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Report
from the Dogwood Center
Contents: Overview Two
trends increase the likelihood of HIV spreading through the sharing of
syringes in the absence of clean needle programs.
First, the price
of heroin has fallen and purity increased.
Second, medical advances in AIDS treatment have resulted in an
increase in life expectancy for persons who inject drugs and who are
already infected with HIV/AIDS. Six major, federally
funded studies have found needle exchange programs are effective in slowing the spread of HIV and
do not increase drug use. Major
medical associations in the United States, including the American
Medical Association, have called for federal funding of needle exchange
programs and, at the state level, the elimination of barriers to sterile
needles. HIV
prevention is cost effective. Pharmacy sale of syringes costs taxpayers
nothing. Preventing new HIV
infections through a needle exchange program is much less costly than
treating a patient with HIV/AIDS, where the annual cost of prescription
medicine can run as high as $17,000 a year. States
where the injection-related AIDS epidemic is most severe In 1998, New York State led the nation with the highest rate of AIDS spread through injecting drug use. Maryland, Delaware, Connecticut, and New Jersey round out the top five. (See Figure 1 and Attachment 1.)
Metropolitan
areas where the injection-related AIDS epidemic is most severe Among
metropolitan areas of over 500,000, New York City, in 1998, had the
highest rate of AIDS spread through injection drug use, followed by the
Baltimore metro area in Maryland, the Jersey City and Newark metro areas
of New Jersey and the Wilmington metro area in Delaware.
(See Figure 2 and Attachment 2.)
The
comparison for both states and metropolitan areas is on the rate of new
injection-related AIDS cases in 1998 per million population, using a
special tabulation from the Centers for Disease Control and Prevention
(CDC). The
rates, based on new AIDS cases in their respective states and
metropolitan areas, are the result of two factors.
The number of new drug-related HIV infections in the area 8 or 10
years previously (in the absence of treatment, the typical interval
between initial infection and the development of AIDS) and the extent to
which persons with injection-related AIDS have been able to gain access
to the life-saving antiretroviral therapies. Although
not a perfect measure, the rankings do permit us to identify those
states and metropolitan areas where the drug-related HIV/AIDS epidemic
is most severe. And where
greater efforts need to be made in prevention. The
crisis among African Americans and Latinos The
injection-related AIDS epidemic has been particularly severe among
African Americans and Latinos. From
the beginning of the epidemic through the end of 1998, African Americans
and Latinos together accounted for three quarters of all
injection-related AIDS cases! In
1998, the rate of injection-related AIDS cases among blacks in the
United States was 14 times higher than the rate for whites. The rate for Latinos was 6 times higher than the rate for
whites. (2) The
epidemic's trend: growing numbers living with injection-related AIDS The
decline in
AIDS deaths and the remarkable success of antiretroviral therapy
in helping people infected with HIV maintain their health has led some
to believe HIV prevention is less important than it once was. That
is not the case. As
antiretroviral therapy has prevented, or at least delayed, the onset of
full-blown AIDS among many individuals with HIV and with AIDS deaths
declining, there are growing numbers of persons living with
injection-related AIDS. (3) With increasing numbers of persons living with HIV and AIDS,
there is an ever growing need for effective prevention. Information on HIV infections is incomplete for a variety of reasons, but we can get some sense of the expanding nature of the epidemic by looking at the trend in injection-related AIDS. (See Figure 3 and Attachment 3.)
By
the end of 1998, 102,000 people were living with injection-related AIDS
(not HIV) in the United States. If
we could add in cases of injection-related HIV, the number of people
living with the virus spread through infected needles would be even
higher. (4) Now
more U.S. residents
are living with injection-related HIV/AIDS than ever before.
In
recent years, there has been an increase in heroin use, the drug most
commonly injected. According
to the Office of National Drug Control Policy, heroin use has increased
as the price of heroin has fallen and availability increased. (5)
Because
of the purity, new users often smoke or sniff heroin, rather than inject
it. However there is the
danger that, when money is short, new users will shift to injecting,
which requires less heroin to produce a high. With
increases both in the number of persons are living with
injection-related HIV/AIDS and the number of heroin users, the need for
effective HIV prevention is also growing. Effective
prevention includes access to sterile needles Drug
education, drug treatment, and condom distribution (to potential
partners of injecting drug users) are important, but not enough by
themselves to eliminate the spread of HIV through infected needles. Improved
access to sterile needles is needed.
This can be done through pharmacy sales of syringes and needle
exchange programs. Needle
exchange programs permit injecting drug users to exchange used needles
for sterile ones. Federally
funded reports from eight major scientific
bodies, including the National
Research Council and Institute of Medicine have all recommended the use
of needle exchange programs as part of an effective HIV/AIDS prevention
strategy. The reports are unanimous in concluding that needle exchange
programs slow the spread of HIV and do not increase drug use. (6)
Needle exchange programs have been shown to reduce the spread of HIV by at least a third. (7) While
publicly acknowledging the validity of the scientific research
supporting the effectiveness of needle exchange programs, Secretary of
Health and Human Services Donna E. Shalala has not released federal HIV
prevention funds for use in needle exchange programs. (8) Recently
the American Medical Association, the American Pharmaceutical
Association, the Association of State and Territorial Health Officials,
the National Association of Boards of Pharmacy and the National Alliance of State and Territorial AIDS Directors issued
a joint letter encouraging state-level action to reduce the legal and
regulatory barriers that currently restrict access to sterile syringes
in nearly every state. (9)
These organizations earlier had stated their support for federal
funding for needle exchange programs. The
states have been very slow to respond to the need for AIDS prevention
through increased access to sterile needles.
Of the ten states with the highest rates of injection-related
AIDS, four (Delaware, Florida, Louisiana, and New Jersey) have laws that
prevent the establishment of needle exchange programs. (10) New
York, Maryland, Connecticut, Pennsylvania, Rhode Island and
Massachusetts permit injecting drug users access to sterile needles
under some conditions, but even with these states, the situation is
mixed. Maryland, for example, permits needle exchange only in
Baltimore City. In
Pennsylvania, needle exchanges exist only on the basis of local
initiative. In
Massachusetts, the Springfield metro area, which ranks 13th in the
nation with regard to injection-related AIDS, has no needle exchange
program. New
York, which leads the nation, has historically had a high concentration
of heroin users. Needle
exchange programs in New York City have resulted in a reduction of the
per capita HIV rate. (11)
However the number of needle exchange programs are still
inadequate to meet the need. And
pharmacy sales of syringes are restricted throughout the state. The
low cost of clean-needle programs Needle
exchange programs not only save lives, they also save money.
Preventing the spread of HIV through needle exchange costs much
less than treating HIV/AIDS after a person is infected.
Using
sophisticated mathematical models, a University of California team of
investigators estimates that, over a five-year period, it costs between
$4,000 and $12,000 in needle-exchange program expenses for each HIV
infection averted. (12)
The cost of medicine for antiretroviral therapy for that same
five-year period would be more than $60,000.
One recent estimate puts the cost of antiretroviral therapy at
over $17,000 for a single year! (13)
If we had the data to add in doctors' fees and hospitalization,
the cost difference between prevention through needle exchange and
treatment would be even greater. Attachment
1. Background information for Figure 1 Injection-related
AIDS cases include persons who inject drugs and the heterosexual
partners of persons who inject drugs.
Rates were calculated by averaging injection-related AIDS cases
among persons age 13 and older for the 3-year period 1996-1998 and then
dividing by persons age 13 and over in 1997.
The states were then ranked by rate.
When ties occurred, the states involved were given the same rank. The
data are from a special tabulation from the Centers for Disease Control
and Prevention. Attachment
2. Background
information for Figure 2 Data
are from the same special CDC tabulation as described in Attachment 1.
Rates were calculated by averaging injection-related AIDS cases
among persons age 13 and older for the 3-year period 1996-1998 and then
dividing by the total population in 1997. The
metro areas were then ranked by rate.
When ties occurred, the metro areas involved were given the same
rank. Attachment
3. Background
information for Figure 3 Injection-related
AIDS cases here refers only to persons who inject drugs and NOT their
sexual partners. Since AIDS
spread through heterosexual sex has been one of the most rapidly
increasing risk groups, Figure 3, by excluding that group, understates
the growth of the epidemic. The
data are from CDC, HIV/AIDS Surveillance Report. U.S. HIV and AIDS cases
reported through June 1999. Vol.
11, no. 1. Tables 25 and 28. Footnotes (1)
Scott D. Holmberg. "The Estimated Prevalence and Incidence
of HIV in 96 Large US Metropolitan Areas."
American Journal of Public Health.
May 1996. p.642. (2)
Data are from the same special CDC tabulation as described in Attachment
1. Rates are calculated in
the same way as in Attachment 1. (3)
The number of persons living with AIDS is not available at the state or
metro area level; the only information available at the state and metro
area level is the number of new AIDS cases.
Estimates of persons living with AIDS in the U.S. are from the
HIV/AIDS Surveillance Reports of the Centers for Disease Control and
Prevention. The 1992 figures are from the 12/1998 report, Table 27 and
the 1993-1998 figures are from the 6/99 report, Table 25. (4)
The CDC reported an additional 22,000 persons living with
injection-related HIV (not AIDS) from 33 states in 1998.
But this number seriously understates the number of persons
living with injection-related HIV, since several states where the
epidemic is severe do not report on the number of persons living with
injection-related HIV and, in any case, many persons with HIV do not
themselves know they are infected.
CDC. HIV/AIDS Surveillance Report.
U.S. HIV and AIDS cases reported through
December 31, 1998, vol. 10, no. 2. Table 6. (5)
In 1998 the average retail price for a pure gram of heroin was
approximately $1,799, significantly lower than in 1981 when the retail
price per gram was estimated to be $3,115. The average purity for retail
heroin in 1998 was 25 percent, much higher than the average of 19
percent reported a decade ago. Office
of National Drug Control Policy. National
Drug Control Strategy 1999. Washington, D.C. 1999. p. 30f.
(7) Robert Heimer, Kaveh Khoshnood, P. Clay Stephens, and others. "Evaluating a needle exchange programme." International Journal of Drug Policy. Vol. 7, no. 2. 1996. pp. 123-129. Later work from many authors confirms the effectiveness of needle exchange programs. See especially Robert Heimer, Keveh Khoshnood, Dan Bigg, Joseph Guydish and Benjamin Junge, "Syringe use and reuse: effects of syringe exchange programs in four cities," Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology. vol. 18. Supplement 1. July 1998. pp. s37-s44. (8)
"U.S. won't fund needle exchanges." Associated Press. April
20, 1998. (9) American Medical Association, American Pharmaceutical Association, Association of State and Territorial Health Officials, National Association of Boards of Pharmacy, and National Alliance of State and Territorial AIDS Directors. "HIV Prevention & Access to Sterile Syringes." Letter to colleagues. October 1999. (10)
Since needle exchange programs reach out to drug users, helping
them to get into both drug treatment and HIV treatment, if needed, areas
with needle exchanges have a more accurate count of the number of
persons infected than do areas where there is no needle exchange
program. (11)
Don C. Des Jarlais, Theresa Perils, Samuel R. Friedman, et al,
"Declining Seroprevalence in a Very Large HIV Epidemic: Injecting
Drug Users in New York City, 1991 to 1996," American Journal of
Public Health, 1998. vol. 88. p.1801-06. (12)
National Research Council and Institute of Medicine, Jacques Normand, David Vlahov, and Lincoln E. Moses, eds.,
Preventing HIV Transmission: The Role of Sterile Needles and
Bleach. Washington, DC:
National Academy Press, 1995, pp. 86-88. (13)
A recent study by Caro Research, an independent consulting firm in
Massachusetts, showed that highly active antiretroviral therapy, using 3
to 4 drugs costs $17,600 a year. Reuters.
"It costs $17,600 a year to treat HIV in U.S.-study."
September 27, 1999. For other materials used on this website, see References.
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