The Wall Street Journal - 10 July 1996
Amanda Bennett, Staff Reporter of The Wall Street Journal

"People's lives are at stake," says one of the researchers, Peter Lurie of the Center for AIDS Prevention Studies at the University of California at San Francisco.

Needle-exchange programs allow drug addicts to swap used needles for clean ones. But needle distribution without prescription is illegal in at least nine states, and nearly all the states have laws prohibiting carrying drug paraphernalia. What's more, under an amendment sponsored in 1988 by North Carolina's Republican Sen. Jesse Helms, such programs are barred from federal funding.

Against that backdrop, Dr. Lurie and his colleague, Ernest Drucker of Albert Einstein College of Medicine in New York, estimate that as many as 10,000 infections could have been prevented between 1987 and 1995 had programs that supply clean needles to addicts been generally available. The researchers reached their conclusion by mathematically combining the results of previous studies of the effectiveness of needle-exchange programs and of the numbers of people expected to use them if they were available.

While other researchers have estimated the impact of needle-exchange programs in individual locations, this is the first attempt to calculate the national effect. "It's unique," says David Purchase, director of the North American Syringe Exchange Network in Tacoma, Wash., a service organization for syringe-exchange programs. Other researchers applauded the effort, even while noting that they believed the figures Drs. Lurie and Drucker obtained -- reductions of infections of between 15% and 33% -- were low.

"It's a very good start, but I think it seriously underestimates the potential effectiveness of syringe exchanges," says Don Des Jarlais, director of research of the Chemical Dependency Institute at Beth Israel Medical Center in New York.

Dr. Des Jarlais himself is presenting a paper at the conference that he says shows syringe exchanges in New York (where they are legal) are "working much better than anyone expected." Since 1992, the doctor says, the programs he studied showed a decrease in HIV infections of more than 50%.

The analysis underscores the battle that continues to rage between politics and science, more than 15 years into the epidemic. This past Monday, President Clinton's own Advisory Council on HIV/AIDS criticized him for failing to support needle-exchange programs. In a report, the panel said that absence of support is "not consistent with current knowledge regarding the impact of such programs on HIV infection." (The Clinton administration has the power to lift the ban on federal funding of needle-exchange programs if scientific evidence shows that is warranted.)

Some who oppose needle-exchange programs believe that they tacitly encourage the use of illegal drugs. Others, such as Democratic Rep. Charles Rangel of New York, who represents a largely minority community in New York City, support needle-exchange programs only if they don't divert resources from drug treatment.

The conflicting nature of the various arguments is evident in the experience of Herbert J. Kleber, a Columbia University professor who was a member of a National Research Council panel that found needle-exchange programs effective in reducing HIV transmission. Dr. Kleber said several months ago that he nonetheless had doubts about the programs, noting that participants in one of them, in Montreal, actually had a higher rate of HIV and of new HIV infections. (An analysis of the Montreal program is also being presented at Vancouver; one of the investigators called the findings "worrisome" and "paradoxical," and said that additional studies were being planned.)

The competing political forces create other complications. In California, Attorney General Dan Lundgren has been aggressively fighting needle-exchange programs, but local officials, like San Francisco Mayor Willie Brown, support them. In Oakland, three exchange sites give out about 50,000 clean needles a month; one part of the program, which offers drug counseling and outreach, is funded by federal and state money, says spokeswoman Camille Anacabe, but the syringe-exchange part of the program is funded by a private foundation.

Nationwide, the number of needle-exchange programs continues to grow, some operating either illegally or on the edge of the law. Dr. Lurie of the Center for AIDS Prevention Studies estimates that there are 88 in operation today, compared with 68 in 1994 and 37 in 1993.

Still, Dr. Des Jarlais says his study demonstrates that the reach of such programs can be greatly extended following legalization. He says after the programs he studied were legalized in 1992, the number of needles distributed increased 25-fold.

The study by Drs. Lurie and Drucker assumes that needle-exchange programs could have grown from zero in 1987 until they served 50% of all needle users in 1994 -- the percentage served in Australia, which implemented such programs early in the epidemic. The study further assumes that preventing infections in drug users also prevents other infections. About 12% of the infections they estimate to have been preventable are among drug users' sex partners and newly born children. However, the study's authors also figure that some infections that appear to be due to intravenous drug use are actually due to sexual transmission and so wouldn't be affected by exchange programs.

Drs. Lurie and Drucker figure that the U.S. could have avoided up to $538 million in treatment costs by preventing new infections through needle exchanges. Dr. Des Jarlais notes, however, that the study doesn't take into account potential infections averted by legalizing pharmacy sales of syringes to drug users, which is another method favored by the prevention community.

Jon Stuen-Parker, an ex-addict and a longtime AIDS activist, doesn't deal in abstracts: He spends much of his time giving out clean hypodermic needles to injection drug users. "Nothing is more urgent than stemming the spread of the virus" among addicts, he says. Last month, Mr. Stuen-Parker was given an 18-month suspended jail sentence in New Hampshire, where it is illegal to possess a syringe without a prescription.

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Preventive Medicine Cutting the Risk

-- Number of injection drug users in U.S. large metropolitan areas: 1,460,300 -- Number HIV positive: 204,000 or 14% -- Estimated new HIV infections among injection drug users: 19,000/year -- HIV infections potentially averted through implementing needle-exchange programs:

1987 to 1995 4,394 to 9,666 1996 to 2000 5,150 to 11,329

Sources: Peter Lurie, University of California at San Francisco/Ernest Drucker, Albert Einstein College of Medicine, Centers for Disease Control

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