Newsgroups: sci.med.aids From: mary.elizabeth@aegis.hivnet.org Subject: NEEDLE EXCHANGE: Contents, Introduction, Executive Summary Organization: AEGIS Network Date: Mon, 15 Nov 1993 11:59:11 GMT [brought to you via National AIDS Clearinghouse, AEGIS, and sci.med.aids] Thanks to The Kaiser Family Foundation and especially, Matt James and Jayne Garrison, this is the first installment of their monograph entitled, "Dimensions of HIV Prevention - Needle Exchange". A paper version of this book can be obtained for free by calling (415) 854-9400. The electronic version downloadable here will be absent the attractive formating available in the paperbook book but the content will be complete. The entire book will be posted in digestable bits, a chapter at a time so as to not flood the forum or my life. The Kaiser Family Foundation seems to want to disseminate this information as widely as possible. Some ideas you might want to consider are faxing this information to folks interested in more SEP information, using it for a newsletter, wallpapering your walls, etc. Please leave any comments or questions about this stuff to me in E-Mail. My username is XHIVCTS on the National AIDS Clearinghouse BBS. If you want to thank anyone for this wonderful opportunity thank the NAC for making this BBS freely available and user friendly. Dan Bigg Dimensions of HIV Prevention Needle Exchange Edited by Jeff Stryker, Center for AIDS Prevention Studies University of California-San Francisco Mark Smith, M.D., M.B.A. A Publication from The Kaiser Forums Sponsored by The Henry J. Kaiser Family Foundation CONTENTS INTRODUCTION vii Drew Altman, Ph.D., President, Henry J. Kaiser Family Foundation, Menlo Park, Calif. EXECUTIVE SUMMARY ix Jeff Stryker, Center for AIDS Prevention Studies, University of California-San Francisco Mark Smith, M.D., M.B.A., Executive Vice President, Henry J. Kaiser Family Foundation, Menlo Park, Calif. A BRIEF HISTORY 1 Sandra D. Lane, R.N., Ph.D., M.P.H., Assistant Professor, Department of Anthropology, Case Western Reserve University, Cleveland, Ohio, and other members of the Needle Exchange Program Evaluation Project, Institute for Health Policy Studies, University of California-San Francisco A REVIEW OF PROGRAMS IN NORTH AMERICA 11 Peter Lurie, M.D., M.P.H., Health Policy Fellow; Donna Chen, M.P.H., Research Assistant, Institute for Health Policy Studies, University of California-San Francisco, and other members of the Needle Exchange Program Evaluation Project LAW AND POLICY 35 Lawrence Gostin, J.D., Executive Director, American Society of Law, Medicine, and Ethics, Boston, Mass. Visiting Professor, Georgetown University Law Center, Washington, D.C. RESEARCH 63 Donald C. Des Jarlais, Ph.D., Director of Research, Chemical Dependency Institute, Beth Israel Medical Center, New York, N.Y. Samuel R. Friedman, Ph.D., Principal Investigator, National Development and Research Institutes Inc., New York, N.Y. THE POLITICS 77 David L. Kirp, LL.B., Professor, Graduate School of Public Policy, University of California-Berkeley Ronald Bayer, Ph.D., Professor, Columbia University School of Public Health, New York, N.Y. UNDERSTANDING THE ATTITUDES OF BLACK AMERICANS 99 Stephen B. Thomas, Ph.D., Associate Professor, Director; Sandra Crouse Quinn, Ph.D., Research Associate, Minority Health Research Laboratory, University of Maryland, College Park THE MEDIA PERSPECTIVE 129 Laurie Garrett, Harvard Journalism Fellow for Advanced Studies in Public Health, Harvard School of Public Health, Boston, Mass. APPENDICES I. FORUM PARTICIPANTS 143 II. FORUM AGENDA 153 III. active needle exchange programs in north america 159 IV. bibliography 165 Introduction Public health officials have understood the tragic link between injection drug use and the human immunodeficiency virus (HIV) since the early 1980s. By now, a third of all cases of acquired immune deficiency syndrome (AIDS) result from shared needles and syringes. But drafting sound public policy and changing behavior to sever that link has proved far more difficult than understanding HIV's deadly routes. Indeed, no issue in HIV prevention is more controversial or emotional than the issue of needle exchange. Should doctors and health officials promote the availability of free, sterile needles to illegal drug users to slow the spread of HIV? Is it possible that needle exchange programs designed to fight HIV might encourage the use of drugs? Will health officials and law enforcement officials undercut each other's efforts? To explore these issues objectively and encourage all sides to air their views together, in December 1992 the Kaiser Family Foundation convened a two-day Kaiser Forum on needle exchange. Papers summarizing the key presentations at that forum are compiled in this book. The papers examine existing needle exchange programs--how they were implemented, funded, and evaluated. They discuss legal issues that must be addressed before such a program can begin. And they frankly discuss the concern in ethnic minority neighborhoods that health officials and society are more concerned about AIDS than about violence and drugs that destroy the lives of so many poor Americans. Allowing free access to sterile needles and syringes is not an easy thing for our society to accept. Nor are its ramifications well understood. Still, we must grapple with this topic; the HIV epidemic demands that we consider many policies regarded as unthinkable two decades ago. By convening the Kaiser Forum and publishing this book, the Kaiser Family Foundation does not endorse or oppose needle exchange. But we do encourage open debate based on solid information. Only then can society make a rational decision. Drew E. Altman President Kaiser Family Foundation EXECUTIVE SUMMARY The question of whether society should ease access to sterile needles and syringes for the injection of illicit drugs has been one of the most enduring controversies in the prevention of the acquired immune deficiency syndrome (AIDS). Since the mid-1980s, public health experts have recommended that needle-and- syringe exchange and distribution be implemented and studied as one facet of preventing transmission of the human immunodeficiency virus (HIV). In 1986, the Institute of Medicine recommended: "It is time to begin experimenting with public policies to encourage the use of sterile needles and syringes by removing legal and administrative barriers to their possession and use."[1] A number of policy groups--including, most recently, the National Commission on AIDS--have echoed these recommendations more forcefully.[2] Despite such recommendations, needle exchange programs have been instituted in fits and starts, with much Sturm und Drang. Although there has been a recent proliferation of programs, both legal and "underground," their growth has been halting, impeded by opposition in minority and church communities, governmen-tal skepticism, bureaucratic intransigence, and the NIMBY ("not in my backyard") phenomenon. This book addresses some particular questions concerning the implementation, funding, evaluation, and legal context of needle exchange programs. These are the issues in the foreground--the trees, if you will. But what about the forest? Why has the needle exchange controversy garnered so much attention and controversy, often at the expense of broader issues in drug policy? According to Grund and colleagues, the syringe and needle have become "fetishized": "Perhaps because of the involvement of biomedical researchers unfamiliar with the worlds of drug users, almost exclusive attention has been focused on the physical objects responsible for transmitting the virus--needles and syringes--often obscuring the fabric of social relationships in which these objects are used."[3] There are striking parallels between the focus on needles and syringes in the drug field and the impact the HIV epidemic has had on sex research. John Gagnon has noted that for researchers and funding sources, "what is interesting about sex is what the disease makes interesting."[4] Carol Vance has written, "The reliance on survey instruments and easily quantified data in biomedically based research increases the tendency to count acts rather than to explore meaning."[5] There are other possible explanations for the focus on needles and syringes. Clearly, needle-and-syringe use and sharing are directly linked to HIV transmission. Needle sharing is a dramatic aspect of drug use upon which it is easy to focus. Finally, implementing needle exchange may be less daunting or expensive than confronting broader issues of crime, HIV prevention, and drug abuse. Though needle exchange is only one aspect of the HIV and drug problem, it is a window that offers a perspective of broader public health questions. How does society view injection drug use and drug users? What is the proper balance between criminal justice and public health approaches to problems involving drug use and the spread of AIDS? Drug use of some type has always been a part of American life, and tolerance of drug use and drug users has waxed and waned.[6] Drug use is an addictive behavior that occurs mostly in private settings. It can be very difficult to change. Drug users tend to be on the margins of society, little valued, and much feared. The first decade of the AIDS epidemic was a time of "neo-Prohibitionist" drug policy, exemplified by the "just say no" slogan that found expression in aggressive criminal justice approaches to drug use and drug users. At the vanguard of the needle exchange controversy have been zealous activists, including many former drug users and individuals whose lives have been touched by losses to AIDS. Acting in a tradition of public- health civil disobedience and treading the path trod by predecessors concerned with reproductive freedom and access to contraceptives, needle exchange proponents have been willing to risk arrest to help clients gain access to sterile drug-injection equipment. Multiple Epidemics As Friedland and Klein have written, "It would be difficult to design a system better suited [than injection drug use] to promote the transmission of a blood-borne infection."[7] Contaminated injection equipment can be the culprit in the spread of a variety of blood-borne and sexually transmitted diseases, such as hepatitis and syphilis, which are transmissible via needle sharing, and others, such as bacterial endocarditis and cellulitis, which threaten users themselves.[8,9] HIV is only the latest concern in this regard. More than half a century ago, a winter outbreak of malaria was reported in Chicago, Ill., New York, N.Y., St. Paul, Minn., and San Francisco, Calif., despite the absence of the probable vector--mosquitoes. Officials discovered that drug users infected with malaria parasites had spread the disease by sharing contaminated needles. The next summer, the general population also suffered when mosquitoes bit malaria-infected drug users and transmitted the infection.[10] HIV poses a risk beyond drug injectors. Sharing contaminated injection equipment threatens not only the sharers but also their sexual partners, their offspring, and successive ranks of sexual partners. The consensus is that the greatest danger for the self-sustaining spread of HIV infection outside of the groups currently at high risk comes from the reservoir of infection among injection drug users.[11] Needle-Sharing Dynamics There are numerous reasons why users inject drugs that can be smoked or snorted. Injection is more economical, as it requires less of the drug to achieve the same high. More immediate relief from withdrawal symptoms may be gained by injection.[12] Drug injection can be an adaptation to a situation in which the only drugs available are of inconsistent, low, or unknown purity. Previously, heroin was the drug of choice among injectors; today, a variety of other drugs--such as cocaine and amphetamines--are injected, sometimes in combination with heroin. Injection is also a social phenomenon. Virtually all injectors are initiated into the practice by friends, lovers, or dealers who not only supply the drug but also provide equipment and guidance for its use.[13] Studies have shown that new users average ten to twenty injections before they obtain their own equipment.[14] The social bond forged during initiation into drug injection is an important aspect of needle sharing. Refusing to share with someone with whom the user has shared previously may signal mistrust or suspicion. If groups of needle sharers were insular, they might afford protection against the spread of infection. Unfortunately, there is enough sharing among the groups to promote the spread of infection. The overwhelming majority of injection drug users share equipment at some point. Needle sharing does not appear to be confined to drug users of a particular background, class, or personality type,[15] and needle sharing habits may vary among regions of the country. There has been some disagreement about whether sharing occurs more frequently among black and Hispanic users. Injection practices--for example, injecting into the muscle or under the skin rather than intravenously--vary considerably among subcultures of drug users and among users of different drugs. Successive use of the same set of injection equipment by multiple users may not be viewed as sharing, because those who share the equipment may never even meet each other. Users who do not share injection equipment may nevertheless risk contamination by mixing and sharing drugs in a process known as "frontloading."[16] Various phenomena encourage the use and sharing of contaminated injection equipment. In New York City and other large cities, "shooting galleries" provide a haven for drug use. Drug users may be reluctant to carry injection equipment when they are near shooting galleries or on their way from purchasing drugs, as this is when they are most likely to be arrested.[12] Drug dealers may rent needles and syringes for their customers' use. In such cases, one set may be reused scores of times, with only a perfunctory rinse between injections. The cost and scarcity of sterile needles and syringes also are reasons for sharing. The Impact of HIV Disease on Injection Practices Patterns of injection drug use have changed with the growing appreciation of the risk of HIV transmission. Several studies dating back to 1984 have reported considerable awareness of HIV transmission among injection drug users. Users have shown considerable willingness to change their behavior, going to great lengths to gain access to sterile injection equipment. Unfortunately, a number of precautionary measures that addicts reportedly use are likely to be quite ineffective. Heroin users have been known to heat the cooker between shots to kill the AIDS virus, but the extent of this practice and its effectiveness are not known. Flushing with tap water and rinsing may unclog the needle and syringe, but they don't decontaminate. A study of needle and syringes retrieved from South Florida shooting galleries revealed that in 20% of those with visible blood, HIV antibodies were present. More disturbingly, even in those with no visible traces of blood, 5.1% were HIV-positive.[17] A number of commonly available decontaminants have proved effective in killing HIV in vitro. Injection drug users are counseled to use household bleach to clean their works--to rinse the needle and syringe twice with full-strength bleach and twice with water to avoid injecting any traces of bleach. Outreach programs in many cities give drug users small, refillable vials of bleach and instructions on how to sterilize injection equipment, often supplemented by graphic illustrations or cartoons.[18] Using bleach to disinfect injection equipment is a feature of many of the AIDS demonstration research projects sponsored by the National Institute on Drug Abuse.[19] The degree to which bleach use under street conditions protects against infection is a matter of concern and study.[20] Drawing the Battle Lines: The Claims for Needle Exchange The primary controversy in the promotion of safer injection practices is this: Would promoting access to sterile needles and syringes interrupt the spread of AIDS, condone or encourage injection drug use, or perhaps do both? Should doctors and public health officials participate in--and should the government support--a program that appears to sanction injection drug use by promoting safer drug injection? Proponents of easier access believe that limitations on the distribution of sterile needles and syringes are cruelly misguided. They argue that several benefits are likely to result from easier access, namely: * The use of sterile injection equipment would reduce the risk of the spread of HIV, hepatitis, and other diseases, even among users who fail to reduce the frequency of injection. * Needle and syringe exchange programs would be one way to bring injection drug users into drug treatment programs. * Needle exchange would be a bridge to general clinical care, including early intervention services for HIV infection. * Contact with a needle exchange program would be an opportunity to impart advice about adopting safer sexual practices. Needle and syringe exchanges are not the only possible means of distribution. Pharmacies in some countries sell needles and syringes to drug users, in some cases giving a discount for equipment returned. They have the advantage of being open for long hours and, at least in urban areas, enjoy relative anonymity. A needle exchange program in Tacoma, Wash., operates out of a clinic pharmacy. In at least thirty-eight states, over-the-counter sale of needles and syringes is permitted by law, but only a portion of pharmacists are willing to sell to customers who they believe are drug dependent. There aren't any guidelines or professional codes to inform pharmacists, whose discretion is highly variable.[21] In St. Louis, Mo., which doesn't have a statute or ordinance prohibiting the sale of needles and syringes, two male graduate students--one black and one white--sought to purchase needles and syringes in local pharmacies. Fourteen of thirty-three drugstores refused to sell or they offered for sale a minimum number of needles and syringes so large as to be impractical. Stores refused to sell to the African American student more often than to the white student.[22] Opponents of needle exchange, including some law enforcement, drug treatment, and church officials, have argued that easing access will undermine the "war on drugs," both symbolically and practically, by giving rise to new ranks of injection drug users.[23] A program that is only partially effective in preventing the sharing of contaminated injection equipment could have the net effect of increasing AIDS deaths if it also boosts the number of injection drug users. Furthermore, opponents say, making sterile needles and syringes more readily available would not eliminate sharing. And they take issue with research findings that support needle exchange.[24] They cite evidence that attributes needle sharing to a variety of cultural and psychological factors, in addition to convenience and economy. Proponents of needle exchange also have encountered vigorous opposition from some black and Hispanic community and church leaders.[25] In the wake of inner-city drug use follows crime and hopelessness for an entire generation. Despite widespread drug use among all sectors of society, drug use among the urban poor is more likely to be linked to violence. Drug dealing is more likely to occur in plain view, with the specter of involvement of the police and criminal justice system. Residents of neighborhoods blighted by drugs have expressed opposition to needle exchange programs because the programs appear to be at odds with the fight against drugs. The programs also have been viewed as a genocidal conspiracy. Harlon Dalton has eloquently voiced these concerns: For us [African Americans], drug abuse is a curse far worse than you can imagine. Addicts prey on our neighborhoods, sell drugs to our children, steal our possessions, and rob us of hope. We despise them. We despise them because they hurt us and because they are us. They are a constant reminder of how close we all are to the edge. And "they" are "us" literally as well as figuratively; they are our sons and daughters, our sisters and brothers. Can we possibly cast out the demons without casting out our own kin?[26] Dalton explains the black community's skeptical view of proposals by the liberal public-health and HIV-prevention establishment to combat the spread of HIV through bleach and needle exchange programs. Addressing white America, he asks: Why can't we choose which of the many problems facing us to tackle first? Suppose we think that crack is more of a menace than AIDS. Are you willing to help us take on that one? Why do you want us to take all the risks? You say that making drug use safer (by giving away bleach or distributing clean needles) won't make it more attractive to our children or our neighbor's children? But what if you are wrong? What if as a result, we have even more addicts to contend with? Will you be around to help us then?[26] These are some of the concerns on both sides of the issue. The debates have had an impact not only on whether needle exchanges get under way but also on how they operate. In some cases, needle exchanges have flourished, winning over community opposition. In other cases, attempts to fashion programs to overcome political opposition have yielded half-hearted and ineffectual efforts. More than thirty needle exchange programs are at some stage of implementation or operation in the United States. Although many function under the aegis of local public health authorities, in almost all cases, concerned activists--often former drug users or members of the AIDS activist group, AIDS Coalition to Unleash Power (ACT UP)--initiated them. Programs vary widely in method of operation. One key variable is locale. Problems of convenience and neighborhood opposition have stymied many fixed-site efforts. In response, some needle exchange programs operate out of distinctively marked mobile vans, which even make "house calls" in some rural areas. Some needle exchanges are located near gymnasiums to target steroid injectors.* In other cases, exchanges operate on street corners at designated hours at the same time each week, with a schedule that becomes known on the street or is available by phone. Obviously, the degree of cooperation of public-health and legal authorities helps determine how "above ground" such programs are. *One may overlook the fact that there are those who inject drugs other than psychoactive drugs. In addition to steroids, injection of vitamins is prevalent in some communities.[27] The way needles and syringes are distributed also varies. The requirement that used equipment be traded in for new equipment is very common and, in some locales, has minimized the danger of discarded equipment. The sanitation department in Tacoma filed an affidavit in 1990 to this effect in a lawsuit involving the needle exchange program there.[28] Programs also vary in how far they go in identifying, coding, and tracking needles to measure the extent of sharing and the degree of hepatitis and HIV infection. For example, researchers at Yale have developed an elaborate system that involves polymerase chain reaction testing of HIV residues in syringes returned to the New Haven exchange.[29] Finally, programs vary in the aggressiveness of outreach and in how they seek and identify clients. Programs may take pains to preserve client anonymity in ways that make it difficult for researchers to follow clients over time. One open question is how strong a link should be forged between needle and syringe distribution, and HIV counseling and drug treatment. Some programs have claimed success in part because of their nonjudgmental nature and an unwillingness to exhort clients to abstain from drug use. Still, if linking the provision of sterile injection equipment to counseling and education is possible without driving clients away, there are compelling reasons to do so. Studies show that even when injection drug users have been willing to modify their drug-use practices, they have been somewhat reluctant to change their sexual practices.[30] Advice about safer sex can be offered along with precautions regarding drug use; many programs that dispense bleach or needles and syringes distribute condoms at the same time. Many exchange programs also are forging more explicit links to substance abuse treatment and clinical care. The program in Tacoma is the largest local source of referral for drug treatment; in addition, it provides on-site screening for tuberculosis. Some programs also discuss and provide referrals for a broader range of social services, such as housing, employment, and family support. The law poses a variety of obstacles to the implementation and operation of needle exchanges. The nonmedical use of narcotic drugs has been illegal in the United States since passage of the Harrison Act in 1914. Courts have recognized the broad powers of states to proscribe or regulate the sale, distribution, and use of addictive drugs.* Courts also have upheld the police powers of the state to regulate drug-use paraphernalia, even when the materials in question, such as needles and syringes, have legitimate medical uses. * However, the U.S. Supreme Court held that to punish the mere "status" of drug addiction is a violation of the U.S. Constitution's prohibition against cruel and unusual punishment. Robinson v. State of California, 370 U.S. 660 (1962). Along with broad paraphernalia laws, eleven states have enacted statutes that specifically address needles and syringes. These laws generally make it a crime to sell a needle and syringe without a prescription, to prescribe a needle and syringe for a known addict, or to possess injection equipment for the purpose of illicit drug use. Such statutes are on the books in some of the states with the largest AIDS caseloads, including New York, New Jersey, and California. Under these regulatory schemes, wholesale druggists and surgical suppliers must keep accurate records of needle and syringe sales. In many jurisdictions, HIV-transmission risks have led policy makers and prosecutors not to enforce paraphernalia and prescription laws. However, prosecutorial discretion is an imperfect solution at best. Federal and state paraphernalia laws may overlap. For prosecutorial discretion to be effective, a consistent message must emanate from the entire law enforcement hierarchy. From the prosecutor to the cop on the beat, the public-health and criminal-justice systems must operate in concert.[31] More than twenty needle exchange volunteers have been arrested for violating laws against possession and distribution of drug paraphernalia. Many defendants have used their trials as a way to educate judges and the public about the rationale for needle exchange programs. Needle exchange defendants have been acquitted in all but two instances. In virtually all of the trials, defendants have invoked the defense of necessity. The particulars of this defense vary from jurisdiction to jurisdiction, but there are certain common elements. Defendants must prove that although they knew they were breaking the law, they acted under a reasonable belief that they did so to avoid a greater and imminent harm, and that there were no other legal means to do so.* The precedent-setting value of these cases is limited, however, because of their trial-level status. Such cases also are expensive and time consuming, as they involve expert testimony from drug-policy, HIV- prevention, and epidemiology experts. Broader legislative reform may be a preferable, long-term strategy. The Hawaii and Connecticut legislatures have authorized pilot needle exchange programs, requiring evaluative studies. Similar legislation in California was vetoed by Gov. Pete Wilson. Until the past couple of years, there weren't enough data from the American experience to change minds on either side of this contentious debate.** The Institute of Medicine added the following caveat to its recommendations favoring greater needle and syringe availability: The actual effects of increasing the legal availability of sterile needles and syringes in the U.S. are unknown. Almost no data have been collected on the relationship between the legal availability of sterile needles and the levels of drug use prior to the AIDS epidemic, and it is doubtful that data collected prior to the awareness of AIDS would be applicable today.[1] Whether policy decisions regarding this issue are to be driven by research findings or by policy makers who are impervious to data and who refuse to doff ideological blinders will become apparent as more data emerge from U.S. programs. *Decision and Order, New York v. Bordowitz, Criminal Ct. of City and County of New York, No. 90N028423 at 25 (June 24, 1991). ** Needle exchange and distribution programs have sprouted and flourished in many foreign locations. The failure in the United States to reckon with the data from these programs is attributable, at least in part, to jingoism. Nevertheless, international comparisons can be tricky. The patterns of drug use differ over time and among countries, as does the response of the health care and criminal justice systems in each country. The demographic and sociocultural profile of drug users also varies. Exactly what threshold of evidence is necessary before one can claim that needle exchange "works?" HIV prevention programs tend to be held to a more rigorous standard of proof than other health-promotion efforts or disease prevention, or other areas of clinical medicine or biomedical research.[32] Needle exchange is held to an even higher standard than other HIV-prevention programs. Admittedly, evidence showing that needle exchange programs reduce the incidence of new HIV seroconversions among drug injectors will be difficult to come by. Barriers to proving such an impact include the incubation period of the virus, the difficulties following drug users over time, the political sensitivities inherent in HIV antibody testing, the expense, and methodological challenges in fashioning control groups of nonclients. Studies involving self-reported behavioral changes and comparisons of AIDS risk behaviors among clients and nonclients are answering shorter-term questions. Model-based studies are yielding other answers. Research Findings A number of studies have not substantiated the concern that distributing clean needles might somehow encourage individuals who have not previously injected drugs to do so. In San Francisco[33] and Amsterdam, the Netherlands,[34] where the characteristics of entire local populations of drug users (clients and nonclients) have been monitored for a number of years, there hasn't been any substantial increase in the number of new, younger drug injectors. There have been some concerns that needle exchanges could deter drug injectors from seeking treatment. This effect is difficult to study in the United States, where treatment on demand is the exception rather than the rule. Still, where there are ambitious needle exchange programs, as in New Haven,[35] the local syringe exchange has become the leading source of referral to drug treatment. Proving the beneficial effects of needle availability turns out to be more difficult than disproving some of the potential harmful effects. However, there has been consistent improvement in self-reported risk reduction after implementation of needle exchanges.[34,36] In a number of cases, it is difficult to isolate the effects of the needle exchange, as needle distribution often is only one aspect of broader HIV-prevention strategies involving multiple interventions. These self-reported behavioral changes have been bolstered by studies of biological variables. HIV seroconversion rates have fallen after the implementation of needle exchanges.[34] Other studies have shown reductions in the transmission of another blood-borne virus: hepatitis B.[37,38] In the United States, much attention has focused on studies conducted in New Haven. Researchers at Yale University modeled HIV transmission before and after the implementation of that city's needle and syringe exchange. Their model estimated that the effect of the exchange was to reduce the incidence of new HIV infections by one-third. Although the study was based on a model, it relied on data from an elaborate tracking and HIV serum-testing system, and thus avoided the biases of self-reported data.[39] Stigma and Symbolism The inattention to the plight of injection drug users, regardless of whether the issue is needle exchange or the general lack of resources for drug treatment and methadone maintenance, can be attributed to the stigma attached to this group. Drug addiction research has failed to capture the attention of the biomedical and behavioral sciences communities--and funding sources--to a degree commensurate with its prominence as a social problem, although the HIV epidemic is changing this. Given the limitations of the current therapeutic armamentarium, much more needs to be known about which drug treatments work. Approaches to treatment have failed to keep pace with trends in "polydrug" use. The lack of a biological treatment for cocaine addiction--one that parallels the use of methadone in heroin addicts--is a particularly worrisome gap. One aspect of the unresponsiveness to the plight of injection drug users concerns their political powerlessness. It may not be appropriate to speak of this group--one that maintains a flourishing, multibillion-dollar trade in illicit substances--as lacking "organization." Yet injection drug users do not have the trappings of a recognized interest or voting bloc, and their political power is feeble at best.[40] Excluding clinicians, public health officials, and treatment center staff, there have been few spokespersons for the interests of injection drug users. As attorney Ruth Harlow noted, "One impact of needle exchange is to show that society cares about these folks."[41] This certainly is one message conveyed by the volunteers and the activists who are willing to be arrested in efforts to reduce the overall risk of HIV infection. The debate about strategies for preventing the spread of HIV infection through contaminated injection equipment is only part of a larger controversy about controlling illicit drug use. Drug policies reflect anxieties that society has at any given time. Attitudes toward the use of narcotics have been tinged with xenophobia and racism, according to drug-policy historians. The lack of obvious solutions on either the supply side or the demand side of the drug problem is readily apparent from the sheer variety of antidrug proposals. Crosscurrents result from the conflicts between two views: that drug use is either an illness to be treated or a crime to be punished. The Harm Principle The needle exchange controversy poses the question of whether we should ever be willing to risk some evil to avoid another harm. The parallels in other public health debates are striking. Consider the controversy about whether providing contraceptives promotes sexual intercourse among the young or outside the bounds of marriage. The U.S. Supreme Court rejected the argument that a ban on the sale of contraceptives to unmarried couples was an appropriate way to deter sexual activity: The reason for this unanimous rejection was stated in Eisenstandt v. Baird: "It would be plainly unreasonable to assume that [the State] has prescribed pregnancy and the birth of an unwanted child [or the physical and psychological dangers of abortion] as punishment for fornication" 405 U.S. at 448. We remain reluctant to attribute any such scheme of values to the State.* The analogy is not perfect, as most would argue that a reasonable societal goal is to eliminate all injection drug use, whereas the likely goal regarding sexual behavior is to delay intercourse until marriage or at least until an age of responsibility. Yet just as sexual intercourse among the young will not cease if access to contraceptives is withheld, injection drug use will continue with or without access to sterile needles and syringes. * Carey v. Population Services International, 431 U.S. 678, 695, 52 L.Ed.2d 675, 97 S.Ct. 2010 (1977). ------------ Excluding clinicians, public health officials, and treatment center staff, there have been few spokespersons for the interests of injection drug users. ------------ Jeff Stryker Center for AIDS Prevention Studies, University of California-San Francisco Mark Smith, M.D., M.B.A. Executive Vice President Henry J. Kaiser Family Foundation, Menlo Park, Calif. References 1. Institute of Medicine, National Academy of Sciences. Confronting AIDS: Directions for Public Health, Health Care, and Research. Washington, D.C.: National Academy Press; 1986:112. 2. National Commission on AIDS. The twin epidemics of substance abuse and HIV. Washington, D.C.:National Commission on AIDS, 1991. 3. 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Harvard Civil Rights-Civil Liberties Law Review 1991;26:113- 184. 11. Turner, C.F., Miller, H.G., Moses, L.E., eds. AIDS: Sexual Behavior and Intravenous Drug Use. Washington, D.C.: National Academy Press, 1989. 12. Connors, M., Galea, R.P. Anthropological investigations of the meaning and practices of needle use and sharing among intravenous drug users (IVDUs). Presentation at the Fourth International AIDS Conference, Stockholm, Sweden, June 12-16, 1988. 13. Des Jarlais, D., Friedman, S., Strug, D. "AIDS and Needle Sharing Within the IV-Drug Use Subculture." In Social Dimensions of AIDS: Methods and Theory, edited by D.A. Feldman, T.M. Johnson. New York, N.Y.:Praeger, 1986. 14. Murphy, S. Intravenous drug use and AIDS: Notes on the social economy of needle sharing. Contemporary Drug Problems 1987;14:373- 396. 15. Dolan, M., Black, H., DeFord, H., et al. Characteristics of drug abusers that discriminate needle-sharers. Public Health Reports 1987;102:395-398. 16. 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