Can drug injectors be encouraged to adopt non‐injecting routes of administration (NIROA) for drugs?

Drug use by injection can cause problems specific to this form of administration. Problems include an increased risk of drug overdose, drug dependence, the transmission of HIV, hepatitis B and hepatitis C and vein damage. Shifting drug injectors from injecting to another route of administration may minimize these problems. The aims of the study were to develop and trial an intervention to assist willing injecting drug users (IDUs) to shift to non-injecting routes of administration (NIROA) and to explore the acceptability and practicality of facilitating NIROA. IDUs were assessed and suitable subjects entered a cognitive behavioural trial consisting of five 1-hour sessions of individual therapy with a registered psychologist. Forty-two subjects were assessed (22 males and 20 females). Thirty subjects entered treatment. The mean age was 36 years. Twenty-one subjects were followed-up at 3 months and 10 subjects at 6 months. At 3 and 6 months, the proportion of subjects who had commenced using NIROA was 30% and 50%, respectively. This pilot study showed that it was possible to assist a minority of drug injectors to move from injecting to the non-injecting administration of drugs. However, many of these appeared to be already motivated to cease using drugs and adopting NIROA was one way of assisting this. Poor follow-up rate, lack of control group, questions about cost-effectiveness and the impact of market factors which possibly constrain shifting to NIROA suggest that further research is needed before it could be said that NIROA should be recommended as a viable harm reduction strategy in the Australian context.     

Doing the possible: harm reduction, injecting drug use and blood borne viral infections in Australia

Most surveys show that, other than among men who inject drugs and have a history of homosexual contact, the prevalence of HIV infection among injecting drug users (IDUs) in Australia is about 2%. Rates of needle sharing have also declined greatly in the last decade, although the high prevalence and incidence of hepatitis C infection suggest that existing strategies have not yet brought this epidemic under control. Harm reduction has been the major Australian approach to the reduction of blood borne viral infections (BBVIs) in IDUs. Harm reduction strategies include needle distribution schemes, drug substitution therapies and education about safe administration practices. Importantly, with IDUs as with gay men, the infected and affected communities have been brought into partnership with health educators, researchers and policy makers. This paper will review Australia's approach to the prevention of BBVI in IDUs and the effectiveness of current strategies. I will argue that while HIV/AIDS among heterosexual IDUs appears to have been successfully prevented, international experiences of rapidly emerging epidemics demonstrate there is little room for complacency. Moreover, reducing the incidence of hepatitis C and hepatitis B among IDUs remains a major challenge.     

'There is no profile it is just everyone': the challenge of targeting hepatitis C education and prevention messages to the diversity of current and future injecting drug users

This paper investigates drug use, knowledge of hepatitis C, and risk minimisation amongst participants of the Sydney inner city dance party/club scene. The aim is to identify factors that contribute to the limited success of hepatitis C education and prevention efforts in Australia and to suggest ways in which they might be improved. The method used was a thematic analysis of 31 semi-structured qualitative interviews with people drawn from the Sydney inner city dance party/club scene. This is a scene where the consumption of recreational drugs is normalised, and where the practice of injecting takes place, albeit less commonly to other routes of administration. In the material presented here, drugs are seen as sources of enjoyment and experimentation, but are not seen as necessary to the functioning of daily life. Indeed, dependency on drugs is largely seen as undesirable. Most participants consider themselves to be both well informed about the drugs they use, and in control of their drug use. Whilst participants in this scene are generally well informed about drugs (and deploy harm reduction strategies to avoid such things as overdose), their knowledge of hepatitis C is limited and vague. The marginal and stigmatised status of injecting both inside and outside the scene appears to contribute to an absence of information and communication about safer injecting and hepatitis C within the scene. Often information about safe injecting is perceived to lack relevance to scene participants and to be aimed at 'other' injecting drug users (IDU). The material discussed confirms the diversity of IDU and the crossover between social, sexual and drug networks. Whilst this poses challenges for education and prevention, the exploration of these networks or scenes has the potential to inform the content of education and prevention materials as well as identifying contexts for dissemination.     

The Role of Physician and Nurse Attitudes in the Health Care of Injecting Drug Users

In 2005, 60 health care workers were recruited through services that attract injecting drug users (IDUs) and asked to complete attitude measures regarding IDU clients. Mediation analyses indicated that conservative health care workers displayed more negative attitudes toward their IDU clients because they believe that injecting drug use is within the control of the IDU. Negative attitudes toward IDU clients, in turn, were associated with worry about IDU clients’ behavior in the clinic and with beliefs that IDU clients should disclose their hepatitis C status to their health care worker. Perceptions of controllability of drug use were also associated with the belief that IDU clients’ ailments were caused by their IDU status. The study's limitations are noted.     

The sharing of injecting paraphernalia by intravenous drug users (IDUs) within a Worcestershire cohort, with specific reference to water and filters

Britain continues to have a drug misuse health strategy that is HIV led. Because of this, little attention has been paid to other blood-borne viruses such as hepatitis. Moreover, while the provision of needle exchange schemes has been particularly successful in containing the spread of HIV, they have had less impact on the prevalence of hepatitis within IDU cohorts. Thus, it is necessary to understand more about the potential pathways through which the hepatitis viruses can be transmitted. One way of achieving this is to assess the propensity of IDUs to share other items of injecting paraphernalia such as water and filters. In addition, it is useful to gauge the level of opinion with respect to health hazards associated with sharing such items, amongst injecting drug users. This study reports on a small pilot project initiated to assess the degree of sharing of filters and water among 40 needle exchange service users in Worcestershire. Results based on questionnaires show that sharing of water and filters is very high within the sample group. Indeed, only 10% of clients reported never sharing either water or filters. The study also demonstrates that although injectors are aware of the health risks associated with sharing (including hepatitis transmission), they continue to participate in high risk sharing activities. Moreover, the majority of IDUs questioned have a mis-conception with respect to the most hygienic sources of water for injecting. For example, only 10% consider sterile water to be the most hygienic source for injecting, with >70% considering tap water in one form or another to be safe. The study is important because it highlights the value of providing sterile water and filters to IDUs to meet their basic and fundamental needs. It is hoped that the findings from this small project will have a wider transferability to other IDU cohorts throughout the UK and beyond.     

Antiretroviral HIV treatment and care for injecting drug users: an evidence-based overview

AIDS-related mortality and the rate of progression to AIDS have dramatically decreased since the advent of highly active antiretroviral treatment (HAART). The overall benefit from antiretroviral HIV treatment has, however, been lesser in HIV-infected injecting drug users (IDUs) than in other patient groups (e.g. men who have sex with men). Poorer outcomes in HIV-infected IDUs are related to a variety of factors, including increased rates of non-HIV-related deaths, hepatitis C, delayed access to effective treatment, lower adherence to care and treatment regimens, continuation of illicit drug use, depression and negative life events. The available evidence strongly suggests the need for the large-scale implementation of comprehensive treatment and care strategies for IDUs that include both treatment of drug dependence and HAART.     

Measuring attitudes toward injecting drug users and people with hepatitis C

Preexisting scales used to measure attitudes toward human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) and homosexuals were adapted to assess attitudes toward people with hepatitis C (HCV) and injecting drug users (IDUs). In 2005, 110 undergraduate psychology students completed these scales, and abbreviated versions of the IDU and HCV scales were then administered to 61 health care workers to establish their relevance in the field. Results indicated that the new scales have good reliability and validity with undergraduates and with health care workers in an applied setting.     

Measuring Attitudes Toward Injecting Drug Users and People with Hepatitis C

Preexisting scales used to measure attitudes toward human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) and homosexuals were adapted to assess attitudes toward people with hepatitis C (HCV) and injecting drug users (IDUs). In 2005, 110 undergraduate psychology students completed these scales, and abbreviated versions of the IDU and HCV scales were then administered to 61 health care workers to establish their relevance in the field. Results indicated that the new scales have good reliability and validity with undergraduates and with health care workers in an applied setting.     

Route transition interventions: Potential public health gains from reducing or preventing injecting

Multiple factors are implicated in the diffusion of injecting drug use (IDU), including individual and demographic characteristics, drug markets, economics, social networks and political and cultural environments. However, studies show that individual transitions away from injecting are possible, and that a recent diffusion of non-injecting routes of administration (NIROA) has occurred in several countries. Injecting is more risk-laden than other routes of drug administration, yet relatively little attention has been paid to reducing or preventing injecting drug use by promoting NIROA. This commentary reviews the case for, and examples of, ‘route transition interventions’ which seek to do this. These include: prescribing oral substitutes; providing non-injecting equipment; providing safer smoking facilities; and training individuals to prevent transitions to injecting, promote NIROA, or prevent the initiation of new injectors. These initiatives have the potential—as yet largely unrealised—to offer public health gains and empower people to control and manage their drug use. Further research is needed to secure commitments at all levels to support this approach.     

The impact of injecting drug use status on hepatitis C-related referral and treatment

More than 160,000 people are living with chronic hepatitis C virus (HCV) infection in Australia, however, rates of medical treatment are low. The aim of this study is to examine uptake and predictors of HCV-related health care services among a community-based sample of people with HCV. A self-administered questionnaire was completed by a largely non-clinical sample of 362 women and 308 men with HCV living in the state of Victoria. Analyses were performed according to injecting drug use (IDU) status: no history of injecting (non-IDUs), previous history of injecting (past-IDUs) and current (within the last 12 months) history of injecting (current IDUs). Bivariate and multivariate predictors of referral to a specialist liver clinic were also assessed. Fifty-one percent of participants were current IDUs, 33% past-IDUs and 16% non-IDUs. Fifty-two percent of women and 37% of men reported ever being referred to a specialist liver clinic and 18% of women and 20% of men reported previous HCV antiviral therapy. Although there were many factors related to an increased likelihood of referral (e.g. being female, longer time since diagnosis, longer consultation time at diagnosis, experiencing HCV-related symptoms), multivariate analysis revealed that not being a current IDU and seeing a GP specifically for HCV were the most important independent predictors of referral. For those who had been referred to a liver clinic, a history of IDU was associated with a lower chance of receiving antiviral therapy. IDU status is associated with both referral and treatment. The extension of HCV treatment services to involve GPs and drug and alcohol practitioners should be explored as models to improve access to antiviral therapy.     

Topic-Focused Bibliography: Syringe Exchange: HIV Prevention,Key Findings,and Future Directions

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.     

Distributive syringe sharing among young adult injection drug users in five U.S. cities

Blood-borne pathogens such as human immunodeficiency virus (HIV) and hepatitis C virus (HCV) are transmitted most commonly among injection drug users (IDUs) through the sharing of needles and syringes. Distributive syringe sharing (DSS) (i.e., passing on a used needle/syringe to another IDU) poses the potential risk of transmitting HIV and viral hepatitis to others. We studied the prevalence and correlates of DSS among IDUs enrolled in a randomized behavioral intervention trial designed to reduce behaviors associated with HIV and HCV transmission in five U.S. cities. Among 3129 IDUs ages 15-30 years who completed the baseline visit, 1432 (45.8%) engaged in DSS during the 3 months prior to baseline. Significant correlates of DSS were perception that peer norms condone needle sharing, frequent injection, not obtaining most syringes from needle exchange programs or pharmacies, injecting most frequently in shooting galleries and with sex partners, low perceived risk of HIV from sharing syringes, increased anxiety, low self-esteem, and having unprotected sex. Restricting to only those IDUs who reported not injecting with previously used syringes, similar independent correlates of DSS were found. These findings suggest that interventions to reduce ongoing transmission of blood-borne infections should focus on altering peer norms among networks of young IDUs.     

HIV Among Drug Users at Beth Israel Medical Center,New York City,the First 25 Years

New York City experienced the first and largest HIV epidemic among injecting drug users (IDUs). Using data collected from IDUs entering the Beth Israel drug detoxification program, we trace the history of this epidemic from the mid-1970s through the early 2000s. The epidemic can best be described in terms of successive stages: (1) introduction and rapid transmission of HIV in the IDU population; (2) stabilization of HIV prevalence at a high level (over 50%); (3) a decline in incidence and prevalence, following large-scale implementation of syringe exchange programs; and (4) a sexual transmission phase, in which HIV prevalence is approximately equal among injecting and noninjecting heroin and cocaine users, and sexual transmission is more important than injecting-related transmission among IDUs. Given the current spread of HIV among IDUs in many places in the world, New York City provides a very strong example for implementation of large-scale comprehensive syringe exchange programs as early as possible in HIV epidemics among IDUs.     

HIV among drug users at Beth Israel Medical Center, New York City, the first 25 years

New York City experienced the first and largest HIV epidemic among injecting drug users (IDUs). Using data collected from IDUs entering the Beth Israel drug detoxification program, we trace the history of this epidemic from the mid-1970s through the early 2000s. The epidemic can best be described in terms of successive stages: (1) introduction and rapid transmission of HIV in the IDU population; (2) stabilization of HIV prevalence at a high level (over 50%); (3) a decline in incidence and prevalence, following large-scale implementation of syringe exchange programs; and (4) a sexual transmission phase, in which HIV prevalence is approximately equal among injecting and noninjecting heroin and cocaine users, and sexual transmission is more important than injecting-related transmission among IDUs. Given the current spread of HIV among IDUs in many places in the world, New York City provides a very strong example for implementation of large-scale comprehensive syringe exchange programs as early as possible in HIV epidemics among IDUs.     

Paradoxes in antiretroviral treatment for injecting drug users: access, adherence and structural barriers in Asia and the former Soviet Union

Offered proper support, injection drug users (IDUs) can achieve the same levels of adherence to and clinical benefit from antiretroviral treatment (ARV) as other patients with HIV. Nonetheless, in countries of Asia and the former Soviet Union where IDUs represent the largest share of HIV cases, IDUs have been disproportionately less likely to receive ARV. While analysis of adherence amongst IDUs has focused on individual patient ability to adhere to medical regimens, HIV treatment systems themselves are in need of examination. Structural impediments to provision of ARV for IDUs include competing, vertical systems of care; compulsory drug treatment and rehabilitation services that often offer neither ARV nor effective treatment for chemical dependence; lack of opiate substitution treatments demonstrated to increase adherence to ARV; and policies that explicitly or implicitly discourage ARV delivery to active IDUs. Labeling active drug users as socially untrustworthy or unproductive, health systems can create a series of paradoxes that ensure confirmation of these stereotypes. Needed reforms include professional education and public campaigns that emphasize IDU capacity for health protection and responsible choice; recognition that the chronic nature of injecting drug use and its links to HIV infection require development of ARV treatment delivery that includes active drug users; and integrated treatment that strengthens links between health providers and builds on, rather than seeks to bypass, IDU social networks and organizations.     

Drug use and the risk of HIV infection amongst injection drug users participating in an HIV vaccine trial in Bangkok, 1999–2003

BackgroundHIV spread rapidly amongst injecting drug users (IDUs) in Bangkok in the late 1980s. In recent years, changes in the drugs injected by IDUs have been observed. We examined data from an HIV vaccine trial conducted amongst IDUs in Bangkok during 1999–2003 to describe drug injection practices, drugs injected, and determine if drug use choices altered the risk of incident HIV infection.MethodsThe AIDSVAX B/E HIV vaccine trial was a randomized, double-blind, placebo-controlled trial. At enrolment and every 6 months thereafter, HIV status and risk behaviour were assessed. A proportional hazards model was used to evaluate demographic characteristics, incarceration, drug injection practices, sexual activity, and drugs injected during follow-up as independent predictors of HIV infection.ResultsThe proportion of participants injecting drugs, sharing needles, and injecting daily declined from baseline to month 36. Amongst participants who injected, the proportion injecting heroin declined (98.6–91.9%), whilst the proportions injecting methamphetamine (16.2–19.6%) and midazolam (9.9–31.9%) increased. HIV incidence was highest amongst participants injecting methamphetamine, 7.1 (95% CI, 5.4–9.2) per 100 person years. Injecting heroin and injecting methamphetamine were independently associated with incident HIV infection.ConclusionsAmongst AIDSVAX B/E vaccine trial participants who injected drugs during follow-up, the proportion injecting heroin declined whilst the proportion injecting methamphetamine, midazolam, or combinations of these drugs increased. Controlling for heroin use and other risk factors, participants injecting methamphetamine were more likely to become HIV-infected than participants not injecting methamphetamine. Additional HIV prevention tools are urgently needed including tools that address methamphetamine use.     

Harm Reduction in the Hills of Northern Thailand

The human immunodeficiency virus (HIV) pandemic has swept through injecting drug user (IDU) communities around the world. Once HIV is present in an IDU community, seroprevalence rates escalate rapidly unless immediate and comprehensive prevention methods are put in place. Such measures often include providing IDUs with sterile injecting equipment and dispensing methadone or other opiate substitution formulas. These measures fall under the rubric of harm reduction-an attempt to reduce the harm to drug users, their families, and communities, including preventing or limiting the transmission of HIV and other blood-borne viruses. In Thailand, HIV-1 spread rapidly among IDUs with seroprevalence rates jumping from 1 to 40% in the space of a year. Current incidence rates are estimated at 11 per 100 person years. This paper describes the establishment and implementation of needle and syringe exchanges among injecting drug users in nine Hilltribe communities in Northern Thailand. The exchanges have been operating for between 1 and 3 years and have been effective in limiting the transmission of HIV within these small communities. The needle and syringe exchanges are run by indigenous staff widi the cooperation of the community and provide a good example of the feasibility of establishing locally-run, community-based harm reduction programs.     

Networks and HIV risk: an introduction to social network analysis for harm reductionists

There is considerable evidence for the belief that networks affect the probability that an injecting drug user (IDU) becomes infected with HIV; the speed with which HIV travels through communities of IDUs; and the extent to which IDUs engage in risk behaviors. This paper gives a brief overview of network concepts and methods and discusses how prevention projects and /or user groups might become involved in network research alongside academic and public health researchers.     

Review of injection drug use in six African countries: Egypt, Kenya, Mauritius, Nigeria, South Africa and Tanzania

Injection drug use (IDU) is becoming an increasingly important mode of HIV transmission globally. The number of African countries experiencing IDU is reported to be growing. This is cause for concern as the phenomenon of IDU is arising within the context of an established and growing HIV epidemic. This article provides a concise review of the available literature pertaining to IDU within six African countries, namely Egypt, Kenya, Mauritius, Nigeria, South Africa and Tanzania. The available information contradicts the prevailing view that IDU is extremely rare or non-existent in most African countries. IDU populations within the selected countries are shown to engage in high-risk sexual and injecting behaviours. IDUs in Africa have the potential to provide a significant contribution to the spread of HIV/AIDS on the continent.     

Modelling the characteristics of the male injecting drug user population in England and Wales

Estimating characteristics of the injecting drug using (IDU) population is of major health importance. This study proposes a method to determine the age-specific rate at which individuals start injecting drugs, and the rate at which individuals leave the IDU population. A simple age-structured model describing the initiation of injecting and the removal of injectors from the IDU population and their evolution over time was fitted to data by maximum likelihood. The peak age at which males start injecting drugs is 21 years. The rate at which IDUs leave the surveyed IDU population (removal rate) increases linearly with age up to a maximum rate and is constant thereafter. The model suggests that the rate at which IDUs started injecting may have peaked during the early 1980s and has declined since. These results reflect the characteristics of a sample of IDUs in contact with services; they suggest that the incidence of injecting drug use has been broadly stable throughout the 1990s with possibly a slight drop in recent years. The actual IDU population may differ from the surveyed sample (in particular they may have a lower average age and length of career) and this must be investigated. Additional modelling work attempting to clarify the difference between the removal rates proposed here and the true cessation rates as they vary with age should also be undertaken.