Source: The Wall Street Journal
Pubdate: Wed, 22 April 1998
Mail: 200 Liberty Street, New York, NY 10281
Author: David Murray
Note: Mr. Murray is director of research for the Statistical Assessment
Service, a nonprofit group in Washington.


The Clinton administration on Monday endorsed the practice of giving clean
needles to drug addicts in order to prevent transmission of the AIDS virus.
"A meticulous scientific review has now proven that needle-exchange
programs can reduce the transmission of HIV and save lives without loosing
ground on the battle against illegal drugs," Secretary of Health and Human
Services announced.

The administration is not unanimous, however; the drug czar, Gen. Barry
McCaffrey, who opposes needle exchange, was out of the country Monday.
Who's right? As recently as a month ago, HHS had resisted needle-exchange
programs. "We have not yet concluded that needle exchange programs do not
encourage drug use." spokeswoman Melissa Skolfield told the Washington Post
March 17. By Monday the department had reached that conclusion, though the
scientific evidence that needle exchanges don't encourage drug use is as
weak today as it was a month ago.

In fact, the evidence is far from clear that needle-exchange programs
protect against HIV infection. Most studies have had serious methodological
limitations, and new studies in Montreal and Vancouver have revealed a
troubling pattern: In general, the better the study design, the less
convincing the evidence that clean needle giveaways protect against HIV.

The Montreal study, the most sophisticated yet, found that those who
attended needle-exchange programs had a substantially higher risk of HIV
infection than intravenous drug addicts who did not. In a much-discussed
New York Times op-ed article two weeks ago, Julie Bruneau and Martin T.
Schechter, authors of the Montreal and Vancouver studies respectively,
explained the higher risk this way: "Because these programs are in
inner-city neighborhoods they server users who are at greatest risk of
infection. Those who didn't accept free needles .... were less likely to
engage in the riskiest activities."

Dr. Bruneau is apparently rejecting her own research. For her study had
statistical controls to correct for precisely this factor. In the American
Journal of Epidemiology, Dr. Bruneau wrote: "These findings cannot be
explained solely on the basis  of the concentration around needle-exchange
programs of a higher risk intravenous drug user population with a greater
baseline HIV prevalence."

Even more troubling, Dr. Bruneau reported that addicts who were initially
HIV-negative were more likely to become positive after participation in the
needle exchange. Dr. Bruneau speculated that needle-exchange programs "may
have facilitated formation of new sharing networks, with the programs
becoming the gathering places for isolated [addicts]."

Janet Lapey of Drug Watch International says needle-exchange programs often
become "buyer's clubs" for addicts, attracting not only scattered users but
opportunistic dealers. Not everyone agrees. Dr. Schechter says that when he
asked his study's heroin users, they reported meeting elsewhere. But a
delegation from Gen. McCaffrey's office returned from Vancouver in early
April with some startling news: Although more than 2.5 million clean
needles were given out last yet, the death rate from illegal drugs has
skyrocketed. Vancouver is literally swamped with drugs," the delegation
concluded. "With an at-risk population, without access to drug treatment,
needle exchange appears to be nothing more than a facilitator for drug use."

The problem for science is that no study has used the most effective method
for settling such issues - a randomized control trial. Moreover,
needle-exchange programs are usually embedded in complex programs of
outreach, education and treatment, which themselves affect HIV risk. A 1996
study showed that through outreach and education alone, HIV incidence in
Chicago-area intravenous drug users was reduced 71% in the absence of a
needle exchange.

Peter Lurie of the University of Michigan argues that "to defer public
health action on the grounds [awaiting better research] is to surrender the
science of epidemiology to thoughtless empiricism and to endanger the lives
of thousands of intravenous drug users." But Dr. Lurie's reasoning appears
circular. Only someone already convinced that needle-exchange programs are
effective at preventing HIV can claim that addicts are jeopardized by
further testing.

And drug use carries risks besides HIV infection. A recent article in the
Journal of the American Medical Association warned that the arrival of a
new drug from Mexico called "black-tar heroin," cut with dirt and shoe
polish, is spreading "wound botulism." This potent toxin leads to paralysis
and agonizing death, even when injected by a clean needle.

Thus, dispensing needles to the addicted could produce a public health
tragedy if this policy does indeed place than at greater risk for HIV or
enhances the legitimacy of hard drug use. Simply put, the administration's
case is unproven.