NEEDLE-EXCHANGE PROGRAMMES IN THE USA: TIME TO ACT NOW

One in three of the more than 570 000 AIDS cases reported in the USA since
the beginning of the epidemic has been caused, directly or indirectly, by
injection drug misuse. Although HIV-infection rates among homosexual men
have fallen, rates due to intravenous drug misuse have soared and about
half of new HIV infections now can be traced to that source. Those affected
are not only the drug misusers infected by contaminated needles but their
sexual partners (most of whom have been poor, black, and Hispanic women)
and the children of women infected by drug misuse or sexual contact with
infected drug misusers. Injection drug misuse is now the leading primary
cause of paediatric AIDS.

Yet, despite this epidemic, the USA remains one of the few industrialised
countries that refuses to provide easy access to sterile syringes. Of the
100 or so US needle-exchange programmes most are small and underfunded, and
some are illegal. Most US states still have laws on drug paraphernalia or
syringe prescription that make it a crime to give a drug misuser a clean
needle.

The Clinton Administration now has an opportunity to address this problem.
In 1997 the US Congress banned the use of Federal funds for needle-exchange
programmes until March 31, 1998, but after that date the legislation allows
funding if the Secretary of Health and Human Services determines that
exchange programmes are effective in preventing the spread of HIV and do
not encourage the use of illegal drugs. But with the deadline fast
approaching, the Secretary of Health and Human Services, Donna Shalala, has
yet to make an official determination, causing AIDS activists to wonder
whether the Administration will refuse to endorse needle-exchange
programmes out of fear that the step will open the President to the charge
that he is "soft on drugs".

If this is true, it would be a remarkably callous decision for the
Administration to make. Yet, given the weight of the scientific evidence
supporting the efficacy of needle-exchange schemes, it is hard to attribute
the reluctance to back such programmes to anything other than political
considerations. Study after study has found that needle-exchange programmes
reduce the risk of HIV infection. In 1993, a study on needle-exchange
programmes by the Centers for Disease Control and Prevention and the
University of California, San Francisco, concluded that "the time has
arrived for federal, state, and local governments to remove the legal and
administrative barriers to increased needle availability and to facilitate
the expansion of needle exchange programmes in the US". In 1995, the
National Academy of Science's Institute of Medicine, an independent
organisation set up by Congress for advice on scientific and technical
matters, concluded that needle-exchange programmes were effective and did
not encourage illegal drug use. In 1997 an independent consensus panel
convened by the National Institutes of Health found that "an impressive
body of evidence suggests powerful effects from needle-exchange programmes
. . . there is no longer doubt that these programs work".

Just last month, the President's Advisory Council on HIV/AIDS issued a
report urging the Administration to move immediately to end the ban on
Federal funding for needle exchanges. "The debate at this time should no
longer be if, but how, needle exchange programs should be established",
wrote the council's chairman, R Scott Hitt. And the debate is not academic.
A study published in The Lancet last year by Peter Lurie and Ernest
Drucker, who used conservative estimates of interventions that give
injection drug misusers access to sterile injection equipment, concluded
that if the USA had adopted such programmes in 1987, it could have
prevented between 4394 and 9666 HIV infections. Moreover, they found that
if current policies are not changed, an additional 5150-11 329 preventable
HIV infections could occur by the year 2000 in the USA. Who will stop these
preventable infections? The Clinton Administration should act now. Delay is
costing lives.