Immunodeficiency Syndrome AIDS As of 1995

HIV infection is eventually fatal; there is no permanently effective treatment for HIV infection. Large-

scale vaccination studies began in the late 1980s, and have continued through the 1990s, focusing on some 27 different vaccines (Henderson, 1999). HIV has now been reported among IDUs in sixty countries, from all continents except Antarctica, and from both industrialized and developing nations.

A disturbing facet of HIV infection among injecting drug users is the potential for the rapid spread of the virus through a local population of IDUs. In Edinburgh, Scotland, HIV spread, after the introduction of the virus, into the local population to infect over 40 percent of the local IDUs within two years (Robertson, 1990). In Bangkok, Thailand, the percentage of HIV-infected IDUs (HIV seroprevalence) increased from 2 percent to over 40 percent in less than one year (Vanichseni et al., 1992). In the state of Manipur, India, over 50 percent of the local population of IDUs were infected with HIV within one year after the introduction of the virus into the group. The rapid spread of HIV among IDUs results from a lack of awareness of HIV/AIDS as a local threat and from mechanisms, such as shooting galleries (places where addicts ''shoot up'' together) and dealers' works, that allow large numbers of the population to be exposed to the virus through infected needles and syringes (Des Jarlais et al., 1992). In the United States, injection drug use accounts for 36 percent of AIDS cases overall. In 1998 alone, 31 percent of the 48,269 AIDS cases reported were IDU-related.

Once HIV becomes well established within a population of IDUs, their homosexual and heterosexual partners and transmission to developing fetuses (perinatal) become additional significant problems. In most developed countries, IDUs are the predominant source for both heterosexual and perinatal transmission of HIV. Since AIDS was identified as an epidemic in the United States, 31 percent of all AIDS cases among men have been attributed to injection drug use as compared to the 59 percent of all cases among women (CDC, 1999).

The need to reduce HIV transmission among and from injecting drug users has led to a variety of prevention programs; as a result, there are approximately 113 exchange programs active in 80 U.S. cities in 30 states (Bowdy, 1999). The programs have had differing degrees of effectiveness, although there is evidence that ''education-only'' programs (i.e., those that do not provide the physical means for behavior change) are the least effec tive. In almost all industrialized and in some developing countries, increasing legal access to sterile (or uncontaminated) injection equipment has become the most common HIV/AIDS prevention strategy for IDUs. This strategy has included both increased over-the-counter sales of sterile injection equipment and syringe-exchange programs, in which IDUs can turn in used injection equipment for sterile equipment at no cost. A study of a Canadian program in the province of Quebec showed that simple equipment exchanges were not enough. To succeed in reducing the total number of IDUs, transitional and basic support services needed to be part of the program (Belanger, et al., 2000).

Increasing legal access to sterile injection equipment has been politically controversial in several industrialized countries, notably the United States and Sweden, and in many developing countries. Concerns have been raised as to whether increased legal access would lead to increased injection of illicit drugs and whether increased legal access would appear to "condone" illicit drug use or "send the wrong message'' about illicit drug use (Martinez, 1992). The decision to support needle exchange programs (NEPs), often lies at the state level. Perhaps the more controversial issue is le-galization—or criminalization—of syringe possession. As of 2000, in an effort to reduce the spread of HIV through injection drug use, many states changed laws making it illegal to purchase, sell, or possess syringes without prescriptions. Other states (e.g., New Hampshire) renewed their NEPs. Unfortunately, in most states it is more a political, rather than a public health issue (AIDS Alert, 2000).

The empirical data on these questions will be reviewed below, but first it is important to address operational issues involved in needle-exchange programs—to specify how needle exchanges actually work before addressing evaluations of their outcomes.

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