Challenging Dogma - Fall 2009

Wednesday, December 16, 2009

A Failure of [Ex]Change: Why Scientific Evidence Regarding Needle Exchange Programs and a Reduction in the Transmission of HIV/AIDS Has Failed to Chan

I. Introduction
“Few would openly support making intravenous drug use of heroin and cocaine capital offences, but that is what withholding sterile injection equipment effectively does.” (Schwartz) (1)
Over two decades have passed since the United States Congress barred federal funding for needle exchange programs (2). Between then and now, the US has taken numerous steps in the “War on Drugs” including increased funding for prevention education, drug enforcement, as well as passing legislation to increase penalties for use, dealing, possession, and even possession of paraphernalia. Congress spent nearly $1 billion on drug prevention media campaigns between 1998 and 2004 alone (3). But despite these steps, numerous individuals continue to use drugs. Currently, there are an estimated 500,000 to 750,000 heroin addicts in the United States, with this figure holding relatively steady (4).
Drug abuse raises numerous societal concerns such as an increased likelihood that drug users will engage in crime, experience homelessness, unemployment, poverty, or more (5). The link between these conditions are not unidirectional however, as they can also contribute to drug use amongst individuals (6). Additionally, public health concerns can arise as all of the previous conditions can lead to serious health risks.
Simultaneously, the US has been waging a different war – one in which they have aimed at increasing awareness of HIV/AIDS as well as working towards preventing its transmission between individuals. This has also been undertaken through direct public health campaigns, as well as increased proliferation of sex education information and the support of numerous non-profit organizations that have assisted in providing free screenings to anyone who might be viewed as at risk.
Despite pursuing solutions to both of these problems, the federal government has made a significant oversight in failing to develop a public health policy that can embrace both concerns through a uniform channel. In this case, that channel would be through the support of needle exchange programs for intravenous drug users. Needle exchange programs would provide sterile injection equipment and related items in order to reduce the increasing transmission of HIV/AIDS within and around this extremely high-risk population. Injection drug use accounts for approximately one third of all AIDS cases making it the second largest transmission method after unprotected sexual intercourse (7)(8), a figure that one would think should drive legislatures and citizens to demand reform.
While current drug policies focus on a goal of use reduction (trying to reduce the overall use of a drug), it seems important to suggest an alternative method to solving these problems may be possible if we work towards harm reduction (trying to reduce the potential harm that drug use can have for either the individual or the community) policies (9). This paper addresses traditional methods of dealing (or attempting to deal) with drug use as well as the transmission of HIV/AIDS within and around this population. It will show how the current US policy has failed to control drug use (use reduction) and in supporting use reduction models it has ignoring and in many instances impeded harm reduction methods. Section II of this paper presents three critiques of US policy around drug and HIV/AIDS programs, and why the behavior models these policies are based off of are flawed. Section III will propose an alternative method in addressing intravenous drug use and the transmission of HIV/AIDS, suggesting alternative behavior models and practices that might assist in a shift from use reduction to harm reduction.
II. Critiques of Current US Drug Policy and Its Failure to Support Associated Risks and HIV/AIDS Education Programs
This section will argue that current methods of drug prevention and drug policy fail for multiple reasons. First, a large amount of current drug prevention programs base themselves in behavior models that assume individuals, and particularly those at risk of using drugs, will make decisions rationally. Second, current policies and programs fail to recognize that various other factors contribute to individual’s behavior, including social and environmental influences. Third, policies and programs around HIV/AIDS prevention programs fail to successfully market prevention through means other than sex education and frequent testing.
A. Current Drug Policies Assume Individual Will Act Rationally
If an individual never starts to use drugs – one of the many goals of current federally funded public health campaigns - this is considered a success. However, the truth of the matter is that no matter how much money is poured into public health campaigns, it’s likely that some individuals will begin to use drugs, and some of these individuals will become addicted. Current drug prevention campaigns err in utilizing the Health Belief Model (HBM) as one of the primary method for preventing individuals from trying drugs, focusing on preventing initial use rather than cessation of those who, are already using. HBM is structured around the belief that individuals (in this case potential, or even current drug users) will weigh the perceived risks and benefits of a current action (in this case the dangers of drug use could include the possibility of addiction, overdose, or other related health risks, versus getting “high”), which will determine a behavior intention resulting in action (10).
Unfortunately, people are neither this predictable nor this rational. This theory presupposes that individuals will act rationally, which has been proven not the case. Additionally, this model functions on the individual level, despite significant knowledge that influences on the group level such as social and environmental factors play an important role in predicting the behaviors individuals and groups will engage in. Individuals might also opt to take part in a behavior spontaneously, skipping numerous steps in HBM and other theories of behavior all together (11).
The “Choose to Refuse” program utilized in Massachusetts by the Essex County District Attorney is one possible source for criticism. In this program, Heroin and OxyContin prevention were promoted to high school students though a utilization of the Theory of Behavioral Inoculation (12). The theory of behavioral inoculation states that if an individual is supplied with enough information beforehand, including arguments against the proposed negative behavior, and prior to communication in which the behavior would takes place, this wealth of information should help drive the individual to remain more resilient to dangerous behaviors (13).
This theory, like the HBM, ignores the fact that social and environmental impacts play a role in individual decision-making. Despite having heard the arguments against heroin use, some may still take part due to peer pressure or other social or environmental factors (for example, the individuals partner or friends may be taking part in intravenous drug use, so the individual will take part to be a part of the group, or because they spontaneously opt to be involved). Additionally, this theory assumes that decisions are always well reasoned (which as previously discussed, is not the case). While the “Choose to Refuse” program attempts to address concerns of social impact, the theory the message is based off of fails to do so.
A shared flaw of both of the HBM and the Theory of Behavioral Inoculation is that they both are susceptible to optimistic biased. Optimistic biased is the belief that while being fully aware of the risks to a specific practice, individuals will be able to control their actions and avoid potentially dangerous outcomes (14). In cases of heroin this could mean an unrealistic expectation of avoiding the development of an addiction, chance of experiencing an overdose, or contracting other diseases through drug related practices (e.g. HIV/AIDS due to needle sharing). The truth of the matter is that individuals regularly overestimate their ability to control something – be it a situation or a craving – and that this “optimism” could allow for dangerous activities to occur regardless of knowledge of risks or benefits.
B. Current Policies Often Utilize Ineffective Methods of Changing Behavior
As previously mentioned, the US government has taken numerous steps in advocating drug prevention messages and creating ad campaigns aimed at “keeping kids off of drugs”. Mass media interventions generally consist of repetition of key messages, disseminated through the use of various media channels such as billboards, television, radio, and more recently emails and online media campaigns (15). Though many recall the early 2000’s ad campaigns against smoking, alcohol, and marijuana use, the messages of the latter campaign failed to create a positive reaction amongst its target audience (16). Instead, evidence suggests that these advertising campaigns may have had no effect on preventing adolescent drug use. Worse yet, the strongest message of this campaign was that all of ones peers were likely smoking marijuana, and as a result the message of the campaign may have had the reverse effect, encouraging rather than discouraging usage amongst those who had not previously used (17)(18).
Previous methods for drug prevention have been equally ineffective. The 1980’s “Just Say No” campaign was heavily critiqued for its use of shock tactics and overly simplistic messages (19). These messages fail to connect with the target audience because it seems that the advertising campaigns have not done the necessary research as to what this audience needs, wants, or values. Instead these messages push images that are either too disconnected from the topic being discussed or attempt to shock the audience – neither addressing the audiences desires. Media messages also seem to fail in that they predominately address alcohol, tobacco, and marijuana use, paying significantly less attention to harder drugs. These messages push the end goal of health, but often fail to take into account social and environmental factors and the assumption that individuals will act rationally – which as previously discussed, they do not. Often these campaigns fail to drive home their core messages due to a poor execution of understanding
Finally, methods utilized by law enforcement to try and control drug use can adversely effect efforts to protect users form additional risk. If law enforcement or legislatures restrict access to sterile injection equipment, users may be more inclined to share or reuse equipment. Additionally, users may avoid needle exchange programs if they fear being arrested upon entering or exiting with paraphernalia (19). These methods do not decrease use – as is their goal – but simply raise the risks involved for those taking part in intravenous drug use.
C. Current HIV/AIDS Education and Drug Prevention Programs fail to Account for Environmental and Social Factors
Another clear example of use reduction as apposed to harm reduction can be observed in the arguments for abstinence only sex education programs. Here, rather than address methods of reducing HIV/AIDS and other sexually transmitted disease through safe practices, arguments have been made for abstinence only sex education as a method of avoiding the risk altogether. However in their drive to increase awareness of HIV/AIDS as a sexually transmitted disease, many prevention programs rely primarily on educational messages, fail to take steps in promoting the role that substance abuse can play in the spread of the disease (20).
One behavioral model designed to address concerns around HIV/AIDS and its transmission is the AIDS Risk Reduction Model (ARRM). ARRM was developed with the goal of assessing associations between risk behaviors and attitudes, with the goal of sexual practices in response to what we’ve learned about HIV/AIDS transmission (21). This model takes into account aspects of the Theory of Planned Behavior, Social Cognitive Theory, and the Health Belief Model (22). As previously discussed, the health belief model is a model for failure in the project of preventing HIV/AIDS transmission and US drug policy. When posed with the chance of sexual or drug related gratification immediately in contrast to the chance of infection and diagnosis in the future, the HBM and theory of planned behavior seems well positioned to be cast to the wind. Another problem around this issue is that most sexual behavior happens spontaneously, and emotions will likely override cognitive decisions (23).
In contrast to these models, harm reduction methods have still managed to take root within sex education programs. They have increased awareness through effective advertising and marketing campaigns, have made individuals knowledgeable about the benefits of condom use, in addition to making them readily available in high risk environments at little to no charge (24). Nonetheless, the understanding that human behavior can be irrational, spontaneous, and influenced by group or social dynamics can still prevent positive health programs from being successful.
III. An Alternate Approach to Current Use Reduction Models
Taking into account the critiques of the current drug treatment and HIV/AIDS education policies, this section presents a proposal for an evidence-based alternative in addressing HIV/AIDS transmission in intravenous drug users. Part A will describe the proposed solution, while Part B will provide support for the solution based in behavioral science models.
A. The Proposed Change
The change needed in current drug policy as well as HIV/AIDS education policy is that programs focusing solely on use reduction should be modified to include elements harm reduction. In order to obtain this change, both diffusion of innovations theory and marketing theory could be utilized to promote the use of needle exchange programs and safer practices around intravenous drug users regarding the sharing and/or reuse of needles.
The proposition of using needle exchange programs in order to promote harm reduction is not an untested theory. Currently 28 states and the District of Columbia have needle exchange programs in place, although these programs receive no federal funding and may face political disconnects within state or local levels (25). Needle exchange programs are structured in such a way that their primary focus is on harm reduction, swapping dirty needles for clean ones, or in some cases providing needles for free or at extremely low costs. In addition to this, needle exchange programs provide services such as HIV/AIDS testing, referrals for addiction treatment, and similar services. Needle exchange programs have also taken into account that not everyone is going to exchange needles, or will be willing to get a new needle rather than share when the opportunity arises. As a result outreach programs and needle exchange programs have provided small vials of bleach with which needles can be sterilized in the convenience of ones own home. Instructions are provided so that individuals know how to clean their equipment as well as to prevent risks of injecting traces of bleach (26).
Several concerns exist around the acceptability of needle exchange programs; primary amongst them is the controversy of easing access to needles. These concerns stem from the belief that if access to needles is eased; more individuals will choose to become intravenous drug users. This simply has not proven to be the case (27), and while positions in support of needle exchange programs advocate this as a means of harm reduction – making drugs safer – there is no question that these drugs are still not safe (28). However the most needle exchange programs propose four possible steps for intravenous drug users: a) get off drugs; b) if you cannot or will not get off drugs, stop injecting drugs; c) if you cannot or will not stop injecting drugs, do not share needles; d) if you cannot or will not stop sharing needles, disinfect needles between sharing partners (29).
B. Proposed Change Support
Two behavior theories seem extremely useful in supporting needle exchange programs and HIV/AIDS prevention is advertising and marketing theory and diffusion of innovations theory. Marketing theory is the concept that addresses how population behavior can be modified by observing what a population needs, wants, or its core values, and presenting a product – in this case the needle exchange program – in such a way that it reinforces these desires, making the product more desirable. In the case of needle exchange programs, the core values that seem best suited to promotion are those of freedom and control (30). Individuals cling to these values, and so one potential framing of a public health messages could be, “With HIV/AIDS infections having the second highest transmission rate amongst intravenous drug users, making needle exchange programs available to the public will help prevent infections from spreading in your community”. This not only gives the individual ownership of the problem, but also reinforces the idea that needle exchange programs are the method of controlling the issue.
Utilizing the diffusion of innovations theory, it also appears that the development of needle exchange programs would provide a method through which intravenous drug users could learn safer practices. This model attempts to explain how and why ideas and concepts spread or become accepted through cultures. In the case of needle exchange programs, this theory could be used to illustrate how the belief that the use of dirty or shared needles is unacceptable when sterile needles are available for free form these programs. As the knowledge of the needle exchange program and what it entails travels between intravenous drug users and members of the community would either be persuaded to accept or reject the program. Assuming they accept, the program could continue implementing its mission to reduce the number of used or shared needles amongst intravenous drug users while late comers could become more aware of the program. Over time, by enough individuals utilizing this service and becoming aware of its existence, the chances are that more individuals would participate, until the practice has become saturated into normalcy and is a confirmed part of the support structure in reducing risk of HIV/AIDS transmission amongst intravenous drug users. Additionally, these programs may seek to utilize peer education programs as well as services unrelated to HIV/AIDS prevention in order to help recovering addicts remain clean and current intravenous drug users stay as safe as possible (31).
IV. Conclusion
The current policies surrounding drug prevention and HIV/AIDS prevention are flawed. With a repeal of the ban on federal funding for needle exchange programs, it is likely that in increase in harm reduction can take place, through reducing risks of transmitting HIV/AIDS between intravenous drug users. This does not require a complete scrapping of current drug prevention programs or HIV/AIDS prevention programs, but rather a modification of what we view as acceptable methods in reducing risk. These methods should be examined using scientifically based evidence rather than pure ideology. “Just as sexual intercourse among the young will not cease if access to contraceptives is withheld, IV drug use will continue with or without sterile needles (32)”. By permitting needle exchange programs to operate with federal funding and protection from persecution by overzealous law enforcement, programs in assisting intravenous drug users stay HIV/AIDS free as well as providing access to treatment for drug addiction (if desired) will likely be able to succeed. Nonetheless, it is important to recognize that the harm reduction model may not be the universally best policy for all drug prevention programs (33). Additionally, it may be useful to approach this policy from a perspective of morality, and whether a model of punishment versus compassion, as well as the United States favoritism of retributive justice, is really an optimal path to continue down (34).

1: Stryker, Jeff. IV Drug Use and AIDS: Public Policy and Dirty Needles. Journal of Health Politics, Policy, and Law. (719-740)
2: Tempalski, Barbara. Placing the dynamics of syringe exchange programs in the United States. Health and Place 2007; 13 (417-431)
3: American Journal of Public Health, 89
4: van Wormer, Katherine. Regarding heroin: British and American approaches. International Social Work. 1999; 42:3 (319-331)
5: Belenjo, Steven. Drug Addiction and Drug Policy, Westport, Connecticut; Greenwood Press, 2000 (240-241)
6: Belenjo, Steven. Drug Addiction and Drug Policy, Westport, Connecticut; Greenwood Press, 2000 (240-241) (241)
7: Heinzerling, K.G., et al, Unmet need for recommended preventive health services among clients of California syringe exchange programs: Implications for quality improvement. Drug and Alcohol Depndence, 2006, 81 (167-178)
8: Tempalski, Barbara. Placing the dynamics of syringe exchange programs in the United States. Health and Place 2007; 13 (417-431)
9: Caulkins, Jonathan, et al. Optimal timing of use reduction vs. harm reduction in a drug epidemic model. International Journal of Drug Policy 2009; 20 (480-497)
10: Edberg, Mark. Essentials of Health Behavior: Social and Behavioral Theory in Public Health, Sudbury, MA; Jones and Barlett Publishers, 2007 (129-143)
11: Rosenstock, Irwin, Historical Origins of the Health Belief Model, Health Education Monographs, 1974, 2:4 (328-335)
12: Choose to Refuse – accessed 12/06/09 – State of Massachusetts Website,
13: Weinstein, ND. Unrealistic optimism about future life events. Journal of Personal Social Psychology 1980; 39:806-820.
14: McGuire, W. (1961). Resistance to persuasion conferred by active and passive prior refutation of the same and alternative counterarguments. Journal of Abnormal and Social Psychology, 63, 326-332. 

15: Faggiano, F, et al. Drugs, Illicit – Primary Prevention Strategies, International Encyclopedia of Public Health, 2008 (249-265)
16 – State Health Facts - accessed 12/6/09
17: Faggiano, F, et al. Drugs, Illicit – Primary Prevention Strategies, International Encyclopedia of Public Health, 2008 (249-265)
18: van Wormer, Katherine. Regarding heroin: British and American approaches. International Social Work. 1999; 42:3 (319-331)
19: Faggiano, F, et al. Drugs, Illicit – Primary Prevention Strategies, International Encyclopedia of Public Health, 2008 (249-265)
20: Aggleton, Peter, et al. HIV/AIDS and injecting drug use: Information, education, and communication. International Journal of Drug Policy, 2005, 16:1 (21-30)
21: Oni, Adesoji A, Education: An antidote for the spread of HIV/AIDS. Journal of the Association of Nurses in AIDS care 2005; 16:2, (40-48)
22: Lanier, Mark M. et al. An empirical assessment of the AIDS Risk Reduction Model (ARRM) employing ordered probit analyses. Journal of Criminal Justice 1996; 20 (537-547)
23: Conner, Bradley, et al. Are cognitive AIDS risk-reduction models equally applicable among high and low-risk seekers? Personality and Individual Differences 2005; 38:2 (379-393)
24: Lanier, Mark M. et al. An empirical assessment of the AIDS Risk Reduction Model (ARRM) employing ordered probit analyses. Journal of Criminal Justice 1996; 20 (537-547)
26: Stryker, Jeff. IV Drug Use and AIDS: Public Policy and Dirty Needles. Journal of Health Politics, Policy, and Law. (719-740)
27: Caulkins, Jonathan, et al. Optimal timing of use reduction vs. harm reduction in a drug epidemic model. International Journal of Drug Policy 2009; 20 (480-497)
28: Caulkins, Jonathan, et al. Optimal timing of use reduction vs. harm reduction in a drug epidemic model. International Journal of Drug Policy 2009; 20 (480-497)
29: Patten, San, et al. The Utility of the Transtheoretical Model of Behavior Change for HIV risk in Injection Drug Users, JANAC, 2000, 11:1 (57-66)
30: Siegel, Michael. Marketing Public Health: An Opportunity of the Public Health Practicioner. Marketing Public Health, Sudbury, MA; Jones and Bartlett Publishers, 2007, (127-152)
31: Center for AIDS Prevention Studies – University of California, San Francisco – Website accessed 12/08/09-
32: Stryker, Jeff. IV Drug Use and AIDS: Public Policy and Dirty Needles. Journal of Health Politics, Policy, and Law. (719-740)
33: Caulkins, Jonathan, et al. Optimal timing of use reduction vs. harm reduction in a drug epidemic model. International Journal of Drug Policy 2009; 20 (480-497)
34: van Wormer, Katherine. Regarding heroin: British and American approaches. International Social Work. 1999; 42:3 (319-331)



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