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

To date, no single agency or group has taken charge of this issue of overwhelming importance to the national health. In drug treatment programs, a level of awareness about AIDS which was never sufficient to control the epidemic now seems to be fading. One woman with HIV disease told the Commission that "[i]n North Carolina, in Narcotics Anonymous, they do not talk about AIDS. It is considered an outside issue." Some individuals with HIV disease are even denied access to treatment programs because of their HIV infection.

Public health and health care agencies have ignored the problem from the other side – not confronting the substance use issues involved with individuals who have HIV infection or who may be at risk. Although in the rest of the developed world, medical and public health professionals have directed national drug policy to target prevention of the spread of HIV within the injecting drug user community, there has been no parallel in claiming such policy-setting responsibility here in the U.S.

The real responsibility for these shortfalls lies with the federal government. Because of the lack of coordination and planning on the federal level with regard to HIV in general, and substance use and HIV in particular, groups in both public health/health care and drug treatment lack direction in the face of the epidemic. The Commission applauds such efforts as the November 1990 "National Conference on HIV and Substance Abuse: State/Federal Strategies" sponsored by ADAMHA, ASTHO, CDC, HRSA, NAPO and NASADAD, which attempted to coordinate state and federal agencies and discover new directions for action.

The conference focused on a number of inter-related issues: the need for increased coordination of traditional public health departments and substance abuse treatment programs; improvement of joint program planning by state health and substance abuse treatment systems; and the need to increase state and federal collaboration in addressing the HIV/substance abuse issue. The recommendations which came out of the conference in the areas of provision of services, evaluation of services, training, and research are insightful and relevant. Examples include many recommendations which reflect the concerns of the Commission:

Provide HIV prevention services in drug treatment settings and services for drug users in public health clinics; Provide outreach to drug users who are not in drug treatment and to the sex partners of drug users; Improve and expand the capacity of drug treatment; Provide drug treatment services in primary health care facilities; Provide primary health care in drug treatment centers; Provide training and cross-training of staff; and, Improve the evaluation of HIV/substance abuse programs.

The question now is, where do we go from here? Without a cohesive national strategy which assigns responsibility, provides leadership and vision, and follows through on coordination, these excellent recommendations and advances will be lost. In order for coordination to truly work, there need to be incentives for public health and drug treatment providers to join together in seeking grants and other federal monies. The present system discourages rather than encourages such cooperation. Demonstration projects need to be set up with a component for evaluation and further funding already in place so that valuable people, time and resources are not lost. Increased federal action in the areas of evaluation, technical assistance and development of training, guidelines, and models can help bring about the cooperation and coordination of health care and drug treatment which are essential to meeting the goal of providing primary care to substance users with HIV disease.