Outbreaks of HIV and hepatitis have convinced officials in small towns across the United States that needle exchange programs are necessary.

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There are now 320 needle exchange programs in the United States. Getty Images

Needle exchange programs operate on the principle of harm reduction.

They provide clean needles to people who use injection drugs with the objective of curbing the spread of infectious diseases, such as hepatitis and HIV.

It’s an approach that has been proven by research to be effective. But it’s also controversial.

Distributing hypodermic needles without a prescription is illegal in many communities. Many political leaders and law enforcement officials view needle exchange programs as encouraging drug use.

With the spread of injection drug use into small towns, however, attitudes about needle exchange programs have been evolving — even in conservative communities.

Once largely concentrated in big cities like New York and Philadelphia, needle exchanges can now be found in rural communities in West Virginia and Tennessee.

The programs track alongside the spread of opiate misuse in small towns with predominantly white populations. Some people change from misuse of prescription opioids to injecting heroin.

The first needle exchange program was established in Tacoma, Washington, in 1988. There were about 100 nationally a decade later.

By 2013, there were 200 needle exchanges, according to Asal Sayas, director of government affairs for amfAR, the Foundation for AIDS Research.

Then, in 2015, after an outbreak of HIV among people using injection drugs in rural Scott County, Indiana, “many states and localities took notice and recognized that their communities were also vulnerable,” Sayas told Healthline.

Shortly afterward, the Centers for Disease Control and Prevention (CDC) identified 220 counties in 26 states that were at high risk of outbreaks similar to that in Scott County, where more than 150 people contracted HIV, largely through needle sharing.

“We saw immediate shifts in policy in states like Kentucky after the Scott County outbreak,” said Sayas.

Sayas said that coincided with a major jump in the number of needle exchange programs.

Currently, there are at least 320 needle exchanges nationally. Moreover, states with Republican legislatures and governors, such as Georgia and Idaho, are among the most recent to legalize needle exchange programs.

Needle exchanges are now legal in 28 states and GOP lawmakers in Florida, Missouri, Iowa and Arizona have introduced bills to legalize needle programs in their states as well, according to a report from Kaiser Health News.

“The proliferation of harm reduction and syringe exchanges is clear evidence that there is a growing acceptance, although it is not universal or even,” Dr. Judith Feinberg, a professor at West Virginia University who founded one of the state’s first needle exchanges and is chairperson elect of the HIV Medicine Association, told Healthline.

In West Virginia, for example, the needle exchange in Huntington is considered a national model, but opposition from a local mayor led to the shutdown of another program in Charleston.

“It’s not mainstream at all,” said Feinberg. “There’s a lot of concern about political pushback.”

Also uneven are how needle programs are structured. At some “you can just walk out with needles,” but others “offer safe injection information, safe sex information” and free condoms, said Feinberg.

This is critical because while sharing dirty needles can spread diseases such as HIV, hepatitis B, and hepatitis C, people who inject drugs also are at higher risk of bacterial infections that can be spread through common but unsafe practices, such as licking needles before injecting.

Feinberg said that programs offering more comprehensive services are more likely to be accepted by skittish officials concerned that needle exchanges increase drug use or crime.

“There’s a lot of resistance and a lot of misunderstanding,” she said. “The whole point is not only to provide syringe exchanges but to establish a trusting relationship so that when users are ready for treatment, they come to you. Syringe exchanges decrease injection drug use and get people into treatment and recovery who might not have found that path otherwise.”

For better or worse, the migration of injection drug use from the inner city to suburbia and small-town America has helped break down the stigma that hampers adoption of programs like needle exchange, said Feinberg.

“When the drug problem is so prevalent in poor rural communities in the South, people know that users are not intrinsically bad or immoral people,” she said.

In some cases, the legislators introducing needle exchange bills have themselves lost friends or family members to opioid addiction.

“It all begins to change people’s minds,” Feinberg said.

Concern about the opioid crisis in rural America also has led to the Trump administration being supportive of needle exchange programs, at least on the public health side of the issue.

Legislation is also pending in Congress that would lift the long-standing ban on using federal funds to pay for hypodermic needles.

On the other hand, the U.S. Department of Justice has sued to prevent a safe injection site — where users could not only get needles but inject drugs in supervised conditions — in Philadelphia.

The agency has threatened “to meet the opening of any injection site with swift and aggressive action.”

Still, “we are in a better place nationally than on the local level,” said Sayas, noting that of the seven states identified by the CDC as being at highest risk of an HIV outbreak among people injecting drugs, needle exchanges remain illegal in six.

Syringe exchanges “have been operating in the U.S. since the late ’80s, and there is nearly 30 years of research demonstrating they are an effective and cost-saving public health intervention,” Sayas said.

“I think it’s incredibly irresponsible when decision-makers oppose evidence-based policies that provide public health benefits despite decades of research. There are costs to individuals, families, and society as a whole when the policy makers’ opposition is rooted in stigma rather than science.”