Thousands of Americans will die of AIDS because politicians refuse to believe scientists who say needle exchanges make good sense
"EVERYBODY who shoots drugs knows about the needle exchange," says Norman, a New York heroin addict in his 40s. Three years ago he tested negative for HIV, "thank God". He uses a Harlem shooting gallery--an apartment where people go to inject drugs. Clean syringes are part of the service, so he never shares needles. The gallery operator collects clean needles free of charge at a Harlem needle exchange.
Norman is one of the lucky few. There are only 76 needle exchanges in the US--all set up with private money--serving perhaps 10 per cent of its estimated 1 to 2 million intravenous drug users. The problem is that federal funds cannot be spent on distributing needles until President Bill Clinton's health officials acknowledge that needle exchanges reduce the spread of HIV and do not encourage drug use.
At the same time, state laws prohibit the distribution of needles without a doctor's permission. According to Denise Paone of Beth Israel Medical Center in New York, more intravenous drug users live in New York than in any other city in the world--about 200 000 people--and half of them are HIV-positive. Despite the enormity of the problem, New York State legislators still refuse to repeal the needle laws.
Last month, the calls of activists and researchers who have lobbied the Clinton administration to support needle exchanges were repeated by a panel of eminent scientists brought together by the US National Academy of Sciences. The panel's report concludes that American laws "unwittingly" contribute to the sharing of contaminated needles, and that "needle exchange programmes can be effective in preventing the spread of HIV and do not increase the use of illegal drugs".
The activists and researchers say this evidence has been staring politicians in the face for some time. "They've had this information for two years and they haven't acted on it," says Dave Fratello of the Drug Policy Foundation, a lobbying organisation based in Washington DC. Peter Lurie from the University of California, San Francisco, goes further. "The failure to implement needle exchange programmes is the worst thing that has ever happened in terms of the federal response to AIDS," he says.
In 1993, Lurie wrote a report for the US Centers for Disease Control assessing the public health impact of needle exchange programmes. It reached the same conclusions as the academy report. But Clinton's assistant secretary for health, Philip Lee, says Lurie's report lacked scientific rigour. However, when a copy of Lee's review of the report was leaked to the press last February, it showed that his own staff supported Lurie.
In the two years since his report, says Lurie, HIV has infected 50 000 intravenous drug users, their sexual partners and children. So official delay will cost thousands of lives. "There is now a complete consensus of all the bodies that have looked at this issue," says Lurie.
Paone is also frustrated with politicians' inaction. "They said before we can act on policy we want scientific studies," she says. Her group found that regular participation in exchange programmes cut an individual's risk of HIV infection by half. "So now where's the policy change?"
The academy's report has now added to the evidence in favour of needle exchanges. It drew its conclusions firstly from studies by Edward Kaplan at an exchange in New Haven, Connecticut. These found that over three months the proportion of needles infected with HIV that were returned to an exchange fell from 67 per cent to 42 per cent.
The panel's second main source was a study in Tacoma, Washington, which compared rates of viral infection among intravenous drug users attending a needle exchange with those of people visiting an HIV testing centre and a methadone programme. The incidence of HIV was too low for statistical sampling, so the researchers used hepatitis B and C as surrogates. They found that only 25 per cent of patients who tested positive for hepatitis B had used the exchange, whereas among those who tested negative for hepatitis B, 74 per cent had used the exchange.
"That's awfully close to being a direct demonstration that the needle exchange reduces the incidence of a blood borne viral disease," says Lincoln Moses, professor of statistics at Stanford University, who chaired the academy panel.
The academy's report seems so far to have made little impact in Washington DC. Politicians who have opposed needle exchanges, such as Jesse Helms, the hardline Republican Senator from North Carolina, now refuse to comment. Like many who oppose exchanges, Helms still insists that they encourage drug abuse. Last month, however, members of Helms's staff who follow health affairs did not even know about the academy and Lurie reports.
From the Presidential camp, Lee's response came in a press release that concluded: "We will immediately review the report and its conclusions in consultation with the relevant [Congressional] committees."
While politicians such as Helms oppose needle exchanges on ideological grounds, many people see the Clinton administration's position as purely self-serving. Fratello says the Democrats are afraid that if they endorsed exchange programmes their conservative opponents would say they were "soft on crime", something they cannot allow with the Presidential election due next year. Donald Grove, a needle exchange worker at the Lower East Side Harm Reduction Center in New York, puts it more colourfully. Politicians fear a TV advertisement by their opponents in the next election showing an addict shooting up, with the message: "This is how my opponent spent your tax dollars."
But if supporters of needle exchanges cannot persuade national and state politicians to act, they are having more success on a local level. Their strategy is to win over people living close to the exchanges, the police, the African-American community, and doctors who treat drug addicts.
Local residents have particularly strong reservations. "I live a block away from the needle exchange," says Nancy Sosman, who is trying to shut down the Lower East Side center, which hands out syringes to 9000 registered clients. "We weren't even aware of the needle exchange in the neighbourhood until we found people shooting up in vacant lots . . . in hallways and between cars." But other residents say that these problems existed before the centre opened.
"The point is proper management," says Beny Primm, head of Addiction Research and Treatment, a large drug treatment programme. For the exchanges to work, he says, they must be acceptable to the community and the users must behave. "I think they're trying, though you can't always control this population."
The politically influential criminal justice system will also have to be won over. "Anything that makes it easy to obtain drugs or use drugs will encourage the use of drugs," says Jerome Storch, a former New York State police detective who is now a professor at John Jay College of Criminal Justice, New York. People accept that logic for cigarettes, he argues. "I've talked to people in countries like England who have had programmes," says Storch. "They tell me that narcotics abuse is escalating." But what about studies like Lurie's which conclude that exchanges do not encourage drug use? "Their literature hasn't spread into our literature," he replies.
But Storch's arguments are not borne out by experience in other countries. In the Netherlands, for example, there is an network of exchanges. Ernst Buning of the Amsterdam Municipal Health Service says: "The estimated number of hard drug users has been stable for the last 10 years."
In Britain, as in the rest of Europe, drug abuse is on the increase, says Colin Sheppard, Deputy Chief Constable of the Norfolk Constabulary. But he does not believe that needle exchanges are to blame. There has been a needle exchange in Norfolk for four years, Sheppard says, but "There is no indication that it is a factor which has increased the number of addicts."
In Britain, pharmacies and more than 250 agencies distribute clean needles. "The police cooperate, nobody is hostile," says Gerry Stimson, director of the London-based Centre for Research on Drugs and Health Behaviour. Before 1987, 60 per cent of injecting drug users regularly shared needles, now the figure is between 10 and 15 per cent. "We have kept prevalence of HIV infection pretty low by international standards," says Stimson. "Outside London the infection among injectors is about 1 per cent, and in London about 7 per cent and stable." Stimson says that Britain distributes between 6 and 8 million syringes a year to 100 000 regular injectors. Last year in the US, 8 million syringes were distributed for more than 1 million injectors.
Next on the list of opponents to American needle exchanges is the African-American community. Half of new AIDS patients in the US are black. Many black doctors, clergy and politicians have opposed giving addicts needles or drugs, because they see such strategies as cheap substitutes for comprehensive drug treatment programmes and attempts to eradicate poverty and discrimination. But opposition is softening. Primm, an influential black doctor, accepts needle exchanges as "the lesser of two evils". And another influential black doctor, Lawrence Brown Jr of Harlem Hospital, signed the academy report.
Finally, doctors who treat addicts in traditional ways still need to be convinced about exchange programmes. "As a compassionate physician, who has had patients die of AIDS, and friends die of AIDS, the last thing I'd want to do is stop something that might prevent the spread of this dreadful disease," says Herbert Kleber, a psychiatrist at Columbia University and a member of the academy's panel. On the other hand, he says, he does not want to encourage intravenous drug use. Kleber says he still dislikes needle exchanges, but, "you put aside your feelings and say, 'What does the science show?" In the end, he too signed the report.
The number of needles distributed free to American drug users is rising, but only slowly. "It's extraordinary if you come from outside the US," says Warwick Anderson, an Australian historian of science at Melbourne University who has studied American public health policy. "The US has served as a control group for the rest of the world. The results are obvious and this de facto trial should be halted." *