HTTP/1.0 200 OK Content-Type: text/html
Source: The Lancet - Volume 351, Number 9096 Pubdate: Sat, 10 Jan 1998 Contact: Editorial NEEDLE-EXCHANGE PROGRAMMES IN THE USA: TIME TO ACT NOW One in three of the more than 570 000 AIDS cases reported in the USA since the beginning of the epidemic has been caused, directly or indirectly, by injection drug misuse. Although HIV-infection rates among homosexual men have fallen, rates due to intravenous drug misuse have soared and about half of new HIV infections now can be traced to that source. Those affected are not only the drug misusers infected by contaminated needles but their sexual partners (most of whom have been poor, black, and Hispanic women) and the children of women infected by drug misuse or sexual contact with infected drug misusers. Injection drug misuse is now the leading primary cause of paediatric AIDS. Yet, despite this epidemic, the USA remains one of the few industrialised countries that refuses to provide easy access to sterile syringes. Of the 100 or so US needle-exchange programmes most are small and underfunded, and some are illegal. Most US states still have laws on drug paraphernalia or syringe prescription that make it a crime to give a drug misuser a clean needle. The Clinton Administration now has an opportunity to address this problem. In 1997 the US Congress banned the use of Federal funds for needle-exchange programmes until March 31, 1998, but after that date the legislation allows funding if the Secretary of Health and Human Services determines that exchange programmes are effective in preventing the spread of HIV and do not encourage the use of illegal drugs. But with the deadline fast approaching, the Secretary of Health and Human Services, Donna Shalala, has yet to make an official determination, causing AIDS activists to wonder whether the Administration will refuse to endorse needle-exchange programmes out of fear that the step will open the President to the charge that he is "soft on drugs". If this is true, it would be a remarkably callous decision for the Administration to make. Yet, given the weight of the scientific evidence supporting the efficacy of needle-exchange schemes, it is hard to attribute the reluctance to back such programmes to anything other than political considerations. Study after study has found that needle-exchange programmes reduce the risk of HIV infection. In 1993, a study on needle-exchange programmes by the Centers for Disease Control and Prevention and the University of California, San Francisco, concluded that "the time has arrived for federal, state, and local governments to remove the legal and administrative barriers to increased needle availability and to facilitate the expansion of needle exchange programmes in the US". In 1995, the National Academy of Science's Institute of Medicine, an independent organisation set up by Congress for advice on scientific and technical matters, concluded that needle-exchange programmes were effective and did not encourage illegal drug use. In 1997 an independent consensus panel convened by the National Institutes of Health found that "an impressive body of evidence suggests powerful effects from needle-exchange programmes . . . there is no longer doubt that these programs work". Just last month, the President's Advisory Council on HIV/AIDS issued a report urging the Administration to move immediately to end the ban on Federal funding for needle exchanges. "The debate at this time should no longer be if, but how, needle exchange programs should be established", wrote the council's chairman, R Scott Hitt. And the debate is not academic. A study published in The Lancet last year by Peter Lurie and Ernest Drucker, who used conservative estimates of interventions that give injection drug misusers access to sterile injection equipment, concluded that if the USA had adopted such programmes in 1987, it could have prevented between 4394 and 9666 HIV infections. Moreover, they found that if current policies are not changed, an additional 5150-11 329 preventable HIV infections could occur by the year 2000 in the USA. Who will stop these preventable infections? The Clinton Administration should act now. Delay is costing lives.