There's a green van parked on the edge of downtown Miami on a corner shadowed by overpasses. The van is a mobile health clinic and syringe exchange where people who inject drugs like heroin and fentanyl can swap dirty needles for fresh ones.
One of the clinic's regular visitors, a man with heavy black arrows tattooed on his arms, waits on the sidewalk to get clean needles.
"I'm Arrow," he says, introducing himself. "Pleasure."
This mobile unit in Miami-Dade County is part of the only legal needle exchange program operating in the state. But a new law in Florida — a needle exchange law that won the support of Florida's conservative legislature, and was signed by Gov. Ron DeSantis Wednesday — aims to change that.
Needle exchanges have been legal in many other states for decades, but southern, Republican-led states like Florida have only recently started to adopt this public health intervention.
The timing of the statewide legalization of needle exchanges comes as Florida grapples with a huge heroin and fentanyl problem. When people share dirty needles to inject those drugs, it puts them at high risk for spreading bloodborne infections like HIV and hepatitis C. For years, Florida has had America's highest rates of HIV.
Even so, Arrow says he and every user he knew always put the drugs first. Clean needles were an afterthought.
"Every once in a while, I did use someone else's and that was a thrill ride — wondering whether or not I was going to catch anything. But I'm blessed; I'm 57 and I don't have anything," says Arrow, whose full name NPR has agreed not to use because of his use of illegal drugs.
"Now I can shoot with a clean needle every time," he says.
The Miami experiment
According to the Centers for Disease Control and Prevention, needle exchanges prevent the spread of viruses among users of injection drugs.
But the advocates who want to offer needle exchanges face challenges. For example, carrying around loads of needles to hand out without prescriptions can violate drug paraphernalia laws. Many states mapped out legal frameworks decades ago to handle this particular public health intervention. But it was illegal to operate exchanges in Florida until 2016. That's when the state legislature gave Miami-Dade County temporary permission to pilot a needle exchange program for five years.
"This is more than just a needle exchange," says Democratic state senator Oscar Braynon. "This has become a roving triage and health center."
Braynon has been sponsoring needle exchange bills — including the bill for the pilot project — since 2013. This year he introduced Senate Bill 366 to allow the rest of Florida's counties to authorize similar programs.
In three years of operation, Miami's pilot program has pulled more than a quarter million used needles out of circulation, according to reports the program filed with the Florida Department of Health. By handing out Narcan — the drug that reverses opioid overdoses — the exchange has prevented more than a thousand overdoses. The program also offers clients testing for HIV and hepatitis C, which is how Arrow knew he was negative. Finally, the program connects people to medical care and drug rehab.
"We have made it so easy for people to get into HIV care now, and we have so many people who we never would have known were infected — and would have infected countless other people — who are on their medications," says Dr. Hansel Tookes, head of Miami's needle exchange pilot program He has been pushing legislators to legalize needle exchanges since he was a medical student six years ago.
Tookes was in Tallahassee, the state capital, this May when the expansion bill passed its final vote. He said he spent the return flight home to Miami staring out the window.
"I looked down at Florida the entire ride," he says, "and I just had this overwhelming feeling like, 'Oh my God, we just did the impossible and we're going to save so many people in this state.' "
Why harm reduction trumped politics
When Republican state senator Rob Bradley first deliberated over needle exchanges in Florida six years ago, he was critical.
"You're trying to make sure the person has a clean needle, which is outweighing the idea of the person breaking the law," he declared back in 2013, before casting his vote against the idea.
This is the primary objection of conservative lawmakers — the concern that these programs promote illegal drug abuse.
Responding to this skepticism with data has been central to changing lawmakers' minds. Decades of research show needle exchanges do not encourage drug abuse, and that they lower other health risks to people who are vulnerable and often hard to reach. It's part of a public health approach known as "harm reduction."
At a recent meeting ahead of the vote on statewide legalization, Ron Book — a powerful Florida lobbyist who chairs the Miami-Dade County Homeless Trust — voiced a question that comes up a lot about the needle exchange and heroin use.
"Doesn't that help encourage it?" he asked Tookes.
"Nobody who used our program — and we collect a lot of data — was a first-time user of opioids when they came there," Tookes told him. "Not one person."
In Miami, the needle exchange pilot project has also earned the support of law enforcement. Officers say it's a relief to know more injection drug users are keeping their syringes in special sharps containers, provided by the exchange, to safely dispose of dirty needles.
"Now, for our officers, when they're doing a pat down ... that sharps container is really protecting you from a loose needle 100 percent of the time," says Eldys Diaz, executive officer to the Miami Chief of Police. "That's an extraordinary source of comfort for us."
This year, when state senator Bradley heard discussion of the needle exchange bill again, he had a different response.
"I just want to say, when I started my career in the Senate, I voted against the pilot project — and I was wrong," he said as he voted for the bill this time. "And the results speak for themselves. It's very good public policy."
The state's new needle exchange law passed unanimously in the Florida Senate and 111 to 3 in the Florida House, and goes into effect July 1.
Arrow gets a future
If it weren't for the tattoos running down his arms, it would be hard to recognize Arrow as the man who once slept under highway overpasses. His skin is now clear, and he has some meat on his bones — he looks healthier.
"How have you been?" Tookes asks, greeting Arrow at a clinic where needle exchange clients can get follow-up care.
"Wonderful," Arrow says. "I feel good."
He looks and feels better, but it's been a rough year.
Last May, Arrow's girlfriend died from a heart infection — a serious condition that can happen to people who inject drugs. After that, Arrow says, he overdosed on purpose. Narcan from the needle exchange brought him back.
But he kept using.
Arrow says he doesn't remember a lot from this period, but does remember using so much heroin that he ran out of fresh needles between visits to the exchange. So he grabbed other people's used needles.
And then he tested positive for HIV and hepatitis C.
Tookes and his colleagues threw Arrow another life raft: They got him an inpatient drug treatment bed.
At Arrow's checkup with Tookes, a string of keychains from Narcotics Anonymous clicked at his waist.
"My chain of sobriety," he says of the links. "I got 30-days, 60-days, and 90-days chips," he says.
Arrow's HIV is under control. And he's connected to health services for people living with HIV, including getting medication that cured his hepatitis C.
Now, he's focused on staying sober, one day at a time. And he's starting to want new things. "Thanks to this man right here," he says, nodding to his doctor — Tookes.
As more Florida counties elect to begin needle exchanges, there's no guarantee that every person who turns to them will get as far as Arrow. But Tookes, Braynon and other supporters hope such services will at least give more people the chance to recover from addiction — and protect themselves from needle-borne illnesses.
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