Proceedings--Workshop on Needle Exchange and Bleach Distribution Programs (1994) / Chapter Skim
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INTERNATIONAL EVALUATIONS OF NEEDLE EXCHANGE PROGRAMS
INTERNATIONAL EVALUATIONS OF NEEDLE EXCHANGE PROGRAMS
Pages 65-110
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From page 67... ...
, followed by injecting drug users (Rio) ; 93~o of the cumulative AIDS cases are men.
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From page 68... ...
As the needle/syringe exchange program is a low threshold project, there is no registration or monitoring of clients. Evaluation of the impact of the exchange program on injecting behavior and the spread of HIV, has therefore mainly taken place in our cohort study on HIV infection and AIDS.
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From page 69... ...
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.
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From page 70... ...
On the other hand, health education messages have also reached drug users who do not want to use the needle and syringe exchange program to obtain clean needles and syringes and prefer to buy their needles and syringes at pharmacies and certain shops. These considerations may imply that the impact of a prevention-program cannot be assessed by studying differences in risk behavior between attenders and non-attenders.
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From page 71... ...
Prevalence and riskfactors of HIV infections among drug users and drug using prostitutes in Amsterdam.
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From page 72... ...
These programmes had not seen the light of day spontaneously but rather, with the exception of the Vancouver needle exchange, were part of a federal government strategy to stimulate the development of pilot intervention programmer for injection drug users. The overall objectives for this initiative on the part of Health Canada were twofold.
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From page 73... ...
Five provinces participated with federal funding for the last of the pilot projects ending in March of 1993. Recognizing the importance of a long term integrated HIV prevention strategy in the injection drug using population, many provincial and local governments not only assumed the responsibility for ongoing funding but proceeded to increase the number of outreach programmer.
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From page 74... ...
Generally speaking these approaches included a comparison group of injection drug users who were not in treatment and not attending needle exchange. Most of the evaluations using this approach experienced difficulty following up individuals, due in part to the policy of allowing participants to remain anonymous, which made repeated participation dependent on the individual to return, or workers/interv~ewers to recognize previous participants and encourage them to participate again.
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From page 75... ...
TABLE 1 Needles Given Out by Year by 5 Urban Canadian Needle Exchange Programs YEAR ~ ~ CITY Toronto ~ Montreal ~ Vancouver ~ Winnepeg ~ Edmonton ~ Total 1989 ~ 4,387 ~ 24,267 ~ 127,806 ~ ~ ~ 156,460 1990 ~ 58,281 ~ 146,211 ~ 343,995 ~ 616 ~ 15,000 ~ 564,103 ,~ 169,423 ~527,248 136,624 1183,000 1992 ~ 120,637 ~ 193,740 ~ 607,385 ~ 24,831 ~ 392,080 ~ 1,338, (to Aug) 1 1 673 In addition to needles, most programs provided alcohol swabs, sterile water for injection, and condoms; many also provided bleach kits and instructions on needle disinfection for use in situations where sterile needles were not immediately available.
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From page 76... ...
Generally the improvements in safe needle use were greater among users of needle exchange than non-users; however in some studies, including the one in Toronto, there is some difficulty with interpreting trends in non-attenders of needle exchange, because trends in the population as a whole may be influenced by the work of the needle exchange, as well as by other services doing HIV education and counselling in the same population, so that the non-attenders are not truly without services, and the impact of the needle exchange in isolation is very difficult to determine. Indeed our own outlook has been that needle exchange should not be considered in isolation, but as part of a multi-service strategy; the reductions seen in risky needle use behaviour in the overall population suggest that the program as a whole is having beneficial impact.
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From page 77... ...
Health and Welfare Initiative to Support Pilot Intervention Programs for Injection Drug Users, Ottawa, July 1989.
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From page 78... ...
A key element of this program was the needle exchange called 'The Works.l1 In May 1991, we began another year of interviews with out of treatment IDUs recruited in the same sites as in the first year of study; this research represented the first year of a three year study in collaboration with the WHO multicentre study of HIV and injecting drug use. This drug user research has been funded by the National Health Research and Development Program of Health Canada.
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From page 79... ...
3. Sources of new, sterile needles also shifted between the two study periods, with needle exchange being reported as the most important source by 46% in year two as compared with I8% in year one, with a drop occurring between the years in the proportion reporting pharmacies or friends as their most important source.
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From page 80... ...
We have completed testing on specimens collected during our third year of study, ending in May 1993, and although we have not completed detailed analysis, the crude seroprevalence rate appears to be approximately the same as in years one and two. CONCLUSIONS We conclude that there has been significant decline in needle use related risk behaviour in this population, at the same time that ongoing HIV prevention efforts have been introduced and expanded.
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From page 81... ...
increase apparent in seroprevalence in our ongoing studies; we intend to continue to monitor the situation as our ci~cy's prevention program continues to be active. The accompanying copy of the poster presented at the With International AIDS Conference in Berlin illustrates the findings presented here.
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From page 82... ...
METHODS From Nov. 1989 to May 1992, we conducted interviews about HIV risk behaviour with IDUs, not in treatment, using thequestionnaire developed for the Wl4O Multicentre Study on Injecting Drug Use and Risk of HIV Infection.
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From page 83... ...
Once a baseline HTV prevalence proportions has been established, it can be followed prospectively to assess the stability of prevalence and document any increases or declines. The gold standard criterion for success, which has appears to have achieved general consensus, is the estimation of baseline HIV incidence with subsequent documented declines in incidence among injection drug users who are attending a needle exchange programme regularly.
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From page 84... ...
. Injection drug users from the correctional setting were study volunteers for an ongoing research project on risk factors for HIV infection among inmates in medium security correctional institutions2.
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From page 85... ...
When asked what they liked about CACTUS-Montreal, the most frequent responses were "the staff' and "it's free." None of the respondents suggested that CACTUS-Montreal dispense or exchange more needles than current quotas. Within the context of a seroepidemiological study conducted in the three correctional institutions, an analysis of seroprevalence levels in injection drug users by attender or non-attender status was conducted.
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From page 86... ...
Individuals who had never obtained or returned needles and who had never responded to questions concerning injection drug use practices were excluded from the analysis. Analyses for the period January 1990 to January 1993 yielded the following seroprevalence proportions: PREVALENCE IN IDU AMENDERS ~~ '~ ~ ~ ~ Proportion 95% CI Year 1 1 49 442 1 11.1% Year2 IT 51 345 1 14.8% Year 3 1 45 1 270 1 16.7% | *
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From page 87... ...
1 . ~ , v 1ne fact anal Hose ~na~v~aua~s are attracted to the site and are participating in risk reduction activities should be viewed as having positive implications for the eventual reduction of HIV transmission in Montreal's injection drug using community.
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From page 88... ...
Montreal's needle exchange: A successful verdict or is the jury still out?
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From page 91... ...
Sterile injecting equipment has been readily available in all major cities and large towns since 1988/1989 and in critical areas beginning in 1986. Drug store sales and needle and syringe exchange programmer (NSEPs)
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From page 92... ...
Evidence has emerged recently of an unofficial needle and syringe exchange programme successfully conducted for almost a year in several prisons in NSW. The Australian experience with HIV prevention among IDUs has stimulated a more critical appraisal of prohibition.
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From page 93... ...
. EPIDEMIOLOGY HIV Infection 'where is a large and consistent body of evidence which indicates that HIV infection is still relatively uncommon in Australian IDUs.
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From page 94... ...
It is estimated that there were only 600 new HIV infections nationally each year in the period 1989 - 90 (National Centre in HIV Epidemiology and Clinical Research, 1992~. These trends are shown in Figure I
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From page 95... ...
A steep gradient of HIV infection has been observed in a study of i,245 Sydney IDUs in 1989 (Ross, 1992, AIDS Care 139-48) with 3.2% of heterosexual male, 12.~% of homosexual/bisexual male and 35.4% of homosexual male IDUs infected with HIV suggesting that HIV entered the IDU population from homosexual/bisexual male IDUs.
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From page 96... ...
Parliamentary allparty AIDS committees were established at Federal and State levels with explicit agreement to refrain from party political conflict. A national drug policy of mininiisation of harm had been declared in 1985 at a meeting of the Prime Minister and State Premiers and facilitated the adoption and implementation of sensitive HIV prevention strategies even though AIDS had not influenced consideration of the original drug policy.
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From page 97... ...
It is difficult to estimate the quantity of injection equipment made available in Australia each year but it is likely that at least three to four million sterile needles and syringes are distributed or exchanged each year. In 1991, New South Wales (population 6.5 million)
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From page 98... ...
When asked to indicate how needles and syringes could be made more available, a range of responses was obtained but more drug stores selling needles and syringes, vending machines and special needle and syringe exchanges were the most common answers received (ANAIDUS, 1991~. Availability of injection equipment had further improved in two of the cities twelve months after the original data collection (ANAIDUS, 1992)
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From page 99... ...
Different kinds of IDUs appear to utilise different kinds of needle and syringe outlets Legal impediments to HIV prevention have recently been comprehensively reviewed including obstacles to NSEP operation (inter Governmental Committee on AIDS, 1992~. The Legal Working Party made recommendations covering repeal of self administration and other offences, the need for more non-custodial sentencing options and supported further research including the investigation of drug policy reform.
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From page 100... ...
In 1989, one sixth of a Sydney sample (limo) were at low risk of HIV infection as they had never shared injection equipment, cleaned injecting equipment effectively 100% of the time it was shared, and were celibate, monogamous, or had not had unsafe sex in the past six months (Wodak, in press)
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From page 101... ...
LOOMING PROBLEMS Hepatitis C and Other Blood Borne Viruses Continuing high levels of unsafe injecting practices and international spread of the HIV epidemic within and to an increasing number of countries suggest that complacency about the possibility of future spread of HIV among (and from) Australian IDUs is unwarranted.
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From page 102... ...
In contrast, unsafe injecting practices among IDUs in the community are increasingly restricted to small social networks. HIV infection within such a network has far less public health impact than infection of a prison inmate with the potential for wide dissemination of HIV within correctional facilities and subsequently following release.
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From page 103... ...
Whether a debate about drug policy reform would have developed in the absence of adoption of needle and syringe exchange programmer is arguable. However, the fact that liberalization of availability of injection equipment has been so beneficial and virtually unaccompanied by unintended negative consequences has certainly drawn attention to the lack of evidence of effectiveness, high costs and major adverse consequences associated with prohibition.
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From page 104... ...
Crime rates and rates of imprisonment are much lower in Australia than the United States. In most western countries including Australia, the questions policy makers ask about the availability of sterile injection equipment for injecting drug users is not whether this is a legitimate strategy to prevent the spread of HIV infection or even whether this policy contributes to improved control of the epidemic.
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From page 105... ...
(1993) Comparison of characteristics and HIV risk behaviours of injecting drug users attending needle and syringe exchange programs and pharmacies.
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From page 106... ...
Rinse (Jo) Drugstore 47.9 70.9 Needle exchange 22.0 32.6 After hours drugstore 14.3 21.2 Using friends 9.21 3.6 Non-using friends 1.2 1.8 Hospitals 1.2 1.8 Dealers 1.1 1.6 Doctors 0.9 1.4 Veterinary surgeons 0.5 0.8 Other 1.7 2.5 TABLE 3 Percentage New Needles and Syringes Were Easily Obtained in Two Cities, 1990 (ANAIDUS, 1992)
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From page 107... ...
* % new N ~ S from after hours drug store 19.7 10.8*
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From page 108... ...
1981 1 982 1983 1984 1985 1986 1987 1 988 1989 1990 Calendar Year Source: National Centre in HTV Epidemiology and Clinical Research. National Working Group on HIV Projections: Estimates and Projections of the HIV Epidemic in Australia, 1981 - 1994.
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From page 109... ...
An important point that bears repeating is that use of HIV seroconversion as an outcome measure may not be feasible or even relevant to the evaluation of needle exchanges. In most of the studies that were presented, needle exchanges were being introduced into populations that were either already heavily saturated with HIV infection or still at a very low level of seroprevalence.
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From page 110... ...
In conclusion, Selwyn observed, based on the existing data and leaving aside the policy and underlying social dimensions for the moment, needle exchange programs do not make things any worse and there are some data -- e.g., from Kaplan in New Haven-that they may make things better. They do not cause people to use drugs, they seem in many instances to promote positive behavioral change, they definitely help provide access to vulnerable and sometimes otherwise inaccessible populations, and they may reduce the risk of transmission of HIV.
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