Pubdate: Thu, 24 Mar 2005
Source: Salon (US Web)
Copyright: 2005 Salon
Contact:  http://www.salon.com/
Details: http://www.mapinc.org/media/381
Author: Maia Szalavitz
Note: About the writer - 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.
Bookmark: http://www.mapinc.org/hr.htm (Harm Reduction)
Bookmark: http://www.mapinc.org/find?137 (Needle Exchange)
Bookmark: http://www.mapinc.org/find?142 (Safe Injecting Rooms)

DEATH PENALTY FOR I.V. DRUG USERS

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.

March 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.

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.
- ---
MAP posted-by: Richard Lake