Direct evaluation of needle and syringe exchange programmes

Harm reduction interventions, behaviours and associated health outcomes in France, 1996-2003

AIMS

To track the effect of the French harm reduction programme targeted at intravenous drug users (IDUs) and associated health outcomes.

MATERIAL

Since 1996, we have collected monthly sales of sterile syringes and substitution treatments (buprenorphine high dosage and methadone) sold to IDUs in the 23 000 pharmacies in France and collated these figures in a single data base (SIAMOIS). To this data base we have also added the number of syringes distributed through community associations, as well as methadone treatments prescribed in public drug dependence clinics.

METHODS

For the period 1996-2003 we analysed syringe sales and prescribed substitution treatments as indicators of access to harm reduction services. We compared variations of these figures over time with trends in health outcome indicators [annual number of fatal overdoses, hepatitis C virus (HCV) and human immunodeficiency virus (HIV) prevalence among intravenous drug users], risk behaviour indicators (rate of syringe sharing or rate of syringe re-use) and legal indicators (heroin and cocaine use-related arrests).

FINDINGS

The number of sterile syringes sold or distributed to IDUs increased from 1996 to 1999 (+ 21%) and then decreased dramatically from 1999 to 2003 (-40%). In 2003, we estimated that more than 100,000 drug users used substitution treatments. Between 1996 and 2003, a decrease in syringe sharing and syringe re-use was observed, HIV prevalence among IDUs decreased from 40% to 20% and HCV prevalence remained high (60-70%). From 1996 to 2003, arrests due to heroin use declined (from 17 328 to 4025) and deaths due to overdoses also decreased (from 465 to 89), whereas arrests for cocaine use increased from 1184 to 2511.

CONCLUSION

Our results indicate that, since 1996 in France, IDUs have had greatly improved access to sterile syringes and substitution treatments. The decrease in syringe sharing and re-use practices and of HIV prevalence during the same time period indicates that the harm reduction policy implemented in France has had a positive impact. However, because of the persistent sharing and re-use of syringes and a remaining high HCV prevalence in IDUs, efforts to facilitate access to sterile syringes must continue, and targeting of at-risk groups must be improved. Behavioural surveys associated with HIV and HCV seroprevalence data are needed to further assess prevention of blood-borne infections among IDUs in France.

[Harm reduction policy related to drug use: the needles exchange programs]

In several developed countries, needles exchange programs (NEPs) are a key preventive tool in harm reduction policy related to drug use. Many studies about NEP show it reduces HIV infections related to syringes sharing when part of others preventive actions. NEPs seem to have no impact on HCV transmission. Furthermore, young drug users, who are at high risk for HIV and HCV infections, are not attending NEPs very often. Trying to maintain high accessibility to sterile syringes, efforts must be stressed on hard-to-reach populations such as young injection drug users (IDU), focusing on their social network. Emphasis must also be put on prevention of unsafe sexual intercourse, often related to syringe sharing, which must be more prevented. Finally, design of assessment studies should be improved.