Eye on the Needle

Needle exchange programs that run on state, local, and private dollars exist all over the country. There are currently over 200 programs in 14 states.  Several major cities have needle exchange programs.  In San Francisco, there is one operated by the San Francisco AIDS Foundation.  In Baltimore, one is run by the Baltimore City Health Department.  But, since 1989, the federal government has banned federal funds from going to any needle exchange programs in the United States.  Recently, efforts to repeal this ban have been picking up, in hopes that the Obama administration will reverse the policy of its predecessors.

Over ten years ago, high ranking officials in the Federal Government showed support for lifting the ban.  In April of 1998, HHS Secretary Donna E. Shalala announced that based on the findings of extensive scientific research, she has determined that needle exchange programs can be an effective part of a comprehensive strategy to reduce the incidence of HIV transmission and do not encourage the use of illegal drugs.  Despite her advice, the Clinton administration left the ban in place.

When Hillary Clinton and Barack Obama were candidates vying for the presidency, both made campaign promises to lift the federal ban.  Since his election and inauguration, President Obama has hinted at lifting the ban, as part of his policy to combat the spread of HIV/AIDS.  On the White House website (www.whitehouse.gov) in the early days of his presidency it read:

The President also supports lifting the federal ban on needle exchange, which could dramatically reduce rates of infection among drug users. President Obama has also been willing to confront the stigma — too often tied to homophobia — that continues to surround HIV/AIDS.

Yet hopes for a change were dashed early in the Obama administration.  The first federal budget outline, released by his White House in early May 2009, kept the ban in place.  The White House cited timing.  White House spokesman Ben LaBolt said the administration isn’t yet ready to lift the ban, but Obama still supports needle exchange. “We have not removed the ban in our budget proposal because we want to work with Congress and the American public to build support for this change,” he said. “We are committed to doing this as part of a National HIV/AIDS strategy and are confident that we can build support for these scientifically-based programs.”

He added, “In recent years, Washington has used the budget process to litigate divisive issues and score political points. This practice, which both sides have engaged in, has limited our ability to tackle our major economic challenges. President Obama decided not to play politics as usual with this budget and while he remains committed to supporting the program he wants to address that through the normal legislative process.”   It is also important to note that the language supporting a lifting of the ban has since been removed from the White House website.

Then on Friday, July 10, the House Appropriations Committee Labor-HHS Subcommittee removed the restrictions on needle exchange programs from the FY 2010 appropriations bill. However, when the bill goes before the full committee on July 17, there is expected to be strong debate over this issue.
Several advocates are severely disappointed at the inaction of the Obama administration thus far. “The syringe exchange ban is a classic case of politics trumping science.  We’ve known for almost the entire course of the HIV epidemic that syringe exchange programs save lives without promoting drug use,” said Jeffrey Levi, Executive Director of Trust for America’s Health.  “Now that we have an Administration committed to public health policy being driven by science, TFAH is joining ranks with many in the public health and AIDS advocacy community to fight for removal of the restriction on use of federal funds for syringe exchange programs.  We hope the Obama Administration will join us and not be a silent bystander to this process.”

Others agree.  “We would like to see the administration embrace all research based strategies that engage people in addiction treatment and reduce the incidence of illness and death related to addiction,”  said Alexa Eggleston of the National Council for Community Behavioral Health.

There are several arguments in favor of needle exchange programs.  First and foremost, it cuts down on the transmission of diseases such as HIV and hepatitis, by preventing the sharing and re-use of contaminated needles.  Beyond HIV, it also cuts down the transmission of countless numbers of other viruses and countless bacteria.  “More than 8,000 people a year are infected with HIV and at least 12,000 people a year are infected with hepatitis C either directly or indirectly due to injection drug use,” said William McColl, Political Director of AIDS Action.

“If the federal syringe ban is not repealed, as many as 300,000 Americans could contract HIV/AIDS or hepatitis C directly or indirectly from injection drug use over the next decade,” said Bill Piper, National Policy Director for the Drug Policy Alliance.  “No one should be denied life-saving interventions solely because of what they put into their body.”

Needle exchange programs also provide a service to the community.  Most programs are a one-for-one exchange; bring in one dirty needle, get one clean one.  Bring in twenty dirty needles, get twenty clean ones.  The benefit is that these needles are disposed of in the proper manner.  Every needle brought into a needle exchange is one less that is discarded on a playground, a street, or a schoolyard.  Many needle exchange programs also provide resources for counseling, as well as testing for HIV. “Syringe exchanges connect people who generally only access health care through the emergency room to numerous medical services including HIV and hepatitis testing, prevention and education and perhaps, most importantly, to substance abuse treatment if asked.  Adopting syringe exchange as a method of bloodborne disease prevention is twenty years overdue,” said McColl.

Opponents of needle exchange programs, and the federal funding of them, often cite the argument that such programs encourage drug use, or at the very least will show signs of condoning it.  Dr. David Murray, chief scientist at the Office of National Drug Control Policy under Drug Czar John Walters is an advocate of the federal ban.  He would prefer that the limited pool of federal funds for drug-related programs be devoted to treatment.  In July 2008, he said recent research shows needle exchange programs don’t change addicts’ behavior.

“When it comes to the distribution of needles, we know that it carries an enablement of continued drug use,” Murray said . “And we fear, the evidence is strong, that it does not succeed in its effort to control the contagion of disease.  Programs don’t address the core of the HIV/AIDS problem, which is the high-risk behavior associated with drug use, such as venereal disease and multiple sexual partners.”

Some experts think differently.  “There is no evidence that such public health programs contribute to an increase of intravenous use of drugs by making drugs seem more socially acceptable, as opponents of such programs frequently fear,” says Vanda Felbab-Brown, a senior fellow at the Brookings Institute.   “In fact, most European countries with such programs have drug consumption rates smaller than the United States that has lagged behind in adopting needle exchange programs.”

The advocacy effort to lift the ban goes beyond groups concerned with health and curbing drug use.  The NAACP and the National Urban League are strong supporters of lifting the ban, African-Americans comprise thirteen percent of the population, but account for almost half of all new HIV cases.  These groups also fear that the federal ban deters state and local government from funding exchanges on their own.

Supporters of lifting the ban also cite economic benefits.  “Syringe exchange has been repeatedly shown through 8 federal studies both to reduce the incidence of HIV and increasingly hepatitis and to not increase substance abuse,” says McColl.  “A single case of HIV has lifetime costs of up to $648,000 whereas it only costs a syringe exchange about $4,000 – $12,000 to prevent a single case of HIV.  A case of hepatitis C costs between 25,000 – $30,000 every single year until it is cured or the patient passes away.”

Even if the ban is lifted, there is no guarantee that the federal government will appropriate funds for needle exchange.  However, it could send a strong message to others that these programs are beneficial, and could very possibly save thousands of lives, as well as billions of dollars in prevented health care costs.

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