On a recent chilly morning in downtown San Antonio, Maria arrived in the parking lot of Grace Lutheran Church hours before the homeless resource center on its property opened.
She sat with her boyfriend and three puppies, labrador-pitbull mixes, on the sidewalk while they waited for an important appointment.
“Maybe I’ll get a place [to live] today,” she said. “I’m getting too old to be on the streets.”
Maria, 41, has been homeless off and on for about seven years and wants to get sober.
Last month, she met outreach workers from Corazón San Antonio‘s Harm Reduction program who traded her used syringes for clean ones and gave her other sanitary supplies. She has thought about entering a recovery program for a while, but there was something about the way these workers approached her that made her want to take the next step.
“They kept coming back,” she said.
Maria is HIV-positive and has been taking medication. Members of Corazón’s team took her to an appointment at the San Antonio AIDS Foundation, where she is eligible for transitional housing.
The Corazón Harm Reduction program launched in early December with a two-year, $780,000 grant from UT Health San Antonio through the Bexar County Harm Reduction Initiative and other federal funding. It’s one of few programs in Bexar County that provides both mobile outreach and a drop-in center for services that aim to reduce negative health consequences associated with drug use, namely fatal overdoses, disease and infection. Outreach workers provide needle exchange, wound kits, bleach kits for disinfection, strips to test drugs for deadly fentanyl, condoms, HIV and hepatitis C testing and Narcan, a life-saving overdose remedy.
The center at 504 East Avenue E is open five days a week from 11 a.m. to 4 p.m. But much of the six-member staff’s work is done outside on the streets and in homeless encampments across the city, where workers haul large bags of supplies and distribute them.
Despite studies that show needle distribution programs reduce rates of HIV and hepatitis C infection, they are controversial, with many perceiving the practice to be enabling more illegal drug use. A bill that would have allowed needle exchange programs in Texas’ largest counties passed the state House of Representatives in 2021 but was not taken up by the Senate.
Madelein Santibanez, the program’s director, argues that by providing these services and building relationships, the program’s staff can earn the trust of people struggling with addiction, building on that trust to steer them to recovery programs or housing. “With harm reduction, our goal isn’t recovery … it’s reducing the stigma and empowering clients to [access] services that reduce the harms that come with substance abuse and other high-risk activities.”
But recovery is a welcome side effect, and the key to fostering that was hiring outreach workers and peer support coaches who have themselves experienced addiction, said Santibanez. “Our coaches can say, ‘Hey, you know, there’s a safer way to inject.'”
Barriers and trauma
A young woman emptied the contents of her small lunchbox onto a sidewalk off of North Zarzamora and West Laurel streets in early January. The characters of a popular children’s cartoon stare up from the box as she starts counting the used syringes she’s collected over the past week or so.
She counts more than 50, which are placed in a needle disposal container. In return, a Corazón outreach worker gives her the same number of clean syringes and other supplies aimed at helping her avoid infections or death.
“Thank you,” she said while packing up her belongings.
A woman collects used syringes during a weekly outreach mission performed by the Corazon Harm Reduction Center on Thursday. 
Madelein Santibanez, executive director of the Corazon Harm Reduction Center, gathers clean syringes to exchange with a person during a weekly outreach mission on Thursday.
It’s unclear if the woman or any of the people the outreach team met that day will ever ask for help in kicking their addiction, said Claudia Delfin, who leads the program’s peer support team. “And that’s OK.”
“A lot of them have different kinds of barriers,” said Delfin, a transgender woman who struggled with addiction in El Paso and Ciudad Juárez before becoming a drug counselor. She’s been in recovery for more than a decade, has received numerous awards for her social work. “We use our motivational interview skills [that] we learn in recovery coach training, how to engage and encourage them to come out,” she said, “because they … have a lot of trauma.”
Hiring peer support staff for the program was an unusual experience, said Gavin Rogers, executive director of Corazón.
“It was the first time I had to set a rule that past heroin use was a job requirement to get a job,” he said. “Sure, a master’s degree from some grad school is great, but lived experience and knowing the pathways and pitfalls of true recovery is what will make the biggest impact and transform lives.”
Rogers recruited Delfin and Corazón peer support coach Abraham Martinez from El Paso, where they worked for Punto de Partida‘s harm reduction program.
The location off of Zarzamora Street is just one of eight different sites that the harm reduction team visits at least twice a week, Santibanez said. Ultimately, she wants to serve 20 sites, based on a map from the San Antonio Fire Department that shows areas prone to incidents of drug overdoses.
“Right now, we’re just trying to have a systematic way of doing it,” she said, noting that the Corazón team will be coordinating with the fire department and other agencies to make sure they’re finding the populations that need supplies the most. “We’re going to need more outreach workers.”
The team is on track to start contributing client data to the local Homeless Management Information System, which government agencies and nonprofits use to track the services utilized by homeless people.
The long road to legal needle exchange and implementation
In 2007, Bexar County became the only county in Texas authorized to test an official needle exchange program, but a lack of support from previous district attorneys meant the pilot program stalled for more than a decade. Meanwhile, the established programs run by religious programs continued to operate underground.
“We went out on the streets illegally,” said Jody Casey, a longtime board member of the Bexar Area Harm Reduction Coalition that was formed in 2003. “We sort of went underground. … We had certain spots where people would know to go” to get clean needles.
It wasn’t until May 2018, amid the nationwide opioid epidemic, that local officials began encouraging religious organizations and nonprofits to go public with needle exchanges. Bexar County Commissioners Court voted in September 2019 to fund what would become the Bexar County Harm Reduction Initiative, which has funded the coalition’s work and that of religious and nonprofit groups.
“We’d been on the streets for about six months and then COVID hit,” Casey said. “Everything shut down.”
Despite that challenge, the initiative distributed more than 3,000 safe injection kits, more than 1,200 condoms, and there were reports of over 300 overdose reversals with Narcan within the first year of the initiative, said Dr. Lisa Cleveland, professor at the UT Health San Antonio School of Nursing, which administers grants and federal funding for Bexar County.
In terms of overdose reversals, Cleveland suspects the true number is much higher, she said. “A lot of times folks don’t want to report those.”
Providing needle exchange, safe injection kits and peer support as well as paving the way into recovery programs is a public health initiative that has a bottom-line financial benefit for the community, Cleveland said.
The services are intended to prevent the costly downstream results of drug use: HIV, hepatitis C, abscesses and other illnesses among a population that rarely has health insurance.
“It’s expensive for taxpayers,” she said. “Providing folks with the resources they need is really not enabling. … You’re just trying to help them do it in a way that is safer [and] less costly for the community.”
Ultimately, Cleveland said, she hopes the work that Corazón Harm Reduction and other groups are doing shows that needle programs need to be legal statewide. There have been several legislative attempts to do so in recent years, but those bills often don’t make it to a vote.
“I’m happy it’s legal in Bexar County, but it’s puzzling to me that it’s not legal throughout Texas, ” she said. “Harm reduction initiatives have been successful for decades in other states and other countries, there’s no reason to believe that it won’t be successful here in Texas.”
By giving drug users such as Maria clean syringes, Corazon’s outreach workers helped pave the way for her to pursue the path to recovery and permanent housing. That’s the ultimate goal of the county’s harm reduction initiative, even if it might seem counterintuitive to some.
“I have to admit, it takes some getting used to,” Corazon’s Rogers said. “Just like in the ’80s when sex ed was moving past abstinence, many people assumed condom dispensing would lead to more sexual promiscuity and harm, when in fact it leads to less harm.”
