Sharon Chamberlain in the exchange room at HIV Alliance.

He carries his needles in a pale green cardboard box. On a warm, sunny Friday afternoon, Jean, an average-looking guy in his early twenties, walks into the HIV Alliance office off Franklin Boulevard in Eugene, Oregon. His brown hair, blonde at the tips, is clean, as are the clothes on his thin body. He wears wire-rimmed glasses, smiles at strangers and looks like just another college student in this university town. As he closes the front door, a welcoming volunteer asks, "Are you here for the needle exchange?"

Jean nods as he sits down on the old black couch, opens the box and pulls out two red plastic containers. They are marked with biohazard symbols and each hold around fifty used needles. Taking the box of needles, the volunteer asks for a count before she puts them in a filing cabinet. One hundred, Jean answers. She gives him two boxes of clean needles.

She also offers him supplies-alcohol wipes, sterile water, bleach, cotton balls, antibiotic ointment and thin elastic strips to tie off the upper arm. Jean takes plenty of each and tries to stuff everything into the green box—but there's too much. The volunteer gives him a plastic bag to carry the rest. Juggling the full bag and the pale green box in both arms, he says goodbye to the volunteer and walks out into the sunshine.

THE GOAL IS TO REDUCE THE SPREAD OF DISEASE-NOT DRUG USE.

HIV Alliance's Sana Needle Exchange Program (NEP) has just supplied free needles to a drug addict.

HIV Alliance opened the Eugene Sana NEP (Sana means "healthy" in Latin) in 1999 to prevent the spread of HIV and hepatitis among intravenous drug users in Lane County, Oregon. Since its first year, the NEP has exchanged more than 686,000 needles. Last year it served 2,800 clients.

Sharon Chamberlain, intravenous drug user outreach director at HIV Alliance, wants to increase that number. Since early 2002, she has worked with volunteers to exchange dirty needles for clean ones. Her hope is that the estimated 10,000 intravenous (IV) drug users in Lane County will stop sharing needles, thereby limiting the spread of blood-borne pathogens.

The goal of the program is to reduce the spread of disease—not drug use.

This means that addicts do not get pressure to quit their habits. Instead, for beginning users, the program provides a starter kit that includes information packets and necessary medical supplies. The NEP gives regular visitors free needles and first aid supplies as well as pamphlets on how to inject properly and offers free HIV testing.

If visitors don't ask about quitting, Chamberlain and the volunteers don't bring it up. They want to foster trust between the NEP and its clients and encourage the exchange. When a user asks-and in fact so many people do ask that there are waiting lists-Chamberlain and company point them to local rehabilitation programs.

But in the meantime, the lesser-of-two-evils strategy seems to be working. According to a study published in The Journal of the American Medical Association, the spread of HIV has slowed where needle exchange programs in the United States have been implemented. According to a 2000 surgeon general's report, while harm reduction methods such as needle exchanges do not reduce drug use, neither do they increase it.

Unfortunately, as shrinking budgets threaten programs specifically dedicated to reducing drug use, needle exhange programs are bearing the burden. Oregon is no exception. Because of severe statewide budget cuts in the beginning of 2003, Eugene's methadone clinic closed. The clinic provided methadone, a non-injected drug that helps addicts stop using heroin gradually. Now, without an intervention option, many addicts have returned to injection use. The NEP has seen an increase of more than 45 percent in needles exchanged and a 20 percent increase in visitors during the past several months. Yet, NEP receives no taxpayer support, so Chamberlain must work with a finite supply of both donations and medical supplies to meet an increasing demand.

She remains undeterred. The thirty-two-year-old knows firsthand the need for the program. Chamberlain was only eleven years old when she began using drugs. Marijuana came first.

"When I was little there was lots of stigma about being the good kid and the preacher's daughter and that kind of stuff. I think that made me start being wild a lot younger."

Within a decade she was shooting heroin.

Early in her addiction, she wondered what she was doing. Later, when she was going full-blown, she didn't care.

"I made sure I didn't think about it. I didn't have any other options—I didn't have clean needles. I didn't want to think about what could happen."

When Chamberlain was injecting drugs, needle exhange programs were rare and typically underground.

Luckily, what easily could have happened—contracting HIV or hepatitis from a contaminated needle—never did.

"It's a miracle really," she says.

But it was not the threat of HIV that finally persuaded Chamberlain to quit. It was a friend's overdose and death in her apartment.

"That's what woke me up," she says. "I was in and out of plenty of rehabs before, but I didn't like being told what I needed to do."

Still, it would take more than desire for Chamberlain to kick her habit. She would need help.

For Chamberlain, help came in the form of a woman whom she calls her "guardian angel."

"She used to come down and talk to me and bring me food," Chamberlain says. "She never pressured me. She just talked to us, all kinds of kids that were on the street."

Eventually the woman took Chamberlain to her apartment to get her off the streets and away from drugs.

"It was terrible, but she wouldn't let me leave or anything. But we had talked about it beforehand and she had helped a lot of people detox before, so she knew. She helped me get through it."

After successfully kicking her addiction, Chamberlain moved to Arizona and followed in the woman's footsteps: she invited addicts into her own home and helped them quit.

When Cahmberlain moved to Eugene and found out about the NEP through a friend, she saw an opportunity to continue helping, though in a different way.

"I didn't have this available to me when I was out there and I'm a really strong believer in helping people reduce their harm when they are out there so that they stay safe."

For now, Chamberlain's intervention is limited to disease reduction. As outreach coordinator, she no longer personally assists addicts to detox.

"I did that a lot when I was in Arizona, but I haven't done it since I've been here," she explains. "There are some professional conflicts in developing that kind of relationship with people and helping them kick."

Nonetheless, she hopes that if the agency can develop more stable funding, it will provide home detox kits for those who want to quit.

BUT FOR NOW, CHAMBERLAIN IS FOCUSED ON REACHING AS MANY IV drug users as possible to exchange as many needles as possible.

In addition to the in-office needle exchanges on Friday afternoons, HIV Alliance goes into the community on Monday, Wednesday and Thursday nights. In a beat-up white van that has been gutted to make room for storage, volunteers load needles, first aid supplies, a table, pamphlets and hot chocolate. At the end of a dead-end street, volunteers set up shop for the NEP's mobile exchange.

"We meet them where they're at," says Kelly Moore, the testing and counseling director, who occasionally accompanies the volunteers and offers free HIV tests.

While those new to the exchange approach cautiously—wary of an ulterior motive lurking behind the cups of hot cocoa—others more familiar with the van and volunteers approach directly. Some talk and idle; others are silent and impatient to leave.

In the hour and a half that the van remains at the end of the street, the volunteers make about a dozen exchanges-the same as an average Friday in the office.

The NEP, with its in-office and mobile exchanges, would not exist without donor support. Local hospitals play a significant role in making the program run, contributing much of the money and supplies.

This assistance is not altruism. Supporting NEPs exchange programs is smart business for hospitals. A 2002 study estimated the cost of treating an HIV-positive patient for life to be between $150,000 and $195,000. Facing these costs, hospitals and health officials believe prevention is the answer and needle exchange programs do the job.

But this win-win situation for hospitals and the NEP may have reached its limit. With the economy flagging, hospitals have been unable to increase their donations to meet the recent surge in demand for clean needles.

SHANE PULLS OUT A SMALL BAG OF METHAMPHETAMINES FROM HIS POCKET. THE TWO GO TO WORK.

"The amount that they give us no longer covers the supplies for a whole year," Chamberlain says.

With two months to go in the fiscal year, HIV Alliance's program has already used the nearly $30,000 donated by the Sacred Heart Medical Center Foundation. Luckily, the program recently received a grant that will help them finish the year and Chamberlain hopes they will find more stable sources of funding in the future.

Right now, she's hoping her luck holds out.

JEAN BLINKS THROUGH THE HAZE THAT MEETS HIM AT THE DOOR OF HIS APARTMENT. Clouds of cigarette smoke hover over every surface in the small poorly furnished rooms. He takes the pale green cardboard box and plastic sack into the bedroom where he and his partner, Shane, proceed to unpack the clean syringes, elastic ties and other supplies. Their hands tremble slightly and sweat glazes Shane's forehead and cheeks, dampening his thick dark eyebrows. It's been too long—he's going through withdrawal, the "feemes" as he calls them. His pale blue eyes widen and blink rapidly as he scans the medical supplies scattered over the desk and bed. Jean tosses the empty box across the room into the corner, and Shane pulls out a small bag of methamphetamines from his pocket.

The two go to work.