It has become increasingly clear that intravenous drug users (IVDU) will emerge in the 1990s as the group at greatest risk for not only acquiring, but spreading HIV infection. The percentage of the total number of cases of acquired immune deficiency syndrome (AIDS) with intravenous drug use as the primary risk factor has increased from 17 percent in 1985 (Des Jarlais 1985) to 20 percent in December of 1988 (Epistat 1988). If those with both homosexuality and drug use as risk factors are taken into account, as well as the sexual partners and the children of IVDU, this percentage nears that of homosexual, non-drug using males. Sexual contacts of IVDU make up at least 55 percent (MMWR 38:369) of the heterosexual category (a conservative estimate). These figures demonstrate the need to take a long hard look at the history and the future of drug use in America and at what can be done to slow the spread of infection among IVDU.

AIDS and Early Attitudes

Before proceeding however we must backtrack somewhat. In June of 1981, clinical investigators reported five cases of Pneumocystis carinii pneumonia (PCP) among five previously healthy homosexual men to the Centers for Disease Control (CDC) (MMWR 30:250). Within a month, 26 cases of the formerly rare neoplasm, Kaposi's sarcoma (KS), were reported among young homosexual men in New York and California (MMWR 30:305). Due to the fact that KS had previously been associated with the recipients of transplanted organs (Myers 1974) and others receiving immunosuppressive therapy (Hoshaw 1980), it was hypothesized that the reported occurrences of KS and PCP in homosexual men were both explainable by an underlying disturbance in immune function.

Concern about the new disease spread slowly at first, probably due to the apparent compartmentalization of the affected subgroups. With the first reports of heterosexual women in the United States acquiring the disease (Masur 1982), news of AIDS began to reach the public. AIDS initially was thought of as a "gay disease," and by some twist of fate and of history in many countries, the U.S. included, it was. In many African countries however, the disease has never shown regard to sex or to sexual preference (Polk 1985). In other areas -Italy and Spain are notable examples (Des Jarlais 1988)-IVDU are the more prevalent risk group, forming the majority of cases. Nonetheless, the fact that AIDS was and is associated with homosexual men, already an extremely stigmatized group, has raised serious moral and ethical questions. Throughout the epidemic there has been talk of the quarantine of those who test HIV positive (Monckton 1987), in the fashion of separating lepers from society. Conservative columnist William F. Buckley, Jr. suggested that "everyone detected with AIDS should be tattooed in the upper forearm, to protect common-needle users, and on the buttocks, to prevent the victimization of other homosexuals." Members of the medical community have likewise joined in the rush to judgement. Dr. James L. Fletcher from Georgia wrote that "health care providers. ..would do well to seek reversal treatment for their homosexual patients just as vigorously as they would for alcoholics or heavy cigarette smokers, for what may not be treated might well be avoided." The rationale being that homosexuals can and should be "cured." Although these opinions are mired in prejudice and bigotry as well as ineffectiveness, they are by no means uncommon.

There is still a very real fear and hatred of homosexuality in this country. Although this year commemorates the twentieth year since the Stonewall riots in New York that mark the beginning of the gay and lesbian revolution, homosexual-related violence increased to near record highs last year. Similarly, 24 states currently have laws making sodomy a crime (Cassens 1985).

Fortunately, the United States generally and the medical community specifically has shown a little more logic, temperance, and compassion in dealing with this risk group. From nearly the beginning, those fighting the battle against AIDS have looked at one major objective: stopping the spread of HIV infection. The greater good of slowing the spread was seen as a larger issue than were personal feelings of morality and religion. Through massive educational efforts in which even Surgeon General C. Everett Koop has participated, positive results are being seen. A good indicator of how extensive safe sex is being practiced is the number of rectal gonorrhea cases reported per year. This number has dropped substantially among homosexual men over the past few years, presumably due to changes in sexual habits such as increased condom usage. Similarly, in one study, 90 percent of a cohort of 125 homosexual men followed at the San Francisco City clinic between 1978 and 1985 reported a decline in the number of non-steady partners from a median of 16 to a median of 1 per four month period (Doll 1987). These dramatic changes have taken place due in part to medical professionals and others coming to the realization that their ethical duty to slow the rate of spread of HIV infection must necessarily outweigh any personal moral beliefs.

Intravenous Drug Use as Risk Factor for HIV Infection

As the growing problem of IVDU susceptibility to HIV infection becomes more and more apparent, similar steps must be taken to slow its spread in this risk group. James W. Curran, M.D., director of the AIDS program at the Centers for Disease Control gets to the root of the problem when he estimates that there are approximately one million addicts who use heroin intravenously, but only 20 percent of these are undergoing treatment at any one time. He warns that if AIDS hits heterosexuals, it will be because we have failed to reach the addicts. Similarly, he warns that if it hits children it will be due to the fact that we have failed to reach the mothers who are on heroin or who are having sex with someone who is on heroin. The word "cocaine" could be substituted for heroin for an even more frightening scenario.

HIV is spread among IVDU primarily by the sharing of equipment for injecting drugs. This includes the needle, syringe, and the "cooker" (a bottle cap or a spoon used to dissolve the drug in water prior to injection) (Des Jarlais 1988). The virus is also spread by sexual activity. There have been two behavioral factors that have been recognized as important for the virus' spread: the frequency of drug injection and the sharing of equipment across friendship groups (Chaisson 1987). Equipment is typically shared across friendship groups at "shooting galleries," which are locations in which IVDU rent equipment for injecting drugs, or through the use of "house works" (equipment kept by the dealer for lending to customers who wish immediate injection). In both cases, the equipment is returned to its owner, ready to be lent to the next customer. The increased danger of cocaine injection lies in the fact that cocaine users tend to inject more frequently, to draw more blood into the hypodermic when injecting, and to use drugs in shooting galleries. Many cocaine users inject ten or more times a day (Chaisson 1989). It is obvious then that in order to slow the epidemic, we must slow the spread of infection among the intravenous drug user. In order to see more clearly what must be done however, we must first see how we have reached the point at which we now stand.

Shifting Attitudes Towards Drug Use in America

The past century has brought dramatic shifts in the social policy that concerns opiate drugs. Opiate use in late nineteenth and early twentieth century America was not seen as an outrageous act that subjected the user to the severe moral and legal sanctions that compose the present climate. Rather, it was viewed much like other minor vices such as dancing, drinking, and smoking (Brecher 1972). Opium in various forms was as readily available as alcohol is today. Although there were many addicts of opium and its derivatives (morphine, laudanum, and heroin are the major ones), the use of these was not generally perceived as morally wrong, and a prohibitory mentality had not yet developed. Some people did have problems with opiate users, however, due to the fact that the drugs generally made users lethargic and inwardly directed. Thus, early critics saw the opiate abuser as "enslaved, unproductive, or at least inefficient, escapist and self-centered" (Morgan 1981). These attributes are all somewhat threatening to Western man, whose emphasis has always been on action, rationality, and predictability. Nonetheless, these fears were not greatly vocalized.

This was all radically changed beginning in 1914 with the Harrison Narcotic Act. Although its original intention was to create a new source of revenue and to control the movement of drugs, the act was later interpreted as an enforcement measure, making the possession of nonprescription opiates illegal (Biernacki 1986). Almost immediately, attitudes towards users changed. Opium came to be viewed as an evil drug, the use of which transformed ordinary, law-abiding citizens into "fiends", not able to control their behavior (Kramer 1976). Dr. Alexander Lambert captured the essence of public opinion concerning heroin. Although he spoke some 65 years ago, attitudes have changed little since. He warned, "Heroin addiction is a public menace, as it increases the rebellious attitude of antisocial youth, and it obliterates all controlling influences of the herd instinct. Heroin...is naturally the drug of choice of the criminal class. It gives them...inflation of personality,..indifference to crime, and the lack of all remorse. Its...effects are its own, not shared by the other opiates" (Morgan 1981). By 1931, the possession of opiates was illegal in 35 states, of cocaine in 36 states, and of hypodermic paraphernalia in eight states (Bonnie 1974).

One of the most tragic casualties of the Harrison Act was the morphine maintenance clinic. It was the last of the non police-related measures aimed at drug abusers for some forty years. Although a few of the clinics were badly managed (such as the New York clinic, the one on which the Federal Bureau of Narcotics based its decision to close all of the others), some were very effective treatment and counseling centers for opiate abusers. The Shreveport, Louisiana clinic was one such facility. Opening in 1919, the clinic, headed by Dr. Willis P. Butler, developed workable treatment strategies to the satisfaction of drug users, local physicians, town officials, the police, and visiting experts. He proved that morphine used in a close clinic setting was a relatively effective maintenance drug (Waldorf 1974). Many people feel that differences between the productive, citizen users of Shreveport in the 1920s and the maligned, criminal users of today appear to be more a function of our morals, laws, and treatments than of drug abusers themselves (Waldorf 1974). Due to the increasing intolerance towards drug use in the United States, the Shreveport clinic was forced to shut its doors in 1923.

Thus, from the 1920s through the 1960s a criminal aspect was considered an innate part of the opiate user's personality. Of course, this stereotype was valid to some extent due to the fact that in order to use the drugs it was necessary to obtain them through illegal channels. A black market arose almost immediately following the Harrison Act, greatly increasing prices of street drugs and forcing many users to resort to theft or "pushing" in order to acquire a sufficient amount of money to support their habits (Biernacki 1981). There were very few public treatment programs during this period (the federal hospitals established in the 1930s in Lexington, Kentucky and in Fort Worth, Texas for the treatment of prisoner and probationer patients were largely considered failures (Morgan 1981)), and treatment usually consisted of impris-onment or other forms of confinement and segregation.

In 1966, Doctors Vincent Dole and Marie Nyswander published their study on a new form of maintenance treatment using methadone. Methadone is a derivative of opium that ideally blocks the euphorigenic action of heroin and other opiates, lessening the craving for these drugs. The advantages of this new procedure, termed narcotic blockade, seemed to be that intravenous heroin use was stopped, drug-related crime was virtually eliminated, and that only a single dose administered daily was necessary (Dole 1966). Drug treatment had finally been cautiously put back into the physician's realm. Where for years the health profession had possessed absolutely no tools for dealing with substance abuse, they now had methadone.

Many people were cautious of this new method however, seeing it as a possibly dangerous means of social control; where large groups of people were taken and addicted to a new, more politically acceptable opiate derivative. Critics saw the specter of hundreds of thousands of addicts, for the most part black and Puerto Rican, and poor, being forced to remain physically dependent upon narcotic drugs dispensed by government-controlled programs (Newman 1977). Operation Helping Hand accused, "maintenance is a diabolic and systematic plan of . extermination of the Black and the Puerto Rican people" (Zinberg 1974). In response to this sort of attitude, Dole issued a statement that said, "I would object to the imposition of methadone maintenance just as strongly as I have objected in the past to its unavailability when the needs of motivated volunteers could not be met'' (Dole 1971).This battle between the methadone maintenance advocates and the dissenters continues today, although with the high risk of HIV infection in the IVDU population the advocates will probably earn a temporary victory. Therefore, this is an example in which slowing the spread of HIV infection is temporarily higher on a hypothetical "ethical scale" than are other ethical concerns.

Causes of Drug Misuse

In studying the problem of HIV infection in this group, it is necessary to look at causes of intravenous drug misuse and at who is more susceptible. Opponents of methadone maintenance are correct in pointing out that heroin abuse has always been more prevalent in the lower classes. The problem of widespread abuse is a recurrent and a cyclical one, with the overall socioeconomic pattern of narcotics use virtually unchanged over the past hundred years (Helmer 1974). Helmer recognizes that "there can be no doubt that overcrowding, congestion, unsanitary conditions, and a lack of the facilities for healthful recreation are predisposing factors in drug addiction". These, obviously, are all problems of the underprivileged. Another important contributing factor concerns the lower class and employment in the secondary labor market. This market is characterized by low wage levels, technological backward-ness, and low skill requirements. Advanced education, skills, and labor stability are neither desired nor rewarded in this market, thus motivation and self-discipline go unrewarded. Wage levels typically average at least one-third below family living incomes, making it nearly impossible for workers to aspire to stable, settled patterns of family living. In addition, breaking into a job in the more stable, primary market is nearly impossible. Therefore being trapped in the secondary labor market often leads to the loss of self-esteem and hope and, possibly, to drug abuse.

Obviously, merely being born into a family in the lower socioeconomic stratum does not automatically portend the life of a chronic heroin user. There are numer-ous other factors that are equally important. As Beckett puts it, "Seed, soil, and climate all need to be right at the same time." In his analogy, the seed is the drug and its availability, the soil is the stressed personality, and the climate is the microclimat of opinion concerning the drug, "If all three are right, heroin addiction can take root. If one is wrong, it is impossible." Many authors speak of an "addictive personality" which is blind to race, sex, or financial status (Lindesmith 1968). This addictive personality coupled with the factors noted above could nudge one down the path that leads to heroin abuse.

Methods for Dealing with Drug Use

In any attempt to treat and/or to educate IVDU it is necessary to study the different cultural and racial groups, as each requires a somewhat unique approach. Mexican-Americans, for example, due to sociocultural reasons, have a large percentage of heroin users. This is compounded by the fact that studies have shown this group to have a higher rate of drop out or expulsion from and a lower rate of completion of methadone maintenance programs than other minorities (Savage 1980). Thus, new approaches must be initiated to deal with this group. Another study has shown that, although AIDS has not thus far infiltrated the American Indian population to any great extent, native Americans may run a higher than average risk of transmitting the HIV virus. This is due to
the fact that one in twenty Indian high school students has been exposed to heroin, compared to only one in two hundred non-Indian students (Vekarde 1980). Finally, over 51 percent of the IVDU with AIDS reported to the CDC as of August 1988 were black. If this is coupled with the knowledge that blacks are much more likely than either whites or Hispanics to inject cocaine (Chaisson 1989) (a practice discussed above as being even more dangerous than heroin injection), it is obvious that drastic steps must be taken in the black community to curb the spread of infection. From even this small sampling of special problems in the overall IVDU population, it is clear that any sort of broad, generalized approach to this problem will likely not be maximally effective.

The most obvious, albeit the most unlikely, method of ceasing the spread of infection would be for all IVDU to simply stop injecting, either voluntarily or involuntarily. Discussing the latter possibility first, we may look at a pamphlet written by Dr. Harold Voth. Warning that "members of the mental health fields are emotionally disturbed and have rather weak personalities, and ... tend to support far-out lifestyles...", he suggests that if parents have suspicions that a child is smoking marijuana they should "carry out a thorough search of his living space and other areas." He counsels parents to do all that is needed to keep their children away from the drug, resorting to violence and police action if necessary. This militant form of "tough love" could conceivably be suggested on a larger scale to temporarily keep IVDU from their drugs. Of course it could not be done indefinitely, and due to the fact that this is not Nazi Germany, this idea would probably not go over well with the vast majority of the populace. For an example of someone at the opposite end of the spectrum we look at Patrick Biernacki, who's Pathways from Heroin Addiction introduces a method of recovery in which treatment is not necessary. This method is contingent on the user's possession of a very strong personality, and on his possession of non heroin related friends and experiences. He feels that this method is possible in all socioeconomic groups and without "hitting bottom." He concedes however that it is not for everyone. It involves an "identity transformation" that not everyone is capable of making. So, although this recovery by choice may be a viable method of recovery (surely much more so than the afore-mentioned recovery by force), it is probably just one of the multivariate methods that is needed.

Biernacki's suggestion succeeds in bringing up the old argument that in order to get to the root of the drug problem, something must be done to decriminalize the user. Ever since the Harrison Act there have been those in favor of the legalization of drugs. Dr. Thomas Szasz, a very individualistic libertarian, holds the belief that drug abuse is neither a criminal nor a medical problem, rather a moral one. He proposes a "medical reformation analogous to the Protestant Reformation, specifically a 'protest' against the systematic mystification of man's relationship to his body." He desires that the layman have direct access to "the language and contents of the pharmacopoeia." His suggestion is that "dangerous" drugs be treated, more or less, as alcohol is treated today (no public intoxication, etc.). Other drugs should be freely available as are items on the shelves of grocery stores. "Neither the use of narcot-ics nor their possession nor their sale to adults should be prohibited, but only their sale to minors." Richard - Stevenson of the University of Liverpool arrives at the same conclusion, coming from an entirely different angle. Rather than seeing the legalization of drugs (in particular heroin) as a matter of personal liberty, he sees it as a matter of economics. A government controlled heroin trade would hypothetically raise tax money, and it would reduce drug-related crime. Although he foresees a small, tempo-rary increase in the number of users, he feels that the good aspects would greatly outweigh the bad. An editorial in The Lancet similarly speaks of the failure of prohibition to slow the demand or the supply of heroin. It suggests that its legalization would be worth considering even if AIDS had never existed. With the danger of HIV infection from non-sterile injection equipment, it may soon become imperative. Legalized heroin would obviously lead to increased sterile needle and syringe availability. With the heightened visibility of users that would follow, the possibility of greater organization would present itself (perhaps in the fashion of the heroin user's union, or junkiebonden, in Amsterdam (Buning 1986)). Unfortunately, even if the legalization of heroin (and possibly cocaine) was found to be the most logical method for not only slowing the spread of HIV infection among IVDU, but also for dealing with overcrowded prisons and with the drug problem in general, it is unlikely that the sweeping changes that would be needed could be instituted quickly enough. This is especially true in the present conservative political climate. In keeping with our argument that the important matter is to slow the spread of infection as quickly as possible, regardless of any underlying moral hesitations however, it is possible that pilot programs of controlled access to injectable drugs could be pushed for with simultaneous decriminalization of IVDU in specific areas. These could provide valuable data on the potential effectiveness of this initiative.

Specific Recommendations

Although the two previous suggestions would probably facilitate the slowing of HIV infection among the IVDU population in their respective ways, neither is immediately useful. Thus, in order to act decisively and expediently, less controversial tactics must be administered initially.

A study in Sacramento is headed by a task force that represents not only the city's drug-treatment programs, but the health department and the police department. The group's function is to study the efficacy of the AIDS education, prevention, and testing (EPT) program, which consists of individual counseling of IVDU concerning their specific dangers of infection. In 1986, 23 percent of the studied drug users reported that they "did not share or they usually or always disinfected their paraphernalia with an effective disinfectant"; this number had increased to 41 percent by the following year (MMWR 38:369). A similar program in Worcester, Massachusetts produced analogous results (MMWR 38:372), suggesting that, at least in medium-sized cities, a concerted educational effort between the different pertinent agencies can achieve a decrease in risky behavior among IVDU.

It has been shown in other studies however, that although education is very important, a clean needle and syringe must be easily and quickly obtained immediately following the purchase of drugs. The period after drugs have been obtained is characterized by an increase in physical withdrawal symptoms. If a clean needle is not available, the user will borrow from another user or will rent the house works (Flynn 1987). Thus, mere knowledge of AIDS is not sufficient for risk elimination.

From this and other data, it has become increasingly clear that readily available needles and syringes are of the utmost importance in combating the virus. Unfortunately, there are presently 12 states (New York is one) in which syringes cannot even be purchased without a prescription, much less obtained for free. The recent, unprecedented demand by drug users for clean equipment is testimony to this group's awareness of the life-threatening nature of needle-sharing (quite in contrast to popular opinion that drug users are apathetic and unable to be taught risk-reducing behavior). The Street Research Unit of the New York State Division of Substance Abuse, composed primarily of ex-users, has noticed "two-for-one" sales, in which some needle sellers are now including an extra needle with the sale of a complete syringe and needle; a "free" needle and syringe included in $25 and $50 bags of heroin; and repackaged old needles sold as new (Des Jarlais 1985). Thus, it is likely that proper distribution of clean equipment would lead to a meaningful reduction in the risk for HIV infection in this group.

Opponents to needle exchange programs contend that drug use could increase and that our nation's young people might get the feeling that government and public health authorities approve of drug use (although in today's climate it is hard to imagine how one could argue that children could possibly get the wrong idea concerning the government's stand on drugs). This perceived acceptance of IVDU would be in direct conflict with the ideals behind the present "war on drugs," the "drug czar," and the recently proposed "drug bonds". This is another case however, in which the over-all ethical problem of slowing the spread of a dangerous, infectious disease is much more important than President Bush's or William Bennett's or any senator's feelings about the immorality of drug use. Needle exchange programs exist today in Sweden, England, Scotland, France, Amsterdam, Italy, and Australia (Brickner 1989, Walters 1988). These programs include the exchange of a clean needle and syringe for used ones, free HIV and drug counseling, and free HIV antibody testing (Brickner 1989). Follow-up studies in the Amsterdam program have shown no evidence that the system has led to an increase in drug injection. The number utilizing the system is estimated at 50 percent of the country's IVDU, and the percentage of these who inject more than once a day has dropped from 90 percent to less than 50 percent (Van der Hoek 1988), signs of the effectiveness of the Amsterdam plan. Similar studies in Edinburgh following the institution of a needle exchange program have shown a decrease in the percentage of users who "always" share equipment from 55 percent to 13 percent in addition to a substantial number who have ceased injecting altogether (Robertson 1986). An important aspect of needle exchange services is that IVDU are reached who may not be in contact with any other means of HIV education (i.e. drug treatment programs) (Green 1988). In addition to the exchange function therefore, these services are a key element in changing behavior and improving the over-all health of IVDU. From these examples it is obvious that establishing a needle exchange program would be an important first step in eliminating new infections in drug users.

Even assuming that it is conceivable to eliminate needle sharing however, new infections will continue unless fundamental changes in sexual behavior coincide with changes in injection behavior. A follow-up study in a San Francisco bleach distribution and education program showed that while 67 percent of the participating drug users were using bleach for safer injection, only 15 percent were practicing safer sex (Watters 1987). This failing can be attributed somewhat to incomplete understanding concerning the dangers of heterosexual sex, but other factors contribute as well. It has been shown that it is relatively easy to introduce condom use into the casual sexual encounters between prostitutes and their customers. Conversely, it seems more difficult to introduce condoms into an ongoing sexual relationship involving "substantial interpersonal commitment" (Des Jarlais 1988). In many cases the partner may not be aware of the user's habit, and thus may not realize the risk.

Besides the danger of spreading HW infection to sexual partners, there is also the threat of female IVDU bearing HIV+ children. Thus, the use of contraception to prevent unwanted pregnancy is very important, and should be the second major area of change. The number of IVDU that consistently use contraception has been historically low, however. In a study published in 1972, it was concluded that female heroin users see "no correlation between contraceptive devices and prevention of pregnancy" (Densen-Gerber 1972). The authors note a "profound apathy and lack of motivation to take any positive steps toward control of their futures...and there is a fundamental desire to get pregnant." In a more recent study researchers found that the most commonly cited reason for the low rate of contraceptive use by IVDU women was confusion between amenorrhea and infertility (Ralph 1986). Many women report that menses have stopped concomitant with heroin use and take this as a sign of infertility. It has also been discovered that those IVDU who are HIV+ and who do become pregnant are not using their seropositivity as a determining factor in the decision to terminate the pregnancy. In fact, decisions to terminate pregnancy are predicted more readily by variables such as prior elective abortion and whether the pregnancy had been unplanned (Selwyn 1989). This is similar to the study where knowledgeable drug users use non-sterile needles, in which the extent of education is not directly related to behavioral change. However, if contraceptives were distributed in the same areas where users purchase their drugs, it is possible that they would be used and that the number of unplanned pregnancies would decrease. This distribution should include condoms, birth control pills and any other device that could be shown to be used effectively by IVDU.

As discussed above, there are many problems with methadone maintenance programs. One of the most important is that some methadone maintained people begin or increase cocaine use after initiation of therapy. Over 24 percent of the cocaine users in one study fit into this category (Chaisson 1989). Thus, therapy for cocaine use must be coupled with greater availability of needles in order to fully maximize methadone programs. For the most part however, methadone has proven a very useful drug for decreasing the occurrence of new infections (Hartel 1988, Blix 1988). One of the most important aspects of methadone treatment is that it stops intravenous injection, thus eliminating the threat of HIV infection from infested needles. In addition, the treatment centers are excellent places to teach safer sex and to counsel drug users. Thus, the third area in which we must concentrate our resources is in the expansion of methadone maintenance and other drug treatment programs to accommodate all IVDU who desire treatment. Reports of three-month waiting lists are as inexcusable as they are commonplace (Des Jarlais 1985), and are another example of the popular view that heroin (and, for that matter, crack and amphetamine) users should be dealt with in a legal manner. In addition to greatly increasing the number of available spots in existing types of treatment and maintenance programs, morphine and/or heroin maintenance programs should be considered for those users who have proven incompatible with the methadone program.

Conclusions

Shifting attitudes over the past one hundred years have had a tremendous effect on the way in which fhe United States has dealt with its drug users, yet have had a much lesser effect on the actual numbers or on the socioeconomic composition of users. It matters little, however, whether IVDU become such due to the extreme pressures of living in the modern world or due to an innate "addictive personality" or due to a conscious embrace of a lifestyle out of the mainstream. The important fact is that people are dying: drug users, their partners, their children. It is not too late to make the fundamental changes that are needed. Expanding drug-treatment centers, establishing needle exchange programs, increasing educational efforts, and distributing birth control devices are all actions that would serve the dual purpose of bringing drug users out into the open where they could be helped more easily, and of greatly slowing the spread of HIV infection. Concurrent with these actions, limited decriminalization of users and alternate maintenance programs should be seriously considered as possible future actions. AIDS is a terrible disease, but it is controllable. It has already been shown that many, if not most, drug users are willing to alter their behavior, if given the proper resources. The step that must first be taken is the realization that, personal morals notwithstanding, it is our ethical duty to do all that is possible to save our brothers and our sisters from a horrible and an untimely death.

Brandon Pomeroy is at the University of Kansas Medical Center and can be contacted at 3901 Booth Ave., Apt. B, Kansas City, Kan. 66103.

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