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THE GENERAL EFFECT OF LIMITING SYRINGE AVAILABILITY WITHIN THE UNITED STATES' INTRAVENOUS DRUG POPULATION, AND THE RESULTANT EFFECT ON THE REST OF THE HETEROSEXUAL COMMUNITY By Matthew Stoll and Eugene Tinelli, M.D., Ph.D. October 1998 ABSTRACT: A study of state policies regarding over-the-counter hypodermic needle sales in the United States and their relation to the AIDS epidemic, which, until recently, has been the leading cause of death among American men aged 25-44. The report presents evidence that state laws outlawing the over-the-counter sale of needles increases the incidence of AIDS in both the intravenous drug-using population, and the non-drug-using, heterosexual population. Until recently, AIDS was the leading cause of death of men aged 25-44 (1). Since the epidemic began in the early 1980s, over 641,000 people have been diagnosed with the disease (2), of whom over 360,000 have died (3). There are two major risk factors for the disease: sexual intercourse with an infected individual and transfer of blood, such as principally occurs through the use of needles used to inject illegal drugs, namely heroin. It is widely known that condoms can help prevent the spread of the disease through sexual activity, and we thus encourage condom use, even if we do not always approve of the sexual activity. It is also known that use of clean syringes and needles (hereafter, needles refers to syringes and needles) would eliminate the spread of the Human Immunodeficiency Virus (HIV) through that medium, yet rather than encouraging, many states prevent the use of clean needles. Here we review the evidence that policies that prevent people from obtaining clean needles increase the incidence of AIDS among intravenous drug users (IDUs); furthermore, since many of the IDUs are heterosexual, this policy may be responsible for the spread of the infectious disease among heterosexuals. Thus, even those who are unconcerned about AIDS among "those people" - principally IDUs and gay men - should be concerned about our needle policy, insofar as it increases the risk of AIDS among all sexually active segments of the population, as well as their children. There is extensive evidence that permitting people to obtain clean needles will reduce the spread of HIV. An article in the Journal of the American Medical Association stated that needle exchange programs around the world, including Amsterdam, Sweden, Australia, Britain, and several cities in the United States, have led to reduced needle sharing among IDUs, as an increasing percentage of this population obtains clean needles from the program (4). That this should lead to a reduction in HIV infection is to be expected, and there is evidence pointing to that outcome. A New Haven study revealed that the presence of HIV DNA in syringes randomly tested on the street decreased by approximately one-third within three months after the implementation of a needle-exchange program (5). A study published in Lancet noted that between 1988 and 1993, cities that instituted needle-exchange programs had decreases in HIV positivity among IDUs reporting for drug-treatment, whereas cities without needle-exchange programs had increases in HIV positivity within that population (6). Based upon the success of such programs, it was estimated that by the year 2000, between 5150 and 11329 AIDS cases would have been prevented had there been needle-exchange programs nationally when their utility was first noted, in 1987 (7). Needle-exchange programs are not the only means by which an individual can obtain a clean needle. In 42 of the 50 states as well as in DC, needles can be bought at a pharmacy without a prescription, although several of these states encourage pharmacists to verify that the customer has a legitimate medical need (8). A comparison of the AIDS incidence and prevalence, as well as a breakdown of the causes of AIDS, in the states that permit needle purchases versus those that bar them, is of interest in order to further understand the extent to which public policy can shape the AIDS epidemic. We compared the incidence of new AIDS cases from July 1996-June 1997 in those eight states with the remaining 42 (9). The eight that ban needles had a per capita incidence of new AIDS cases of 29.23/100,000 population, as compared to 18.34 in the remaining states. If we examine the AIDS incidence exclusively in cities that during that year had a population of at least 500,000, the picture is the same, although the numbers are somewhat higher: 32.82 per 100,000 in the states that ban needles, versus 22.83 in those that permit sales without a prescription (10) (See Figure 1, available in hyperlink and also found at the end of this document.) We then examined the state-by-state breakdown of AIDS cases by risk factor, to see what patterns emerged. For this, we examined cumulative AIDS cases, since that was the data that was available (11). Since Connecticut only began permitting sales of needles without a prescription in 1992 (12), we included it among the states that ban needles, because passage of the new law would clearly be of no benefit for anyone whose AIDS case was diagnosed before 1992 or who even became HIV+ before that time, even if the actual onset of AIDS (which occurs at a median of 10 years after infection (13)) took place after passage of the law. Among the nine states that require (or have required) prescriptions, 39.73% of the AIDS cases among adults with an identifiable risk factor involved IDUs (including a fraction of them who also fell into the men who have sex with men (MSM) category), versus 27.19% among the other 41 states and DC. One might object to this data on the grounds that cities such as New York have an excessive amounts of IDUs, thus skewing the data. We addressed this objection in two ways. First, we subtracted from the nine states that ban needles any data from cities that had a 1990 population of greater than 500,000 (Boston, Mass., Chicago, Illinois; New York, NY; Los Angeles, Ca; San Jose, Ca; San Diego, CA; and San Francisco, CA) (14) and compared the resulting data with the data from the rest of the Union. Subtracting out those cities actually led to an increase in the proportion of AIDS cases associated with IDU, from 39.73% to 46.28% (See Figure 2, available in hyperlink and also found at the end of this document.) The other method we used to prevent any one city or state from having a disproportionate effect was to figure out the percentages of AIDS cases associated with each risk factor individually for each state, then averaging the nine or 42 (including DC) separate numbers. This way, a state with a small AIDS population carries as much weight as a state with a large AIDS population. Here, the pattern is even more striking. Among the nine, IDUs accounted for an average of 42.78% of the AIDS cases, versus 23.56% among the remainder of the states. Again, when we subtracted out the big cities among the states that ban needle sales, the average percentage of AIDS cases associated with IDU increased, from 42.78% to 45.27% (See Figure 3, available in hyperlink and also found at the end of this document.) It should be noted that this increase in percentage of AIDS cases associated with IDU within those nine states occurs within the context of an already higher cumulative AIDS total, relative to the population. Since the population of each of the states has varied over the duration of the AIDS epidemic, in order to obtain a single population figure for each state, we took the arithmetic average of the state's population in every year between 1981, when the epidemic began, and 1996, the latest year for which data from the CDC's AIDS Public Information Data Set are available (15). Although this may not be the most precise figure available for the total number of people at risk, any imprecision should occur equally in either direction, so that this figure should enable us to get a more complete picture of the effect of the needle laws. The nine states that regulated needles had a total cumulative AIDS tally (all causes) of 3.63 per 100million inhabitants (based upon the average population figure.) In contrast, the remainder of the Union had a cumulative AIDS tally of 1.66, for a ratio of 2.18. (Because of rounding, the ratios may appear to be slightly inaccurate.) Among IDUs (including those who also were MSMs), the figures were 1.33 in the states with prescription laws, versus 0.41 in the others, for a ratio of 3.24. Note that this ratio is higher than the one for all AIDS cases; this simply restates the information in the above paragraphs, namely that needle laws hit IDUs particularly hard (See Table 1).
a a Men who have sex with men b non-IDUsc Includes blood transfusion and organ recipientsOne final pertinent piece of data on this subject relates to IDUs within any given city who may have differing access to needles, especially if the city restricts needles: diabetics. A national study of 2921 IDUs, of whom 41 were insulin-dependent diabetics, revealed lower HIV positivity among the diabetics (9.8% vs. 24.3%), despite similar sexual practices and duration and intensity of drug use (16). Based upon all the data, we submit the following conclusion: the needle policy in states such as New York is responsible for substantially increasing the mortality rate from AIDS. One may object to placing responsibility for these AIDS cases on the state, arguing that the use of these needles is voluntary and thus that the users assume the full risk of their actions. This argument runs into a fatal contradiction. Let us consider the rationale behind the laws banning drugs as well as needles. These items are banned notbecause the excessive use of certain drugs may be harmful to one's health - since such a rationale would surely necessitate banning cholesterol-laden foods in addition to cigarettes and alcohol - but because we believe these drugs to be addictive. That is, we believe that once an individual has begun using drugs such as heroin, the nature of the drug forces him to continue. If that is so, then it follows that the use of contaminated needles is likewise coerced, as it is surely the only needle available, so preventing the addict from obtaining clean needles is, in effect, consigning him to death. On the other hand, if we believe that heroin use is a choice, then we have rejected the major rationale for the laws against it, and we must conclude that heroin, along with the needles needed for its injection, should be available on the free market. One may also object to loosening the availability of needles on the grounds that this will encourage further drug use. Even if this were so, it is still far from clear that needles should be banned, because it neglects the fact that the individual user is much better off with clean needles; it is surely cold-hearted to sacrifice the lives of the many (IDUs) on behalf of the health of the few (those who might be encouraged to use drugs because they are less dangerous.) However, this is a moot point, since numerous studies have shown that needle exchange programs do not lead to increased intravenous drug use. According to the Lindesmith Center (17), six government studies have concluded that needle exchange programs do not lead to an increase in drug use. The report also stated that openings of needle exchange programs in San Francisco and in New Haven were followed by increases in the mean age of IDUs, which is inconsistent with the notion that needle availability will result in the recruitment of newer, younger IDUs. One potential objection to the presentation of this data is that there may be intrinsic differences between the two groups of states that account for the difference in the AIDS cases, and that the evident effect of the syringe laws is merely a coincidence. For instance, there might be differences in social factors or in the actual reporting of AIDS cases between the two sets of states that are largely responsible for the reported differences in AIDS incidence. There are several factors arguing against this. One is the consistency of the findings within the nine states; that is, the states that permit needles to be sold over the counter had a cumulative AIDS total of 0.41 cases/100 million that were associated with IDU; in contrast, only one of the nine states that require prescriptions (New Hampshire) had a total that was less than that. Second, the trends we see are not significantly altered by either focusing on or ignoring large cities. For instance, the 1996-1997 AIDS incidence was higher in the states that regulated needles, whether one focused on the states as a whole or specifically on the large cities within each state. Likewise, dropping the date from some of the largest cities, such as New York, Chicago, and Boston, within the states that regulate needles actually increased the percentage of cumulative AIDS cases that were associated with IDU. Third, this data is consistent with other findings presented above, such as the finding that diabetic IDUs were less likely to develop AIDS than non-diabetic IDUs, despite having similar sexual practices (18). Finally, these findings are entirely consistent with what our intuition should tell us to expect: namely that folks intent on injecting themselves with drugs are more likely to share needles with other drug users if they are not permitted to purchase clean ones than they would be otherwise, and that this act of sharing needles with drug users will increase their chances of getting AIDS, which in turn will put other people - primarily their sexual partners and children - at risk. There are perhaps some who, while acknowledging the causative relationship between laws against needle purchases and increased rates of HIV among IDUs, are perfectly content to see those people go to their early graves. To these kind-hearted souls, we think we need to point out the connection between AIDS among IDUs and AIDS among heterosexuals (heterosexuals refers to those who do not inject drugs) as well as among newborns. Regarding heterosexuals, although they constitute a smaller percentage of all AIDS cases in the nine states that regulate needles than in the remaining states and DC, the per capita incidence of AIDS among heterosexuals is actually higher in those nine states because the overall incidence of AIDS is higher. Specifically, the cumulative incidence of AIDS among heterosexuals in the states that regulate needles was .252 per 100 million, versus .156 in the rest of the Union, a ratio of 1.64 (See Table 1). Although one might argue that this could reflect more unsafe sexual practices in the nine states, we may also speculate that at least some of this difference is due to the increased prevalence of AIDS among IDUs, many of whom are sexually active heterosexuals. For example, Nelson et al. reported that nearly 45% of 2921 IDUs interviewed claimed to have engaged in sexual intercourse with at least 11 different partners over the past 10 years (19), although it is not clear how many of these men and women engaged in safe sex. Note that since only 5% admitted to receptive anal intercourse, it is likely that this population of IDUs is largely comprised of sexually active heterosexuals. Further evidence for the link between AIDS among IDUs and AIDS among non-drug using heterosexuals comes from the CDC, who reported in 1996 that cases of AIDS among heterosexuals partners of IDUs has increased steadily during the 1990s, such as a 9% increase among women and a 17% increase among men from January to June of 1995 (20). As of 1996, among women, 43.2% of AIDS cases were due to heterosexual contact with an IDU (21). IDUs clearly provide a bridge between homosexual men and heterosexual men and women. Those who are not concerned about IDUs and gay men who acquire AIDS ought to give pause to the reality that AIDS among those populations, particularly the former, substantially increases the chances that a non-drug using, heterosexual man or woman will be infected with the disease. Finally, we should consider the substantial number of people with AIDS whose behavior cannot be said to be responsible for their disease. This includes adults and children who are infected with the virus as a result of a blood or other tissue transfusion. Although this is a very rare cause of the disease, it might be significant that even this category of AIDS has a higher per capita cumulative incidence within the nine states that regulate needles (.059 per 100 million, versus .044, including hemophiliacs {See Table 1}), no doubt a result of increased contamination of the blood supply. In addition, we must consider infants who are born infected with the virus. Whatever we may think of their parent's behavior, we must acknowledge the tragic cases that these babies present. A report released by DrugSense cited a study by the Department of Health and Human Services which found that 75% of newborns with HIV/AIDS became infected as a direct or indirect result (i.e., heterosexual contact with an IDU) of intravenous drug use (22). Not surprisingly, then, the nine states that regulate needles account for more than one-half (52%) of all newborns who acquired AIDS through their mother's risk factors, despite accounting for under one-third (31.5%) of the total population of the United States (22). Our needle policy is killing not only men and women who chose to self-medicate with illicit drugs, not only their heterosexual partners, but also children who made the mistake of being born to women engaging in unsafe practices. How many adults with AIDS, and how many children with AIDS, would be living normal, healthy lives if not for policies in several states that prevent adults from purchasing needles without a prescription? How many lives are we willing to sacrifice in order to take a moralistic stance on what ought to be a private matter? ENDNOTES:
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