DEATH PENALTY FOR I.V. DRUG USERS

The Bush Administration Is Considering Imposing a Gag Rule on U.S.-Funded
Groups That Provide Clean Needles to Addicts, Despite Their Huge Success in
Preventing the Spread of HIV.

March 24, 2005 - Sexual behavior is one of the most difficult human
behaviors to alter, and the tragedy of the ongoing global HIV pandemic
reflects the enormous complexity of that effort.

But one cause of HIV transmission is far easier to remedy than unprotected
sex: intravenous drug use with contaminated needles.

Unfortunately, the United States is now trying to block the most effective
method for fighting needle-transmitted AIDS -- distributing clean needles
to addicts -- by pressuring the United Nations Office on Drugs and Crime to
suppress data showing the success of needle-exchange programs and by
considering an international "gag" rule on AIDS groups that work with
needle users and receive American funding. This would be tragic even if
clean-needle programs saved only the lives of drug users, but they can have
a far greater impact on the epidemic if instituted quickly enough.

Contrary to popular stereotype, it's far easier to get an addict to use a
clean needle than it is to get a man to use a condom, so containing HIV
among addicts also massively reduces risk of later sexual and
mother-to-child transmission. I should know, because as a woman and a
former I.V. drug user, I first wrote about this issue 15 years ago for the
Village Voice, in an effort to debunk myths that were being used way back
then to block needle exchange.

My argument at the time was based on some suggestive data, my own
experience and common sense, but now there is overwhelming scientific
evidence to favor these programs.

It breaks my heart that more than ever before, politics is overshadowing
science at the cost of so many lives.

While some countries with large HIV epidemics among heterosexuals (most
notably Uganda) have reduced its prevalence to 5-10 percent, the numbers
infected are stabilizing, not declining.

In such heterosexual epidemics, for each person who dies, someone else is
newly infected to take his or her place. And in many nations, heterosexual
infection rates are still climbing. In the United States there is some
evidence of an unfortunate resurgence in HIV infections among gay men. Both
heterosexually and homosexually transmitted infections continue to plague
minority communities, with HIV rates among African-Americans doubling
between 1988-1994 and 1999-2002. In those cases, the opportunity to fight
HIV with clean needles either was lost or never existed.

In 1989, Congress, led by Sen. Jesse Helms, banned federal funding for
needle exchange in this country, which essentially allowed HIV to get a
foothold in our minority communities. But in many other parts of the world,
particularly in the former Soviet Union and Asia, HIV is still mainly
transmitted by drug use. For example, 75 percent of new infections in
Russia and more than half of those in China result directly from I.V. drug
use. In these epidemics, in which heterosexual and pediatric cases
overwhelmingly begin with transmission from addicts, even a moderately
effective intervention with addicts done early can have major effects.
Providing sterile syringes to addicts to fight HIV is not just moderately
effective, however.

In fact, it may be the best-supported intervention in all of public health.

In 2004, the World Health Organization conducted a review of more than 200
studies on the issue, and concluded that "there is compelling evidence that
increasing the availability and utilization of sterile injecting equipment
by [I.V. drug users] reduces HIV infection substantially ... There is no
convincing evidence of any major, unintended negative consequences."

Alex Wodak, director of the Drug and Alcohol Service at St. Vincent's
Hospital in Sydney, Australia, and the author of the WHO review, says, "I
find it incredible that a major country was prepared to go to war on flimsy
evidence that we now know was wrong but is not prepared to save the lives
of its own citizens when the evidence is as strong as it gets in public
health." In New York state, for example, which spends $1 million annually
on syringe exchange and has also decriminalized pharmacy sales of needles,
infection rates among I.V. drug users dropped from 50 percent or higher in
the early '90s to 10-20 percent in 2002. At the peak of the HIV epidemic in
New York, at least two-thirds of heterosexual and pediatric infections
resulted from sex with I.V. drug users.

In 2003, by contrast, there were just five HIV-infected babies born in New
York, compared with 321 at the epidemic's peak. While some of this success
is due to medications used to prevent transmission from mother to child,
infection rates among mothers are also down, having decreased by almost
half between 1990 and 1999. In fact, the much publicized "down low"
transmission from African-American bisexual men to women has become a
larger factor in the epidemic in New York only because drug-related
infections (outside prisons) have declined.

Incredibly, conservatives in Congress, led by Rep. Mark Souder, R-Ind., are
considering a needle-exchange version of the abortion gag rule, which
prevents U.S.-funded international aid organizations from mentioning
abortion to pregnant women.

This new move could stop American-funded groups from even telling
intravenous drug users that they should use clean needles, let alone where
to get them -- at a stage in the epidemic when clean needles would be
maximally effective in preventing indirect, as well as direct, transmission
in many countries.

The United States is already alone among developed countries in refusing to
fund syringe-swap programs here or abroad.

And rather than recognize the success of states like New York that fund
their own programs, the president wants to export its failed and disastrous
policy overseas.

In yet another example of its attempts to suppress science that does not
support its ideology, the Bush administration recently threatened the U.N.
Office on Drugs and Crime with loss of funding if it did not remove from
its literature and Web site supportive information about needle exchange
and other "harm reduction" programs for addicts that do not demand
complete, immediate abstinence from drugs.

The United States is the major financial supporter of UNODC.

After a meeting with a U.S. State Department official last November, UNODC
director Antonio Maria Costa promised to "review" its statements on the
subject, saying the organization would now "neither endorse needle exchange
as a solution for drug abuse nor support public statements advocating such
practices."

Only months earlier, Costa had made the opposite pronouncement: "The
HIV/AIDS epidemic among injecting drug users can be stopped -- and even
reversed -- if drug users are provided, at an early stage and on a large
scale, with comprehensive services such as outreach, provision of clean
injecting equipment and a variety of treatment modalities, including
substitution treatment [like methadone]."

He added that fewer than 5 percent of the world's I.V. drug users have
access to such help, and he went on to criticize countries that incarcerate
large numbers of addicts because this increases HIV rates.

That last bit likely was a sensitive point, since America has the largest
documented prison population in the world.

It's enough to make a former I.V. drug user like me think about shooting up
again. At a meeting of the 48th Session of the Commission on Narcotic Drugs
in Vienna, Austria, in early March, Costa did make at least a modest
attempt to stand up to American pressure, saying that needle exchanges are
"appropriate as long as they are part of a comprehensive strategy to battle
the overall drug problem."

Nonetheless, American drug czar John Walters reiterated U.S. opposition to
needle exchange in his speech to the group.

Japan was our only public ally -- with all of Europe, Latin America (led by
Brazil), and even Iran favoring needle exchange.

While China did not explicitly speak up for needle exchange, with 70
percent of its HIV infections linked to I.V. drug use, it is experimenting
with such programs and argued passionately for other harm-reduction
measures like methadone maintenance.

Though support of needle exchange by human rights groups, who raised the
issue before the meeting started, may have blunted the impact of the U.S.
attack, the American grandstanding did manage to kill a resolution that
would have stated UNODC's support for needle access and human rights for
addicts. Public health experts worry that the Bush administration's stance
will undermine still shaky political support in countries that need to
expand needle-exchange programs if they are to successfully ward off HIV. A
gag rule on needle exchange would force AIDS groups to drop their programs
or lose funds, seriously undermining access to clean needles for millions
around the world.

Even if the administration supports a death penalty by AIDS for I.V. drug
users, you'd think the innocent lives of their children or unwitting
spouses might count for something.

Or perhaps, being fiscal conservatives, opponents might worry about the
thousandfold greater expense of HIV/AIDS treatment, compared with pennies
for sterile needles.

Although the Clinton administration declined to overturn the 1989 Helms
amendment banning federal funding for needle-exchange programs, at least it
was honest that it was making a political, rather than a scientific or
fiscal, decision, as science writer Chris Mooney noted in the American
Prospect. But the Bush administration is trying to deny the science, too,
which means the harm of its stance won't be limited to the current debate.

One administration official even suggested that the Washington Post contact
several AIDS researchers who'd done studies on needle exchange, claiming
that their work supported its contentions that such programs are
ineffective and dangerous.

When the Post called the researchers, however, they denied the
administration's charge, stating that their data demonstrated the opposite.
It's worth looking more closely at one of these studies, which is in the
small minority of the hundreds now published to even suggest any kind of
negative result.

In 1997 in the journal AIDS, Stephanie Strathdee and her colleagues
reported that despite having North America's largest needle-exchange
program, instituted in the late '80s, Vancouver's rate of HIV infections
had increased dramatically during the early to mid-'90s. Worse, needle
exchange users were more likely than other addicts to be HIV positive. But
as Strathdee and others have noted repeatedly, this does not mean that
needle exchange caused participants to become infected.

In fact, during the period of the study, Vancouver began to be flooded with
cocaine.

Injectors, who had previously used primarily heroin, started shooting coke
as well. Since cocaine is injected far more frequently than heroin because
of its shorter-lasting high, the number of daily injections is often
greater by a factor of 10 or more, increasing the odds of being exposed to
HIV. Syringe exchanges tend to attract only the poorest, highest-risk users
in Canada because needles can be legally purchased at pharmacies there,
which might have confounded the data, but the program also had a variety of
limitations that contributed to its initial failure.

As Vancouver improved its program, however, and even opened safe-injection
rooms, infection levels among I.V. drug users stabilized and then began to
drop, according to Canadian government statistics. New HIV infections among
I.V. drug users fell by more than 70 percent between 1995 and 2000, though
part of this drop may represent saturation of the I.V. user population. (A
study on the injection rooms published this week in the Lancet found that
addicts who used the facility were 70 percent less likely to share needles
than those who didn't visit it.) A 1997 study that compared cities around
the world with and without needle-exchange programs found that those with
programs had an average annual decrease in the prevalence of HIV of 5.8
percent, while those without programs had an increase of 5.7 percent.

No study has ever found that the existence of needle exchange motivates
addicts to keep taking drugs -- in fact, most find that syringe-exchange
users are more likely than other addicts to seek treatment.

It's no surprise, therefore, that every major public health body that has
looked at the issue -- from the World Health Organization to the American
Medical Association to the Institute on Medicine to the International
Federation of Red Cross and Red Crescent Societies -- has strongly endorsed
making sterile injection equipment available to addicts.

The policies that the Bush administration endorses as alternatives to
needle exchange -- attempts to reduce the supply of illegal drugs, for
example -- have not been shown to affect drug-use rates, let alone reduce
HIV. Despite U.S. drug-control budgets that have increased almost
exponentially since the 1980s, the purity of cocaine and heroin has at
least quadrupled, the prices of both drugs have dropped by at least half,
and neither addicts nor teenagers report difficulty purchasing most drugs.

It profoundly saddens me that I must still cite studies to defend needle
exchange nearly 20 years after activists first began to fight for it. It
also disturbs me that needle-exchange programs rarely get the credit they
deserve. A Jan. 30 New York Times story on the virtual end of HIV infection
in newborns in the United States didn't even mention the role of clean
needle programs in this accomplishment.

And the articles about bisexual black men infecting heterosexual female sex
partners have largely neglected the critical role that I.V. drug use in
minority communities has played in the epidemic.

One can make a good case, in fact, that there wouldn't even have been such
an epidemic in black and Latino heterosexual populations if the United
States had provided clean needles earlier and hadn't insisted on locking up
(without access to condoms or needles) so many minority drug users.

The U.K. dodged this bullet: Under the conservative government of Margaret
Thatcher, it rapidly implemented clean-needle measures in response to the
outbreak of AIDS, starting in 1986. HIV prevalence has rarely reached more
than 1 percent among intravenous drug users there, compared with over 50
percent at the epidemic's peak in New York. Heterosexual AIDS in the U.K.,
consequently, is almost entirely limited to immigrants who were infected in
Africa. Says Neil Hunt, a director of the U.K. Harm Reduction Alliance and
an honorary research fellow at Imperial College London, "It's a largely
unheralded, astonishing success."

So why is it so hard for U.S. policymakers to accept that needle provision
works? A large part of it is surely prejudice related to drug-war
propaganda -- for instance, the belief that addicts are out of control and
thus unwilling to protect themselves even when protection is offered.

And some of it may even reflect a desire to simply let addicts die. But I
also think some people believe that addicts like to share needles, the same
way many people prefer to have sex without condoms, and that changing such
behavior would take too much effort.

And for those who suggest that needle exchange encourages drug use and
keeps addicts using longer, I would argue that it is not the presence or
absence of needles that determines one's desire to get high. For many, drug
use stems from deep unhappiness and an inability to handle distress, not
from an effort to obtain extra pleasure in their lives.

Compassion is the appropriate response to such suffering, and for many
addicts, the first place they ever experience such grace is at a
needle-exchange program.

It's the one place that accepts them just as they are.

Contrary to critics' claims, needle-exchange programs offer a message of
hope, not a "counsel of despair," as U.S. officials recently claimed.

They do not tell addicts that they are forever doomed to addiction and
might as well kill themselves. Instead, they say, "We want you to live; we
believe you are valuable." And that message is often the spark that starts
recovery. It's far from all that is needed, but without it, many are too
demoralized to try. I can't abide the idea that my country is still
fighting against HIV prevention. But what's most infuriating is that such
action is not only unnecessary but also inhumane.

It's throwing a symbolic sop to the religious right (which isn't even
especially focused on the issue) at the demonstrable cost of human lives.