HIV-prevention strategies
Authors: Lawrence Gostin
Journal: The Lancet (1997)

Lurie and Drucker (March 1, p 604)1Lurie P Drucker E An opportunity lost: HIV infections associated with lack of a national needle-exchange programme in the USA.Lancet. 1997; 349: 604-608Summary Full Text Full Text PDF PubMed Scopus (131) Google Scholar call attention to the substantial public-health issue of HIV infection associated with injection drug use in the USA. About half of all new HIV infections in the USA are estimated to occur among injection drug users (IDUs).2Holmberg SD The estimated prevalence and incidence of HIV in 96 large US metropolitan areas.Am J Pub Health. 1996; 86: 642-654Crossref PubMed Scopus (482) Google Scholar In 1995, 75% of IDU-associated AIDS cases occurred among African Americans (50%) and Hispanics (25%). The rate of IDU-associated AIDS per 100 000 people is 3·5 for whites and 50·9 for African Americans.3Centers for Disease Control and PreventionAIDS associated with injecting-drug use–United States, 1995.MMWR. 1996; 45: 392-398PubMed Google Scholar Despite the high morbidity and premature mortality and the inequitable racial distribution, federal and state governments continue to impose many barriers to effective prevention strategies. Lurie and Drucker discuss two impediments to effective prevention: the ban on federal funding of needle-exchange programmes and the reluctance of states and municipalities to implement such programmes. In a study sponsored by the Centers for Disease Control and Prevention, we identified additional barriers to effective prevention of HIV infection and AIDS among IDUs.4Gostin LO Lazzarini Z Jones TS Flaherty K Prevention of HIV/AIDS and other blood-borne diseases among injecting drug users: a national survey on the regulation of syringes and needles.JAMA. 1997; 277: 53-62Crossref PubMed Google Scholar In a national survey, we found that a network of laws and regulations exists at the federal level, in the 50 states, and in many localities that make it a criminal offence to sell, distribute, or possess drug paraphernalia, including drug-injection equipment. The overall effect of such laws is that important public-health prevention programmes may be thwarted by criminal law enforcement. Needle-exchange programmes have questionable legal authority in most states in the USA, and health officials and community activists who distribute syringes for the purposes of drug injection may be in violation of the law. In addition, pharmacists, especially in states with statutes on syringe prescription, cannot sell syringes over the counter, or may have to ask the customer intrusive questions and take his or her name and address. Consequently the large network of US pharmacies are not able effectively to take part in HIV-prevention activities. Finally, IDUs themselves may be committing a criminal offence by complying with public-health advice to carry and use sterile syringes for each injection. Funding and expansion of needle-exchange programmes, though important, are not sufficient HIV-prevention strategies. A comprehensive, well-financed, strategy to prevent both drug use and HIV/AIDS among IDUs would: eliminate regulations that bar the availability and use of sterile drug-injection equipment; expand access to high-quality treatment for drug and alcohol dependency; provide education and counselling on the harms of illicit drugs; adopt effective community strategies to discourage drug use and associated criminal activities; provide rehabilitation for offenders; and provide support for affected families and young people.