HIV prevalence among IDUs in Australia: a methodological review

Learning from HIV epidemics among injecting drug users

HIV/AIDS was the defining issue for international harm reduction during its first twenty years. This issue was marked by strong contrasts: rapid HIV transmission in some populations of injecting drug users, and close to elimination of HIV in other populations; a formidable research base for designing effective HIV programmes and persistent political problems in implementing evidence-based programmes on a public health scale. Elevated rates of HIV infection among ethnic minority drug users have occurred in many different countries. We do not yet have systematic knowledge of how to reduce stigmatization of AIDS or people who use drugs. Nevertheless, international harm reduction for people who use drugs has moved beyond HIV/AIDS to a variety of other health and social problems, while retaining firm bases in science and human rights.

The effectiveness of methadone maintenance treatment: an overview

This paper reviews the evidence for the effectiveness of methadone maintenance as used in the treatment of opioid dependence. Findings from randomized controlled trials and observational studies suggest that methadone maintenance reduces heroin use, crime, injection-related risk behaviours and premature mortality among people dependent on opioids. The research further suggests that two aspects of treatment are important in ensuring this effectiveness. Methadone treatment is more effective when higher doses (>50 mg) are employed and, overall, the evidence suggests that a treatment goal of successful maintenance on methadone rather than total abstinence is appropriate. The importance of ancillary services in treatment outcome is less clear and is the subject of current research and debate.

HIV risk exposure of injecting drug users in Sydney

One thousand two hundred and forty-five Sydney injecting drug users (IDUs) were interviewed by questionnaire in 1989 to determine demographic and behavioural characteristics. One-sixth (16.7%) were considered to be at low risk of HIV from either needle sharing or sexual transmission as they had either never shared injecting equipment, or had not shared for years, or cleaned their injecting equipment effectively on 100% of the occasions when they did share; and were either celibate or monogamous or, if they had multiple partners, had not had unsafe sex in the previous 6 months. Over half (50.7%) had either unsafe injecting or sexual behaviour with the remaining third (32.6%) engaging in both unsafe injecting and sexual practises. Women were more at risk from sharing injection equipment than men but men were more at risk from sexual transmission than women. Increasing age was associated with greater likelihood of safer sex but age had no effect on injecting practises. There was no relationship between unsafe injecting and sexual practises. Amphetamine use was associated with low risk injecting practises while heroin use was associated with low risk sexual transmission. These findings indicate appreciable residual risk behaviour sufficient to allow for at least a slow diffusion of HIV among injecting drug users.

Harm reduction in Australia: has it worked? A review

The literature is reviewed with a view to determining what evidence exists for the success of Australia's policy of harm minimization in relation to drug use. While there are relatively few examples of strategies which can unequivocally be said to have succeeded, there are many more for which the evidence is suggestive. While there has been a considerable mushrooming of research since the advent of the National Campaign on Drug Abuse, it would appear that little of this has measured the extent to which harm has been reduced. The National Drug Strategy would benefit from more policy-orientated research which measures drug-related harm if it is to be, as claimed, research driven.

Diffusion of the D.A.R.E and syringe exchange programs

We examined the diffusion of the D.A.R.E program to reduce use of illicit drugs among school-aged children and youths and the diffusion of syringe exchange programs to reduce HIV transmission among injection drug users. The D.A.R.E program was diffused widely in the United States despite a lack of evidence for its effectiveness; there has been limited diffusion of syringe exchange in the United States, despite extensive scientific evidence for its effectiveness. Multiple possible associations between diffusion and evidence of effectiveness exist, from widespread diffusion without evidence of effectiveness to limited diffusion with strong evidence of effectiveness. The decision theory concepts of framing and loss aversion may be useful for further research on the diffusion of public health innovations.

Pharmacist ambivalence about sale of syringes to injection drug users

OBJECTIVE

To examine pharmacists' attitudes and practices surrounding human immunodeficiency virus (HIV) prevention among injection drug users.

DESIGN

Focus groups.

SETTING

Urban and rural sites in Colorado, Connecticut, Kentucky, and Missouri.

PATIENTS OR OTHER PARTICIPANTS

Eight focus groups, with 4 to 11 pharmacists participating in each group.

INTERVENTIONS

Transcripts of focus group discussions were evaluated for common themes by the authors and through the use of NUD*IST.

MAIN OUTCOME MEASURES

Willingness to sell syringes to all customers, views on syringe exchange programs (SEPs), knowledge of laws governing syringe sales and racial, ethnic, or gender biases in syringe selling practices.

RESULTS

Two pharmacists established their own policies of selling syringes to everyone, and three expressed a willingness to have their pharmacies serve as SEPs. A total of 20% of the pharmacists expressed an interest in learning more about the efficacy of SEPs and distribution of syringes by pharmacists, and were willing to change their views based on this information. Many also indicated a general willingness to work with SEPs or to participate in the effort to curb the spread of HIV. However, a majority of pharmacists opposed having SEPs in their pharmacies and reported selling syringes only within specific limits: to known diabetics, to individuals who looked reasonable, or to individuals who presented a logical explanation. No racial, ethnic, or gender bias was observed.

CONCLUSION

Opinions among pharmacists varied across and within sites. While a majority of pharmacists would not establish SEPs in their own pharmacies, nearly all would participate in other HIV-prevention programs. Educational programs for pharmacists may be valuable in HIV-prevention efforts.

Research, politics, and needle exchange

We now have had 15 years of public discussion of and research on needle exchange programs. The data have shown these programs to be usually, but not always, effective in limiting HIV transmission among injection drug users. Needle exchange programs are conceptualized within a larger framework of providing ready availability of sterile injection equipment for injection drug users. Continuing research is clearly needed regarding how to maximize the availability of sterile injection equipment and how to integrate this with other needed health and social services for drug users. Many initial opponents of needle exchange programs have become supporters of the programs. The number of programs in the United States has been increasing by about 20% per year, and this can be considered substantial progress in reducing HIV infection among injection drug users. Important opposition remains, however, based primarily on the symbolic values expressed in government support for the programs. These value conflicts over needle exchange, which have existed since it was first considered in the United States, cannot be resolved with data. In the late 1980s, the value conflicts greatly hampered the collection of relevant data--there was no federal funding of research on needle exchange programs. Currently, there is considerable research on needle exchange, but many researchers are quite concerned about possible misuse of findings. This may be considered progress to an important but modest degree. Whether current and future research will be used to improve HIV prevention efforts remains to be seen.

[The persistence of risky conduct for HIV transmission among intravenous drug users in Madrid, Seville, and Valencia. The Working Group of the Médicos del Mundo for the Monitoring of HIV Infection and the Risk Practices of Intravenous Drug Users]

OBJECTIVE

To determine the prevalence of HIV infection and risk-taking behavior for infection among intravenous drug users in Madrid, Seville, and Valencia (Spain). To study the main factors associated with such behavior.

MATERIAL AND METHODS

Personal interviews were carried out with 821 intravenous drug users recruited in 1994 and 1995 among recent participants in three needle-exchange programs. Subjects were asked about their risk-taking behavior in the 30 days preceding the interview. Bivariate statistical methods and logistical regression techniques were used.

RESULTS

In the month before the interview, 13.8% of the subjects in Valencia, 18.1% in Madrid, and 26.9% in Seville used needles that had been used by other people, usually (73-88%) without disinfecting them effectively. Condom use during the reference period was 50% in Seville, 42.5% in Madrid, and 34.2% in Valencia. The prevalence of HIV infection ranged from 30.1% in Seville to 43. 2% in Madrid. Multivariate analysis showed that the factors most closely associated with accepting used needles were: needle sharing (OR = 12.2), residence in Seville (OR = 6.6), and HIV positivity (OR = 4.6). The factors most closely associated with not using condoms systematically were: ignorance of personal HIV serological state (OR = 4.1), needle sharing (OR = 3.7), and HIV negativity (OR = 3.3).

CONCLUSIONS

The risk of HIV transmission among intra-venous drug users in Spain is high (infection and risk-taking behavior have a high prevalence), so programs designed to reduce this risk should be increased quickly.

HIV and HCV prevalence among trawler crew

A survey of 51 people who work on trawlers was carried out to describe injecting and sexual behaviour and the prevalence of HIV and HCV antibody. All crew members who were departing from an Australian port during the last week of February 1996 to work on trawlers were asked to complete a brief, self-administered questionnaire and provide a finger prick blood sample. Questionnaires were received from 51 (77%) and blood samples from 45 (68%) of the 66 crew from 15 vessels. Almost half the respondents reported ever injecting illicit drugs. No respondents had HIV antibody while 27% had HCV antibody detected. Among 20 injecting drug user (IDU) respondents, the prevalence of HCV was 55% (95% CI 32%-77%). Twelve respondents reported new sex partners in the past month of whom half reported no condom use with these sex partners. The survey emphasises the diversity of the IDU population in Australia. Yet it would appear that regardless of the sub-population surveyed that HCV is endemic among IDUs in Australia. Effective HCV prevention programs targeted specifically for these (and other) sub-populations of IDUs should be devised.

Infection with HIV and hepatitis C virus among injecting drug users in a prevention setting: retrospective cohort study

OBJECTIVES

To estimate the incidence of HIV and hepatitis C virus and risk factors for seroconversion among a cohort of injecting drug users.

DESIGN

Retrospective cohort study.

SETTING

Primary healthcare facility in central Sydney.

SUBJECTS

Injecting drug users tested for HIV-1 antibody (n=1179) and antibodies to hepatitis C virus (n=1078) from February 1992 to October 1995.

MAIN OUTCOME MEASURES

Incidence of HIV-1 and hepatitis C virus among seronegative subjects who injected drugs and underwent repeat testing. Demographic and behavioural risk factors for hepatitis seroconversion.

RESULTS

Incidence of HIV-1 among 426 initially seronegative injecting drug users was 0.17/100 person years (two seroconversions) compared with an incidence of hepatitis C virus of 20.9/100 person years (31 seroconversions) among 152 injecting drug users initially negative for hepatitis C virus. Incidence of hepatitis C virus among injecting drug users aged less than 20 years was 75.6/100 person years. Independent risk factors for hepatitis C virus seroconversion were age less than 20 years and a history of imprisonment.

CONCLUSIONS

In a setting where prevention measures have contributed to the maintenance of low prevalence and incidence of HIV-1, transmission of hepatitis C virus continues at extremely high levels, particularly among young injecting drug users.

Vietnamese-speaking injecting drug users in Melbourne: the need for harm reduction programs

While research on aspects of injecting drug use (IDU), including injecting and sexual risks for HIV transmission, has been progressing in 'mainstream' Australian populations, there has been little among non-English speaking background (NESB) communities in Australia, particularly the South-East Asian communities, of which the Vietnamese is the largest. This exploratory study employed and trained peer workers to recruit and interview IDUs of Vietnamese origin in Melbourne on a wide range of subjects related to risks associated with their drug using, as an initial assessment of risk-taking behaviours for blood-borne viruses among Vietnamese-speaking IDUs. A finger-prick blood sample was taken where possible to measure antibody status to HIV, HBV and HCV. The profile which emerged was not dissimilar to that of their English-speaking counterparts prior to the benefit of currently available harm-reduction programs. A relatively isolated group whose social world often related only to other Vietnamese-speaking drug users, they were engaging in unsafe sex and unsafe injecting and were unfamiliar with procedures for cleaning injecting equipment and where they could seek out information and services, including needle exchanges. This study has identified an urgent need not only to promote currently available information and services to this group, but also to provide culturally relevant education and other harm-reduction measures needed to prevent transmission of HIV, other BBVs and STDs. The study has highlighted the lack of responsiveness of mainstream health services to the needs of Vietnamese-speaking IDUs.

A mathematical model of HIV transmission in NSW prisons

A mathematical model was developed to estimate HIV incidence in NSW prisons. Data included: duration of imprisonment; number of inmates using each needle; lower and higher number of shared injections per IDU per week; proportion of IDUs using bleach; efficacy of bleach; HIV prevalence and probability of infection. HIV prevalence in IDUs in prison was estimated to have risen from 0.8 to 6.7% (12.2%) over 180 weeks when using lower (and higher) values for frequency of shared injections. The estimated minimum (and maximum) number of IDU inmates, infected with HIV in NSW prisons was 38 (and 152) in 1993 according to the model. These figures require confirmation by seroincidence studies.

Deciding to risk it: toward a multivariate model of unsafe injecting behavior

This paper reports on a set of studies which sought to explain why Australian injecting drug users (IDUs) continue to share injecting equipment despite the provision of needles and syringes, drug treatment, education programs, and HIV testing. A range of situational and psychological factors were implicated in risk-taking, and these are integrated into a theoretical model which reflects the decision-making processes that occur when IDUs decide to take a risk.

A Tale of Two Countries: Attempts to Control HIV among Injecting Drug Users in Australia and the United States

Prevalence of injectable drug use is surprisingly similar in Australia and the United States. HIV prevalence among injection drug users (IDUs) is less than 5% in Australia and about 14% in the United States. IDUs accounted for 2.5% of AIDS cases in Australia in 1994 and 28% in the United States in 1993. Harm reduction was officially adopted in Australia in 1985 but has been explicitly rejected by the U.S. government. In 1994, needle programs exchanged over 10 million syringes from over 4,000 outlets in Australia while 55 needle exchange programs in the United States exchanged almost eight million syringes. Since 1985, methadone maintenance expanded almost ten-fold in Australia but barely increased in the United States. Timely and vigorous adoption of harm reduction strategies in Australia and the relative lack of such programs in the United States is the most plausible explanation for the good control of HIV among IDUs in Australia and poor control in the United States.

HIV in the mentally ill

OBJECTIVE

To review the published literature in relation to prevalence of HIV infection and risk behaviours for HIV among the mentally ill to assist in the development of appropriate strategies for public health policy, surveillance and clinical management of HIV and HIV risk in these groups.

METHOD

A search of published literature was carried out using 'Medline', in association with following up appropriate papers cited in the references of journals identified.

RESULTS

The North American literature shows an increased risk of HIV infection in psychiatric patients receiving treatment in both inpatient or community settings. HIV infection is associated with a number of risk behaviours, particularly male homosexual sex and injecting drug use, and being the sexual partner of a person with a history of these. Impulsivity, high levels of sexual activity during acute exacerbations of psychiatric illness, poor skills at negotiating safe sex, homelessness and drug abuse are all risk behaviours common among those affected by some mental illnesses. The mentally ill also have a comparatively poorer knowledge of HIV/AIDS. There is a dearth of published Australian data addressing the question of HIV seroprevalence or risk in the mentally ill. Although there has been development and implementation of HIV risk-reduction programs overseas, the development and evaluation of any programs in Australia has not been published.

CONCLUSIONS

Arguably, Australia has developed a comprehensive program of national surveillance for HIV infection and has been relatively successful in its response to the HIV epidemic, with the high rates of infection in the early to mid-1980s substantially reduced to around 600 new diagnoses per year. However, while risk behaviours which exposed those infected with the virus are recorded, underlying conditions which predispose them to these behaviours are not. Nevertheless, there is HIV infection amongst mentally ill and intellectually disabled people in Australia. Examination of the North American experience reveals opportunities to prevent a high rate of HIV infection in those with mental illness in Australia. Such a program would require adequate risk behaviour assessment, appropriate diagnostic testing and management, and development of specific educational interventions which are properly evaluated to ensure their effectiveness.

A History of Peer-Based Drug-User Groups in Australia

The active involvement of at-risk communities has been the hallmark of Australia's response to the AIDS epidemic, including community groups often supported by government funding. Organizations of injecting drug users (IDUs) at state and national levels have been key in providing input to policy, program development, and delivery, but their important contributions have so far been inadequately documented. We review here available information about the histories and impact of user groups, and report that their mere existence has had a profound effect on the nature of the response to HIV among IDUs, and their activities on the prevention of an epidemic among most sectors of the IDU community. After checkered careers and different evolutions, the greatest challenge now facing user groups is to sustain a relevant role in an atmosphere of developing complacency—that the epidemic is over—and that user groups are no longer useful to governments. The history of IDU organizations in Australia is not over, but their future is yet to be defined.

HIV infection among injecting drug users in the South Australian methadone program

OBJECTIVE

To investigate risk factors for infection with HIV among injecting drug users (IDUs) in South Australia.

DESIGN

Retrospective case-control study comparing HIV-infected and uninfected IDUs who had received methadone at any time between January 1981 and June 1991.

RESULTS

Most HIV-infected clients were diagnosed between 1985 and 1987. Men were more likely to be infected than women. A history of imprisonment was associated with a higher risk of infection on univariate but not multivariate analysis. Infected IDUs on average were three years younger than noninfected IDUs when they first injected drugs.

CONCLUSIONS

Prevention programs should target young drug injectors. Prisons are important places to institute prevention programs.

Spread of bloodborne viruses among Australian prison entrants

OBJECTIVES

To assess spread of bloodborne viruses among prison entrants in Victoria, Australia.

DESIGN

Voluntary confidential testing of all prison entrants for markers of exposure to bloodborne viruses with collection of minimal data on demography and risk factors over 12 months.

SETTING

Her Majesty's Prisons, Pentridge and Fairlea, Victoria, Australia.

SUBJECTS

3429 male and 198 female prison entrants (> 99% of all prison entrants); 344 entered prison and were tested more than once.

MAIN OUTCOME MEASURES

Prevalence and incidence of antibodies to HIV, hepatitis B, and hepatitis C viruses, and minimal data on risk factors.

RESULTS

1562 (46%) gave a history of use of injected drugs, 1171 (33%) had antibody to hepatitis B core antigen, 1418 (39%) were anti-hepatitis C positive including 914 (64%) of the men who injected drugs, 91 (2.5%) were positive for hepatitis B surface antigen, and 17 (0.47%) were positive for antibody to HIV. Incidence rates for infection with hepatitis B and C virus were 12.6 and 18.3 per 100 person years, respectively; in men who injected drugs and were aged less than 30 years (29% of all prison entrants) these were 21 and 41 per 100 person years. Seroconversion to hepatitis B or C was associated with young age and shorter stay in prison. Only 5% of those who were not immune to hepatitis B reported hepatitis B immunisation.

CONCLUSIONS

Hepatitis B and C are spreading rapidly through some populations of injecting drug users in Victoria, particularly among men aged less than 30 years at risk of imprisonment in whom rates of spread are extreme; this group constitutes a sizeable at risk population for spread of HIV. This spread is occurring in a context of integrated harm reduction measures outside prisons for prevention of viral spread but few programmes within or on transition from prisons; it poses an urgent challenge to these programmes.

Blood-borne virus infections among Australian injecting drug users: implications for spread of HIV

To describe the epidemiology of infection with hepatitis C virus (HCV), hepatitis B virus (HBV) and human immunodeficiency virus (HIV) among injecting drug users (IDUs) in Australia, in relation to the potential for further spread of HIV in IDUs, a cross-sectional analysis was performed on data from a sample of injecting drug users, correlating markers of exposure to blood-borne viruses with sex, age, sexual orientation, primary current drug injected and duration of injecting in rural and metropolitan Victoria, Australia. The subjects were currently active IDUs from a wide spectrum of age, sex, sexual orientation, geographical location and social background, contacted and recruited through their social networks and from community agencies and prisons by trained peer workers who interviewed and collected blood from them in the field. Sera were tested for antibody to HIV, HCV and hepatitis B core antigen (HBcAg), for hepatitis B surface antigen (HBsAg), and for HCV RNA using reverse transcription and polymerase chain reaction (RT-PCR). At entry to the study, 4.5% (14/311) had antibody to HIV, 47% (146/308) to HBcAg and 68% (206/303) to HCV. Prevalence of HBsAg was 1.8% overall (5/282), and 50% (84/168) were positive for HCV RNA. By multivariate analysis, HIV seropositivity was strongly associated with a history of homosexual contact in males and with exposure to HBV but not to HCV. Those who reported their current primary injected drug to be amphetamines were at greater and continuing risk of HIV infection than were current heroin injectors, while the reverse applied for HCV.(ABSTRACT TRUNCATED AT 250 WORDS)

A national surveillance system for newly acquired HIV infection in Australia. National HIV Surveillance Committee

OBJECTIVES

The purpose of this study was to describe the establishment of a national surveillance system for newly acquired human immunodeficiency virus (HIV) infection and present the first 3 years' results.

METHODS

All new cases of diagnosed HIV infection were reported to the national HIV surveillance center through state and territory health authorities. Information sought on each case included evidence of whether the infection had been newly acquired, defined by the diagnosis of HIV seroconversion illness or by the report of a negative or indeterminate HIV antibody test result occurring within the 12 months prior to diagnosis of infection.

RESULTS

Of 3602 reported cases of HIV infection in adults and adolescents newly diagnosed in Australia between 1991 and 1993, 11.4% were identified as newly acquired. The majority (85%) of cases of newly diagnosed HIV infection occurred among men who reported homosexual contact, and 15% of these cases were identified as newly acquired. Average age at diagnosis was 31 years for cases of newly acquired infection and 34 years for other cases.

CONCLUSIONS

Surveillance for newly acquired HIV infection has been established at a national level in Australia and provides valuable information for planning primary HIV prevention programs.

Risk factors for hepatitis C virus infection among injecting drug users in Sydney

OBJECTIVE

To study risk factors for hepatitis C virus (HCV) infection in injecting drug users (IDUs) from central Sydney.

SETTING AND SUBJECTS

All IDUs attending a primary health care facility in central Sydney between December 1991 and November 1992 who underwent HCV antibody testing.

METHODS

Information was obtained retrospectively from client forms routinely completed at the time of medical consultation. Additional information on injecting history and practice was obtained from the registration forms of subjects who also attended the needle syringe exchange programme at the same health care facility.

RESULTS

Of the 201 IDUs tested, 118 (59%) had HCV antibodies, which did not differ significantly between males and females. HCV prevalence increased significantly with age, being highest in IDUs who were aged 35 years or more (93%) and lowest in IDUs aged under 20 years (17%). HCV prevalence increased significantly with time since first injecting, from 26% for IDUs who had injected for less than 3 years to 94% for those who had injected for more than 10 years. HCV prevalence was also significantly higher in heterosexual IDUs as compared with homosexual male IDUs, and in opiate users as compared with stimulant users, even after adjustment for age and duration of injecting. HCV prevalence was strongly associated with exposure to hepatitis B virus, but was not associated with exposure to HIV.

CONCLUSION

Recent HCV transmission indicates ongoing injecting risk behaviour despite HIV prevention efforts, and underlies the potential for increased transmission of HIV through the sharing of injecting equipment. Within the population of IDUs, those who are heterosexual or inject heroin appear to be at increased risk of HCV infection.

The 1993 Okey Memorial Lecture. Cross-national studies of AIDS among injecting drug users

HIV infection among injecting drug users has become a world-wide public health problem. This raises fundamental questions about the modifiability of drug-using behavior and of the influence of different national settings upon the modification of drug use behavior. Data from the World Health Organization Multi-site Study of HIV and Injecting Drug Use and studies of HIV among drug injectors in New York City (the US component of the WHO study) are used to address these questions. There is no clear relationship between HIV seroprevalence and current levels of risk behavior in the WHO cities, and the range in seroprevalence is much greater than the range in current risk behavior. Nonetheless, historical trend data enable us to discern at least two broad patterns in different cities. HIV epidemics appear to have been successfully prevented among IDUs in some cities, in that seroprevalence has remained low and stable over several years. These cities are characterized by community outreach programs and good access to sterile injection equipment. On the other hand, high seroprevalence epidemics have also occurred in many different cities. Stabilization of seroprevalence has eventually also occurred in these cities, but this still includes moderate rates of new HIV infections. How to reverse high-seroprevalence situations remains one of the more difficult questions in HIV epidemiology. The epidemiology of HIV infection among injecting drug users also needs to include analyses of the impacts of decisions by political and public health leaders. A three-category scheme for classifying political decisions is offered: data-free decisions, data-based decisions, and data-proof decisions.