Source: New York Times (NY) Contact: http://www.nytimes.com/ Pubdate: Tue, 21 Apr 1998 Author: Cheryl Gay Stolberg BAN ON FEDERAL FUNDS FOR NEEDLE EXCHANGE TO CONTINUE WASHINGTON -- After a bitter internal debate, the Clinton administration on Monday declined to lift a 9-year-old ban on federal funding for programs to distribute clean needles to drug addicts, even as the government's top scientists certified that such programs do not encourage drug abuse and can save lives by reducing the spread of AIDS. The decision, announced by Donna Shalala, the secretary of health and human services, was immediately denounced by public-health experts and advocates for people with AIDS, who had been told in recent days that the ban was about to be lifted. "At best this is hypocrisy," said Dr. Scott Hitt, chairman of the President's Advisory Council on HIV and AIDS. "At worst, it's a lie. And no matter what, its immoral." The decision came after a week of negotiations between Shalala's staff and the White House, according to two administration officials familiar with the talks. Shalala had been pressing to rescind the ban, with some restrictions, and was prepared to defend that decision on Capitol Hill, knowing it was bound to be controversial. But the president's policy advisers feared that Republicans might push through legislation that would strip federal money from organizations that provide free needles, even though the money was used for other purposes. Late Sunday night, as Clinton returned from Chile, he decided to instruct Shalala to announce that federal funds would not be released, despite the scientific evidence that needle-exchange programs help prevent the spread of HIV. "Any Republican could have offered a resolution, and we almost certainly would have lost," said one of the officials, both of whom spoke on condition they not be identified. "We don't have the votes for this in an election year." To further complicate matters, Gen. Barry McCaffrey, the retired Army officer who is the administration's director of national drug policy, has been been fighting to retain the ban. Sandra Thurman, the White House director of national AIDS policy, has argued strenuously that it should be lifted. But McCaffrey argued that such a move would send the wrong message to children -- a position that another official said was "an important consideration" for Clinton. The ban dates back to 1989, when Congress declared that no federal money could be spent to support clean-needle programs until the government could provide scientific evidence that such programs both reduced the spread of HIV, the virus that causes AIDS, and did not encourage drug use. The administration offered that scientific evidence Monday for the first time. With the evidence in hand, the administration was free to begin drafting guidelines for how federal money could be spent for needle-exchange programs. Although Shalala's staff had come up with such guidelines, the president declined to endorse them, officials said. In effect, the decision means that state and local governments, which receive block grants from Washington for AIDS prevention efforts, are still barred from using that money for needle exchange. As the debate has continued, needle-exchange programs have cropped up across the United States. Today there are about 100 programs in 20 states, many operating on a shoestring budget, with private or local funds. In many states, needle exchange remains illegal, but law-enforcement officers look the other way and allow the programs to continue. Public-health experts had been hoping a release of federal funds would have legitimized these programs. (In New York, officials can grant permission for certain needle-exchange programs to operate.) "There are states that for years have hidden behind federal opposition to needle exchange to justify their own inaction," said Dr. Peter Lurie, who in 1993, while teaching at the University of California at San Francisco, published the first government-financed survey of the effectiveness of needle-exchange programs. Monday's decision, he said, means state and local officials will have to "push forward for needle exchange even in the face of the federal government's cowardice." Federal officials have estimated that every day 33 people become infected with the AIDS virus as a result of intravenous drug use, a figure that includes drug abusers themselves, as well as their partners and children. Intravenous drug use is also responsible for most of the increase in AIDS, particularly among the poor and minorities. Dr. David Satcher, the surgeon general, said Monday that 40 percent of all new AIDS infections in the United States are either directly or indirectly attributed to infection by contaminated needles; among women and children, the figure is 75 percent. Lurie, who now works as a research associate at Public Citizen, a Washington advocacy group specializing in public-health issues, estimated Monday that had the government paid for needle-exchange programs, 17,000 lives could have been saved during Clinton's eight years in office. "It is frustrating in the extreme," he said, "to see political considerations take precedence over public-health ones, particularly when a huge cost in human life is predictable." The decision clearly made the government's top scientists uncomfortable. At the press conference announcing it, Shalala was accompanied by a phalanx of them, including Satcher and Dr. Harold Varmus, director of the National Institutes of Health, as well as two institute directors and two officials from the Centers for Disease Control and Prevention in Atlanta. Most shifted uncomfortably in their seats as reporters peppered Shalala with questions about the administration's decision, although none publicly disagreed with it. Shalala declined to discuss the internal debate between her office and the White House -- or even her own recommendations to the president -but said the administration hoped that its pronouncement would spur state and local governments to pay for the programs on their own. In defending the decision not to release federal funds, she said studies show that needle-exchange programs work best when they are carefully designed within local communities. "We are sending the message that the senior scientists of this government, in conjunction with a number of scientists around the world," have concluded that "these needle-exchange programs do in fact work in reducing HIV transmission and do not encourage drug use," she said. Indeed, while critics have complained that the programs promote drug abuse, Varmus said Monday that is clearly not the case. An extensive review of the scientific literature, Varmus said, provided "increasingly strong evidence" that needle-exchange programs can be an effective means of bringing addicts in for treatment. He cited a Baltimore study of nearly 3,000 addicts, which found that the needle-exchange program dramatically reduced the sharing of tainted needles, and that half the participants in the program entered treatment. As expected, Monday's decision prompted a flurry of announcements from Congress. Sen. John Ashcroft, R-Mo., called the administration's position "an intolerable message that it's time to accept drug use as a way of life." But Rep. Nancy Pelosi, D-Calif., complained that the administration had missed an opportunity to save lives. "It defies logic," she said, "to determine a program's efficacy and then not fund the program, especially in the middle of an epidemic. The administration's decision shows a lack of political will in the midst of a public-health emergency."