When “Just Say No” Isn’t Enough - Stopping HIV Infections Among Drug-Using Populations
June 20, 2006 - Every day, far from the capital city's power brokers and historic monuments, Ron Daniels ventures deep into a Washington, D.C., rarely seen by tourists. In the city's red-light districts, alleys and drug dens, he and the team at Prevention Works, a D.C.-based nonprofit, dispense clean needles and syringes, a grass-roots attempt to stem new HIV infections in the city with the nation's highest AIDS rate.
On June 13, at a Congressional briefing on HIV prevention among drug-using populations hosted by Representative Raúl Grijalva (D-AZ.) and co-sponsored by amfAR, Mr. Daniels and a panel of public health experts came together to send a clear message: Lifesaving public health measures, such as syringe exchange programs, must be made available for individuals who are unable to quit using drugs.
"We cannot continue to treat drug users like they don't matter and like they're not human beings," Daniels said. "We cannot keep pushing them to the borders of our society and expect to get different results."
Dr. Monica Ruiz, deputy director of public policy at amfAR, moderated the discussion and presented an overview of HIV infection among injection drug users in the United States and harm reduction interventions to prevent new infections among this group.
"Repeatedly, scientific evidence has supported the effectiveness of syringe exchange programs as part of a comprehensive HIV prevention strategy, as well as an effective public health intervention that reduces transmission of HIV and does not encourage the illegal use of drugs," Dr. Ruiz said. "amfAR strongly supports the implementation of harm reduction programs as an effective public health strategy."
Injection drug use accounts for close to 25 percent of all AIDS cases diagnosed in the United States, but the law prohibits federal funding of syringe exchange programs. Public health providers must rely on state or local funds to finance these programs. Washington, D.C., where 1 out of every 20 residents is living with HIV, is the only city in the nation barred by federal law from using its own local tax dollars to support syringe exchange programs. Private donations, including those from amfAR and its supporters, keep organizations such as Prevention Works alive.
"This is an issue that can be devastating to families, communities, and individuals," said Rep. Grijalva. "To close off a means to reach all populations affected by HIV/AIDS is a mistaken and shortsighted policy. It is unscientific and runs counter to the mission of public health for the entire community."
Other than receiving a blood transfusion from an HIV-positive donor, sharing needles and syringes is the most efficient way of transmitting HIV, explained Dr. Don Des Jarlais of the Beth Israel Medical Center and an amfAR grantee. But while sharing injection equipment is a very efficient way of transmitting HIV, there is solid evidence that you can prevent epidemics of HIV among drug users, Des Jarlais said.
"Arguably HIV prevention for drug users works better than any other type of prevention we have, with the exception of antivirals for mother-to-child transmission," Des Jarlais said. "Prevention of HIV for drug injectors really does work."
When New York City went from exchanging about 250,000 syringes per year before 1992 to about 3 million per year ever since, the rate of new infections was reduced by more than 75 percent, Des Jarlais explained. If the rate of new infections had remained the same, the city would have had an estimated 50,000 additional HIV infections among drug users alone. Taking into account that drug users have sexual partners who do not use injection drugs, you are talking about approximately 10,000 additional infections that were prevented when New York City expanded its program, he said.
Widespread access to sterile injection equipment and community involvement are critical when trying to prevent HIV epidemics among drug users, Des Jarlais said.
"You have to work actively with drug users, provide education, provide trusted communication, and then you see large-scale behavior change," he explained.
This was a lesson the city of Baltimore learned in the mid 1990s when substance abuse was escalating dangerously.
"HIV was one of the consequences of the drug epidemic in Baltimore," said Dr. Joshua Sharfstein, the city's health commissioner. "In the early 1990s, HIV was rising faster than any other cause of death in the city. It was already the number one cause of death among African-American men and number two among African-American women."
The city took action, initially investing its own money to improve and expand Baltimore's drug treatment programs, including outreach, counseling and testing, and syringe exchange.
More than 700 million syringes have been exchanged since 1994—about 6,700 a week. Syringe exchange sites also provide condoms, HIV counseling, referrals to medical care, drug overdose prevention, screening and treatment for other sexually transmitted diseases, and care for wounds and abscesses, Sharfstein said.
New HIV diagnoses in Baltimore city have declined by 25 percent since 1998 and new HIV diagnoses due to injection drug use have dropped 20 percent since the implementation of syringe exchange, Sharfstein said.
Panelist Dr. Nabila El-Bassel, of the Columbia University School of Social Work, urged that the needs of women also be taken into account when dealing with HIV infections among drug-using populations. Women in the United States now comprise 30 percent of people living with HIV/AIDS; 20 percent of those women were infected through injection drug use.
HIV prevention interventions for women encourage them to use condoms and practice mutual monogamy. But this is simply not a realistic expectation for women who lack the power, due to a number of socio-economic factors, to demand that a partner be faithful or that he use a condom.
"There is an urgent need for gender-based HIV prevention interventions for drug-using women, El-Bassel said. "These prevention models must consider the connection of all of the risk factors affecting women: violence, post traumatic stress disorder, child abuse, and others."
It seemed fitting, then, that Daniels ended his remarks with a letter of gratitude from the mother of a D.C. woman currently in recovery for heroin addiction.
"All indications are that she has the skills and self-knowledge and motivation to stay drug free in the long term," she wrote. "Thanks to you she is also healthy. Even in the fall of her deepest addiction, she remained aware of the danger to herself and others in sharing needles and used the needle exchange program religiously. I cannot thank you enough. It would be a tragedy to have my daughter back, only to lose her to HIV and AIDS."