A novel approach to fighting HIV infection among drug addicts: acceptance

The New York Times has an interesting article this week on HIV and drug addiction. As has been known since early in the epidemic, intravenous drug use is a pretty efficient way of transmitting HIV. Addiction also leads to behaviors -- like trading sex for money and drugs -- that further multiplies risk. For those working in public health, intravenous drug users are a challenge; they are often called a 'hard to reach community' for good reason, because what they do is illegal, and they have to duck and cover for fear of being turned into the authorities. The group is also deeply stigmatized by the wider community: as trash, car crashes, disease-vectors, worst case scenarios. Those in bioethics who talk about protection of the vulnerable are usually not thinking about drug users: the preferred vulnerable are typically the non-addicted poor, the non-addled disabled, or innocent children and fetuses. (Bioethicists steer clear of that part of town, mentally as well as physically.) There is always the spoken or unspoken accusation of addicts being responsible for their predicament, and there is no way around it: a lot of drug addicts are in rough shape and live in rough circumstances. Some of the photos accompanying the New York Times piece are cringe-evoking, and leave no room for romanticizing drug use.

That should not take away from the point of the article, however. St. Paul's Hospital in Vancouver has set up Insite, a place downtown where injection drug users can get clean needles, and get tested and treated for HIV. A package of medical services is offered by staff nurses: basic care for needle infections, gynecological exams and tests for sexually transmitted diseases, and referrals for drug treatment. The strategy of aggressively testing for and treating HIV seems to be working: HIV incidence in Vancouver has apparently fallen by half. Up to now, Insite has managed to get an exemption from Canada's narcotic laws, so drug users can shoot up inside the premises without the risk of being arrested or robbed, and stand less chance of dying of an overdose.

The program is unusual in its acceptance of the grim reality of addiction. Most often, public health approaches with this community are strongly mediated (or hampered) by common sense morality, the law, and politics. For example, a number of studies worldwide have shown that clean needle exchange programs can play an important role in lowering HIV transmission, but such programs run headlong into stigmatizing attitudes about addicts and have only rarely been fully embraced. The Insite initiative gives a glimpse of what public health interventions with this population could be like when they are provided with funding, legal immunity, and minimal political pushback and moralizing. It looks like such programs could do some good on individual and population levels. While this approach might catch on, at least in Canada, other affluent countries (like the United States) are far away from having the social and political conditions to emulate this model, and others in developing countries are even further still.