NATIONAL COMMISSION ON
ACQUIRED IMMUNE DEFICIENCY SYNDROME

Full Report: The Twin Epidemics of Substance Use and HIV
Washington, DC, July 1991

The failure of the federal government to recognize and confront the twin epidemics of substance use and HIV infection has become glaringly apparent to the Commission throughout its nearly two years of hearings and site visits. The federal government's strategy of interdiction and increased prison sentences has done nothing to change the stark statistics:

• Approximately 32 percent of all adult/adolescent AIDS cases are related to IV drug use.
• Of the pediatric AIDS cases related to a mother with/at risk for HIV infection, 70 percent are directly related to maternal exposure to HIV through IV drug use or sex with an IV drug user.
• 71 percent of all female AIDS cases are linked directly or indirectly to IV drug use.
• 19 percent of AIDS cases among men are directly linked to IV drug use, and an additional 7 percent of AIDS cases among men are linked to both homosexual/bisexual contact and IV drug use.
• African American and Hispanic communities are being extremely hard hit by the twin epidemics. While African Americans make up 28 percent of all diagnosed AIDS cases and Hispanics make up 16 percent; of the cases attributed to IV drug use, African Americans account for 45 percent of cases and Hispanics for 26 percent.
• The city of New York has an estimated 200,000 IV drug users (who are 50 percent HIV positive) with only 38,000 publicly funded treatment slots.
• The National Institute on Drug Abuse (NIDA) recently estimated (based on provisional data) that approximately 107,000 persons are currently on waiting lists for drug treatment.

These twin epidemics transcend all economic, geographic and racial boundaries; everyone is affected. Substance use enhances the spread of HIV infection through the sharing of needles and the practice of unsafe sex related to crack (the smokeable form of cocaine), alcohol, and other substances. Despite this insidious and indisputable link between substance use and HIV infection, the Office of National Drug Control Policy continues to virtually ignore it, and neglect the real public health and treatment measures which could and must be taken to halt the spread.

Repeatedly, medical and treatment experts have come before the Commission and stressed the absolute importance of treatment on demand. Increasing treatment slots is a stated goal of the federal drug control policy, yet, as Dr. Robert Newman told the Commission, " . . .there seems to be nothing.. .to indicate that any government agency either at the federal or at any of the 50 state levels is indeed pursuing the objective of expansion on a massive scale to make treatment for addicts who want it readily available." Providing quality treatment and treatment on demand may be an expensive proposition, but so is the unchecked spread of HIV infection. For a successful short and long-term solution we must shift our focus from expensive prison beds which represent society's failure, to less expensive treatment slots which represent our only hope, and provide easily accessible drug treatment to all those who need and request it. (See Appendix A) As the Commission Working Group on Social/Human Issues stated in its April, 1991 report, "...it is fundamentally unjust, as well as unwise, to tell those who seek treatment for drug addiction that there is no room; but then tell them that the taxpayers are willing to spend thousands of dollars a year to keep them in jail."

We must also take immediate steps to curb the current spread of HIV infection among those who cannot get treatment or who cannot stop taking drugs. Outreach programs which operate needle exchanges and distribute bleach not only help to control the spread of HIV, but also refer many individuals to treatment programs. Legal sanctions on injection equipment do not reduce illicit drug use, but they do increase the sharing of injection equipment and hence the spread of HIV infection.

If HIV transmission related to substance use is going to stop, the federal government must take a leadership role in coordinating public health and drug treatment on all levels and in creating and implementing a cohesive national plan. Currently, the issue of HIV and substance use is falling through the cracks, and without clear policy directives to the medical, public health and drug treatment communities it will continue to do so.

The federal government must also ensure that the great strides made from research and demonstration projects are not lost through cut-backs or lack of funding. Successful demonstration projects should be identified and funding made available for their continuation as active federal projects. Funding for research on substance use and HIV should be expanded, not cut back or simply held constant. Research, both sociological and epidemiological, holds the key to discovering the answers to crucial questions around HIV and substance use. Clinical trials, a key component to research, should be open to individuals with a history of, or current, substance use problems.

Finally, all levels of government and the private sector must work together to attack the deep-rooted social and economic problems which promote and sustain substance use. The poor of this nation, especially in communities of color, have been inordinately hard hit by the twin epidemics of HIV and substance use. In order to combat these epidemics which affect the entire nation, we must provide basic needs such as housing, medical care and food. HIV education and drug treatment often seem like luxuries to individuals who do not know where they will sleep at night or where their next meal will come from. To reach the point where our nation's drug epidemic is really a thing of the past, we must create communities and neighborhoods which promote health and hope, not addiction and despair.

RECOMMENDATIONS:

To help work toward these goals the Commission puts forward the following recommendations:

1. Expand drug abuse treatment so that all who apply for treatment can be accepted into treatment programs. Continually work to improve the quality and effectiveness of drug abuse treatment.

2. Remove legal barriers to the purchase and possession of injection equipment. Such legal barriers do not reduce illicit drug injection. They do, however, limit the availability of new/clean injection equipment and therefore encourage the sharing of injection equipment, and the increase in HIV transmission.

3. The federal government must take the lead in developing and maintaining programs to prevent HIV transmission related to licit and illicit drug use.

4. Research and epidemiologic studies on the relationships between licit and illicit drug use and HIV transmission should be greatly expanded and funding should be increased, not reduced or merely held constant.

5. All levels of government and the private sector need to mount a serious and sustained attack on the social problems that promote licit and illicit drug use in American society.

of Substance Use and HIV

It is my firm belief that policies related to AIDS and policies related to drugs are so intertwined that commenting and really wrestling and getting to the solutions to one will impact the other, and that it is necessary to consider both national drug policy and national policies related to AIDS.

-Kurt Schmoke, December 18, 1990
-Testimony before the National Commission on AIDS