By JOSIAH D. RICH
Last weekend’s Group of 8 meeting in St. Petersburg offered an unprecedented opportunity to focus the most powerful nations on the AIDS catastrophe rapidly unfolding in Eastern Europe and Asia, including Russia.
Although the news from Beirut dominated the G-8 agenda, the meeting produced a communique on infectious diseases that quietly but undeniably supports "comprehensive, evidence-based strategies of prevention." This language may seem mild, but preventing AIDS among drug users is controversial: Needle exchange, while endorsed by nearly every major U.S. medical association, is neither funded nor endorsed by the U.S. government or its AIDS programs. Yet HIV infection is sweeping nearly unchecked through Eastern Europe and Asia as huge numbers of injection-drug users contract the disease through shared needles, and then unknowingly infect their partners and children.
To turn back this wave of the AIDS pandemic, the United States, Russia, and other G-8 countries must promote HIV-prevention strategies proven to work _ all of them.
National AIDS prevention plans that are large-scale and science-based must be put into action in Eastern Europe and Asia. If not, localized HIV epidemics will expand into the general public.
Fortunately, preventing HIV among drug users is fairly straightforward. Numerous studies have shown that four tactics, used simultaneously, can drastically reduce HIV infection among injection-drug users: 1) access to sterile needles, 2) accessible addiction treatment (including methadone or buprenorphine), 3) outreach and HIV risk-reduction education, and 4) sexual risk-reduction education, including condom promotion.
The evidence is strong that access to clean needles does not promote drug addiction. In fact, programs providing clean needles have prevented millions of HIV infections and helped connect users to addiction treatment. Used in conjunction with the three other tactics against HIV, clean-needle programs can prevent the virus from spreading. Without them, HIV infection among drug users can skyrocket, with devastating consequences.
President Bush’s Emergency Plan for AIDS Relief is a vast improvement over previous U.S. government programs to combat global AIDS. Unfortunately, though, the world’s most influential donor in the fight against AIDS has failed to articulate proven strategies to prevent the spread of this disease at home and abroad.
One such limitation is the ban on federal funding for needle exchange in the United States and in U.S. programs abroad.
The U.S. Office of the Global AIDS Coordinator recently published the Emergency Plan for AIDS Relief’s HIV-prevention guidelines for drug injectors. The guidelines endorse much-needed medication-assisted addiction therapies for injection-drug users, but they make these therapies a priority for already HIV-infected drug injectors. This means that to get access to therapies, drug users must be tested for HIV. Requiring people to learn their HIV status in order to gain access to addiction treatment only creates another barrier to treatment and prevention.
Limiting access to any successful HIV-prevention method is not consistent with medical and public-health ethics, nor is it likely to curb the spread of HIV. Thus, the United States misses a singular opportunity to prevent HIV infection among vulnerable populations.
The guidelines also fail to explain that needle-exchange programs are a scientifically established practice with proven effectiveness.
Access to clean needles and to heroin-addiction treatment does not always fall along obvious ideological lines. Federally funded clean needles are available for drug users in Tehran, for instance, but not in New York. Methadone treatment is available in New York but not Moscow. In fact, Russia _ facing a catastrophic injection-drug-fueled AIDS epidemic _ has made illegal the most effective addiction treatment to date: substitution therapy (methadone or buprenorphine).
HIV/AIDS is a global human-rights problem. Solutions based on scientific research must be implemented without bias, discrimination, or dilution.
The global HIV/AIDS pandemic cannot be contained, let alone reversed, unless governments and other supporters pay heed to the lessons of more than two decades of prevention and treatment. Millions of U.S. tax dollars have gone into research to determine what prevents transmission of the HIV virus. The money has been well spent and the evidence is clear.
(Josiah D. Rich, M.D., a professor of medicine and community health at Brown University, is an attending physician at Miriam Hospital in Providence, R.I., and an adviser to the Health Action AIDS Campaign of Physicians for Human Rights.)