Are we anywhere near there yet? The state of harm reduction in North America in 2017

Harm reduction and HIV/AIDS in North America The emergence of the new disease, AIDS (first reported as a clinical syndrome in the USA in 1981), was the principal reason for the birth of harm reduction in the mid to late 1980s. The first appearance of clinical evidence of AIDS was based on the appearance of opportunistic infections among young populations not normally associated with such infections—e.g., Kaposi’s sarcoma and other symptoms of immune disorders, normally mostly seen among older populations. The fact that these first cases were among young gay men hospitalized in Los Angeles [1, 2] became the basis of the initial professional and popular conceptions of AIDS and the primacy of sexual risk, especially for gay men. We now know that AIDS cases and deaths were already occurring among heterosexuals of both sexes and newborns, but this occurred without any awareness of them at that time. In addition, we now have ample evidence that many HIV infections were already occurring among people who inject drugs (PWID) in the USA and probably in parts of Europe as well. These injecting drug-using populations had well-documented outbreaks of Pneumocystis carinii pneumonia and other opportunistic infections seen in PWID in NYC as early as 1978, but not recognized as AIDS at the time (e.g., [3, 4] Friedland, Drucker et al.). In the years following, continuing reports about AIDS cases and deaths among PWID appeared, with one of the first published in NEJM as early as December 1981 [5]. But little attention was paid to the role of drug injecting and heroin dependence in this new and mysterious disease—at the time still frequently called GRID (gay-related immune disorder) and widely associated in the public mind with male to male sex as the primary cause of the early epidemic. Human immunodeficiency virus (HIV), the virus responsible for AIDS, was first recognized in 1983–1984; the first tests which could reliably identify HIV antibodies in humans became widely available in early 1985. With this new capacity for diagnosis of individual cases came the start of epidemiological documentation of the wide spectrum of at-risk populations for HIV, including pregnant women, newborn infants, dialysis patients, and hemophiliacs. With this rapidly mounting evidence of the scale and global extent of this new epidemic, the initial concerns about AIDS did not immediately focus on cases related to PWID, perhaps the most marginal group at risk, where criminalization and stigma kept them “in the closet.” Nonetheless, as this relationship become clear, many in the drug treatment and policy communities assumed that this aspect of AIDS would produce more public understanding of this new aspect of the clinical and public health significance of IV drug use and lead to steps to address HIV in that field. As early as 1984, the Centers for Disease Control (CDC) issued strong advice to PWID to stop sharing needles and syringes [6]. There was however widespread recognition that without the provision of sterile injecting equipment, this advice was unachievable for many PWID. By that year, however, the first needle and syringe programs (NSPs) had begun in the Netherlands in response to outbreaks of hepatitis B virus infection, providing a model of a most effective public health intervention to stop the spread of HIV among and from PWID. By 1993, the evidence of the effectiveness and safety of NSP in prevention of HIV transmission was more than convincing (Lurie et al., 1997), but despite this, NSPs were not widely implemented in the USA, at a great cost in lives [7]; indeed, many localities in the USA prosecuted those engaged in running NSPs. From the outset, Canada had a very different public health response, with very different outcomes and initiatives, including the * Correspondence: [email protected]; [email protected] College of Global Public Health, New York University, New York, USA Full list of author information is available at the end of the article