Needle-exchange issue put on front burner

Advocates point to scientific evidence

New studies, a new AIDS czar, and new state laws are putting pressure on the federal government to lift the ban on federal funds for needle-exchange programs and devote more resources to fighting what is becoming the primary mode of HIV infection in the United States.

More than one-third of the 548,102 recorded AIDS cases in the United States are attributed to injection drug use or having sex with HIV-positive injection drug users (IDUs). Federal health officials also estimate that as many as half of the 50,000 new HIV infections last year resulted from sharing dirty needles or having sex with IDUs. Yet, traditional prevention efforts among IDUs have failed to stem this deadly tide.

For the past four years, epidemiologists have been studying needle-exchange programs to determine whether they provide an effective and affordable method of preventing HIV infection among IDUs. Nearly all of these studies, including six federally funded reports, have concluded that needle-exchange programs can prevent HIV infection in this country without increasing drug use.

Despite scientific evidence that needle-exchange programs work, many Americans find providing clean needles to drug users morally — and politically — indefensible. Champions of needle-exchange programs have faced daunting challenges in the search for federal funding for the programs.

Until this year, that is. Several recent developments, including a report from Secretary of Health and Human Services Donna Shalala, MD, to the Committee on Appropriations for the Departments of Labor, Health and Human Services, Education, and Related Agencies, point to a sea change in the politics surrounding needle-exchange programs.

"It’s moving more quickly than I had thought," says Lawrence Gostin, JD, professor of law at Georgetown University and a leading authority on the legal aspects of needle-exchange programs. "I am very hopeful and optimistic now that the government will lift its ban on federal funding, and also optimistic that more and more states will decrease the criminal penalties for the purchase of syringes."

In January, Gostin published results of a national survey on the regulation of syringes and needles in the Journal of the American Medical Association.1 The study’s authors concluded that "deregulation of syringe sale and possession [at the state level] would reduce morbidity and mortality associated with bloodborne diseases among IDUs, their sexual partners and their children."

In another boost for needle-exchange programs, a consensus panel convened by the National Institutes of Health in February also concluded that needle-exchange programs reduced risky behavior among IDUs. Citing a serious gap between scientific findings and government policy, the panel recommended states remove legislative barriers against needle-exchange programs and increase funding for substance abuse treatment.

Most recently, Shalala issued a comprehensive overview of research on needle-exchange programs in the United States. Although the Department of Health and Human Services has funded pilot projects to evaluate needle-exchange programs, it is restricted from directly funding such programs until the Surgeon General determines they are effective in reducing the spread of HIV and the use of illegal drugs.

While Shalala’s report did not endorse needle-exchange programs, she concluded that numerous needle-exchange studies "indicate that needle exchange programs can have an impact on bringing difficult-to-reach populations into systems of care that offer drug dependency services, mental health, medical and support services. These studies also indicate that needle exchange programs can be an effective component of a comprehensive strategy to prevent HIV and other bloodborne infectious diseases."

Those remarks are viewed by needle-exchange advocates as tacit support from Shalala. With no Surgeon General currently in place, the evaluation of needle-exchange programs becomes Shalala’s responsibility, according to officials at the Centers for Disease Control and Prevention. When asked at a recent meeting of CDC AIDS officials what the next step would be, Ron Valdeseri, MD, assistant director for the National Center for HIV, STD and TB Prevention, was reluctant to comment.

"Officially, the prohibition is still in place," he said. "We are encouraged by the fact that in the report the Secretary recognized that it appears that access to sterilized injection equipment is an important component of a comprehensive approach to HIV prevention."

Indeed, at the XI International Conference on AIDS, one needle-exchange expert estimated that a decision by Congress to lift the ban on federal funds for needle-exchange programs could have prevented 10,000 HIV infections and saved $500 million in health care costs during the past ten years.

In yet another committee report, the Presidential Advisory Council on HIV/AIDS recommended at its April meeting that the government lift the prohibition on federal funds for the estimated 75 needle-exchange programs currently in place in the United States. One of the committee members, Sandra Thurman, subsequently was named President Clinton’s new AIDS czar. Thurman recently recommended that a needle-exchange policy should be based on scientific research rather than political considerations.

Several states have already made changes in their drug paraphernalia and syringe laws. In Rhode Island, where nearly 50% of AIDS cases are attributed to intravenous drug use (the national average is 35%), state legislators are considering a bill that would reform local laws on possession of non-prescription syringes, which is now considered a felony. The governor of New Mexico recently signed a bill that substantially decriminalized the purchase of syringes, Gostin says.

Five years ago, Connecticut became the first state to legalize the purchase and possession of up to 10 syringes at a time without a prescription. A survey of IDUs found that as many as 75% of addicts report buying their syringes at a pharmacy instead of on the street.

Reference

1. Gostin L, Lazzarini J, Jones T, et al. Prevention of HIV/AIDS and other bloodborne diseases among injection drug users. JAMA 1997; 277:53-62.