NEEDLE-EXCHANGE PROGRAMS DO WORK

The recent vote of no confidence by the Presidential Advisory Council on
AIDS regarding the Clinton administration's commitment to stopping the
spread of the disease is the latest controversy in the debate over federal
funding of needle-exchange programs.

Although most Western democracies embraced exchanges as an effective HIV
prevention strategy years ago, no such consen-sus has emerged in the U.S.
Although exchanges have been implemented in more than 100 U.S. cities, most
function on shoestring budgets and on the fringes of the law, largely as a
result of the government's refusal to fund them.

Toward the end of the 1997 legislative session, Congress again extended the
federal ban. Among the arguments presented by opponents, including U.S.
Rep. Dennis Hastert (R-Ill.), were the results of studies that supposedly
demonstrated that needle exchanges are ineffective at reducing the spread
of HIV and may even exacerbate the problem.

In fact, our studies concluded otherwise. Referring to our research,
congressional leaders claimed that drug injectors using needle exchanges
have higher rates of HIV infection than those who don't.

Looking at just the numbers, this might appear to be true. In Vancouver,
the HIV prevalence of program participants was 32 percent, while only 14
percent of individuals who never used the exchange were HIV-infected.

In Montreal, the rate of new HIV infections was 8 percent yearly among
needle-exchange users, compared to 3 percent for non-users.

But these findings do not indicate that needle exchanges exacerbate the
spread of HIV infection, as opponents suggest.

Because the programs in question are located in inner-city neighborhoods,
they cater to drug users with the highest risk for HIV infection. Program
participants engage in the riskiest behaviors, including frequent syringe
sharing and unsafe sex.

By comparison, individuals who are less likely to engage in these
activities purchase syringes legally and use the exchange programs less.
The needle exchanges in Montreal and Vancouver are, in fact, very
effectively targeted: They serve the highest-risk individuals in the
highest-risk settings.

Congressional critics also concluded that the recent increase in HIV
infection among Vancouver's drug users confirmed the ineffectiveness of the
programs. How, critics asked, could this occur unless the Vancouver
program, which exchanges more than 2 million syringes a year, was
ineffective if not harmful?

The answer is not that the programs cause harm but that they are not enough.

So what conclusions should public officials come to in light of our
research findings? Here in Canada, they responded by expanding
needle-exchange programs and adding more outreach services, more drug
treatment and more health-care services. We've begun to learn--as the Dutch
and Swiss did years ago--that only a full continuum of harm reduction,
addictions treatment and medical services can effectively address this
complex public health problem.

Dr. Julie Bruneau Assistant clinical professor Department of psychiatry,
University of Montreal

Dr. Martin T. Schechter Professor of epidemiology University of British Columbia