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In an event rarely witnessed in Washington, D.C., a presidential advisory council has publicly castigated the President who appointed them for a "lack of political will."
The group taking this step was the Presidential Advisory Council on HIV/AIDS, and the issue was the White House's inaction on a recommendation to allow government funds to support needle exchange programs as a strategy to slow the spread of the AIDS virus.
In the last five years in particular, HIV has been making alarming inroads among intravenous drug users and their sexual partners, accounting for about 40,000 new cases annually, according to the Centers for Disease Control and Prevention. Most of the AIDS cases among women and children in the U.S. are traceable directly or indirectly to injection drug use.
A number of studies conducted in both in the U.S. and Europe, including six federally funded studies, have shown needle exchange programs to be effective for slowing the virus's spread in this population.
In September 1996, based on the convincing results of these studies, APA's Board of Trustees adopted a policy statement backing "the removal of government restrictions on the availability of sterile syringes specifically within the structure of organized needle exchange programs."
APA also called on the government to "broaden the availability of these programs in targeted areas and provide public health education to promote safer hygiene practices among [intravenous drug users]. . . ." APA coupled its statement with an endorsement of a "core strategy" of earmarking more government resources to increase the inadequate availability of detoxification and treatment programs for all substance abusers.
The situation that angered the 34-member presidential council so much that it issued a statement of "no confidence" in President Clinton is that despite the growing body of evidence, he has failed to affirm publicly the efficacy of needle exchange programs or initiate the steps necessary to lift the ban on using federal funds for these efforts.
While the programs operating in the U.S. are funded with local or private dollars, there has been a Congressionally mandated ban on using federal funds to conduct needle exchange initiatives, which was enacted out of fear that the programs would contribute to an increase in drug use, even if they can rein in the spread of HIV. The law permits the ban to be lifted, however, if the Secretary of Health and Human Services determines that needle exchange programs are effective in reducing HIV transmission and do not contribute to increased drug usage.
The presidential AIDS council points out in unusually strong language that data confirm both of these conditions, and insists that "a lack of political will" is keeping the Clinton Administration from following through on its commitment to do whatever is necessary to "reduce the number of infections each and every year until there are no more new infections."
The members state further in a report sent to Clinton on March 17 that "[d]espite years of study and an overwhelming preponderance of scientific evidence, no action has been forthcoming. All six federally funded reports, an NIH Consensus Conference report, and many other reputable studies have concluded that needle exchange programs reduce HIV transmission and do not encourage drug use."
With this evidence in hand and "support for needle exchange programs by the AMA and the American Public Health Association . . .the continuing delay by Secretary Shalala is appalling," the council states.
The AIDS advisers called on Shalala to "issue an immediate determination that needle exchange programs meet the two-pronged test laid out in the law," so that local and state officials finally have access to federal funds with which they can begin or expand these promising and effective programs.
The council is particularly distressed because the failure to back these projects is exacting a devastating toll on poor, largely minority communities, especially African American and Latino, where the rapid spread of HIV attributable to intravenous drug use is "shameful." Council members reminded the President that as part of his Race Initiative he vowed to eliminate the health disparities between minority and white populations, but without "bold leadership and political courage" from him, that goal will not be achieved.
They are backing the demands of the African-American AIDS advocates who consult to the CDC's African-American Initiative that the President and Surgeon General "declare a state of emergency in the African-American community concerning AIDS and public health," develop an intensive media effort to alert the public to the status of the AIDS epidemic in that population, and devise a new strategy "to interrupt the devastation of drug addiction and HIV/AIDS" among African Americans.
"Every day that passes without action can be measured in needless new infections, infections we know how to prevent," the members emphasized in their letter to Clinton. "The time for study and unwarranted delay is over."
A leading psychiatrist in the field of addiction treatment and research, Mindy Fullilove, M.D., of the New York State Psychiatric Institute and Columbia University, agrees strongly with the AIDS council's rebuke of the Clinton Administration. "These programs have been proven to be very valuable and should be a great help fighting the spread of HIV. Not everyone is able to get into a treatment program, and the result of this terrible inaction has been that the disease has spread needlessly," said Fullilove, who is also a member of the APA Council on Addiction Psychiatry.
It took little time after the council's report for battle lines to be drawn in Congress. Senator John Ashcroft (R-Mo.), recently touted as a Presidential candidate in 2000, issued a statement in which he rejected the AIDS council's plea to expand needle exchange programs. Unswayed by the studies showing no link to increased drug use, he warned that providing drug users with clean needles "is like giving bulletproof vests to bank robbers. This proposal would hurt kids, tear apart families, and damage the culture. . . . If Secretary Shalala falls for the clean-needles pitch, it would be a tragic new example of the Administration's cease-fire in the War on Drugs," Ashcroft said.
Representative Nancy Pelosi (D-Calif.), however, took the AIDS council's report as an opportunity to urge the Clinton Administration to certify that needle exchange programs are effective and do not increase drug use so the funding ban can be removed.
"The science is in. The findings are clear. The Administration has the evidence," she emphasized. "Secretary Shalala should exercise her authority and immediately lift the ban on federal funding of needle exchange programs."
The chair of APA's Commission on AIDS, Boston psychiatrist Marshall Forstein, M.D., is dismayed that in the face of a dramatic rise in HIV among injection drug users, partisan infighting is holding up approval of needle exchange programs.
"I am outraged that an intervention to save potentially thousands of lives is not being funded simply because of the political heat such an endorsement would create," he told Psychiatric News. "Do we imagine for one moment that if an intervention were available to prevent a catastrophic illness among members of Congress, even if it were politically 'hot,' that we would be witnessing such unconscionable neglect?"
The ban's Congressionally imposed time limit was scheduled to expire on March 31, but by that date neither Clinton nor Shalala had indicated whether the government would begin spending federal funds on this type of AIDS prevention effort. -K.H.