Letter from Dr. Sam Friedman

Honorable Elias A. Zerhouni, M.D.
Director
National Institutes of Health
9000 Rockville Pike
Bethesda, Maryland 20892

Dear Dr. Zerhouni:

By this time, given the reaction in the scientific community to Representative Mark Souder's letter, I am sure that you have received a large number of letters from leading scholars about the positive impact of harm reduction measures, and, more specifically, syringe exchange. I am writing this letter to address two other aspects of harm reduction: 1. over-the-counter access to sterile syringes; and 2. drug users' organizations.

We studied the 96 largest metropolitan areas in the United States to compare those where syringes could be purchased over the counter with those where prescriptions were required (Friedman, Perlis & Des Jarlais, 2001). In the 60 metropolitan areas where syringes could be purchased without prescriptions, the median proportion of the population who injected drugs was 0.71%; in the 36 metropolitan areas where prescriptions were needed, 0.89% of the population injected drugs (p = .0937). This suggests that letting injection drug users and other people purchase syringes over the counter does not "do harm" in terms of increasing the proportion of the population who inject drugs.  We also found that over-the-counter syringe access was associated with less HIV infection among injection drug users. Their median HIV prevalence rate was 6.51% in the 60 metropolitan areas where syringes were available without prescription, but median HIV prevalence was 12.25% in the 36 metropolitan areas where prescriptions were required (p = .0007). HIV incidence among drug injectors was also lower in metropolitan areas where syringes could be purchased over the counter; 17% of these metropolitan areas had HIV incidence of at least 1% per person-year at risk, as compared with 61% of the metropolitan areas where prescriptions were needed (p .001). I should note that similar results were obtained if we considered means rather than medians in comparing the percentage of the population who inject drugs and the percentage of injection drug users who are HIV infected; and that the difference in HIV incidence rates remains large and significant when controlling for HIV prevalence rates in these metropolitan areas.

This study thus found that laws against over-the-counter purchase of syringes are not associated with lower population proportions of IDUs, but that they are associated with higher HIV transmission. This suggests both that laws that require a prescription to buy syringes may well be contributing to the spread of HIV/AIDS and also that they do not seem to be restricting the injection of illicit drugs.

In a number of other countries, including Britain, Canada, and Australia, public funds have been made available to assist drug users' organizations to conduct HIV/AIDS and hepatitis prevention activities among their peers (Wodak et al. 1998; Friedman & Knight 2003; Friedman, de Jong, and Wodak, 1993). These organizations, like similar groups of patients or consumers with conditions or consumption patterns that are legal, also contribute advice to public health and police officials. Although I am aware of no randomized controlled trials or other similar evaluations of their impacts, specific projects of some of these users' groups have been evaluated and found to be effective. In addition, the relevant national, state, and provincial governments have found them effective enough to continue funding them for many years.

Finally, I want to end on a personal note. I have been conducting research on the AIDS epidemic among injection drug users in New York City and elsewhere since 1983. During that time, I have become friendly with many current drug users and ex-drug users. Many of those who were HIV-infected have become sick with AIDS; and many of these have died. Since the early 1990s, when the beginning of syringe exchange in New York was associated with a rapid and large-scale decline in new HIV infections, far fewer of these men and women have become infected. Since the mid-90s, when effective anti-retroviral therapy became available, far fewer of those who are infected have become ill each year; and far fewer have died. On a human level, the pain associated with infection among my friends was reduced by syringe exchange and other harm reduction measures; and that associated with AIDS and death was reduced by clinical research. I am grateful every day that public health and medicine have made this improvement possible. I would like to urge you to try to safeguard these gains by standing firm against powerful voices who ignore the findings of science and whose policies could greatly hinder the ability of medicine and public health to prevent epidemics and the pain of disease and death.

Sincerely yours,

Samuel R. Friedman, Ph.D.
Senior Research Fellow, Institute for AIDS Research
Core Director, Center for Drug Use and HIV Research

References
Friedman SR, Perlis TE, Des Jarlais DC. (2001). Laws prohibiting over-the-counter syringe sales to injection drug users: Relations to population density, HIV prevalence and HIV incidence. American Journal of Public Health, 91:791-793.
Wodak A, Strathdee S, Friedman SR, Byrne J.  (1998).  The Global Response to the Threat of HIV Infection among and from Injecting Drug Users.  AIDS Targeted Information 12;6:R41-R44.
Friedman, Samuel R, Knight, Kelly. (2003). What is the role of structural interventions in HIV prevention? Fact Sheet 46, Center for AIDS Prevention Studies, San Francisco.
Friedman SR, de Jong W, Wodak A. "Community Development as a Response to HIV among Drug Injectors."  AIDS 92/93-A Year in Review 7(1993; suppl. 1):S263-S269.