On World AIDS Day last year, President Obama recognized the progress against the HIV epidemic, saying there is "the real possibility of an AIDS-free generation." This possibility, however, was dealt a serious blow in January when Congress gutted a key component of HIV prevention by reinstating a ban on federal funding of syringe exchange programs. The current budget negotiations will feature another struggle over this issue of urgent importance to "Susan," a 30-year-old injection drug user and other drug users in the U.S.
The ban's revival, buried in an amendment to a trillion-dollar spending package, caught the public health and human rights communities by surprise. Hadn't this issue been resolved in 2009 when the prohibition was lifted? There is widespread consensus in science, public health and drug treatment that needle exchange, by reducing the sharing of infected needles, saves lives, doesn't increase drug use and brings many people into recovery (see the U.S. National HIV/AIDS Strategy). Decades of the federal ban had left the nation with a lot of catching up to do. Even in cities with syringe exchange programs, coverage falls short, with only about 10 percent of injection drug users having consistent access to clean needles.
The federal money at stake was not a large amount, but in states where syringe exchange is legal, programs could be expanded and progress made in providing injection drug users with clean equipment to reduce HIV and hepatitis transmission. According to the National Association of State and Territorial AIDS Directors (NASTAD), nine states and one city had applied to use $2.7 million in federal HIV prevention funding to expand syringe exchanges.
In New York State, 21 syringe exchanges provide 3 million clean needles annually to drug users at 50 sites. These programs have reduced cases of HIV transmission from drug use from 52 percent of new AIDS cases in 1992 to 5.4 percent in 2008. According to state health department officials, New York used federal funds after the ban was lifted to expand programs into new areas, provide more drug counseling and referrals to treatment and increase the safe return of used syringes.
Momentum for new programs was beginning to grow as well, with bipartisan support. In Colorado, Governor Bill Ritter, a Democrat, signed a public health exception to the drug laws to permit syringe exchange, and New Jersey's law permitting syringes to be purchased over-the-counter at pharmacies was signed by Governor Chris Christie, a Republican.
Syringe exchange is one of the greatest public health successes of the 20th century. After rapid spread of HIV through shared needles early in the epidemic, injection drug use is the only category of transmission that has shown steady decline, largely due to syringe exchange programs. Study after study confirms that syringe exchange lowers HIV and hepatitis transmission, without increasing drug use. In fact, the U.S. Surgeon General found "ample evidence" that these programs promote entry into drug treatment. "Steve," a drug user in Miami, told Human Rights Watch, "People actually want clean needles, and the human contact at the needle exchange is important in a lot of ways."
But much work remains to be done to overcome legal barriers at the state level. Florida has an estimated 96,000 injection drug users, 20 percent of them infected with HIV. Yet Florida is one of 35 states with no clear legal authority for syringe exchange.
The drug paraphernalia laws that criminalize syringe possession leave public health officials reluctant to take any steps that might violate the law. So "needle exchange" in Miami consists of Steve and one other person risking arrest to distribute clean syringes. This meets an urgent need in minority communities, as African Americans who inject drugs are 10 times as likely to become infected with HIV from a dirty needle and Latinos 5 times as likely as their white counterparts.
The sad irony of attaching this ban to a spending bill is that it will cost the taxpayers millions of dollars. The AIDS Foundation of Chicago estimates that access to sterile syringes in Illinois has reduced HIV transmission among drug users by two-thirds since 2001, saving taxpayers in that state more than $200 million in medical costs. While a clean syringe costs pennies to provide to Chicago residents like Susan, it can cost up to $350,000 over her lifetime to treat her if she gets HIV. Lifetime treatment for Hepatitis C costs $100,000 to $300,000 but much more if a liver transplant is necessary.
We need strong federal leadership to end this phony controversy. President Obama's 2013 budget proposal authorizes funding for syringe exchange, and the administration should fight for it. Federal agencies that administer these funds should treat the ban as a "teaching moment" for state health departments, law enforcement and the public that syringe exchange programs save lives, save money, and bridge people into treatment. The Department of Justice should review the state laws that are blocking implementation of syringe exchange and provide guidance for how to make these laws compatible with the National AIDS Strategy.
Most important, the lives of real people like Susan must stop being used as political footballs. Susan is more likely to share needles, more likely to contract HIV and hepatitis, and less likely to enter drug treatment if she has no access to a syringe exchange program. The beginning of the end? Yes indeed -- not for AIDS, but perhaps for Susan.
