Looking back, it is perhaps unfortunate that the first major drug abuse-related policy initiative advocated by the now mobilized “AIDS community” was syringe exchange. While of incontrovertible effectiveness in reducing the transmission of HIV and other blood borne infections among injecting drug users (see, for example, Jones and Vlahov, 1998), syringe exchange galvanized the opposition of drug treatment providers aligned with conservatives against the AIDS community. The same issue highlighted a second division—between some prominent African-American community leaders and the then predominantly white AIDS community.
This early fissure helped to allow the AIDS community to evolve into the AIDS services sector without inclusion of drug treatment providers (or, for many years, consideration of needs of drug users beyond sterile syringes). The largely abstinence-based substance abuse treatment system, in turn, found itself to be an isolated advocate for “drug treatment on demand” as an alternate approach to prevention of HIV transmission among injecting drug users. Some AIDS advocates responded hostilely to this call for enhanced drug treatment capacity as they viewed it as undermining advocacy for syringe exchange. This debate helped ossify two systems that were each already isolated from the mainstream health and social services system in opposition to one another.
While the field of HIV prevention has more explicitly addressed the prevention of transmission through injecting behaviors (though, not the integrated needs of injecting drug users for both syringe-related and sexual risk reduction), the HIV care system has remained far less responsive to the special needs of HIV-infected substance users than their prevalence would suggest. Examples abound: the first Ryan White Comprehensive AIDS Resources Emergency (CARE) Act authorized by Congress in 1990 mandated 11 categories of membership on the Title I planning councils, but did not include drug treatment providers, representatives from state substance abuse agency, or consumers who were substance users. In the 1996 reauthorization, a requirement for one representative of drug treatment providers was added. In the 2000 version, additional language was added about the need for the consumer representatives (as well as services allocations) to reflect the epidemiology in an area. As our past work has documented, Ryan White planning councils have largely not assessed, planned for, or allocated funds for the special needs of active substance users, including for substance abuse treatment, nor have they addressed particular barriers in receipt of HIV care (Finkelstein et al., 1999, 2001). As the following report will demonstrate, the conceptual divide between substance use and HIV has permeated research, data collection, planning, financing, and service delivery. Unfortunately, the place where complete integration and synthesis remains is within the estimated 360,000 individuals in the United States currently coping with both issues.