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The New York Times
February 26, 2005
EDITORIAL

Ideology and AIDS
http://www.nytimes.com/2005/02/26/opinion/26sat1.html

The Bush administration has contributed to suffering and death through the so-called global gag rule, which prohibits Washington from giving money to any group that performs - or even talks about - abortions. Organizations that provide desperately needed family planning and women’s health services have lost their financing. Now there are moves in Congress and inside the administration to apply a similar rule to needle exchange programs. That would be an even more deadly mistake.

Allowing drug users to trade used needles for clean ones gets dangerous needles off the street and minimizes needle sharing. A proven weapon against AIDS transmission, it has not been shown to increase drug use, and indeed may reduce drug addiction by providing a way to talk to drug users and lead them to treatment. It is endorsed by virtually every mainstream public health group.

Getting users into drug treatment is the best way to keep them safe. But the push for treatment - which is expensive and difficult - should come with needle exchanges. Drug use is not a significant source of AIDS infection in Africa. In parts of Asia, the former Soviet bloc and Eastern Europe, needles are the major source of infection; three-quarters of all newly infected people in Russia are intravenous drug abusers, as are half of those newly infected in China. These are just the places where the AIDS epidemic is likely to explode next. A bumper poppy crop in Afghanistan will worsen the outlook, producing cheap heroin that could turn opium smokers into heroin injectors and thus fuel the epidemic.

Opponents of needle exchanges, mainly among the religious right, argue that the practice muddies the message that illegal drug use is unacceptable, and keeps drug abusers from suffering the consequences of their addiction. By this twisted logic, doctors should refuse to treat lung cancer in smokers. In any case, AIDS infections from sharing needles are not limited to drug users. They infect sexual partners, spreading the epidemic through societies.

While Washington does not buy syringes for needle-exchange programs, it does give money to groups that use other people’s money to administer needle exchanges. But some conservatives are attempting to stop even that. The assistant secretary of state for international narcotics and law enforcement, Robert Charles, warned the United Nations Office on Drugs and Crime, which currently holds the rotating chairmanship of the joint program Unaids, that the organization should not work on needle exchange issues and should remove positive references to them from its Web site, which it did.

Representatives Mark Souder of Indiana and Tom Davis of Virginia, both Republicans, have asked the United States Agency for International Development for details on all financing for programs in which any group strongly advocating needle exchanges also participates. These lawmakers claim that a U.N. drug agency report attacks needle exchange as encouraging drug use. In fact, the report makes no such accusation and endorses needle exchanges.

In the Senate, a member of the staff of Sam Brownback, the Kansas Republican, has compiled a grossly inaccurate chart of programs financed by the Global Fund to fight AIDS, Tuberculosis and Malaria that is subtitled “Immoral, Illegal (with bilateral funds) or Inconsistent with U.S. Foreign Policy.” Needle exchanges rank high. At the moment, Mr. Brownback’s office says he does not intend to attempt to block these programs. But some newer right-wing lawmakers are considering it.
So far, attempts to eliminate needle-exchange programs overseas seem to have limited support. Many administration officials and conservatives in Congress do not want to see crucial AIDS prevention measures derailed or American support withdrawn from such organizations as the Global Fund. One important test will be what the administration does in early
March at the annual meeting of the United Nations Commission on Narcotic Drugs. Last year, United States representatives there attacked the scientific evidence in favor of needle exchanges as unconvincing. This year, the United States should refrain from such attacks - and members of Congress should call off their budding witch hunt.

Washington’s antipathy toward needle exchanges is a triumph of ideology over science, logic and compassion. The United States should help pay for these important programs. If it cannot bring itself to do so, it should at least allow the rest of the world to get on with saving millions of lives.

The Washington Post
Deadly Ignorance
Sunday, February 27, 2005; Page B06

THE BUSH administration is quietly extending a policy that undermines the global battle against AIDS. It is being pushed in this direction by Congress, notably by Rep. Mark Edward Souder (R-Ind.). But some administration officials zealously defend this policy error, claiming scientific evidence that doesn’t exist.

The administration’s error is to oppose the distribution of uncontaminated needles to drug addicts. A large body of scientific evidence suggests that the free provision of clean needles curbs the spread of AIDS among drug users without increasing rates of addiction. Given that addicts are at the center of many of the AIDS epidemics in Eastern Europe and Asia, ignoring this science could cost millions of lives. In Russia, as of 2004, 80 percent of all HIV cases involved drug injectors, and many of these infections occurred because addicts share contaminated needles. In Malaysia, China, Vietnam and Ukraine, drug injectors also account for more than half of all HIV cases.

Once a critical mass of drug users carries the virus, the epidemic spreads via unprotected sex to non-drug users.
The administration claims that the evidence for the effectiveness of needle exchange is shaky. An official who requested anonymity directed us to a number of researchers who have allegedly cast doubt on the pro-exchange consensus. One of them is Steffanie A. Strathdee of the University of California at San Diego; when we contacted her, she responded that her research “supports the expansion of needle exchange programs, not the opposite.” Another researcher cited by the administration is Martin T. Schechter of the University of British Columbia; he wrote us that “Our research here in Vancouver has been repeatedly used to cast doubt on needle exchange programs. I believe this is a clear misinterpretation of the facts.” Yet a third researcher cited by the administration is Julie Bruneau at the University of Montreal; she told us that “in the vast majority of cases needle exchange programs drive HIV incidence lower.” We asked Dr. Bruneau whether she favored needle exchanges in countries such as Russia or Thailand. “Yes, sure,” she responded.

The Bush administration attempted to bolster its case by providing us with three scientific articles. One, which has yet to be published in a peer-reviewed journal, was produced by an author unknown to leading experts in this field who is affiliated with a group called the Children’s AIDS Fund. This group is more renowned for its ties to the Bush administration than for its public health rigor: As the Post’s David Brown has reported, it recently received an administration grant despite the fact that an expert panel had deemed its application “not suitable for funding.” The two other articles supplied by the administration had been published in the American Journal of Public Health. Although each raised questions about the certainty with which needle-exchange advocates state their case, neither opposed such programs.

Evidence that the administration does not cite leaves little doubt about the case for needle exchange. A study of 81 cities published in 1997 in the Lancet, a medical journal, found that in cities without needle-exchange programs, HIV infection rates among injection drug users rose by nearly 6 percent per year; by contrast, cities that had introduced free-needle programs witnessed a decrease in infection rates of about the same magnitude. Elias A. Zerhouni, the director of the National Institutes of Health, wrote last year that exchange programs “can be an effective component of a comprehensive community-based HIV prevention effort,” and a World Health Organization technical paper agreed that the provision of clean needles and syringes should be “a fundamental component of any comprehensive and effective HIV-prevention programme.” Addressing legitimate methodological questions about the research favoring needle exchange, the WHO reasonably concluded that incomplete scientific evidence does not confer the freedom to ignore the knowledge we do have.

Respecting science does not appear to be the administration’s priority, however. Not only is it refusing to spend federal dollars on needle exchange, but the administration also is waging a campaign to persuade the United Nations to toe its misguided line.

The U.N. Office on Drugs and Crime, which is heavily reliant on U.S. funding, has been made to expunge references to needle exchange from its literature, and the administration is expected to continue its pressure on the United Nations at a meeting that starts March 7. The State Department’s new leadership needs to end this bullying flat-earthism. It won’t help President Bush’s current effort to relaunch his image among allies. And it’s almost certain to kill people.

Wall Street Journal
Bush Ties Money For AIDS Work To a Policy Pledge

By MICHAEL M. PHILLIPS
Staff Reporter of THE WALL STREET JOURNAL
February 28, 2005; Page A3

WASHINGTON—The Bush administration is barring private American AIDS organizations from winning federal grants to provide health services overseas unless they pledge their opposition to prostitution, as part of a broader Republican effort in recent weeks to apply conservative values to foreign-assistance programs.

The White House move comes as Republican lawmakers have been pressing the administration to cut off funds to private organizations that encourage clean-needle programs overseas for intravenous drug users—a group at the center of the AIDS epidemic in Central Asia and other areas. Some also are pressing to ban federal funding of all AIDS organizations that fail to accept the president’s social agenda on such issues as sexual abstinence and drug abuse. At stake are billions of dollars in U.S. funds that private health organizations working in the developing world spend on AIDS programs (See related article.)

Administration officials recently started requiring U.S. AIDS groups seeking federal grants as support for their overseas programs to sign a pledge publicly opposing prostitution. “There is conservative support” for AIDS programs, said Sen. Sam Brownback, a Kansas Republican. “But there are areas of concern...that risk the continued support from a number of conservative members and conservative groups.”

Many AIDS organizations are reluctant to issue a statement condemning prostitution because they work closely with prostitutes on health initiatives such as distributing condoms. The groups say such official stigmatization would increase the women’s isolation, making it harder for them to receive AIDS prevention and treatment services. Many nongovernmental organizations in the AIDS field are critical of the administration moves.
“This is another salvo in the campaign that the administration and its fellow conservatives are undertaking to create more and more litmus tests and blacklists of those they’re willing to do business with,” said Susan Cohen, director of government affairs for the Alan Guttmacher Institute, a private think tank that does research on sexual and reproductive health and favors abortion rights.

The dispute marks an escalation in the decades-long debate over attaching moral strings to U.S. foreign assistance. Until now, that battle has centered largely on whether U.S. aid should go to groups providing abortion counseling and services overseas. The new policy shift regarding prostitution stems from two 2003 laws, one applying to AIDS grants and the other to sex trafficking, which involves luring or forcing individuals into prostitution. The Bush administration had previously applied the requirement only to overseas groups because the Justice Department initially advised that it would be an unconstitutional violation of free speech to demand that American grant applicants support Mr. Bush’s policy. But the Justice Department reversed itself last fall.
The charged debate over morality and AIDS programs has drawn new fuel recently from the practice known in the AIDS field as “harm reduction.” Many AIDS groups—some of them considered liberal on social issues—say the best way to limit the disease is to acknowledge that some people inevitably engage in risky behavior—intravenous drug use, prostitution or multipartner sex, for example—and health workers should try to both discourage those activities and make them less dangerous.

Some conservative groups, on the other hand, urge a just-say-no approach, arguing that making prostitution and intravenous drug use less risky encourages people to engage in them. At a recent congressional hearing, John Walters, the director of the Office of National Drug Control Policy, said, “We have been pretty aggressive with international bodies that have...drifted toward harm reduction, more aggressive than I believe others have been in the past.”

Mr. Bush, who has made AIDS prevention and treatment a centerpiece of his effort to convey a compassionate side to his conservatism, asked Congress for $3.2 billion for international HIV programs for fiscal 2006. Most such spending is channeled through the U.S. Agency for International Development and the Department of Health and Human Services to private organizations and other health groups working in developing nations.
The new strictures from the White House and Congress match proposals of various conservative religious groups that claim credit for helping the president win re-election. Some are now for the first time applying for such grant money.

Janice Crouse, a senior fellow at Concerned Women for America, an evangelical lobbying and advocacy group, says left-leaning groups have long dominated international AIDS programs, and the changes pursued by the administration and Congress aim to redress that imbalance. Ms. Crouse describes the dominant side as a “connected inside group of people who are mostly liberal,” and says, “They have large staffs, they have experts in grant writing, and they’ve had almost exclusive access to government and foundation funding.”

Until last year, CWA had never applied for government funding or ventured across the line between advocacy and hands-on operations. In November, however, the group won a $113,000 State Department grant to teach Mexican church and community leaders to combat sex trafficking. The group hopes to apply for more money to help the Mexicans set up hotlines and shelters for victims of sex trafficking. Some health groups charge that the administration and Republicans are imposing their social agenda on a medical crisis. “Social conservatives inside and outside this administration are going way beyond trying to transform what the government funds to focusing on who the government funds,” Ms. Cohen said.

A major target of congressional Republicans is an institute founded by billionaire investor George Soros, who spent millions of dollars during last year’s presidential campaign trying to defeat Mr. Bush. Mr. Soros’s Open Society Institute supports programs that allow heroin addicts in the former Soviet bloc to swap dirty syringes for clean ones in order to limit the spread of HIV. The group receives some federal funds, though Mr. Soros’s aides say that money isn’t applied to needle-exchange programs.

Marc Wheat, chief counsel to the Subcommittee on Criminal Justice, Drug Policy and Human Resources, says his boss, Indiana Republican Rep. Mark Souder, began investigating Mr. Soros’s group before Mr. Soros became involved in the presidential campaign. “We’ve been concerned about what the Open Society Institute has been doing for a while,” Mr. Wheat said. Under the new antiprostitution requirement, even organizations whose prevention and treatment programs for AIDS have nothing to do with prostitutes must now certify in writing their acceptance of the pledge or face a funding ban. “If you’re trying to go after the spread of HIV, it is not inconsistent to be concerned about issues of prostitution,” said Kent Hill, USAID’s acting assistant administrator for global health.

Some private organizations expressed dismay at the new policy. “I’m sure there are good intentions motivating the implementation of this policy, but...we feel very concerned that this will fuel stigma against sex workers,” said Geeta Rao Gupta, president of the International Center for Research on Women.

U.S. officials say some AIDS grant applicants have signed the pledge, but the administration won’t identify them. While the administration has focused on prostitution, Republicans in Congress are working to yank federal funding from private groups that advocate or discuss clean-needle exchange programs. Leaders of that effort include Reps. Souder and Tom Davis, the Virginia Republican. Sen. Brownback laid out his goals in a strategy memo for allies this month that called for a ban on USAID grants to organizations that don’t fully support the president’s views on issues ranging from drug use to sexual abstinence.

“How many lives have been saved from this totally preventable disease by the ‘disease control’ efforts of these longstanding and aggressive family planners, drug legalizers and pro-prostitution groups?” the memo asked rhetorically. The Brownback memo singled out Population Services International, a Washington-based nonprofit organization involved in family planning and AIDS work abroad, for sponsoring a sexually suggestive condom ad on Kenyan television, even though the ad itself wasn’t funded by the U.S. government.

PSI says that sexually provocative ads are the most effective in getting people’s attention and persuading them to practice safer sex. The memo also accused groups associated with Mr. Soros of using USAID funds to hand out clean needles in Eastern Europe and Asia. USAID policy forbids using federal money to finance needle exchanges.
Aryeh Neier, president of Mr. Soros’s Open Society Institute, said it doesn’t take a position on drug legalization or use federal money to finance its needle-exchange programs in Central Asia. The institute uses some USAID money to discourage drug use, but is largely funded by $400 million a year from Mr. Soros, Mr. Neier said.

Write to Michael M. Phillips at michael.phillips@wsj.com