IDU remains major HIV risk factor
In the same summer that the Centers for Disease Control and Prevention’s (CDC) latest data show that injection drug use remains a major factor in AIDS cases, a new study offers evidence that needle exchange programs do not cause an increase in injection drug use.
CDC data from 1994 to 2000 show that 25% of total 765,559 cumulative AIDS cases diagnosed through December 2000 were of injection drug users (IDUs).1 The CDC’s HIV data collected from the 25 states that have had HIV-infection case reporting since 1993 also show that HIV diagnoses reported among IDUs declined 42% between 1994 and 2000, while HIV diagnoses among men who have sex with men (MSM) declined by 15%, and heterosexual HIV transmission had increased by 9% in the same period.1
Most public health officials attribute the decline to the proliferation of needle exchange programs and other initiatives that have made clean needles readily available to IDUs.
"Needle exchange programs decrease drug use communitywide when they are done right," says Robert Heimer, PhD, associate professor of epidemiology, public health, and pharmacology at Yale University School of Medicine in New Haven, CT.
"The federal ban on needle exchange funding has increased drug use because well-run, well-supported, well-integrated needle exchange programs are points of contact for drug users who seek to enter treatment," he says.
Heimer researched the issue of needle exchanges serving as gateways to drug treatment and found when there is adequate funding for a substance abuse treatment counselor, the needle exchange program will not only encourage IDUs to enter drug treatment, but it will encourage other drug users as well, such as crack cocaine users.2
"But as resources have dried up for needle exchange in Connecticut, and there is no federal funding, these programs have stopped decreasing drug use," he adds.
Nonetheless, the federal government has continued to refuse to fund needle exchange programs, and some states have outlawed the practice, claiming that it encourages people to inject illegal drugs.
Former President Bill Clinton told researchers and others at the XIV International AIDS Confer-ence in Barcelona in July 2002 that he was wrong to refuse to lift the ban on federal funding of needle-exchange programs, and that he had bowed to pressure that it would send the wrong message on the drug front.
To date, no research has supported the political argument that needle exchanges increase injection drug activity, and a new, five-year study provides very strong evidence that needle exchange programs do not cause IDUs to inject more drugs.
Basically, the study shows that there is no significant difference in the number of injections between IDUs who use a needle exchange program and those who obtain needles through other means, says Dennis Fisher, PhD, professor of psychology and the director of the Center for Behavioral Research and Services in Long Beach, CA.
With a randomized controlled trial, from May 1997 to June 2000, investigators compared IDUs who were given access to a needle exchange program with IDUs who were trained in how to purchase needles and syringes at pharmacies.2
Researchers designed the study with a comparison group to answer critics who charge that previous needle exchange program studies were tainted by selection bias, Fisher says.
"The problem with needle exchange studies is that for a number of years, people couldn’t figure out how to do a comparison study," he explains. "We figured out how to do it by randomizing injectors to either a needle exchange condition or to pharmacy sales conditions."
The study recruited 653 IDUs in Alaska, at a time when needles and syringes were legal for sale in pharmacies without prescriptions, Fisher says. "We went a little further and provided maps to pharmacies and told IDUs what to say and what not to say and how to keep track of which pharmacies were more likely to sell. Then we compared these two parts of the clinical trial and did an honest-to-goodness prospective, randomized arm of the clinical trial of needle exchange."
Investigators studied negative effects, such as an increase in drug use, in both parts of the study and found that there was no increase in drug use and no significant difference between the two groups, he says. "The one place where we did marginally see a difference was actually a bigger decrease in cocaine drug use in the needle exchange arm of the study, but the effect was marginal," Fisher adds.
IDU participants were studied at six months, 12 months, and 18 months, and researchers never saw an increase in injection drug use, he says.
According to CDC data, IDU continues to account for a major HIV transmission source in most states.
In Connecticut, Maryland, Massachusetts, New Jersey, New York, Pennsylvania, and Puerto Rico, IDU was the greatest risk factor among people living with AIDS at the end of 2001.
Historically, some Northeastern urban areas have had greater numbers of AIDS patients who are IDUs; but in most of these states, there has been some effort in the past decade to decrease HIV transmission among IDUs through prevention programs that include needle exchange and over-the-counter pharmacy sale of syringes, Heimer says.
One major exception to that trend is New Jersey, which had actively arrested volunteers running needle exchange programs in the late 1990s and currently has no organized needle exchange programs, he says.
New Jersey also has the second-highest number of IDUs living with AIDS in the nation, according to CDC data; and unlike its neighboring states, it has had no decrease in the incidence and prevalence of HIV infection among IDUs, Heimer explains. New York, which began in 2001 to reverse its AIDS epidemic among IDUs through needle exchange programs, had 25,721 IDUs living with AIDS at the end of 2001. New Jersey had 6,949 IDUs living with AIDS at that time.
Likewise, New Jersey is one of only three states and territories where the number of people living with AIDS (PLWA) who were infected through heterosexual contact outnumbers the PLWA who were infected through homosexual contact, according to CDC data.
Connecticut and Puerto Rico are the other places where MSM transmission has resulted in fewer AIDS cases through 2001 than IDU and heterosexual sex transmission.
"Certainly, in many locations, the easiest introduction to the virus into heterosexual populations comes from IDUs, but that doesn’t mean that we have to have IDUs to see large-scale heterosexual epidemics," Heimer says. "And it’s clearly easier to change risky injection behavior than risky sexual behavior because IDUs like clean needles and don’t like to use old and dirty needles."
1. Lee LM, et al. HIV diagnoses among injection-drug users in states with HIV surveillance — 25 states, 1994-2000. MMWR 2003; 52(27):634-636.
2. Heimer R. Can syringe exchange serve as a conduit to drug treatment? J Subst Abuse Treat 1998; 15:183-191.
3. Fisher DG, Fenaughty AM, Cagle HH, et al. Needle exchange and injection drug use frequency: A randomized clinical trial. J AIDS 2003; 33(2):199-205.