HIV-related Risk Behaviour Among a Non-clinic Sample of Injecting Drug Users

This paper focusses upon HIV-related risk behaviour among a sample of injecting drug users purchasing injecting equipment at a retail pharmacy in Glasgow. It is shown that the majority of the individuals interviewed were concerned about HIV/AIDS and that many were optimistic about their chances of avoiding contracting the virus. However, it is shown that the shared use of injecting equipment was continuing and that many individuals were prepared to provide their own injecting equipment to others, even if they were unprepared to re-use it again themselves. We also consider here the possibility of encouraging drug injectors to switch to non-injecting drug use and the potential basis for any sexual transmission between drug injectors and others. The paper concludes with a consideration of some of the policy implications of this work.     

The preparedness to share injecting equipment: an analysis using vignettes

This paper reports on the use of vignettes to study drug injectors’preparedness to share injecting equipment. Separate vignettes referring to borrowing and passing on injecting equipment have been submitted to 505 injecting drug users in Glasgow. Injectors were asked to identify their own likely response in each of the situations described within the vignettes. It was shown that even among those injectors not reporting any actual sharing in the last 6 months a significant proportion would still be prepared to share injecting equipment within certain situations. The preparedness to share injecting equipment was seen to be influenced by such factors as social distance, sex and length of time injecting. It is suggested that even in situations where drug injectors may have modified their behaviour in the direction of lower levels of reported sharing, a propensity to share may remain. This suggests the continuing need to provide injectors with easy access to sterile injecting equipment; in addition, services working with injecting drug users may need to focus not only upon actual sharing behaviour but also upon what we have described here as the preparedness to share. Indeed, the latter dimension should stand as a warning to services of the potential for sharing injecting equipment to increase in the future.     

Pharmacy-based needle exchange (PBNX) schemes in south east England: a survey of service providers

Aims. To describe the activities of service providers with regard to (i) the business operation and policies defining pharmacy-based needle exchange (PBNX) in South East England; (ii) the day-to-day work of PBNX outlets from the provider perspective; and (iii) problems encountered by PBNX providers. Design. (i) Postal self-completion questionnaire to all participating PBNX community pharmacies in South East England; and (ii) postal self-completion questionnaire to needle exchange coordinators. Setting. Community pharmacy needle exchanges. Participants. Pharmacists in charge of needle exchange; and needle exchange coordinators. Findings. Data were collected (i) from 381/440 (86.7%) participating community pharmacists, and (ii) 32/36 (88.9%) of coordinators. The study found that PBNX was reaching injecting drug users (many of whom used PBNX regularly), and providing a wide range of injecting equipment. Although pharmacists reported that problems such as shoplifting occurred relatively frequently, more serious problems such as violence were relatively rare. However, PBNX pharmacists reported needing further training for themselves and their staff. Suggested improvements included better advertising of services and improving returns rates for used injecting equipment. Conclusion. Needle exchange can reasonably be provided by non-specialist health care professionals such as community pharmacists. However, attention should be paid to the educational needs of service providers who also require adequate support.     

Sexual partners of injecting drug users: the risk of HIV infection

The sexual mediation of HIV infection by injecting drug users to the heterosexual population has become a major issue in AIDS prevention. Infection that is acquired through sharing contaminated injecting equipment can be passed on to non–injecting drug using partners and to non–drug using partners through sexual intercourse. A study of risk behaviour among injecting drug users in the North West of England focused, interalia, upon aspects of their sexual activity and attitudes that have relevance for HIV transmission. It was found that in those respondents with regular partners, the level of sexual activity was related to the partner's use of drugs. The use of condoms was low in the sample as a whole, including those who reported having casual sexual contacts and sharing others’ injecting equipment. These data confirm the need for concern and the advisability of targetting safer–sex education on drug users.     

Hepatitis C prevalence and risk behavior of injecting drug users in Sydney: a continuing concern

This study examines patterns of injecting drug use and hepatitis C (HCV) risk behavior among injecting drug users. A survey of injecting drug users attending needle and syringe programs (NSPs) in the Sydney metropolitan area and members of NSW Users and AIDS Association (NUAA) yielded 336 responses. Demographic, behavioral and drug-use information was collected from injecting drug users aged from 14 to 64 years. The majority of respondents (66%) were HCV positive, 28% had tested negative and 5% did not know their status. Prevalence was higher among men than among women (54% vs 44%). Two thirds of respondents (72%) reported frequent heroin injection. Multivariate analysis identified the following significant risk factors for hepatitis C: being more than 30 years of age, an injecting history of five years or more, and having shared drug injecting equipment with a HCV positive user. The most significant factor associated with needle sharing was having unprotected sex with sexual partners and having a positive hepatitis C test result. Early identification of these factors should be a component of HCV prevention programs. Our data indicate that the promotion of safer injecting continues to be an important public health issue with regard to reducing HCV infections.     

Participant Observation and its Place in the Study of Illicit Drug Abuse

Participant observation has long been utilized as a valuable research methodology in the study of illicit drug abuse. It should not be viewed in isolation, but seen as an essential complement to the quantitative analysis of trends in drug use, such as epidemiological studies and the monitoring of services for drug users. Fieldwork conducted at the Drug Indicators Project and other relevant studies highlight the practical and ethical problems faced by the participant observer, including issues of access, co-operation and confidentiality. This is particularly pertinent when working with drug users not in contact with services. When working with drug users in a treatment context, the need to be flexible and sensitive to the needs of agency staff is stressed, and the ways in which participant observers can operate as volunteers are explored. Contemporary concern about HIV infection, AIDS, and risk behaviour amongst drug users, raises the potential for an expansion and redefinition of the role of the participant observer to take on some of the functions of health educator, and two options are suggested.     

开展针具交换工作所遇到的困难和风险及对策

目的 旨在分析开展针具交换工作所遇到的困难和风险,为探讨克服困难、规避风险的策略和措施提供参考.方法 对江西省18名针具交换专家、6名工作人员、16名同伴教育员和160名静脉注射毒品者(IDU)进行了调查.结果 针具交换工作中存在的困难包括:开展针具交换工作的支持性环境有待改善,可利用资源有限;工作人员对IDU情况了解不多,对工作质量没有直接控制权,对同伴教育员控制力不够和缺乏有效的监督手段;同伴教育员工作积极性不高,开展工作的时间和精力有限等.风险包括:工作人员受到吸毒人员的恐吓、威胁和伤害;存在被污染针具划伤的危险等.结论 加强领导开发,部门协调,社区宣传;提高同伴教育员数量和质量;加强工作过程监督;加强安全防范,保障工作人员和同伴教育员人身、财产安全等措施有利于困难和风险的应对.     

Multi-site samples of injecting drug users in Edinburgh: prevalence and correlates of risky injecting practices

Aims. To estimate the frequency of injecting and prevalence of equipment sharing and other risky injecting practices among intravenous drug users (IDUs) and to identify correlates of these behaviours. Design. Three cross-sectional surveys of IDUs by face-to-face interview in the years 1992-94. Setting. Multiple treatment and non-treatment sites throughout the city of Edinburgh, Scotland, UK. Participants. Six hundred and thirty-four interviews of 480 IDUs who reported having injected a drug in the previous six months. Measurements. Self-reports of drug-taking behaviours, service contact, sexual behaviour and HIV knowledge, and anonymous testing of saliva for HIV antibodies. Findings. Only 18% had injected at least daily. Thirty-five per cent had accepted or passed on used equipment. Eighty-five per cent of subjects recruited from non-treatment sites were receiving treatment for their drug taking. Multivariate analyses indicated that risky injecting was associated with a consistent history of sharing, polydrug injecting, injecting in prison, having recently started injecting, and recent experience of methadone detoxification. Conclusions. Injecting frequency and equipment sharing have declined substantially in Edinburgh during the past 10 years and are low compared to other cities in the United Kingdom and elsewhere. These improvements have occurred in the context of remarkably high levels of drug treatment service contact. Our findings support the international evidence indicating that IDUs have modified their injecting habits significantly without completely eliminating this form of HIV risk. High levels of service contact in Edinburgh provide ample opportunities to instigate further HIV prevention measures which target identifiable subgroups of IDUs who persist in risky injecting.     

Injecting equipment sharing and perception of HIV and hepatitis risk among injecting drug users in Budapest

In central European states, rates of HIV among injection drug users (IDUs) have been low although Hepatitis C (HCV) infection is widespread. The goal of our study was to assess HIV infection, risk perceptions and injecting equipment sharing among IDUs in Budapest, Hungary. Altogether 150 IDUs were interviewed (121 structured interviews between 1999 and 2000 and 29 ethnographic interviews between 2003 and 2004). The majority of them injected heroin (52% and 79%) and many injected amphetamines (51% and 35%). One person tested positive for HIV. Two thirds (68%) shared injecting equipment (syringes, cookers and filters). Some participants said they shared syringes because they were not carrying them for fear of police harassment and that they reused filters as a backup drug supply. In multivariate analysis, sharing of injecting equipment was associated with higher perceived susceptibility to HIV/AIDS, lower self-efficacy for sterile equipment use, higher motivation to comply with peer pressure to use dirty injecting equipment and with having a criminal record. The high levels of injecting risk-behaviors found in this study are a cause for serious concern. Interventions for HIV-prevention need to address not only sharing syringes but also sharing and reusing of other injecting equipment and drug filters.     

Drug injecting and syringe use in the HIV risk environment of Russian penitentiary institutions: Qualitative study

BACKGROUND: Evidence highlights the prison as a high risk environment in relation to human immunodeficiency virus (HIV) and hepatitis C virus (HCV) transmission associated with injecting drug use. METHODS: We undertook qualitative studies among 209 injecting drug users (IDUs) in three Russian cities: Moscow (n = 56), Volgograd (n = 83) and Barnaul in western Siberia (n = 70). RESULTS: Over three-quarters (77%) reported experience of police arrest related to their drug use, and 35% (55% of men) a history of imprisonment or detention. Findings emphasize the critical role that penitentiary institutions may play as a structural factor in the diffusion of HIV associated with drug injection in the Russian Federation. While drugs were perceived to be generally available in penitentiary institutions, sterile injection equipment was scarce and as a consequence routinely shared, including within large groups. Attempts to clean borrowed needles or syringes were inadequate, and risk reduction was severely constrained by a combination of lack of injecting equipment availability and punishment for its possession. Perceptions of relative safety were also found to be associated with assumptions of HIV negativity, resulting from a perception that all prisoners are HIV tested upon entry with those found HIV positive segregated. CONCLUSION: This study shows an urgent need for HIV prevention interventions in the Russian penitentiary system.     

Hospital health care for HIV infection with particular reference to injecting drug users

Models of health care developed for HIV and AIDS tend to reflect the experience of San Francisco or London where the majority of patients affected have been homosexual or bisexual. The services developed in these areas may not be appropriate for other risk groups such as injecting drug users. The author, who has been closely involved in developing an HIV service in Edinburgh mainly for injection drug users, undertook a travel fellowship to compare and contrast HIV medical services in Amsterdam, New York and San Francisco with particular regard to what was available for injecting drug users. The provision of drug related and HIV medical services at the same site by the same doctors appears to provide the most efficient service but has yet to be systematically evaluated.     

Distributive sharing among HIV-HCV co-infected injecting drug users: the preventive role of trust in one's physician

This study, based on data from the MANIF 2000 cohort study, investigates the relationship between the lending of injecting equipment, drug use, and experience with HIV care. The sample comprised 224 HIV-HCV co-infected patients who reported having injected drugs in the previous six months and their 538 visits to clinical services. Longitudinal data were collected for medical status, and self-reported risk behaviors. A logistic regression GEE model was used to identify correlates of distributive sharing. After multiple adjustment, patients who reported trust in physicians were significantly less likely to report lending injection equipment while cocaine users were at increased risk. Promoting dialog between physicians and injecting drug users (IDUs) may play an important role in HIV-HCV positive prevention.     

Prevalence of HIV and associated risk behaviour in attendees at a Dublin needle exchange

The aim of this study was to measure the prevalence of HIV infection and assess the level of equipment-sharing and unsafe sexual activity among attendees at a Dublin needle exchange. Using an anonymous unlinked approach, attendees were asked to complete a brief questionnaire and provide a sample of saliva for HIV testing. Of the 144 attendees eligible for inclusion during the study period, 106 agreed to participate and complete a questionnaire, a response rate of 74%. Of the 81 respondents who submitted a usable saliva sample, 14.8% were HIV positive. Half of the respondents claimed that they had not shared equipment during the preceding 28 days, but a third had shared with multiple partners. Half of the respondents claimed that they had multiple sexual partners during the preceding year, but only a quarter said that they always used condoms. The prevalence of HIV infection is similar to that found in routine linked testing of drug users in Ireland. The high level of unsafe injecting and sexual activity makes clear the need for more effective health promotion among drug users in Dublin.     

Intravenous drug users and broken needles—a hidden risk?

Aims To determine the frequency with which intravenous drug users (IDUs) experience broken needles during their injecting careers. Design Cross‐sectional survey. Participants Seventy intravenous drug users held in police custody in Bristol between May and September 2002. Measurements Self‐reported history of experience of broken needles. Findings Fourteen (20%, 95% CI 11–29%) had experienced a needle breaking while injecting. The total number of broken needles was 23, of which 14 (61%) were recovered, four by surgical intervention, and the remainder as a result of direct action by the individual. Of the 23 broken needles, nine (39%) were reported to be fresh needles, whereas the remainder were being re‐used. Conclusions IDUs may well experience, directly or indirectly, incidents involving broken needles during the course of their injecting careers. Given the potential for embolization and the risk of subsequent complications when this occurs, we recommend that harm minimization guidance should include advice about this potential hazard and the need for early action to retrieve broken needles.     

The epidemiology of hepatitis C among injecting drug users in Belgium

In industrialised countries, injecting drug use is currently the most important risk factor for infection with hepatitis C, resulting in high prevalence rates of hepatitis C among injecting drug users. To contain the hepatitis C epidemic major efforts should be done to prevent new infection among injecting drug users. Monitoring infection rates are crucial as it may provide feedback on the effectiveness of interventions. In this article the epidemiology of hepatitis C among injecting drug users in Belgium is briefly reviewed. More specifically the prevalence of anti-HCV antibodies, the prevalence of co-infections, the proportion of chronic HCV carriers, the distribution of genotypes and preventive measures among injecting drug users in Belgium are discussed and compared to the situation elsewhere in Western Europe.     

The role of needle exchanges in modifying sharing behaviour: cross-study comparisons 1989–1993

In this paper the relationship between sharing behaviour and needle-exchange attendance is examined. Data from three studies of drug misuse canned out consecutively from 1989 to 1993 in the north-west of England are compared. Samples differed in their drug preferences. Analyses of sharing injecting equipment comparing exchange attenders and non-attenders revealed different patterns in each of the studies. Among opiate injectors no differences were observed in the proportions using others' injecting equipment, but attenders not in treatment were more likely to pass on their used equipment. This was attributed to uneven patterns of availability in the early days of exchange provision. Primary amphetamine users attending a needle exchange shared less than non-attenders, although overall levels of sharing were higher. Frequency of sharing was lowest in the third study of poly drug users but proportions sharing were similar to the opiate users. There was no effect of exchange attendance on sharing. Multiple logistic regressions identified other important predictors in these studies, e.g. treatment status, an injecting partner and injecting friends. Interpretations of the relationship between exchanges and sharing should take account of local availability of sterile equipment and the characteristics of exchange clientele.     

Self-reported overdose among injecting drug users in London: extent and nature of the problem

Aims. To estimate the extent and nature of overdose and factors associated with overdose among injecting drug users in London. Design. Three hundred and twelve current injecting drug users were recruited and interviewed in community settings by a team of "privileged access interviewers". Measurements. A structured questionnaire was used that covered the following areas: demographic characteristics, drug use, injecting behaviour, sharing practices, severity of drug dependence, experience of overdose, injecting-related health problems and treatment history. Findings. The results showed that experience of overdose was common (38%). A majority (54%) had witnessed someone else overdose. Overdosing was not a solitary experience; over 80% of subjects who had overdosed had done so in the presence of someone else, but only 27% reported ambulances having been called. Factors found to be associated with overdose were: age at which injecting began; gender (women being more likely to experience overdose); use of alcohol; and polydrug injection. The overall rate of overdosing was one per 6 years of injecting; however, once an individual had an overdose the chance of having another increased. The risk of experiencing a first overdose fell with years of injecting. Conclusions. Harm-reduction interventions with drug injectors should educate users on the risk factors associated with overdose and actions that should be taken when someone has overdosed. Interventions designed to reduce the risk of overdose may be more effective if they are differentially targeted on drug injectors who have already experienced an overdose.     

Initiators: An Examination of Young Injecting Drug Users Who Initiate Others to Injecting

Research about initiation to injecting drugs emphasises the role that relationships with others plays in the experience, suggesting investigations of initiation should include an examination of both initiates and initiators. This paper uses cross-sectional data collected from 324 young, early-career injecting drug users (IDU) to describe the socio-demographic characteristics, drug and injecting practices, and harm reduction knowledge and practices of people who report initiating others to injecting. Fifty-five participants (17%) reported giving someone else their first injection. They reported initiating a total of 128 other people within the first 5 years of their own injecting. Compared to non-initiators, initiators were more likely to pass on harm reduction information [odds ratios (OR): 2.36, 95% confidence intervals (CI): 1.26–4.40]. However, the quality of this information was unknown and initiators did not have more accurate knowledge of blood borne viruses (BBV) than non-initiators, and commonly obtained needles and syringes from sources where the sterility of the equipment could not be guaranteed.     

The first and second decades of AIDS among injecting drug users

This paper examines findings and trends from the first decade of research on AIDS among injecting drug users as a basis for projecting into the next decade. One of the most disturbing aspects of AIDS and HIV infection among injecting drug users which emerged in the first decade is the globalization of the problem. Further geographic spread can be expected, particularly in developing countries. Rapid spread of HIV among drug injectors has occurred in many different cities, with a lack of AIDS awareness and mechanisms for efficient mixing of the at-risk population appearing to be important contributing factors. Drug injectors have modified their behavior in response to a wide variety of AIDS prevention programs. No single type of prevention program should be viewed as a panacea, and a comprehensive system of programs will undoubtedly be needed. Changing sexual risk behavior has proven to be considerably more difficult than changing drug injection risk behavior, and is an area in need of much more research.