The magnitude of the epidemic and the severity of the health consequences posed by HIV infection within the population of injection drug users, their sexual partners, and their offspring are not at issue. What is being strenuously debated in the United States is whether certain AIDS prevention programs, directed at this highly vulnerable population, should be implemented with the assistance of the federal government.
Needle exchange programs, in which used needles are exchanged for new, sterile ones, are widely used in many industrialized countries (e.g., France, the Netherlands, Great Britain, Australia, Canada) as part of public health efforts to reduce the spread of HIV and other blood-borne infections among drug users, their sexual partners, and the general population.
In the United States, although approximately 75 needle exchange programs have been initiated in 55 cities, many are small and the programs have not yet been endorsed by the federal government as a viable intervention for AIDS prevention. The debate in the U.S. Congress has been intense between members who are particularly interested in AIDS prevention initiatives and members who are concerned that the use of federal funds to implement needle exchange programs would have the unintended effect of increasing injection drug use in those communities already plagued by drug abuse. To date, the impasse between these two camps has blocked any use of federal funds for needle exchange program services.
Indeed, the use of appropriated funds by the Department of Health and Human Services to support needle exchange programs has been specifically prohibited or restricted by the language contained in a series of statutes2 enacted by Congress since 1988. The U.S. General Accounting Office (1993) recently analyzed the legal authority applicable to the federal support of research and services related to needle exchange. It concluded, primarily on the basis of language contained in section 514 of the "General Provisions" of the 1993 Departments of Labor, Health and Human Services, and Education, and Related Agencies Appropriation Act, that, although the Department of Health and Human Services is restricted from using certain funds to support the funding of needle exchange programs directly, it does have the authority to conduct demonstration and research projects that involve the provision of needles. Nevertheless, the ban on federal support for needle exchange program services still remains in effect: "… unless the Surgeon General of the United States determines that such programs are effective in preventing the spread of HIV and do not encourage the use of illegal drugs" (U.S. Congress, 1992a). This current prohibition applies regardless of the legal standing of the programs operating in individual states. As a result, needle exchange programs across the country cannot use