Backed by an arsenal of data and degrees in medicine and public health, Dr. Howard Koh, the state’s public health commissioner, considers needle-exchange programs a proven way to keep intravenous drug users free of the deadly HIV virus until they’re ready to seek treatment for their addiction. Billy Breault, armed with a passion for his community and the political know-how to make his voice heard, regards such programs as a virtual death sentence for hardscrabble neighborhoods like his, a blue-collar section of Worcester just south of the city’s downtown.

It is in those equally dramatic terms–and with a clash of views that stark–that a decade-long debate over needle-exchange programs in Massachusetts has been cast. With data showing AIDS increasingly to be a plague on intravenous drug users, their sexual partners, and their children, needle-exchange advocates are turning up the volume. But so too are Breault and the allies he has cultivated in cities across the Commonwealth.

In March, the state Department of Public Health launched a $100,000 public information campaign–complete with radio ads, billboards, and bus placards–aimed at building support for needle-exchange programs in seven Massachusetts cities with a high prevalence of IV drug use –and related HIV and AIDS cases. “We’ve gotten very aggressive with this media campaign,” says Koh.

According to state officials, IV drug use now accounts for roughly half of all cases of HIV and AIDS in Massachusetts, with that proportion even higher in the targeted cities. By allowing IV drug users to trade used syringes for new ones, public health officials say, exchange programs reduce needle sharing among addicts, a prime vector for the transmission of HIV, the virus that causes AIDS. The evidence that needle-exchange programs reduce the spread of HIV is now irrefutable, according to the US Surgeon General. The American Medical Association agrees. So do the National Academy of Sciences, the Centers for Disease Control and Prevention, and a bevy of other big-wig science and public health organizations.

In the mid-1990s, the Legislature authorized establishment of needle-exchange programs in up to 10 Massachusetts communities–but only with approval of local authorities. Four municipalities–Boston, Cambridge, Northampton, and Provincetown–have signed on. But elsewhere, needle exchange has hit a wall.

In Worcester, the city council has twice voted down needle-exchange programs, with Breault leading the public opposition. “It would have a devastating impact on our quality of life,” declares Breault, a veteran anti-crime-and-arson activist in that city who has emerged as the state’s leading foe of needle exchange. The Springfield and New Bedford city councils approved needle-exchange programs only to have the measures reversed by citizen-led ballot questions–campaigns Breault lent a crucial helping hand.

Breault doesn’t buy the scientific conclusions of the CDC and other groups. What’s more, he says needle-exchange programs will turn communities that are already battling drug problems into magnets for addicts and the crime that comes with them.

Public health officials counter that study after study has shown no increase in drug use or crime associated with needle exchange. Indeed, advocates argue that exchange programs can serve as a gateway to treatment. That’s exactly what’s happened in Boston, say city health officials, who report that approximately one-quarter of the roughly 2,000 addicts enrolled in Boston’s needle-exchange program enter some type of addiction treatment program each year.

State officials hope the current media campaign will begin to turn the tide of opinion in the seven cities being targeted–Fall River, Gloucester, Holyoke, Lynn, New Bedford, Springfield, and Worcester.

Not everyone wants to wait for a change of heart. Many health experts and advocacy groups, such as the Boston-based AIDS Action Committee, want the state to be able to site needle-exchange programs without local approval. They say that a public health intervention combats a life-threatening disease shouldn’t be held hostage to popular opinion.

They’ve found an unlikely ally in state Sen. James Jajuga, an ex-state trooper who has been the Legislature’s most fervent supporter of needle- exchange programs. The Methuen Democrat spent 19 of his 21 years on the state police force as a narcotics officer, and his experience convinced him that needle-exchange programs are the right thing to do.

“Just saying no doesn’t work,” says Jajuga. “People are getting infected.”

Last year Jajuga inserted an amendment into the state budget that would have removed the requirement for local approval of needle-exchange programs. But Gov. Paul Cellucci vetoed the measure, saying the Department of Public Health should do a better job persuading local officials to approve programs for their communities. Jajuga vows to push the measure again this year.

Another bill, cosponsored by Sen. Robert Travaglini (D-East Boston) and Rep. Thomas McGee (D-Lynn), would allow over-the-counter sale of syringes at pharmacies. Massachusetts is one of only six states that bans non-prescription needle sales. Although legalizing over-the-counter needle sales would seem one way out of the Koh-Breault deadlock–it would make clean needles readily available without concentrating distribution to addicts in vulnerable neighborhoods–the prospects for this measure seem even more dim than for Jajuga’s plan.

In addition to the media campaign, DPH has awarded planning grants of approximately $10,000 each to public health groups in nine different cities. State officials hope that a detailed blueprint, developed locally, will allay concerns in the targeted cities.

To Breault, the grants are just an attempt to soften up the locals. “The ivory tower crowd, the AIDS Action crowd,” is saying “we know what’s best,” Breault fumes, his voice dripping with sarcasm. “We’re going to go enlighten all you good ignorant folks in the city of Worcester.”

One central Massachusetts city has already just said no. In March, the Fitchburg City Council voted unanimously to oppose needle-exchange planning, and the local agency that had been awarded a DPH planning grant threw in the towel.

Still, officials in some target cities are keeping an open mind. Gloucester Mayor Bruce Tobey has worked hard to turn around the economy of his seaside city, and to shake its reputation for harboring not only a famous fishing fleet, but also a hidden heroin problem. But he doesn’t pretend there are no longer IV drug addicts in Gloucester, where a health services organization received one of the DPH planning grants.

“We can’t put our head in the sand,” he says. “I know there’s an issue and we have to engage it.” Tobey hasn’t endorsed the idea of a needle-exchange program in Gloucester, but he isn’t closing the door to one either.

State officials say that’s all they’re asking–for now. But if a plan for needle-exchange goes further, Tobey will have to contend with Billy Breault–who has contacts of his own in Gloucester.