Treatment Issues: Newsletter of Current Issues in HIV/AIDS - Volume 19, Number 5 & 6, May / June 2005
Daniel Raymond

Do we still have an HIV epidemic among injection drug users in the United States?

The Centers for Disease Control (CDC) made headlines in June by presenting new estimates that over a million people in the U.S. are HIV-positive. Coverage of the National HIV Prevention Conference focused heavily on two overlapping groups — men who have sex with men, and African-American men and women— who collectively account for the majority of new infections. Injection drug use was virtually absent in media accounts, reflecting a broader marginalization of IDUs in current HIV prevention discussions.

It would be natural to infer that the omission of IDUs reflects a shift in epidemiology — if we're not talking about injection drug use and HIV anymore, presumably it's no longer a problem. One might imagine that the HIV epidemic among IDUs has peaked or has been contained through needle exchange and harm reduction measures. Indeed, by some measures this is true: the percentage of new AIDS diagnoses attributed to HIV infection through injection drug use has been declining for several years. And needle exchange is credited with dramatically slowing the spread of HIV. In New York City, for example, HIV prevalence among IDUs fell from 55–60% in the early 1990s to about 15% today.

Yet these numbers belie the fact that injection drug use directly accounts for about one in four of all HIV infections and indirectly contributes to even more infections through sexual transmission. Among women, the majority of HIV cases result from injection drug use or sex with an HIV-positive IDU — yet drug injection rarely figures into discussions of women and HIV. Moreover, the success of needle exchange in New York City and elsewhere has never been fully realized. Local political opposition has blocked needle exchange across the country. Even established programs struggle to survive — the San Francisco Needle Exchange, focused on young injectors, almost lost their city funding this year, while Puerto Rico's health department is shifting needle exchange funding away from existing programs and towards inexperienced agencies. The most recent national survey of syringe exchange programs (SEPs) found that "in 2002, for the first time in eight years, the number of SEPs, the number of localities with SEPs, and public funding for SEPs decreased nationwide."

A new study on the cost effectiveness of various HIV prevention strategies gives new urgency to local struggles for needle exchange and syringe access. Researchers from the RAND Corporation and Tulane University calculated that needle exchange programs in high- and medium-prevalence cities could prevent nearly 2,700 HIV infections each year. The report concluded that interventions prioritized by the CDC's Advancing HIV Prevention (AHP) initiative would fail to meet targets for reducing transmission. The CDC's HIV Prevention Strategic Plan aims to reduce HIV infections to 20,000 per year by the end of 2005 — an impossible goal to reach, given current infection rates.

If it sounds like the CDC has written off HIV prevention for IDUs, part of the problem is the on-going exodus from the agency of leading researchers like Richard Garfein and Steven Jones, leaving a dearth of expertise and loss of focus on drug injectors. But much responsibility lies with the ban on federal funding of needle exchange written into federal appropriations bills by Congress. The federal ban has effectively starved syringe exchange programs of adequate funding and limited their growth and impact. Needle exchange and harm reduction remain controversial within Congress and the Bush Administration. Rep. Mark Souder held a hearing in February designed to discredit harm reduction, while U.S. representatives made an unsuccessful attempt to pressure UNAIDS' Programme Coordinating Board to expunge references to needle exchange from a new HIV prevention strategy document.

IDUs and needle exchange advocates are in desperate need of political leadership and will at both local and federal levels. The CDC may claim its hands are tied by the federal funding ban, but it compounds the problem by rendering IDUs invisible in HIV prevention.

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