Editorial
100% HIV Prevention: Missed Opportunities for Injection Drug Users? Lucy Bradley-Springer, PhD, RN, ACRN, FAAN* Key words: HIV, injection drug use, needle/syringe exchange programs The paradox to public health is if you do a very good job, no one knows it. Jonathan Mermin (quoted in Rudavsky, 2015)
I’ve been wondering about the recent lack of focus on injection drug use in the HIV landscape. Oh sure, it is always mentioned in the same breath as sexual risk, and rote prevention rules are spouted (don’t use, don’t inject, don’t share, and clean your works) with the same commitment as in days past, but it just isn’t as ‘‘there’’ as it used to be. It’s not even ‘‘there’’ for long when a major outbreak occurs among injection drug users (IDUs). Remember the 2015 Indiana HIV outbreak in a group of IDUs? It was an outbreak, which – appropriately – came to light only when an ‘‘‘astute’ public health nurse’’ (Rudavsky, 2015) noticed more than double the number of annual HIV cases in IDUs in a short period of time. It made quite a splash when it happened, but the publicity didn’t last long. I suspect that the IDU focus began shifting when the Centers for Disease Control and Prevention (CDC, 2009) reported an 80% decrease in HIV infection in IDUs from the 1980s to 2006. Unfortunately, in HIV, success often heralds a loss of interest, even when lost interest is not warranted.
HIV Prevention for IDUs While the data for HIV incidence in IDUs are excellent, they are nowhere near what I believe is an
attainable goal of eliminating HIV in this population. This is not the time to back off on prevention efforts in IDU communities; to do so is to miss the opportunity to attain a 0% HIV transmission rate in IDUs. So I checked out the latest fact sheet on HIV and IDU (CDC, 2015) to find out how the CDC is helping to prevent HIV infection in IDUs. The CDC: (a) provides funding, (b) supports intervention programs, (c) supports biomedical approaches including preexposure prophylaxis, (d) publishes guidelines, and (e) conducts surveys (CDC, 2015). Not a bad list, but one major thing was missing–never even mentioned in the fact sheet. Any guesses? Here’s a clue. The same CDC (2009) report that revealed decreasing HIV rates in IDUs also noted that IDUs in a large national study continued to report sharing injection equipment (32.8%). A more recent study in Philadelphia also noted fewer cases of HIV in IDUs, but found rates of sharing hovering at about 60%, and more common in IDUs who were ages 18 to 35 years, female, and White (Brady, Nassau, Shinefeld, & Mezzacappa, 2015). And–good news! A proven method to decrease the sharing of injection equipment has been studied since the mid-1990s. Studies have shown that this method decreases transmission and incidence of Lucy Bradley-Springer, PhD, RN, ACRN, FAAN, is an Associate Professor at the University of Colorado Denver Anschutz Medical Campus, School of Medicine, Aurora, Colorado, USA; the Principal Investigator of the Mountain Plains AIDS Education and Training Center; and Editor of the Journal of the Association of Nurses in AIDS Care. (*Correspondence to: Lucy.Bradley-Springer@ucdenver. edu).
JOURNAL OF THE ASSOCIATION OF NURSES IN AIDS CARE, Vol. 26, No. 5, September/October 2015, 503-505 http://dx.doi.org/10.1016/j.jana.2015.06.005 Copyright Ó 2015 Association of Nurses in AIDS Care
504 JANAC Vol. 26, No. 5, September/October 2015
HIV, hepatitis, and other blood-borne infections; increases the use of drug treatment programs by IDUs; demonstrates cost-effectiveness when compared to lifelong HIV treatment, hepatitis C virus treatment/cure, or liver transplant; and provides all of these benefits without encouraging more individual drug use or recruiting new users (Get the Facts, nd). What could this miracle method be?
Needle/Syringe Exchange Programs I’m sure you have already identified needle/syringe exchange programs (N/SEPs) as this wonder intervention. The amazing thing is that the CDC does not fund, support, study, or publish guidelines on this extremely important tool in the HIV IDU prevention arsenal. Of course, there is a good reason that they don’t: federal law does not allow them to do so. Current law (HR 255, the Consolidated Appropriations Act 2012, Division F, Title V, Section 523) states: Notwithstanding any other provision of this Act, no funds appropriated in this Act shall be used to carry out any program of distributing sterile needles or syringes for hypodermic injection of any illegal drugs. (Department of Health and Human Services, 2012) To make this statement clear, the Act also specifically prohibits federal funding for: (a) human resources (i.e., people to run N/SEPs); (b) delivery systems (i.e., mobile or fixed sites to work out of); or (c) the purchase of injecting equipment (specifically, needles and syringes; Department of Health and Human Services, 2012). Of course, to be fair, some communities and some states had already figured out how to fund N/SEPs, so some IDUs do receive the benefits of access to sterile injecting equipment as well as the social services offered by many of these programs. It is disappointing, however, to deal with the reality: the CDC is a federal agency and, as such, must abide by federal law, even if that law prohibits an evidence-based, fiscally conservative, disease-dodging prevention method. It just doesn’t make sense for the CDC, one of the premier health institutions in the United States, to ignore the positive effect that could be realized by the support of N/SEPs.
Raising Hope On June 16, 2015, the U.S. House of Representatives revealed a draft of their federal spending bill for 2016, in which this language appears: Notwithstanding any other provision of this Act, no funds appropriated in this Act shall be used to purchase sterile needles or syringes for the hypodermic injection of any illegal drug: Provided, that such limitation does not apply to the use of funds for elements of a program other than making such purchases if the relevant State or local health department, in consultation with the CDC, determines that the State or local jurisdiction, as applicable, is experiencing, or is at risk for, a significant increase in hepatitis infections or an HIV outbreak due to injection drug use, and such program is operating in accordance with State and local law. (Harm Reduction Coalition, 2015) Remember: this is a draft. It remains to be seen if this language survives in the final bill. Even if it does, it is only a small crack in the punitive language from the 2012 law. All that we see here is the ability to use N/SEPs in case of an outbreak or the risk of an outbreak of hepatitis or HIV in an IDU community. It is, however, as we say in harm-reduction circles, safer, healthier, and less risky than what we currently have. And, as we also note in harm reduction, if you can make this one small step, you will have time to think about your next step. And, aren’t all IDUs who share equipment at risk of an outbreak of HIV or hepatitis? I mean, really? Disclosures
The author reports no real or perceived vested interests that relate to this article that could be construed as a conflict of interest.
References Brady, K., Nassau, T., Shinefeld, J., & Mezzacappa, C. (2015). Analyzing trends in HIV risks for injection drug users by respondent-driven sampling. Retrieved from http://www. croiconference.org/sessions/analyzing-trends-hiv-risks-inje ction-drug-users-respondent-driven-sampling
Bradley-Springer / Editorial Centers for Disease Control and Prevention (2009). HIV-associated behaviors among injecting-drug users–23 cities, United States, May 2005-February 2006. Retrieved from http:// www.cdc.gov/mmwr/preview/mmwrhtml/mm5813a1.htm Centers for Disease Control and Prevention (2015). HIV and injection drug use. Retrieved from http://www.cdc.gov/hiv/ pdf/g-l/cdc-hiv-idu-fact-sheet.pdf Department of Health and Human Services (2012). Dear colleague letter. Retrieved from http://www.nastad.org/sites/ default/files/102846_OHAP_ECOPY_EXCHANGE_03282 012-103554.CPY_.pdf Get the Facts. (nd). Syringe/needle exchange programs. Retrieved from http://www.drugwarfacts.org/cms/Syringe_ Exchange#sthash.h1KwSNY8.nCLXWyc3.dpbs Harm Reduction Coalition (2015). Syringe exchange progress in federal spending bill. Retrieved from http://harmreduction. org/miscellaneous/syringe-exchange-progress-in-federal-spen ding-bill/ Rudavsky, S. (2015). CDC: Indiana has ‘one of the worst’ HIV outbreaks. Retrieved from http://www.usatoday.com/story/ news/nation/2015/04/28/indiana-hiv-outbreak/26498117/
Erratum JANAC regrets that an author’s name was misspelled in the article ‘‘Culture-Specific Factors Contributing to HIV Risk Among Jamaican Adolescents,’’ which was published in the March/April 2007 (18/2) issue, pages 35-47. The fifth author’s last name is correctly spelled Kahwa. Author Group as originally published: M. Katherine Hutchinson, PhD, RN, Loretta Sweet Jemmott, PhD, RN, FAAN, Elyssa B. Wood, MPH, RN, Herme Hewitt, PhD, RN, Eulalia Kawha, PhD, RN, Norman Waldron, MD, Beverly Bonaparte, PhD Author Group as corrected: M. Katherine Hutchinson, PhD, RN, Loretta Sweet Jemmott, PhD, RN, FAAN, Elyssa B. Wood, MPH, RN, Herme Hewitt, PhD, RN, Eulalia Kahwa, PhD, RN, Norman Waldron, MD, Beverly Bonaparte, PhD DOI of original article: 10.1016/j.jana.2007.01.008 JOURNAL OF THE ASSOCIATION OF NURSES IN AIDS CARE, Vol. 26, No. 5, September/October 2015, 505 doi: 10.1016/j.jana.2015.07.004 Copyright Ó 2015 Association of Nurses in AIDS Care
505
100% HIV Prevention: Missed Opportunities for Injection Drug Users? Lucy Bradley-Springer, PhD, RN, ACRN, FAAN* Key words: HIV, injection drug use, needle/syringe exchange programs The paradox to public health is if you do a very good job, no one knows it. Jonathan Mermin (quoted in Rudavsky, 2015)
I’ve been wondering about the recent lack of focus on injection drug use in the HIV landscape. Oh sure, it is always mentioned in the same breath as sexual risk, and rote prevention rules are spouted (don’t use, don’t inject, don’t share, and clean your works) with the same commitment as in days past, but it just isn’t as ‘‘there’’ as it used to be. It’s not even ‘‘there’’ for long when a major outbreak occurs among injection drug users (IDUs). Remember the 2015 Indiana HIV outbreak in a group of IDUs? It was an outbreak, which – appropriately – came to light only when an ‘‘‘astute’ public health nurse’’ (Rudavsky, 2015) noticed more than double the number of annual HIV cases in IDUs in a short period of time. It made quite a splash when it happened, but the publicity didn’t last long. I suspect that the IDU focus began shifting when the Centers for Disease Control and Prevention (CDC, 2009) reported an 80% decrease in HIV infection in IDUs from the 1980s to 2006. Unfortunately, in HIV, success often heralds a loss of interest, even when lost interest is not warranted.
HIV Prevention for IDUs While the data for HIV incidence in IDUs are excellent, they are nowhere near what I believe is an
attainable goal of eliminating HIV in this population. This is not the time to back off on prevention efforts in IDU communities; to do so is to miss the opportunity to attain a 0% HIV transmission rate in IDUs. So I checked out the latest fact sheet on HIV and IDU (CDC, 2015) to find out how the CDC is helping to prevent HIV infection in IDUs. The CDC: (a) provides funding, (b) supports intervention programs, (c) supports biomedical approaches including preexposure prophylaxis, (d) publishes guidelines, and (e) conducts surveys (CDC, 2015). Not a bad list, but one major thing was missing–never even mentioned in the fact sheet. Any guesses? Here’s a clue. The same CDC (2009) report that revealed decreasing HIV rates in IDUs also noted that IDUs in a large national study continued to report sharing injection equipment (32.8%). A more recent study in Philadelphia also noted fewer cases of HIV in IDUs, but found rates of sharing hovering at about 60%, and more common in IDUs who were ages 18 to 35 years, female, and White (Brady, Nassau, Shinefeld, & Mezzacappa, 2015). And–good news! A proven method to decrease the sharing of injection equipment has been studied since the mid-1990s. Studies have shown that this method decreases transmission and incidence of Lucy Bradley-Springer, PhD, RN, ACRN, FAAN, is an Associate Professor at the University of Colorado Denver Anschutz Medical Campus, School of Medicine, Aurora, Colorado, USA; the Principal Investigator of the Mountain Plains AIDS Education and Training Center; and Editor of the Journal of the Association of Nurses in AIDS Care. (*Correspondence to: Lucy.Bradley-Springer@ucdenver. edu).
JOURNAL OF THE ASSOCIATION OF NURSES IN AIDS CARE, Vol. 26, No. 5, September/October 2015, 503-505 http://dx.doi.org/10.1016/j.jana.2015.06.005 Copyright Ó 2015 Association of Nurses in AIDS Care
504 JANAC Vol. 26, No. 5, September/October 2015
HIV, hepatitis, and other blood-borne infections; increases the use of drug treatment programs by IDUs; demonstrates cost-effectiveness when compared to lifelong HIV treatment, hepatitis C virus treatment/cure, or liver transplant; and provides all of these benefits without encouraging more individual drug use or recruiting new users (Get the Facts, nd). What could this miracle method be?
Needle/Syringe Exchange Programs I’m sure you have already identified needle/syringe exchange programs (N/SEPs) as this wonder intervention. The amazing thing is that the CDC does not fund, support, study, or publish guidelines on this extremely important tool in the HIV IDU prevention arsenal. Of course, there is a good reason that they don’t: federal law does not allow them to do so. Current law (HR 255, the Consolidated Appropriations Act 2012, Division F, Title V, Section 523) states: Notwithstanding any other provision of this Act, no funds appropriated in this Act shall be used to carry out any program of distributing sterile needles or syringes for hypodermic injection of any illegal drugs. (Department of Health and Human Services, 2012) To make this statement clear, the Act also specifically prohibits federal funding for: (a) human resources (i.e., people to run N/SEPs); (b) delivery systems (i.e., mobile or fixed sites to work out of); or (c) the purchase of injecting equipment (specifically, needles and syringes; Department of Health and Human Services, 2012). Of course, to be fair, some communities and some states had already figured out how to fund N/SEPs, so some IDUs do receive the benefits of access to sterile injecting equipment as well as the social services offered by many of these programs. It is disappointing, however, to deal with the reality: the CDC is a federal agency and, as such, must abide by federal law, even if that law prohibits an evidence-based, fiscally conservative, disease-dodging prevention method. It just doesn’t make sense for the CDC, one of the premier health institutions in the United States, to ignore the positive effect that could be realized by the support of N/SEPs.
Raising Hope On June 16, 2015, the U.S. House of Representatives revealed a draft of their federal spending bill for 2016, in which this language appears: Notwithstanding any other provision of this Act, no funds appropriated in this Act shall be used to purchase sterile needles or syringes for the hypodermic injection of any illegal drug: Provided, that such limitation does not apply to the use of funds for elements of a program other than making such purchases if the relevant State or local health department, in consultation with the CDC, determines that the State or local jurisdiction, as applicable, is experiencing, or is at risk for, a significant increase in hepatitis infections or an HIV outbreak due to injection drug use, and such program is operating in accordance with State and local law. (Harm Reduction Coalition, 2015) Remember: this is a draft. It remains to be seen if this language survives in the final bill. Even if it does, it is only a small crack in the punitive language from the 2012 law. All that we see here is the ability to use N/SEPs in case of an outbreak or the risk of an outbreak of hepatitis or HIV in an IDU community. It is, however, as we say in harm-reduction circles, safer, healthier, and less risky than what we currently have. And, as we also note in harm reduction, if you can make this one small step, you will have time to think about your next step. And, aren’t all IDUs who share equipment at risk of an outbreak of HIV or hepatitis? I mean, really? Disclosures
The author reports no real or perceived vested interests that relate to this article that could be construed as a conflict of interest.
References Brady, K., Nassau, T., Shinefeld, J., & Mezzacappa, C. (2015). Analyzing trends in HIV risks for injection drug users by respondent-driven sampling. Retrieved from http://www. croiconference.org/sessions/analyzing-trends-hiv-risks-inje ction-drug-users-respondent-driven-sampling
Bradley-Springer / Editorial Centers for Disease Control and Prevention (2009). HIV-associated behaviors among injecting-drug users–23 cities, United States, May 2005-February 2006. Retrieved from http:// www.cdc.gov/mmwr/preview/mmwrhtml/mm5813a1.htm Centers for Disease Control and Prevention (2015). HIV and injection drug use. Retrieved from http://www.cdc.gov/hiv/ pdf/g-l/cdc-hiv-idu-fact-sheet.pdf Department of Health and Human Services (2012). Dear colleague letter. Retrieved from http://www.nastad.org/sites/ default/files/102846_OHAP_ECOPY_EXCHANGE_03282 012-103554.CPY_.pdf Get the Facts. (nd). Syringe/needle exchange programs. Retrieved from http://www.drugwarfacts.org/cms/Syringe_ Exchange#sthash.h1KwSNY8.nCLXWyc3.dpbs Harm Reduction Coalition (2015). Syringe exchange progress in federal spending bill. Retrieved from http://harmreduction. org/miscellaneous/syringe-exchange-progress-in-federal-spen ding-bill/ Rudavsky, S. (2015). CDC: Indiana has ‘one of the worst’ HIV outbreaks. Retrieved from http://www.usatoday.com/story/ news/nation/2015/04/28/indiana-hiv-outbreak/26498117/
Erratum JANAC regrets that an author’s name was misspelled in the article ‘‘Culture-Specific Factors Contributing to HIV Risk Among Jamaican Adolescents,’’ which was published in the March/April 2007 (18/2) issue, pages 35-47. The fifth author’s last name is correctly spelled Kahwa. Author Group as originally published: M. Katherine Hutchinson, PhD, RN, Loretta Sweet Jemmott, PhD, RN, FAAN, Elyssa B. Wood, MPH, RN, Herme Hewitt, PhD, RN, Eulalia Kawha, PhD, RN, Norman Waldron, MD, Beverly Bonaparte, PhD Author Group as corrected: M. Katherine Hutchinson, PhD, RN, Loretta Sweet Jemmott, PhD, RN, FAAN, Elyssa B. Wood, MPH, RN, Herme Hewitt, PhD, RN, Eulalia Kahwa, PhD, RN, Norman Waldron, MD, Beverly Bonaparte, PhD DOI of original article: 10.1016/j.jana.2007.01.008 JOURNAL OF THE ASSOCIATION OF NURSES IN AIDS CARE, Vol. 26, No. 5, September/October 2015, 505 doi: 10.1016/j.jana.2015.07.004 Copyright Ó 2015 Association of Nurses in AIDS Care
505
