A Publication from The Kaiser Forums; Sponsored by The Henry J. Kaiser Family Foundation
Edited by: Jeff Stryker, Center for AIDS Prevention Studies University of California-San Francisco; Mark Smith, M.D., M.B.A. -

Studies involving self-reported behavioral changes and comparisons of AIDS risk behaviors among clients and nonclients are answering shorter-term questions. Model-based studies are yielding other answers.

Research Findings

A number of studies have not substantiated the concern that distributing clean needles might somehow encourage individuals who have not previously injected drugs to do so. In San Francisco33 and Amsterdam, the Netherlands,34 where the characteristics of entire local populations of drug users (clients and nonclients) have been monitored for a number of years, there hasn't been any substantial increase in the number of new, younger drug injectors.

There have been some concerns that needle exchanges could deter drug injectors from seeking treatment. This effect is difficult to study in the United States, where treatment on demand is the exception rather than the rule. Still, where there are ambitious needle exchange programs, as in New Haven,35 the local syringe exchange has become the leading source of referral to drug treatment.

Proving the beneficial effects of needle availability turns out to be more difficult than disproving some of the potential harmful effects. However, there has been consistent improvement in self-reported risk reduction after implementation of needle exchanges.34,36 In a number of cases, it is difficult to isolate the effects of the needle exchange, as needle distribution often is only one aspect of broader HIV-prevention strategies involving multiple interventions.

These self-reported behavioral changes have been bolstered by studies of biological variables. HIV seroconversion rates have fallen after the implementation of needle exchanges.34 Other studies have shown reductions in the transmission of another blood-borne virus: hepatitis B.37,38

In the United States, much attention has focused on studies conducted in New Haven. Researchers at Yale University modeled HIV transmission before and after the implementation of that city's needle and syringe exchange. Their model estimated that the effect of the exchange was to reduce the incidence of new HIV infections by one-third. Although the study was based on a model, it relied on data from an elaborate tracking and HIV serum-testing system, and thus avoided the biases of self-reported data.39

Stigma and Symbolism

The inattention to the plight of injection drug users, regardless of whether the issue is needle exchange or the general lack of resources for drug treatment and methadone maintenance, can be attributed to the stigma attached to this group. Drug addiction research has failed to capture the attention of the biomedical and behavioral sciences communities--and funding sources--to a degree commensurate with its prominence as a social problem, although the HIV epidemic is changing this. Given the limitations of the current therapeutic armamentarium, much more needs to be known about which drug treatments work. Approaches to treatment have failed to keep pace with trends in "polydrug" use. The lack of a biological treatment for cocaine addiction--one that parallels the use of methadone in heroin addicts--is a particularly worrisome gap.

One aspect of the unresponsiveness to the plight of injection drug users concerns their political powerlessness. It may not be appropriate to speak of this group--one that maintains a flourishing, multibillion-dollar trade in illicit substances--as lacking "organization." Yet injection drug users do not have the trappings of a recognized interest or voting bloc, and their political power is feeble at best.40

Excluding clinicians, public health officials, and treatment center staff, there have been few spokespersons for the interests of injection drug users. As attorney Ruth Harlow noted, "One impact of needle exchange is to show that society cares about these folks."41 This certainly is one message conveyed by the volunteers and the activists who are willing to be arrested in efforts to reduce the overall risk of HIV infection.

The debate about strategies for preventing the spread of HIV infection through contaminated injection equipment is only part of a larger controversy about controlling illicit drug use. Drug policies reflect anxieties that society has at any given time. Attitudes toward the use of narcotics have been tinged with xenophobia and racism, according to drug-policy historians.

The lack of obvious solutions on either the supply side or the demand side of the drug problem is readily apparent from the sheer variety of antidrug proposals. Crosscurrents result from the conflicts between two views: that drug use is either an illness to be treated or a crime to be punished.
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