Articles tagged as "Injecting drug use and HIV prevention"

Injecting-drug users

Des Jarlais DC, McKnight C, Goldblatt C, Purchase D. Doing harm reduction better: syringe exchange in the United States. Addiction. 2009 Feb 10. [Epub ahead of print]

To trace the growth of syringe exchange programs in the United States since 1994-95 and assess the current state of syringe exchange programs, annual surveys of US syringe exchange programs known to the North American Syringe Exchange Network (NASEN) were mailed to executive directors with follow-up interviews by telephone and/or e-mail. Response rates have varied between 70% and 88% since surveys were initiated in 1996. The numbers of programs known to NASEN have increased from 68 in 1994-95 to 186 in 2007. Among programs participating in the survey, numbers of syringes exchanged have increased from 8.0 million per year to 29.5 million per year, total annual budgets have increased from $6.3 to $19.6 million and public funding (from state and local governments) has increased from $3.9 to $14.4 million. In 2007, 89% of programs permitted secondary exchange and 76% encouraged it. Condoms, referrals to substance abuse treatment; human immunodeficiency virus (HIV), hepatitis C virus (HCV), hepatitis B virus (HBV) counselling and testing and naloxone for overdose were among the most commonly provided services in addition to basic syringe exchange. Each of these services was provided by 40% or more of syringe exchange programs in 2007. While syringe exchange has remained controversial in the United States, there has been very substantial growth in numbers of programs, syringes exchange and program budgets. Utilizing secondary exchange to reach large numbers of injecting drug users and utilizing syringe exchange programs as a new platform for providing health and social services beyond basic syringe exchange have been the two major organizational strategies in the growth of syringe exchange programs in the United States.

Editors’ note: Two-thirds of these US programmes do not adhere to a restrictive ‘one-for-one’ needle exchange policy and 89% permit secondary exchange, allowing an individual participant to exchange for peers who do not necessarily attend the exchange. These policies have served to increase the numbers of sterile syringes available to injecting drug users with the result that HIV incidence in the USA has declined to under 1 per 100 person years and the majority of new infections among injecting drug users appear to be sexually transmitted. The recent Congress bill lifting the 20-year ban on federal funding for needle exchange http://www.speaker.gov/blog/?p=1885 may encourage more equitable service coverage across the US, reduce stigmatisation of drug users, and facilitate a move toward integration of services for drug users into the regular health system.

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Trial conduct

Doab A, Topp L, Day CA, Dore GJ, Maher L. Clinical trial literacy among injecting drug users in Sydney, Australia: a pilot study. Contemp Clin Trials. 2009 Apr 16. [Epub ahead of print]

This pilot study examined knowledge, understanding and perceived acceptability of key methodological concepts in clinical trials among injecting drug users in Sydney, Australia. Participants were clinical trial-experienced (n=17) and trial-naïve (n=99) people who inject drugs who were recruited from community needle and syringe programs, and through institutions involved in clinical trials with injecting drug using participants.  Cross-sectional data were collected via a study-specific interviewer-administered survey. Following detailed verbal explanations, higher proportions of trial-experienced than trial-naïve participants demonstrated an understanding of all clinical trial concepts assessed, including single blinding (94% versus 60%); placebo (94% versus 49%); equipoise (71% versus 60%); comparison (59% versus 46%); randomisation (59% versus 21%); and double blinding (47% versus 3%).  Multivariate analyses indicated a better understanding among trial-experienced participants. Participants who demonstrated an understanding of ‘placebo’ and ‘double blinding’ were significantly more likely to perceive these concepts to be acceptable than those who did not. The results indicate the need for targeted education programs that adequately inform people who inject drugs about clinical trial concepts prior to recruitment to a clinical trial, and support adaptations of informed consent procedures to ensure trial participants’ comprehensive understanding of methodologies and their implications.

Editors’ note: Despite a generally good understanding of trial concepts among people who inject drugs, with those who had already participated in a trial unsurprisingly knowing more, the perceived acceptability of equipoise, placebo, and double blinding was only 55-60%. Given that future candidate hepatitis C and HIV vaccine trials will need to recruit and retain large numbers of injecting drug users, clinical trial literacy programmes are needed for this key population. Among the adaptations that could improve informed consent procedures would be considering them in the context of wider community engagement, with informed consent viewed as an ongoing process rather than simply a procedure at recruitment (cf UNAIDS/AVAC Good Participatory Practice Guidelines for Biomedical HIV Prevention Trials).

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Injecting drug use

Altaf A, Saleem N, Abbas S, Muzaffar R. High prevalence of HIV infection among injection drug users (IDUs) in Hyderabad and Sukkur, Pakistan. J Pak Med Assoc. 2009;59(3):136-40.

Altaf and colleagues aimed to estimate size of the injecting drug user population, determine the behaviours that put injecting drugs users at high-risk of HIV exposure, and assess the prevalence of HIV. As part of second generation surveillance, they investigated specific demographic and behavioural characteristics of people who inject drugs in Hyderabad and Sukkur in 2005. It was a cross sectional study. The survey was preceded by geographic mapping to determine size estimation and to define sampling procedures prior to conduct an integrated behavioural and biological survey. A sample size of at least 400 was calculated for each city. Besides calculating frequencies, chi square was used for comparing variables among HIV positive and negative injecting drug users like time elapsed as an injector, number of injections, using unsterile needles, and self perception of risk of acquiring HIV infection. A total of 800 ( Hyderabad 398; Sukkur 402) questionnaires and dried blood samples were collected. The estimated number of injecting drug users in both cities was 3,225 ( Hyderabad 975 and Sukkur 2250 respectively). Average age of the injectors in Hyderabad was 36.5 years and 34.6 years in Sukkur. Using unsterile injecting equipment for last injection was reported by 34 (8.5%) in Hyderabad and 135 (33.6%) in Sukkur. In both cities behaviours such as injecting drugs for more than 10 years (p = 0.00) and injecting four or more times in a day (p = 0.11) were significantly associated with HIV seropositivity. In Hyderabad the HIV seroprevalence was 25.4% (101/398) and in Sukkur it was 19.2% (77/402). In conclusion, the burden of HIV among people who inject drugs in Hyderabad and Sukkur is extremely high and can play a significant role in transmitting the infection to other vulnerable groups.

Editors’ note: Fluctuations in heroin availability, purity, and price have led many of the estimated 484, 000 heroin users in Pakistan to change over to injecting rather than less cost-efficient snorting or smoking. This first reported serosurvey from Hyderabad and Sukkur in Sindh province north of Karachi reveals that over one in five injectors (defined as having injected drugs for non-therapeutic purposes in the past 6 months) in these cities already has HIV infection. There is an urgent need for an organised programme of harm reduction services in both cities to reduce the negative health, social, and economic consequences of drug use for individual injectors and the wider community.


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Harm reduction

Todadze K, Lezhava G. Implementation of drug substitution therapy in Georgia. Cent Eur J Public Health. 2008;16(3):121-3.

The geopolitical uniqueness of the regional socioeconomic situation and the existence of territories outside the control of the national government have facilitated the spread of drug use in Georgia. A special problem is injection of opiates, in particular heroin and Subutex (buprenorphine). It has been established that among registered HIV infected individuals the main route of transmission is injecting drug use. Although the prevalence of HIV among people who inject drugs is only 1-3%, the high number of injecting drug users and the high prevalence of hepatitis C in this population creates high risk of dramatic spread of HIV in Georgia. Beginning at the end of 2005, the Global Fund to fight HIV/AIDS, Tuberculosis and Malaria supported methadone substitution programmes in Georgia. At present, three programmes are functioning. At the same time, they involve 230 patients altogether. The studies carried out by the Research Institute on Addiction, with the aim to control the efficacy of pilot programmes have revealed a dramatic improvement of psychophysical state of patients, with very high rate of re-socialization and decriminalization, and significant diminishment of drug-related risky behaviour. Obtained results indicate high efficiency of methadone substitution programmes in Georgia, as an important tool both for treatment of opioid dependence and harm reduction. In order to obtain a more significant impact on public health, substitution therapy programmes have to be further expanded.

Editors’ note: Drug use in Georgia, an important drug transit route from Asia to Europe, escalated in the early 1990s following the breakdown of the Soviet Union, and ensuing unemployment and social pessimism. Despite economic development and crime reduction, drug use has not decreased. The Georgian parliament passed a law in 2002 permitting substitution therapy. This report of improved health and psychosocial patient outcomes from Georgia’s first methadone substitution programme should spur expansion of the programme there and set an example for other Eastern European countries.


Jürgens R, Ball A, Verster A. Interventions to reduce HIV transmission related to injecting drug use in prison. Lancet Infect Dis. 2009;9(1):57-66. The high prevalence of HIV infection and drug dependence among prisoners, combined with the reuse of non-sterile injecting drug equipment, make prisons a high-risk environment for the transmission of HIV. Ultimately, this contributes to HIV epidemics in the communities to which prisoners return on their release. Jürgens and colleagues reviewed the effectiveness of interventions to reduce injecting drug use risk behaviours and, consequently, HIV transmission in prisons. Many studies reported high levels of injecting drug use in prisons and HIV transmission has been documented. There is increasing evidence of what prison systems can do to prevent HIV transmission related to injecting drug use. In particular, needle and syringe programmes and opioid substitution therapies have proven effective at reducing HIV risk behaviours in a wide range of prison environments, without resulting in negative consequences for the health of prison staff or prisoners. The introduction of these programmes in countries with an existing or emergent epidemic of HIV infection among injecting drug users is therefore warranted, as part of comprehensive programmes to address HIV in prisons.

Editors’ note: Although most prisoners living with HIV contract their infections before imprisonment, the risk of acquiring HIV in prison through use of contaminated injecting equipment is high. Prisoners have the right to receive health care, including preventive measures, equivalent to that available in the community. Furthermore, national commitments to universal access to prevention, treatment, care, and support cannot be achieved without introducing and rapidly expanding comprehensive HIV programmes in prisons. Thus, implementation of evidence-informed HIV programming in prisons is an essential component of any national AIDS programme.


Bayoumi AM Md Msc, Zaric GS Phd. The cost-effectiveness of Vancouver’s supervised injection facility. CMAJ. 2008;179(11):1143-1151.

The cost-effectiveness of Canada’s only supervised injection facility has not been rigorously evaluated. Bayoumi and colleagues estimated the impact of the facility on survival, rates of HIV and hepatitis C virus infection, referral to methadone maintenance treatment, and associated costs. They simulated the population of Vancouver, British Columbia, including injection drug users and persons infected with HIV and hepatitis C virus. The model used a time horizon of 10 years and the perspective of the health care system. They compared the situation of the supervised injection facility with one that had no facility but that had other interventions, such as needle-exchange programmes. The effects considered were decreased needle reuse, increased use of safe injection practices and increased referral to methadone maintenance treatment. Outcomes included life-years gained, costs, and incremental cost-effectiveness ratios discounted at 5% per year. Focusing on the base assumption of decreased needle reuse as the only effect of the supervised injection facility, they found that the facility was associated with an incremental net savings of almost $14 million and 920 life-years gained over 10 years. When the authors also considered the health effect of increased use of safe injection practices, the incremental net savings increased to more than $20 million and the number of life-years gained to 1070. Further increases were estimated when they considered all 3 health benefits: the incremental net savings was more than $18 million and the number of life-years gained 1175. Results were sensitive to assumptions related to injection frequency, the risk of HIV transmission through needle sharing, the frequency of safe injection practices among users of the facility, the costs of HIV-related care and of operating the facility, and the proportion of users who inject in the facility. Vancouver’s supervised injection site is associated with improved health and cost savings, even with conservative estimates of efficacy.

Editors’ note: Supervised injecting facilities or SIFs provide a hygienic, safe environment for people to inject their previously obtained illicit drugs under supervision. SIFs reduce overdose mortality, decrease public injecting and discarding of syringes, and increase referrals to social and health services. This computer simulation estimates considerable cost savings and improved health outcomes comparing a supervised injecting facility to standard needle exchange and methadone maintenance treatment. Findings such as these, combined with results from acceptability, feasibility, and anticipated impact studies, support evidence-informed decision-making about the introduction and continued functioning of such programmes.

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Injecting drug use

Malta M, Strathdee SA, Magnanini MM, Bastos FI. Adherence to antiretroviral therapy for human immunodeficiency virus/acquired immune deficiency syndrome among drug users: a systematic review. Addiction 2008;103(8):1242-57.

Adherence to highly active antiretroviral therapy (HAART) is a key predictor of survival for human immunodeficiency virus (HIV)-infected people. Suboptimal adherence among marginalized populations such as HIV-positive drug users could be associated with clinical failure and the emergence of viral resistance. Malta and colleagues aimed to conduct a systematic review of studies assessing adherence to HAART among HIV-positive drug users and identify factors associated with non-adherence to HIV treatment. Seven electronic databases were searched for peer-reviewed papers published in English, French, Spanish or Portuguese, from 1996 to 2007. Studies were excluded if they presented only qualitative data, were reviews themselves or assessed other populations without disaggregating data on people who use drugs. Findings on adherence were extracted and summarized. Forty-one studies were considered, which studied a total of 15 194 patients, the majority of whom were HIV-positive drug users (n = 11 628, 76.5%). Twenty-two studies assessed adherence using patient self-reports, eight used pharmacy records, three used electronic monitoring [i.e. Medication Event Monitoring Systems caps], six studies used a combination of patient self-report, clinical data, and Medication Event Monitoring Systems caps, and two analyzed secondary data. Overall, active substance use was associated with poor adherence, as well as depression and low social support. Higher adherence was found in patients receiving care in structured settings (e.g. directly observed therapy) and/or drug addiction treatment (especially substitution therapy). While lower than other populations-especially among users of stimulants, incarcerated drug users and patients with psychiatric comorbidities-adherence to HAART among HIV-positive people who use drugs can be achieved. Better adherence was identified among those engaged in comprehensive services providing HIV and addiction treatment with psychosocial support.

Editors’ note: This is the first systematic review summarising the growing body of research on adherence to antiretroviral treatment among drug users. As with other populations, self-reported adherence tended to be higher than other adherence measurements. The structured daily routines of substitution therapy or directly observed treatment, higher self-esteem and self-efficacy, and positive patient-provider relationships made adherence more likely. Non-coercive, comprehensive HIV management and care assists traditionally marginalized patients to access, accept, and adhere to complex therapeutic regimens. All 41 studies considered in this review were from high-income countries. Similar studies are urgently needed in the developing and transitional countries that have experienced the largest HIV epidemics among drug users in recent years.

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Injecting drug use

Mathers BM, Degenhardt L, Phillips B, Wiessing L, Hickman M, Strathdee SA, Wodak A, Panda S, Tyndall M, Toufik A, Mattick RP; for the 2007 Reference Group to the UN on HIV and Injecting Drug Use. Global epidemiology of injecting drug use and HIV among people who inject drugs: a systematic review. Lancet. 2008;372(9651):1733-45.

Injecting drug use is an increasingly important cause of HIV transmission in most countries worldwide. Mathers and colleagues set out to determine the prevalence of injecting drug use among individuals aged 15-64 years, and of HIV among people who inject drugs. They did a systematic search of peer-reviewed (Medline, EmBase, and PubMed/BioMed Central), internet, and grey literature databases; and data requests were made to UN agencies and international experts. 11 022 documents were reviewed, graded, and catalogued by the Reference Group to the UN on HIV and Injecting Drug Use. Injecting drug use was identified in 148 countries; data for the extent of injecting drug use was absent for many countries in Africa, the Middle East, and Latin America. The presence of HIV infection among injectors had been reported in 120 of these countries. Prevalence estimates of injecting drug use could be ascertained for 61 countries, containing 77% of the world’s total population aged 15-64 years. Extrapolated estimates suggest that 15.9 million (range 11.0-21.2 million) people might inject drugs worldwide; the largest numbers of injectors were found in China, the USA, and Russia, where mid-estimates of HIV prevalence among injectors were 12%, 16%, and 37%, respectively. HIV prevalence among injecting drug users was 20-40% in five countries and over 40% in nine. Worldwide, an estimated 3.0 million (range 0.8-6.6 million) people who inject drugs might be HIV positive. The number of countries in which the injection of drugs has been reported has increased over the last decade. The high prevalence of HIV among many populations of injecting drug users represents a substantial global health challenge. However, existing data are far from adequate, in both quality and quantity, particularly in view of the increasing importance of injecting drug use as a mode of HIV transmission in many regions.

Editors’ note: This systematic assessment of peer-reviewed and grey (non-peer-reviewed) literature by the 2007 Reference Group to the UN on HIV and Injecting Drug Use found that injecting drug use is occurring in 148 countries of the world of which 128 have reported HIV infection in this population, an apparent rise since the last such study published in 2004. Inadequate investment in research to document HIV prevalence and to evaluate HIV prevention programmes with a view to improving performance is hampering evidence-informed decision-making to minimise harms. Enough is known already about HIV prevention, as well as treatment and care of HIV-positive injecting drug users, for effective action. It is important to study local impact so that strategies can be adjusted for optimum results.

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Needle–syringe programmes

Kidorf M, King VL. Expanding the public health benefits of syringe exchange programmes. Can J Psychiatry. 2008 Aug;53(8):487-95.

The objective of this study is to provide a brief history of community syringe exchange programmes, describe the clinical profile of those who attend them, identify factors interfering with the transition of syringe exchange programmes participants to more comprehensive substance abuse treatment services, review studies designed to improve rates of treatment seeking, and offer practical suggestions to facilitate links between syringe exchange programmes and substance abuse treatment. Relevant articles were identified using a PubMed literature search of English-language journals from 1997 to 2007. Studies were included that evaluated the effectiveness of syringe exchange programmes or methods for increasing treatment enrolment in syringe exchange programme participants or other out-of-treatment intravenous drug users. Relevant articles prior to 1997 were identified using reference lists of identified articles. Syringe exchange programmes have little impact on rates of drug use or injections. Substance abuse treatment reduces human immunodeficiency virus transmission through drug use reduction and psychosocial functioning improvement, yet syringe exchange programme participants only infrequently engage in treatment. Psychological and pharmacological interventions delivered at the syringe exchange programme setting can improve treatment seeking in syringe exchange programme participants. Use of syringe exchange programmes by substance abuse treatment programs can improve harm-reduction efforts at these settings. Kidorf and colleagues concluded that efforts to improve the link between syringe exchange programmes and substance abuse treatment should include interventions to enhance cooperation across programs, motivate treatment enrolment and syringe exchange programme use, and expand access to treatment. A more fluent and bidirectional continuum of services can enhance the public health benefits of both of these health care delivery settings.

Editors’ note: Community-based syringe exchange programmes and substance use treatment programmes share a common goal – reducing the harm associated with substance use disorder - but they function as independent silos. Conceptualising them as part of a continuum of therapeutic harm reduction services can strengthen the connections between them. Syringe exchange programmes tend to draw in hard-to-reach drug users, who have a more severe spectrum of drug use and may become motivated for treatment. Drug users that are responding poorly to substance use treatment need to be encouraged to participate in community syringe exchange programmes.

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Epidemiology

Ba O, O’Regan C, Nachega J, Cooper C, Anema A, Rachlis B, Mills EJ. HIV/AIDS in African militaries: an ecological analysis. Med Confl Surviv. 2008;24(2):88-100.

The HIV pandemic is considered a security threat. Policy-makers have warned of destabilization of militaries due to massive troop deaths. Estimates of the rate of HIV within African militaries have been as high as 90 per cent. Ba and colleagues aimed to determine if HIV prevalence within African militaries is higher than their host nation prevalence rates. Using systematic searching and access to United States Department of Defense data, the authors abstracted data on prevalence within militaries and their host communities. They conducted a random effects pooled analysis to determine differences in HIV prevalence rates in the military versus the host population, obtaining data on 21 African militaries. In general, HIV prevalence within the military was elevated compared to the general population. The differences were significant (odds ratio 1.97, 95% confidence interval: 1.58-2.45, P < 0.001). Further, inflated rates of HIV in militaries compared to non-military males of similar age were also significant (6.09, 4.47-8.30, P < or = 0.0001). States with recent conflicts and wars had elevated military rates, but these were also not significant (P = 0.4). Population levels predicted military prevalence rates (P < or = 0.001). HIV prevalence rates in most African militaries are significantly elevated compared to their host communities.

Editors’ note: The high HIV prevalence documented in the militaries of some countries in Africa is not surprising given that they are comprised predominantly of young, sexually active males. It does raise concerns about the potential for shortages in the numbers of qualified and experienced military personnel available for deployment, particularly when the armed forces play a key role in maintaining and promoting peace in the region. Intensified HIV prevention and antiretroviral treatment are key to maintaining a healthy military.


Strathdee SA, Lozada R, Ojeda VD, Pollini RA, Brouwer KC, Vera A, Cornelius W, Nguyen L, Magis-Rodriguez C, Patterson TL; Proyecto El Cuete. Differential effects of migration and deportation on HIV infection among male and female injection drug users in Tijuana, Mexico. PLoS ONE. 2008;3(7):e2690.

HIV prevalence is rising, especially among high risk females in Tijuana, Baja California, a Mexico-US border city situated on major migration and drug trafficking routes. Strathdee and colleagues compared factors associated with HIV infection among male and female injection drug users in Tijuana in an effort to inform HIV prevention and treatment programmes. Injection drug users aged > or = 18 years were recruited using respondent-driven sampling and underwent testing for HIV, syphilis and structured interviews. Logistic regression identified correlates of HIV infection, stratified by gender. Among 1056 injection drug users, most were Mexican-born but 67% were born outside Tijuana. Reasons for moving to Tijuana included deportation from the US (56% for males, 29% for females), and looking for work/better life (34% for females, 15% for males). HIV prevalence was higher in females versus males (10.2% vs. 3.5%, p = 0.001). Among females (N=158), factors independently associated with higher HIV prevalence included younger age, lifetime syphilis infection and living in Tijuana for longer durations. Among males (N=898), factors independently associated with higher HIV prevalence were syphilis titres consistent with active infection, being arrested for having 'track-marks', having larger numbers of recent injection partners and living in Tijuana for shorter durations. An interaction between gender and number of years lived in Tijuana regressed on HIV infection was significant (p = 0.03). Upon further analysis, deportation from the U.S. explained the association between shorter duration lived in Tijuana and HIV infection among males; odds of HIV infection were four-fold higher among male injectors deported from the US, compared to other males, adjusting for all other significant correlates (p = 0.002). Geographic mobility has a profound influence on Tijuana's evolving HIV epidemic, and its impact is significantly modified by gender. Future studies are needed to elucidate the context of mobility and HIV acquisition in this region, and whether US immigration policies adversely affect HIV risk.

Editors’ note: These findings suggest that geographic mobility may have had a differential effect on the risk of HIV infection among male and female injecting drug users in Tijuana, with a three-fold higher HIV prevalence documented among the women. However, its cross-sectional design means that a causal relationship cannot be confirmed. Nonetheless, supportive programmes for migrants, deportees, and other displaced persons on both sides of the U.S.-Mexico border could help mitigate the effects of social disruption and displacement.

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Harm reduction

Wodak A, McLeod L. The role of harm reduction in controlling HIV among injecting drug users. AIDS. 2008;Suppl 2:S81-92.

Injecting drug users now account for one in 10 new HIV infections world wide. Yet it has been known since the early 1990s that HIV among injecting drug users can be effectively, safely and cost-effectively controlled by the early and vigorous implementation of a comprehensive package of strategies known as 'harm reduction'. This concept means that decreasing drug-related harms is accorded an even higher priority than reduction of drug consumption. Strategies required involve: explicit and peer-based education about the risk of HIV from sharing injecting equipment; needle syringe programmes; drug treatment (including especially opiate substitution treatment), and community development. Many countries experiencing or threatened by an HIV epidemic among injecting drug users have now adopted harm reduction but often implementation has been too little and too late. Although coverage is slowly improving in many countries, HIV is still spreading faster among injecting drug users than harm reduction programmes while coverage in correctional centres lags far behind community settings. The scientific debate about harm reduction is now over. National and international support for harm reduction is growing while almost all the major UN organizations responsible for drug policy now support harm reduction. Only a small number of countries, led by the USA, are still vehemently opposed to harm reduction. Excessive reliance on drug law enforcement remains the major barrier to increased adoption of harm reduction. Sometimes zealous drug law enforcement undermines harm reduction. A more balanced approach to drug law enforcement is required with illicit drug use recognized primarily as a health and social problem.

Editor’s Note: With injecting drug use reported from 144 countries, of which 128 have detected HIV among injecting drug users, the pragmatic approach of harm reduction must be scalled-up deliberately and rapidly around the world. It is no longer conscionable to deny access to sterile needles and syringes and to substitution treatment for injecting drug uses in the face of the evidence of their effectiveness in reducing HIV infection. Promotion and protecting the human rights of injecting drug users underpin effective public health responses to stem the HIV epidemic among them. There is no time to lose.


Gowing L, Farrell M, Bornemann R, Sullivan L, Ali R. Substitution treatment of injecting opioid users for prevention of HIV infection. Cochrane Database Syst Rev. 2008;(2):CD004145.

Injecting drug users are vulnerable to infection with HIV and other blood borne viruses as a result of collective use of injecting equipment as well as sexual behaviour. Gowing and co-authors aimed to assess the effect of oral substitution treatment for opioid-dependent injecting drug users on rates of HIV infections,and high risk behaviours. They searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and PsycINFO to March 2007. They also searched reference lists of articles, reviews, and conference abstracts. Studies were required to consider the incidence of risk behaviours, or the incidence of HIV infection related to substitution treatment of opioid dependence. All types of original studies were considered. Two reviewers independently assessed studies for inclusion. One reviewer extracted data from included studies, assessed quality, and confirmed decisions by consulting with all other reviewers. The authors included thirty-three studies, involving 10,400 participants. The majority were not randomised controlled studies and there were problems of confounding and bias. The studies varied in several aspects limiting the extent of quantitative analysis. Studies consistently showed that oral substitution treatment for opioid-dependent injecting drug users was associated with statistically significant reductions in illicit opioid use, injecting use, and sharing of injecting equipment. It was also associated with reductions in the proportion of injecting drug users reporting multiple sex partners or exchanges of sex for drugs or money, but had little effect on condom use. It appears that the reductions in risk behaviours related to drug use do translate into reductions in cases of HIV infection. The authors conclude that oral substitution treatment for injecting opioid users reduces drug-related behaviours with a high risk of HIV transmission, but has less effect on sex-related risk behaviours. The lack of data from randomised controlled studies limits the strength of the evidence presented in this review.

Editor’s Note: This review assessing the effectiveness of oral substitution treatment in reducing injecting and sexual risk behaviours included studies of methadone, buprenorphine, LAAM (levo alpha acetyl methadol), codeine, and slow release morphine but not of the injectable preparations used in Switzerland, the Netherlands, the United Kingdom and Germany. Substitution treatment, a key pillar of harm reduction, reduces risk behaviours and HIV acquisition. It is high time to remove legal, policy, and other barriers to offering it to opioid dependent injecting drug users around the world.

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Injecting drug use

Sylla L, Bruce RD, Kamarulzaman A, Altice FL. Integration and co-location of HIV/AIDS, tuberculosis and drug treatment services. Int J Drug Policy 2007; 18:306-12.

Injection drug use plays a critical role in the HIV epidemic in several countries throughout the world. In these countries, injection drug users are at significant risk for both HIV and tuberculosis, and active injection drug use negatively impacts treatment access, adherence, and retention. Comprehensive strategies are therefore needed to effectively deliver preventive, diagnostic, and curative services to these complex patient populations. Sylla and colleagues propose that developing co-located integrated care delivery systems should become the focus of national programmes as they continue to scale-up access to antiretroviral medications for drug users. Existing data suggest that such a programme will expand services for each of these diseases; increase detection of tuberculosis and HIV; improve medication adherence; increase entry into substance use treatment; decrease the likelihood of adverse drug events; and improve the effectiveness of prevention interventions. Key aspects of integration programmes include: co-location of services convenient to the patient; provision of effective substance use treatment, including pharmacotherapies; cross-training of generalist and specialist care providers; and provision of enhanced monitoring of drug-drug interactions and adverse side effects. Central to implementing this agenda will be fostering the political will to fund infrastructure and service delivery, expanding street-level outreach to injection drug users, and training community health workers capable of cost effectively delivering these services.

Editors’ note: The case for co-location of HIV, TB, and drug treatment services is strong. The “two diseases-one life” nomenclature for TB/HIV puts the focus on the patient, adding drug treatment services and reproductive health services recognises the need for integrated care for this complex and vulnerable patient population.

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