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INTRODUCTION
DESPITE eight major national reports affirming the benefits of needle exchange programs (NEPs) in preventing the spread of HIV/AIDS (1-8), they remain controversial with legislators and the general public (9). In contrast, a wide swath of public health professionals maintains that conclusive scientific evidence has proven that NEPs: 1) prevent the transmission of HIV, and 2) do not increase drug use. A recent statement by then-Surgeon General David Satcher captures the prevailing position among public health authorities: "After reviewing all of the research to date, the senior scientists of the Department and I have unanimously agreed that there is conclusive scientific evidence that syringe exchange programs, as part of a comprehensive HIV prevention strategy, are an effective public health intervention that reduces the transmission of HIV and does not encourage the use of illegal drugs" (10). With such apparently compelling scientific evidence, one wonders why NEPs have not gained greater public support. In this paper, we analyze the arguments of proponents and opponents of needle exchange and recommend an alternative framework for advancing the cause of HIV/AIDS prevention by means of NEPs.
We begin with a brief review of the status of needle exchange programs in Massachusetts where every popular referendum seeking public approval for the opening of new local NEPs in Massachusetts has been defeated. We then examine possible reasons for the failure of scientific evidence to sway public attitudes. The paper raises the question of whether exclusive reliance on empirical research represents the most appropriate response to what we see as primarily normative, ethical concerns voiced by opponents to needle exchange. Our analysis is based on the policymaking framework developed by Stone (11), who argues that the process of policymaking is rarely reducible to questions of empirical fact. Rather it inevitably entails struggle over the meaning and significance that various policy options hold for collective community life. Stone contends that disputes over the "enduring values of community life" drive controversies over public policies. This paper identifies four themes that frame the opposition's values and ensuing ethical concerns about needle exchange. We conclude with recommendations for future directions in this critical public health policy debate.
NEEDLE EXCHANGE IN MASSACHUSETTS
In a continually evolving environment, NEPs operated in an estimated 36 states at the...