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The impact of the needle and syringe-exchange programme in Amsterdam on injecting risk behaviour
... Informes desde farmacias también de L'Hos-pitalet de Llobregat muestran su participación en la entrega y recogida de jeringuillas, dispensación de metadona y realización de tests rápidos para la determinación de anticuerpos frente al VIH. (5) En Mataró, desde 1993 existe también un Programa de Intercambio de Jeringuillas en el marco del Plan Municipal de Drogodependencias del Ayuntamiento de Mataró. ...
... Informes des de farmàcies també de L'Hospitalet de Llobregat mostren la seva participació en el lliurament i recollida de xeringues, dispensació de metadona i realització de tests ràpids per a la determinació d'anticossos en front del VIH. (5) A Mataró, des del 1993 existeix també un Programa d'Intercanvi de Xeringues en el marc del Pla Municipal de Drogodependències de l'Ajuntament de Mataró. ...
... Contribution of the pharmacies has been interesting, some of them performing harm reduction strategies for many years. Also Hospitalet de Llobregat pharmacies report their participation in the delivery and collection of syringes, methadone dispensing and carrying out rapid tests for the detection of antibodies against HIV (5). ...
IV JORNADA DE REDUCCIÓ DE DANYS A CATALUNYA
COMUNICACIONS
Herramientas para el análisis ético de los fenómenos NIMBY / Eines per l’anàlisi ètica dels fenòmens NIMBY / Tools for ethic analysis of phenomena NIMBY
Ibogaína: una alternativa humanitaria al problema de la cronificación de adictos a sustancias / Ibogaïna: una alternativa humanitària al problema de la cronificació d’addictes a substàncies / Ibogaine: a humane alternative to the problem of developing chronic substance abusers
¿Y ahora qué? / I ara què? / What now?
Menores y reducción de daños / Persones menors en programes de reducció de danys / Minors and Harm Reduction
Guía de buenas prácticas en los Programas de Intercambio de Jeringas
/ Guia de bones pràctiques en els Programes d’Intercanvi de
Xeringues / Guide to good practice in Syringe Exchange Programs
22
Consumo de sustancias y otras conductas de riesgo en prisión /
Consum de substàncies i altres conductes de risc a presó /
Substance use and other risk behaviors in prison
24
Evaluación del Programa de intercambio de jeringuillas del Centro
Penitenciario de Brians 1 (2007 - 2012) / Evaluació del Programa
d’intercanvi de xeringues (PIX) del Centre Penitenciari de Brians
1 (2007 - 2012) / Evaluation needle exchange program in Prison
Brians 1 (2007 -2012)
26
REVISIÓ
Programa de intercambio de jeringas en prisiones / Programa d’intercanvi
de xeringues a presons / Needle exchange programs in prison
28
GLOSSARIO / GLOSSARI / GLOSSARY
... The sharing of needles and syringes for injecting drugs has been found to be related to multiple drug use (5,6), younger age (7,8), homelessness (9,10), cocaine use (including injecting) (11), injecting drug use by a regular partner (9) or by peers (12), drug craving (13), little experience with injecting (13), and frequency of injecting (14). Both in Amsterdam and elsewhere, drug users who take advantage of SEs report lower levels of sharing than users who do not avail themselves of the SEs (2,8,(14)(15)(16). ...
... The sharing of needles and syringes for injecting drugs has been found to be related to multiple drug use (5,6), younger age (7,8), homelessness (9,10), cocaine use (including injecting) (11), injecting drug use by a regular partner (9) or by peers (12), drug craving (13), little experience with injecting (13), and frequency of injecting (14). Both in Amsterdam and elsewhere, drug users who take advantage of SEs report lower levels of sharing than users who do not avail themselves of the SEs (2,8,(14)(15)(16). Can this difference in fact be attributed to the access to syringes provided by SEs? ...
... Results from another Amsterdam study (3,8) suggest that users who regularly exchange needles and syringes for new ones, when compared with other IDUs, inject more frequently, for a longer period, and are more often in contact with methadone programs. In the United Kingdom, SE clients were found to be especially older, longer term injectors (2). ...
To enhance the prevention of human immunodeficiency virus infection, factors related to regular participation in the Amsterdam Syringe Exchange and the borrowing of syringes were studied in 131 HIV-seronegative injecting drug users in a 1989-90 survey. A total of 29 percent of the users reported borrowing syringes, that is injecting drugs at least once in the past 4-6 months with a needle or syringe previously used by someone else. Users at increased risk of borrowing are previous borrowers, long term moderate-to-heavy alcohol users, current cocaine injectors, and drug users without permanent housing. Regular clients of the syringe exchange, when compared with other injecting drug users, were found more often to be frequent, long term injectors. They borrowed slightly less often than other users, but this was not statistically significant, even after controlling for frequency of injecting or other potential confounders. The results suggest that, 5 years after the start of the Amsterdam Syringe Exchange, drug use characteristics govern an individual injecting drug user's choice of exchanging or not exchanging syringes. The conclusion is that it seems more important to direct additional preventive measures at injecting drug users with an increased risk of borrowing rather than at users who do not participate in the syringe exchange or who do so irregularly.
... This policy focuses on the prevention of drug use and on the limitation of harm to users and society by offering specialized services to drug users, and is often referred to as "harm reduction" policy. One of the most famous examples of harm reduction is the syringe-exchange program with injecting drug users, which originated in 1984 in Amsterdam as a preventive measure to stop the spread of the hepatitis B and the HIV virus among injecting drug users and has been adopted worldwide since for the prevention of all blood borne diseases, including hepatitis and AIDS (Hartgers et al., 1989). Since then, many other types of harm reduction have been developed ranging from test services for recreational drug users (Spruit, 2001) to heroin assisted treatment and safe injection rooms for chronic, often treatment refractory drug addicts (Blanken et al., 2010;Kerr et al., 2007). ...
... However, evidence for the effectiveness of this kind of approach is limited. The recognition that drug use is unavoidable, harm reduction is a much more active approach of offering prevention care to drug users, as exemplified by the famous syringe-exchange program with injecting drug users (Hartgers et al., 1989). In chapter 2, two arguments were given in favour of a drug analysis and testing system as a worthwhile prevention tool. ...
The findings in this thesis show that drug monitoring can be used to
resolve some health issues and that it can also be applied to gain insights
for the development of drug policy. Through all layers of drug politics,
nationally or internationally, the DIMS is consulted for information updates.
The data in this thesis show that the illicit psychostimulant markets in The
Netherlands are very dynamic and continuously changing. When the purity
of certain psychostimulants dropped, the probability of new psychoactive
substances or new adulterants appearing on the market increased. Also,
the market dynamics of illicit drugs showed remarkable similarities with that
of regular consumer products. With regard to prevention activities, timely
monitoring by DIMS has repeatedly resulted in timely mass media
172
warnings and through the DIMS network the communication was
specifically directed at the groups at risk and maintained at a level of
professionalism appreciated by these specific groups. The results in this
thesis support the awareness of drug users about the drugs they consume
and show the increasing awareness about the option of drug testing.
Coupling the chemical data of the DIMS to the information that was
communicated by the drug consumers yielded many new insights into the
different effects of the expected, but mainly unexpected, psychostimulants
and other substances in the drug samples. These examples can be seen
as a basis for more refined research.
Finally, with some notes on future directions, promising new avenues for
assembling drug data are underway, like drug monitoring through the
analysis of public wastewater for example. Especially, combining different
sources of drug data and more frequent reports would hold promise for
optimal data for interpretation and creating timely drug policies.
Furthermore, while warranting anonymity, enriching the DIMS database in
the future with new items, like dose, route of administration, age, gender
etc., would greatly increase the scientific value of the DIMS data, leaving
less room for speculation or misinterpretation of effects.
... Wodak and Cooney (2004) identified 28 primary studies of injecting risk behaviour (defined as needle/syringe borrowing, lending, or reuse). Among these studies, there were 24 positive (Bluthenthal et al., 1998;Bluthenthal et al., 2000;Cox et al., 2000;Des Jarlais et al., 2000;Donoghoe et al., 1989;Frischer and Elliott, 1993;Gibson et al., 2002;Gleghorn et al., 1998;Guydish et al., 1995;Guydish et al., 1998;Hartgers et al., 1989;Heimer et al., 1998;Keene et al., 1993;Oliver et al., 1994;Paone et al., 1994;Peak et al., 1995;Power and Nozhkina, 2002;Schoenbaum et al., 1996;Singer et al., 1997;van Ameijden and Coutinho, 1998;van Ameijden et al., 1994;Vlahov et al., 1997;Watters, 1994), one negative (Klee et al., 1991), and three indeterminate (Donoghoe et al., 1992;Hartgers et al., 1992;Klee and Morris, 1995) results relating to the association between NSPs and injecting risk behaviour. The reviewers did not formulate any conclusions specifically regarding injecting risk behaviour. ...
... The 23 studies identified by Gibson et al. (2001) (Bluthenthal et al., 1998;Broadhead et al., 1999;Donoghoe et al., 1989;Donoghoe et al., 1992;Frischer and Elliott, 1993;Guydish et al., 1995;Guydish et al., 1998;Hagan et al., 1994;Hartgers et al., 1989;Hartgers et al., 1992;Keene et al., 1993;Klee et al., 1991;Klee and Morris, 1995;Oliver et al., 1994;Paone et al., 1994;Peak et al., 1995;Schoenbaum et al., 1996;Singer et al., 1997;van Ameijden and Coutinho, 1998;van Ameijden et al., 1994;Vlahov et al., 1997;Watters, 1994) were covered in the later core reviews, with the exception of Broadhead et al., 1999, andHagan et al., 1994. The authors concluded that there is substantial evidence that NSPs are effective in preventing HIV risk behaviour among IDUs. ...
... Published studies have looked at the impact of needle exchange programs in industrialised countries (Brogly et al., 2000;Des Jarlais et al., 2000;Donoghoe et al., 1989;Hagan et al., 1995;Hartgers et al., 1989;Holtgrave et al., 1998;Hunter et al., 1995;Kaplan & Heimer, 1994;Peak et al., 1995;Perucci et al., 1992;van Ameijden & Coutinho, 1998). However, most of these studies explored the impact of an intervention on IDU reported risk behaviour (Donoghoe et al., 1989;Hartgers et al., 1989;Holtgrave et al., 1998;Hunter et al., 1995;Peak et al., 1995) and very few have explored how an intervention has affected the HIV incidence in the IDU population (Brogly et al., 2000;Des Jarlais et al., 2000;Kaplan & Heimer, 1994;Perucci et al., 1992;van Ameijden & Coutinho, 1998) and how many HIV infections were averted (Kaplan & O'Keefe, 1993;Jacobs et al., 1999;Laufer, 2001). ...
... Published studies have looked at the impact of needle exchange programs in industrialised countries (Brogly et al., 2000;Des Jarlais et al., 2000;Donoghoe et al., 1989;Hagan et al., 1995;Hartgers et al., 1989;Holtgrave et al., 1998;Hunter et al., 1995;Kaplan & Heimer, 1994;Peak et al., 1995;Perucci et al., 1992;van Ameijden & Coutinho, 1998). However, most of these studies explored the impact of an intervention on IDU reported risk behaviour (Donoghoe et al., 1989;Hartgers et al., 1989;Holtgrave et al., 1998;Hunter et al., 1995;Peak et al., 1995) and very few have explored how an intervention has affected the HIV incidence in the IDU population (Brogly et al., 2000;Des Jarlais et al., 2000;Kaplan & Heimer, 1994;Perucci et al., 1992;van Ameijden & Coutinho, 1998) and how many HIV infections were averted (Kaplan & O'Keefe, 1993;Jacobs et al., 1999;Laufer, 2001). Even fewer have explored the impact of a NEP on HIV transmission between IDUs and their non-IDU sexual partners (Donoghoe et al., 1989). ...
Objectives: To develop a mathematical model to estimate the impact on HIV transmission of a needle exchange project (NEP) in Svetlogorsk, Belarus.
Background: From the mid -- 1990’s, there has been a rapid spread of HIV infection amongst intravenous drug users (IDUs) in Svetlogorsk. In 1997, when the IDU HIV prevalence had reached 74%, two NEPs were established in the town. These interventions have been operating, with some interruptions due to a lack of funding in 1998, up to present.
Methods: This paper presents a deterministic epidemiological model ‘IDU 2.4’ that simulates the transmission of HIV among IDUs sharing injecting equipment, and between IDUs and their sexual partners. The model incorporates the impact of the interrupted distribution of clean syringes and condoms, is validated against data from Svetlogorsk, and is used to estimate the impact of the intervention on HIV transmission.
Results: The model predicts that, between 1997 and 2000 the intervention averted 414 HIV infections in Svetlogorsk (CI, 180---690) and caused a 6.5% decrease in IDU HIV prevalence compared to if there had been no intervention. The gap in funding in 1998 and 1999 resulted in a 35% reduction in the HIV infections averted among the IDUs during that period and the IDU HIV prevalence being 3.2% higher in 2000 (CI, 1.9%---4.6%) than if there had been no gap in funding.
Conclusions: The model predicts that the intervention had an important impact on HIV transmission in Svetlogorsk even though the HIV prevalence amongst the IDUs is high. The findings reinforce the importance of replicating similar projects in the region and highlight the detrimental impact of gaps in funding.
... This policy focuses on the prevention of drug use and on the limitation of harm to users and society by offering specialized services to drug users, and is often referred to as "harm reduction" policy. One of the most famous examples of harm reduction is the syringe-exchange program with injecting drug users, which originated in 1984 in Amsterdam as a preventive measure to stop the spread of the hepatitis B and the HIV virus among injecting drug users and has been adopted worldwide since for the prevention of all blood borne diseases, including hepatitis and AIDS (Hartgers et al., 1989). Since then, many other types of harm reduction have been developed ranging from test services for recreational drug users (Spruit, 2001) to heroin assisted treatment and safe injection rooms for chronic, often treatment refractory drug addicts (Blanken et al., 2010;Kerr et al., 2007). ...
... However, evidence for the effectiveness of this kind of approach is limited. The recognition that drug use is unavoidable, harm reduction is a much more active approach of offering prevention care to drug users, as exemplified by the famous syringe-exchange program with injecting drug users (Hartgers et al., 1989). In chapter 2, two arguments were given in favour of a drug analysis and testing system as a worthwhile prevention tool. ...
Tibor Brunt onderzocht het Drug Informatie en Monitoring Systeem (DIMS), een landelijk netwerk dat de samenstelling van drugs als ecstasy en cocaïne analyseert. Die middelen zijn van gebruikers zelf afkomstig. Het is een effectieve manier om riskante stoffen te detecteren die aan de drugs worden toegevoegd, en om te meten welke gevolgen dat heeft voor de gezondheid van gebruikers. Dit is met normale psychofarmacologische onderzoeksmethodes niet mogelijk. Daarnaast kan via het DIMS informatie over preventie worden gegeven aan gebruikers die normaal gesproken niet bereikt zouden worden.
... As it was hypothesized that sexual networks of injecting and non-injecting PWUD could be mixed and thus an important risk factor for sexual HIV transmission, non-injecting PWUD were also included in the cohort. Inclusion of former, current and non-PWID in the cohort facilitated the study of the incidence of IDU initiation along with the impact of NSP on increases in IDU [17,18]. ...
The Netherlands is well known for its early adoption of harm reduction (HR) programs at the height of its heroin crisis in the 1970s/1980s, including the implementation of the first needle and syringe program worldwide. In this manuscript, we describe how the Amsterdam Cohort Studies (ACS) among people who use drugs (PWUD) was conceived within the context of the Dutch HR approach, including the challenges scientists faced while establishing this cohort. This required striking a balance between public health and individual benefit, solving research dilemmas in the face of uncertainty, developing controversial innovative and cutting-edge interventions, which changed the prevention landscape for PWUD, and using longitudinal cohort data to provide unique insights. Studies from the ACS covering follow-up between 1985 and 2016 revealed that participation in both opioid agonist therapy and needle and syringe programs led to a major decrease in the risk of HIV and hepatitis B and C infection acquisition. ACS data have shown that the observed decrease in incidence also likely included shifts in drug markets and drug culture over time, selective mortality among those with the highest levels of risk behaviour, demographic changes of the PWUD population, and progression of the HIV and HCV epidemics. Moreover, HR programs in the Netherlands provided services beyond care for drug use, such as social support and welfare services, likely contributing to its success in curbing the HIV and viral hepatitis epidemics, increasing access and retention to HIV and HCV care and ultimately decreases in overdose mortality over time. Given the low coverage of HR programs in certain regions, it is unsurprising that continued HIV and HCV outbreaks occur and that transmission is ongoing in many countries worldwide. If we aim to reach the World Health Organization viral hepatitis and HIV elimination targets in 2030, as well as to improve the life of PWUD beyond infection risk, comprehensive HR programs need to be integrated as a part of prevention services, as in the Netherlands. We should use the evidence generated by longstanding cohorts, including the ACS, as a basis for which implementation and improved coverage of integrated HR services can be achieved for PWUD worldwide.
... Examples include New York, USA (peak seroprevalence in the early 1980s of 55-60%), 1 Amsterdam, Netherlands (peak sero prevalence in 1986-87 of 34%), 2 and Edinburgh, UK (peak seroprevalence in the mid1980s of 65%). 3 The second generation of outbreaks occurred during the late 1980s and through the 1990s after development of the antibody test, knowledge that HIV outbreaks and HIV transmission among PWID could be controlled through largescale syringe access programmes, and development of trusting relationships between PWID and local public health authorities. 4 Locations that have had previous HIV epidemics among PWID during this period include France (1993), Italy (1994), Spain (1994), Portugal (1995), and Vancouver, Canada (1997), and Ireland, the Netherlands, 5 and Finland (all before 2001) and Eastern Europe (Estonia, Russia, and Ukraine 2000-10). 6,7 However, by 2000, the practice of combined prevention and care for HIV among PWID and the concept of monitoring intervention coverage had been fully devel oped. ...
During 2011–16, HIV outbreaks occurred among people who inject drugs (PWID) in Canada (southeastern Saskatchewan), Greece (Athens), Ireland (Dublin), Israel (Tel Aviv), Luxembourg, Romania (Bucharest), Scotland (Glasgow), and USA (Scott County, Indiana). Factors common to many of these outbreaks included community economic problems, homelessness, and changes in drug injection patterns. The outbreaks differed in size (from under 100 to over 1000 newly reported HIV cases among PWID) and in the extent to which combined prevention had been implemented before, during, and after the outbreaks. Countries need to ensure high coverage of HIV prevention services and coverage higher than the current UNAIDS recommendation might be needed in areas in which short acting drugs are injected. In addition, monitoring of PWID with special attention for changing drug use patterns, risk behaviours, and susceptible subgroups (eg, PWID experiencing homelessness) needs to be in place to prevent or rapidly detect and contain new HIV outbreaks.
... The remarkable challenge that facing this situation meant empowered the prison health administration, with the collaboration of the Spanish Ministry of Health, to undertake efficient and advanced measures in the community with remarkable success as far as prevention and health promotion are concerned. Several studies have concluded that Needles Exchange Programmes (NEPs), are efficient in modifying high risk practices directly related to intravenous drug use, and therefore, are efficient in reducing the risk of infection transmission [9][10][11][12][13]. Moreover, OST contributes indirectly to harm reduction by increasing access to care and encouraging better compliance [14]. ...
... Such policies aim to reduce harm to users and society by offering specialised services to drug users, referred to as the 'harm reduction' approach (Marlatt et al., 2012). A good example of a harm reduction strategy is syringe exchange programmes, which originated in 1984 in Amsterdam as a measure to stop the spread of the hepatitis B virus and the human immunodeficiency virus (HIV) among injecting drug users and has since been adopted globally in an attempt to prevent the transmission of viral blood-borne diseases in this group and their social environment (Hartgers et al., 1989). Other examples of harm reduction approaches include heroin-assisted treatment and safe injection rooms for chronic, often treatment-refractory, drug users (Kerr et al., 2007;Blanken et al., 2010). ...
... * One core and on e su pplementary re view idenƟ fied her e in re laƟon to OST were al so idenƟfied in the sea rch for NSP, the prov ision of ster ile dru g prepa raƟon e quipment , IEC and SIFs. Avants et al., 2004;Baker et al., 1993;Ball et al., 1998;Batki et al., 1989;Bluthenthal et al., 1998;Bluthenthal et al., 2000;Brooner et al., 1998;Calsyn et al., 1992;Colon et al., 2009;Cox et al., 2000;Deren et al., 1995;Des Jarlais et al., 2000Donoghoe et al., 1992;Donoghoe et al., 1989;Frischer and Elliott, 1993;Gibson et al., 2002;Gleghorn et al., 1998;Guydish et al., 1998Guydish et al., , 1995Hagan et al., 1993;Hart et al., 1989;Hartgers et al., 1989Hartgers et al., , 1992Heimer et al., 2002;Heimer et al., 1998; Supplementary Table 1). Supplementary reviews are not described in relation to IRB since the evidence included in these reviews did not alter the evidence statement derived based on studies identified in core reviews (see Table 1). ...
This is the protocol for a review and there is no abstract. The objectives are as follows: To assess the impact of needle/syringe programmes with and without opiate substitution therapy (OST) on the incidence of HCV infection among people who inject drugs (PWID).To assess the effect of OST alone on the incidence of HCV infection among PWID.
How effective are needle/syringe programmes (NSP) with and without the use of OST for reducing HCV incidence among PWID?How effective is OST alone for reducing HCV incidence among PWID?How does the effect of NSP and OST vary according to duration of treatment (i.e. for NSPs weekly attendance versus monthly)?How does the effect of NSP vary according to the type of service (fixed site versus mobile; high coverage versus low coverage)?How does the effect of OST vary according to the dosage of OST, type of substitution used and adherence to treatment?
... Wodak & Cooney identified 28 primary studies of IRB (needle/syringe borrowing, lending or re-use); among these, there were 24 positive [41][42][43]45,50,[54][55][56]60,61,[64][65][66][67][68][69][70][71][72][73][74][75][76][77], one negative [51], one indeterminate result [78] and two showing no association [48,79]. . The authors concluded that there is substantial evidence that NSPs are effective in preventing HIV risk behaviour among IDUs. ...
AIMS: To review the evidence on the effectiveness of harm reduction interventions involving the provision of sterile injecting equipment in the prevention of hepatitis C virus (HCV) and human immunodeficiency virus (HIV) transmission among injecting drug users (IDUs). The interventions assessed were needle and syringe programmes (NSP), alternative modes of needle/syringe provision (pharmacies, vending machines and outreach) and the provision of injecting equipment other than needles/syringes. METHODS: Systematic searches of the English language literature to March 2007 were undertaken to identify systematic, narrative or meta-analytical reviews (also known as a review of reviews) of the impact of interventions on HCV transmission, HIV transmission or injecting risk behaviour (IRB). Critical appraisal criteria classified the reviews as either high quality ('core') or supplementary: a framework based on the quality of reviews, the reviewers' conclusions and the designs/findings of the primary studies was used to derive evidence statements. RESULTS: Three core and two supplementary reviews of injecting equipment interventions were identified. According to the proposed framework, this study found (a) insufficient evidence to conclude that any of the interventions are effective in preventing HCV transmission; (b) tentative evidence to support the effectiveness of NSP in preventing HIV transmission; (c) sufficient evidence to support the effectiveness of NSP (and tentative evidence of an additional impact of pharmacy NSP) in reducing self-reported IRB; and (d) little to no evidence on vending machines, outreach or providing other injecting equipment in relation to any of the outcomes. CONCLUSIONS: The evidence is weaker than given credit for in the literature. The lack of evidence for effectiveness of NSP vis-à-vis biological outcomes (HCV and HIV incidence/prevalence) reflects the limitations of studies that have been undertaken to investigate these associations. Particularly for HCV, low levels of IRB may be insufficient to reduce high levels of transmission. New studies are required to identify the intervention coverage necessary to achieve sustained changes in blood-borne virus transmission.
... The three core reviews included 43 primary studies between them, 26 of which appeared in at least two of the reviews (Avants et al., 1999;Avants et al., 2004;Baker et al., 1993;Ball et al., 1998;Batki et al., 1989;Bluthenthal et al., 1998;Bluthenthal et al., 2000;Brooner et al., 1998;Calsyn et al., 1992;Colon et al., 2009;Cox et al., 2000;Deren et al., 1995;Des Jarlais et al., 2000Donoghoe et al., 1992;Donoghoe et al., 1989;Frischer and Elliott, 1993;Gibson et al., 2002;Gleghorn et al., 1998;Guydish et al., 1998Guydish et al., , 1995Hagan et al., 1993;Hart et al., 1989;Hartgers et al., 1989Hartgers et al., , 1992Heimer et al., 2002;Heimer et al., 1998;Supplementary Table 1). Supplementary reviews are not described in relation to IRB since the evidence included in these reviews did not alter the evidence statement derived based on studies identified in core reviews (see Table 1). ...
Injecting drug use is a major risk factor for the acquisition and transmission of HIV and Hepatitis C virus (HCV). Prevention of these infections among people who inject drugs (PWID) is critical to reduce ongoing transmission, morbidity and mortality.
A review of reviews was undertaken involving systematic literature searches of Medline, Embase, CINAHL, PsychINFO, IBSS and the Cochrane Library (2000-2011) to identify English language reviews regarding the effectiveness of harm reduction interventions in relation to HIV transmission, HCV transmission and injecting risk behaviour (IRB). Interventions included needle and syringe programmes (NSP); the provision of injection paraphernalia; opiate substitution treatment (OST); information, education and counselling (IEC); and supervised injecting facilities (SIFs). Reviews were classified into 'core' or 'supplementary' using critical appraisal criteria, and the strength of review-level evidence was assessed.
Twelve core and thirteen supplementary reviews were included. From these reviews we identified: (i) for NSP: tentative review-level evidence to support effectiveness in reducing HIV transmission, insufficient review-level evidence relating to HCV transmission, but sufficient review-level evidence in relation to IRB; (ii) for OST: sufficient review-level evidence of effectiveness in relation to HIV transmission and IRB, but tentative review-level evidence in relation to HCV transmission; (iii) for IEC, the provision of injection paraphernalia and SIFs: tentative review-level evidence of effectiveness in reducing IRB; and either insufficient or no review-level evidence for these interventions in relation to HIV or HCV transmission.
Review-level evidence indicates that harm reduction interventions can reduce IRB, with evidence strongest for OST and NSP. However, there is comparatively little review-level evidence regarding the effectiveness of these interventions in preventing HCV transmission among PWID. Further studies are needed to assess the effectiveness and impact of scaling up comprehensive packages of harm reduction interventions to minimise HIV and HCV transmission among PWID.
... A variety of practical, methodological and ethical problems surround any attempt to undertake randomised, controlled trials with hidden populations of people involved in illegal, highly stigmatised activities within community settings. Nevertheless, many other research designs have proven feasible including: prospective studies that compare the incidence of HIV infection and related risk behaviours in needle exchange attenders and non-attenders over time (Oliver et al 1994;Des Jarlais et al 1996;Schoenbaum et al 1996;van Haastrecht 1996;Bruneau et al 1997;Hagan et al 1999;Schechter et al 1999); multiple cross-sectional studies examining the correlations between use of NSPs and risk behaviours for HIV Singer et al 1997;Bluethenthal et al 1998;Broadhead et al 1999); case-control studies comparing people who acquired HIV with a matched sample from the same population who did not become infected (van Ameijden 1992; Hagan et al 1994;Hagan et al 1995;Bruneau et al 1997;Patrick et al 1997); observational studies comparing NSP attenders with non-attenders (Hartgers et al 1989;Klee et al 1991;Donoghoe et al 1993;Frischer and Elliott 1993;Hartgers et al 1993;Keene et al 1993;van Ameijden et al 1994;Watters et al 1994;Klee and Morris 1995;Bruneau et al 1997;Strathdee et al 1997;Bluethenthal et al 1998;van Ameijden and Coutinho 1998); longitudinal studies of the clients of NSPs, which looked for reductions in risk behaviours -usually without comparison groups (Donoghoe et al 1989;Oliver et al 1994;Hagan et al 1995;Vlahov et al 1997) observational studies of NSP clients that compare people according to the length of time they have used the NSP or according to the proportion of syringes they obtain from the NSP (Paone et al 1995;Guydish et al 1995;Guydish et al 1998); multiple cross-sectional designs without pre and post comparisons (Peak et al 1995); ecological studies comparing cities with high and low prevalence of HIV or examining the characteristics of cities that have averted HIV spread (Ljungberg et al 1991;Stimson 1995;Groseclose et al 1996;Hurley et al 1997;Lamden et al 1998); and, modelling studies looking at the circulation time of syringes and the proportion of HIV-infected returned syringes (Heimer et al 1993;Kaplan and O'Keefe 1993;Kaplan and Heimer 1995). ...
... Consistent with previous findings in both international252627282930 and Chinese settings212223 , our findings indicate that provision of clean needle/syringes does not increase the injecting frequency among IDUs, and furthermore that increased availability of clean needles/ syringes may substantially contribute to the reduction in repeated use of dull syringes and sharing activities among Chinese IDUs. Liu et.al., in 2007, demonstrate that the rate of syringe sharing in the past 30 days among IDUs who regularly attend NSPs (15%) is two to three times lower than non-attendees (32-44%) in ...
Background
Needle-syringe exchange programs (NSPs) have been substantially rolled-out in China since 2002. Limited studies reported effectiveness of NSPs in a Chinese setting. This study aimed to assess the association between accessibility to NSPs and drug-use risk behaviors of IDUs by investigating primary (self-reported) data of IDUs recruited from NSP sites, community settings and mandatory detoxification centers (MDCs) in Hunan province, China.
Methods
A cross-sectional survey was conducted in Hunan province in 2010. IDU recruits participated in a face-to-face interview to provide information related to their ability to access NSPs, demographic characteristics, and injecting behaviors in the past 30 days.
Results
Of the total 402 participants, 35%, 14% and 51% participants indicated low, medium and high ability to access NSPs in the past 30 days, respectively. A significantly higher proportion of IDUs (77.3%) from the high-access group reported ≤2 injecting episodes per day compared with medium- (46.3%) and low-access (58.8%) groups. Only 29.0% of high-access IDUs re-used syringes before disposal in the past 30 days, significantly lower than those in the medium- (43.1%) and low-access (41.3%) groups. Reported levels of needle/syringe sharing decreased significantly as the ability to access NSPs increased (16.3%, 12.7% and 2.5% in the low, medium and high access groups, respectively). Ninety percent of IDUs recruited from MDCs had low ability to access NSPs.
Conclusions
Increased NSP accessibility is associated with decreased levels of injecting frequency, repetitive use and sharing of injecting equipment among Chinese IDUs. Mandatory detention of IDUs remains as a major barrier for IDUs to access NSPs in China.
... The discussion focused on the potential of an SEP to reduce morbidity, mortality, and economic costs associated with injection drug use. Data from the medical literature were presented addressing the effectiveness of SEPs as an HIV prevention strategy, including studies showing that SEPs do not encourage drug use among SEP participants or the recruitment of first-time users, do not result in an increase in needle littering or crime, and may in fact be ideal sites for recruiting IDUs into drug user treatment (Guydish et al., 1993; Hartgers, Buning, van Santen, Verster, and Coutinho, 1989; Hudoba, Grenyer, and O'Toole, 2004; Khoshnood, Blankenship, Pollack, Roan, and Altice, 2000; Wodak and Cooney, 2006). In addition, the Centers for Disease Control and Prevention guidelines (Centers for Disease Control and Prevention, 2000; Centers for Disease Control and Prevention, 1999), which recommend syringe exchange for IDUs who are not ready to enter drug user treatment were reviewed and provided authoritative support for the value and acceptance of syringe exchange as an HIV prevention strategy to many who were not previously familiar with the published data. ...
Little published information exists to guide health care institutions in establishing syringe exchange program (SEP) services. To address this gap, this article discusses organizational issues encountered in the implementation of a hospital-based SEP in San Francisco, California (USA). Investigators collaborated with a community organization in implementing a county hospital-based SEP. SEP services integrated into a public hospital presented unique challenges directly related to their status as a health care institution. In the course of introducing SEP services into a hospital setting as part of a clinical trial, various ethical, legal, and logistical issues were raised. Based on these experiences, this paper provides guidance on how to integrate an SEP into a traditional health care institution.
... Wodak & Cooney identified 28 primary studies of IRB (needle/syringe borrowing, lending or re-use); among these, there were 24 positive [41][42][43]45,50,[54][55][56]60,61,[64][65][66][67][68][69][70][71][72][73][74][75][76][77], one negative [51], one indeterminate result [78] and two showing no association [48,79]. . The authors concluded that there is substantial evidence that NSPs are effective in preventing HIV risk behaviour among IDUs. ...
To review the evidence on the effectiveness of harm reduction interventions involving the provision of sterile injecting equipment in the prevention of hepatitis C virus (HCV) and human immunodeficiency virus (HIV) transmission among injecting drug users (IDUs). The interventions assessed were needle and syringe programmes (NSP), alternative modes of needle/syringe provision (pharmacies, vending machines and outreach) and the provision of injecting equipment other than needles/syringes.
Systematic searches of the English language literature to March 2007 were undertaken to identify systematic, narrative or meta-analytical reviews (also known as a review of reviews) of the impact of interventions on HCV transmission, HIV transmission or injecting risk behaviour (IRB). Critical appraisal criteria classified the reviews as either high quality ('core') or supplementary: a framework based on the quality of reviews, the reviewers' conclusions and the designs/findings of the primary studies was used to derive evidence statements.
Three core and two supplementary reviews of injecting equipment interventions were identified. According to the proposed framework, this study found (a) insufficient evidence to conclude that any of the interventions are effective in preventing HCV transmission; (b) tentative evidence to support the effectiveness of NSP in preventing HIV transmission; (c) sufficient evidence to support the effectiveness of NSP (and tentative evidence of an additional impact of pharmacy NSP) in reducing self-reported IRB; and (d) little to no evidence on vending machines, outreach or providing other injecting equipment in relation to any of the outcomes.
The evidence is weaker than given credit for in the literature. The lack of evidence for effectiveness of NSP vis-à-vis biological outcomes (HCV and HIV incidence/prevalence) reflects the limitations of studies that have been undertaken to investigate these associations. Particularly for HCV, low levels of IRB may be insufficient to reduce high levels of transmission. New studies are required to identify the intervention coverage necessary to achieve sustained changes in blood-borne virus transmission.
In this chapter, we present notes on the harm reduction approach to drug use with special focus on the current opioid epidemic in United States. Harm reduction is the most recent, and we believe the most effective, framework for addressing the problems of psychoactive drug use in large, complex societies. Harm reduction arose in opposition to previous perspectives on psychoactive drug use, including an ethnocentric condemnation of people who use certain types of drugs, and an insistence that persons with problematic drug use should not use any psychoactive drugs, including medications. We then examine specific principles of current harm reduction. Harm reduction addresses both illicit and licit drugs, which is vital given the recent prescription opiate epidemic in the United States. Harm reduction incorporates scientific knowledge about drugs. Harm reduction is continuously evolving. We then present an historical timeline for major events in the development of harm reduction in the United States. Finally, we discuss harm interventions for addressing the current opioid epidemic and provide tips for healthcare providers for working with people who use drugs.
EDITORIAL IV JORNADA DE REDUCCIÓ DE DANYS A CATALUNYA
COMUNICACIONS
Herramientas para el análisis ético de los fenómenos NIMBY / Eines per l’anàlisi ètica dels fenòmens NIMBY / Tools for ethic analysis of phenomena NIMBY
Ibogaína: una alternativa humanitaria al problema de la cronificación de adictos a sustancias / Ibogaïna: una alternativa humanitària al problema de la cronificació d’addictes a substàncies / Ibogaine: a humane alternative to the problem of developing chronic substance abusers
¿Y ahora qué? / I ara què? / What now?
Menores y reducción de daños / Persones menors en programes de reducció de danys / Minors and Harm Reduction
Guía de buenas prácticas en los Programas de Intercambio de Jeringas / Guia de bones pràctiques en els Programes d’Intercanvi de Xeringues / Guide to good practice in Syringe Exchange Programs
Consumo de sustancias y otras conductas de riesgo en prisión / Consum de substàncies i altres conductes de risc a presó / Substance use and other risk behaviors in prison
Evaluación del Programa de intercambio de jeringuillas del Centro
Penitenciario de Brians 1 (2007 - 2012) / Evaluació del Programa d’intercanvi de xeringues (PIX) del Centre Penitenciari de Brians 1 (2007 - 2012) / Evaluation needle exchange program in Prison
Brians 1 (2007 -2012)
REVISIÓ Programa de intercambio de jeringas en prisiones / Programa d’intercanvi de xeringues a presons / Needle exchange programs in prison
GLOSSARIO / GLOSSARI / GLOSSARY
The aim of this study is to review the syringes programs in Europe principally in Spain. Syringes programs exchange programs (SEP's) are designed to active UDI population, facilitating sterilized injection paraphernalia, to diminish the risk of blood born virus transmission, associated to this material sharing. After the first programs of syringes in Amsterdam in 1984, several countries adhered to this initiative. In the Spanish State they arise as of the year 1989, mainly from associations implied in the fight against the AIDS, extending to drug addicts attention programs and soon present in the autonomic and national plans and, as of 1997, in some prisons. In this review, we examine the modalities of SEP, specially innovating modalities like the SEP in pharmacies or prison, and other interventions carried out from this programs, analysing their strengths and weaknesses. In addition to this historical route and its peculiarities according to the different models, the evaluations of these devices have been reviewed, showing that SEP's are effective in the reduction of HIV incidence among IDU's, contact with IDU's who have no access to other services, minimize the number of circulating used syringes, provide education and counselling for a safer drug use, and facilitate the entrance to drug treatment. We suggest aspects to consider at the time of implanting a program of these characteristics, in a framework of a community approach, combining prevention, treatment and harm reductions strategies.
The needle and syringe exchange in Amsterdam was initiated in 1984 by the Junky Union. To date, ample data are available to support the role of the needle exchange in facilitating drug injectors to use drugs in a safer way: no increase in drug use could be validated, participants of the exchange schemes were less involved in needle sharing, the supply of large quantities of needles to drug users did not lead to an increase in needle stick accidents by the general public, and, finally, the HIV prevalence among drug injectors has remained stable since 1986, while the incidence of acute hepatitis B has gone down.
Social learning theory-based models have recently provided the foundation for a series of twelve controlled human immunodeficiency virus (HIV) risk reduction intervention studies that have examined sexual behavior change. These interventions have been tested with adolescents, gay and bisexual men, inner-city women, college students, and seriously mentally ill adults. We report the first meta-analysis of these intervention studies. We found that, as expected, the mean weighted effect of HIV-risk reduction interventions on behavioral outcomes was positive and strongly significant (d+=0.25). Moreover, the studies' effect sizes were consistently positive, ranging from 0.11 to 0.53, and were largest when the outcomes were measured close in time to the intervention. We discuss other methodological challenges that, if solved, should enhance the success of future HIV-risk reduction interventions.
Objectives
To contribute to harm reduction in injecting drug users (IDUs) by the implementation of a programme to withdraw abandoned syringes from public places, as well as to collaborate on the social reinsertion of IDUs.
Methods
Descriptive study of the Syringe Withdrawal Community (RECOJE in Spanish), carried out from 1997 to 1999 by IDUs, the We Are Helpful Association (ASUT in Spanish) and the Social and Health Prevention and Attention Service (SAPS in Spanish) of the Red Cross, in Ciutat Vella (Barcelona, Spain).
Results
4,332 syringes were withdrawn, 849 in 1997, 1,324 in 1998 and 2,159 in 1999. The mean number of syringes withdrawn each time was 57 ± 33. 45 different IDUs worked in RECOJE. 74.2% of the abandoned syringes were found in parks, gardens, car parks and open spaces.
Conclusions
RECOJE can be a valid programme for harm reduction complementary to the exchange syringe programmes. It could improve the self-esteem, external image and organization of IDUs, contributing to their social reinsertion.
The past decade witnessed an alarming increase in prevalence of human immunodeficiency virus (HIV) infection. In this paper, we review the literature on factors which influence the reduction of risk behaviors for human immunodeficiency virus among gay and bisexual men, intravenous drug users, and non-intravenous drug using heterosexual adolescents and adults. In this review, specific attention is paid to the reduction of sexual modes of viral transmission. Several risk reduction factors are identified. Methodological limitations are discussed and suggestions for further research are offered.
The purpose of this study was to determine if alcohol use is independently associated with needle-sharing behavior. Participants were 196 active injection drug users recruited into the Providence, Rhode Island Needle Exchange program between July 1997 and March 1998. All subjects were administered a 45-minute questionnaire that included questions on quantity/frequency of alcohol use and the alcohol abuse section of the Structured Clinical Interview for DSM-III-R (SCID; Spitzer, Williams, Gibbon, & First, 1992). Drug risk behaviors, including needle sharing were assessed using the HIV Risk Assessment Battery (RAB; Navaline et al., 1994). Of 196 IDUs, 60% had used alcohol in the last month. Twenty-eight percent met criteria from the Diagnostic and Statistical Manual for Mental Disorders, 3rd ed., rev. (DSM-III-R; American Psychiatric Association, 1987) for alcohol abuse over the last 6 months. One half of IDUs had shared needles in the last 6 months. Increasing levels of alcohol ingestion were associated with greater RAB drug risk scores and greater needle sharing. Using multiple logistic regression, high-level “at-risk” alcohol use (odds ratio [OR], 2.5) and alcohol abuse (OR, 2.3) were significantly associated with needle sharing when controlling for other demographic and behavioral factors previously found to be associated with sharing. The results of this study showed that prevalence of alcohol abuse is high in this population and is associated with needle sharing. HIV prevention effects in needle exchange programs should address alcohol use.
HIV among injecting drug users (IDUs) has now been documented in over 60 countries in the world, and there are an additional 40 countries where injecting drug use has been reported including widespread epidemics in Southeast and southern Asia and in Latin America. At present HIV infection is almost always fatal, and there is no promise that a preventive vaccine will become available soon. Given the enormity of the HIV epidemic among IDUs and the critical need to reduce the spread of HIV transmission to and from IDUs, prevention efforts are essential. Syringe-exchange programs have become a major component of HIV prevention strategies in most developed countries and work within the philosophy of harm reduction. Increasing access to sterile syringes has been met with considerable controversy. Opponents of syringe exchange have generally argued that increasing access to sterile syringes would simultaneously increase the number of injecting drug users, increase the frequency of injection for already active IDUs, and appear to “condone” an illegal behavior. To date many research studies and four major reviews of syringe exchange literature have been conducted. All studies thus far have shown no increase in illicit drug injection associated with syringe exchanges, and significant decrease in drug risk behaviors.
In line with the recent emphasis in Britain on health service accountability and the publication of the Patient's Charter, this paper reports the views of 164 methadone users concerning the “ideal” methadone programme. Drug users called for a flexible service both in terms of sites, dispensing regimes and choice of methadone preparation. Such a programme should also provide comprehensive primary health care and an integral HIV service. In addition it should deal with a wide range of practical issues such as accommodation and legal matters and also provide practical assistance such as creche facilities. It was felt that certain groups, for instance pregnant women and those individuals who are HIV positive, should be given privileged access. The majority felt that urine testing was a valid management strategy, and also felt that anti-social or violent behaviour should warrant expulsion from a methadone programme. They recommended the use of ex-drug users as counsellors. The drug users displayed a sophisticated attitude to the research and highlighted the potential value of consumer surveys of experienced service users in informing the planning and development of methadone programmes.
RESUMEN En el presente trabajo se realiza una revisión de los programas de jeringuillas en Europa, y en el Estado Español. Los programas de intercambio de jeringuillas (PIJs) se dirigen a la población usuaria de drogas por vía intravenosa (UDI) en consumo activo, facilitando material de inyección esterilizado, para minimizar el riesgo de contagio de virus transmisibles por sangre, asociados al uso compartido de dicho material. Tras los primeros programas de jeringuillas en Ámsterdam en 1984, varios países adhirieron a esta iniciativa. En el Estado Español surgen a partir del año 1989, principalmente desde asociaciones implicadas en la lucha contra el síndrome de inmunodeficiencia adquirida (SIDA), extendiéndose a los programas de atención a toxicómanos y luego presentes en los planes autonómicos y nacionales, y, a partir de 1997, en algunas prisiones. En este trabajo anali-zamos las distintas modalidades de PIJ y las intervenciones que se llevan a cabo desde los programas, analizando sus fortalezas y debilidades, centrándose en modalidades de intervención especialmente innovadoras como los PIJs en farmacias o en prisión. Además de este recorrido histórico y de sus peculiaridades según los distintos modelos, se han revisado las evaluaciones que de estos dispositivos se han llevado a cabo, las cuales indican que los PIJs son efectivos y eficaces en la reducción de las tasas de virus de inmuno-deficiencia humana (VIH) entre los consumidores, contactar con UDIs que no acceden a otros servicios, disminuir el número de jeringuillas usadas en circulación, ofrecer educa-ción y consejo para un consumo más seguro, y posibilitar la entrada a tratamientos de drogodependencias. Se proponen algunos aspectos a tener en cuenta a la hora de implantar un programa de reducción de daños y riesgos de estas características, enmarcado en un abordaje comunitario, que combinase la prevención, el tratamiento y las estrategias de reducción de daños. Palabras clave: Programas de jeringuillas. Reducción de daños. Heroína. Virus de inmunodeficiencia humana. ABSTRACT The aim of this study is to review the syringes programs in Europe principally in Spain. Syringes programs exchange programs (SEP's) are designed to active UDI population, facilitating sterilized injection paraphernalia, to diminish the risk of blood born virus transmission, associated to this material sharing. After the first programs of syringes in Amsterdam in 1984, several countries adhered to this initiative. In the Spanish State they arise as of the year 1989, mainly from associations implied in the fight against the AIDS, extending to drug addicts attention programs and soon present in the autonomic and national plans and, as of 1997, in some prisons. In this review, we examine the modalities of SEP, specially innovating modalities like the SEP in pharmacies or prison, and other interventions carried out from this programs, analysing their strengths and weaknesses. In addition to this historical route and its peculiarities according to the different models, the evaluations of these devices have been reviewed, showing that SEP's are effective in the reduction of HIV incidence among IDU's, contact with IDU's who have no access to other services, minimize the number of circulating used syringes, provide education and counselling for a safer drug use, and facilitate the entrance to drug treatment. We suggest aspects to consider at the time of implanting a program of these characteristics, in a framework of a community approach, combining prevention, treatment and harm reductions strategies.
This is the first comprehensive international review of the evidence for needle syringe programmes. The major, and now overwhelmingly strong, finding is that needle syringe programmes reduce HIV transmission effectively, safely and cost effectively. The size of the benefit is substantial. There is compelling evidence that needle syringe programmes reduce HIV incidence and HIV prevalence by reducing HIV risk behaviour. The Bradford Hill criteria, generally regarded as the most robust method of assessing public health interventions, were used for the evaluation framework. Conservatively, six of the nine Bradford Hill criteria were fulfilled (strength of association, replication of findings, temporal sequence, biological plausibility, coherence of evidence, and reasoning by analogy). Three of the Bradford Hill criteria were not fulfilled (specificity of association, biological gradient and experimental evidence). Five additional criteria were clearly fulfilled (cost-effectiveness, absence of negative consequences, feasibility of implementation, expansion and coverage, unanticipated benefits, and application to special populations). The findings in this review are consistent with seven published national reviews conducted by, or on behalf of, United States government agencies, which had previously found that needle syringe programmes were effective in reducing HIV infection among injecting drug users and did not increase illicit or injecting drug use. Countries affected or threatened by HIV infection among injecting drug users should carefully consider the convincing evidence now available for the effectiveness and safety of needle syringe programs with a view to establishing or expanding needle syringe programs to scale. Although some research questions still remain unanswered, and areas exist where improved research methodology is needed, the failure to implement needle syringe programmes in time and on a sufficient scale cannot be justified by a lack of available evidence.
A meta-analysis of 16 educational interventions and 10 needle exchange programs was performed to estimate the effectiveness of reducing HIV risk behaviors in the injecting drug user population. Information on intervention, outcome, design and demographics was coded and analyzed for all educational and needle exchange program evaluation studies published between January 1984 and May 1995. The weighted mean effect size for the 6,251 study subjects of the 16 educational interventions was 0.749 (95% CI, 0.708 to 0.790), and the weighted mean effect size for the 1,675 study subjects of the 10 needle exchange programs was 0.279 (95% CI, 0.207 to 0.352), suggesting that both interventions had a positive impact on reducing HIV risk behaviors associated with injecting drug use. However, these results were dependent upon research design, outcome type and follow-up time.
Behavioral research to prevent the spread of human immunodeficiency virus (HIV) infection has made significant progress over the past decade. Most importantly, studies have repeatedly shown that theory-based prevention interventions that build self-efficacy through self-management and communication skills training successfully reduce HIV risk behaviors. Simultaneously, communities have mobilized to develop programs that assist persons in reducing their risk for HIV infection. The degree to which behavioral sciences have contributed to community-based HIV prevention programming is examined in this paper through a systematic assessment of technology transfer in the area of sexual risk behavior reduction. We analyzed the content of twelve community-based HIV risk-reduction programs targeting gay and bisexual men developed by seven of the nation's largest AIDS service organizations. Telephone interviews were conducted with community program developers to determine the source of their programs and whether they had been influenced by behavioral sciences. Evidence was mixed with respect to the degree to which behavioral sciences have contributed to the development of community-based programs. Program elements often reflected research-based models but with questionable fidelity. Evidence for diffusion of research-based information occurred most often when community organizations received direct consultation from behavioral scientists. We suggest that technology transfer in HIV prevention requires behavioral scientists working in communities to serve as translators of theoretical constructs for practical applications. Preventing the spread of HIV could therefore be improved through partnerships between behavioral researchers and communities.
The injecting behaviour and risky needle use of a sample of 193 methadone maintenance clients was investigated. The majority of the sample (n = 116) reported injecting one or more drugs in the month prior to data collection. Compared with non-injectors, the injectors were slightly younger, had been on the methadone program for a shorter period of time, had lower methadone doses and more severe drug and legal problems. The injecting sub-group was examined in more detail by comparing those subjects whose injecting practices conformed to guidelines on minimizing risk of HIV transmission with those who, in the preceding month, made at least one injection contravening these guidelines and thus placed themselves at risk of contracting HIV. A greater proportion of these risky injectors were unemployed. Importantly, risky injectors had lesser knowledge of means of preventing the spread of HIV than safe injectors. It is concluded that the reduction of HIV transmission could be enhanced by improvements in methadone programs, particularly ensuring adequate dosing and high retention rates. Further, there is a need to improve knowledge with regard to what are safe and what are risky injecting practices and needle/syringe cleaning methods.
Intravenous drug users are frequently exposed to parenterally transmitted viral infections, and these infections can spread to the general population through sexual activity. We investigated the prevalence of serologic markers for human immunodeficiency virus type 1 (HIV-1), human T-cell lymphotropic virus type I/II (HTLV-I/II), hepatitis B virus (HBV), and hepatitis C virus (HCV) in intravenous drug users and their sexual contacts. Of 585 drug users from northern California tested for these serologic markers, 72% were reactive for the antibody to HCV, 71% for the antibody to hepatitis B core antigen, 12% for HTLV-I/II antibodies, and 1% for the HIV-1 antibody. The prevalence of serologic markers for these four viruses correlated with the duration of intravenous drug use, the ethnic group, and the drug of choice. More than 85% of subjects infected with either HCV or HBV were coinfected with the other virus. All persons reactive to HTLV-I/II antibodies had antibodies for either HBV or HCV. Of 81 sexual contacts tested, 17% had evidence of HBV infection while only 6% were reactive for HTLV-I/II antibodies and 4% for the antibody to HCV. None of this group was infected with HIV-1. We conclude that HTLV-I/II and HCV are inefficiently transmitted to sexual contacts while HBV is spread more readily. Programs designed to discourage the sharing of drug paraphernalia, such as needle and syringe exchanges, should decrease the risk of parenterally spread viral infections in intravenous drug users and thus slow the spread of these infections to the general population.
The widespread use of household bleach (5.25% sodium hypochlorite) as a disinfectant by IV drug users may cause an increase in the number of IV injections of this substance. We report the case of a 31-year-old man who injected less than 1 mL of bleach and then experienced transient left-sided chest pain and vomiting. The patient did not have any serious complications. This report is similar to the only other reported case in the medical literature of an IV injection of a small amount of bleach. Based on these two reports, household bleach appears to be safe when used as a disinfectant by IV drug users, but more studies are needed.
Measures taken to reduce HIV risk by injecting drug users have been reported in many countries, but a minority of injectors continue to engage in risky practices. In an ongoing cohort study, 207 drug injectors were interviewed and anonymously tested for HIV antibodies in saliva in 1989. Injectors reporting recent syringe sharing were compared with those not recently sharing; injecting events where sharing did and did not take place were examined. Those recently sharing syringes differed significantly from the non-sharers on several factors, including: use of heroin, dihydrocodeine and temazepam; injection of heroin, temazepam and prescribed methadone; accommodation and contact with other injectors; means of financial support and recent involvement in crime; secondary sources of injecting equipment and unsafe disposal; employment of HIV protective strategies; treatment contact with general practitioners; number of sexual partners and injecting status of sexual partners. The two groups were not significantly different in terms of attendance at syringe-exchange schemes and self-reported HIV antibody status. Syringe sharing would appear to be related to social circumstances and life-style factors rather than just individual choices and motivation.
In this short paper we describe the operation of a pharmacy-based scheme operating in Glasgow to provide injecting drug users with sterile injecting equipment. The operation of the scheme is described under a number of headings: its physical location, the policy of selling injecting equipment, the return of previously used equipment, counselling and referral, and, the style of working of pharmacy staff. It is shown that while retail pharmacies may be an important point of contact with injecting drug users it should not be assumed that pharmacy staff already possess the requisite skills for working in this area. There is a need for pharmacists' and their staff to be able to draw upon the experience of colleagues working in this area in order to benefit from a pool of common experience. In addition there is a need to provide staff with access to appropriate back-up and support services.
In a population based survey conducted in France in 1988, 41 respondents reported present or past intravenous drug use. Controlling for age and gender, intravenous drug users (IDUs) engage in more high risk sexual behavior than the general population (sex with other IDUs, multiple partners), but they do not use condoms more frequently. They are five times more likely to have had an HIV test.
Three hundred and eighty six injecting drug users entered into an HIV study through methadone programs over a 40 month period. Differences in oral, intranasal and parenteral use of heroin and cocaine were assessed between four consecutive 10 month intake groups. Heroin smoking and cocaine freebasing were increased in the later intake groups, while there were no significant changes in injecting variables. No relationship between sexual risk behaviour and cocaine freebasing was found. HIV seropositivity was less among cocaine freebasers at 19% compared to 32% among non freebasers. The increase in heroin smoking and cocaine freebasing may have a favourable preventive effect on the spread of HIV among this high risk group.
To determine if behavioral changes in intravenous drug users in Amsterdam have retarded the HIV (human immunodeficiency virus) epidemic in this group in recent years, we report that: HIV-antibody seroprevalence in annual samples of injectors has been constant over the years 1986-89; HIV-antibody incidence in a cohort of injectors appears to have decreased from 1986 to 1987 and stabilized after that until 1989; acute hepatitis B incidence in all drug users in Amsterdam declined rapidly between 1985-89. It is concluded that changes in drug use behavior so far appear to have resulted in a stabilization of the epidemic among injectors, at a level with a still disturbingly high incidence rate of 5-6 per 100 person-years.
In this specially commissioned BJA series experienced clinicians will be giving their personal and frontline views as to how the practical business of treating people with substance problems is best handled.
One of the methadone programmes of the Amsterdam Municipal Health Service is the ‘methadone by bus’ project. Two mobile clinics cruise the city, stopping at six different locations daily. The liquid methadone is consumed on the spot and clean needles and condoms are available. This project is based on the principles of ‘harm-reduction’, i.e. if it is not (yet) possible to ‘cure’ a hard drug user, one should at least try to minimize the harm they cause to themselves and their environment. As soon as a client refrains from the use of illegal drugs, the client can ‘graduate’ to other methadone programmes with a higher threshold. To prevent double prescription, all Amsterdam methadone programmes participate in the central methadone registration. The Amsterdam Municipal Health Service has contact with over 50% of the drug users. The estimated number of hard drug users has remained stable over the last 5 years, whilst the average age of drug users has increased to 32 years. In the future, increasing the average dosage and the provision of injectable drug users will be discussed to assess their role in further harm reduction.
The author's goal in this article, is not merely to propose public health strategies for the future, but also to examine why government has been so slow, so equivocal, in its public health response to the acquired immune deficiency syndrome (AIDS) epidemic. He argues that there has been a fundamental ambivalence in perceptions of the epidemic. For some, AIDS is perceived as a disease, with sympathy for sufferers. Once AIDS is viewed as a disease, like other catastrophic diseases, it follows that public policy will be based upon science and epidemiology--health education, research and treatment.
For others, AIDS is caused by willful, irresponsible behavior. Persons infected with human immunodeficiency virus (HIV) are seen as morally blameworthy and deserving of punishment. Once AIDS is seen to be caused by willful, immoral behavior, public policy will, at least in part, be punitive towards persons carrying the infection (e.g., criminal penalties and discriminatory treatment), and overly protective of the sensibilities and morals of the wider community (e.g., censorship of explicit public health messages directed at those groups who are blamed for spread of the epidemic).
In this article, the author sets out a number of constructive public health policies which have gained virtually unanimous support in the public health community. These should be the priorities for our public health agenda for the decade, and not the largely irrelevant moral and punitive concerns which have captured a large segment of media reports, public opinion and legislative initiative.
The particular situation of the Swiss canton of Vaud (population 550,000) provides favourable observational conditions to assess the efficacy of a methadone treatment scheme in reducing the risk of human immunodeficiency virus (HIV) infection among drug users. On the one hand, the canton has a long tradition of methadone treatment dispensed by medical practitioners. On the other hand, no legal access to clean injection equipment was provided up to 1989. For the 754 drug addicts having entered at least one course of treatment at the end of 1988, HIV status was assessed through two surveys conducted at mid-1986 and at end 1988 among the private practitioners and in the screening centers, hospitals, medico-social institutions and prisons. The overall annual HIV seroconversion rate shifted only slightly from 13% in the first study period (1984 to mid-1986) to 11% in the second period (mid-1986 to end 1988). In both periods, patients no longer on treatment, mostly stable abstainers, were the less exposed to HIV infection with a relative risk of 0.65 (p < 0.05). For those still on treatment, the risk of infection was associated directly (p < 0.001) with the frequency of courses and inversely (p < 0.001) with the duration. Between patients with more than 18 months spent on treatment and those with less than 6 months, the relative risk gradient was 0.8 and 1.4 before mid-1986 and widened out to 0.3 and 2.1 later on. This is mainly due to an increasing HIV incidence among newcomers into treatment.(ABSTRACT TRUNCATED AT 250 WORDS)
Vending machines providing sterile injection equipment are part of the AIDS prevention measures for injecting drug users (IDU) in Berlin. A study was carried out to assess characteristics (history of iv drug use, frequency of use of the machines, contact with counselling units for IDU, attitudes towards the machines, HIV serostatus) in users of syringe vending machines. Of the 313 individuals surveyed, 77% reported using the vending machines regularly (more than four times a week). Compared to other studies of IDU in Berlin (eg at syringe exchange programmes) the users of the vending machines had a significantly shorter history of iv drug use. Overall, 72% of the IDU had had contacts at some time with specialised agencies for counselling on drug abuse and AIDS; however, only 33% had such contacts currently. Sixty-five percent of the IDU commented critically on the machines or made suggestions for improvement; 18% had experienced that the machines did not always work well, 14% called for more machines. HIV seroprevalence based on self-reported test results (N = 252) was 20%. In multivariate statistical analysis positive HIV serostatus was associated with site of interview, longer history of intravenous drug use, and current contact with counselling agencies. Despite the ready availability of syringes and needles, 25% of the participants reported borrowing injection equipment from other IDU in the previous six months. This proportion was significantly higher in IDU younger than 25 years (39%).(ABSTRACT TRUNCATED AT 250 WORDS)
By Septemer 30th 1991, 19579 cases of AIDS among injecting drug users had been reported in Europe. HIV seroprevalence rates among drug injectors vary from less than 5% in some cities to over 50% in others. Since the estimated number of drug injectors in Europe is between 750000 and 1.000000. HIV is a considerable threat to drug injectors, their sex partners and their off-spring, affecting large numbers of citizens in the European region. This paper gives an overview of the magnitude of the drugslAIDS problem, in the European region, and the concrete measures that have been taken to prevent HIV infection among drug users. Data from the evaluation of methadoneprogrammes, needle and syringe exchange schemes and data on sexual behaviour change of drug users are critically reviewed. Limitations of the methods used for the evaluation of prevention activities are also discussed Based on all the material reviewed, the main conclusions are the following.
-AIDS is a greater threat to public health than problem drug use.
-more accurate and reliable evaluation methods need to be utilized at European Community level.
-a combination of prevention measures should be used in ordet to reduce the further spread of HIV infection among injecting drug users.
The behaviors and attributes of 503 Scottish injecting drug users were modeled using the linear structural equations program LISREL. Drug use was directly related to prison experience, sexual activity, sharing of injecting equipment, and prostitution. Although the prevalence of HIV among the sample was low (2.0%), the pattern of risk behaviors observed in the data affords potential for future spread of the virus. Harm reduction measures taken by injectors in response to the threat posed by AIDS were inversely related to drug use but, more encouragingly, directly related to awareness of the disease, treatment for drug use, and prostitution.
How best can injecting drug misusers obtain clean injecting equipment in a city where drug injecting is widespread? An exchange service for needles and syringes throughout Glasgow has been established in health centres and clinics in the evening. Over the past four years seven new exchanges have been opened and over 2700 injecting drug misusers have attended. Attendances rose from under 1000 in 1988 to 28,000 in 1992. The exchanges also provide a wide range of other health and social services. Public hostility to the exchanges has abated. During the same period equipment sharing in the city diminished and the observed prevalence of HIV among injecting drug misusers stabilised at around 1%.
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