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Jocelyn Elders Speaks Out on Harm Reduction & Clean Needles: an answer to stemming the tide of HIV and HCV
Reported by Jules Levin
  I am writing from the opening plenary session of the Harm Reduction Coalition Conference in Seattle. The Harm Reduction Coalition is based in New York City and is a coalition of community groups who implement programs of harm reduction and needle exchange. There are 1,000 people in the audience who are dedicated to the concept of harm reduction which includes clean needle exchange programs. It's an interesting and diverse group of people attending this conference. They are dedicated to the proposition that harm reduction is crucial for drug users and serves society. Many people will not stop using IV drugs. For those that are willing to stop IV drugs and enter drug recovery that is great. But many users will not. These individuals will continue to use IV drugs and share dirty needles that will spread HIV and HCV, unless these individuals have access to and use clean needles. Providing clean needles is a pragmatic approach to meet individuals on their terms. Providing more government funding for recovery beds and detoxification programs will also help. Access to methadone maintenance will help as well, but also important is more emphasis in methadone maintenance programs giving clients the real option of transitioning people off methadone to being drug free.
Attendees at this conference are from all over including from South America, Pennsylvania, LA, Seattle, NYC, Wash DC, Philadelphia, Florida and other parts of the USA. There is quite a bit of discussion about hepatitis C on the agenda and I'll be delivering a 3-hour talk on hepatitis C, barriers to care, and treatment.
Access to clean needles is a controversial subject. There is a political power base that asserts that making clean needles available to drug users will encourage drug use. On the other hand proponents of needle exchange believe that providing clean needles can reduce the spread of HIV and HCV and providing clean needles does not encourage IV drug users. I agree with the latter, it is crucial to offer clean needles to IVDUs. The continuing use of IV drugs is more complicated than just the availability of clean needles. There are many reasons why drug users do not stop using drugs, and whether or not clean needles are provided most users will continue using IV drugs. But providing clean needles can help prevent transmission of HIV and HCV. I believe needle exchange is appropriate and needed to help prevent the spread of HIV and HCV. In fact, IVDU is the leading source for transmission of HCV. As well, the demographics of HIV is such that a leading cause for spread of HIV is IV drug use with dirty needles, sharing needles or drug paraphernalia where one person is infected with HIV or HCV. Often the same dirty needle contains blood or microscopic levels of blood containing both HIV and HCV; both HIV and HCV are often contracted at the same time from the same dirty needle. Studies show that 70% of IVDUs contract HCV in the first year of using IV drugs. HCV is more easily transmissible than HIV. At once, government officials and politicians realize that IV drug use a leading source for HIV and HCV and that the availability of clean needles can help stem this tide, but the stigma, controversy, and bias against making clean needles available creates a political climate charged with many barriers and difficulties for government approval and funding of needle exchange. Voters do not in general like the notion of needle exchange as they believe it will help promote IVDU.
Dr. Jocelyn Elders, former Surgeon General in the Clinton Administration, is delivering a plenary talk. In her talk she said she wrote a letter in support of needle exchange and was fired for this among other similar things. She said we need to keep fighting for the kinds of services needed. She said we can't talk about sex and drugs in our society. And she is right. Many of our citizens do not want to talk about this. It is true that IVDUs are not an appealing or sympathetic crowd to politicians and voters, so they don't have political clout. Unfortunately the IVDU community disproportionately consists of people of color and women. The "war against drugs" has gone on for decades but we still do not have a victory against drugs Elders said. Federal budgets in the war against drugs are very large. She said 60% of people in prisons are there due to drug-related crimes, mostly just using drugs. She said although we have made progress in decreasing AIDS deaths, risk of contracting HIV through IVDU continues to be a problem. Since the epidemic of HIV began, injection drug use has directly or indirectly accounted for more than one-third of AIDS cases in the US and this trend continues. In 2000 28% of new AIDS cases were directly or indirectly a result of IVDU. The demographics of HIV are changing. I think she said that 13,000 individuals die each year due to not having access to clean needles. Minorities are disproportionately affected by these issues.
The CDC reports: Sharing syringes and other equipment for drug injection is a well known route of HIV transmission, yet injection drug use contributes to the epidemic' s spread far beyond the circle of those who inject. People who have sex with an injection drug user (IDU) also are at risk for infection through the sexual transmission of HIV. Children born to mothers who contracted HIV through sharing needles or having sex with an IDU may become infected as well. Since the epidemic began, injection drug use has directly and indirectly accounted for more than one-third (36%) of AIDS cases in the United States. This disturbing trend appears to be continuing. Of the 42,156 new cases of AIDS reported in 2000, 11,635 (28%) were IDU-associated.
Racial and ethnic minority populations in the United States are most heavily affected by IDU-associated AIDS. In 2000, IDU-associated AIDS accounted for 26% of all AIDS cases among African American and 31% among Hispanic adults and adolescents, compared with 19% of all cases among white adults/adolescents.
IDU-associated AIDS accounts for a larger proportion of cases among adolescent and adult women than among men. Since the epidemic began, 57% of all AIDS cases among women have been attributed to injection drug use or sex with partners who inject drugs, compared with 31% of cases among men.
Noninjection drugs (such as "crack" cocaine) also contribute to the spread of the epidemic when users trade sex for drugs or money, or when they engage in risky sexual behaviors that they might not engage in when sober. One CDC study of more than 2,000 young adults in three inner-city neighborhoods found that crack smokers were three times more likely to be infected with HIV than non-smokers.
I captured a number of key points below that Elders made in her talk; she made some bold statements.
Elders said "42% of HCV in USA related to IVDU. 50-80% of IVDUs get HCV within first year of IVDU. Blacks are disproportionately arrested for drugs and drug paraphenalia. 70-90% of adult IVDUs are HCV+. Access to clean needles is a proven way to address these problems and reduce risky behavior. Participants in clean needle programs are more likely to not share needles, reduce spread of HIV, are far more likely to enter treatment program, and increases use of other helpful services. Sales of clean needles by pharmacies should be legal. We should take drug users serious. Decriminalize marijuana. Medicalize drug treatment. Addiction is a medical illness not a criminal justice issue (at heart). Just the use of drugs is a health issue but a crime related to that is a criminal justice concern. We need to reform the criminal justice system. We spend too much money on prisons. We need parity between punishment for pot vs cocaine....we need to educate, educate...the community, drug users. If you've lost your child to drugs you know how painful this is...we need more drug treatment programs...and needle exchange programs...30 million people use drugs...10 million are casual...2 million need treatment and there are only 150,000 beds for treatment of drug abuse. ...prison guards should be trained about HIV [and HCV] treatment...pastors say using drugs is a sin but they should stop moralizing from the pulpit....go out and get involved....the church should find a released prisoner and help them get back into society.....services to drug users should be non-judgemental......we need to combine services to address problem by CBOs, govt, etc.
[her final message is] "We need to share, communicate, serve the people that need to be swerved, cooperate with other, collaborate [is like an abnormal sex act between consenting adults], we need to form partnerships, we need awareness about the multitude of problems (homelessness, addiction, housing). No one organization can do all this by themselves. We need strong advocacy with an action plan right for community. We need access to clean needles. We need to take risks to bring about change. Change is very hard: the time is not right, is a constant refrain. Fight is necessary to make change.....Don't ask what's happening, make things happen.....Educate and empower patients, clients, and community.....not to know is bad but not to want to know is worse.....and not to hope is unthinkable.....but not to care is worse. When you are dancing with a bear you can't get tired. You have to wait for the bear to get tired". Needless to say her talk was very well received by the audience.
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