Source: New York Times 
Author: Christopher S. Wren 
Pubdate: Mon, 23 Mar 1998


The debate over the propriety of handing out sterile syringes to people who
inject illegal drugs, to reduce the spread of AIDS, has reached the White
House, where President Clinton's two main policy advisers on the issue have
staked out opposing positions.

Their disagreement makes prospects for government financing of
needle-exchange programs more unlikely when a ban on such spending, imposed
by Congress in 1992, expires at the end of March.

One adviser, Sandra Thurman, the White House director of national AIDS
policy, advocates spending on the programs as a way of saving lives by
reducing the incidence of AIDS contracted from shared needles. But at a
spirited meeting on Tuesday, the other adviser, Barry McCaffrey, the
retired Army general who is the administration's director of national drug
policy, ferociously opposed any government subsidy.

In a subsequent letter to Ms. Thurman, he reiterated his belief that buying
clean needles for drug users would send the wrong message to young
Americans who are being told that illegal drug use is wrong. The money, he
said, would be better used expanding drug treatment programs.

"As public servants, citizens and parents we owe our children an
unambiguous 'no use' message," McCaffrey wrote. "And if they should become
ensnared by drugs, we must offer them a way out, not a means to continue
addictive behavior." His letter was leaked to some members of Congress. A
copy was provided to The New York Times by someone opposed to needle
exchanges. McCaffrey's fervent opposition to paying for needle exchanges,
and the esteem with which he is regarded on Capitol Hill, will probably
undercut whatever support exists for exchange programs. Many members of
Congress already oppose the concept or do not want to look as if they are
soft on drug use in a congressional election year.

In a joint statement released on Saturday, Ms. Thurman and McCaffrey sought
to play down their increasingly public differences over needle exchange.
They said they agreed on other issues, like the need to make drug treatment
programs more widely available.

They said they would leave it to Donna Shalala, the secretary of health and
human services, to settle the needle exchange issue. Ms. Shalala, who has
sided with McCaffrey on other drug policy questions, has yet to decide
whether the needle exchange programs deserve government money. Congress
asked her to determine whether the programs prevent the spread of HIV, the
virus that causes AIDS, and do not encourage the use of illegal drugs. In
February 1997, a report released by the National Institutes of Health said
"there is no longer any doubt that these programs work" to prevent the
spread of HIV and said that "needle exchange programs should be implemented
at once." Ms. Shalala said that she wanted to study the matter. In his
letter to Ms. Thurman, McCaffrey pointed out that the government does not
ban needle exchanges, and that approximately 100 communities have set up
programs. The public health consequences of sharing dirty needles is not
insignificant. Approximately 280,000 to 300,000 Americans suffer from AIDS
and as many as 600,000 others are infected with HIV, according to Ms.
Thurman's office. The Centers for Disease Control and Prevention estimate
that one-third to one-half of new HIV cases involve people who injected
drugs or had sex with people who did. The cost of caring for an adult with
AIDS can exceed $100,000.

"You have to understand that every day, 33 Americans become infected as a
result of drugs," Ms. Thurman said on Saturday in a telephone interview.
While not all cases of HIV transmission can be prevented, she said, "I
think we have a moral obligation to stop as many as we can." Public
tolerance for needle programs has increased. A Harris poll reported in
October that 71 percent of the Americans surveyed supported needle
exchanges. The poll was commissioned by the Lindesmith Center, a group that
advocates needle exchange programs.

Other groups that have endorsed the programs, in principle, include the
American Bar Association, the American Medical Association, the American
Public Health Association and the U.S. Conference of Mayors. In August,
George Soros, the international financier and philanthropist, donated $1
million to finance needle-exchange programs in the San Francisco area. Both
supporters and critics of the programs have cited studies to support their
arguments. Dr. Peter Beilenson, the city health commissioner in Baltimore,
reported to a House subcommittee in September that his city's
needle-exchange program had reduced significantly the sharing of used
needles and provided a point of access to medical treatment for hard-core
addicts. Ms. Thurman agreed that needle-exchange programs have become
conduits to health care. "This is an opportunity often for people to pull
their lives together," she said. "If using a needle-exchange program
facilitates it in some way, we need to look at it very seriously."

But critics have cited another study, which reports that intravenous drug
users who joined Montreal's needle-exchange program became infected with
HIV at a higher rate than nonparticipants. The study was published last
year in the American Journal of Epidemiology.

If the ban on government money is lifted, McCaffrey wrote, "There is the
troubling question of how such a message would be received by our young
people." Ms. Thurman replied. "I know he has concerns about that and I do
too, but the overwhelming evidence is that people coming into
needle-exchange programs are older."

"Nobody's going to stick a needle in their arm because someone hands them a
needle," she said.