Public health, politics clash over HIV prevention

On March 17, the Presidential Council on HIV/AIDS unanimously passed a stern "no confidence" vote on the Clinton administration's HIV prevention effort. In their decision, they cited the President's lack of support for needle exchange programs (NEPs), which are designed to curb the spread of HIV among IV drug users. In a public statement, the council argued that current policy banning federal support for these programs "threatens public health and directly contradicts scientific evidence."

Numerous studies show that NEPs don't promote new IV drug use or increase injections among current users. In addition to providing clean needles for current IV drug users, the programs provide counselors with an opportunity to coax addicts into comprehensive drug treatment programs. NEPs are endorsed by all major US public health organizations, including the American Medical Association and the American Public Health Association. Support for these programs, as well as evidence of their efficacy, has been provided by sectors of the US medical and public health communities that include the National Institutes of Health (NIH) and the Centers for Disease Control (CDC). In February, an NIH panel reviewed many of these studies and affirmed their conclusions. The CDC believes that at least half of all new AIDS cases are related to dirty needle use. The number of new cases among women are on the rise, one reason being that the virus is transmitted through heterosexual sex wih IV drug users. In the March issue of The Lancet, researchers at the University of California, San Francisco, concluded that NEPs could have prevented nearly 10,000 HIV infections among IV users, their sex partners, and their children in the US since 1987.

Even with evidence mounting and pressure increasing from public health advocates, Health and Human Services Secretary Donna Shalala announced on April 20 that although the administration stood firmly behind the scientific evidence supporting NEPs, it would not lift a federal funding ban on the programs. Instead, it encouraged community based, grass roots efforts to implement NEPs. Most AIDS activists see the decision as a defeat because federal funding is essential to boost the prevalence of NEPs. Shalala's announcement did little more than affirm what people following the issue already know. President Clinton's initial fervor for tackling the AIDS epidemic has lost much momentum. Though he voices hope for a cure within ten years, his administration ignores the implications of current knowledge for effective AIDS prevention policy. Though we cannot cure the disease, we fully understand how the disease is transmitted and thus, how to substantially reduce future transmissions. This fact begs the question, why don't we put this knowledge into action? The answer is that in the political arena, public health issues compete with a number of other priorities.

In the NEP debate, the chief rival to effective AIDS prevention is the nation's perpetual drug war. Many citizens and policy makers still harbor genuine concerns that NEPs will promote drug use. Drug czar Gen. Barry McCaffrey worries that needle exchange would send children the wrong message. Robert Maginnis, senior policy analyst for the Family Research Council, believes that federally funded programs "will be interpreted as an official endorsement of illegal drug use...it promotes a culture of death by condemning addicts to the killing fields of heroin and by encouraging drug use among the most vulnerable." Sen. John Ashcroft (R-MO) asked, "Why not simply provide heroin itself, free of charge, courtesy of the American taxpayer?" Public opinion polls show that a majority of Americans believe that the war on drugs is a failure. At the same time, a majority also believes that by continuing the drug war, the US is fighting the good fight, failure or not. Drug use is viewed as abhorrent criminal behavior, associated with a culture of violence and complete moral degradation. In response to public concern, many politicians posture themselves as tough on drugs and crime and promise to take whatever steps are necessary to stem the tide and reclaim our nation from their plague. There is no question that drug use and addiction are overwhelming national problems, desperate for solutions.

The difficulty for NEP advocates lies in the strength of the anti-drug sentiment. Thus, efforts designed to help the addict receive drug treatment and protection from HIV are flagged by public concerns of subsidizing further drug use. The issue is seen not as an effort to reduce the spread of HIV, but as a retreat in the drug battle. Consequently it is much easier for lawmakers to dismiss NEP initiatives, despite their AIDS prevention value, than to support efforts designed to slow HIV transmission. So what does President Clinton do? As with many other issues, he jumps forward with two feet into the mushy middle—displeasing some for publicly supporting an effort they find offensive, and discouraging others for not putting money where his mouth is.

AIDS prevention efforts in NC

NEPs, in any form, are presently illegal under NC state law; needles are classified as illegal drug paraphernalia. The NC State Senate killed a bill for a pilot NEP during the last legislative session. The bill did pass the committee stage, but was never voted on by the larger body. According to the Common Sense Foundation, Senate leadership worried that the issue could be used against them in the next election. Evelyn Foust, chief of the state's HIV/STD Prevention and Care Services, believes that lawmakers' reluctance to approve the project has more to do with genuine concerns that NEPs will encourage new drug use than with political posturing. Foust stresses that the key is to educate policy makers and the general public to the benefits both of a needle exchange program and more general HIV prevention efforts. So far, efforts at education may have fallen on too many deaf ears. In recent years the General Assembly, with significant public support, has done away with anonymous AIDS testing and instituted an "abstinence only" policy for sex education in the public schools —neither of these policies promotes AIDS prevention. If past action is any indicator, the trend does not bode well for possible NEPs in NC. Stella Kirkendale, with the AIDS Service Agency (ASA) in Raleigh, and other activists, don't want money. They only want the chance to start a NEP, monitored by the state and augmented by comprehensive drug treatment efforts. Citizens need only look to western NC to see needle exchange at work. "Asheville currently has a successful, though technically illegal needle exchange program," she says, "because of strong local support and an understanding with local law enforcement." The ASA and other AIDS advocacy groups were pleased with the strides NEPs made in the General Assembly, despite the end result. These groups are now focusing on consolidating their support networks and preparing to apply pressure in upcoming legislative sessions. The short session convening in May (and lasting until summer) will deal largely with budgetary issues. Kirkendale stresses that at least for this session, another AIDS program will be the focus of support. Primary concern is for ADAP - the AIDS drug funding program, which is presently out of money and awaiting approval of a proposed $18 million appropriation in this year's budget.

At this point, it is hard to predict whether NEPs will gain acceptance at a national and/or state level or remain on the periphery. The Clinton administration's affirmation of NEP benefits may bolster efforts to promote them, or at least open a larger public debate on their value and importance. In NC, the issue has important backing from outgoing State Health Director Dr. Ron Levine and his replacement Dr. Charles McBride, both of whom strongly support an exchange program's public health benefits (McBride comes to NC from Connecticut, a state with very successful NEPs). With community based perseverance and continuing educational efforts, anything can happen. If you are interested in learning more about needle exchange programs, other HIV prevention efforts, or AIDS treatment programs, contact the AIDS Service Agency (834-2437) or HIV/STD Control (733-7301).