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.
March 24, 2005 Maia Szalavitz is the author of the forthcoming book "Tough Love America: How the 'Troubled Teen' Industry Cons Parents and Hurts Kids" (Riverhead, 2005). She has also written for the New York Times, Elle, Redbook and other publications.
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