Crack Pipe Distribution Considered

Looking to boost HIV prevention efforts in San Francisco, some staff members at the city's health department and community-based organizations are starting to talk about distributing crack pipes.

The possibility was discussed at a recent meeting of the HIV Prevention Planning Council, which sets priorities for HIV prevention in the city.

Among other benefits, such a plan could help city and nonprofit staff connect people that aren't otherwise being reached with HIV and other health care services, according to a presentation by HPPC member Paul Harkin, who's HIV services programs manager for the Glide Foundation, and Alli Kraus, syringe access coordinator for Glide Health Services, at the HPPC's meeting Thursday, January 9.

Among other concerns, people may currently use cracked or broken pipes, said Harkin. Referring to the city's practice of providing clean syringes to injection drug users, which has been credited with cutting the number of local HIV infections, he said, "We do it with syringes, and we should be doing it with pipes."

Kraus called crack cocaine use "a significant driver" of HIV infection in San Francisco. Crack smokers are likely to engage in unprotected sex and may have sex in exchange for money, and use of the drug "accelerates HIV disease progression," among other issues, according to the presentation. Additionally, people who use crack are twice as likely "to contract HIV compared to someone who is not affected by the driver."

The drug "primes the immune system for HIV infection," said Kraus.

Many who use crack are homeless and are among those "least likely to be in care for HIV," and they're also "more likely to develop" AIDS and die from AIDS-related illnesses, according to the information she and Harkin provided.

"We're doing next to nothing for crack smokers," said Kraus, and by alienating them, "we are exacerbating" health risks.

Asked in a phone interview after the meeting about the negative reaction people may have to the idea of distributing crack pipes, HPPC Co-Chair Tracey Packer said, "Our job as the HIV Prevention Planning Council is to explore the most appropriate ways to prevent HIV, and the information that was shared [at Thursday's meeting] needs to be explored."

After Harkin and Kraus's presentation, the HPPC voted unanimously for a four-point action plan.

Packer, who also serves as director of community health equity and promotion for the health department's population health division, said the first step is to compile evidence and data that demonstrates that use of appropriate crack pipes addresses health issues among crack users.

Next, legal issues and policies around crack pipe distribution will be explored. The health department will take the lead on working with city agencies including the offices of the city and district attorneys, and the police department, to explore how the needs of crack users can be met around this issue, said Packer.

The third step is to build capacity among community-based providers, including nonprofits, and clinical providers like City Clinic, on engagement and care for crack users in San Francisco to ensure that providers fully understand the health issues that crack users face, she said.

The final part will include an inventory of what treatment is available and an examination of whether it's sufficient.

Some at Thursday's meeting said the pipes would be inexpensive. Packer said, "We haven't really done any calculations yet," on cost.

She also said, "I cannot commit to any timeline right now" on any plans. "There's a lot of exploration work that needs to be done first."

In an interview, HPPC member Harkin noted that other places are already distributing crack pipes. He referred to such distribution as "a balanced intervention" that would include "wrap-around services."

"Toronto has successfully been doing this for many years," he said.

People present at Thursday's meeting expressed strong support for the idea of distributing crack pipes, but some wondered about how it could be done legally.

HPPC member Laura Thomas, who's also part of the HIV Health Services Planning Council and deputy state director for California for the Drug Policy Alliance, noted, "Right now it's a violation of California law to be in possession of drug paraphernalia."

Thomas said, "I would love to see [City Attorney] Dennis Herrera look through all this" to see what can be done.

Asked about the idea of distributing crack pipes, Gabriel Zitrin, a spokesman for Herrera, said in an email, "The legality of a department policy is something we can't really comment on, because our legal advice to city departments is considered privileged information between attorneys and our clients. If they ask for our advice we provide it, but it has to be kept between us and them."

Spokespeople for Mayor Ed Lee didn't respond to an email Tuesday, January 14 seeking comment on whether Lee would support crack pipe distribution in order to aid the city in combatting HIV.