Illustration by Fernando Vicente

This week, the Great and the Good of the AIDS industry gather in Vienna for the biennial AIDS circus. With delicious irony, the conference, held right next to the barracks of the UN’s Drug Warriors, will focus in part on getting more countries to do the one thing that really works in HIV prevention — providing clean needles to drug injectors.

That means that there will be a lot of talk about the evidence base. There’s always a lot of talk at these conferences, and although I escaped Vienna just before the start of the conference (to see the inimitable Grace Jones play Lovebox), I’m as much of a windbag as anyone. While pontificating in the BMJ video (below) about the evidence base for harm reduction, I think there’s a more important point to be made to the small coterie of scientists who wash around in the larger tide of 20,000 AIDS junkies, Poz Professionals, singing orphans, dancing hookers, jostling NGO workers, bewildered journalists and UN PR-wallahs that floods these conferences.

The point, made at greater length in an essay in the Lancet (pdf), is that we can’t look at scientific evidence in isolation. [The collage at the top of this post comes from the essay. For works of both anatomical and philosophical beauty, do browse Fernando Vicente's illustrations]. Yes, there’s lots of scientific evidence that harm reduction saves lives. But there’s a huge body of political evidence, too. And that evidence suggests that politicians do what voters want, or, at very best/worst, what politicians think they can get away with. For many politicians in many countries for many years, that has meant not spending voters’ money on helping people take drugs more safely.

As long as that is true, the scientific evidence will continue to be secondary. No matter how many well-spoken epidemiologists do their bit on YouTube.

Or, for that matter, how many nice people stand at the entrance to festivals such as Lovebox handing out orange wristbands that read “Nice People Take Drugs”. As I wandered in with my happy band of blue-tongued smurfs, I reflected that if ever there was a case of preaching to the converted…
But I also take issue with the statement, which has a UNICEF lobbyist ring to it. “Most people at risk for HIV are young” does NOT translate into “Most young people are at risk for HIV”. Nice people take drugs, certainly. But are we to believe that most people who take drugs are nice? Maybe yes, maybe no; since a majority of young people in the UK take drugs, it rather depends on your view of human nature.

Still, the folks at Release who run the campaign have come up with some fun ideas. I especially like the “Politicians Drug Confessions” playing cards.

You can buy them here.

An appeal would fly in the face of the data (which show that Insite reduces overdoses and many of the other frankly nasty things that happen to people who live with addiction to injectible drugs). It would fly in the face of pragmatism — up just one flight of stairs from the safe injecting room is a drug treatment centre which works to help people get off drugs when they’re ready to try. Detox is never an easy thing to achieve; our best bet is to have really strong links between services for current injectors and services that help them stop. But most of all it would fly in the face of any remaining self-respect that Canadians might have about their political system. Because although the newspapers talk of “the Harper government” doing this or that, Canada actually has no government right now, or at least none that answers to the normal description of parliamentary democracy. What right, then, does Harper have to be prosecuting court cases that waste tax dollars and lives?

Harper’s bully boy tactics may work for Insite in the end, though. HealthCanada is typically mealy-mouthed about an appeal, saying: “While the government respects the court’s decision, it is disappointed with the outcome. The government is reviewing the decision carefully. Until this review is complete, it would be inappropriate to speculate on future action on the part of the government of Canada.” But it’s very clear that a Liberal government would not keep banging its head against the wall of common sense that Insite represents. And by sending parliament packing until March, Harper may just have signed the death warrant for his own “government”. That would be good news for Insite users and other Canadians alike.

Thanks to Miriam for bringing this to my attention while I’m in distant Vietnam.

The change, buried in a massive budget bill passed by Congress in mid December and and since signed into law by President Obama, passed with very little comment in the blogosphere. But it has the potential to revolutionise HIV prevention in many parts of the US as well as in other countries. US cities and states have been allowed to provide injectors with clean needles if they (the cities and states) paid for them themselves, but in conservative states it has often been hard to get local politicians to come up with the cash. Similarly, nothing is stopping countries outside the US funding their own harm reduction programmes, but the yeay or nay of the world’s largest funder of HIV programmes can have a huge effect on what local governments choose to do (and not to do!)

Perhaps people didn’t notice the good news about harm reduction because they were caught up in the histrionics of the Drug Warriors in New York City, who are apoplectic that the health department is handing out perfectly sensible advice on how to shoot up safely.

Dubbed “Smack for Dummies” by the New York Post, the pamphlet has the Warriors fretting that young mothers might come across it in a clinic waiting room, read the instructions on keeping your veins healthy, and think: “Hmm, that looks easy. Maybe I’ll try shooting up before I pick the kids up from playgroup this afternoon”.

I’m glad to say that Mayor Bloomberg and the NY health department are both standing firm.

Also in the deluge of good news from Washington — the omnibus spending bill does not earmark any money for abstinence-only sex ed programmes that we know don’t work.

While colleagues at USAID say they haven’t had any official word on the implications of the bill for HIV funding in other countries, everyone’s optimistic that the common sense, so late to arrive, will be quickly exported.

Unlike the United States, the UK has bothered to track HIV infection among large, representative samples of drug injectors (both current injectors and those in methadone and other treatment programmes) since close to the start of the epidemic. Part of this effort involved testing anonymous samples of left over blood for HIV — the samples were usually taken from treatment or diagnostic purposes and are stripped of all but the most basic demographic and risk information (age, sex, length of time injecting, recent needle sharing) before being tested with HIV. The results, shown separately for London and the rest of England and Wales are shown below.

(Click to enlarge)

Yes, prevalence for the whole of England and Wales (including London — Scotland has its own system and reports separately) has risen by over 77% in the last decade. But still, fewer than one injector in 60 is infected with HIV. If you draw the graph using a normal percentage scale, you’ll see something close to the true level of infection — still too high, of course, but not exactly an overwhelming prevention failure when compared with data from any city or country that doesn’t have needle exchanges. The graph compares what happened in the UK with what happened in Jakarta, just because I happened to have the Indonesian data handy. But it would look just the same with data from Bangkok or Moscow or even New York in the years before the city (with no help from the federal government) began to hand out needles.

(Click to enlarge)

Since I’m just a numbers nerd and obviously don’t have a great visual imagination, perhaps someone could help me out here: how can you conclude from these pictures that safe injecting programmes fail to prevent HIV?

Does this signal a new wave of common sense in HIV prevention in the United States? That’s certainly what we expected when Obama was elected. During his campaign, for example, he recognised that sterile needle programmes cut HIV infection among injectors, saving lives and money, and pledged to end a ban on funding those programmes from federal coffers. So cities such as his home town of Chicago, pictured in the map below, will now be able to use central money to provide clean needles to the inner city injectors that need them most. As long as they set up in one of the grey spaces. In the cemetary, in other words.

(Click to enlarge)

On this fantastic map, which comes from Yale University’s Dr. Russell Barbour by way of Stop the Drug War, the red areas are the parts of town where it would be illegal to operate a federally funded needle exchange under new rules proposed by Congress. The Drug War Chronicle provides an interesting history of the needle exchange shenannigans. Essentially, Obama did not remove the ban from a budget bill because he thinks policy shouldn’t be made through sub-clauses in budget bills. Democrats on the committee discussing the bill disagreed, and dropped the ban. Then Republicans, not willing to give up the idea that the availability of clean needles would have us all racing to start shooting up smack, decided to protect the innocent by forbidding needle programmes within 1,000 feet of “a public or private day care centre, elementary school, vocational school, secondary school, college, junior college, or university, or any public swimming pool, park, playground, video arcade, or youth centre, or an event sponsored by any such entity”. That’s the red bits on the map of Chicago above. Here’s Dr, Barbour’s map of needle exchange exclusion zones in San Francisco:

This is clearly just a way of pulling the rug from under any effort to increase access to clean needles. We’ve come to expect this kind of implaccable opposition from conservative Drug Warriors in the United States. We used to expect the Brits to be more rational about their drug policy, and the UK has, thank God, held on to its policy of providing clean fits for anyone that needs them. But with the sacking of the government’s independent advisor on drugs David Nutt for repeating his independent advice after the government chose to ignore it, I’m not so sure.

I’m not even going to wade in here about whether or not idependent scientific advisers to government should shut up after their advice is ignored, but I will commend to you a wonderful paper by Dr Nutt on the dangers of Equasy, (pdf) an irrational addiction to horse riding. This has been seized on by many who have not read it as an example of his inappropriate analyses. Irony, where art thou?

The US Drug Warriors also joyously seized on the latest round of anonymous surveillance of HIV among drug injectors in Britain, sending out an e-mail crowing about rising rates of HIV and drawing a link between that and the fact that the UK was the first country in the world to have national injection safety programmes. My next post will put those rather one-eyed claims into perspective.

Note the rueful way the Canadian researchers lament the absence of US participation in the North American Opiate Medicate Initiative. In their excellent paper in the New England Journal of Medicine researchers from Vancouver and Montreal thank “the many U.S. scientists who contributed to the early design discussions but ultimately were unable to participate in the trial” because of what they ellipitcally call “financial and logistic barriers”.

This trial was being planned at the same time that the Traditional Values Coalition, defender of all that is Right and Good in America, were sticking the Republican Rottweilers on the National Institutes for Health for funding studies of sexual and drug-taking behaviour. No surprise, then, that US scientists had to drop out of the study. There is no reason in the world to believe that heroin prescription wouldn’t work as well in the US as it does in Canada, the UK or any other country at reducing consumption of street heroin, keeping people in treatment and cutting crime among that hard core of users that have tried and failed to get off smack by using methadone or just saying no. But in the current climate (yes, even with the Obama administration in occupation) there’s really not much point in doing studies in the States — no amount of evidence will lead to a policy change. As Virginia Berridge points out in an interesting editorial in the same issue of NEJM, drug policy is more a matter of history and culture than it is of science. America, founded on puritanism, has always been less tolerant of opiates than the Brits, who used them to fuel an unequal trade with China and some properly great literature.

One finding that surprised the Canadian researchers: while most people in the study obviously knew if they were taking methadone (orally) or heroin (injected) a small number of users were randomly assigned to inject hydromorphone instead of heroin. Neither they nor the study staff knew who was getting the real thing and who was getting the semi-sythetic cough suppressant. Amazingly, not one of the people shooting up cough medicine for a year could tell they weren’t taking smack. As the researchers pointed out in slightly mealy-mouthed research-speak, “the benefits of injectable opiod maintenance might be achievable without the emotional and regulatory barriers often presented by heroin maintenance”. Meaning that we might get away with prescribing drugs to help chronic users stabilise their lives if we could just stay out of the headlines. The “SMACKING UP YOUR TAXES TO SUPPORT JUNKIES!” type headlines.

A finding that didn’t surprise the Canadian researchers: people who were injecting drugs, even on prescription, were much more likely to OD than people on methadone — mostly because the heroin doesn’t mix so well with some of the other drugs they had been taking (crack cocaine use didn’t change for any of the study groups in Canada, although it fell in all groups in the UK). BUT, as the researchers point out, all but one of the overdoses happened in the study clinic, where staff were able to administer nalaxone and provide other support so that users got through the overdose ok. If they’d been out shooting up street smack, the chances are they wouldn’t have been so lucky. Which is one more reason to support supervised injecting facilities such as Vancouver’s impressive Insite.

One thing the Canadian researchers didn’t report was the relative cost of the different approaches. The UK study reported that heroin maintenance cost about £15,000 per person per year, about a third of the cost of a year in jail. But it took a report on the BBC to tell us that we could put three people on methadone for a year for the same amount. The question is: how many of them would still be on treatment at the end of the year?

(The Beeb story has an interesting video interview of one of the users of the programme, but sadly no embed code).

The IAS conference on HIV Pathogenesis, Treatment and Prevention in Cape Town, South Africa produced its usual crop of second rate abstracts on issues currently fashionable in the HIV industry — gender, health systems strengthening, scaling up — along with the inevitable calls for more cash. The IAS also runs the biennial international AIDS conferences — giant circuses full of amusing but expensive set-pieces: protesting sex workers, singing orphans, earnest celebs. There’s so little science at those conferences that a lot of researchers have abandoned them in favour of low-key, high-science meetings such as CROI. It seems IAS is trying to claw its way back on to the scientific platform with the pathogenisis sub-conferences. Perhaps we’ll see more good sense from the organisation now that it is coming under the spell of the inimitable Robin Gorna.

Among the conference’s silliness was a study of the protective effect of circumcision in anal sex between men in Soweto. It’s hard to tell much from an abstract and this came from a good research team so perhaps I’m being unfair. This cross-sectional study (picked up by IRMA) reports results for men who only ever act as tops in anal sex with other men. Not one iota surprisingly, the results are exactly the same as for men who only ever act as tops in vaginal sex with women (i.e. all men who have vaginal sex): uncircumcised men are four times more likely to be infected with HIV.

What does that tell us? Almost nothing of any use in HIV prevention programming. Over 13% of the guys in the study had HIV. In the very high prevalence settings of Southern Africa, guys (and boys and infants) should be getting snipped regardless of their eventual sexuality. We don’t need more clinical trials of exclusively insertive MSM to prove that, especially since 80% of these blokes are also shagging women. But the South African study doesn’t mean gay guys in other parts of the world will necessarily be protected by circumcision. In this study, three quarters of respondents said they were only ever tops. (If you believe them, spare a thought for the remaining quarter; they must be getting poked painfully frequently just to make the numbers add up.) If you don’t believe them it may well be because that degree of role separation is unusual in many gay communities. Indeed one of the reasons HIV spread so rapidly among gay men is that the very people who are most likely to get infected (because they’re taking it up an orifice not designed for the purpose) are also most likely to infect others (because they give as good as they get). Heteros don’t have that flexibility, and that slows transmission down.

For practical purposes what we’d like to know from the Soweto data is: does circumcision protect men who have anal sex against HIV regardless of whether they are a top, a bottom, or “versatile”?

More silliness from Canada on needle exchange, but some good news from the States on that front, too. Of which more after I’ve unpacked more boxes. In the meantime, this comment on trafficking hysteria from another member of the Silliness Police over at Preipheries.

Leave aside the fact that they used Respondent Driven Sampling (RDS), a fashionable but deeply unsatisfactory method that could more honestly be named GSS — Glorified Snowball Sampling. [An aside for nerds: if you want to know why RDS is a bad idea even for drug injectors read this fabulous paper by Greg Scott. You've just got to love the young lady who has organised a training scheme to help non-injectors fool study staff into letting them participate. Ah, the land of enterprise...] Leave aside the fact that they inexplicably excluded from analysis the 8% of the sample who knew they were HIV infected. (This is the agency that invented Positive Prevention, for God’s sake. They ought to be supremely interested in the ongoing risk behaviours of people who are already infected.) Leave aside the three year time lag between collection of routine public health surveillance data and publication of the results –a delay that borders on the unethical. Even if those problems didn’t exist, you’d still have almost nothing of interest to write home about, because the analysis is so uninformative.

The headline figure is needle sharing — close to a third of injectors who think they are HIV negative used a needle that might already have been used by another injector at some time in the preceding 12 months. We’re talking about smack and crack users here, people who inject toxic substances into their bodies perhaps as often as three times a day. In most countries, we ask injectors to think back over the last week, and even then we get some dodgy results. How US injectors can remember what they did 11 months earlier I can’t imagine.

Then there’s information about sex. For some reason, they only report vaginal sex, although anal sex between men carries a far higher risk of HIV infection in the United States than any other activity. We’re told, wide-eyed, that 62% of injectors had unprotected vaginal sex in the last year, and that 42% had more than one partner in that time. But we don’t know if the sex with multiple partners was protected, we don’t know whether the unprotected sex was with injecting partners. Despite the CDC’s pronouncement that “a substantial proportion of IDUs are at risk for acquiring HIV infection through their sexual behavior in addition to their drug use”, we actually have no way of knowing whether the sex added to their risk or not.

I could rant on with more examples of missed opportunities for useful analysis, but I guess I’ve made my point. I do want to congratulate CDC, though, on their “honesty box”. They don’t try to fudge data loss and missing values:

“During May 2005–February 2006, a total of 13,519 persons were recruited to participate; of these, 1,563 (11.6%) were found ineligible, and 46 had missing recruitment information. Among the remaining 11,910 participants, data for 1,609 were excluded: 881 who already knew they had HIV infection, 334 whose data were lost during electronic upload, 288 initial participants (whose responses were excluded as part of the respondent-driven sampling methodology), 68 who could not be identified as either male or female, and 38 who gave responses with questionable validity.”

Interesting that CDC doesn’t allow for transgender injectors. Interesting that they provide “technical assistance” on HIV surveillance to countries such as Cambodia and Vietnam who have in the past made a far better fist of the work than CDC does at home.

The governors of the United Nations Organisation on Drugs and Crime (not Drugs and Pleasure, you note, or Drugs and Health, but Drugs and Crime) gather in Vienna from tomorrow to take stock of the dismal failure of the world’s attempts to erradicate addiction by spraying crops, locking up dealers, in some countries even shooting junkies (Thailand, step forward and take a bow). Former Colombian President Cesar Gaviria, who also chairs the Latin American Commission on Drugs and Democracy, was yesterday quoted by The Guardian as saying “Prohibitionist policies based on eradication, interdiction and criminalisation have not yielded the expected results. We are today farther than ever from the goal of eradicating drugs.” The Economist goes further, calling the century-old war on drugs (launched at a conference in Shanghai in 1908) “illiberal, murderous and pointless”.

The Economist argues for legalisation. While their logic is impeccable, the likelihood that the honchos in Vienna will include legalisation as part of their roadmap for the next 10 years — or even a distant destination to put into the SatNav — is currently between nil and zero percent. It is not, however, impossible, that the balance might swing to an approach more tightly focused on cutting out the preventible harm associated with drug taking and addiction. (The two, I need hardly remind readers of this blog, are not the same, though it is hard to discern that from the approach of either the US or the UK government.) We think of “harm reduction” as needle programmes to reduce HIV and hepatitis transmission, but it is far more than that. A less prohibitionist approach might reduce the number of Mexicans killed every year while dilligently trying to keep up supplies to ever-voracious consumers in the US — around 6,000 a year. It might reduce the number of young black men who are put in touch with real criminals by being thrown into jail on drug-related offences — one in five black guys in the States spend time in the slammer, seven times the rate of white men in the same age groups. And it might shift some of the billions we spend supporting failed prohibition policies to demand reduction and quality treatment programmes. Demand reduction programmes may help young people stay off drugs in the first place, much as anti-smoking campaigns have made tobacco fundamentally uncool among young people in some populations. And we know that treatment helps people who are addicted and don’t want to be taking drugs to get clean.

In his inaugural speech, President Obama promised to “restore science to its rightful place”. Yesterday, he signed an initiative to take the church-led meddling of the Bush era out of science. “It is about ensuring that scientific data is never distorted or concealed to serve a political agenda — and that we make scientific decisions based on facts, not ideology,” Obama said.

The fact is that the 100 year long war on drugs — a war motivated by ideology not science — has failed. It has made life more dangerous and uncertain for people in the poor countries that produce most drugs, and the rich countries that consume them. Even the head of UNODC is begining to nod towards harm reduction. Perhaps, with Obama’s words ringing loudly in their ears, those gathered in Vienna this week will opt to try a new stratgey.

Interestingly, I can’t find anything anywhere from anyone who has actually nicked the pills off their Mum, crushed them up, rolled them and smoked them. A politician says it feels like taking smack, but his account doesn’t sound very first hand account on either score. Tooli Nhlapo, a documentary maker with SABC, said that after they smoke the meds “The children do not know where they are and they stop making sense”.

How much sense were they making in the first place? Quite a lot, in a teen-eyed view, you might argue. Smack costs money. ARVs are free, to those who need them. It’s just a matter of getting the meds from the hands of patients to those of bored, thrill-seeking teens. More than one in 10 teens is infected with HIV in some parts of the country and bored, thrill-seeking teens are the very ones most likely to be infected. So they could stop swallowing their meds and start smoking them (especially if we press ahead with the WHO’s “potential strategy” of testing everyone annually and putting pills in the hands of every infected person right away). Others teens are apparently buying ARVs off people who would rather have cash to buy booze than take their meds. It slightly begs the question: if teens have cash to spare why don’t they just skip the extra step and get high on booze right away? Are manufacturers of alcopops missing a trick in the South African market?

It’s hard to know how much of this is real and how much is just another silly season media beat-up. I notice that the usually very sensible Treatment Action Campaign doesn’t dignify the reports with any comment. But if the reports are even partly true, it is one more strike at the heart of the prevention approach which relies on young people making sensible decisions about their long-term future in the face of diversions like sex or drugs that will deliver fun right now.