry you have to be an exchanger.”
“Please.”
“No.”
“Then fuck you bitch.”

One man comes in with the accepting calm some heroin users have, a perspective which recognizes the world’s absurdity and remains amusedly indifferent. I’ve known people like this and they are often prolific readers. He noticed the book I was reading face down on the supply table, Elaine Pagel’s The Origin of Satan, concerning the political uses of the devil in early Christianity.

“Are you a fellow traveler?” he asked. “You an atheist? I’m an atheist.”
    “Too much commitment. I’m an agnostic,” I told him.
“I hear that.” He said. God is big in Hunter’s Point.