July 28, 1998
New York City has the world's largest and most complex injection-drug HIV epidemic, so its reduction is "fantastic," says Jason Farrell, founder of Manhattan's Positive Health Project, one of the numerous small needle-exchange programs that have been credited with helping to curb the city's epidemic. Helene Gayle, director of the AIDS program at the federal Centers for Disease Control, says the new findings "show that you can make a difference, even with a population that a lot of people write off."
But in the same breath, experts warn that the good news is extremely tenuous. True, if the current low rate of new infections can be maintained, then the epidemic will probably shrink even further. But the decline could be reversed by any number of factors -- including changes in AIDS-prevention or drug-treatment policies, such as the hotly contested issue of needle exchange.
Last April, President Clinton overrode the advice of his own secretary of health, as well as findings from numerous scientific studies showing that syringe exchange slows the spread of HIV without increasing drug abuse, and refused to approve federal funding for such programs, which currently operate on shoestring budgets underwritten by state and private money. Now, Congress is considering a Republican bill that would ban even indirect federal funding for needle-exchange programs.
If this bill is passed, say advocates, the federal government could not pay for any service, even medical care or counseling, administered by a needle-exchange agency. Even federal "pass-through" funds, which are dispersed by the city or state, could be denied to such organizations. In a separate, but no less alarming development, Mayor Rudolph Giuliani has proposed phasing out the city's methadone programs, which currently give thousands of heroin addicts an alternative to injecting drugs.
"The epidemic among drug users could go away tomorrow if every addict were given all the needles they needed," says NYU's Michael Marmor, a coauthor of Des Jarlais's study. "But," warns this veteran researcher, who was on the team that identified the original 1981 outbreak of Kaposi's sarcoma that would later be recognized as AIDS, "the opposite could happen if officials crack down on needle exchange or reduce methadone availability."
Des Jarlais agrees. Noting that New York City has had 50,000 cases of full-blown AIDS among IV-drug users, their sexual partners, and their children, he says, "That's more AIDS cases than in any European country. This is still a huge HIV epidemic, and we have a long way to go before we get it fully under control."
Des Jarlais released his groundbreaking findings at the recent 12th World AIDS Conference in Geneva. But hoping to publish the full results in a scientific journal, Des Jarlais didn't trumpet his study, so it was almost lost among the more than 6000 scientific papers presented there. Only the Boston Globe picked up on it. Even so, Des Jarlais's study has created a stir among local researchers and frontline AIDS workers, many of whom say they, too, are seeing signs of an ebbing epidemic.
Farrell's needle-exchange program, for example, has witnessed a sharp decrease in the number of new participants who test positive for HIV. The CDC is finding a pattern similar to Des Jarlais's in two New Yorkbased studies of its own, says Scott Holmberg, an epidemiologist with the agency. And Ellie Schoenbaum, who heads the highly respected AIDS epidemiology program at Montefiore Medical Center in the Bronx, says that the proportion of HIV-positive injection-drug users in Montefiore's large methadone program "maxed out at about 45 percent" in the late 1980s. Now, she says, the proportion of new enrollees who are infected with HIV is down below 30 per cent. Similarly, Des Jarlais found that the proportion of the city's drug users who are HIV-positive had fallen from 44 percent in 1991 to 28 percent in 1996.
And Des Jarlais discovered that the rate of new infections has also dropped. Epidemiologists measure new infections per 100 "person-years at risk," or PYAR, which could mean 100 individuals who are injecting drugs for one year, or 50 people who are injecting for two years. Des Jarlais found that new infections had dropped from a high of about 13 per 100 PYAR during the early, explosive phase of the epidemic, to 4.4 during the epidemic's relatively stable period of the late 1980s and early 1990s, to less than 2 in 1996, the most recent year for which data is available.
If this low rate can be maintained, the epidemic will probably keep dwindling, though "it won't go to zero," says Des Jarlais. When the epidemic levels off, what percent of IV-drug users will remain infected? The current 28 percent? 20 percent? 10 percent? "We don't know," he says.
By analyzing 15 studies, Des Jarlais maximized the chance of drawing an accurate picture of the epidemic. The studies recruited users from the street, drug treatment programs, STD clinics, and other venues. Importantly, Des Jarlais says, the studies included "a lot of younger injectors," who are considered harder to track and more vulnerable to infection. Encouragingly, Des Jarlais reports that their rates of infection are only slightly higher than those of older addicts.
Still, he says, there are between 150,000 and 200,000 IV-drug users in New York City, so "there are almost undoubtedly subgroups -- such as those who live far from syringe-exchange programs, use crack, or engage in same-gender sex -- who might have higher" rates of infection. Indeed, NYU's Marmor has found that women addicts become HIV-positive at higher rates than their male counterparts, probably because women are more vulnerable to sexual infection.
The epidemic has slowed for two main reasons, experts agree. The first is the brutal cycle of the epidemic itself. "A lot of HIV-positive injectors have died," says Des Jarlais, "so fewer people are there to transmit the virus." The second reason, he says, is the "continued reductions in injection risk behavior since 1984. Syringe exchange has been an important part of that reduction -- not the only part, but an important part."
Only 15 to 20 percent of the city's IV-drug users are estimated to use needle-exchange programs. Yet those programs reach the most hardcore users, says Des Jarlais, and that magnifies their effect. "If I inject a lot and go to a syringe exchange, then I'm not passing dirty needles to people who only inject occasionally," Des Jarlais explains. "If we're getting those at greatest risk for transmitting the virus, then we can protect the population as a whole."
Several experts pointed to another cause: the sea change from injecting heroin to sniffing it. But that change is also subject to sudden reversal. If government interdiction or drug-cartel greed were to force up the price of heroin or reduce its purity, sniffers might well start injecting again, because mainlining heroin provides the same high with less drug. With needle-exchange programs already stretched thin, that could force addicts to share needles, and HIV could surge back up.
In short, the improvement in New York's epidemic is fragile. And yet, from needle exchange to safer-sex education to vaccine research, prevention almost always receives far fewer resources than treatment and care. Chris Lanier, coordinator of the National Coalition to Save Lives Now, a group working to lift the ban on federal funding of needle exchange, explains that "a politician can stand by the bedside of someone who's sick," but averting illness offers no such dramatic, heart-tugging scenes. That's doubly true for IV-drug users, who are so stigmatized that they evoke not compassion but scorn. To keep HIV on the run, then, AIDS advocates will have to fight not only the virus, but also prejudice and complacency. "The thing about prevention," says Lanier, "is that you've got to keep doing it."
Research assistance: Tyler Schnoebelen
More articles by Mark Schoofs.
This article was originally published in the Village Voice.
More articles by Mark Schoofs.