Pubdate: Sun, 5 Jul 1998
Source: Boston Globe (MA) 


GENEVA -- A collection of 17 studies unveiled here last week shows beyond
doubt, researchers say, that the AIDS epidemic among New York City's 150,000
injecting drug users has been brought under control.

The findings, which were almost lost amid the thousands of reports at the
12th World AIDS Conference that adjourned Friday, provide the first
convincing evidence that programs to reduce sharing of hypodermic syringes
among drug users can reverse the course of the epidemic within this
highest-risk population.

Earlier research has repeatedly shown such programs reduce risky behavior,
but this is the first to link these prevention efforts to the bottom line: a
broad and lasting impact on new AIDS virus infections.

``The great news that it is possible to control this epidemic'' among drug
users ``is one of the best things we've heard in more than 15 years,'' said
Don C. DesJarlais, perhaps the world's leading authority on this facet of AIDS.

DesJarlais conducted the studies with colleagues at New York's Beth Israel
Medical Center, where he heads the Chemical Dependency Unit, and the New
York City Health Department.

Since about half of the nation's estimated 40,000 new AIDS-virus infections
each year occur among injecting drug users or their sex partners, the New
York findings carry major implications for reining in the overall epidemic.

The New York studies also appear likely to revive a stalemated debate about
the urgency of funding needle exchange programs to reduce transmission of
human immunodeficiency virus, or HIV, among drug users.

The Clinton administration acknowledged in late April that providing sterile
needles and syringes to drug users reduces the spread of AIDS while not
increasing illicit drug use. But President Clinton decided not to fund
needle exchange efforts after a fierce debate among his top advisers.

``The new data make even more unconscionable the Clinton administration's
refusal to fund needle exchange programs,'' said Peter Lurie of the
Washington-based Health Research Group. ``Responsibility for the unnecessary
infections that will ensue lies with Bill Clinton himself.''

Dr. Helene Gayle, who heads AIDS programs at the US Centers for Disease
Control and Prevention, last week acknowledged that politics rather than
public health data are obstructing federal funding for needle exchange.

``We all know science should be the basis of our policy,'' Gayle said. ``But
it's not a perfect world. People in policy roles juggle a lot of things.
Needle exchange is a complex issue in a complex world.''

In the Clinton administration, federal funding of needle exchanges has been
opposed by General Barry McCaffrey, the director of the White House Office
on Drug Policy, who is concerned about the message such programs send to
drug users. That sentiment is shared by Congress. On April 29 the House of
Representatives voted 287-140 against funding needle exchanges.

Other than transfusion of blood containing HIV -- no longer a problem in
developed countries -- sharing contaminated needles is the most efficient
way to spread the deadly virus. Needle-sharing among illicit drug users also
spreads hepatitis B and C, two other dangerous viral infections.

Sharp reduction in needle-sharing in New York, researchers say, is a major
factor in bringing the spread of HIV there under control. That is something
many thought would never happen in New York, which has the world's biggest
and longest-established drug-associated AIDS epidemic.

New York City has tallied more cases of AIDS among injecting drug users,
their sex partners, and their children -- up to 80,000, using the current
definition of the disease -- than any European country.

Public health officials say an epidemic has been controlled when new cases
do not exceed one or two cases for every 100 ``person-years at risk,'' or
100 people at risk of infection for one year. At that rate, an epidemic is
no longer growing.

Five new studies show that HIV infections among injecting drug users in New
York are occurring at a rate of 1.4 cases per 100 person-years. In the early
1980s, when HIV infections were spreading explosively among the city's
illicit drug users, the rate was 13 per 100 person-years.

Another dozen studies, involving more than 11,000 New York City drug users,
show that the percentage who are infected at a given time, a measure known
as seroprevalence, has dropped from 44 percent in the 1980s to 28 percent

The sharp decline in HIV transmission and prevalence among New York drug
users has not yet shown up in the statistics for the number of AIDS cases,
DesJarlais said, because there is a 10-year lag time between HIV infection
and AIDS diagnosis. Recent triple-drug treatments to suppress HIV, which are
getting to a sizable fraction of addicts and recovering addicts, may
increase that lag.

DesJarlais, who has been tracking HIV in drug users for years, said he first
began to suspect the falloff in infections within the past year. But the
``eureka moment'' did not occur until he pulled together data to present in

The findings represent a broad spectrum of drug users from drug treatment
programs, clinics for sexually transmitted diseases, street outreach
efforts, and needle exchange programs. All showed very similar drops in both
the proportion of HIV-infected clients and new cases of HIV infection.

DesJarlais said the reductions appear due, in about equal measure, to two
factors. First, thousands of drug users infected in the 1980s have died, so
they are not infecting others in exponential fashion.

More important, from a public health standpoint, is the undeniable effect of
needle exchange programs. Beginning in 1992, New York State began funding
such efforts, and now spends about $1 million on them in New York City.

About two-thirds of the city's 150,000 injecting drug users are
participating in needle exchange programs, DesJarlais said. An earlier study
found a 70 percent drop in new HIV infections among drug users in needle
exchange programs compared with others not obtaining clean needles.

``We've seen a dramatic change in risky behavior along with the drop in
prevalence and incidence'' of HIV among drug users, the researcher said. The
proportion of users' injections that involve shared syringes has dropped in
recent years from about half to around 2 percent.

But DesJarlais cautioned that risky behavior could increase again if
prevention efforts are not maintained -- or if the price of heroin
increases, which would drive many addicts to switch from sniffing the drug
to injecting it.

Nationally, there are about 120 needle exchange programs funded by states,
cities and private groups. Massachusetts has state-funded programs in
Boston, Cambridge, Provincetown, and Northampton.

The landmark importance of the New York studies was not lost on those at the
conference who are struggling with rapidly growing AIDS epidemics among drug
users in their countries.

``This is very important information,'' said Alec Katchaturian of the
Russian Federation, where injecting drug use is behind explosive growth in
HIV infections.

``You're in the situation we were about 1979,'' DesJarlais told Katchaturian.

- ---
Checked-by: Melodi Cornett