In this the tenth year of the HIV epidemic the nation continues to face not one epidemic, but two: the twin epidemics of substance use and HIV infection. Since the early 1980s the close and deadly link between the sharing of injection drug equipment and HIV has been well recognized. More recently, the link between non-injectable substances, such as alcohol and crack, and unsafe sexual activity which can result in the spread of HIV infection has also become glaringly evident. Yet, instead of responding to these epidemics with public health and treatment measures to cope with both, the federal government's primary response has been imprisonment and increased jail sentences, often ignoring drug/HIV relationships. The dire results of this myopic criminal justice approach are shown in the following statistics:

• Within the estimated half to 1.5 million people who inject drugs in the United States, the rate of HIV infection has increased rapidly over the past decade.
• Approximately 32 percent of all adult/adolescent AIDS cases are related to IV drug use. (IV drug use; Male homosexual/bisexual and IV drug use; and Heterosexual contact with an IV drug user).
• 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 (i.e. sexual transmission from an IV drug user) 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.

Despite these dreadful growing numbers, (see Appendices B and C) our national drug control strategy does not reflect the immediacy of the problem, the need for significant expansion of drug treatment to permit treatment on demand, or the obvious and critically important relationship between HIV infection and substance use. To address this huge public health threat, the National Commission on AIDS convened a hearing on "Substance Use and HIV" in January 1991. Through the testimony of experts and individuals who are experiencing the problems of HIV and substance use firsthand, the Commission was better able to identify certain key issues and the urgent actions the nation must take to deal with these twin epidemics. Current programs are seriously wanting.