Letter from Congressman Mark Souder to the Director of National Institute of Health. Maryland.USA.

Honorable Elias A. Zerhouni, M.D. Director April 27, 2004

Dear Dr. Zerhouni:

As you know, “harm reduction” is an ideological position that assumes individuals cannot or will not make healthy decisions. Advocates of this position hold that dangerous behaviors, such as drug abuse, should be accepted by society and those who choose such lifestyles – or become trapped in them  –  should be enabled to continue these behaviors in a less harmful manner. Often, however, these lifestyles are the result of addiction, mental illness of other conditions that should and can be treated rather than accepted as normative, healthy behaviors. Sadly, harm reduction largely ignores these realities and programs driven by this ideological position have not been adequately reviewed with unbiased, scientific rigor.

I am concerned that harm reduction programs that sustain continued drug abuse, such as injection rooms and needle distributions, likely weaken drug abusers’ defenses against infection, sustain drug abusers’ long term risk for disease, and minimize the benefits of the available treatments for HIV disease. These dangers seem to have received insufficient attention by some federal health agencies. Yet, peer-reviewed scientific and anecdotal evidence appear to support this assertion.

Needle exchange is the most visible harm reduction program for injection drug users (IDUs). The first needle exchange programs (NEPs) in the United States were established in Tacoma, Portland, San Francisco, and New York City in the late 1980s in an effort to prevent HIV infection among IDUs. By 1997, there were 113 such programs in more than 30 states.

Vancouver, British Columbia, administers the largest NEP in North America, distributing nearly three million needles every year. The city has a publicly sanctioned site specifically designated for addicts to inject under medical supervision absent of law enforcement. The results of this approach have been horrific. When the Vancouver NEP was established in the late 1980s, the estimated HIV prevalence in Vancouver was 1 to 2 percent among the city’s population of 6,000 to 10,000 IDUs. While the expectation was for needle exchange to decrease HIV rates, the opposite has occurred. Both HIV and Hepatitis C have reached “saturation” among the injection drug using population, meaning few if any of those who are not already infected are left to become newly infected, according to the Vancouver Drug Use Epidemiology report published by the city in July 2003. The HIV prevalence among the Vancouver Injection Drug User Study (VIDUS) cohort is 35 percent with “one of the highest incidence rates reported worldwide,” according to the 2003 Vancouver Drug Use Epidemiology report. The VIDUS has an astounding 82 percent prevalence of Hepatitis C.

While both HIV and Hepatitis C rates have increased in Vancouver since the establishment of the NEP, research has directly linked the NEP to this trend. A study published in the journal AIDS in 1997 found that “frequent NEP attendance” was actually one of the “independent predictors of HIV-serostatus” among IDUs. The study found that HIV-positive IDUs were more likely to have attended NEP and to attend NEP on a more regular basis compared with HIV-negative IDUs. Of those IDUs observed who became HIV infected during the course of the study, about 80 percent said they had no difficulty accessing syringes. And with only one lone exception, the NEP was the main source of syringes for all of those who became infected. Needle sharing by IDUs in Vancouver is normative, and quite widespread. VIDUS data published in 1997 found 76 percent of HIV-positive IDUs studied admitted to borrowing used needles as did 67 percent of HIV-negative IDUs. Thirty-nine percent of HIV-positive IDUs lent used needles (Strathdee S.A., et. al. “Needle exchange is not enough: lessons from the Vancouver injecting drug use study.” AIDS. 1997; 8: F56-65).

The failure of harm reduction to control infectious disease is not limited to Vancouver.

Researchers in Montreal studied nearly 1,600 needle-exchange participants for an average of 21.7 months. The study revealed seroconversion probability of 33 percent among needle exchange users and 13 percent among non-users. The case-control study suggested that consistent needle exchange use continued to be associated with HIV seroconversions during follow-up. Despite adjustments for confounders, the researchers noted that HIV risk elevations related to needle exchange remained both substantial and consistent in their cohort of intravenous drug users (Bruneau J., et. al. “High rates of HIV infection among injection drug users in needle exchange programs in Montreal: results of a cohort study.” Am J Epidermal. 1997;146: 904-1002).

A study of needle exchange programs in Seattle found no protective effect of needle/syringe exchange on the transmission of Hepatitis B or Hepatitis C among participants. The highest incidence of infection with both viruses occurred among current users of the exchange (Hagan H, et. al. “Syringe exchange and risk of infection with Hepatitis B and C viruses.” Am J Epidermal. 1999; 149: 203-218).

Needle exchanges focus almost exclusively upon a single mode of transmission among IDUs-sharing of contaminated needles-and largely ignore other important factors such as the individual, the behaviors that cause risk taking, the impact of the substance on the individual and the substance being abused itself. Studies are increasingly finding these factors play significant harm to IDUs that cannot be reduced by merely providing an unlimited supply of clean needles.

A 10-year study published in the Archives of Internal Medicine found that the biggest predictor of HIV infection for both male and female IDUs is high-risk sexual behavior, not sharing needles used to inject drugs. High-risk homosexual activity was the most important factor in HIV transmission for men; high-risk heterosexual activity was most significant for women. Risky drug-use behaviors also were strong predictors of HIV transmission for men but were less significant for women, the study found.

“In the past, we assumed that IDUs who were HIV-positive had been infected with the virus through needle-sharing,” noted Dr. Steffanie Strathdee of the Johns Hopkins University Bloomberg School of Public Health in Baltimore, who conducted the study. “Our analysis indicates that sexual behaviors, which we thought were less important among IDUs, really carry a heavy weight in terms of risks for HIV seroconversion for both men and women.” (Strathdee, S.A., et al. “Sex differences in risk factors for HIV seroconversion among injection drug users.” Archives of Internal Medicine 161:1281-1288, 2001)

Another recent study has found that drug abuse reduces the benefits of AIDS therapy. “There is evidence that HIV-positive injecting drug users benefit less than other risk groups from highly active antiretroviral therapy that has been available since 1996,” according to a study published in the European Journal of Public Health (“Limited effect of highly active antiretroviral therapy among HIV-positive injecting drug users on the population level.” European Journal of Public Health, 2003;13(4):347-349).

Previous research has also demonstrated that “club drugs” can adversely affect AIDS treatment outcomes, both through drug interactions and by affecting adherence to HIV drugs. Methamphetamines and MDMA have a potential interaction with all of the protease inhibitors and delavirdine used to treat HIV infection. Both GHB and marijuana have also demonstrated potential interaction with AIDS medications.

Recently, there has also been some discussion about the possibility that continued drug abuse by those being treated for HIV infection could potentially spawn drug resistant strains of HIV. This could result from the negative impact of illegal drugs on the body’s natural defenses and from insufficient adherence to drug taking regimens by those under the influence of controlled substances.

Now investigators at the McLean Hospital Alcohol and Drug Abuse Research Center in Belmont, Massachusetts, have found that cocaine itself has a direct biological effect that may decrease an abuser’s ability to fight off infections. “This research suggests a link between cocaine use and compromised immune response and could help explain the high incidence of infectious disease among drug abusers,” observes Dr. Steven Grant of NIDA’s Division of Treatment Research and Development (Halpern, J. H., et al. “Diminished interleukin-6 response to proinflammatory challenge in men and women after intravenous cocaine administration.” Journal of Clinical Endocrinology and Metabolism 88(3):1188-1193, 2003).

Research has demonstrated that MDMA is immunosuppressive (Connor, T.J., “Methylenedioxymethamphetamine (MDMA, ‘Ecstasy’): a stressor on the immune system.” Immunology 111(4):357- 367, April 2004) and there is a relationship between meth abuse and immune dysfunction (Qianli, Y., et. al. “Heart disease, methamphetamine and AIDS.” Life Sciences 73(2):129-140, May 2003).

This scientific and anecdotal evidence appears to indicate that harm reduction programs have failed to provide a prevention panacea for drug abusers against the dangers of HIV, hepatitis and other health risks.

Please provide a summary of the available scientific data demonstrating:

(1) The impact of drug abuse on the body’s immune system;

(2) Impaired decision making that increases HIV risk as a result of drug intoxication;

(3) HIV risk by drug users attributable to risky sexual behavior in exchange for drugs and drug money;

(4) Cultural or normative needle sharing behaviors by drug using populations; and

(5) Inferior health outcomes among those being treated for HIV infection.

The finding that continued drug abuse may impair treatment benefits of those infected with HIV while further damaging the immune system raises the alarming possibility that sustained drug abuse may incubate resistant strains of HIV. Have there been or are there any studies, ongoing or planned, examining the possibility that continued drug abuse by those being treated for HIV infection could contribute to the development of drug resistant strains of the virus?

Thank you for your assistance with this request. Please provide a response by September 1, 2004.

Mark E. Souder Chairman, Subcommittee on Criminal Justice, Drug Policy and Human Resources

Comment by NDPA:
(The statistics on problems resulting from needle exchange schemes and injecting rooms in the studies above show that far from preventing problems they actually increase problems. These results are the same from all over the world.   Far from protecting the health of drug users these programmes actually increase the probability that users will contract life threatening illnesses like Hep C.  

Recently at the annual meeting of the Federation of Drug And Alcohol Professionals (FDAP) in London , NDPA Director Peter Stoker gave an evidence based presentation on the failure of such programmes. Of 22 drug workers in the workshop 21 still voted that injecting rooms should be provided for users.

This is a stunning indictment of workers whose goal is supposed to be (in accordance with UK National policy) to help drug users achieve abstinence.  It would seem that for them dogma  outweighs data.  (Perhaps their position becomes clearer if one considers the result of another debate at the same meeting, which rejected the motion that ‘Drug Workers should themselves be drug free’).