Consumer Reports on AIDS and the Needle Exchange

AIDS/NEEDLE EXCHANGE August 1994

According to a study by Consumer Reports, intravenous drug use is one of the most common vehicles for the transmission of the AIDS virus both directly between drug users and indirectly between the users and their sexual partners and children ("Can Clean Needles Slow the AIDS Epidemic?" July 1994, p. 466).

"One-third of the 339,000 AIDS cases reported by late 1993 to the U.S. Centers for Disease Control and Prevention (CDC) have been associated directly or indirectly with intravenous use of cocaine or heroin or both." The rate that AIDS is spreading in the drug user population continues to increase.

The high incidence of AIDS among intravenous drug users can be attributed to the sharing of syringes contaminated with HIV. "Laws restricting possession of injecting equipment under penalty of imprisonment encourage the sharing of needles and syringes." By possessing fewer syringes and sharing the ones they have, addicts reduce the risk of arrest. Also, because access to injection equipment is limited by tough laws, addicts recycle and share the syringes they have.

The increasing spread of HIV among injectors is not the norm among Western nations. Most countries have made injection equipment legally accessible to drug users. In some countries, including Germany, Norway and the Netherlands, syringes can be purchased from vending machines.

In the Netherlands, the Dutch have successfully reduced the spread of AIDS with a program that combines needle exchanges, regular medical examinations for addicts, distribution of methadone and condoms, and referrals to hospitals and drug treatment programs.

Other nations that operate needle exchange programs include Australia, the United Kingdom, Germany and Sweden.

In Edinburgh, Scotland, officials allow physicians to prescribe, free and on demand, oral versions of most drugs used by addicts. Those in the program are encouraged to avoid needles and are required to undergo medical counseling. The object is to reduce risky drug-taking behavior and then attempt to cure addiction.

The program has not only reduced the number of addicts injecting drugs, it has also effectively diminished the spread of HIV via intravenous drug use. After peaking at 120 new cases a year in the mid-80's, the number has steadily declined to eight new cases reported in 1992.

The reported rate of AIDS cases in Britain is 2 per 100,000 which is significantly lower than the U.S. rate of 18.5 per 100,000.

Australia and Canada, which have a punitive approach to illicit drug use, fund needle exchanges and permit pharmacy sales of syringes.

Despite successful programs abroad, the U.S. continues to keep clean needles and syringes out of the hands of users. Ten states including California, Illinois, New Jersey, and New York require prescriptions to purchase injecting equipment.

As the AIDS epidemic intensified, Congress continued to pass legislation restricting access to injecting equipment. In the past 12 years Congress has passed eight bills with provisions that bar or inhibit funding for needle exchanges. While drug treatment programs have received federal funding, it has been limited. The U.S. Food and Drug Administration reports that there are about 100,000 drug users on waiting lists at any given time.

Only recently have large-sized, officially-sanctioned programs been established in inner-city locales where there are both drug addicts and a high incidence of AIDS. In the mid 1980s the city of New Haven, Connecticut was faced with a significant drug-related AIDS epidemic where more than 60 percent of reported AIDS cases could be traced to drug injection. Faced with these numbers, state legislators reacted by funding a pilot needle exchange program exempt from drug-paraphernalia laws. The bill also provided funding for an independent evaluation of the program by professor Edward H. Kaplan of Yale University's Schools of Management and of Medicine.

Kaplan set up a system that randomly tested used needles that had been exchanged for new ones. Of the needles tested in March 1991, 50.3 percent were positive for HIV, compared with a 67.5 percent for a baseline sample of 160 street needles serving as a comparison. Mathematical models used to digest data on contamination rates, the circulation time of needles, and other data, estimated that the program reduced the HIV transmission rates by 33 percent among participants. Two major studies investigating the New Haven trials for the government -- one by the General Accounting Office, the investigative branch of Congress, and one by the University of California for the Center for Disease Control -- found Kaplan's results to be valid. The University of California reported that "overall, [the statistical methodology] is a remarkably efficient and sound method for estimating [needle exchange] effects."

Both studies also concluded that the 33 percent drop in HIV transmissions was an underestimate because of Kaplan's use of a conservative methodology. Other results of the study indicate that there was no evidence that intravenous drug use increased with the introduction of the needle exchange.

Results also suggest that needle exchange programs may encourage participants to seek treatment. One out of six addicts who participated in the exchange later entered treatment programs. The ethnic composition of those who entered treatment differed vastly from those who normally obtain treatment. Of those who left the program to seek treatment, 41 percent were black, 25 percent were Hispanic, and 34 percent where white. By comparison, the population currently in treatment in New Haven was 63 percent white, 27 percent black, and only 9 percent Hispanic.

Advocates of needle exchange programs say that these programs reach people who are normally wary of government programs. They suggest that a well-run needle exchange can serve as an out-reach program that can be a bridge to treatment for those who distrust the government and normally avoid its programs.

In response to the New Haven results, Connecticut has enacted legislation expanding the program to Bridgeport and Hartford. In July 1992, the state decriminalized possession of injection equipment and now drug users can obtain, without a prescription, up to 10 syringes at a time and carry them without penalty. Last fall, the state of Maine also rescinded its prescription laws.

The University of California study recommended the repeal of all prescription laws and bans on purchase and possession of injection equipment.

"Federal funding is critical," says Dr. Don C. Des Jarlais, who is heading an evaluation of New York City's needle-exchange program. "Most state governments are in worse shape than the Federal Government. Without federal funds, we are going to be limited in what we can accomplish in this [AIDS] epidemic."