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Sunday, Jul 12, 2009
The Bush administration is considering imposing a gag rule on U.S.-funded groups that provide clean needles to addicts, despite their huge success in preventing the spread of HIV.
Mar 24, 2005 | Sexual behavior is one of the most difficult human behaviors to alter, and the tragedy of the ongoing global HIV pandemic reflects the enormous complexity of that effort. But one cause of HIV transmission is far easier to remedy than unprotected sex: intravenous drug use with contaminated needles. Unfortunately, the United States is now trying to block the most effective method for fighting needle-transmitted AIDS -- distributing clean needles to addicts -- by pressuring the United Nations Office on Drugs and Crime to suppress data showing the success of needle-exchange programs and by considering an international "gag" rule on AIDS groups that work with needle users and receive American funding.
This would be tragic even if clean-needle programs saved only the lives of drug users, but they can have a far greater impact on the epidemic if instituted quickly enough. Contrary to popular stereotype, it's far easier to get an addict to use a clean needle than it is to get a man to use a condom, so containing HIV among addicts also massively reduces risk of later sexual and mother-to-child transmission. I should know, because as a woman and a former I.V. drug user, I first wrote about this issue 15 years ago for the Village Voice, in an effort to debunk myths that were being used way back then to block needle exchange. My argument at the time was based on some suggestive data, my own experience and common sense, but now there is overwhelming scientific evidence to favor these programs. It breaks my heart that more than ever before, politics is overshadowing science at the cost of so many lives.
While some countries with large HIV epidemics among heterosexuals (most notably Uganda) have reduced its prevalence to 5-10 percent, the numbers infected are stabilizing, not declining. In such heterosexual epidemics, for each person who dies, someone else is newly infected to take his or her place. And in many nations, heterosexual infection rates are still climbing. In the United States there is some evidence of an unfortunate resurgence in HIV infections among gay men. Both heterosexually and homosexually transmitted infections continue to plague minority communities, with HIV rates among African-Americans doubling between 1988-1994 and 1999-2002.
In those cases, the opportunity to fight HIV with clean needles either was lost or never existed. In 1989, Congress, led by Sen. Jesse Helms, banned federal funding for needle exchange in this country, which essentially allowed HIV to get a foothold in our minority communities. But in many other parts of the world, particularly in the former Soviet Union and Asia, HIV is still mainly transmitted by drug use. For example, 75 percent of new infections in Russia and more than half of those in China result directly from I.V. drug use. In these epidemics, in which heterosexual and pediatric cases overwhelmingly begin with transmission from addicts, even a moderately effective intervention with addicts done early can have major effects.
Providing sterile syringes to addicts to fight HIV is not just moderately effective, however. In fact, it may be the best-supported intervention in all of public health. In 2004, the World Health Organization conducted a review of more than 200 studies on the issue, and concluded that "there is compelling evidence that increasing the availability and utilization of sterile injecting equipment by [I.V. drug users] reduces HIV infection substantially ... There is no convincing evidence of any major, unintended negative consequences."
Alex Wodak, director of the Drug and Alcohol Service at St. Vincent's Hospital in Sydney, Australia, and the author of the WHO review, says, "I find it incredible that a major country was prepared to go to war on flimsy evidence that we now know was wrong but is not prepared to save the lives of its own citizens when the evidence is as strong as it gets in public health."
In New York state, for example, which spends $1 million annually on syringe exchange and has also decriminalized pharmacy sales of needles, infection rates among I.V. drug users dropped from 50 percent or higher in the early '90s to 10-20 percent in 2002. At the peak of the HIV epidemic in New York, at least two-thirds of heterosexual and pediatric infections resulted from sex with I.V. drug users.
In 2003, by contrast, there were just five HIV-infected babies born in New York, compared with 321 at the epidemic's peak. While some of this success is due to medications used to prevent transmission from mother to child, infection rates among mothers are also down, having decreased by almost half between 1990 and 1999. In fact, the much publicized "down low" transmission from African-American bisexual men to women has become a larger factor in the epidemic in New York only because drug-related infections (outside prisons) have declined.
