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.

Colin Beavan draws a parallel between injectors and consumers. You can’t break an addiction to consumer goods any more easily than you can break an addiction to smack, he suggests. So why not work on programmes that reduce the damage done by consumption, while quietly working to wean people off their self-destructive behaviour? I’m pleased to see the value of harm reduction recognised. But I rather fear that Colin’s missing an essential point.

“There is no question that excess consumption both causes damage to the planetary habitat and has the potential to make people less happy. A “reduce consumption” message is good for the planet and good for the people.”

The thing is, when people are consuming drugs it doesn’t make them less happy, it makes them more happy. That’s why they take them for long enough to get addicted. Yes, drugs can send your life into a meltdown and make you pretty miserable eventually, but most people who take drugs don’t think an reduce consumption message is good for them, any more than most people who consume i-Pods think that. Colin’s point, so far. The big difference, though, is this: there’s a consensus among people who don’t take drugs that filling your body with toxic and intoxicating substances isn’t a smart or desirable thing to do. But we’re still a very long way indeed from that kind of social disapproval of consumerism. In fact, consumption continues to be approved of and actively promoted by the vast majority of humans. Most people buy i-Pods because they think having one will make them happier. They think that because there’s a massive, multi-squillion dollar industry telling them so. And they may even be right.

Heads up to the greens — harm reduction is a hard enough sell even when you’re trying to work to reduce things that most people believe to be harmful. The thought of reducing the harms associated with something everyone is happy about makes me want to go and take drugs.

The Vancouver needle exchange is especially well known among HIV researchers; it was among the first to show that giving out sterile injecting equipment prevents the spread of HIV, and among the first to eat its claims as HIV rose steeply even among needle exchange clients. It a long and interesting story (see shamless plug at the bottom of this post), but most public health officials agree that needle exchanges help keep people alive and disease-free, while making it more likely they’ll get into treatment and off drugs.

Public health officials are one thing, the Public is another. Many Canadians, including an increasingly conservative government spurred on by international police bodies, are uncomfortable about treating addiction as a health issue. So when the needle exchange was evicted from its current spot and decided to set up together with an array of other social services, there was a predictable outbreak of footstamping. It didn’t help that the proposed site was across the street from a primary school, and that there didn’t seem to have been a whole lot of consultation. More fulminating.

The irony of this is that what the punters object to is the idea that they are paying to maintain people in their addiction. Which takes us back to the addiction and homelessness thing. Homelessness and lack of access to basic social services make it more difficult for people to kick their addictions. Putting the needle exchange in a single centre with those other services will make it easier for junkies to access services that help them stop being junkies. Giving out needles just makes it more likely that Canadian taxpayers won’t have to pay for a lifetime supply of expensive anti-retorviral drugs for people once they stop shooting up. Making the needle exchange homeless is bad for junkies, but it is also bad for people who would like to see less addiction and lower public spending in Vancouver.

Shameless plug: You’ll be able to read more about the Vancouver needle exchange controversy in The Wisdom of Whores, which will be published by Penguin Canada in May, 2008.

The US congress house of representatives House Committee on Foreign Affairs agreed to spend an astonishing US$ 50 billion of US taxpayers’ money on overseas HIV/AIDS treatment over the next five years. (US President George Bush had only asked for US$ 30 billion.) Here’s what acting chairman Howard Berman had to say:

Twenty million innocent men, women and children, we must remember, have perished from HIV/AIDS – 20 million. Forty million around the globe are HIV-positive. Each and every day, another 6000 people become infected with HIV. We have a moral imperative to act, and act decisively…In response to the desperate need for lifesaving medicine and new health care workers in nations hit hard by HIV/AIDS, the bill before us authorizes $50 billion over five years.

(my emphasis)

Care providers are whingeing that the bill will undermine treatment because a 55% minimum for spending on treatment has been dropped, but that doesn’t seem likely. Spending money on medicine is easy and popular both at home and abroad. So I’ll bet most of the money will still be spent on (US-made medicines) and their delivery. Happily, the rule that has so far shovelled over a billion dollars into the black hole of abstinence-only programmes has been dropped. But since our concern is for the innocent, the anti-prostitution loyalty oath stays, despite the best efforts of Bound, Not Gagged and others. This compels organisations who accept any one of the 50 billion dollars on offer to refuse to recognise sex work, thus making it extremely difficult to work effectively with those (wicked, naturally) people who sell and buy sex, even with money from other sources. Some commentators suggest that the Democrats didn’t even bother to fight this one in the compromise bill. If that’s true, shame on them.

Another anomaly: no PEPFAR money can be used to provide contraceptives. US taxpayers are committed under this bill to help infected women avoid passing HIV on to their infants. They’re committed to pay for expensive antiretroviral treatment for the kids if the prevention programmes fail. They’re committed to supporting orphans left behind once those infected women die of AIDS. But they can’t help HIV positive women avoid getting pregnant in the first place. Go figure.

Needle exchange update:The use of PEPFAR money to support sterile needle programmes for drug injectors was not mentioned in any of the official reporting on the compromise bill. The earlier Democrat version of the bill (pdf full text here) appeared to leave the door open for funding needle exchange, which is vital to countries such as Vietnam, by talking vaguely about “evidence-based prevention”. I haven’t been able to get hold of the full text of the compromise bill, so don’t know whether this door to common sense and fewer infections has also been closed.

On the other hand, the plan commits the government to treatment and prevention which follows evidence, not ideology. This includes “injectable heroin and methadone where they have been proved to work and reduce crime”. This will enrage people who believe that taxpayers shouldn’t be buying smack for addicts, even if it keeps the thieves from their doors.

Interestingly, amphetamines have fallen out of favour with Brits since 1996, but cocaine use (including crack) has been on the rise. Not surprising: a gram of coke costs almost exactly the same now as it did 20 years ago in absolute terms, while wages and indeed benefits have risen sharply. (More about supply, demand and pricing of drugs in this Home Office report.)

The strategy argues for better methadone maintenance programmes in UK prisons, to which I say hear, hear. Predictably, since this comes from the Home Office, there’s nothing on rolling our needle exchange programmes in jail (though it seems Scotland may take the initiative on that soon). I guess you can’t have it all. One of the things I do like about the strategy is that it doesn’t have a pigs-might-fly “Drug Free Britain” goal. Rather, it focuses very clearly on problem drug use. This, for example, from the Home Secretary’s foreword:

“Our ambition is clear. We want a society free of the problems caused by drugs”

I can think of a couple of other nations that would do well to adopt such pragmatism.

Tut tut, said George Bush. And in his budget proposal for 2009, he will try to have the ban reinstated. He did this on the very day that the NAACP and others called on Congress to drop a ban on federal funding for needle programmes nationwide (a position which is, incidentally, supported by Barack Obama. NAACP is no doubt shocked at HIV prevalence among the capital’s blacks, which, at close to 5%, rivals that of many African nations. The organisation has been banging the “more clean needles, please” drum since at least 1997, to no avail. While it makes not a jot of sense, the administration’s “clean needles spread drug use” drum appears to sound more loudly.

McManus is rightly infuriated by how keen most Congressmen are to bring home the pork, in other words, to bundle spending on useless projects that people in their home constituencies want, as a condition of allowing spending on things the nation needs. “Representative Mike Simpson (R-Idaho) … noted that the budget measure “would not have passed” if the earmarks hadn’t been attached. In other words, funding the war and legitimate government operations isn’t as important to many in Congress as making oneself look good before greedy constituents,” McManus writes. I’m right behind him when he suggests cutting out the pork might help the US’s increasingly obese budget deficit slim down a bit. But what he doesn’t mention is that the same quid pro quo attitude can actually achieve some sensible things, too.

Bush will more or less have to sign this bill. With it, finally, a provision which will allow Washington DC to fund needle exchange programmes to try to put a lid on its shamefully high HIV incidence rates. Also in the small print: the bill will give Bush 6.5 billion for HIV programmes in developing countries — even more than the president asked for, and probably more than can be spent sensibly. But at least this bill suspends the absurd requirement that a third of HIV prevention money be spent on abstinence-only programmes that have been proven not to work. There’s a boost to open access publishing, too (see Where do bears shit?)

One in 30 adults in Washington DC is infected with HIV, and that’s just the people we know about. That puts the capital of the United States on a par with Congo, Ethiopia and Angola.

Why these scandalously high rates, over 9 times the national average? The report (pdf file, 139 pages) from the Washington DC Department of Health doesn’t say. But here’s one guess: Federal funds can’t be used to pay for programmes that help drug injectors to shoot up more safely (even though all the major federally funded scientific institutions say these programmes save money as well as lives). For over 200 cities in the country, the restriction has been annoying, but not fatal. They’ve spent state or city funds on making sure injectors have easy access to sterile needles and syringes, in programmes that also refer drug users to detox services. Poor old DC is hamstrung by the need to get Congress to approve its spending, and Congress has forbidden DC to provide safe injecting programmes for nearly a decade. So injectors share needles, their sex partners get infected, and Washington glories in HIV infection rates that are higher than those of Angola, Ethiopia, Congo or Rwanda.