Harm reduction and HIV in the United States: a review of the history, efficacy, and future directions

Since the emergence of HIV in the United States in the 1980s, efforts have been made to reduce the risk of virus transmission by encouraging alterations in the behaviors that perpetuate its spread. The advent of harm reduction campaigns aimed towards injection drug users (IDU) represents one such effort, but these methods have historically not been readily accepted due to the national attitudes regarding illicit drug use. IDU constitute a population for whom the impact of HIV continues to be extreme. It is well established that this population engages in risk behaviors at a level exceeding the non-IDU population, while simultaneously receiving an inadequate degree of health and prevention services. The prolonged insufficiency of services targeting IDU has contributed a substantial morbidity and mortality burden to an epidemic of significant public health importance around the globe. Recently, there has been an upsurge in the support of employing needle and syringe exchange programs (NSEP) and housing-first (HF) models as measures to prevent HIV transmission. A favorable attitude towards these programs and the people they serve, however, has yet to be widely adopted by US policymakers and mainstream society. This review of primary and secondary literature examines the challenges faced in the establishment of harm reduction programs in the United States, and considers the evidence of the efficacy of such programs as they relate to HIV risk behaviors and transmission, drug injection behavior, and related health outcomes. It was concluded that despite difficulties in linking the NSEP and HF harm reduction approaches directly to HIV incidence reduction, there is substantial evidence in support of reduced HIV risk behavior associated with these programs. The complexity of the numerous interacting lifestyle factors contributing to HIV risk and transmission in IDU poses a challenge to researchers, and there is limited cost-effect analysis available. As evidence supporting the association of harm reduction programs with a decline in some of the harmful lifestyle factors accumulates, however, there is room for optimism regarding widespread employment of such programs in the future