NATIONAL COMMISSION ON
ACQUIRED IMMUNE DEFICIENCY SYNDROME
Full Report: The Twin Epidemics of Substance Use and HIV
Washington, DC, July 1991
Table of Contents
THE TWIN EPIDEMICS OF SUBSTANCE USE AND HIV
- Introduction
- Overview
- National Drug Control Policy
- Recommendation 1
- Recommendation 2
- Recommendation 3
- Recommendation 4
- Recommendation 5
The failure of the federal government to
recognize and confront the twin epidemics of substance use and
HIV infection has become glaringly apparent to the Commission
throughout its nearly two years of hearings and site visits. The
federal government's strategy of interdiction and increased
prison sentences has done nothing to change the stark
statistics: Repeatedly, medical and treatment experts
have come before the Commission and stressed the absolute
importance of treatment on demand. Increasing treatment slots is
a stated goal of the federal drug control policy, yet, as Dr.
Robert Newman told the Commission, " . . .there seems to be
nothing.. .to indicate that any government agency either at the
federal or at any of the 50 state levels is indeed pursuing the
objective of expansion on a massive scale to make treatment for
addicts who want it readily available." Providing quality
treatment and treatment on demand may be an expensive
proposition, but so is the unchecked spread of HIV infection.
For a successful short and long-term solution we must shift our
focus from expensive prison beds which represent society's
failure, to less expensive treatment slots which represent our
only hope, and provide easily accessible drug treatment to all
those who need and request it. (See Appendix A) As the
Commission Working Group on Social/Human Issues stated in its
April, 1991 report, "...it is fundamentally unjust, as well
as unwise, to tell those who seek treatment for drug addiction
that there is no room; but then tell them that the taxpayers are
willing to spend thousands of dollars a year to keep them in
jail." We must also take immediate steps to curb
the current spread of HIV infection among those who cannot get
treatment or who cannot stop taking drugs. Outreach programs
which operate needle exchanges and distribute bleach not only
help to control the spread of HIV, but also refer many
individuals to treatment programs. Legal sanctions on injection
equipment do not reduce illicit drug use, but they do increase
the sharing of injection equipment and hence the spread of HIV
infection. If HIV transmission related to substance
use is going to stop, the federal government must take a
leadership role in coordinating public health and drug treatment
on all levels and in creating and implementing a cohesive
national plan. Currently, the issue of HIV and substance use is
falling through the cracks, and without clear policy directives
to the medical, public health and drug treatment communities it
will continue to do so. The federal government must also ensure
that the great strides made from research and demonstration
projects are not lost through cut-backs or lack of funding.
Successful demonstration projects should be identified and
funding made available for their continuation as active federal
projects. Funding for research on substance use and HIV should
be expanded, not cut back or simply held constant. Research, both
sociological and epidemiological, holds the key to discovering
the answers to crucial questions around HIV and substance use.
Clinical trials, a key component to research, should be open to
individuals with a history of, or current, substance use
problems. Finally, all levels of government and the
private sector must work together to attack the deep-rooted
social and economic problems which promote and sustain substance
use. The poor of this nation, especially in communities of
color, have been inordinately hard hit by the twin epidemics of
HIV and substance use. In order to combat these epidemics which
affect the entire nation, we must provide basic needs such as
housing, medical care and food. HIV education and drug treatment
often seem like luxuries to individuals who do not know where
they will sleep at night or where their next meal will come
from. To reach the point where our nation's drug epidemic is
really a thing of the past, we must create communities and
neighborhoods which promote health and hope, not addiction and
despair. To help work toward these goals the Commission puts forward
the following recommendations: 1. Expand drug abuse treatment so that all who apply for
treatment can be accepted into treatment programs. Continually
work to improve the quality and effectiveness of drug abuse
treatment. 2. Remove legal barriers to the purchase and possession of
injection equipment. Such legal barriers do not reduce illicit
drug injection. They do, however, limit the availability of
new/clean injection equipment and therefore encourage the
sharing of injection equipment, and the increase in HIV
transmission. 3. The federal government must take the lead in developing
and maintaining programs to prevent HIV transmission related to
licit and illicit drug use. 4. Research and epidemiologic studies on the relationships
between licit and illicit drug use and HIV transmission should
be greatly expanded and funding should be increased, not
reduced or merely held constant. 5. All levels of government and the private
sector need to mount a serious and sustained attack on the social problems that promote licit and
illicit drug use in American society. The Twin Epidemics of Substance Use and HIV
It is my firm belief that policies related to AIDS and policies related to
drugs are so intertwined that commenting and really wrestling and getting to the
solutions to one will impact the other, and that it is necessary to consider
both national drug policy and national policies related to AIDS. (1)
-Kurt Schmoke, December 18, 1990
In this the tenth year of the HIV epidemic the nation continues to face not
one epidemic, but two: the twin epidemics of substance use and HIV infection.
Since the early 1980s the close and deadly link between the sharing of injection
drug equipment (*) and HIV has been well recognized. More recently, the link between
non-injectable substances, such as alcohol and crack, and unsafe sexual activity
which can result in the spread of HIV infection has also become glaringly
evident. Yet, instead of responding to these epidemics with public health and
treatment measures to cope with both, the federal government's primary response
has been imprisonment and increased jail sentences, often ignoring drug/HIV
relationships. The dire results of this myopic criminal justice approach are
shown in the following statistics:
Despite these dreadful growing numbers, (see Appendices B and C) our national
drug control strategy does not reflect the immediacy of the problem, the need
for significant expansion of drug treatment to permit treatment on demand, or
the obvious and critically important relationship between HIV infection and
substance use. To address this huge public health threat, the National
Commission on AIDS convened a hearing on "Substance Use and HIV" in January
1991. Through the testimony of experts and individuals who are experiencing the
problems of HIV and substance use firsthand, the Commission was better able to
identify certain key issues and the urgent actions the nation must take to deal
with these twin epidemics. Current programs are seriously wanting.
Through the Commission's hearings and site visits over the last year and a
half, the wide range and diverse nature of substance use and the population of
substance users has become very much apparent. Substance use problems cross all
lines of age, geography, ethnicity and economics. Infants, adolescents and
adults, rural and urban, poor and rich –
all are affected. Of special concern
to the Commission is the importance of recognizing the behaviors that put an
individual at risk for exposure to HIV whether or not that individual believes
he or she fits into the category of "drug addict." Some high school and college
athletes share needles to inject steroids.(10) Individuals from cultures and
countries with differing medical practices often share needles to inject
vitamins.(11) Practicing these behaviors poses the danger of transmitting
and acquiring HIV just as sharing a needle to inject heroin or cocaine does.
The Commission is also deeply concerned by the force with which these twin
epidemics have struck communities of color, women, and adolescents. There are
significantly elevated rates of HIV infection among blacks and Hispanics
compared with whites.(12) The rates of HIV infection related to IV drug use are
also growing among women, many of whom do not perceive that they are at risk.(13)
Adolescents are especially at risk. Adolescents, and others, who avoid
intravenous drugs still expose themselves to the risk of HIV infection through
unsafe sexual behavior during the use of alcohol and other substances. It is
important, when considering this issue, to be realistic about when young adults
in the U.S. begin having sex. "In 1990, the researchers at the Alan Guttmacher
Institute in New York and the Urban Institute in Washington analyzed federally
funded surveys of boys and girls conducted in 1988. They reported [that] both
boys and girls were more likely to be sexually experienced than those surveyed
in the late '70s and early '80s. Half of girls had sex by age 17; half of boys
by age 16." The survey also shows that, "...3 out of 4 unmarried 19-year old
women and 5 out of 6 unmarried 19-year old men were sexually experienced." (14)
The linkage between sexual behavior and substance use is vividly reflected in
the following example from Dr. Robert Johnson of Adolescent Medicine at the
University of Medicine and Dentistry of New Jersey:
[O]ur last four adolescents who had heterosexual transmission of the disease
all had sexual behavior that was associated with alcohol use, particularly a
drug form of 'wine cooler' named Cisco, and these young people who had used
condoms in other situations did not use condoms [here]...
Adolescents, and others, are also at risk through the growing practice of
trading drugs, especially crack (the smokeable form of cocaine), for sex. Dr.
Johnson gave the following example which dramatically illustrates this
connection:
One particular crack dealer...in our adolescent clinic in Newark revealed
that in the month of August he had sex with 30 different women in trade for
crack. In addition, he carried on a sexual relationship with his girlfriend who
did not use drugs. All of this activity occurred without the benefit of the
protection of condoms. In that month, he and his girlfriend, and his
girlfriend's new boyfriend, and his girl friend's new boyfriend's alternative
sexual partner, all became infected with gonorrhea and chlamydia.(15)
While much of this, and other substance using activity, is concentrated in
urban areas, there has been an increasing trend towards substance use,
especially crack, in suburban and rural areas as well. The Commission previously
highlighted this trend in its August 1990 report on HIV in rural America.
Another disturbing trend, with serious implications for the HIV epidemic, is the
resurgence of heroin use in the Northeast.(16)
It can be seen from even this small sample of issues that substance use plays
a major role in the transmission of HIV disease –
indeed, a much larger role
than has been generally recognized. Clearly, our nation's drug control policies
must recognize this inextricable linkage between drugs and HIV disease and be
designed to address the two aggressively and simultaneously.
To date, the National Drug Control Policy has failed to address the
coupling of the epidemics of HIV and substance use. Indeed, thus far, the Office
of National Drug Control Policy (ONDCP) and other federal agencies have barely
recognized the linkages. In the 1991 report from ONDCP, (a 161 page report),
there are only three paragraphs of text addressing this issue. The failure to
acknowledge this –
the obvious –
is bewildering and tragic. The first step is
for the ONDCP, and other federal drug agencies to fully recognize the problem.
In order to do this, the federal government must recognize that HIV and
substance use is one of the issues of paramount concern within the "war on
drugs." Any program which does not deal with the duality of the HIV/drug
epidemic is destined to fail.
The current national approach to the problems of substance use is to deal
with those who are addicted primarily by means of the criminal justice system.
Clearly, this approach is not working and a public health approach is
desperately needed. Despite the fact that "we [a]re incarcerating people at a
greater rate than any nation in the world, and incarcerate blacks at a higher
rate than South Africa,"(17) substance use continues, and transmission of HIV
related to injection drug use has increased rapidly over the past decade.(18) The
criminal justice system is the least viable setting for providing treatment and
addressing issues of HIV and substance use. Yet this has become the primary
strategy in our "war on drugs." Those forums which should have a proactive role
in dealing with substance use, namely the medical and public health communities,
have been seriously neglected. We must develop a system which coordinates public
health and health care with treatment and outreach, both of which have shown
positive results.
Expand drug abuse treatment so that all who apply for treatment can be
accepted into treatment programs. Continually work to improve the quality and
effectiveness of drug abuse treatment.
Repeatedly, medical and treatment experts have come before the National
Commission on AIDS and stressed the absolute necessity of treatment on demand.
It has been over three years since the Presidential Commission on HIV made their
recommendations for developing "a plan for increasing the capacity of the drug
treatment system so that the goal of treatment-on-demand can be met. " Yet we
still lack the commitment we need from the federal government to achieve this
goal. While treatment expansion is a stated goal of the federal drug control
policy, no real gains have been made on any level. As Dr. Robert Newman told the
Commission, "...there seems to be nothing...to indicate that any government
agency either at the federal or at any of the 50 state levels is indeed pursuing
the objective of expansion on a massive scale to make treatment for addicts who
want it readily available."(19) We must also work to ensure that the quality of
treatment is constantly improving. Immediately available, effective,
high-quality treatment slots are the final goal. The Commission recognizes that
improved quality of treatment and treatment on demand are expensive; but so is
the unchecked spread of HIV infection. As the following statement illustrates,
we are putting the available, much needed resources elsewhere:
Exactly a year ago the White House issued a strategy on drug abuse control in
which it made reference to a request for $1.5 billion for one fiscal year to
expand by 24,000 the number of prison beds in the federal system in addition to
even more massive expansion of prisons at the state and local level.
Contrast those very specific and massive goals with what was said in that
strategy report with regard to treatment. It was proposed that $100 million, be
added for treatment expansion to allow 11,000 additional treatment slots to be
created and to put that into perspective, the Institute of Medicine within the
last six months referred to an estimate of 66,000 people in our country
currently being identified as on waiting lists for various types of treatment
programs." (20)
The numbers are likely even higher. NIDA has made estimates based on
provisional data which indicate that as many as 107,000 persons are currently on
waiting lists for drug treatment.(21) And, as early as 1988, "more than half of
New York City's estimated 200,000 HIV drug users were infected with HIV. At any
given time, about 33,000 publicly funded drug treatment slots were available to
assist these people. " As of September 1990, there were a little over 38,000
publicly funded treatment slots.(22)
The reality of these numbers was made clear to the Commission through the
following eloquent testimony of a woman who lives every day with the epidemics
of HIV and substance use:
I still work the streets to support a $150 a day habit of heroin and crack. I
am forced to have sex with approximately ten men per day to support my habit,
which is putting me at risk of further HIV infection, sexually transmitted
diseases, and rape or death. What I want to tell you is that if I ha[d]] been
accepted into a drug treatment program three years ago, I would not be sitting
here in front of you today telling you that I am HIV infected.(23)
Federal officials have questioned the wisdom of treatment on demand on three
major grounds: first, there are already enough open slots in treatment programs,
but poor coordination results in waiting lists; second, the efficacy of
treatment methods is still unknown; and third, treatment on demand may create a
"revolving door" effect with substance users moving in and out of treatment
programs without ever taking treatment seriously.(24)
The government has argued that with a computerized system and increased
coordination we could fill all the available slots, thus rendering new slots
redundant. Further coordination between treatment centers and a computerized
program to help expand access are excellent ideas, but coordination can only do
so much. Treatment programs need to be easily accessible to people in need –
being shunted to another part of the city to an open treatment slot may make
treatment impossible for many substance users. Open slots in certain treatment
programs may also reflect programs which are not thought to work by the
substance users themselves. Whether the perception is justified or not, research
should be done on what draws substance users to a particular program or type of
treatment, and what drives them away. While the Commission recognizes this need to coordinate treatment programs to
make the system of providing care as efficient as possible, it also recognizes
that many of the "open slots" may, in fact, exist only on paper. Budget cuts on
both the state and federal levels have limited the operating capacity of many
treatment programs, while leaving the original operating capabilities "on the
books." Therefore, a treatment center listed as having 100 slots may in fact
have only enough staff and equipment to serve 70 individuals –
leaving a
"phantom" 30 spots "unfilled." Questions about the efficacy of treatment have been raised by many medical
problems. The Commission recognizes the frustration faced by those who try to
treat substance use, and believes that further research into treatments for
specific "new" and "multiple" substance use behaviors must be developed; at the
same time we must continue to treat individuals with the methods which we have
on hand. As the Commission's vice chairman Dr. David Rogers said in response to
this argument, "We don't use the excuse of, 'We don't know quite how to treat you ' to people with congestive heart
failure . . . [or] . . . cancer." (25)
Finally, the Commission does not agree that treatment on demand will create a
lax attitude among those who seek treatment, as officials of ONDCP have argued.
Instead, the Commission recognizes the medical nature of substance use problems
and the need to provide treatment for those problems. As Dr. Rogers said, "I
know of no other fatal disease in which we say, 'Go away; we'll treat you
later.' [Or, in which we] use the excuses of, '... [Y]ou may not behave; you
may not stay in treatment. '"(26) The Commission recognizes the role of relapse in
the process of drug treatment and believes strongly that treatment on demand can
offer the substance user the hope of further treatment rather than the despair
of waiting with further risk of death and disease.
In order for treatment to be truly available we also need to remove those
barriers placed in the path of the substance user which can make it virtually
impossible to gain access to care and treatment. As one witness told the
Commission:
The drug treatment system to many substance abusers is unworkable and
unmanageable. Addicts must apply for treatment, and keep in mind that most are
homeless and with no support services. They must have at least two pieces of
identification, a permanent mailing address, be Medicaid eligible, give and pay
for a urine test, have an initial first fee for screening for the screening day,
go through a series of interviews and processes, and after all this they may be
admitted and medicated. This is too much for an addicted person to face.(27)
Given these requirements, it is no wonder that there may be some open slots
in drug treatment centers. Treatment programs, secondary to law enforcement
efforts, housed in dilapidated centers, and poorly staffed, now have been
charged with not only treating substance use, but also solving the problem of
HIV. It is little wonder that the problem continues to grow.
Remove legal barriers to the purchase and possession of injection equipment.
Such legal barriers do not reduce illicit drug injection. They do, however,
limit the availability of new/clean injection equipment and therefore encourage
the sharing of injection equipment, and the increase in HIV transmission.
National drug policy must recognize the success of outreach programs which
link needle exchange and bleach distribution programs with drug treatment. The
Commission has visited numerous programs throughout the country which distribute
bleach and some that exchange clean needles. These programs have demonstrated
the ability to get substance users to change injection practices. Most
significantly, these programs, rather than encouraging substance use, lead
substantial numbers of substance users to seek treatment.
For example, the Tacoma, Washington project conducts a syringe exchange and
other AIDS prevention activities, as well as providing some basic services. Soon
after its establishment it became the "largest referral source to treatment
in [the] county."(28) Studies of demonstration projects like these have
shown that they are an immediate and effective way of addressing the public
health threat of HIV and of reducing demand. Yet, state to state, and even city
to city, policy and practice on this issue differs to such a degree that
outreach workers may have the full cooperation of the local police in one area,
and be arrested in another. There must be increased coordination between law
enforcement officers and outreach workers. The very real fear that clean
syringes and bleach vials will be used as evidence for arrest and prosecution
may be having a "chilling effect" on drug users' practice of safer injection
behaviors. These legal sanctions on injection equipment thus serve to increase
the sharing of injection equipment and, through this behavior, the transmission
of HIV. It is imperative that we remove these legal barriers so that the
transmission of HIV can be lessened for those who cannot stop injecting drugs.(**)
Examples from some U.S. cities and the U.K., the Netherlands, and Australia
show that cooperation of law enforcement and public officials can make a major
difference in the success of outreach programs. In Tacoma, where the city and
county jointly run the health department, all city and county representatives
who sit on the health board have been educated about AIDS. The chief of police
is also "AIDS educated" and was able to cooperate with the outreach programs in
the city. This syringe exchange and basic needs outreach program in Tacoma has
resulted in "approximately an 80 percent reduction in risk behavior in terms of
injecting practices of the people that use the exchange as opposed to those who
don't." In the documentary "Taking Drugs Seriously," a film about the Merseyside
Regional Health Authorities' harm reduction approach in the U.K., Allan Parry,
Director of the Maryland House in Liverpool, believes that "the main reason
we're keeping down the spread of the virus is because of the police support of
[syringe exchange] activity." Detective Superintendent and Drug Squad Chief
Derek O'Connell explains that while they do not support decriminalization...,
"because of the AIDS problem which is now recognized by the government as a
very, very serious problem, it would be remiss if we didn't give support
wherever it was needed." In fact, since beginning their new "cautioning" program
which steers individuals toward drug dependency programs instead of prosecuting,
they have seen "an 85% success rate; that is, people not re-offending."(30)
The federal government must take the lead in developing and maintaining
programs to prevent HIV transmission related to licit and illicit drug use.
To date, no single agency or group has taken charge of this issue of
overwhelming importance to the national health. In drug treatment programs, a
level of awareness about AIDS which was never sufficient to control the epidemic
now seems to be fading.(31) One woman with HIV disease told the Commission that
"[i]n North Carolina, in Narcotics Anonymous, they do not talk about AIDS. It is
considered an outside issue."(32) Some individuals with HIV disease are even
denied access to treatment programs because of their HIV infection.(33)
Public health and health care agencies have ignored the problem from the
other side –
not confronting the substance use issues involved with individuals
who have HIV infection or who may be at risk. Although in the rest of the
developed world, medical and public health professionals have directed national
drug policy to target prevention of the spread of HIV within the injecting drug
user community, there has been no parallel in claiming such policy-setting
responsibility here in the U.S.
The real responsibility for these shortfalls lies with the federal
government. Because of the lack of coordination and planning on the federal
level with regard to HIV in general, and substance use and HIV in particular,
groups in both public health/health care and drug treatment lack direction in
the face of the epidemic. The Commission applauds such efforts as the November
1990 "National Conference on HIV and Substance Abuse: State/Federal Strategies"
sponsored by ADAMHA, ASTHO, CDC, HRSA, NAPO and NASADAD,(***) which attempted to coordinate state and federal agencies and discover new
directions for action.
The conference focused on a number of inter-related issues: the need for
increased coordination of traditional public health departments and substance
abuse treatment programs; improvement of joint program planning by state health
and substance abuse treatment systems; and the need to increase state and
federal collaboration in addressing the HIV/substance abuse issue.(34) The
recommendations which came out of the conference in the areas of provision of
services, evaluation of services, training, and research are insightful and
relevant. Examples include many recommendations which reflect the concerns of
the Commission:
Provide HIV prevention services in drug treatment settings and services for
drug users in public health clinics; Provide outreach to drug users who are not
in drug treatment and to the sex partners of drug users; Improve and expand the
capacity of drug treatment; Provide drug treatment services in primary health
care facilities; Provide primary health care in drug treatment centers; Provide
training and cross-training of staff; and, Improve the evaluation of
HIV/substance abuse programs.(35)
The question now is, where do we go from here? Without a cohesive national
strategy which assigns responsibility, provides leadership and vision, and
follows through on coordination, these excellent recommendations and advances
will be lost. In order for coordination to truly work, there need to be
incentives for public health and drug treatment providers to join together in
seeking grants and other federal monies. The present system discourages rather
than encourages such cooperation. Demonstration projects need to be set up with
a component for evaluation and further funding already in place so that valuable
people, time and resources are not lost. Increased federal action in the areas
of evaluation, technical assistance and development of training, guidelines, and
models can help bring about the cooperation and coordination of health care and
drug treatment which are essential to meeting the goal of providing primary care
to substance users with HIV disease.(36)
Research and epidemiologic studies on the relationships between licit and
illicit drug use and HIV transmission should be greatly expanded and funding
should be increased, not reduced or merely held constant.
While the definite link between HIV transmission and substance use is
well-established, many questions about the relationship between substance use
and HIV remain unanswered. What effect does continued substance use have on the
progression of HIV disease? What behaviors place individuals at the greatest
risk for transmission? Although further research is essential to help us answer
and provide solutions for these and related questions, much has been learned
thus far – policy makers are not in a scientific vacuum. Since the beginning of
the epidemic we have learned much more about injection drug use and substance
use and sexual practices which are linked to HIV. Research into these topics
should not be relegated to private sponsors because of a mistaken perception
that substance use and HIV are not critical national problems. Such research
falls squarely under the aegis of the federal government.
There are two issues of particular concern to the Commission within the
larger context of research on HIV and substance use. First, the future of
projects funded through demonstration grants and second, the potential cuts in
the number of federally funded investigator-initiated grants. The Commission's
concern for demonstration projects is reflected in the discussion above on
outreach projects. The whole concept of "demonstration" projects needs to be
better defined; the evaluation process should be designed so that successful
projects can be identified at an early stage. Funding can then be made available
for their continuation as on-going federal projects. A consistent policy must be
developed to prevent the shutdown of successful programs and the loss of trust,
staff and progress.
The Commission is also concerned with proposed cuts in funding for
investigator-initiated grants and the numbers of programs to be covered in the
coming years. The Commission believes strongly that funding for research on HIV
and substance use should be increased and is specifically concerned with the
potential cuts in the numbers of grants available under ADAMHA. The Commission
believes that the basic and applied research funded through this mechanism is
often among the most productive and creative and holds great potential for
progress in finding the answers to crucial questions around HIV and substance
use. To cut these innovative programs, either in funding amount or numbers of
grants, would delay once again the answers to questions which are crucial in
curbing the spread of these epidemics.
Clinical trials are a key component of research and can offer both immediate
and future benefits in treatment and care of HIV disease. The Commission
believes strongly that those with a history of, or current, substance use
problems should be actively enrolled in clinical trials. As with the provision
of primary care, it may be appropriate to look to increased cooperation with
treatment centers for finding participants and conducting these clinical trials.
All levels of government and the private sector need to mount a serious and
sustained attack on the social problems that promote licit and illicit drug use
in American society.
The combined epidemic of HIV and substance use has hit hardest the
individuals in our society who are least equipped to deal with it –
the poor.
The poor of this nation, especially within communities of color, lack access to
medical care, housing, food, and other basic needs. Substance use treatment and
HIV education may often seem like luxuries to people who do not know where they
will sleep at night or where their next meal will come from. As Sandra
Vining-Bethea of the Bridgeport Women's Project told the Commission, "It's hard
to educate a woman who is homeless and hungry."(37)
Those who live in poverty are also subject to extremes of social neglect
which can add to the likelihood of substance use and risk practices. As Dr.
Robert Fullilove of the Psychiatric Institute in New York told the Commission:
The one thing we know about poverty in this country in the last 20 years is
that it has really altered the structure of many of the neighborhoods in the
United States. Blacks and Latins are increasingly concentrated in areas that are
becoming poorer and poorer, and with that concentration has come a tremendous
increase, not just in HIV infection, not just in the prevalence of drug abuse,
but a whole host of other serious social problems ranging from crime to just
about anything that you can possibly describe. (38)
If the nation is to provide treatment and education which will move people
away from substance use problems and the risk of HIV infection, it must
recognize the role which poverty plays in this dilemma.
As Dr. Fullilove went on to tell the Commission:
. . .the most common feature of drug abuse is relapse. And we think relapse
is related to environmental factors, the degree to which people live in
neighborhoods where the neighborhood itself is a toxic agent that promotes addiction.
. . . Unless we are able to stabilize the communities in which drug
abuse, (particularly non-white communities), unless we're able to stabilize these neighborhoods and provide them with some kind of economic base,
the underground economy which pushes and promotes crack cocaine addiction is going to do far more to damage our efforts to reach
individuals. . . . (39)
While attacking the problems of HIV and substance use in the short-term with
the methods discussed above, the federal government must lead the way in
simultaneously addressing the larger social issues of poverty, homelessness and
lack of medical care. We must work cooperatively with both the public and
private sectors to remove these barriers to prevention and treatment. (*) The Commission uses "injection drug equipment" to refer to those
paraphernalia that carry the potential for contamination: the syringe, needle,
"cooker," cotton and rinse water.
(**) Twelve states currently require prescriptions to obtain needles. Source: AIDS Policy Center, Intergovernmental Health Project, The
George Washington University, June l99l.
(***) The Conference was sponsored by the following organizations:: Alcohol, Drug
Abuse, and Mental Health Administration (ADAMHA); Association of State and
Territorial Health Officials (ASTHO); Centers for Disease Control (CDC); Health
Resources and Services Administration (HRSA); National AIDS Program Office (NAPO); and the National Association of State Alcohol and Drug Abuse Directors
(NASADAD).
1. Schmoke, K. (1990) Testimony before the National Commission on AIDS.
Baltimore, December 18. Transcript at pp. 141-42.
2. DesJarlais, D. Personal Communication, May 30, 1991.
3. Centers for Disease Control (1991) "AIDS/HIV Surveillance." (IJ.S.
AIDS cases reported through May 1991) pp. 9-10.
4. Ibid.
5. Ibid.
6. Ibid.
7. Ibid.
8. The Citizens Commission on AIDS for New York City and Northern New Jersey.
(1991) AIDS: Is There a Will to Meet the Challenge? p. 31.
9. National Institute on Drug Abuse (NIDA)/Division of Applied Research.
(1991) "Drug Services Research Survey." Conducted by Brandeis
University. (Estimates based on provisional data pending refined data in Fall,
1991).
10. Kamens, D. (1991) Testimony before the National Commission on AIDS.
Chicago, March 13. Transcript p. 92.
11. Marin, B. (1990) AIDS prevention for non-Puerto Rican Hispanics. AIDS
and Intravenous Drug Use: Future-Directions for Community-Based Prevention
Research, NIDA Research Monograph 93:39.
12. Hahn et al. (1989) HIV Prevalence. Journal of the American Medical
Association 261:2682.
13. Philadelphia Inquirer, "Study: Women fail to see AIDS risk."
Lauran Neergaard p. A4 March 29, 1991.
14. USA Today, "Fewer kids save sex for adulthood," pp.
lD, lE, March
5, 1991.
15. Johnson, R. (1991) Testimony before the National Commission on AIDS.
Washington, January 17. Transcript at pp. 53-60.
16. Des Jarlais, D. (1991) Personal Communication. July 2, 1991.
17. Mulligan, D. (1991) Testimony before the National Commission on AIDS.
Washington, January 17. Transcript at p. 133.
18. Des Jarlais, D. (1991) Personal Communication. May 30, 1991.
19. Newman, R. (1991) Testimony before the National Commission on AIDS.
Washington, January 17. Transcript at p. 124.
20. Newman, R. (1991) Testimony before the National Commission on AIDS.
Washington, January 17. Transcript at pp. 125-26.
21. National Institute on Drug Abuse (NIDA)/Division of Applied Research.
(1991) "Drug Services Research Survey. " Conducted by Brandeis
University. (Estimates based on provisional data pending refined data in Fall,
1991).
22. The Citizens Commission on AIDS for New York City and Northern New
Jersey. (1991) AIDS: Is There a Will to Meet the Challenge? p. 31.
23. Yvette. (1991) Testimony before the National Commission on AIDS.
Washington, January 17. Transcript at p. 110.
24. Primm, B. (1991) Testimony before the National Commission on AIDS.
Washington, January 17.
Kleber, H. (1990) Testimony before the National Commission on AIDS.
Washington, March 15.
25. Rogers, D. (1990) Testimony before the National Commission on AIDS.
Washington, March 15. Transcript at p. 74.
26. Rogers, D. (1990) Testimony before the National Commission on AIDS.
Washington, March 15. Transcript at pp. 73-74.
27. Serrano, Y. (1991) Testimony before the National Commission on AIDS.
Washington, January 17. Transcript at p. 108.
28. Purchase, D. (1991) Testimony before the National Commission on AIDS.
Washington, January 17. Transcript at p. 102.
29. Purchase, D. (1991) Testimony before the National Commission on AIDS.
Washington, January 17. Transcript at p. 103.
30. Parry, A. (1990) Taking Drugs Seriously (Video 30 minutes) An Open Space
Video/BRC, Liverpool. (N. Platt, director; K. Hinchey, editor; M. MacCormack,
producer.)
31. Sorenson, J. (1991) Testimony before the National Commission on AIDS.
Washington, January 17. Transcript at p. 141.
32. Thompson, A. (1991) Testimony before the National Commission on AIDS.
Washington, January 17. Transcript at p. 134.
33. Sorenson, J. (1991) Testimony before the National Commission on AIDS.
Washington, January 17. Written testimony at p. 2.
34. Primm, B. (1991) Testimony before the National Commission on AIDS.
Washington, January 17. Transcript at pp. 34-35.
35. Department of Health and Human Services. (1991) Draft Report of The
National Conference on HIV and Substance Abuse: State/Federal Strategies.
November 13-15, 1990. pp. ix-xii. (Please note: In the final version
recommendations appear in the body of the report.)
36. Coye, M. (1991) Testimony before the National Commission on AIDS.
Washington, January 17. Transcript at pp. 163-66
37. Vining-Bethea, S. (1991) Testimony before the National Commission on
AIDS. Washington, January 17. Transcript at p. 100.
38. Fullilove, R. (1991) Testimony before the National Commission on AIDS.
Washington, January 17. Transcript at p. 62.
39. Fullilove, R. (1991) Testimony before the National Commission on AIDS.
Washington, January 17. Transcript at p. 62.
The appendix charts are not reproduced here. Their titles are: Appendix A. Proposed funding for new prison beds vs. new
treatment slows in 1992 Appendix B1. Total adult IVDU associated AIDS cases by
year,1983-1990 Appendix B2. Adult IVDU associated AIDS cases by sex and
year, 1983-1990 Appendix C1. Adult male IVDU associated AIDS cases by race
and year, 1983-1990 Appendix C2. Adult female IVDU associated AIDS cases by race
and year, 1983-1990 June E. Osborn, M.D., Chairman
Executive Summary
These twin epidemics transcend all economic,
geographic and racial boundaries; everyone is affected.
Substance use enhances the spread of HIV infection through the
sharing of needles and the practice of unsafe sex related to
crack (the smokeable form of cocaine), alcohol, and other
substances. Despite this insidious and indisputable link between
substance use and HIV infection, the Office of National Drug
Control Policy continues to virtually ignore it, and neglect the
real public health and treatment measures which could and must
be taken to halt the spread.
RECOMMENDATIONS:
-Testimony before the National Commission on AIDS
Federal response to treatment on demand
David E. Rogers, M.D., Vice-Chairman
Diane Ahrens
Scott Allen
Harlon L. Dalton, Esq.
Don C. DesJarlais,, Ph.D.
Eunice Diaz, M.S., M.P.H.
Donald S. Goldman, Esq.
Larry Kessler
Charles Konigsberg, MD., M.P.H.
Belinda Mason
Honorable J. Roy Rowland, M.D.
Honorable Dick Cheney
Honorable Edward J. Derwinski
Honorable Louis W. Sullivan, M.D.
