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Friday, Mar 04, 2005

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HIV: needle exchanges work

By Mike Trace & Ruth Runciman

American strongarm tactics threaten to scupper successful U.N. harm reduction drug programmes.

DOES ANYONE remember the AIDS and drugs panics of the mid-1990s? We would guess that even those who were interested in drugs and health policy at the time will only have a vague recollection of fears that the new killer HIV virus would be spread by drug injectors sharing needles, then passed on to the rest of society through sexual contact.

At the time, doomsday scenarios of the rampant spread of drug-related HIV infection were fuelled by epidemics in Scotland, Thailand, and the United States, and panic solutions such as island camps for drug injectors were discussed. The national epidemic never happened. HIV rates among drug injectors in the United Kingdom have stayed below 1 per cent since the early 1980s, and transmission from injectors to sexual partners has never been a significant factor in the disease's development.

How this public health disaster has been averted has received little attention: in the U.K., infection rates have remained low because the Government was among the first in the world to introduce public health measures. Targeted education campaigns, the provision of clean syringes and easy access to drug treatment services that did not demand abstinence — activities known as harm reduction — were backed by the Government.

Spain, Germany, the Netherlands, Canada and Australia have had similar positive results from harm reduction policies, while countries which did not introduce them rapidly or widely enough have experienced higher HIV rates among drug injectors. The prevalence of injecting drug use is growing: there are an estimated 13 million injectors in the world, 80 per cent living in developing countries.

Consequently countries in the former Soviet Union, Asia and Latin America that are facing epidemics are largely dependent on aid and the support of the United Nations agencies to introduce effective infection prevention. Over the last 10 years, as the evidence base for effective HIV prevention among drug users has improved, such support has, albeit slowly, been forthcoming. The U.K. has been supportive in the former Soviet Union; the Soros and Gates foundations have been active in HIV prevention and the issue has been addressed through the World Health Organisation, UNAids and the U.N. Office on Drugs and Crime.

These bodies agreed on joint statements last year confirming their support for education, treatment and syringe exchange as essential elements of any national HIV-prevention strategy. So does that mean that a good example of how to tackle a clear public health threat is set to continue? Unfortunately not.

The U.S. has remained sceptical about harm reduction, preferring a drug policy based on enforcement and a treatment approach that demands abstinence; it also punishes continued drug use. In recent international debates on drug policy, Washington has criticised countries that deviate from the war on drugs approach, but it has, to some extent, accepted a focus on HIV prevention by other states.

There are signs, however, that this uneasy consensus is cracking and the gloves are off. The U.S. has always been by far the biggest donor to AIDS programmes. Government agencies have indicated they are uncomfortable with their aid being used to fund harm reduction, but now there are moves to cancel any U.S. support for HIV prevention programmes that include harm reduction measures: the very measures that are proven to be most effective in averting epidemics.

The U.S. State Department has begun to exert pressure on the U.N. office on drugs and crime to retract its stated support for public health measures such as needle exchange.

Following a meeting with State Department narcotics head Robert Charles last November, UNODC executive director, Antonio Costa, wrote to Mr. Charles promising to "review all statements ... and will be even more vigilant in the future," and stating that "we neither endorse needle exchange as a solution for drug abuse, nor support public statements advocating such practices." The U.S. is, of course, by far the biggest donor to the UNODC.

Disturbingly, this tactic of applying pressure to national governments and international agencies to pursue policies preferred by U.S. conservatives does not seem to be limited to drug policy. Similar moves are apparent in reproductive health and prostitution. The common denominator is the strong advocacy of a morality-driven policy in the face of evidence of what works best in protecting public health.

The international community meets next week in Vienna to review progress in reducing global drug problems. The issue of how to tackle drug-related HIV infection is scheduled to be a major theme.

The exchanges will take place with almost no media or parliamentary scrutiny, but the positions agreed will affect the lives of millions of people, and the scale and course of the HIV pandemic in years to come.

If the outcome is a retrenchment from the progress made in recent years by U.N. agencies, this would represent a victory of moralism and financial muscle over evidence and tolerance.

(Mike Trace chairs the International Drug Policy Consortium; Ruth Runciman chairs the UK's National Aids Trust.)

— © Guardian Newspapers Limited 2004

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