Removing Obstacles to Prevention One Ban at A Time: New Bill Would Allow Federal Funds for Syringe Exchange

Jodi Jacobson

Rep. Jose Serrano has introduced a bill to lift the federal ban on funding for syringe exchange to prevent the spread of HIV and other infections among injection drug users.  Passing this bill quickly could save untold numbers of lives.

Representative Jose Serrano (D-NY) yesterday re-introduced HR 179, the Community AIDS and Hepatitis Prevention (CAHP) Act of 2009.  The bill, which has 28 original co-sponsors, would eliminate all laws preventing federal funding from being used by state and local jurisdictions for syringe exchange.  The New York-based Harm Reduction Coalition is spearheading an advocacy effort through Democracy In Action to get more cosponsors and to pass the bill.

Lifting the ban on federal funding would be one of several wins needed in the struggle to restore evidence-driven approaches to prevention across a wide-spectrum of public health programs.  Bans on syringe exchange have been in place for years, even through the Clinton Administration.  Under the Bush Administration, domestic bans on federal funding were used to create de facto bans on U.S. international funding of syringe exchange: USAID and the State Department "voluntarily" applied the domestic ban on federal funding of needle and syringe exchange to foreign assistance programs under pressure from the White House.

These bans have been maintained despite mounting evidence of the efficacy of exchange programs.  According to a study by the University of California-Davis, for example:

Drug users with access to controversial syringe-exchange programs are up to six times less likely to put themselves at risk of HIV infection.

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Among injecting drug users who already have some access to clean syringes, a syringe-exchange program results in a two-fold reduction in HIV risk behavior, according to the study.   For drug users with no other easy access to clean syringes, the benefits are even more significant — a six-fold reduction in risk behaviors. 

Syringe exchange and other tales of corrupted policy are the neglected underbelly of the global AIDS success story of the Bush Administration.  Along with restrictions on funding for prevention of sexual transmission, the ban on needle/syringe exchange greatly undermined U.S. efforts to prevent new HIV infections under the President’s Emergency Plan for AIDS Relief (PEPFAR).  For example, in Vietnam, a country funded by PEPFAR, the U.N. estimated that there were 260,000 people living with HIV in 2005 with 57% of HIV cases among injecting drug users. 

Likewise, in sub-Saharan Africa, where 80 percent of new infections result from unprotected sex, the U.S. has funded and continues to fund organizations that refuse to provide comprehensive information on safer sex practices….indeed which deny that safer sex is even possible.  And the links are clear:  People who are addicted to injection drug use also have sex, acting as a pathway to HIV and Hepatitis infection among others.

Last year, Serrano was widely lauded by prevention advocates for his efforts to lift the needle exchange ban in the District of Columbia.  The ban on the use of local and federal funds for this purpose had been written into DC’s federal appropriations since 1998, during which time countless new HIV infections took place through use of dirty needles.   Serrano oversees the budget for D.C. in his role as Chair of the House Appropriations Subcommittee on Financial Services and General Government.

With the introduction of HR 179, we may finally get rid of one more piece of a legacy of ideology and political expediency over evidence that has cost lives and money in the United States and abroad.  The Obama Administration can hasten this process by showing unflinching support for evidence-based programs such as syringe exchange.  The good news is that the most immediate problem is not so much a lack of resources as a complete waste of the resources being deployed.

News Health Systems

GOP Governor Opposed to Needle Exchange Programs Changes Tune During HIV Outbreak

Martha Kempner

Indiana Gov. Mike Pence this week declared a public health emergency for Scott County, a rural part of the state that has seen an alarming number of new HIV cases in the past few months, all of which have been among injection drug users.

Indiana Gov. Mike Pence (R) this week declared a public health emergency for Scott County, a rural part of the state that has seen an alarming number of new HIV cases in the past few months, all of which have been among injection drug users.

Calling this an epidemic and a “crisis of drug abuse,” Pence—who has vehemently opposed needle exchange programs in the past—issued a temporary order allowing health officials in the county to hand out clean needles for at least the next 30 days.

There have been 79 confirmed HIV diagnoses since December, and others are under investigation. Scott County, in a typical year, would see about five new HIV cases. The outbreak appears to have begun with people who shared needles to inject Opana, a type of oxymorphone that is only available by prescription.

It is prescribed less frequently than other similar pain medications like OxyContin because it is so strong. Some of those infected also report injecting other drugs, including methamphetamine.

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Scott County is a rural area close to the Kentucky border with about 24,000 residents, 19 percent of whom live below the poverty line. County officials told Business Insider that they have fought narcotics use in the area for years and that addiction to prescription drugs has been the main issue.

Using an unclean needle is considered one of the most efficient ways to transmit HIV. Research has estimated, for example, that for every 10,000 times a woman has penile-vaginal intercourse with an infected male partner, four would likely end up with HIV transmission. In contrast, for every 10,000 times an uninfected person shares needles with an infected person, 63 would likely end up in HIV transmission.

Sharing dirty needles is not the only way injection drug users can transmit HIV—it can also happen by sharing water to clean needles and syringes, sharing bottle caps or spoons used to heat drugs and dissolve them in water, and sharing filters (such as cotton balls) to filter out particles before injecting drugs.

Whether or not a person becomes infected depends in large part on the quantity of blood to which they are exposed, and the viral load of the person with whom they are sharing (the more blood and the more virus in the blood, the higher the chance of transmission).

This is why many public health organizations support programs that make clean needles available for drug users. A position paper signed by numerous organizations—including AIDS United, amFAR, and the Human Rights Campaign—argued for such programs:

Infected needles result in 3,000-5,000 transmissions of HIV each year and an estimated 10,000 transmissions of the hepatitis C virus. Syringe Exchange Programs (SEPs) are a proven cost-effective approach for preventing transmission of HIV and viral hepatitis among injection drug users, reducing risk of “accidental pricks” to sanitation workers and police, and engaging injection drug users in substance abuse treatment programs.

SEPs are controversial, as some people fear that providing needles will encourage drug use and send the wrong message to the community. A federal law prevents the government from funding such programs and about half of the states, including Indiana, have banned such programs.

Pence has supported his state’s ban on needle exchange, saying that SEPs are not good anti-drug policy.

In the midst of a clear public health crisis, however, Pence is putting this view aside for now. Pence said that after meeting with federal advisers, he has decided to make an exception for Scott County.

“I’m going to put the lives of the people of Indiana first,” he said.

State officials are setting up a mobile command center in Scott County, and experts from the U.S. Centers for Disease Control and Prevention (CDC) have been in the area since Monday.

“I have deep compassion for people who are trapped by this addiction and we want to make sure people know they’re no alone,” Pence said in an interview, according to The New York Times. “There is help, there is treatment, and we’re surging into the county now to make that available.”

Commentary Sexual Health

Women Deserve to Know About HIV Prevention Medication Too

Anna Forbes

One in four people living with HIV in the United States are women. So why is HIV prevention medication overwhelmingly only targeted at men who have sex with men?

In 2012, the Food and Drug Administration (FDA) approved the use of the antiretroviral medication Truvada as the first form of PrEP (pre-exposure prophylaxis), a pill to protect against getting HIV. To date, the United States is the only country to give regulatory approval to PrEP for HIV prevention. The Centers for Disease Control and Prevention (CDC) then issued clinical guidelines for prescribing PrEP to adults at risk of HIV. PrEP has been proven to reduce the risk of acquiring HIV equally well in both men and women—with a protection rate of up to 96 percent when taken daily without interruption or missed doses. Yet three years later, PrEP-centric media campaigns and clinical prescriptions continue to primarily target men who have sex with men.

We at the U.S. Women and PrEP Working Group, a national advocacy coalition of more than 100 women’s health advocates, health-care providers, researchers, policymakers, and industry partners, believe that everyone has the right to affordable access to the tools they need to implement their sexual and reproductive choices. Full PrEP availability—for both cis and trans women—is both a reproductive justice and human rights issue. March 10 is National Women and Girls HIV/AIDS Awareness Day. So it’s a good time to ask the question: Why are women being excluded from this potentially life-saving medication?

Of the six oral PrEP studies completed to date, only one took place in the United States. It only enrolled men and a few transgender women who have sex with men. Two international studies that only enrolled women did not show PrEP as successful, but researchers attributed this to the fact that most of the participants did not take the pills daily as instructed. In still other studies involving heterosexual couples, women who did take PrEP consistently achieved a high level of protection—showing that PrEP does work well across the gender spectrum.

Even so, the success of the trial involving American men, combined with the lack of positive data from the trials enrolling women, generated domestic press coverage that generally implied PrEP is “for men,” thus making women invisible as potential PrEP users.

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In the United States, about one in four people living with HIV is a woman. Black women, who make up only 13 percent of the female population, comprise nearly two-thirds (64 percent) of new HIV infections among U.S. women. Yet when sociologist Judith Auerbach conducted focus groups in six U.S. cities among 144 women at high risk of HIV on their thoughts about PrEP, she discovered they were overwhelmingly unaware of the effectiveness of the medication for women.

Fewer than 10 percent of the women had even heard about PrEP; those who had thought it was only a tool for men, not for women. The remaining 90 percent were “upset, frustrated, and even angry that they had not learned of it before.” They saw the failure of health professionals to reach out to them with information about PrEP as a “societal devaluation” of their lives.

In addition to human rights concerns, this kind of low awareness of PrEP’s availability is also highly problematic for practical reasons. Gender-based differences in social and economic power can sometimes make it difficult or impossible for many women to insist on condom use, and consistent condom use is infrequent overall. In a 2010 national probability study, only 22 percent of men and 18 percent of women reported using male condoms during the last ten times they had vaginal intercourse—and cis women are twice as likely to acquire HIV during heterosexual vaginal intercourse without condoms than are their male partners. Finally, women with HIV in the United States are more likely to be living in poverty and have less access to health care than men living with HIV. All of these factors make access to effective HIV prevention, including the option of PrEP, crucial for women.

Advocates are, however, making inroads in ensuring that PrEP becomes part of the narrative for women at risk of HIV. With funding by the CDC Foundation and its partners, the Sustainable Health Center Implementation PrEP Pilot Study (SHIPP) is under way. As the first PrEP study enrolling women in the United States, this demonstration project is designed to show how PrEP provision can be implemented sustainably. SHIPP is enrolling 1,200 volunteers at four federally qualified health centers in Illinois, Pennsylvania, New Jersey, and Texas. These volunteers select PrEP as a part of their sexual health and primary care services. SHIPP’s results—including the rates of PrEP uptake, consistency of use, and protection from HIV—are expected in 2017. To date, about 40 percent of enrolled SHIPP participants are women, a victory for the Working Group and other PrEP supporters across the country.

In the meantime, family planning clinics and private OB-GYNs are well situated to educate women about PrEP, since 99 percent of American women, at some point in their lives, have used contraception. Not surprisingly, cost is a key concern among women considering PrEP use; these facilities can also help patients affordably obtain the medication. At this point, Truvada is the only pill approved as PrEP; Truvada Track, an advocates’ project monitoring PrEP access, reports that it is routinely covered by insurers and Medicaid. Gilead, the pharmaceutical company producing Truvada, also has a patient assistance program that supplies the drug to those without coverage and assists with co-pays to cover the testing and other services associated PrEP access and monitoring.

To choose whether or not to use PrEP, women need information about the medication, clinicians need to be educated about its use for women, and the drug needs to be affordable and accessible. While we are monitoring the implementation of SHIPP, we will continue to pressure policymakers, health-care professionals, and the CDC to reach out to women. In addition, we will continue to mobilize women to demand more.

Everyone deserves the right to HIV prevention tools that we can use without our partner’s participation—for the sake of our safety, health, and well-being. In short, we are tired of asking permission to protect our own lives.