EVANSVILLE, Ind. — Lavender Timmons popped the trunk of her weather-beaten 2007 Ford Focus parked near the city’s homeless shelter. Regulars gathered around, including one drug user who in the past bought sterile syringes from the illicit market.
Timmons, executive director of Evansville Recovery Alliance, wanted to offer them new needles to keep them from contracting HIV, hepatitis C or other infections. But a police car idled a couple blocks away.
“The cops are watching us,” Timmons said.
A decade after users injecting prescription painkillers sparked a historic HIV outbreak in a southern Indiana county, programs providing sterile needles that contained the crisis are fading. They may disappear completely next year — and nationwide, they are also in peril. The Trump administration has declared that no federal funding can go toward supplies that “promote or facilitate drug use” — even though decades of research has shown that syringe programs reduce disease transmission rates and do not appear to increase injection frequency or neighborhood crime rates.
Evansville has never authorized needle exchanges. Advocates, such as Timmons, who have lobbied for needle exchanges are losing hope — even as fentanyl and methamphetamine users continue to inject with used needles. Under state law, a county health officer must first declare an HIV or hepatitis C emergency — and there is not enough testing to quantify the need, Timmons said, despite some support from local officials.
In Indiana, possessing a syringe without a prescription constitutes a low-level felony. On the recent weekday outside the homeless shelter, Timmons, 42, left donated packs of new syringes in her trunk. She handed out opioid overdose reversal medication, hygiene kits, fentanyl testing kits and snacks.
“I don’t want to give them anything that’s going to get them in trouble,” she said.
A historic outbreak
Underground syringe service programs emerged in the United States during the HIV/AIDS epidemic of the 1980s as experts realized that shared needles helped transmit the disease. Cities and states soon began legalizing programs. As the opioid crisis surged in subsequent decades — driven first by painkillers, then illicit fentanyl — the absence of syringe programs proved catastrophic, particularly in rural White communities.
In rural Scott County, Indiana, less than an hour’s drive to Louisville, the HIV outbreak infected 235 people in 2015. Media flocked to the county, as did federal health officials who tracked the spread and helped testing and outreach.
Critics at the time ripped the governor, Mike Pence (R), for waiting two months to declare a state of emergency. Researchers later concluded the outbreak could have been prevented had officials acted faster.
Pence opposed the creation of syringe service programs in Indiana, although he eventually established an emergency one in Scott County; lawmakers later authorized them under certain conditions, including that an outbreak needed to be certified first by a local health official.
“I was lucky enough not to catch HIV” because of the program, said Becky Wells, 34, before a group gathered for a motorcycle fundraiser in Austin, Indiana. She started injecting drugs during the HIV outbreak after her father died.
A program staffer who had delivered new needles to Wells’s home drove her to rehab in 2020. Wells, a mother of three, remains sober and now works at Holding Space Recovery Project, a harm reduction nonprofit that deploys teams to connect users with recovery coaches as well as HIV and hepatitis C testing and supplies. In Austin, hundreds of people — all touched by the opioid and HIV crisis — gathered under a fierce August sun to raise money for the group, founded by former syringe program employees Kelly Hans and Lisa Webster.
They celebrated the many victories: Open drug use on the streets has disappeared, and many former users are thriving in recovery.
But needle drug use has not disappeared — and workers can no longer distribute clean syringes. In 2021, Scott County commissioners closed the syringe program. “I know people that are alcoholics, and I don’t buy him a bottle of whiskey,” one commissioner remarked.
But people mired in addiction will use drugs anyway and need the additional services these programs provide, said Jerrica Hall, 35, who contracted HIV a decade ago.
The Scott County syringe program helped her secure health insurance, which paid for HIV medications. Today, she is sober and married to a partner without HIV. “I never thought back then that I could find love. I have three beautiful children that are HIV negative,” said Hall, who is president of the board for Holding Space.
Research cited by former Indiana health commissioner Jerome Adams, who served as U.S. surgeon general during President Donald Trump’s first term, noted that new syringe program users are five times as likely to enter drug treatment compared to those who did not use them. Centers for Disease Control and Prevention researchers later reported that the number of participants who reported sharing injection equipment dropped dramatically. By 2018, Scott County saw a 96 percent reduction in new HIV infections and a 76 percent drop in new hepatitis C infections.
Some who escaped HIV still paid a steep price. When the program shut down, Matthew Colwell could no longer get sterile syringes and turned to dull discarded needles, sometimes injecting fentanyl every 20 minutes. Colwell, 24, beat his addiction but contracted endocarditis, heart inflammation caused by bacteria from contaminated needles.
He spent nearly a month in the hospital. Today, even moderate exercise prompts his heart to race abnormally. “My heart is still messed up to this day,” Colwell said.
Changing approaches
Data on the number of syringe programs nationwide is imprecise because many are not sanctioned and do not advertise to avoid crackdowns. In the five years after Indiana started its syringe exchange, the number of known programs roughly doubled, according to the North American Syringe Exchange Network, a harm reduction group.
The Biden administration supported syringe programs, although federal funding by law could not be used to purchase the needles themselves.
HIV diagnoses increased 5 percent among people who inject drugs between 2018 and 2022, according to the CDC. But communities across the country are now pushing back against needle exchange programs.
Health officials in Bangor, Maine, have recorded a spike in HIV cases among injection drugs users since 2023. The city stopped a newly authorized program from distributing sterile needles at parks and closed a new facility in July because it was not zoned properly. In rural Lewis County, Washington, the American Civil Liberties Union filed a federal lawsuit in September aimed at overturning an ordinance that barred a ministry from handing out sterile syringes and other supplies. West Virginia — a Republican state hit hard by the opioid crisis and HIV infections — has continued to impose restrictions on syringe exchanges.
Last year, Nebraska Gov. Jim Pillen (R) vetoed a bipartisan bill that would have green-lit syringe exchanges, saying they would re-create the “failed policies of drug-infested cities like San Francisco here.” Even San Francisco scaled back syringe programs in April, tying clean needles to treatment or other services.
The Trump administration has taken aim at these programs, blasting its predecessor’s backing of the programs as “dangerous.” In a July 29 letter, the Substance Abuse and Mental Health Administration, which administers billions in grants to states, prohibited the use of grants to purchase needles, sterile water, saline, vitamin C or any other supplies “to promote or facilitate drug use” — or support such services.
The stance comes as Health and Human Services Secretary Robert F. Kennedy Jr., who has acknowledged publicly contracting hepatitis C through injection drug use years ago, had pledged $100 million to fund local and state programs to prevent, test, treat and cure the virus. About half of all acute hepatitis C infections result from injection drug use, according to a Sept. 10 JAMA Network article.
It remains unclear whether federal grants can be used to pay staff salaries or other operations for organizations that offer syringes among other services. The agency said it will ensure grants “are aligned with both the administration’s priorities and sound clinical practice” and recently removed a CDC webpage that touted benefits of syringe programs.
Organizations or states may shut down their programs for fear of losing other funding, said Beth Meyerson, director of the University of Arizona’s Harm Reduction Research Lab. “States that weren’t supportive in the first place will use this as their shield” from criticism if they shut down needle exchanges, Meyerson said.
An uphill battle
In Indiana, after the SAMHSA letter was published, the health department ordered groups that get state funding to destroy “safer use” supplies commonly given to injection users such as cookers, cottons, tourniquets and sterile water.
At least 11 of Indiana’s 92 counties have operated syringe programs, though three have closed in recent years. The remaining eight serve many of the most populous regions and may close next summer if lawmakers don’t renew a state law, said Indiana state Rep. Ed Clere, a moderate Republican who supports the programs.
He cited state data that between 2020 and the start of 2024, the programs distributed more than 161,600 doses of naloxone, the opioid reversal medication. “Sterile syringes are a way to get people in the door,” Clere said. He added that he plans to fight for the law’s renewal but admitted that the administration’s stance makes a “steep hill even steeper.”
The office of Indiana Gov. Mike Braun (R) did not reply to requests for comment, but his chief health policy aide emailed Clere in August saying that Braun does not believe syringe programs “align with the administration’s priorities or long-term approach to addressing addiction in Indiana.”
In Clark County, just outside Louisville, health officials warn that ending the syringe program could trigger more needle-sharing and infectious disease because it collects used syringes from users and drop boxes. “We actually take more off the street than we give out,” said Eric Yazel, the county health officer.
Back in Evansville, Timmons pulled a wheeled cart down a concrete path to a plaza on a bend of the Ohio River. Armed with a trash picker, she scoured the ground for orange-tipped syringes. Every day, Timmons fans out across Evansville — Indiana’s third-largest city — to gather syringes. Most are handed over by users who trust her.
Her efforts underscore another vexing problem posed by the lack of a syringe program: People have nowhere to legally dispose of used needles.
The homeless often camp on this scenic stretch in Evansville’s downtown overlooking Kentucky, discarding needles that pose a danger to children. Sometimes, people try to sharpen discarded needles by rubbing them on concrete to reuse them or rigging them with safety pins, leading to infections.
The work is personal for Timmons. She experienced a chaotic childhood in Evansville. Her mother used drugs, and they were often homeless. In her 20s, Timmons battled her own addiction, wandering the country by hopping trains.
She now runs the alliance on a shoestring budget, relying solely on private donations of supplies. Another harm reduction group recently donated a chrome-colored van that she hopes to use as a mobile syringe center if her group can ramp up testing.
She makes her rounds to homes, encampments along the railroad tracks and the run-down motels lining Evansville’s Fares Avenue strip. Then each week, she or another volunteer drive two hours to dispose of used needles at a state-designated site in Bloomington.
“I’ve seen people injecting themselves with a lot of rigged-up sharp things,” Timmons said, adding that one user she knows developed wounds from this approach and recently died of sepsis. “It doesn’t work.”
