Subject: NEEDLE EXCHANGE: Contents, Introduction, Executive Summary
From: [email-masked]
Date: Mon, 15 Nov 1993 11:59:11 GMT
Newsgroups: sci.med.aids

[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.

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