News

A prestigious U.S. scientific body is urging governments to adopt politically controversial measures to cut the spread of HIV-AIDS among injection drug users.

A new report from the Institute of Medicine, commissioned by UNAIDS and the Bill and Melinda Gates Foundation, suggests the scientific evidence is clear: Programs that provide access to methadone therapy and clean syringes reduce the risk of transmission of HIV among people who inject illegal drugs.

“A clean needle won't prevent a sexual transmission. ... But it will prevent a needle-borne transmission,” Dr. Hugh Tilson, chairman of the panel that wrote the report, said in an interview.

“So if your objective is to reduce the likelihood of HIV transmission, you want to have the needle- and syringe-access program embedded in a multicomponent program which includes education, outreach, access to medical care and certainly information about effective methods of prevention of HIV transmission to sexual partners and, God help us, to their offspring.

“The evidence is clear," he said that such programs "are effective in achieving the social objective of reducing the spread of HIV.”

The report lists as “encouraging” but preliminary the evidence on whether safe injection sites such as Vancouver's Insite program reduce the spread of HIV-AIDS among drug users. The federal government recently put off deciding on the fate of the pilot program until the end of 2007, saying there is still insufficient evidence to approve a requested three-and-a-half year extension.

Dr. Evan Wood, an addiction researcher with the B.C. Centre of Excellence in HIV-AIDS, disagreed with the report's assessment that the evidence is still preliminary on the impact of safe injection sites on the spread of HIV among drug users. He said, however, that several key scientific publications on the Insite program were published after the panel began writing its report.

“That's not a disagreement of interpretation of research,” he said of the report's position. “It's more that this report was probably finalized before those papers were published.”

Dr. Tilson confirmed that the new studies were made public too late to be considered by his committee.

There are an estimated 13.2 million injecting drug users worldwide. And it is believed that in parts of Eastern Europe, countries of the former Soviet Bloc and portions of Asia, the sharing of contaminated injection drug paraphernalia is the leading mode of HIV transmission, putting sexual partners of and children born to infected drug users at risk as well.

“This is an urgent public health challenge that remains largely unmet,” Dr. Tilson said. “Several approaches to reducing injection drug behaviours can work and affected nations cannot afford to wait to act.”

While the report's recommendations are aimed primarily at developing countries with major populations of injecting drug users, it notes its findings are also applicable in other countries.

The Institute of Medicine – an agency of the U.S. National Academy of Sciences – was asked to assess the evidence for or against programs aimed at reducing the risk of HIV transmission through safer injection drug use.

The question is a politically loaded one, challenging the not-uncommon view that such programs condone drug use. Detractors also argue that these programs deter addicts from trying to kick their habit and may encourage others to start using injection drugs.

Dr. Wood welcomed the fact that the report sticks to the science.

“Reports like this are very encouraging, because they promote dealing with the problem of injection drug use in an evidence-based fashion,” said Dr. Wood, whose area of expertise is injection drug use and addiction research.

“So many aspects of society's response to addiction – and injection drug use is one of the things that presents the biggest public health emergency in terms of addiction – are dealt with in ways that are often times known not to be effective.”

Dr. Tilson acknowledged that any discussion on this topic is layered with morals and political imperatives that can override the scientific evidence.

“Our job isn't to second guess or even influence that. It's to inform it with the evidence – so that one may not hide behind rhetoric that the evidence suggests something when it doesn't,” said Dr. Tilson, an epidemiologist at the University of North Carolina.

He noted a longstanding joke that whenever scientists write a report, the last recommendation will always be: “More research is needed.”

“But in this case, we actually say: We know enough so that we mustn't use the need for more research as an excuse for inaction,” Dr. Tilson insisted.

“So we actually do not end with 'More research is needed.' And what we say instead is ‘Action is needed.' ”