The Fourth Conference on Retroviruses and Opportunistic Infections was held the last week of January in Washington. An annual event, it is the probably the world’s most important scientific meeting of AIDS specialists. At one of this year’s sessions, Dr. Steffanie Strathdee, a Canadian epidemiologist, presented preliminary data from a major study of high-risk behavior underway in Vancouver. Since May 1996, the Vancouver Injection Drug Use Study has periodically blood-tested, interviewed, and counseled roughly 900 intravenous cocaine and heroin users.
After only seven months, nearly 10 percent of initially HIV-negative participants in the program had experienced “seroconversion”: They had become infected with the virus. Overall, the Vancouver research subjects injected themselves an average of 4.5 times each day. Forty percent of those who knew they were HIV-positive nevertheless reported having lent contaminated needles to other drug users in the preceding six months. Fully 60 percent of the test group, including those still clear of the virus, reported having borrowed someone else’s used needle in the preceding six months.
All this, despite the fact that 95 percent of the drug users under study in Vancouver routinely received sterile hypodermic syringes, free of charge, from a well-financed public “needle-exchange” program. That program is mammoth: The government of British Columbia distributed 2.3 million clean needles in 1996. “We always thought we were lucky” to have “a great needle- exchange program,” one of Dr. Strathdee’s colleagues has ruefully acknowledged. “We had a problem, but now we have a bigger problem.”
Down here in the Lower Forty-eight, meanwhile, the assumption is increasingly widespread that needleexchange programs like Vancouver’s are a practical necessity. AIDS activists are virtually unanimous — and many frontline public-health officials and professional medical associations appear to agree — that restrictive state laws and a federal-funding ban on clean-needle initiatives are killing people. These proponents have won a receptive media audience.
The New York Times editorial page, for example, has for several years been evangelizing regularly on behalf of needle-exchange programs, which now number more than 100 around the country. According to the Times, the Clinton administration’s position on such programs — Health and Human Services secretary Donna Shalala approves their adoption by state and local agencies but declines to allow federal money to be spent on them — represents a shameful failure of “courage.” Crude public arguments about ” politics and morality” must give way to science, the Times pronounces. The available evidence is “unequivocal” and “highly persuasive” that supplying clean needles to addicts deters HIV infection without encouraging drug use.
We’ll set politics and morality aside for a moment. The available evidence most commonly cited by needle-exchange advocates — the Times has yet to take note of Vancouver’s depressing results — turns out to be, if you actually read it, highly equivocal and therefore unpersuasive. To date, the most comprehensive treatment of sterile needles as a tool against HIV transmission is a two-year investigation organized by the National Academy of Sciences in 1993. The NAS study, published in 1995, explicitly “does not recommend” a national needle-exchange program. It does recommend caution, further research, and targeted federal funding for local “communities that desire such programs,” since they sometimes “can be effective in preventing the spread of HIV” and “do not increase the use of illegal drugs.”
But NAS reached even this last, rather temporizing conclusion by making ” multiple assessments” of a “logical network of evidence” in which it “may be possible” to discern a “plausibility” that needle-exchange programs are ” implicated” in a positive “change process.” In English, this means the academy employed criteria it admits “would be classified as relatively weak” when measured against “traditional” scientific standards. All the previously published research on which NAS based its assessment of needle-exchange programs had, in the NAS panel’s judgment, obvious “methodological limitations”: inadequate sample populations, high drop-out rates, “improper” study controls, and “problematic” or “incomplete” data and analysis.
In particular, the academy decided that the two most widely heralded federal clean-needle studies actually prove very little. A 1993 General Accounting Office report indicating that needle exchanges “do not increase injection drug use” was, in NAS’s jargon-drenched appraisal, “not fully characterized.” GAO, it seems, had excluded from its final review any needle program in which drug use did increase or remained level. Another 1993 report, commissioned from the University of California by the federal Centers for Disease Control, speaks for itself: Then-contemporary data “do not . . . provide clear evidence that needleexchange programs decrease HIV infection rates.”
In addition to cloudy behavioral and epidemiological data, all manner of practical and logical problems surround clean-needle programs. Even if one were prepared to stipulate their immediate utility, there would remain the question whether they need largescale public funding. Sterile needles are cheap; they cost 50 cents or less apiece, a minuscule amount of money to addicts who quite commonly spend hundreds of dollars a day to maintain their habits. And it is not clear such needles are otherwise unavailable to addicts who want them. Forty-one states do not even require a prescription for needle purchases in pharmacies. Forty-five states still criminalize possession of syringes for use in the consumption of illegal drugs, but those laws are rarely enforced — and then only against drug dealers, not users.
Then there is the matter of public order and safety. Experience suggests that the insertion into American inner-city neighborhoods of millions more hypodermic needles would result in some large number of them being discarded on sidewalks where children run and play. And experience also suggests that expanded needle-exchange programs might well become magnets for drug use, even if they did not increase rates of addiction. Drug-related crime in the Downtown Eastside section of Vancouver, where that city’s clean-needle initiative is headquartered, is epidemic. “It’s been getting progressively worse” since the program began in 1989, according to one Vancouver police detective. “Our problem is, that area is known nationwide as a place to come for drugs.”
It could certainly happen here. No one can tell for sure. The “long-term effects of these programs on the level of illicit drug use in communities are not yet known,” concedes the National Academy of Sciences. Some imperfect research suggests that needle-exchange programs work. Some imperfect research suggests they don’t. But “sooner or later,” the NAS referees insist, “there comes a time for decision on the basis of evidence in hand.” So the academy makes its call, favoring the “plausibility” that further needle initiatives might reduce HIV transmission against the real possibility that they will fail — and make things worse.
Finally we are back to politics and morality. The practical question needle- exchange programs involve is essentially and only a political one: whether to legalize and fund them, or not. And in the absence of conclusive practical evidence one way or the other, it is a question that can be answered only with reference to morality.
Two competing moralities are at issue here. There is that oddly newish upper-middle-class libertarianism which has it that adults bent on self- destruction should be allowed — and helped — to achieve their goal in “safe, ” timely, and effective fashion. It is now respectable for people to argue that cancer and glaucoma patients should have access to “medical” marijuana cigarettes, though no one has yet proved that smoking pot is ever necessary or good for you. Worse, some of the nation’s leading lawyers and “ethicists,” joined by two federal appellate courts, have lately concluded that truly ” moral” American laws must permit doctors to euthanize their terminal or chronically incapacitated patients when asked to do so.
Against this view stands the simpler, old-fashioned morality that so frustrates AIDS activists and the New York Times: Government should not, in principle, play facilitator to any life-denying impulse. In this particular case, government should not make itself a technician of cocaine and heroin addiction. Especially when there is nothing but glorified guesswork with which to justify the move.
The Clinton administration, for whatever reasons, is right to deny federal funding to needle-exchange programs. Congress should support the president. And work to ensure that he does not change his mind.
David Tell, for the Editors
