Education Series
Number 2
April 1991
Rod Sorge is an AIDS activist and as a member of ACT-UP helped to start their Needle Exchange in New York City. As editor of Health/PAC Bulletin he wrote this aricle on drug policy, AIDS and harm reduction.
We have understood HIV transmission for years. The routes are obvious,
limited, and modifiable, yet HIV seroprevalence has steadily increased around
the world. There have been only limited medical advances in the treatment of
HIV-related illness. Because of a lack of federal leadership on all fronts, from
funding to discrimination, misguided research priorities at the National
Institutes of Health (NIH) and the Food and Drug Administration (FDA)(1), and
because the virus continues to confound researchers the more it is studied (2),
the dream of making AIDS a chronic but manageable condition remains mostly a
dream as we start to live through its second decade.
Instead of producing safer sex education for men who have sex with men, the
government still demands as end to such sexuality; and instead of producing
safer drug use education, the government demands an end to drug use by force
rather than treatment. Many of our laws and cultural mores regarding sexuality
(like prostitution and sodomy laws) and drug use (such as hypodermic possession
and drug paraphernalia statutes) only create a climate that promotes silence,
secrecy, hate, and shame at a time when we need to be talking openly about sex
and drug use. It is not surprising, then, that most of the AIDS prevention
education that has been effective has been developed outside of government
agencies and in the communities at which it is aimed.
As the “second wave” of the epidemic crests, and seroprevalence
reaches staggering levels among intravenous drug users (IVDU’s) there is a
growing movement among providers, AIDS activists, researchers, and policymakers
toward a drug policy paradigm aimed not a incarcerating and punishing users, or
at positing abstinence as the only alternative to drug taking, but at educating
users about how to reduce drug-related harm. AIDS activists across the country
are establishing, often illegally, programs in which drug users learn how to
clean their works with bleach to help limit the transmission of HIV from the
sharing of contaminated needles. Once again the prevention debates — quagmires
of personal anti-drug morality and local politics — and have taken public
health into their own hands. This article, …attempts to articulate to
articulate some of the arguments and developments in the U.S. movement for harm
reduction.
The Needle Exchange Controversy in New York
Nowhere has the debate about needle exchange and safer injection education
been as intense as in New York City. The complex racial realities and politics
that dominate many aspects of New York life have likewise influenced this
discussion. Where three socio-epidemics — homelessness, drug addiction , and
AIDS — intertwine to devastate communities of color, some argue that needle
exchange or bleach distribution programs are merely a way of ignoring the scope
and gravity of these epidemics, paltry interventions that mock the realities of
many people’s lives. Most opponents of needle exchange programs believe that
drug treatment should be given top priority, and that anything less is a
non-solution. Some contend, despite much evidence to the contrary, that needle
distribution would add to the problem by encouraging drug use or, at the very
least, by sending “mixed messages” about drug use.
In their search for a single and immediate solution, opponents of
harm-reduction measures simplify the complex phenomenon of drug taking and the
complex lives and motivations of drug users. Their arguments reflect a lack of
knowledge about addiction as it currently exists in New York City, the realities
of the services that are needed, how much they will cost, and how long it will
take for them to be actualized.
What may seem like an inadequate response to AIDS and drug-related harm from
the vantage point of a policymaker or church leader can nevertheless be a
life-saving strategy from a drug user’s viewpoint. Proponents of needle exchange
and distribution programs do not support such programs as solutions to the AIDS
epidemic or drug-related harm. But that these programs can help prevent HIV
infection, and help prevent those already immunosuppressed or HIV infected from
contracting life-threatening infections, is undeniable.
The issue of risk-reduction education has been largely portrayed as a
controversy between black church and political leaders on the one hand and white
health officials on the other. However, such a generalization eclipses the fact
that many Latino and African-American AIDS advocates and services providers have
spoken out in support of the immediate implementation of needle exchange
programs and do so with input from drug users themselves and from those who live
in neighborhoods affected by AIDS and drug-related harm. Debra
Fraser-Howze, director of the Black Leadership Commission on AIDS, an
organization that is one of the most outspoken opponents of needle exchange,
admitted that needle exchange, bleach distribution, and safer injection
education “are not about AIDS, but about power and control” (3). But
in the struggle over who will determine drug and AIDS policy, those who most
require empowerment and control are continually left out: active and former drug
users themselves.
Just Say No to Just Say No’
Drug use as it exists in the United States is largely the result of diverse
forms of socio-economic coercion, but the sources of that coercion are made
diffuse and indirect shifting the focus away from the physical considerations
and the origins of addiction to the presumed recalcitrance of the individuals
user. The “just say no” approach to drug “education”
typifies this attitude: the recalcitrant individual is the one who won’t or
can’t say no. The “choices” are clearly set forth. What type of person
are you/will you be? The life conditions that often lead to drug-related
problems are seldom raised in the mainstream discourse about drug addiction.
Rather, the addict is solely accountable for her or his addiction, while racism,
classism, poverty, and heterosexism almost never enter the picture. Each addict
is viewed as a separate case, a separate individual having made a personal
choice to use drugs. In the age of AIDS, the logic goes, choosing to become
addicted and choosing not to end one’s addiction make HIV a self inflicted
condition. The just-say-no approach also denies the fact that drugs can be used
more safely than they often are, and stablishes the equation drug use = drug
abuse. Our culture hypocritically calls those who use heroin and cocaine
“drug abusers” while “social drinkers” and cigarette smokers
escape even the label of “drug user.”
“Just say no” introduces the appearance of a choice when in
actuality often no choice exists, thereby establishing a structure through which
blame and accountability can be meted out. Drug-related harm prevention programs
aimed at intravenous drug users and their sexual partners and families are
essentially non-existent in New York, except for the work of ADAPT (the
Association for Drug Abuse Prevention and Treatment) and a few other
community-based organizations that distribute bleach kits and show addicts how
to clean their needles. Drug addicts must be given realistic choices if they are
to avoid health problems and change their drug-taking behavior. There must be
immediate implementation of community-based needle exchange programs and the
decriminalization of hypodermic needles and drug paraphernalia to prevent
further HIV infection among this population. Such measures must be seen as
components of a larger effort that includes drug treatment and health care for
users. U.S. drug policy must be reworked to acknowledge and confront the AIDS
crisis and the realities of addiction. HIV will continue to spread unchecked
until effective needle exchange programs and safer drug use education are
standards of preventive care for drug users.
Drug users will not be given choices — of treatment, needles, or safer
injection education — if, as is currently the case, they are considered to have
relinquished some of their rights merely by using drugs. In the United States,
as addicted person is expendable. That intravenous drug users are prohibited
from obtaining life-saving clean needles and unable to obtain drug treatment
constitutes a government-sanctioned violation of their human and constitutional
rights. The user’s right to the pursuit of life has been abandoned.
Drug Use and AIDS in New York
Intravenous drug users constitute the second largest but fastest-growing AIDS
caseload in New York State. Compared to the rest of the United States, people
with AIDS in New York are three times as likely to be IVDU’s. For 1988 and 1989,
heterosexual drug users made up a larger proportion of AIDS cases in New York
City than gay men (43 percent versus 41 percent in 1988, and 43 percent versus
40 percent in 1989). Findings from studies of patients in methadone programs and
detoxification units estimate 50 to 60 percent seropositivity among these
patients (4). The New York City Department of Health estimates that by 1993, 50
percent of New York City’s AIDS cases will be among IVDU’s (5).
Just as drug addiction has devastated communities of color, so HIV infection
among IVDU’s disproportionately affects Latinas, Latinos, and African-Americans.
However, a large proportion of deaths among New York City’s HIV infected IV drug
users is not classified by the Centers for Disease Control (CDC) as AIDS (6);
similarly, HIV manifestations in women–especially gynecological symptoms–do
not fit the CDC’s definition of AIDS (7). Thus, there is a relative under
counting reflected in the statistics that purport to show the impact of AIDS on
drug users. (Figure 1) The number of births to women who use narcotics cotinues
to increase, in some areas dramatically. In northern Brooklyn, for instance, a
75 percent increase in such births occurred in just one year (1985-86) (9). IV
drug use is a factor in at least 80 percent of New York City’s pediatric AIDS
cases (10).
Statistics on drug addiction and treatment reflect city and state attitudes
and are, therefore, difficult to obtain. Most of the widely used numbers
relating to drug use in New York–the ones that appear in the media and that the
state uses for budgetary purposes come from the Statewide Comprehensive
Five-Year Plan of the New York State Division of Substance Abuse Services (DSAS).
DSAS is the arm of the state bureaucracy charged with all drug treatment and
prevention services for New York State. It conducts needs assessment studies and
statistical research, which is often outdated by the time it is available, but
almost no research into treatment modalities. The most recent Five-Year Plan, an
outline of what has been done and what is proposed regarding drug treatment
services in the state over a five-year period, covers 1984-85 through 1988-89,
and most of the statistics it gives are completely outdated. The annual updates
to this larger report lag behind so that they, too, are outdated by the time
they reach the public.
DSAS calls heroin use a “stabilizing problem,” estimating the
heroin-using population to be around 200,000 for New York City and 60,000 for
the rest of New York State (11). These numbers represent what the state calls
“primary heroin addiction.” The most widespread secondary drug used by
heroin addicts is cocaine, with 71 percent of users administering it
intravenously (12). New York also has an estimated 350,000 cocaine and crack
addicts (13). There is some substantial overlap between the heroin and cocaine
using populations (as well as alcohol users), as polyaddiction becomes more
prevalent that addiction to a single drug.
There are currently about 43,000 drug treatment slots in New York State for
all addictions, including alcohol. About 35,000 of these slots are for heroin
users, and most of them are methadone based and thus useless to those who inject
cocaine, amphetamines, or other non-opiates. Methadone maintenance programs
continue to operate at 105 percent utilization, according to DSAS’s Five-Year
Report. However, those who work in drug treatment tell us that because there is
no centralized referral services that monitors drug treatment openings, many
slots remain empty for weeks because people elsewhere do not know they are
available. The treatment capacity for New York City’s cocaine users is even more
inadequate: there are only 97 publicly funded cocaine-specific treatment slots
in the entire city–a truly astounding statistic for a city with an estimated
350,000 cocaine and crack users (14). Only 30 residential treatment slots exist
in the entire state for women with dependent children–5 in Rochester and 25 in
New York City–even though a majority of intravenous drug users have children,
most of whom are in the custody of their mothers (15). Nationwide, as estimated
80 percent of active intravenous drug users are not in any kind of treatment
(16).
Accessibility of Health Care
Most IV drug users lack any firm connections to even the most basic health
care. Their most accessible option is emergency room treatment in one of New
York City’s public hospitals where, due to severe shortages of staff, beds,
supplies, and money, decent and immediate care is almost impossible to get. The
hospitals are so over-utilized and under funded that even easily administered
Medicaidaccepted treatments and prophylaxes for HIV-related conditions are
unavailable. This is the case with aerosolized pentamidine, for example, which
serves as a prophylaxis for pneumocystis carinii pneumonia. Even though this
illness can be successfully prevented, it is by far the most common
“indicator disease” of AIDS diagnosis in New York State (17).
Most of the treatment for HIV and the opportunistic infections that define an
AIDS related condition are experimental. That is, the Food and Drug
Administration (FDA) has not yet approved them for use. Such experimental
treatments are available only by participating in the clinical drug trials that
test a drug for safety and efficacy in humans. These trials are conducted by the
National Institutes of Health (NIH) under a system known as the AIDS Clinical
Trials Group (ACTG). These trials are highly restrictive. Protocol criteria
prevent many people–women, people of color, IVDU’s, children, those taking
other treatments, and those who are “too healthy”–from participating
in them and thus receiving treatment. Some drugs tested in ACTG trials are too
toxic for people who have health problems resulting form prolonged or unhygienic
drug use. Liver problems, as gauged by liver function tests, for instance, often
keep active or recovering drug users out of trials. Instead of varying trial
designs to broaden protocol requirements for those currently excluded (but who
will presumably take the drug after its approval), the trials remain limited
both in their usefulness to patients and for data collection. (It should be
noted that the one alternative to the ACTG system is the Community Based
Clinical Trials (CBCT) Network, which has been somewhat more cognizant of the
needs of drug users and has thus enrolled more of them into its trials. The CBCT
Network conducts trials independently of NIH, and has successfully tested agents
that have subsequently been approved by the FDA). Lastly, may of the trials
incorporate double-blind placebo controls, which act to deter enrollment,
especially of people who already have nothing to expect from the system.
As of June 1990, only about 8.9 percent of all those enrolled in ACTG trials
had reported some prior drug use, and 0.5 percent of trial participants were
active (“illicit”) drug users (18). Currently, there is only one trail
designed specifically with recovering drug users in mind, ACTG 055, which
intends to study the pharmacokinetics of AZT in people taking methadone. ACTG
082 will enroll a small group of pregnant women in their third trimester who
have a history of drug use to evaluate the pharmacokinetics, safety, and urinary
excretion of intravenous and oral AZT. There have been no trials that offer drug
treatment in conjunction with treatment for AIDS-related conditions (19).
Besides entry criteria, there are numerous other problems that make clinical
trials inaccessible to most IV drug users: no childcare is provided; trials are
often not located near sick people (there are no ACTG center in Texas or Puerto
Rico, for instance), and no travel reimbursements is provided to participants;
no housing is provided for those who may need it; no meals are provided; and no
option to obtain treatment for drug addiction is offered. ACTG researchers might
dismiss the lack of such “amenities” as the fault of the health care
system, which they cannot change but rather must work around. Provision of such
services by the ACTG system would of course call the entire nature of clinical
trials into question by suggesting that research should simultaneously be a form
of treatment.
Most IVDU’s with HIV disease lack basic, everyday physical and social
supports. With this community, like most poor communities, we must keep in mind
the entire health care picture. Comparatively speaking, clinical trials are far
down on the list of priorities, even though they could be life-preserving,
unless earlier obstacles to care are addressed. As one advocate for
African-Americans points out, “AIDS research is not a basic means of
survival in our community–it is an extraordinary means” (20). This
describes the situation of IVDU’s. It is impossible for those who need
experimental treatments to use (or want to use) the current system if their
basic life necessities remain unmet.
Needles: A Health Issue
Intravenous drug users commonly contract bloodborne infections and diseases
like hepatitis, encephalitis, endocarditis, and sexually transmitted diseases,
develop abscesses that promote infections; and suffer from other conditions that
are a direct result of using unclean injection equipment. Though HIV-related
illness may be the most well-known, it is only one of many health problems an
injecting drug users faces. This fact was recognized early in the Netherlands,
where needle exchange programs were originally developed to help prevent the
spread of hepatitis B.
Clean injection equipment for drug users is a form of preventive health care.
In the United States and other “first world” countries, it would be
unthinkable for a person to visit a hospital or doctor’s office and be injected
with a needle that was previously used on another patient. But receiving an
injection in a hospital and injecting “illicit” drugs, while they
entail the same physical act and thus the same physical risks, are perceived as
moral worlds apart and therefore are judged differently. Although sterile
needles and syringes could prevent drug users from contracting HIV and a host of
other infections, users are denied access to such instruments and can even be
arrested for having them. While clean needles should be a public health issue,
they remain a drug policy issue. But U.S. drug policy, of course, is synonymous
with law enforcement. Not only is access to medical treatment for drug users
non-existent, but simple, cost-effective preventive health care measures like
needle exchange are actively disallowed and criminalized. With AIDS, this
prohibition means legally sanctioning a public health disaster.
Members of the AIDS activist community of New York City, most visibly
embodied in the organization ACT UP (the AIDS Coalition to Unleash Power), have
taken control of their lives in many ways despite AIDS. They often know more
about treatments for HIV-related conditions than doctors do. They have created
clinical drug trials separate from those of the government, tested drugs the
government would not test, found ways to get drugs to those who couldn’t afford
them, and found ways to care for their sick when no one else would. They have
struggled against the ghastly media depictions of people with AIDS and provided
alternative representations. And they have cast off the smothering label of
“AIDS victim”: they are people living with AIDS. This change was much
more tan a linguistic one.
New York City’s IV drug users who have AIDS or are HIV positive are not
living with AIDS. For them, HIV is a death sentence. Their day-to-day struggles
for basic necessities preclude any possibility of mobilization or political
action or community building to demand access to drug and medical treatment.
Needle exchanges can be a departure point for a user’s process of empowerment
and can even serve therapeutic purposes for active and former users involved in
needle distribution.
In countries with a national health plan, adequate housing, and other
services–in short, where the quality of life for drug users is much
better–addicts have successfully organized themselves to fight for their human
rights and against stereotypic and degrading images of drug users. Groups like
the Junkiebonden (junky unions) of Amsterdam, the Western Australian Intravenous
Equity (WAIVE), and Queensland Intravenous A.I.D.S. Association (QuIVAA) of
Queensland, Australia, have done for addicts many of the things ACT UP and other
AIDS organizations have done for and as people with AIDS. In Amsterdam, the
first syringe exchange established to prevent HIV transmission was initiated by
a user-based organization called MDHG in 1984. And the Rotterdam Junky Union was
distributing clean syringes in high-drug use areas of Rotterdam as early as 1981
(21). The IV drug user’s condition in New York City and the United States is
situational, not necessary.
Needle Exchange: One Model
The terms “needle exchange” and “needle distribution” do
not do justice to the concepts that they try to name. The words refer to only a
small part of the event that needle exchange is. “Harm reduction” is
the term most often used to describe the drug policy paradigm upon which needle
exchange is predicated. The First International Conference on the Reduction of
Drug Related Harm was held in April 1990 in Liverpool–a new force on the drug
policy scene. The term “risk reduction” rather than “harm
reduction” might sound better to ears in the United States, where it has
become a staple in the discourse of AIDS education, particularly when talking
about safer sex. The analogue to “safer sex” is “safer drug
use.” The fact that the latter phrase is never uttered is telling.
ACT UP/New York’s Needle Exchange Committee is currently operating the only
needle exchange programs in New York City, with four “permanent” sites
in three of the city’s boroughs–as permanent as they can be considering that
the possession and distribution of needles are criminal activities in this
state.1 Along with needles, ACT UP outreach volunteers hand out kits that
contain bleach, clean water, cotton, cookers, condoms, referral information, and
illustrated instructions on how to wear condoms and how to clean works. Alcohol
pads, medicine for abscesses, and lubricant to use with condoms, especially for
sex workers who use the service are provided.
ACT UP runs a very user-friendly project. Addicts are not required to give a
needle in order to get one. Because the group’s resources are currently limited
and because the program is completely run by volunteers, it operates only two
days a week. A 24 hour, seven-day-a-week program might have stricter return
criteria. In addition, many of those who use the exchange re homeless, so it is
unrealistic to demand that addicts save their works from one exchange to the
next, when exchanges happen only twice a week. In fact, a majority of New York’s
addicts–whether homeless or not–do not carry works with them unless they
intend to use them immediately, for fear of getting arrested. Despite this
situation, at the six-month mark of ACT UP’s project in August 1990, many
needles are being collected. At the oldest site, an almost one-for-one exchange
occurs each week. It is clear that many users are willing to risk arrest to use
this program. What is often overlooked or ignored by critics of needle
distribution is the interaction that takes place during the encounter. It is
this interaction between the giver and receiver of the needle that is the
significant component of needle exchange, especially when encounters are
repeated, and trust–maybe even friendship–is established.
Along with getting needles and bleach kits, drug users get counseling
sessions where they can ask questions–sometimes for the first time–about HIV
transmission, receive advice on how to care for their abscesses, or simply have
an opportunity to talk to someone who will listen to what they have to say. The
exchange comes to encompass more than the needle.
ACT UP’s Needle Exchange Committee has ironed out most of the practical
problems it faces in order to operate viable programs: obtaining needles, which
is, of course, illegal in New York State; having enough supplies; maintaining a
consistent exchange schedule; and setting up pro bono legal support and a bail
fund for addicts or outreach volunteers who are arrested during an exchange. The
group is now trying to set up opportunities for users to receive more
far-reaching care by connecting them with medical services, drug treatment, and
other services from community-based organizations (the “bridge”
concept). These services should all be a part of needle exchange. In Australia,
where needle exchanges are located in the same building as drug treatment
facilities, the connection between AIDS prevention and other services is
difficult to ignore.
But while the concept of needle exchange as a “bridge” to drug
treatment is important, needle exchanges must be viewed as helpful and
life-saving independent of further linkages. In a place like New York City or
Newark, New Jersey, where very little drug treatment exists and primary care for
drug users is extremely limited, needle exchange can be a bridge to other
services only insofar as those services exist. The drug treatment that is
available in New York and New Jersey is mostly methadone based, so that many
methadone patients who are addicted to more than one drug are shooting cocaine
or other non-opiates while “in treatment.” In addition, recovery from
drug addiction is usually a long process with much recidivism. And, finally,
there are many people who will use a needle exchange program who do not wish to
stop using drugs at that point in their lives. While needle exchange can and
should be viewed as one step in a continuum of care, an addict must be able to
use it to the extent she or he wishes. If that means going no further than
obtaining needles to shoot up more safely, this must be respected.
Because the personal interaction that occurs during a needle exchange is so
important, decrimininalization of needle possession in itself would not be a
sufficient AIDS prevention measure for IVDU’s. Even if the needle possession
statue were removed, deeper-rooted cultural stereotypes about drug users and
drug use would persist as barriers to easy access to needles and syringes.
Members of ACT UP’s Needle exchane travel to states without paraphernalia laws
to purchase needles, but are often perceived as drug users and thus refused
service. In England, where syringes have long been legally available from
pharmacies and where the philosophy of harm reduction is much more widely
accepted, many drug users have traditionally been turned away, and thus do not
consider this a viable route for obtaining injection equipment (22). Finally,
although needles are less expensive in pharmacies than on the street, all
economic restrictions are lifted in free needle exchanges. The street Price of a
needle in New York City is currently two to three dollars.
Reflecting back on the years of the AIDS epidemic we have live through so
far, it is clear that the most effective prevention methods and system of care
have been community-initiated and based. Needle exchange programs will not be
helpful if they are inconveniently located, staffed by judgmental people, or
coercive in any way. They must be located in neighborhoods where people buy and
use drugs, be staffed by people who know the language spoken there (both the
ethnic and street language), and offer points of identification and support to a
user of the exchange. This means having active and former addicts and
HIV-positive people involved, as well as residents of the neighborhood in which
the exchange site is located. Needle exchange on a significant scale cannot take
place without the removal of hypodermic and paraphernalia statues, but the
repeal of such laws would not make needle exchange unnecessary.
There must be a shift in drug policy from the punitive, law enforcement
philosophy that now serves as its base to an understanding that drug use is a
socio-medical phenomenon that cannot be “treated” by jailing people.
It is this mindset that is responsible for keeping needle exchange interventions
so limited in the United States. Needle exchange must be viewed as a medical
intervention against infection that results from the fact that people use drugs,
and must be recognized as providing real, life saving options to users. These
advances will come, however, only when drug users gain their rights, and are
treated as people rather than criminals.
References
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The NIH has spent most of its time and money looking at antivirals, specifically nucleoside analogues such as AZT, while ignoring other drugs designed to treat the opportunistic infections of which most people with HIV/AIDS die. This state of affairs has continued even though AZT has shown only limited efficacy, is extremely toxic, and is not tolerated by many with HIV/AIDS. Harrington, M. A critique of the AIDS Clinical Trials Group. Report prepared by the Treatment and Data Committee of Act Up/New York, May 1, 1990. Treatment Agenda 1990. Presented at the Sixth International Conference on AIDS. San Francisco: June 1990. Prepared by the Treatment and Data Committee of ACT UP/New York. [NAMA Note: Some problems regarding AZT toxicity can be reduced with an adjustment of dose.]
-
Levy, J. A. Changing concepts in HIV infection: Challenges for the 1990s. Presented at the Sixth International Conference on AIDS. San Francisco: June 20, 1990.
-
Meeting of members from the ACT UP Needle Exchange Committee and ADAPT with Debra Fraser-Howze. San Francisco: June 23, 1990.
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1987 Update to the Statewide Comprehensive Five-Year Plan, 1984-85 Through 1988-89. Albany: New York State Division of Substance Abuse Services, 1987. p. 22.
-
Frank, B. and Hopkins, W. Current drug use trends in New York City. New York: New York State Division of Substance Abuse Services, June 1989. p. 11-155.
-
Sufian, M. et al. Impact of AIDS on Puerto Rican intravenous drug users. Hispanic Journal of Behavioral Sciences May 1990 12(2): 125.
-
Anastos, K. and Marte, C. Women-The missing persons in the AIDS epidemic. Health/PAC Bulletin Winter 1989 19(4).
-
1987 Update to the Statewide Comprehensive Five-Year Plan, and Frank and Hopkins, op. cit. Note: These statistics show only cases of CDC-defined AIDS, not HIV seroprevalence.
-
Simeone, R. et al. The northern half of Brooklyn: An assessment of the drug abuse problem. New York: New York State Division of Substance Abuse Services, 1989. p. 2.
-
1987 Update to the Statewide Comprehensive Five-Year Plan.
-
Ibid. p. 22.
-
Frank and Hopkins, op.cit.
-
Henneberger, M. City Drug Treatment System Can’t Keep Up with Addicts. New York Newsday August 20, 1990. p.3.
-
Ibid. p.23.
-
Drucker, E. et al. IV drug users with AIDS in New York City: A study of dependent children, housing and drug addiction treatment. Unpublished paper available from: Dr. Ernest Drucker, Montefiore Medical Center, Bronx, NY. July 20, 1988.
-
Centers for Disease Control. Update: Reducing HIV transmission in intravenous-drug users not in drug treatment-United States. Morbidity and Mortality Weekly Report August 10, 1990 39(31).
-
AIDS Surveillance Monthly Update for Cases Reported through May 1990. Bureau of Communicable Disease Control, New York State Department of Health. Albany, New York: 1990. p. 14. Pneumocystis carinii pneumonia is the indicator disease in 59.9% of AIDS diagnosis in the state, followed by Kaposi’s sarcoma, 12.8%.
-
Personal communication. Office of Communications, Division of AIDS, National Institutes of Allergies and Infectious Diseases, Bethesda, MD, August 15, 1990.
-
Ibid.
-
Fraser-Howze, D. Clinical trials from the perspective of communities of color. Presented at the Sixth International Conference on AIDS. San Francisco: June 1990.
-
Grund, J.-P. C. et al. Reaching the unreached: An outreach model for One the Spot’ AIDS prevention among active, out of treatment drug addicts. Presented at the First International Conference on the Reduction of Drug Related Harm. Liverpool, England: April 9-12, 1990.
-
Newcombe, R. Preventing the spread of HIV infection among and from injecting drug users in the U.K. International Journal on Drug Policy September-October 1989 1(2): 21-22.
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