HIV prevention clashes with politics over needle-exchange programs

Opinion polls mixed on public support for federal funding

It’s been more than a year since national public health leaders sent a letter to U.S. Department of Health and Human Services Secretary Donna Shalala, advising her that needle-exchange programs were useful in preventing the spread of HIV and didn’t increase drug use. But the controversy didn’t end there, and AIDS activists contend that the government still has done too little to promote or fund these programs on the national or state levels.

"For some time we’ve had mountains of evidence that needle-exchange programs decrease the spread of HIV, and now we have studies showing they do not promote drug abuse and crime," says Daniel Zingale, executive director of AIDS Action in Washington, DC. "From our perspective, there are no more legitimate reasons against these life-saving programs being implemented."

New Jersey’s Republican Gov. Christine Whitman is on the other side of the fence, encouraging state health officials to get drug users into treatment but permitting arrests of volunteers who distribute needles to heroin addicts. "The governor has made her position very clear: She feels needle exchange sends out the wrong message," says Larry Ganges, MSW, director of the intervention and care services unit for the New Jersey Department of Health and Senior Services in Trenton.

"If you check the literature, there are certainly studies that talk from both sides of the issues, including several studies that indicate needle-exchange programs do not serve the greater good," Ganges says.

AIDS Alert searched research papers on Medscape (www.medscape. com) for studies, letters, and editorials containing the words "needle exchange," and found 31,125 references. Among the top 125 references, 30 of these were first-time references to studies. Of the 30 studies, 28 concluded that needle-exchange programs were helpful in preventing the spread of HIV, and two had negative or mixed conclusions.

One 1998 study even concluded that illegal syringe-exchange programs can be effective HIV prevention programs, resulting in lower rates of needle-based risk behavior among African-American and HIV-positive injection drug users.1

Forty-two states have legalized the sale of hypodermic syringes without a prescription, with some permitting or even funding needle-exchange programs and others allowing pharmacists to sell needles over the counter.2 However, some states — such as New Jersey and California — have actively enforced drug paraphernalia or prescription laws by arresting needle-exchange program volunteers. A 1997 study shows that this type of enforcement can deter addicts from using the program and volunteers from participating in it.3

Public opinion fickle on needle exchange

Public opinion surveys have shown that many Americans are conflicted about whether needle-exchange programs work and whether they should be federally supported. While the Menlo Park, CA-based Kaiser Family Foundation reports that 66% of Americans support needle-exchange programs, a recent poll by the conservative Family Research Council contradicts that finding.

The Washington, DC-based organization asked 1,000 registered voters nationwide in February to state which of the following opinions was closest to their own:

• "Voter A says that needle-exchange programs reduce the spread of the HIV virus and do not contribute to more drug use. Federal funds should be used to give syringes to drug addicts."

• "Voter B says that the science supporting needle-exchange programs is uncertain and that giving needles to addicts would increase drug use as well as send pro-drug messages to vulnerable teens."

The survey reported that 34% of the voters surveyed agreed with "Voter A" and 59% agreed with "Voter B." Another 7% said they were confused or didn’t know. Also, only 29% of the voters polled said they support needle-exchange programs and 65% oppose them when asked this question: "Would you support or oppose giving clean needles to drug addicts to slow the spread of the AIDS virus if you knew that this might increase illicit drug use among America’s youth?"

Perhaps partly because of uncertain public sentiment regarding such programs, some states have opted to stay away from needle exchanges and instead lend more support to programs that get drug addicts into treatment. New Jersey, for instance, has a comprehensive program aimed at getting IV drug users into treatment. (See story on New Jersey’s program targeting IV drug users, p. 63.)

Some say the United States has opened Pandora’s box for too long, and most of the evils caused by the spread of HIV through the drug-using community already have descended on the mainstream population. They cite the increasing numbers of heterosexual women and minorities becoming infected with HIV as evidence of this trend.

AIDS rises rapidly among women due to drugs

For example, the latest statistics from the Atlanta-based Centers for Disease Control and Prevention (CDC) show that the number of women with AIDS more than quadrupled between 1987 and 1997. The 2,900 female cases of AIDS in 1987 climbed to 12,119 cases by 1997. In contrast, the number of men with AIDS rose by only half, from 25,970 to 39,863. Also, unlike the five-year declining AIDS trend evident among men, women’s cases have continued to rise in the past five years.

Moreover, injection drug use accounted for 39% of the AIDS cases among African-American men and 39% of Hispanic men. Drug use also was the cause of AIDS in 49% of African-American women, 44% of Hispanic women, and 45% of white women, according to 1997 data. Among white men with AIDS, only 13% were infected through injection drug use. (See AIDS data charts, inserted in this issue.)

"Heterosexual transmission of HIV is very much tied geographically and otherwise to where there’s a lot of HIV infection among injection drug users," says T. Stephen Jones, MD, a CDC medical epidemiologist and associate director for science in the Division of HIV Prevention.

For example, heterosexual transmission of HIV is a bigger problem in the Northeast than in the Midwest because HIV is more prevalent among injection drug users in the Northeast, Jones says. "Injection drugs are a really efficient way to spread the virus through blood," he adds.

A 1997 CDC update cites several studies showing the benefits of needle-exchange programs, which the CDC recommends as a prevention strategy but is unable to fund due to a ban — in place since 1988 — on federal government money for syringe exchanges. One study of 543 users in six states found that injection drug users were more likely to have used a virus-free needle if they were in a city with a needle-exchange program. (See article on CDC’s suggestions for reducing HIV’s spread through injection drug use, p. 66.)

An Australian physician and AIDS researcher says the United States could have avoided that trend if the country had attacked the spread of HIV among drug users early on.

"We instituted needle exchange in Australia very early," says Cassy Workman, MMBS, associate director of AIDS Research Initiative and director of Ground Zero Medical in Sydney.

"We established needle exchange in a widespread manner, which is now entrenched as part of our drug culture in Australia, so we never had a cross-over [of the AIDS epidemic] into the IV population," she adds. "There’s a critical window period in which you can do something about it, and if you do, you stop the cross-over, and if you don’t, and do what America has done and wait, letting HIV get into the substantial IV population, then it’s problematic."

Queensland gives out 3 million needles a year

For example, the state of Queensland in Australia distributed more than three million syringe kits through its free needle-exchange program last year, costing $500,000 (Australian) and saving the nation $279 million in potential health costs of treating IV drug users for HIV and all other diseases they might otherwise contract through contaminated needles.4

However, Australia did a lot more than just implement needle-exchange programs, Jones says. The nation also increased drug substance abuse programs by tenfold.

"What the CDC is recommending is for people not to put all their HIV prevention in one basket," Jones says. "Make sure syringes are available for people who want to inject drugs, and make sure you have good counseling and testing programs to reach drug users."

For instance, he adds, a state like New Jersey, which has a lot of injection drug users, should have a good medical program to help users reduce risks, and this program also should be available in jails and prisons.

Workman gives this anecdotal example of how different Australia’s HIV demographics are from the United States’: "I have 500 patients who are positive, and among them are four [male] heterosexuals, a dozen IV drug users, and four women."

The state of New Jersey, according to statistics through Dec. 31, 1998, has counted 26,238 people living with HIV, and 36% of these are women. New Jersey also has the highest AIDS rate among women in the United States, which at 31% is more than double the national women’s AIDS rate of 15%.5

One of the latest studies to add weight to the argument in favor of needle-exchange programs comes from the Johns Hopkins University School of Public Health in Baltimore. Johns Hopkins researchers studied crime rates in neighborhoods visited by vans from Baltimore’s needle-exchange program and found that crime rates in those areas remained the same as those in other neighborhoods over a two-year period.6

Baltimore’s program, paid for with $321,000 from state and city funds, has dispensed 2.3 million needles to 8,300 addicts over 4.5 years.6

Johns Hopkins researchers also surveyed high school students, asking them whether seeing a needle-exchange program might lead them to use drugs. The survey found that 11% of the 500 students surveyed said it would, but about 50% said that seeing a family member or friend use drugs would cause them to try drugs.

Despite these studies and more like them, needle-exchange programs continue to have the orphan cousin status shared by contraceptive education programs in schools. While few states go to the extreme that New Jersey has to prevent these programs from existing, most do not provide adequate funding, AIDS advocates charge.

"In places where needle-exchange programs are operating, we are avoiding a significant number of new infections," Zingale says. "If we implemented them more broadly, we could significantly improve the HIV infection rate."

Wisconsin program could be model

Zingale points to a program in Wisconsin as an example of a well-run needle-exchange program. The Wisconsin project is funded entirely through private money and is operated by the nonprofit AIDS Resource Center of Wisconsin in Milwaukee.

The program has exchanged more than one million needles since its inception in February 1994 at 14 sites across the state, says Mike Gifford, deputy executive director.

"Needle exchange is legal in Wisconsin, and that has allowed us to grow this program into a successful program," Gifford says. "But the problem is the federal, state, and local governments refuse to fund needle exchange."

Gifford estimates the program reaches about one in four injection drug users in Milwaukee and one in 10 users statewide. But if the program was fully funded with $200,000 in government funds added to the $300,000 already spent in private money, it could reach nearly all Milwaukee injection drug users and about half of the state’s users, he adds.

Wisconsin’s ban on funding is particularly frustrating, Gifford says, because a recent local survey shows that Milwaukee residents support needle-exchange programs. When the center interviewed 409 Milwaukee adults, asking them whether they favor or oppose using needle-exchange programs to reduce the spread of AIDS in Greater Milwaukee, 57% said they were in favor; 36% were opposed; 7% were undecided.

"The state of Wisconsin has a remarkable track record of providing care and treatment of people with HIV through drug treatment and support care," Gifford says. "But the state has not made a commitment on HIV prevention and has not increased funding in the past 10 years."

Wisconsin does give the AIDS Resource Center money for HIV counseling and testing services for drug users. In fact, the center’s green needle-exchange vans are accompanied by red vans where addicts may seek an HIV test. Also, the center’s $9.2 million budget, which includes $6.2 million from government sources, has funding for drug treatment.

All drug users who use needle-exchange services are given HIV prevention information, condoms, and safe sex kits, and they can receive a referral to a drug treatment center if they so choose, Gifford says. "We like to think of it as a real comprehensive needle-exchange program."

References

1. Kong D. AIDS advocates seek to deregulate syringes. Boston Globe Online, April 7, 1999:7B.

2. Bluthenthal RN, Kral AH, Lorvick J, Watters JK. Impact of law enforcement on syringe exchange programs: A look at Oakland and San Francisco. Med Anthropol 1997; 18:61-83.

3. Bluthenthal RN, Kral AH, Erringer EA, Edlin BR. Use of an illegal syringe exchange and injection-related risk behaviors among street-recruited injection drug users in Oakland, California, 1992 to 1995. J Acquir Immune Defic Syndr Hum Retrovirol 1998; 18:505-511.

4. Qld needle exchange gave out 3 million syringe kits. Australian Broadcasting Corp. News Online, April 15, 1999.

5. Groves B. AIDS rate highest for N.J. women. Bergen Record Online, March 31, 1999.

6. Bor J. Needle program no spur to crime. Baltimore Sun, March 30, 1999:1B.