The AIDS epidemic is far from over.
Although prevention efforts are succeeding in the gay community, the human immunodeficiency virus is claiming large numbers of new victims among intravenous drug users, their sexual partners and children born to them.
One sign of the changing nature of the crisis is that drug-related AIDS cases comprised 48 percent of all new AIDS cases in Maryland last year, up from 27 percent in 1986.
The National Commission on AIDS, an advisory group, brought this problem into focus last week with a report urging a bold step: Give addicts legal access to needles so they'll be less likely to share them and spread the AIDS virus.
State laws prohibit possession of drug paraphernalia. In Maryland, addicts think twice before carrying around their own needles. "Because you're taking a chance getting busted," said Tony, an ex-addict and Baltimore resident who doesn't want his last name used.
But the commission's report received a cool reception. Federal and state officials are loathe to try something that appears to condone drug use. And yet, as the number of drug-related AIDS cases continues to mount, so will the pressure to act.
Last year there were 14,000 new adult AIDS cases in the United States associated with intravenous drug use, more than double the total of 1987. More cases will follow: As many as 50 percent of the addicts in some cities are believed to be infected with the AIDS virus. In Baltimore, researchers tracking a group of 2,200 addicts say 25 percent test positive.
These figures underscore what commission chairman Dr. June E. Osborn calls the "flash-fire potential of HIV transmission through injection drug use."
Reaction to the commission's report focused on its endorsement of needle exchanges in which addicts turn in used needles for new ones, usually as part of a program that encourages them to obtain drug abuse treatment. Such programs run in a few American cities, including Tacoma, Wash. and New Haven, Conn., several European countries and Australia.
"These programs have demonstrated the ability to get substance abusers to change injection practices," the commission said. "Most significantly, these programs, rather than encouraging substance use, lead substantial numbers of substance users to seek treatment."
The report was praised by private organizations such as the AIDS Action Council in Washington and HERO, a Baltimore group.
"I think it's safe for me to say that HERO strongly supports anything that will help discourage the sharing of needles by addicts," said Susan Kromholz, deputy director.
But city, state and federal public health officials said the commission's verdict on needle exchange programs is premature. They expressed caution even in the face of added evidence from a study released last week by Yale University that found New Haven's program had reduced new infections by 33 percent.
"There is not an awful lot of data to show, at least any I have heard, this is the way to go," said Elias A. Dorsey, acting Baltimore health commissioner.
David Vlahov, an assistant professor at the Johns Hopkins School of Hygiene and Public Health who is conducting the study of Baltimore addicts, is also skeptical, but believes the time is right for a "scientific evaluation" of needle exchanges.
"I think there's enough information suggesting it could be helpful. . . . On the other hand there are enough concerns that there might be negative impact associated with this that we should have some caution in terms of moving forward."
Although ambivalent about needle exchanges, public health experts strongly support the commission's recommendation that drug treatment programs be expanded. The commission condemned the Bush administration for emphasizing a criminal justice approach to the drug problem and failing to recognize the link between drug use and AIDS.
There's also wide agreement on the obvious: Current efforts to ++ stem drug-related AIDS infections are not working well.
In Baltimore, HERO's outreach workers dispense condoms and give addicts bleach to clean their needles, efforts which have produced small successes. Programs such as Man Alive, which treats former heroin users, also provide condoms and AIDS counseling. But prevention programs, while effective with the gay population, haven't worked as well with drug users.
"The gay community has done a very effective job in educating themselves and putting into place education and prevention programs," observed Dan Bross, executive director of the AIDS Action Council, which represents more than 500 community groups. "There are not community-based organizations that are springing up to take care of injection drug users."
Fearing the law, often transient, addicts are a moving target for those who are trying to help them. But addicts and those who deal with them are quick to rebut the notion that they don't care about their health.