As discussed by Mitty and colleagues,1 the proportion of HIV infections associated with injection drug use (IDU) has dropped dramatically across the United States, including the northeastern portion of the country. In the early days of the epidemic, it quickly became clear that where there was a large population addicted to illegal substances administered by injection, the transmission of HIV infection would be high. Shared injecting equipment is one of the most efficient vectors of this disease, given the lack of disinfection among users. While many have been willing to write off injection drug users as social outcasts, incapable of making positive decisions, advocates were quick to point out that a person with an addiction had the capacity to take protective steps. The concept of harm reduction, ie, reducing the risks associated with a harmful activity (the equivalent of putting seat restraints into automobiles), gained credibility. Creative thinkers from the drug treatment and infectious disease communities began describing outreach programs that taught safer injection practices and supplied clean syringes. The challenges to make such programs routinely available across the country included the corresponding increased interest by state legislatures to introduce and consider passing laws to limit or prohibit access to drug use paraphernalia and Congress barring federal agencies from providing economic support for these programs. What many anti-syringe programs often failed to acknowledge was the associated health education and treatment access that could be provided to injection drug users-both of which are considered essential parts of a good program. What the data now show is that despite community reservations, legislative opposition, and funding restrictions, something has worked. In 2003, the CDC reported a reduction of 42% in the rate of HIV infection associated with IDU, based on data from 25 states.2 The Northeast, including New York City and Hartford, Conn, which had very high infection rates in the early years, were excluded from the CDC report because of differences in data sources. Mitty and colleagues approach the question of what has happened in this high-incidence region using multiple data sources and seeking to arrive at best estimates of the changes in infection rates, looking at a slightly later period than that reported by the above-mentioned CDC report. No matter what perspective is used, the data are consistent. Drug users are not, at present, contributing to the burden of HIV transmission at the rate they once did. Mitty and colleagues’ closing reminder, however, is critical: the fact that the rates have gone down does not justify the assumption that the programs that serve this population can be stopped or even downsized. As with any health promotion activity that supports sustained behavior change in a population at risk, continuing access to information and programmatic services is essential to sustaining the progress made. We’ve done something right. Let’s be sure to keep on doing it! Kristine M. Gebbie, DrPH, RN Joan Grabe Dean (acting) Hunter-Bellevue School of Nursing City University of New York New York References 1. Mitty JA, Bazerman LB, Selwyn K, et al. Decrease in the proportion of injection drug use–related HIV/AIDS in Massachusetts, New York, Connecticut, and Rhode Island. AIDS Reader. 2008;18:000-000. 2. Centers for Disease Control and Prevention. HIV diagnoses among injection-drug users in states with HIV surveillance-25 states, 1994-2000. MMWR. 2003;52:634-636.
