Research-Informed Policy: Our Most Critical Unresolved Issue in AIDS

Within the context of the United States, the most critical unresolved issue regarding syringe exchange is not a question of research, not a question of gaps in our knowledge, and not a question of intervention efficacy, it is, instead, one of strategy: how to most effectively respond at the local and national levels to opposition to syringe exchange. As research scientists, our work is guided by an often unarticulated belief that research matters and therefore good research will inform good policy. Repeatedly, in the arena of syringe exchange research, however, we have had to confront the painful reality that research that does not conform with politically dominant perspectives is ignored or, worse still, is misrepresented and used to justify unhealthy health policy (Buchanan et al., 2003, Shaw and Singer, 2003).

In Springfield, Massachusetts, for example, despite the existence of rigorous research and analyses indicating major health costs (in terms of the significant number of preventable infections that result from not having syringe exchange or even pharmacy purchases of syringes without a prescription) and despite the backing of local public health officials, the city council has not been able to decide to implement syringe exchange. The debate has gone on for several years, during which time the cumulative number of infections in the city related to injection drug use has continued to climb. Council members have been caught between their awareness of the proven public health benefits of syringe exchange and the actions of a vocal opposition in one sector of the local community. The result has been a deadlock on effective public health policy.

In Willimantic, Connecticut, an existing syringe exchange that was effectively reaching an unusually large drug-injecting population for a small city in a semirural area was closed down by the Connecticut Department of Public Health, again because of the vocal opposition of one sector of the community. In neither of these cases, not surprisingly, was the perspective of individuals who inject drugs considered. Ostracized as “outside of the community,” drug users are not granted a voice in health policies that affect their well-being; quite simply, because they are defined as “bad people” their perspectives are irrelevant. Without doubt, this insidious pattern of demonization has contributed, needlessly, to continued spread of HIV/AIDS. Worse still, even well-established syringe exchange programs that have effectively contributed to slowing the epidemic among drug users and lower infection prevalence levels in this population have faced numerous structural impediments (Heimer et al., 1997).

At the national level, of course, over a decade of data collection and multiple commissioned reviews of the literature with consistently positive findings by an array of government bodies has failed to convince an administration, Democratic or Republican, that syringe exchange is good public health policy. Rather than being accepted as a rational, measured, and reality-based approach to public health, the whole program of harm reduction, syringe exchange included, has come to be defined by the powers that be as newest threat to the American way of life (clearly filling a void left by the collapse of the Soviet Union).

Speaking truth to power is always a worthy goal. In an epidemic, however, it is insufficient. How, strategically, to overcome the ideological barriers that separate us from the types of evidence-based public health policies that are needed at the national and local levels to effectively confront the AIDS epidemic in the United States remains our most critical contemporary unresolved issue.