Book Review

Preventing HIV Transmission: The role of sterile needles and bleach

N Engl J Med 1997; 336:1035-1036April 3, 1997

Article

Preventing HIV Transmission: The role of sterile needles and bleach
Edited by Jacques Normand, David Vlahov, and Lincoln E. Moses. 334 pp. Washington, D.C., National Academy Press, 1995. $37.95. ISBN: 0-309-05296-3

Most health workers, including many who care for injection-drug users or are involved in programs to prevent transmission of the human immunodeficiency virus (HIV), do not know the steps used by injection-drug users to prepare and inject illegal drugs. The National Academy of Sciences panel report, Preventing HIV Transmission: The Role of Sterile Needles and Bleach, is an excellent introduction to the world of injection-drug users and can help general readers understand how to prevent the transmission of blood-borne infections from one injection-drug user to another. Because about half of all cases of hepatitis C virus and one third of all cases of AIDS in the United States are directly or indirectly associated with injection-drug use, effective preventive measures for injection-drug users are of obvious importance.

The injection-drug user's syringe and needle are contaminated by blood when blood is drawn into the syringe to verify that the needle is in a vein (known as “registering” among injection-drug users). That blood may contain HIV or other infectious blood-borne agents. The use of the blood-contaminated syringe and needle by another injection-drug user allows the direct transfer of blood and blood-borne agents to another potentially susceptible person. A less widely recognized mechanism by which blood and blood-borne agents are transferred occurs when the contaminated syringe is used to draw up water to dissolve drugs or distribute drug solution among injection-drug users. Blood from the syringe can contaminate the equipment and water used to prepare illegal drugs for injection, including containers (“cookers”) used to dissolve drugs, small pieces of cotton or cigarette filter (“cottons”) used to filter out particles when the drug solution is drawn into the needle and syringe, and water used to dissolve drugs and rinse out syringes.

The main factor associated with HIV infection among injection-drug users is the practice of sharing equipment for preparing or injecting drugs. The report's key conclusion emphasizes the preventive value of sterile needles and syringes: “For injection drug users who cannot or will not stop injecting drugs, the once-only use of sterile needles and syringes remains the safest, most effective approach for limiting HIV transmission.” Furthermore, the report implicates “the restricted availability of sterile needles and syringes” as a cause of the sharing of syringes and drug-preparation equipment, which fosters the transmission of blood-borne infections.

Injection-drug users' access to sterile needles and syringes is restricted by two types of laws. One type, found in nine states, requires the presentation of a prescription for syringes as a condition of their sale. The second type is the drug-paraphernalia laws, which establish criminal penalties for the distribution and possession of a wide variety of equipment used to prepare and use illegal drugs, including syringes and needles. Drug-paraphernalia laws exist in most states, and according to the report, these laws “were designed to decrease the prevalence of injection drug abuse, but they also inhibit users from carrying their own supply of needles and syringes and thus unwittingly contribute to the sharing of contaminated ones.”

The report advocates the repeal of laws that restrict the availability of syringes. “Legislative bodies should remove legal sanctions for the possession of injection paraphernalia. Appropriate legislative bodies should repeal laws in the nine states that require a prescription in order to purchase injection equipment.”

The National Academy of Sciences Panel on Needle Exchange and Bleach Distribution Programs was created by Congress in part to provide a scientific review of available data to help resolve the acrimonious policy debates surrounding two strategies to prevent HIV infection associated with injection-drug use: the use of bleach to disinfect syringes (and other drug equipment) and the exchange of sterile needles and syringes for used, blood-contaminated ones (needle-exchange programs). The panel included distinguished scientists from a variety of disciplines. Some members of the panel had previously supported needle-exchange programs, and others had opposed them.

In this report, the preventive measure of providing bleach to injection-drug users to disinfect syringes and needles receives a mixed review. Bleach disinfection is recommended only when injection-drug users do not have sterile syringes and are reusing blood-contaminated needles and syringes. Although disinfection with bleach can substantially reduce the risk associated with the reuse of blood-contaminated syringes, the multistep disinfection procedure (sequentially filling the syringe with water and household bleach) is not always reliably followed by injection-drug users.

Whether needle-exchange programs are an effective measure for preventing HIV infection and what effect they may have on drug use were central questions considered by the National Academy of Sciences panel. Congress has blocked the use of federal funds to support needle-exchange programs unless they can be shown to prevent HIV transmission without increasing drug use.

On the basis of the “pattern of evidence,” the panel found that “well-implemented needle exchange programs can be effective in preventing the spread of HIV and do not increase the use of illegal drugs.” Therefore, the panel recommends that “the Surgeon General make the determination . . . necessary to rescind the present prohibition against applying any federal funds to support needle exchange programs.”

Whether the unanimous findings and recommendations of this panel of distinguished scientists will help resolve the often emotional debate on the merits of needle-exchange programs remains to be seen. As of December 1996, the congressional ban on funding such programs was still in effect. In any case, readers interested in the interwoven problems of illicit drug injection and HIV infection and AIDS should find this report pertinent and clearly written.

T. Stephen Jones, M.D.
Centers for Disease Control and Prevention, Atlanta, GA 30333