SPINS AND NEEDLES

In 1989, Congress imposed a temporary, conditional ban on federal funding of local AIDS-prevention projects that distribute sterile hypodermic needles and syringes to intravenous drug users. The ban was to be lifted at the discretion of the secretary of health and human services, provided the secretary could certify two things about needle-exchange programs, or “NEPs”: first, that they were an effective epidemiological control on the human immunodeficiency virus; and second, that they did not “encourage” the use of illegal drugs. Early last year, Clinton HHS chief Donna Shalala certified that these NEPs are effective. Early last week, she certified that they are safe. “Extensive research,” she announced, now indicates that the provision of free, clean “works” to addicts does nothing to undercut the nation’s antidrug efforts. Nevertheless, Shalala did not lift the needle-funding ban.

She had wanted and expected to lift the ban, it appears. As late as 9 a.m. on April 20, only hours before her scheduled press conference, Shalala was still preparing to say that the administration was concerned only with ” science, science, science” — and that “the evidence is airtight” that federally supported needle distribution is a good idea. AIDS activists, for whom the virtues of needle exchange are a matter of gospel, had been alerted that welcome news was imminent. And various demonstration-program options were already being refined.

But at the last minute, White House chief of staff Erskine Bowles rang Shalala on the phone and told her no. President Clinton, it seems, had changed his mind the previous evening. Science, science, science notwithstanding, the president had concluded that it might not go over too well with the public were the federal government to start plunging taxpayer dollars into the arms of junkies nationwide. So Shalala abruptly canceled the multi-camera media event she had planned. Instead, she invited a handful of print reporters to hear a hastily constructed, incoherent account of how and why the administration had decided to withhold federal money from what the government’s own health experts had unanimously deemed a risk-free, “life saving intervention.”

On display during this episode, in cartoonishly exaggerated form, were two bedrock elements of the Clintonesque style: chaotic, all-nighter policy ” analysis” and an ability simultaneously to announce and defy some set of deeply held principles. The explanatory spin was necessarily thick and dizzying, and the White House quite predictably got hammered for it. Newspaper editorials were unusually nasty. And organizations and individuals who would ordinarily have been delighted to receive even a purely rhetorical administration endorsement of NEPs were nastier still. Actress Elizabeth Taylor, on behalf of the American Foundation for AIDS Research, complained that “our colleagues in Washington have chosen to play politics with human lives.” Even the chairman of the White House AIDS advisory panel called the president’s final decision “immoral.”

It is no doubt the case that the Clinton political advisers who engineered this eleventh-hour reversal wouldn’t know the specialized research literature on clean needles if it bit them on the ankle. In that sense, we suppose, the president is merely getting what he deserves. But we can’t help feeling a tad sorry for him, just the same. Because he has been sandbagged here — by his own senior health appointees at HHS. These people do know the specialized research literature on clean needles. And it does not say what they say it says. Donna Shalala and Co. — eager to appease their AIDS constituency, and unconcerned that they might embarrass the president in the process — are spinning, too.

No, they’re just plain lying.

Last year’s determination by Shalala that NEPs “can” arrest the transmission of AIDS infection among addicts who would otherwise share contaminated needles was already a stretch, as we reported on these pages at the time. She based her preliminary approval of the idea largely on a 1995 National Academy of Sciences survey of then-current needle-program data. But those data, as the final NAS report itself made explicitly clear, were highly ambiguous and methodologically imperfect. Every study available for review by the academy — and by Shalala in 1997 — depended entirely for its conclusions on self-reports of HIV status by addicts, some of whom may have been infected without realizing it. No such study could reliably predict relative rates of infection for NEP participants and non-participants, because the blood samples necessary to make such a reliable prediction did not exist.

So the question now is: What exactly has HHS obtained these past twelve months by way of “conclusive scientific evidence” that drug addicts are less likely to contract AIDS if they are given sterile needles — and more likely to get sober? Standing beside Donna Shalala last week, Harold Varmus, director of the National Institutes of Health, cited two “recent findings.” One was his own agency’s policy statement on “Interventions to Prevent HIV Risk Behaviors.” That statement is, indeed, a vehement broadside in behalf of needle distribution. But it was prepared in February 1997, before last year’s HHS needle announcement, and deals with no new data whatsoever. Varmus also favorably mentioned an October 1997 study of needle-exchange enrollees in Baltimore. The Baltimore study, in fact, detected no relative decrease in HIV infection rates among its subjects. And it, too, relied on addict self- reports.

In other words, there still hasn’t been a single credible research project that tracks the lab-tested HIV exposures of drug addicts in needle programs and then reveals anything useful about whether the programs do much good.

We take that back. There have been two such projects. And neither is reassuring.

In the July 1997 issue of the journal AIDS, Canadian researchers reported results from an 18-month study of intravenous drug users in Vancouver. That city has the largest needle-exchange program in the Western Hemisphere — and for most of last year had the highest HIV infection rate in the industrialized world. Of 257 Vancouver addicts who initially tested negative for HIV, 24 had been exposed to the virus within six months, despite the fact that 23 of them reported regularly obtaining sterile equipment from the NEP Sharing of contaminated needles remains a “normative” behavior among addicts, this study’s authors concluded. Wide distribution of clean needles does not change this “alarming” fact.

An article published in the December 1997 American Journal of Epidemiology contains some even more alarming facts from Montreal. Roughly 1,600 of that city’s intravenous drug users were tracked for an average period of nearly two years. Most important, the blood results of Montreal NEP participants were directly compared, with elaborate statistical controls, against the blood results of addicts who did not take advantage of local needle-exchange services. NEP enrollees were more than twice as likely as nonenrollees to become infected with HIV. Clean-needle distribution has ” possibly deleterious effects on HIV transmission,” this study’s researchers reluctantly decided. “We believe that caution is warranted before accepting NEPs as uniformly beneficial in any setting.”

This is what the United States Department of Health and Human Services characterizes — deliberately and dishonestly — as “conclusive scientific evidence” in favor of federal clean-needle spending. And HHS would have had its way last week, ironically enough, but for the political cowardice of a blissfully unaware White House. Next time around, we may not be so lucky. Bill Clinton’s poll-obsessed fecklessness is too feeble a barrier with which to protect the country from such an apparently dreadful idea. Congress ought to act preemptively. Lift the temporary, conditional ban on federal needle spending. Replace it with a permanent, unconditional one.

David Tell, for the Editors