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Politics seems to have won out over science in the contentious battle over whether the Clinton Administration should authorize federal funding for needle exchange programs to help stop the spread of AIDS.
In an April 20 announcement that appears to end a review by White House advisers that has gone on for years, the Clinton Administration acknowledged that while needle exchange programs seem to slow the spread of HIV among injection drug users without increasing use of such drugs, it is unwilling to commit federal health funds to the effort.
The Administration added, however, that it believes the programs are worthwhile and that state and local governments should continue to support them.
Donna Shalala, Secretary of Health and Human Services, went so far as to declare needle exchange programs a "life-saving intervention," but then added that she thought locally designed and funded efforts would be the best way to proceed in this section of the AIDS fight's front line.
"It is unfortunate that the politics of drug policy in the United States is taking priority over the science and medical necessity of supporting needle exchange programs at the federal level," Marshall Forstein, M.D., chair of the APA Commission on AIDS, told Psychiatric News. "The Administration is playing politics with people's lives. . . . There is tremendous scientific evidence that these programs lower HIV transmission and do not increase drug use."
In mid-March the Presidential Advisory Council on HIV/AIDS, a 34-member group Clinton appointed to help guide federal decision making on the epidemic, castigated the President and Shalala for failing to lift the nine-year-old ban on using federal funds for needle exchange programs. The council cited multiple studies, including six sponsored by the federal government, all of which produced data pointing to the efficacy of these projects, and none of which found that free needles or syringes contributed to an increase in use of illicit intravenous drugs (Psychiatric News, April 17). Needle exchange programs are operating in dozens of U.S. cities, all funded with state or local money or through private sources.
The council said that it has lost confidence in the Clinton Administration's stated commitment to take every possible step to rein in the spread of HIV infection. Since early in the decade, the epidemic's most virulent spread has been among intravenous drug users and their sexual partners. This transmission route accounts for one-third of the 600,000 or so AIDS cases that have been reported in the U.S. in the last 15 years and about 40,000 new cases annually.
In its pull-no-punches March statement, the Presidential council blamed the Administration's inaction on "a lack of political will." Council members contended that the government's reluctance to lift the funding ban amounts to caving in to opponents who argue that the easy availability of free needles will produce more addicts and convey the message that injecting illegal drugs may not be as dangerous as long maintained.
Forstein said that the Administration's decision is tantamount to declaring expendable the drug addicts who are too poor to buy their own clean needles.
Apparently even Secretary Shalala felt that the rug had been pulled out from under her by the White House's needle exchange decision. On the morning the announcement was made, Shalala was ready to give a statement saying that based on solid evidence of efficacy, the Administration was ready to recommend that selected programs should receive federal money. According to a report in the Washington Post, she planned to declare the needle exchange research "airtight."
Yet three hours before she was to make her announcement, she received a phone call from White House Chief of Staff Erskine Bowles, who informed her that the original decision was proving to be too politically hazardous, with little Congressional backing, and that Clinton had reversed his earlier support, the Post reported. On learning the news, disappointed officials at the Department of Health and Human Services canceled a scheduled news conference on the needle exchange decision and substituted a small-scale, camera-free briefing at which Shalala explained the Administration's half-a-loaf position on funding needle exchange programs.
Among the influential opponents who tipped Clinton's decision in favor of retaining the ban was the head of the White House's war on drugs, Barry McCaffrey. According to news reports, the Administration had been leaning toward allowing federal funds to be used to support these programs until the forceful and outspoken former general convinced Clinton of the risk that such a stance would compromise the nation's antidrug campaign.
There were also rumors, according to the Post, that McCaffrey had contacted Republican opponents of needle exchange programs to alert them to Clinton's and Shalala's apparent support in enough time to marshal their resources to help torpedo the decision.
One Republican Senator, Paul Coverdell of Georgia, quickly used the government's decision as an opportunity to introduce a bill that would prohibit the HHS secretary from ever being able to end the ban on funding needle exchange programs.
Particularly frustrating to AIDS advocates and public health policymakers is that Shalala finally acknowledged that, according to the research evidence, the two-pronged test Congress set for lifting the federal funds ban had been met: The programs contribute to a reduction in the virus's spread and do not make injection drug use more appealing. Daniel Zingale, director of the organization AIDS Action, likened Shalala's announcement to a declaration that the world is obviously not flat, and then denying Columbus the money to begin exploring it.
Within days of the Clinton Admin-istration's decision on federal funding for needle exchange programs, the Centers for Disease Control and Prevention (CDC) published data showing that since 1994 there has been no significant decline in the incidence of new HIV infection .
David Satcher, M.D., who had until recently headed that agency and is now the U.S. Surgeon General, stated that from a public health perspective he is "disappointed" by Clinton's decision to withhold federal dollars for an apparently efficacious strategy against the spread of AIDS. -K.H.