Archival Content: 1999-2005
HIV Prevention Among Drug Users:
Laws, Regulations, and Practices
As seen above with adolescents, the nature and scope of HIV prevention initiatives for drug users are shaped by various laws and regulations. This section examines some of the more important laws and regulations for prevention planners and program managers to consider when planning HIV prevention programs, including prescription and paraphernalia laws, regulations protecting the confidentiality of clients in drug treatment, and HIV and AIDS reporting requirements.
These laws have been enacted primarily to discourage illicit drug use. They impose severe restrictions on the purchase and possession of equipment used to administer drugs.
These and other laws, such as "drug-free zones" that prohibit persons convicted of a drug-related crime from entering certain locations during certain times of the day, are considered by many advocates of HIV risk reduction to be major barriers to obtaining and carrying sterile syringes. According to a report on syringe exchange by the Institute for Health Policy Studies, University of California, San Francisco, these laws contribute to continued syringe sharing reported among IDUs (Lurie et al., 1993). Many groups have called for the repeal of these laws, including the National Commission on AIDS and the National Research Council (National Commission on AIDS, 1991; Normand, et al., 1995), as well as the recent NIH Consensus Development Conference (NIH , 1997) and many communities have changed their laws. Case Example 4.3 provides a description of changes made in Connecticut's laws. However, access to sterile syringes continues to evoke debate as states and communities review their policies in light of drug control and HIV prevention efforts.
Changes in Connecticut's Prescription and Paraphernalia Laws
In 1990, New Haven, Connecticut, instituted a needle exchange program. The program included a syringe tracking and testing system that was designed to monitor the extent of syringes exchanged and the presence of HIV in used needles. This system generated data from which an estimate of HIV transmission could be determined. These findings suggested that needle exchange reduced the HIV infection rate among injecting drug users in the community by 33 percent. In response, the Connecticut legislature continued funding the New Haven program, expanded services to two other cities, and legalized over-the-counter pharmacy sales and possession of syringes. It also led to educational programs for pharmacists and changes in prescription and paraphernalia laws that had restricted the purchase and possession of injecting equipment.
Source: Normand et al.,1995
Both law enforcement officials and pharmacists are considered key "gatekeepers" who can influence the ability of drug users to obtain and possess sterile syringes. Because of their roles and responsibilities in enforcing prescription and paraphernalia laws, law enforcement officials and pharmacists often come into conflict with advocates of syringe exchange and other similar strategies to reduce the risk of HIV transmission among drug users. At the same time, they are among the professionals and community leaders who can make valuable contributions to the planning and implementation of community-wide HIV prevention efforts for IDUs. Effective community-based HIV prevention programs require their ongoing support and participation.
Law enforcement officials
In general, law enforcement officials are considered to be "tough on drugs." In addition to recognizing that many risk reduction measures, such as syringe exchange programs, are in violation of prescription and paraphernalia laws, many believe that these types of programs will result in: (1) a rise in the number of needles in circulation in a community; (2) an increase in crime and in other drug-related social ills; (3) an increase in the number of police officers receiving needle sticks; and (4) a decrease in the amount of attention devoted to addressing the underlying causes of addiction. Case Example 4.4 demonstrates the important role that the attitudes and behaviors of law enforcement personnel play in the use of sterile syringes by IDUs.
Fear of Arrest Prevents Sterile Syringe Possession
In a study conducted among 147 IDUs in Eastern Connecticut, only 30 percent reported that they normally carry syringes, primarily due to the fear of arrest. About 25 percent of drug-related arrests in this part of the state included drug-paraphernalia possession charges, in spite of the change in Connecticut law in 1992 to allow the legal possession of up to 10 syringes.
Source: Grund et al.,1995.
Pharmacists function as gatekeepers for IDUs to obtain syringes because they are a principal source of sterile syringes. For example, in Connecticut after the 1992 law change permitting the sale of up to 10 syringes without a medical prescription, over 80 percent of pharmacies sold nonprescription syringes and drug users reported significant increases in their purchase of syringes from a pharmacy. In states that have prescription laws, pharmacists have to be alert for falsified prescriptions. In some, pharmacists who knowingly sell syringes to customers for the purpose of injecting illicit drugs can have their licenses suspended.
Inconsistencies in practices among pharmacists are documented even in states where no prescription laws exist. In a 1991 study, for example, less than 15 percent of pharmacists surveyed in a southern state reported that they sold any syringes (Compton et al., 1992). The remainder said they sold syringes only to those with a prescription, even though one was not required. Many pharmacists reported requiring each customer purchasing a syringe to sign for it as an indication that the intended use was for legitimate medical reasons. Pharmacists' discretion over the sale of syringes may affect equal access among IDUs , even where laws do not specifically prohibit sales, as shown in Case Example 4.5.Case Example 4.5
Pharmacist Practices Related to the Sale of Syringes
The following results were reported from a study in which two male research assistants (one white, one African American) attempted to buy needles in 33 pharmacies:
Source: Compton et al.,1992.
The American Pharmaceutical Association has officially endorsed syringe exchange as a viable part of any comprehensive approach to HIV prevention that includes outreach, counseling, treatment, and community involvement in program design (Normand et al., 1995). The Association believes pharmacists are in a unique position to make a significant contribution to HIV prevention efforts by providing access to sterile syringes.
This position is not universal however, and debates regarding the appropriateness of various HIV risk reduction strategies occur. During a 1995 panel workshop on syringe exchange and bleach distribution programs sponsored by the National Research Council and the Institute of Medicine, the National Association of Chain Drug Stores (composed of pharmacy retailers) and the National Pharmaceutical Association (composed of professional pharmacists) expressed concern over: (1) disposal of used needles and syringes; (2) liability for occupational exposure of workers; (3) adherence to federal rules and regulations; (4) personal discretion; and (5) the high cost of complying with state and federal regulations (Normand et al., 1995).
A number of federal, state, and local laws have been enacted to protect the confidentiality of those receiving treatment for drug abuse, HIV, sexually transmitted diseases (STDs), and general medical or mental health problems. However, medical care providers are required by law to report to their state public health departments all cases of individuals diagnosed with AIDS, some STDs, tuberculosis, and other infectious diseases. All 50 states now require reporting of AIDS cases by name to the public health department, and 26 states require named reporting of those testing positive for HIV antibodies (CDC, 1995). Reporting drug use, however, is a different matter.
Confidentiality of Drug Abuse Treatment Patient Information
In an effort to encourage participation in drug treatment programs, federal regulations that protect the identities of persons in alcohol and drug treatment were enacted in the early 1970s, implemented in 1975, and revised in 1987 by the Department of Health and Human Services (Title 42, Part 2, Code of Federal Regulations). Recently, Congress reaffirmed and reorganized the original statutes by merging them into Title 22 of the Public Health Service Act. This law ensures that strict federal confidentiality standards are in place for clients in treatment. It also prohibits the disclosure, except under limited conditions (see Table 4.2), of information about patients by programs receiving federal assistance that allows them to provide treatment, counseling, assessment, and referral services for people with drug problems.
All state and local laws that address the confidentiality of patients in drug treatment are superseded by this federal confidentiality law, unless state laws are more restrictive. Although there are exceptions, even a court order is insufficient for disclosing information without prior notification of the program and the client. Drug treatment programs that offer on-site HIV antibody testing, therefore, may seem to face a dilemma of complying with required HIV/AIDS reporting and limiting disclosure of information about clients in drug treatment. However, this does not necessarily have to be the case. The law does not specifically prohibit the release of information about a client's HIV/AIDS status, even though the release of information that would directly or indirectly identify an individual as a drug treatment client is restricted. Table 4.2 lists those circumstances where disclosure of information about a patient's drug treatment is permitted.
Confidentiality and Protection against Discrimination of People Living with HIV/AIDS
Since the early years of the AIDS epidemic, the social stigma and the threat of discrimination against persons with AIDS has been clearly recognized. Because of this discrimination, many states have passed special laws to protect against the unwarranted release of information about a person's HIV status. These laws are intended to promote fair treatment and make it more likely that persons at risk will accept HIV testing and early intervention.
In addition to these laws, broad protections against discrimination are provided by the 1990 Americans with Disabilities Act (ADA). The ADA prohibits discrimination in housing, public access, and employment against people who have or are perceived to have a disability. Under the act, those who are infected with HIV or diagnosed with AIDS are considered "people with disabilities."
The ADA requires drug treatment providers to make "reasonable accommodations" to ensure that individuals with HIV/AIDS can participate in and benefit from treatment services. Such accommodations include arranging home administration of methadone, reducing the number of required weekly therapeutic sessions, and making special living arrangements in a residential setting in order to curb opportunities for exposure to infectious disease. In addition, the act makes it illegal to require HIV testing as a condition for admission to drug treatment.
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