Critical Condition Facing Needle Exchange Programs: The Politics of Science

I was asked in January to write this editorial in response to the question, “what is the most critical contemporary unresolved issue that is associated with syringe and needle exchange programs (NEPs).” I quickly thought of a series of critical SNEP issues that depended on specific contexts: laws and policies, the existence and duration of SNEPs, and the coverage of syringes exchanged relative to the number of drug users. Regardless of the social, legal, or political context of the SNEPs, the main goals of SNEPs are to distribute clean syringes and to take used syringes out of circulation in an effort to decrease the risk of disease spread (Kaplan and Heimer, 1994). As succinctly stated by David Purchase, founder of the first SNEP in the United States, “the point is the point” (personal communication). But recent events in the U.S. congress shifted the focus of my answer to this critical question. The most critical conditions facing NEP programs in the United States as well as in many countries with U.S. funded HIV/AIDS prevention efforts are the ignorance of politics and the politics of science.

In their extensive review of the effectiveness of SNEPs in the impressive body of research documenting reductions in HIV/AIDS, hepatitis B, and hepatitis C infections among injection drug users (IDUs), Wodak and Cooney (2004) asserted that the cumulative research findings which span time, populations, and continents support a casual relationship between SNEPs and HIV/AIDS. Based on the time-tested method of deductive reasoning, one would assume that the body of first-generation research would be widely embraced as truth and inform policies and practices in a number of diverse countries spanning from Eastern Europe to Southeast Asia where HIV/AIDS epidemics rage among IDUs.

In addition to the relationship between SNEP and risk behaviors, infectious disease prevalence, first-generation SNEP research included defying other myths that served as fodder for those against SNEPs, including demonstrating that they are not associated with an increase in criminal activity (Marx et al., 2000), they do not result in an increase of discarded contaminated syringes (Doherty et al., 1997, 2000) they are not associated with the creation of risky IDU networks (Junge et al., 2000), and they do not increase the number of IDUs by their mere presence in a community. In addition to defying these myths, research have found that SNEPs are associated with entry into drug treatment (Brooner et al., 1998; Heimer et al., 1998; Strathdee et al., 1999) and can serve as a link to a range of needed health services (Riley et al., 2002) to marginalized populations. As far as expanding the reach of SNEPs, there is an increased focus on the role of secondary syringe exchangers, who often have access to at-risk IDUs that otherwise are not reached by services. Finally, overdose prevention and naloxone distribution programs are increasingly becoming incorporated into the fabric of SNEPs’ basic services (Bigg, 2002; Seal et al., 2003; Sherman et al., 2003, 2004).

But as we continue to learn again and again, science does not inform sound judgement and good policies, as exemplified by the United States. Rather, scientific integrity and research has been under attack for the past 4 years, with morality and politics, rather than science, informing the priorities of many government-sponsored research and public health initiatives. Because the United States is the largest single donor country in the world, our policies have far-reaching influence. As a result, we are back to the basics of having to “prove” a proven argument—that SNEPs do not cause drug use and are not a part of a large drug legalization agenda. How can we still be having this conversation in 2005? Through the rest of the Western industrialized world and many parts of the developing world, SNEPs are a vital component of the fight against drug abuse and HIV/AIDS.

On Wednesday, February 16, 2005, Rep. Mark Souder (R-Indiana), chair of the Government Reform subcommittee on Criminal Justice, Drug Policy and Human Resources, held a hearing entitled, “Harm Reduction or Harm Maintenance: Is There Such Thing as Safe Drug Abuse?” Over the past 3 years, Rep. Souder has stridently expressed his disdain for any response to drug abuse other than that of abstinence. Specifically, he has attacked syringe exchange programs, through misrepresenting scientific research findings and extolling abstinence-based treatment as the only answer.

This hearing has not gone unnoticed. In addition to the hundred activists who attended the 5-hour long hearing, editorials in the Washington Post and New York Times have exposed the ludicrous and vicious nature of Souder and such colleagues as Senator Sam Brownback of Kansas who have not only demonized SNEPs but have initiated conversations about withdrawing financial support from any organization that supports SNEPs.

Although debates continue on the effectiveness of condoms and syringes in abating the HIV/AIDS epidemic, people continue to contract the disease that is entirely preventable. An estimated 4.8 million new HIV infections occurred worldwide during 2003, which is roughly 14,000 infections each day. More than 95% of these new infections occurred in developing countries (CDC, 2004). In the United States, approximately 40,000 new HIV infections occur each year, which translates to roughly 110 people each day. In 2003, 17% of reported new HIV infections in the United States were attributed to injection drug use or sex with an IDU. Additionally, 43% of all AIDS cases among African American men and 53% of African American women diagnosed through 2003 were attributed to injection drug use or sex with an IDU. Although millions have been spent on prevention with IDUs, the need to increase the reach of SNEPs is grossly apparent. This translates to the changing of drug paraphernalia laws, lifting the illegal nature of syringe exchange, and the expansion of funding to increase the number of SNEPs, now estimated at 140 in the United States.

The potentially deleterious effects of this administration and congress’ policies toward not simply funding such cost-effective and necessary prevention tools such as harm reduction, but their active attempts to ban the provision of this service throughout the globe is beyond critical. As researchers, we have an obligation to continue doing the research that improves the health and welfare of our study participants. As important, we are obliged to engage in the political process that so single-mindedly defies the logic and reason that is the very basis for our work.