HIV/Injecting-Drug-Users

Interviewed by Mark Gold, MD

FEATURED ADDICTION EXPERT:
Frederick S. Southwick, MD
Professor of Internal Medicine and Former ​Chief of Infectious Diseases at the University of Florida

2010 Harvard University Advanced Leadership Fellow
Expert in Medicine, Infectious Disease and Medical Errors​

We see patients who smoke cigarettes, drink and/or abuse drugs. How does this affect their immune status or ability to fight common infections? Any association between a drug dependency like cigarettes and/or marijuana, smoking and/or alcohol drinking?

Smoking is a major risk factor for developing pneumonia. Those who smoke 20 or more cigarettes a day have three times the risk of developing pneumonia. Cigarette smoke damages the tracheal lining of the lungs, alters the consistency of the fluid that coats this lining, and destroys the cilia that move bacteria and other foreign substances out of the lung. When the fluid coating the tubes of the lung becomes thicker as a consequence of the inflammatory reaction to smoke, cilia can no longer transport this fluid, and the foreign particles, including bacteria, usually trapped by this fluid can no longer be transported out of the lungs. Damage to the cilia also interferes with this important protective mechanism.

Alcohol and other sedating drugs interfere with the function of the epiglottis. This large flap of tissue covers the trachea to prevent saliva, food and liquids from entering the lungs. We have all accidently choked on water when our epiglottis malfunctions and water enters the lung. We quickly cough it out. When drugs lead to sedation our epiglottis is more likely to malfunction and food, saliva and bacteria from the mouth can more easily enter the lungs. Sedation also interferes with our cough reflex, and as a consequence, severe aspiration pneumonia can follow an overdose or an episode of heavy drinking.

Drug abuse often leads to malnutrition and some drugs, particularly alcohol, can depress the body’s ability to produce white blood cells. Malnutrition and the loss of these cells can depress the normal acute immune response to infection, and as a consequence, infections are often more severe and life threatening in alcoholics and patients who suffer drug abuse.

Do substance abusers or addicts have more mono, flu, pneumonia, TB or other Infectious Diseases (ID)?

The incidence of mononucleosis is not known to be higher. Influenza is more severe in addicts with depressed immune responses. Tuberculosis may have a higher incidence in addicts because their depressed immune function allows the organism to more readily spread in the lungs and throughout the body.

What are some IDs associated with intravenous drug users?

Another major risk for infection is the use of intravenous drugs. Too often the drugs being injected into the blood stream are contaminated with bacteria, particularly Staphylococcus aureus (found on the skin) and Pseudomonas (found in tap water). These bacteria can infect the heart valves leading to endocarditis, a very serious and potentially fatal infection. Once bacteria enter the blood stream they can also lodge in small vessels of the bones, particularly the vertebral bodies or back bones resulting in bone infection or osteomyelitis. This infection is associated with chronic pain, fever and loss of energy. Osteomyelitis is very difficult to treat and requires six weeks of high dose intravenous antibiotics. Despite prolonged therapy, this infection often relapses resulting in years of pain and suffering.

In addition to bacteria contaminating intravenous drug preparations, shared needles can transmit viruses – Hepatitis B, Hepatitis C, and HIV virus.  Hepatitis B and Hepatitis C both can lead to severe liver inflammation that causes scaring of the liver called cirrhosis. Eventually the liver fails resulting in ascites (filling of the abdominal cavity with fluid), dilatation and bleeding of the esophageal veins (esophageal varices) resulting in gastrointestinal bleeding, and difficulty detoxifying substances in the blood resulting in the loss of alertness and eventually coma (called Hepatic encephalopathy).

HIV is another dreaded and all too common complication of IV drug use.

What would you evaluate all IV addicts for?

All IV addicts should be screened for Hepatitis B, Hepatitis C and HIV. They should also be screened for STDs.

What vaccinations would you suggest for patients with substance use disorders?

They should receive the influenza vaccine annually and the two pneumococcal vaccines. Also, if they are Hepatitis B antibody negative, they should receive the Hepatitis B vaccine.

Can you explain Hepatitis C. What is it? Who gets it? Why do so many addicts and abusers have it? What can you do to prevent it? Diagnose it? Treat it?

Hepatitis C is a virus that specifically infects the liver. This virus is transmitted by blood and blood products. Before the virus was recognized in the early 1990s, it contaminated our blood supply. Risk factors associated with an increased risk of Hepatitis C include:

  • persons receiving blood transfusions or transplanted organs before July of 1992
  • those who received clotting factors before 1987
  • anyone born to a mother with Hepatitis C virus
  • anyone who shared needles to inject drugs, or who had tattoos or body piercing with unsterile equipment

Addicts who use intravenous drugs and share needles are at very high risk, because the virus is transmitted by needles contaminated with virally infected blood. Individuals infected with Hep C have very high numbers of viral particles in their blood, and when they share a needle with an uninfected person, that person is at high risk of inadvertently injecting those viral particles intotheir own blood stream and infecting their liver. The best way to prevent the spread of Hep C is to avoid IV drug use.

Another alternative is to use a clean needle, and never share needles. In some areas of the country, needle exchange programs have been instituted to prevent the spread of Hep C, Hep B, and HIV. The diagnosis can be readily made with a blood test that measures antibodies directed against the virus. This is a very sensitive and specific test and anyone who falls into the above risk groups should undergo testing because we now have excellent antiviral therapy for this infection. Direct acting antiviral therapy offers high cure rates of over 95% in most cases. Treatment usually takes 8-12 weeks of a single pill once per day. In more complicated cases, treatment may be continued for 24 weeks. The cost of treatment is very high ($1,000/ pill) usually costing between $80,000-100,000 to achieve a cure.

Is there a new epidemic of STDs. Which? Who gets which? Why do so many addicts and abusers have it? What can you do to prevent it? Diagnose it? Treat it?

Drug abuse is associated with increased sexual activity and the more sexual partners one has the greater the risk of STDs. The incidence of syphilis in the U.S. has increased among women by 36% from 2015 to 2016 and 15% in men during this same period. Also, the incidence of newborn syphilis has increased by 28% as a consequence of transmission from mother to child.

The group with the highest incidence of this infection is men having sex with men (MSM), and about ½ of MSM who have syphilis also have HIV. The incidence of gonorrhea has also increased during this time period by 22%. This is a particularly worrisome development because strains of gonorrhea are increasingly becoming drug resistant meaning that we are at risk of running out of antibiotic treatments for this infection in the future. Condoms prevent the spread of these diseases; and should always be used given the high risk of STDs among drug abusers.

Public health workers try to identify contacts when a STD case is reported so that these contacts can be tested and treated to prevent the further spread of infection. All patients who have more than one sexual partner or who use illicit drugs should be screened for syphilis, gonorrhea, chlamydia, Hepatitis B and HIV, particularly sexually active women under 25, pregnant women, and men having sex with men.

Syphilis, Hepatitis B and HIV are detected primarily through blood tests. Gonorrhea and chlamydia are tested using vaginal and urethral (opening of the penis) swabs. These tests are all very sensitive and specific. Syphilis, gonorrhea and chlamydia are treated with antibiotics and can be cured. Hepatitis B, like Hepatitis C, can now be cured using antiviral agents, but at great expense. HIV requires lifelong treatment.

Can you explain HIV? AIDS? What is it? Who gets it? Why do so many addicts and abusers have it? What can you do to prevent it? Diagnose it? Treat it?

HIV stands for Human Immunodeficiency Virus and is caused by a retrovirus that is transmitted primarily through blood and through sexual contact as an STD. HIV is a lifelong infection that over time destroys immune cells and results in opportunistic infections (infections by organisms that rarely infect people with normal immune systems) including cryptococcal (fungal) meningitis, pneumocystis pneumonia, and toxoplasmosis brain infections.

When the immune system deteriorates to the point of allowing these infections to develop, HIV infection is said to have progressed to AIDS or Acquired Immune Deficiency Syndrome.  Anti-retroviral medications can lower the viral counts and reverse this immunodeficiency; however, these medications cannot completely eradicate the infection, and they must be taken for life. If anti-retroviral medications are discontinued, the infection reactivates.

Can you explain what is HPV?  Is it just a woman’s problem? Who gets it? Why do so many addicts and abusers have it? What can you do to prevent it? Diagnose it? Treat it?

Human papilloma virus (HPV) is a wart causing virus that is transmitted by close skin to skin contact and is most commonly transmitted by vaginal or anal sex. A high percentage of people become infected but our immune system often clears the virus; however, when the virus remains active it can cause genital warts that have a cauliflower like appearance. This virus can cause mouth and throat, penis, anal, vaginal and cervical cancer. The diagnosis of HPV is usually made based on examination. Cervical pap smears are recommended periodically for women to look for atypical precancerous cells. Treatment consists of removing the precancerous cells through surgical procedures. When cancer develops, chemotherapy and surgical resection are required.

There is no medical treatment for HPV. However, a very effective vaccine is now available that can prevent HPV induced cancer. The vaccine is recommended for all children at age 11-12 years and can be given up to age 21 for women and up to age 26 for men. This vaccine is strongly recommended for men who intend to have sex with men, transgenders, and adolescents who are immunocompromised, including patients with HIV.

For many years, we treated cigarette-related cancers rather than identifying smokers and helping people stop smoking. Is that still happening today with alcohol and drugs? With no drug testing or limited in Pediatrics and Medicine, how can asking the patient if they use or inject drugs identify and help treat the primary disease or users?

The newspapers and television news are now publicizing the worsening drug epidemic in our country. This epidemic has spread to people in every socioeconomic class. Given the many health risks of drug addiction, physicians and nurses have an obligation to ask questions about this potentially life-threatening behavior. Drug addiction is a disease, and to identify and treat this disease, medical caregivers are obligated to inquire about this important health issue. And those who suffer from drug addiction need not be ashamed. They should be open to help. The infectious disease risks of continuing addiction are real and potentially life threatening. Therapy for addiction is available and can be effective. Why wait until the damage has been done?

Source:

https://www.rivermendhealth.com/resources/qa-frederick-southwick-infections-and-addiction/  May 2018

THE PUBLIC HEALTH BENEFITS AND SOCIAL EFFECTS OF NEEDLE EXCHANGE PROGRAMS ARE AT BEST UNCERTAIN, AND AT WORST ARE DEVASTATING TO BOTH ADDICTS AND THEIR COMMUNITIES

A. NEEDLE EXCHANGE PROGRAMS ARE NOT SCIENTIFICALLY

PROVEN TO REDUCE THE EPIDEMIC OF HIV OR HCV INFECTION

AMONG INJECTION DRUG USERS

B. NEEDLE EXCHANGE PROGRAMS DO NOT REDUCE SUBSTANCE

ABUSE, BUT IN FACT FACILITATE AND ENCOURAGE SUBSTANCE

ABUSE

C. NEEDLE EXCHANGE PROGRAMS ARE DESTRUCTIVE TO THE

COMMUNITIES IN WHICH THEY ARE USED

D. NEEDLE EXCHANGE SENDS A BAD MESSAGE TO SCHOOL CHILDREN.

PROVISION OF NEEDLES TO ADDICTS WILL ENCOURAGE DRUG USE.

THE MESSAGE IS INCONSISTENT WITH THE GOALS OF OUR

NATIONAL YOUTH-ORIENTED ANTI-DRUG CAMPAIGN.

A. NEEDLE EXCHANGE PROGRAMS ARE NOT SCIENTIFICALLY PROVEN TO REDUCE THE EPIDEMIC OF HIV OR HCV INFECTION AMONG INJECTION DRUG USERS

(i) The New Haven Study

NEP activists frequently cite the results of a New Haven, Conn., study, published in the American Journal of Medicine, which reported a one-third reduction of HIV among NEP participants. However, the New Haven researchers tested needles from anonymous users, rather than the addicts themselves, for HIV. They never measured “seroconversion rates,” which determine the portion of participants who become HIV positive during the study. Also, sixty percent of the New Haven study participants dropped out; those who remained were presumably more motivated to protect themselves, while the dropouts likely continued their high risk behavior.1

Essentially, the New Haven study merely reported a one-third decrease in HIV-infected needles themselves, which, considering the fact that the NEP flooded the sampling pool with a huge number of new needles, is hardly surprising. Even Peter Lurie, a University of Michigan researcher and avid NEP advocate, admits that “the validity of testing syringes is limited.”2

Furthermore, the New Haven study was based on a mathematical model of anonymous needles using six independent variables to predict the rate of infection. The unreliability of any of the variables invalidates the result. The New Haven study also assumed that any needle returned by a participant other than the one to whom it had been given had been shared, and that any needle returned by the original recipient had not been shared. Both assumptions are suspect.3

Also, the role of HIV transmission through sexual activity is downplayed. Prostitution often finances a drug habit. Non-needle using crack addicts have high incidence of HIV. Recent studies reveal that the greatest HIV threat among heterosexuals is from sexual conduct, not from dirty needles.4
Less than one-third of the New Haven subjects practiced safe sex. In the New Haven study, sampling
error alone could account for the 30 percent decline.5

(ii) The HHS / NAS Study

In 1992, Congress directed the U.S. Department of Health and Human Services (HHS) to study NEPs. HHS in turn commissioned the National Academy of Sciences (NAS), an independent, congressionally chartered, non-government research center, to conduct the study. According to the Congressional directive, if the NAS could show that NEPs worked and did not increase drug use, the Surgeon General could lift the ban on federal funding. The study was completed in 1995, and it concluded that well run NEPs could be effective in preventing the spread of HIV, and do not increase the use of illegal drugs. The NAS panel further recommended lifting the ban on federal funding for NEPs and legalization of injection paraphernalia.

 

Now, seven years after the NAS study, Congress has yet to lift the NEP funding ban, clearly indicating that Congress maintains serious doubts as to the validity of the NAS/HHS conclusions regarding NEPs. Of note is that study chairman Dr. Lincoln E. Moses cites the dubious New Haven study as a basis for the NAS findings.6

The NAS panel admitted that its conclusions were not based on reviews of well-designed studies, and the authors admitted that no such studies exist. Incredibly, the panel reported that “[t]he limitations of individual studies do not necessarily preclude us from being able to reach scientifically valid conclusions.”7

Two of the physicians on the NAS panel, Herbert D. Kleber, M.D. and Lawrence S. Brown, M.D., say the news media exaggerated the NAS’s findings. “NEPs are not the panacea their supporters hope for…We personally believe that the spread of HIV is better combated by the expansion and improvement of drug abuse treatment rather than NEPs, and any government funds should be used instead for that purpose.”8

Dr. Kleber, executive vice president for medical research at Columbia University, added: “The existing data is flawed. NEPs may, in theory, be effective, but the data doesn’t prove that they are.”9

This questionable NAS study represents the cornerstone research data used by the notoriously-politicized U.S. Department of Health and Human Services. The pro-NEP advocacy of HHS, and its supporting data, has yet to convince Congress that NEPs are scientifically proven to reduce HIV infection while not increasing drug usage.

(iii) The CDC Study

The Centers for Disease Control (CDC) conducted a study whose chief architect, Dr. Peter Lurie, recommended NEPs. The CDC report calls for federal funds for NEPs and the repeal of drug paraphernalia laws.

However, although the CDC study endorses NEPs, Dr. Lurie, the study’s author, acknowledges numerous problems: None of the studies were randomized, and self-reported behavior was often the basis for outcomes. Poor follow up and rough measurement of risk behavior also present problems, and he notes that syringe studies have limited validity. The report concludes: “Studies of needle exchange programs on HIV infection rates do not, and in part due to the need for large sample sizes and the multiple impediments to randomization, probably cannot provide clear evidence that needle exchange programs decrease HIV infection rates.”10 randomization, probably cannot provide clear evidence that needle exchange programs decrease HIV infection rates.”11

 

(iv) The Montreal Study

A 1995 Montreal study, published in the American Journal of epidemiology, showed that IDUs who used the NEP were more than twice as likely to become infected with HIV as IDUs who did not use the NEP. Thirty three percent of NEP users and 13 percent of nonuser became infected. There was an HIV seroconversion rate of 7.9 per 100 person years among NEP participants, and a rate of 3.1 per 100 person years among non-participants.12

A high percentage of both groups shared intravenous equipment in the last six months: 78 percent of NEP users and 72 percent of non-NEP users. Risk factors identified as predictors of HIV infection included previous imprisonment, needle sharing and attending an exchange in the last six months. The study authors stated: “We caution against trying to prove directly the causal relation between NEP use and reduction in HIV incidence. Evaluating the effect of NEPs per se without accounting for other interventions and changes over time in the dynamics of the epidemic may prove to be a perilous exercise.” The study concluded: “Observational epidemiological studies…are yet to provide unequivocal evidence of benefit for NEPs.”13

(v) The Vancouver Study

Vancouver has the largest NEP in North America, and was praised in the 1993 CDC report. It is financed by public funds, and by 1996 was distributing over 2 million needles per year. A 1997 evaluation of the needle exchange program in Vancouver showed that since the program began in 1988, AIDS prevalence in intravenous users rose from approximately 2% to 27%. This occurred despite the fact that 92% of the intravenous addicts in that jurisdiction participated in the needle exchange program.14

The Vancouver study also found that 40% of the HIV-positive addicts who participated in the program had lent a used syringe in the previous six months, and that 60% of HIV-negative addicts had borrowed a used syringe in the previous six months. Despite the enormous number of clean needles provided free of charge, active needle sharing continued at an alarming rate. After only eight months, 18.6 percent of those initially HIV negative became HIV positive.15

The Vancouver study corroborates a previous Chicago study which also demonstrated that its NEP did not reduce needle-sharing and other risky injecting behavior among participants. The Chicago study found that 39% of program participants shared syringes, compared to 38% of non-participants; 39% of program participants, and 38% of non-participants “handed off” dirty needles; and 68% of program participants displayed injecting risks vs. 66% of non-participants.16

The Vancouver report noted that “it is particularly striking that 23 of the 24 seroconverters reported NEP as their most frequent source of sterile syringes, and only five reported having any difficulty accessing sterile syringes.”17

The authors continue: “Our data are particularly disturbing in light of two facts: first, Vancouver has the highest volume NEP in North America; second, HIV prevalence among this city’s IDU population was relatively low until recent years. The fact that sharing of injection equipment is normative, and HIV prevalence and incidence are high in a community where there is an established and remarkably active NEP is alarming.”18

What should be obvious from all of the studies above is that there is no conclusive scientific evidence that NEP’s arrest HIV infection. Indeed, there is evidence that NEP’s breed HIV infection.

Some claim that the federal government supports NEPs. While the previous administration’s Department of Health and Human Services actively favored NEPs, those who were actually in charge of our national drug policy do not. General Barry McCaffrey, then director of the Office of National Drug Control Policy (ONDCP), when addressing the issue of NEPS stated “we have a responsibility to protect our children from ever falling victim to the false allure of drugs. We do this, first and foremost, by making sure that we send them one clear, straightforward message about drugs: They are wrong and they can kill you.” McCaffrey’s strong views influenced President Clinton not to approve federal aid money for NEPs.19

A further elaboration of the ONDCP’s policy was provided by James R. McDonough, Director of Strategic Planning for ONDCP, who wrote:

The science is uncertain. Supporters of needle exchange frequently gloss over gaping holes in the data — holes which leave significant doubt regarding whether needle exchanges exacerbate drug use and whether they uniformly lead to decreases in HIV transmission. It would be imprudent to take a key policy step on the basis of yet uncertain and insufficient evidence.

The public health risks may outweigh potential benefits. Each day, over 8,000 young people will try an illegal drug for the first time. Heroin use rates are up among youth. While perhaps eight persons contract HIV directly or indirectly from dirty needles, 352 start using heroin each day, and more than 4,000 die each year from heroin/morphine-related causes (the number one drug-related cause of death).Even assuming that NEWS can further accelerate the already declining rate of HIV transmission, the risk that such programs might encourage a higher rate of heroin use clearly outweighs any potential benefit.

Treatment should be our priority. Treatment has a documented record of reducing drug use as well as HIV transmission. Our fundamental obligation is to provide treatment for those addicted to drugs. NEPS should not be funded at the expense of treatment.

Supporting NEPS will send the wrong message to our children. Government provision of needles to addicts may encourage drug use. The message sent by such government action would be inconsistent with the goals of our national youth-oriented anti-drug campaign.

NEPS do nothing to ameliorate the impact of drug use on disadvantaged neighborhoods. NEPS are normally located in impoverished neighborhoods. These programs attract addicts from surrounding areas and concentrate the negative consequences of drug use, including of criminal activity.20

(vi) Among IV drug users, HIV is transmitted primarily through high-risk sexual contact

Another reason why NEPs may not retard the spread of HIV is that HIV is transmitted primarily through high-risk sexual contact, even among IV drug users. Contrary to prior assumptions, recent studies on the efficacy of NEPs have discovered that it is not needle exchange, but instead, high-risk sexual behavior which is the main factor in HIV infection for men and women who inject drugs, and for NEP participants. A recently released 10-year study has found that the biggest predictor of HIV infection for both male and female injecting drug users (IDUs) is high-risk sexual behavior and not sharing needles. High-risk homosexual activity was the most significant factor in HIV transmission for men and high-risk heterosexual activity the most significant for women. The study noted that in the past the assumption was that IDUs who were HIV positive had been infected with the virus through needle sharing.21

The researchers collected data every 6 months from 1,800 IDUs in Baltimore from 1988 to 1998. Study participants were at least 18 years of age when they entered the study, had a history of injection drug use within the previous 10 years, and did not have HIV infection or AIDS. More than 90 percent of them said they had injected drugs in the 6 months prior to enrolling in the study. In their interviews, the participants reported their recent drug use and sexual behavior and submitted blood samples to determine if they had become HIV POSITIVE since their last visit. The study showed that sexual behaviors, which were thought to be less important among IDUs, are the major risk for HIV seroconversion for both men and women.22

If the above conclusions are correct, the very presumption of NEP efficacy becomes suspect. Indeed, the use of needle exchange programs to address a problem which is caused primarily by high-risk sexual behavior would seem to be highly misguided.

Another reason that Needle Exchange Programs do not effectively address the issue of “saving lives” is that HIV (regardless of how it is contracted) is not the primary cause of death for IVUs. A study conducted at the University of Pennsylvania followed 415 IV drug users in Philadelphia over four years. Twenty eight died during the study. Only five died from causes associated with HIV. Most died of overdose, homicide, suicide, heart or liver disease, or kidney failure.23

Clean needles, even if they in fact prevent HIV, will do nothing to protect the addict from numerous more imminent fatal consequences of his addiction. It is both misleading and unethical to give addicts the idea that they can live safely as IV drug abusers. Only treatment and recovery will save the addict. The myth of “safe IV drug use” is a lie which is perpetuated by NEPs, and it is a lie which will tend to kill the addict, although his corpse may be free of HIV, for whatever consolation that will provide to the NEP proponent.

B. NEEDLE EXCHANGE PROGRAMS DO NOT REDUCE SUBSTANCE ABUSE, BUT IN FACT FACILITATE AND ENCOURAGE SUBSTANCE ABUSE.

The rise of NEPs, with their inherent facilitation of drug use (coupled with the provision of needles in large quantities), may also explain the rapid rise in binge cocaine injection which may be injected up to 40 times a day. Some NEPs encourage cocaine and crack injection by providing “safe crack kits” with instructions on how to inject crack intravenously. Crack cocaine can be, and generally had been, ingested through smoking. But the easy and plentiful availability of needles facilitates crack injection, creating a new segment of IV drug users, subject to health dangers they would otherwise have been spared exposure to. In some NEPS, needles are provided in huge batches of 1000, and although there is supposed to be a one-for-one exchange, the reality is that more needles are put out on the street than are taken in.24

NEPs also facilitate drug use through lax law enforcement policies. Police are instructed not to harass addicts in areas surrounding NEPs. Addicts are exempted from arrest because they are given an anonymous identification code number. Since police in these areas must ignore drug use, and obvious and formidable disincentive to drug use disappears. As the presence of law enforcement declines in these areas, the supply of drugs rises, with increased purity and lower prices, attracting new and younger consumers.25

Many drug prevention experts have warned that the proliferation of NEPS would result in a rise in heroin use, and indeed, this has come to pass. (However, the increase in drug use was ignored by the federally-funded studies which recommended federally funding NEPS). The National Center on Addiction and Substance Abuse at Columbia University reported August 14, 1997 that heroin use by American teens doubled from 1991 to 1996. In the past decade, experts estimate that the number of US heroin addicts has risen from 550,000 to 700,000. 26

In 1994, a San Francisco study regarding a local NEP falsely concluded that there was no increase in community heroin use because there was no increase in young users frequenting the NEP. The actual rate of heroin use in the community was not measured, and the lead author, needle provider John Watters, was found dead of an IV heroin overdose in November 1995. According to the Public Statistics Institute, hospital admissions for heroin in San Francisco increased 66% from 1986 to 1995.27

In Vancouver, site of the largest NEP in North America, heroin use has risen sharply. In 1988 when the NEP started, 18 deaths were attributed to drugs. In 1993, 200 deaths were attributed to drugs. A 1998 report notes that drug deaths were averaging 10 per week. Now Vancouver has the highest heroin death rate in North America, and is referred to as Canada’s “drug and crime capital.”28

The 1997 National Institutes of Health Consensus Panel Report on HIV Prevention praised the NEP in Glasgow, Scotland, but the report failed to note Glasgow’s massive resultant heroin epidemic. Subsequently, as revealed in an article entitled “Rethinking Harm Reduction for Glasgow Addicts,” Glasgow took the lead in the United Kingdom in deaths from heroin overdose, and its incidence of AIDS continues to rise.29

Boston’s NEP opened in July 1993, and the city became a magnet for heroin. Logan Airport has been branded the country’s “heroin port.” Boston soon led the nation in heroin purity (average 81%), and heroin samples of 99.9% are found on Boston streets. Subsequently, Boston developed the cheapest, purest heroin in the world and a serious heroin epidemic among the youth. The Boston NEP was supposed to be a “pilot study,” but there was no evaluation of seroconversion rates in the addicts nor of the rising level of heroin use in the Boston area.30

Similarly, the Baltimore NEP is praised by those who run it, but the massive drug epidemic in the city is overlooked. The National Institute of Health reports that heroin treatment and ER admission rates in Baltimore have increased steadily from 1991 to 1995. At one open-air drug supermarket (open 9 a.m. to 9 p.m.) customers were herded into lines sometimes 20 or 30 people deep. Guarded by persons armed with guns and baseball bats, customers are frisked for weapons, and then allowed to purchase $10 capsules of heroin.31

One thing should be clear from the foregoing: since the implementation of NEPs, heroin use in our country has boomed. It is obvious: a public policy of giving needles to heroin addicts facilitates and encourages heroin use.

C. NEEDLE EXCHANGE PROGRAMS ARE DESTRUCTIVE TO THE COMMUNITIES IN WHICH THEY ARE USED.

Most citizens oppose NEPs in their communities, and are concerned about the prospect of dirty needles being discarded in public places. These fears are not without merit. NEPs distribute millions of needles every year, and there is little or no accountability for needles once they have been distributed. A survey conducted in 1998 revealed that in million needles unaccounted for.32

Carelessly discarded needles create a well-documented public hazard:

* On February 11, 2001, a six-year old from Glade View, Florida, stabbed five children with a discarded syringe. (Kellie Patrick/Scott Davis, “Playground Attack Raises Health Worries,” Sun Sentinal, 2/9/00, p 1B).

* On February 2, 2001, a nine year old from the Bronx stabbed four children with a discarded needle. (Diane Cardwell, “Boy Accused of Needle Attack,” The New York Times, 2/2/01, p. A17.)

* On February 13, 2001, a syringe left at a bus station stuck a four year old boy. (Mike Hast, “Big Fines for Syringe Litterers,” Frankson & Hastings Independent, February 13, 2001,www.mapinc.org/drugnews/v01/n304/ a08.html.)33

Besides the physical hazard created by discarded needles, there is a commonsense perception that NEPs bring an air of decay to the communities that host them. After several years of operation, 343 Massachusetts towns and cities (out of a total of 347) continue to decline the option of approving a local NEP, although of the 10 available slots, only 4 are taken.

In March 1997, accompanied by a New York Times reporter, a member of the Coalition for a Better Community, a New York City group opposed to NEPs, visited the Lower East Side Needle Exchange. She was not asked for identification and was promptly given 40 syringes (without having to produce any to exchange). She was also given alcohol wipes and “cookers” for mixing the drugs, and she was given an exchange ID card that would exempt her from arrest for possession of drug paraphernalia. She was then shown how to inject herself.34

Community opposition to the Lower East Side Needle Exchange arose soon after implementation of the local NEP due to an increase in dirty syringes on neighborhood streets, in school yards and in parks. There was observed to be a dramatic increase in the public display of injecting drugs. NEP users were seen selling their syringes to buy more drugs. Exchange workers themselves were photographed selling needles offsite. Neighbors perceived the Lower East Side NEP as little more than a wholesale distribution center for clean needles and a social club for addicts. Pro-needle activist Donald Grove concurred: “Most needle exchange programs actually provide a valuable service to users beyond sterile
injection equipment. They serve as sites of informal organizing and coming together. A user might be able to do the networking to find good drugs in the half an hour he spends at the street based needle exchange site networking that might otherwise have taken half a day. [Grove, D. The Harm Reduction Coalition, N.Y.C., Harm Reduction Communication, Spring 1996].35

In 1998, a U.S. Government official was sent to Vancouver, site of the largest NEP in North America, to assess the high incidence of HIV among NEP participants, and the skyrocketing death rate due to drug overdose. He reported that the highest rates of property crime in Vancouver were within two blocks of the needle exchange. He also observed, pursuant to a tour with the Vancouver Police, that there was a 24 hour drug market and plain view injection activity in the area immediately adjacent to the needle exchange. Most poignantly, he was told, in a private interview with an elementary school teacher, that the children at area schools are not allowed outside at recess for fear of needles.36

CONCLUSION

There is ample evidence to suggest that very fundamental premises used to justify and support NEPs are seriously flawed.

First, NEP participants routinely continue to share needles, and large percentages of the NEP participants are HIV positive, meaning that NEPs do nothing more than continue the spread of HIV (and HCV). Significantly, no one has been able to explain satisfactorily why enhanced needle availability in and of itself would discourage needle sharing: needle sharing is an intrinsic aspect of IV drug use, and a NEP-issued needle will transmit HIV as well as any other needle.

Second, NEP studies have discovered (inadvertently) that needle sharing is not even the primary cause of HIV infection for IVUs. It is primarily through high-risk sexual behavior that IVUs contract HIV; free needles do nothing to prevent sexually transmitted disease.

Furthermore, HIV (regardless of how it is contracted) is not even the primary cause of death for IVUs. Most die of overdose, homicide, suicide, heart or liver disease, or kidney failure. Clean needles may protect an addict from HIV, but they do nothing to protect him from the more numerous, and more imminent fatal threats of his addiction. Several key NEP proponents have died of heroin overdose; no doubt their needles were very clean.

Third, the science is inconclusive. Although the proponents of NEPs uniformly aver that the scientific debate regarding the efficacy of NEPs is over, in truth, even the reports favoring NEPs are burdened with imprecise methodology, and many of the authors of those reports caution that their results should not be deemed conclusive. Today, there is still no conclusive scientific evidence: (1) that NEPs reduce the spread of HIV and HCV, or (2) that NEPs do not encourage IV drug use. Indeed, the correlation between the rise of NEPs and the explosion of IV drug use, if it is a coincidence, is a remarkable one.

Dispassionate observers will look at the current epidemic of heroin and IV cocaine use as a tragedy which might have been averted, or mitigated, but for the misguided mercies of the NEP concept.

Fourth, while the benefits of NEPs may be in doubt, the costs to the surrounding communities are very real. The overwhelming majority of communities dread the prospect of a local NEP, for self-evident and well-documented reasons.

Notes

1New Jersey Family Policy Council, Needle Exchange Programs – Panacea or Peril, New Jersey Family Policy Council, POB 6011, Parsippany, NJ 07054, 973-263-5258, www.njfpc.org/research-papers/needle.htm 2. Loconte, Joe, Killing Them Softly,” Policy Review, The Heritage Foundation, 214 Massachusetts Ave. NE, Washington, DC 20002, p. 19 (August, 1998) 3. See New Jersey Family Policy Council, Needle Exchange Programs – Panacea or Peril, supra, note 1. 4.Mathias, Robert, high-Risk Sex Is Main Factor in HIV Infection for Men and Women Who Inject Drugs@, NIDA NOTES Staff Writer, NIDA Notes, (National Institute on Drug Abuse, Washington, DC) Volume 17, Number 2 (May 2002) (Source: Strathdee, S.A., et al.

Sex differences in risk factors for HIV seroconversion among injection drug users.@ Archives of Internal Medicine 161:1281-1288, 2001)

1

See New Jersey Family Policy Council, Needle Exchange Programs- Panacea or Peril, supra, note 1.

1 Id.

1See Loconte, Joe, Policy Review, supra, note 2.

1

See New Jersey Family Policy Council, ANeedle Exchange Programs – Panacea or Peril, supra, note 1.

1

See New Jersey Family Policy Council, Needle Exchange Programs- Panacea or Peril, supra, note 1.

4 Id.

4See Loconte, Joe, Policy Review, supra, note 2.

4 See New Jersey Family Policy Council, Needle Exchange Programs – Panacea or Peril, supra, note 1. 4 Sex differences in risk factors for HIV seroconversion among injection drug users.@ Archives of Internal Medicine 161:1281-1288, 2001) 5 See New Jersey Family Policy Council, Needle Exchange Programs- Panacea or Peril, supra, note 1.

6 Id.

7See Loconte, Joe, Policy Review, supra, note 2.

8 See New Jersey Family Policy Council, Needle Exchange Programs – Panacea or Peril, supra, note 1.

9 See Loconte, Joe, Policy Review, supra, note 2.

10See New Jersey Family Policy Council, Needle Exchange Programs – Panacea or Peril, supra, note 1. 11See New Jersey Family Policy Council, Needle Exchange Programs – Panacea or Peril, supra, note 1.

12 Bruneau J, Lamothe F, Franco E, Lachance N, Desy M, Soto J, et al. High rates of HIV infection among injection drug users participating in needle exchange programs in Montreal: results of a cohort study. Am J Epidemiol 1997;146(12):994-1002.

13 Id.

14Strathdee SA, Patrick DM, Currie SL, Cornelisse PG, Rekart ML, Montaner JS, et al. Needle exchange is not enough: lessons from the Vancouver Injecting Drug Use Study. AIDS 1997;11(8):F59-F65. British Columbia Centre for Excellence in HIV/AIDS.

15 Id.

16 National Research Council/ Institute of Medicine, Preventing HIV Transmission: the Role of Sterile Needles and Bleach, National Academy Press, Washington DC, p. 302-304, 1995.

17 See: Strathdee SA,et, al., supra, note 14.

18Id.

19Drug Czar Statement on Administration Decision to Continue Ban on Use of Federal Funds for Needle Exchange Programs,” Press Release, Office of National Drug Control Policy (ONDCP), Washington, D.C., April 24, 1998.

20 James R. McDonough, Director of Strategic Planning, Executive Office of the President, Office of National, Drug Control Policy, Washington, DC. 20503 to Ms. Elizabeth Edwards, Arizonans for a Drug-Free Workplace, P.O. Box 13223, Tucson, AZ 85732; Letter dated April 14, 1998.

21Mathias, Robert, High-risk Sex Is Main Factor in HIV Infection for Men and Women Who Inject Drugs@, NIDA NOTES Staff Writer, NIDA Notes, (National Institute on Drug Abuse, Washington, DC) Volume 17, Number 2 (May 2002) (Source: Strathdee, S.A., et al. Sex differences in risk factors for HIV seroconversion among injection drug users. Archives of Internal Medicine 161:1281-1288, 2001.

22 Id.

23 See Loconte, Joe, Policy Review, supra, note 2.

24Janet D. Lapey, MD, Needle Exchange Programs: 1998 Report, April 1998, Drug Watch, P.O. Box 45218, Omaha, Nebraska 68145-0218

25 Id. 26Id. 27 Id.

28 Id. 29 Id. 30Id. 31Id.

32Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, HHS, Washington, DC 2001;50:384-388.

33Maginnis, Robert L., 2001 Update On The Drug Needle Debate, Insight, Number 235, July 16, 2001, Family Research Council, 801 G. St. NW, Washington, DC 2001.

34See New Jersey Family Policy Council, ANeedle Exchange Programs – Panacea or Peril, supra, note 1.

35D.B. Des Roches, Information, Memorandum for the Director, Through: the Deputy Director, Subject: Vancouver Needle Exchange Trip Report, Executive Office of the President, Office of National Drug Control Policy, Washington, D.C. 20503, April 6, 1998.

 

Source: Testimony of David G. Evans, Esq.

Executive director, Drug-free Schools Coalition before the Health and Human Services

Committee of the New Jersey Assembly, Trenton, NJ in opposition to a-3256

September 20, 2004

Women who inject drugs are about 39% more likely to become infected with hepatitis C virus than men who inject drugs, research suggests.

A range of factors could account for the disparity, the researchers wrote in Clinical Infectious Diseases.

“Our findings provide important evidence that sex disparities in  exist independent of selected behavioral risk and demographic factors,” researcher Kimberly Page, PhD, MPH, division chief of the department of internal medicine at the University of New Mexico Health Sciences Center, and colleagues wrote. “When considering HCV risk differential among women, multiple factors including biological, social and network factors — as well as differential access to prevention services — need to be considered.”

The researchers assessed data from seven of the 10 InC3 Collaborative studies of HIV and HCV among PWID ((people who inject drugs ), which included locations in the United States, Europe and Australia.

Page and colleagues included data from 1,868 PWID, 590 (31.58%) of whom were women. No data from participants who reported being transgender were assessed. In all, the researchers found 511 PWID with incident HCV during follow-up. Of those, 182 (31.5%) were female.

The unadjusted female-to-male HR for HCV infection was 1.38 (95% CI, 1.15-1.65). The disparity remained significant after adjustment for behavioral and demographic risk factors, the researchers said, slightly rising to 1.39 (95% CI, 1.12-1.72).

Page and colleagues cited previous studies suggesting biological and social factors that may help to explain the difference.

“All of these factors should be studied further to better understand sex-related differences in risk and to maximize prevention effects of drug treatment programs and their potential to reduce acquisition of blood-borne viruses, including HCV and HIV,” they wrote.

Disclosure: Esmaeili reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.

Source: https://www.healio.com/infectious-disease/hepatitis-c/news/in-the-journals/%7Be0c3d409-03c9-4d3b-a277-13edeb16b8e6%7D/women-injecting-drugs-at-higher-risk-for-hcv-than-men 2nd Sept.2017

Steroid use in Britain’s gyms is growing so fast, dirty needles are being disposed of in fitness centre sharps bins. The explosion in the popularity of potentially lethal muscle-building drugs has led to hundreds of thousands taking jabs. Their numbers now outstrip drug addicts who inject themselves with heroin in the UK, a Sunday Mirror investigation reveals.  Our findings today confirm rising fears among drug charities and health experts that use of anabolic steroids – which mimic the effects of male hormone testosterone – is spiralling out of control. We discovered HIV infection among steroid injectors has risen to the same level found in heroin users – 1.5 per cent.

At one needle exchange in Warrington staff told us 90 PER CENT of the syringes they see have been used for steroids compared to only 10 per cent for heroin. Another exchange said children as young as 15 were using the drugs.

Anabolics can become addictive and lead to heart attacks, strokes and a higher chance of liver and prostate cancer as well as psychological problems. Killer Raoul Moat was on them when he shot three people in two days in 2010.

They are all too easily available online. But it is the tolerance of the growing problem by gyms around the country that is most worrying.

A shocked fitness fan who spotted one of the “sharps” bins containing used needles at a Virgin Active health club in London told us: “I couldn’t believe my eyes. “It’s one of the poshest gyms I’ve been in, £100 a month, and the bins were sitting right there in the toilets. It’s the first time I’ve seen that. I had a look and there were loads of needles and swabs.”

Easygym say they have the bins in their clubs for “safety reasons” and there are plans in place to introduce them in Dragon’s Den star Duncan Bannatyne’s 61 health clubs. Anytime Fitness is considering whether to introduce them.  The clubs are following recommendations from health watchdog NICE – but nowhere near far enough.

NICE is concerned that gym users will share needles and spread HIV and Hepatitis B and C. It asked gyms not just to provide sharps bins but also sterile syringes for its members. None of the gyms we spoke to said they did this.

But the watchdog’s policy of accepting steroid use and the gyms’ adherence to that was yesterday blasted by tragic mum Tina Dear, whose Royal Marine son Matthew, 17, died just weeks after he started using steroids to bulk up. He is throught to have had a severe reaction sending his body into shock.

Tina, of Southend, Essex, said: “Needles bins in gyms normalise steroid use. People will go into changing rooms, see the gym has provided a bin and naturally presume steroids are safe.

“They’ll think it’s OK. But it’s not. It’s Russian Roulette. People don’t know what they’re taking. Gyms should be practising zero tolerance, especially when it comes to youngsters who look up to the older guys. They need positive role models.”

Jim McVeigh is acting director at the Centre for Public Health at Liverpool John Moores University and Britain’s leading expert in the misuse of anabolic steroids.  He said the official figure of 70,000 steroid users in the UK was wrong. He warned: “It’s safe to say there are hundreds of thousands of steroid users in this country, more than heroin injectors.”

Needle exchanges – first set up in the wake of the AIDS crisis – confirm what he believes. One in Yorkshire, run by drug and alcohol charity Crime Reduction Initiatives (CRI), deals with 70 per cent steroid users compared to 30 per cent heroin.

And the problem is affecting younger and younger people.   David Rourke from CRI’s Sheffield needle and syringe programme said he’s heard of children as young as 15 using steroids. He said: “We deal with guys over 18, but elsewhere I know of much younger kids.”

He believes the bins are a good idea. He said: “I have heard of gyms where used needles are shoved up into ceiling tiles. A safe alternative can’t be a bad thing.” Steroids are legal for personal use, but Jim McVeigh warned that is no indication they are safe. He said: “The fact is, users are taking a big risk. Often they don’t have a clue what they’re taking.

“These are people who wouldn’t buy a hotdog off the street, but they’ll take drugs off a stranger on the internet and inject themselves. There have been no long-term clinical tests on these substances, and most users take a cocktail of anything up to 12. They are playing with fire. We have no idea what long term health effects will be.”

Researchers from Public Health England and Liverpool John Moores University last year surveyed 395 men who used steroids and other performance enhancing drugs. As well as the one in 65 found to have HIV, the study also found one in 18 had been exposed to Hepatitis C and one in 11 had been to Hepatitis B.

While dealing steroids person to person is illegal, buying them online is easy. A simple Google search presents dozens of outlets offering the drugs. Gyms who have installed the bins yesterday defended their use.

Virgin Active said: “Sharp boxes are installed for practical and safety purposes for those with medical conditions, or needing to dispose of razors. Their presence in no way condones the use of steroids in our clubs.” Any illegal steroid activity is reported to the police, the spokesman added.

Easygym said: “Steroid use is not something we encourage or promote. For Health and Safety reasons only we provide a sharps bins for needles and razor blades. Bannatyne Health Clubs said: “The 61 health clubs will all have sharps boxes shortly.”

Anytime Fitness added: “We are currently looking at a sharps policy.” Professor Mike Kelly, Director of the NICE Centre for Public Health said: “Research shows people who inject these drugs are at an increased risk of blood-borne viruses including hepatitis.

“Needle and syringe programmes aim to stop people sharing potentially contaminated injecting equipment. Delivering these programmes in gyms is an important way to protect people.”  But mum Tina, still grieving her lost son, said: “Gyms should be pushing education as their first priority instead of putting bins in their toilets.” * For more advice visit cri.org.uk and matthewdearfoundation.co.uk

Drug is a fuel for violent crime

Men on steroids are twice as likely to be involved in violence and carry weapons, say US studies.  Scientists have linked steroid use to mood swings, paranoid jealousy, extreme irritabililty and impaired judgement. Anabolics addict Raoul Moat shot his ex-girlfriend Samantha Stobbart, her new partner Chris Brown and blinded PC David Rathband after blasting him in the face in 2010.  In a letter to police, Moat, 37, described his anger saying: “It’s like the Hulk. It takes over and it’s more than anger and it happens when I’m hurt.”

Ex-US Marine David Bieber, who shot dead PC Ian Broadhurst in Leeds in 2003, was also pumped up on steroids. His father blamed the drugs for his 48-year-old son’s descent into a life of violence and crime.  And 35-year-old Norwegian mass murderer Anders Breivik, who killed 77 people in a bombing and shooting rampage in July 2011, was a heavy steroid user too.

Serious health risks for users Anabolic steroid users take enormous risks to boost the size of their muscles.  But it’s not only serious medical conditions – from high blood pressure to liver, kidney and prostate cancer – they could trigger.

Taking the drugs can also can lead to a reduced sperm count, infertility, shrunken testicles and baldness in men. It can also cause severe acne.  In women, steroid use can increase facial and bodily hair growth, deepen the voice and cause problems with periods.  And some of the darker side effects are psychological, such as aggressive behaviour, mood swings, manic behaviour and even hallucinations.

Source: http://www.mirror.co.uk/news/uk-news/sunday-mirror-investigation-reveals-shocking-3816366#ixzz36tr76b7s 

A daily dose of powerful anti-HIV medicine helped cut the risk of infection with the AIDS virus by 49 percent in intravenous drug users in a Bangkok study that showed for the first time such a preventive step can work in this high-risk population.

“This is a significant step forward for HIV prevention,” said Dr. Jonathan Mermin, director of the U.S. Centers for Disease Control and Prevention, which helped conduct the clinical trial along with the Thailand Ministry of Health.

The study, published on Wednesday in the journal Lancet, looked at the treatment approach known as pre-exposure prophylaxis, or PrEP, in which HIV treatments are given to uninfected people who are at high-risk for HIV infection.

The drug used in the study was Gilead’s older and relatively cheap generic HIV drug tenofovir. The study was launched in 2005.

Prior studies of this approach showed it cut infection rates by 44 percent in men who have sex with men, by 62 percent in heterosexual men and women and by 75 percent in couples in which one partner is infected with HIV and the other is not. The new results showed that it also protects intravenous drug users.

“We now know that PrEP can work for all populations at increased risk for HIV,” Mermin said in a statement.  Based on the results, the CDC plans to recommend that U.S. doctors who wish to prescribe this treatment for their patients follow the same interim guidelines issued last year to prevent sexual transmission among other high-risk individuals.

Intravenous use of drugs like heroin accounts for about 8 percent of all new HIV infections in the United States and about 10 percent of new HIV infections worldwide. In some regions, such as Eastern Europe and Central Asia, injection drug abuse accounts for about 80 percent of all new infections.

The new findings involved more than 2,400 intravenous drug users in Bangkok who were not infected with the human immunodeficiency virus, which causes AIDS, and were being treated at the city’s drug treatment clinics.  Half took tenofovir and half took a placebo. All participants were given HIV prevention counseling, risk-reduction strategies such as condoms and methadone treatment, and monthly HIV testing.

At the end of the study, there were 17 HIV infections among people taking the HIV medication, compared with 33 infections among those not taking the drugs, the researchers found.  The researchers also looked to see what factors influenced infection rates among those taking the HIV medication. They found that people who took their medication at least 71 percent of the time had a 74 percent lower risk of becoming infected with HIV.

Although it was not clear how the preventive drug treatment worked – by stopping infections caused by sharing dirty needles or by unprotected sex among drug users – the study produced a reduction in infection rates, said Dr. Salim Abdook Karim of the University of KwaZulu-Natal in Durban, South Africa and of Columbia University in New York.

“The introduction of PrEP for HIV prevention in injecting drug users should be considered as an additional component to accompany other proven prevention strategies like needle exchange programs, methadone programs, promotion of safer sex and injecting practices, condoms, and HIV counseling and testing,” Karim, who was not involved in the study, wrote in a commentary accompanying the study in the Lancet.

“PrEP as part of combination prevention in injecting drug users could make a useful contribution to the quest for an AIDS-free generation,” Karim added.
Source: http://www.foxnews.com/health/   13th June 2013

Every morning, Sergei Kislov takes the bus to the rundown outskirts of this port city for the methadone doses that keep him off heroin without suffering withdrawal. Now that Russia has taken over Crimea, the trips are about to end.

“For a month and a half I won’t be able to sit or sleep or eat,” Kislov said. “It’s a serious physical breakdown.”

Across the Black Sea peninsula, some 800 heroin addicts and other needle-drug users take part in methadone programs — seen as an important part of efforts to curb HIV infections by taking the patients away from hypodermic needles that can spread the AIDS-causing virus.

But Russia, which annexed Crimea in mid-March following a referendum held in the wake of Ukraine’s political upheavals, bans methadone, claiming most supplies end up on the criminal market. The ban could undermine years of efforts to reduce the spread of AIDS in Crimea; some 12,000 of the region’s 2 million people are HIV-positive, a 2012 UNICEF survey found.

After years of rapid growth in the infection rate, the Ukrainian Health Ministry reported the first decline in 2012.

Many have attributed that decline to methadone therapy. According to the International HIV/AIDS Alliance of Ukraine, which helps fund many local projects with money from the Global Fund to Fight AIDS, Tuberculosis and Malaria, drug injectors accounted for 62 percent of new HIV infections in Ukraine in 2002. By 2013, that number was down to 33 percent.

HIV is an illness that often sweeps up those people who aren’t socially secure,” said Denis Troshin, who runs the local NGO, Harbor-Plus, which helps coordinate methadone therapy for 130 of Sevastopol’s recovering addicts. “Many of them were put in the (medical) records at some point, but then they disappear for many years and by the time they show up at the hospital again they’re nearly dead. Our goal is to find them, convince them to come to the doctor and not miss their treatment.”

In Russia, which recommends that addicts quit cold turkey, HIV is spreading rapidly. According to the Russian Federal AIDS Center, the number of people registered as infected increased by nearly 11 percent in 2013.

While methadone doesn’t have the same euphoric effect as heroin, it weans addicts off the drug by blocking the pain, aches and chills of withdrawal. In preparation, Kislov has already started reducing his daily intake of methadone by about 10 milligrams each week.

Although he voted enthusiastically for Crimea to join Russia, he didn’t expect the methadone program to end so quickly.

“It is happening at such a pace that it’s going to be a massacre here,” he said. “They’re abandoning 130 people and forcing them to fend for themselves, even if that means we’ll end up stealing again and going to jail.”

Patients say that since the program started here five years ago, local doctors had been nothing but supportive of the therapy. They reassured recovering addicts ahead of the referendum that the program would be extended at least until the end of the year.

That attitude changed on March 20, when the director of Russia’s Federal Drug Service, Viktor Ivanov, announced that the program would be banned in Crimea.

“As it turns out, the lives of the people participating in this program are less important than politicking,” said Troshin. “It’s as if (the doctors) are saying: ‘We’re doing everything according to how Russian law is even before it’s implemented … We’re so zealous that we’re closing (the program) right now and we don’t care about the 130 families who will be affected.'”

Troshin says the group has sent letters to both local and national politicians. But even if the group gets permission from local authorities to extend the program, the Ukrainian health minister told local news agencies Monday that Ukraine would not be sending any more methadone to Crimea, and recommended that any addicts there move to mainland Ukraine if they wanted to continue their treatment.

For Alexander Kolesnikov, a 40-year-old who has now been in the group for four years, moving to Ukraine isn’t a possibility. He’s proud of being from Sevastopol and has an aging, diabetic mother to care for.

But while the two went proudly to the polls on March 16 to vote for joining Russia, they are now dreading how a return to life without methadone might affect them.

“One half of my mother’s heart is for Russia — for example, she will get a higher pension and she’ll have a better standard of living,” he said. “But the other half of her heart supports me, and she doesn’t want to see me in that state ever again.”

Source:  www.news/yahoo.com  4th April 2014

AN AUSTRALIAN trend for drug users to smoke rather than inject drugs like crack cocaine, methamphetamines and heroin will lead to serious lung damage, a UK expert warns.

Dr Alistair Story told the Thoracic Society of Australia and New Zealand meeting in Darwin yesterday that Australian data showed drug users were following overseas trends, using a ‘respiratory route’ rather than injecting drugs.

“In the United Kingdom, there is a trend among health care providers to describe smoking rather than injecting drugs as a harm reduction measure,” Dr Story, a respiratory specialist at University College Hospitals NHS Foundation Trust, said.

“However, I prefer to call this harm diversion. We know that injecting drugs is extremely damaging to health, but so is smoking drugs.”

He said there was a low awareness of the risks of smoking drugs in terms of lung damage among health care providers working with drug addicts.

Integrating respiratory health care into drug treatment services was a missed opportunity as a consequence, he said.

Dr Story, who pioneered outreach lung disease diagnosis and response programs among drug addicts, alcoholics and homeless people in London said drug users who choose to smoke the drug needed to understand the health consequences of chronic lung diseases.

“The lung is a non-regenerative organ and declining lung health is a one way ticket,” he said.

Source: www.medicalobserver.com.au 29th March 2013

 

A significant increase (more than 10-fold) in the number of newly diagnosed HIV-1 infections among injecting drug users (IDUs) was observed in Greece during the first seven months of 2011. Molecular epidemiology results revealed that a large proportion (96%) of HIV-1 sequences from IDUs sampled in 2011 fall within phylogenetic clusters suggesting high levels of transmission networking. Cases originated from diverse places outside Greece supporting the potential role of immigrant IDUs in the initiation of this outbreak.

Source: Eurosurveillance, Volume 16, Issue 36, 08 September 2011

Just under 9% of HIV-positive individuals in the UK are co-infected with hepatitis C virus, investigators report in the Journal of Viral Hepatitis.
“In comparison with other large cohort studies, the overall HCV [hepatitis C virus] prevalence of 8.9% in the UK…is low,” comment the investigators. They believe that this is because of the low prevalence of HIV among injecting drug users in the UK. However, approximately 20% of HIV-positive patients in the UK have never been tested for hepatitis C, despite guidance that all patients should be screened annually.
Encouragingly, there was no evidence that co-infection resulted in a poorer response to antiretroviral therapy. Liver disease caused by hepatitis C is now a major cause of illness and death in HIV-positive patients. However, detailed information on the prevalence of hepatitis C among HIV-positive individuals in the UK is lacking. There is also little information on hepatitis C testing and the impact of co-infection on responses to HIV therapy
Therefore investigators from the UK Collaborative HIV Cohort (UK CHIC) undertook an observational study involving 31,765 patients provided with care at ten specialist HIV clinics between 1996 and 2007. Prevalence of co-infection (determined by a positive hepatitis C antibody result), trends in testing, and responses to HIV therapy were monitored. Overall, 64% of patients had been tested for hepatitis C at least once. The proportion of patients screened for the virus increased from 9% in 1996 to 80% in 2007.
“There has been a clear instruction that all HIV-positive patients should be screened since at least 2004,” write the investigators. Nevertheless, “20% of patients under follow-up in 2007 had not apparently ever been tested. The latest BHIVA [British HIV Association] guidelines recommend screening all HIV-positive patients at diagnosis, with annual repeat testing in those who are negative.”
Testing rates differed according to HIV risk group, and was highest for gay men (74%), followed by heterosexual men and women (63%). Although injecting drug use is a well-established risk factor for hepatitis C, only 50% of individuals with a history of injecting drug use had been tested for the virus.
However, the investigators think that the true prevalence of testing in this group is likely to be higher. They comment: “these patients may be more likely to have been tested previously.” The researchers also suggest that the higher rates of mortality and loss to follow-up among injecting drug users could also mean this group were less likely to be screened for hepatitis C.
Overall prevalence of hepatitis C was 9%, and prevalence was 8% among those who were receiving care in 2007. By contrast, prevalence in the general UK population is estimated to be 0.44%. The investigators suggest that the significantly higher prevalence of the infection among patients in the UK CHIC reflects “the shared transmission routes of HCV and HIV.”
Prevalence of hepatitis C differed between HIV risk groups. It was highest in injecting drugs users (84%), followed by gay men (7%), and heterosexual men and women. However, the investigators suggest that some hepatitis C infections in gay men may actually be due to injecting drug use, who suggest that this behaviour may be “underreported by some MSM [men who have sex with men], sufficient to place them at risk of HCV infection…underreporting of IDU as a risk for HCV transmission in MSM may also affect other cohorts.”
Most co-infected patients were men (80%), white (82%), and their median age was 37. The strongest independent risk factor for co-infection with hepatitis C was HIV transmission group. Injecting drug users were significantly more likely to be co-infected than all other risk groups (p < 0.0001). The impact of co-infection on responses to antiretroviral therapy was analysed in the 9669 patients who started HIV treatment after 2000. A total of 4% of these patients were co-infected. Overall, 91% of patients achieved an undetectable viral load. Co-infected patients were just as likely as individuals who were only infected with HIV to achieve this outcome. There was no association between co-infection and subsequent rebound in viral load. In addition, CD4 cell count increases were comparable between co-infected and HIV-mono-infected patients. “We found no association between HCV co-infection and either the initial virological response, the rate of viral rebound or the CD4 count response,” emphasise the investigators. They note that results from the Swiss HIV cohort study showed that co-infection did not have an impact on virological responses to therapy. “The overall cumulative prevalence of HCV of 8.9% in UK CHIC is lower than other cohorts among whom the proportion of IDU is higher,” conclude the researchers. However, they emphasise that this rate of co-infection still “represents a substantial burden of disease.” Source:www.aidsmap.com Feb 14th 2011

More than a half of the people in Scotland with known HIV infection are drug injectors. Two studies have suggested that injecting with a consequent risk of HIV transmission is prevalent among drug misusers in prison. There is also concern over the lack of treatment for drug misuse in prison. Drug misusers attending needle exchange centres seem able to maintain a low level of risk behaviour, although their attendance may be interrupted by imprisonment.’ Little is known about their drug taking, injecting, and sharing of needles in prison. Subjects, methods, and results
A questionnaire was administered to 81 drug injectors at two Glasgow needle exchanges in January 1990. Semistructured indepth interviews were conducted
with another 19 injectors at the same exchanges in June 1990.

Of the 81 injecting drug misusers (61 men and 20 women), 56 (69%) had served at least one term in custody (median 5 terms, range 1-40), of whom 39 (31 men and 8 women, mean age 23 7 years) had served their most recent sentence during 1989. Of the 56 former prisoners, 55 were aware that other inmates had misused drugs and 36 said that they themselves had misused drugs in prison. Only four (11%) of those misusing drugs in prison had taken cannabis alone. Other drugs taken were buprenorphine, temazepam, heroin, cocaine, and valium. Forty nine had seen other inmates injecting drugs, and 14 men said that they themselves had injected drugs in prison. Forty five had seen others sharing needles in prison, and six said that they themselves had shared needles in
prison. This means that 43% (six of the 14) of those admitting to injecting also shared needles. Fifty one subjects said that they had not been offered treatment for drug problems while in custody, although 46 stated that the prison authorities knew that they were drug misusers. Four of the eight women had been
offered some form of treatment for withdrawal symptoms, but 47 of the 48 men said that they had not been offered any treatment.

All 81 subjects were asked whether they might inject and share needles in prison in the future. Sixty seven thought that they would misuse drugs and 55 that thev
would inject them; 20 thought that they would share injecting equipment. These figures are higher than those reported for actual misuse, injecting, and sharing
needles.

Comment
This study shows that most drug injectors attending Glasgow needle exchanges have been in prison. Six subjects (11%) admitted to sharing needles in prison.
The true extent of sharing may be greater as the other eight who reported injecting drugs in prison were unlikely to have had exclusive access to their own
equipment. Respondents in the semistructured interviews emphasised this fact-“When you hide your needle, someone else might find it and it gets used in
their circle, so you can’t say how many get to use it.” Estimates of the number of people sharing one needle varied between five and 100. It therefore seems highly
probable that when a drug misuser shares needles inside prison, this may occur more frequently and among a wider group of people than it would outside
prison. Little treatment seems to be offered for drug problems in Scottish prisons. Fifty one (910%) respondents said they had received no treatment at all. This contrasts with a recent study that found that only 40% of a group of 50 drug misusers in London had not received treatment while in custody. This apparent
lack of treatment offered in Scottish prisons, together with the prevalence of reported injecting drug misuse and sharing of needles are matters of serious concern.
This study was funded by the Nuffield Foundation,

Source: www.bmj.com Vol.302. Number 6791

HIV rates much higher among daily needle exchange users than those who do not use the exchange program, according to latest study
HIV incidence was 75 percent higher among daily users of Vancouver’s needle exchange program (NEP) than among drug abusers that did not use the program, according to a new study published in the latest edition of the American Journal of Medicine. Vancouver, Canada boasts the largest NEP in the Western Hemisphere.

Source: The American Journal of Medicine Volume 120, Issue 2, Pages 172-179 (

Needle-exchange programmes designed to cut injection drug users’ risk of HIV, the virus that causes AIDS, and other infections do seem to reduce needle sharing, but there is only limited evidence that they lower disease transmission, a new research review concludes.
Reporting in the journal Addiction, researchers say that based on their study — an analysis of five previous reviews of needle-exchange programs — the evidence for the programs’ effectiveness is weaker than generally thought.
However, they also stress that their review did not find needle-exchange programs to be ineffective either.  “The findings of this review should not be used as a justification to close NSPs (needle and syringe programs) or hinder their introduction,” write the researchers, led by Norah Palmateer, of Health Protection Scotland, part of the UK National Health Service.
“Insufficient or weak evidence of an effect is not evidence of no effect,” Palmateer told Reuters Health in an email. “It is more a reflection of the studies and evidence available.”   It is not that studies on needle-exchange programs have been “poor,” Palmateer said,  but they are limited by the nature of their design.
Studies looking at needle-exchange programs have been observational, rather than controlled clinical trials where researchers would, for example, randomly assign some communities to start a program, and then compare them over time with program-free communities.   Observational studies, Palmateer noted, are subject to limitations like “selection bias.” For example, if those injection drug users at greatest risk of HIV are most likely to use the programs, then a study may find that program attendees have a higher rate of infection than drug users not involved in needle-exchange.
Needle-exchange programs have always been controversial, with opponents arguing that they sustain people’s addictions and send the wrong message about drug use. The U.S. just recently repealed a ban on federal funding for needle-exchange programs, though some cities have long had their own programs.
Advocates of the programs, including many public-health and HIV experts, point to studies showing that needle and syringe exchange can cut HIV transmission — such as a 2004 review by the World Health Organization (WHO) that concluded there is “compelling evidence” that the programs reduce HIV infections.  However, individual studies have come to mixed conclusions, including those covered by the WHO review, according to the current study.
Palmateer and her colleagues found that of the 10 studies in the WHO review focusing on HIV transmission, five had positive findings; of those five, four had weaknesses in their design that limit the conclusions that can be drawn.
Palmateer’s team also looked at two other reviews that covered many of the same studies as the WHO review. One research team came to similar conclusions as the WHO, while the other was more guarded — saying that the evidence that needle-exchange programs reduce HIV transmission is “modest.”  Overall, Palmateer and her colleagues conclude, there appears to be “tentative” evidence that needle-exchange programs reduce HIV transmission among injection-drug users.
When it came to hepatitis C, a liver infection usually spread through infected blood, there was insufficient evidence to say whether the programs are effective or not, according to Palmateer’s team. Of the five reviews she and her colleagues analyzed, the three major ones did not examine hepatitis C “in any depth,” the researchers write.
There was also insufficient evidence of the effectiveness of alternatives to standard needle-exchange programs — including vending machines that sell syringes and needles, and outreach programs that go to drug users rather than having them come to a clinic.   On the other hand, there was “strong” evidence across the reviews that needle-exchange programs reduce the sharing or reuse of dirty needles, and no evidence of harmful effects, according to Palmateer’s team.
Exactly why the evidence for disease prevention is not as strong is not entirely clear. Studies may have failed to detect an impact, but limitations of the programs themselves may also be at work.  For example, many of the needle-exchange programs studied in these reviews had strict limits on the number of syringes and needles they could give clients, Palmateer and her colleagues note. So while they might have reduced users’ needle sharing and reuse, it might not have been adequate.
It is not known what “level of coverage” — that is, the amount of injecting equipment given to clients — is needed to lower HIV and hepatitis C rates, according to Palmateer’s team. And at any rate, the optimal level will vary from one locale to another.  “The main public health implications of the findings are that a higher level of coverage of interventions, including (needle and syringe programs), is likely required to reduce blood-borne virus transmission,” Palmateer said.
She noted that this may be especially true of hepatitis C, which is most commonly transmitted through drug-equipment sharing. In the U.S., injection drug use is believed to account for most new cases of hepatitis C and about one-fifth of new HIV cases.

SOURCE: Addiction, online March 2, 2010.

Filed under: HIV/Injecting-Drug-Users :

Infections among injecting drug users

Key Messages
1. Needle and syringe sharing has declined in recent years, however with around a quarter of injecting drug users continuing to share the level remains higher than in the mid-1990s.

2. Injecting into the groin and the injection of crack cocaine, which are associated with higher levels of
infection and risky injecting, have become more common.

3. Injecting site infections are common, with around one third of injecting drug users reporting having had an
abscess, sore or open wound at an injecting site in the last year.

4. Transmission of HIV and HCV infection through injecting drug use remains higher than in the late 1990s, with a fifth of recent initiates having hepatitis C and around one in 100 having HIV. Overall almost half of injecting drug users are now infected with hepatitis C and about one in 90 with HIV.

5. There has been a marked increase in the number of injecting drug users receiving the hepatitis B vaccine,
with two-thirds now reporting vaccination.

6. Services to reduce injecting related harms and support for those who want to stop injecting should continue to be developed in line with published guidance.

Key Findings
Behaviours: Levels of reported needle and syringe (direct) sharing have declined in recent years, following an increase in the late 1990s. In 2007, around a quarter of injecting drug users (IDUs) reported direct sharing in the previous month; this level remains higher than in the mid-1990s when about a sixth reported this. The sharing of other injecting equipment remains even more common. There are also indications that
two other factors associated with a greater risk of infection have become more common, with almost one in three IDUs now reporting injecting into the groin (femoral vein) and athird reporting the injection of crack-cocaine.

Hepatitis C: Overall, almost half of IDUs in the UK have been infected with hepatitis C. However, there are marked variations in hepatitis C prevalence within the UK, with low prevalences found in some areas. The overall prevalence of hepatitis C infection among IDUs has probably increased in recent years. Current levels of hepatitis C transmission remain higher than in the late 1990s with a fifth of IDUs becoming
infected within three years of starting to inject.

HIV: The incidence of HIV among IDUs is higher than in the late 1990s with around one in 100 now becoming infected within three years of starting to inject. The overall prevalence of HIV infection among IDUs however remains low compared to many other countries. In England & Wales, the overall HIV
prevalence among IDUs is currently around one in 90. Within England and Wales prevalence has increased amongst IDUs outside London: where it has risen from around one in 400 in 2002 to about one in 150 in 2007. However, the prevalence is higher in London, with around one in 20 HIVinfected. In Scotland, the prevalence of HIV among IDUs was around one in 350 in 2007, which is the lowest level reported
since this was first measured in 1989.

Voluntary confidential diagnostic testing: Uptake of testing for hepatitis C among IDUs in contact with drug services, after increasing markedly, now appears to be levelling off with around three-quarters having ever had a test. It is estimated that around half of IDUs with hepatitis C in contact with these services remain unaware of their infection, and that this proportion has not changed in recent years. There are also likely to be many current and former IDUs not in contact with services that will be unaware they have hepatitis C. Whilst most IDUs in contact with services report having had a test for HIV at some point, only two thirds
of those with HIV are aware of their infection.

Vaccination: The proportion of IDUs reporting uptake of hepatitis B vaccination has increased in recent years, with around two-thirds now reporting accepting at least one vaccine dose. However, the transmission of hepatitis B continues among IDUs.

Bacterial infections: Injecting site infections, which may cost the NHS as much as £47 million per annum, remain common with around one-third of IDUs reporting having had an abscess, sore or open wound at an injecting site in the last year. There are continuing problems ranging from localised injection site infection through to invasive disease associated with meticillin resistant Staphylococcus aureus and severegroup A streptococcal infection. The ongoing occurrence of wound botulism and tetanus cases also remains a concern.

Filed under: HIV/Injecting-Drug-Users :

PhD [S]; Sarang, Anya [//]; Lewis, Kim MSc [P]; Parry, John PhD [P]
Abstract:
Objective: To measure HIV prevalence and associated risk factors among recent initiates into drug injecting in 2001 and 2004 in Togliatti City, Russian Federation.

Design: Two unlinked, anonymous, cross-sectional, community-recruited surveys of injecting drug users (IDUs) with oral fluid samples for anti-HIV testing.

Methods: IDUs completed an interviewer-administered questionnaire, and oral fluid samples were tested for antibodies to HIV. Demographic characteristics and injecting risk behaviors were compared between subsamples of IDUs who reported injecting for 3 years or less in each of the survey years, 2001 (n = 138) and 2004 (n = 96). Univariable and multivariable analyses explored risk factors with anti-HIV among these new injectors.

Results: Among IDUs overall, although HIV prevalence was high, a lower prevalence was found in 2004 (38.5%, 95% confidence interval [CI]: 34.1 to 42.9) than in 2001 (56%, 95% CI: 51.2 to 60.8). A significantly lower prevalence of HIV was found among new injectors in 2004 (11.5%, 95% CI: 5.0 to 17.9) than in 2001 (55.2%, 95% CI: 46.7 to 63.8). Proportionally, fewer new injectors reported injecting daily, injecting with used needles/syringes, and frontloading in 2004 compared with 2001. Decreased odds of anti-HIV were associated with being recruited in 2004 and with a history of drug treatment. Increased odds of HIV were associated with exchanging sex, duration of injection, and frontloading.

Conclusions: Findings indicate a decrease in HIV prevalence among new injectors between 2001 and 2004 and emphasize the role of provision of needle/syringes through pharmacies and providing access to voluntary HIV testing. These findings have implications for other cities in which explosive HIV outbreaks have occurred.
Source: JAIDS Journal of Acquired Immune Deficiency Syndromes. 47(5):623-631, April 15, 2008.

Filed under: HIV/Injecting-Drug-Users :

A new study published in the Journal of Acquired Immune Deficiency Syndromes finds that HIV prevalence in the city Toggliatti in Russia declined from 56 percent in 2001 to 38.5 percent in 2004, “despite the lack of needle and syringe exchange.” The study found that “a history of drug treatment was associated with a reduced likelihood of testing positive for HIV,” and credits less frequent injection of drugs for the overall reduction in HIV among new injectors, “rather than interventions through services, such as needle exchanges.”
Compare the HIV decline in Toggliatti, Russia—which has no needle exchange program—to the HIV explosion in Vancouver, Canada, which boasts the largest and one of the oldest needle distribution program in North America.
When Vancouver’s needle exchange program (NEP) was established in the late 1980s, the city’s estimated HIV prevalence was 1 to 2 percent. By 1997, one-quarter of the of the drug users in Downtown Eastside were infected with HIV, with a transmission rate of nearly 19 percent, giving Vancouver the distinction of having the highest infection rate of any city in the developed world. By 2003, an estimated 40 percent of the drug using population in Vancouver was infected with HIV. Research has directly linked needle exchange to this trend. A study published in the Journal of Acquired Immune Deficiency Syndromes in 1997 found that “frequent NEP attendance” was one of the “independent predictors of HIV-serostatus” among IDUs. The study found that HIV-positive IDU were more likely to have ever attended NEP and to attend NEP on a more regular basis compared with HIV-negative IDUs. With only one exception, the NEP was the main source of syringes for all of those who became infected during the course of the study.
Source: http:// www.aidsmap.com/en/news/AA1E32BC-20EF-4B93-B811-83CF26FEF1F9.asp April 23, 2008

A significant decline in risky injecting practices and a decline in HIV prevalence in new drug injectors was seen in a Russian city severely affected by HIV between 2001 and 2004, despite the lack of needle and syringe exchange, researchers from the London School of Hygiene report in the April 15th edition of the Journal of Acquired Immune Deficiency Syndromes.

The researchers believe that word of mouth, and growing awareness of the rising number of HIV diagnoses, contributed to the shoft, but also note that changes in the drug market during the study period may have driven the change in injecting and equipment sharing practices.

Several major cities worldwide have witnessed explosive outbreaks of HIV due to injecting drug use. In these contexts, some research suggests that new injectors might adopt riskier behaviours, or alternately, within the context of an HIV outbreak, new injectors might adopt safer behaviours than longer term injectors. Thus, measuring behavioural change in targeted populations may help to monitor risks in a changing epidemic.

Therefore investigators from the London School of Hygiene and Tropical Medicine examined two anonymous, cross-sectional community-recruited surveys of injecting drug users in Toggliatti city, which is in the Samara region of Russia. They also conducted a review of new HIV diagnoses in the region since 2000.

Participants in both surveys had used injection drugs in the previous four weeks and consented to HIV testing via oral fluid samples. The participants analysed were injecting drug users who had injected for three years or less (recent injectors): 138 people in 2001 and 96 in 2004.

Participants were identified by respondent-driven sampling, in which those initially recruited act as ‘seeds’ for an expanding chain of referrals. Mathematical modelling was then used to estimate population effects. Injection drug use was estimated to occur in 5.4% of the registered population of the city, but in 2.7% of the assumed genuine population, close to 1 million people.

In 2004, a lower proportion of injecting drug users reported injecting daily, using used needles, syringes or filters, or front-loading – when a solution of drug is passed from a donor syringe into another person by removing the needle. Although fewer injecting drug users in 2004 reported contact with drug treatment services, needle exchange or outreach workers, more had been tested for HIV.

Overall HIV prevalence was high among injecting drug users, but it declined between 2001 and 2004, from 56% to 38.5% A significantly lower prevalence of HIV was found among new injectors in 2004 (11.5%, 95% CI: 5.0 – 17.9) than in 2001 (55.2%, 95% CI: 46.7 – 63.8). A history of drug treatment was associated with a reduced likelihood of testing positive for HIV, while increased odds of HIV were associated with exchanging sex for drugs and sex work, duration of injection (odds ratio 1.4 per year), and front-loading. Most injecting equipment was obtained from pharmacies in both surveys.

Examination of surveillance data revealed that in 2000, 97% of new HIV cases were linked with IDU whereas that figure had fallen to 56.4% by 2005.

The reduction in HIV among new injectors in 2004 seems likely to be related to general risk awareness and changes in injection practice rather than interventions through services, such as needle exchanges. However, the authors suggest that “IDUs, and IDUs involved in sex work specifically, should be targets for sexual risk reduction interventions”.

Given the nature of IDU-related health services in this region, the authors write that “we emphasize the need for increasing access to voluntary and confidential HIV testing in combination with increasing the accessibility of sterile injecting equipment through pharmacies”.

Source: Platt L et al. Changes in HIV prevalence and risk among new injecting drug users in a Russian city of high HIV prevalence. J Acquir Immune Defic Syndr 47: 623 – 631, 2008.


HIV transmission among injecting drug users is happening more often now than at the beginning of the decade, the Health Protection Agency says in a report issued this week. Infections in people who began injecting recently indicate recent transmissions, and prevalence in this group has risen considerably in recent years. However, overall HIV prevalence in drug users is stable.

The Health Protection Agency’s Unlinked Anonymous Prevalence Monitoring Programme’s Survey of Injecting Drug Users is an annual study of over 3,000 current and former injectors. The study is carried out at specialist services such as needle exchanges or methadone treatment programmes in England, Wales and Northern Ireland. Participants complete a questionnaire and provide an oral fluid sample for HIV testing.

Looking at the whole group of current and former injectors, 1.6% had HIV (51 of 3209 people), two-thirds of whom were aware of their infection. Prevalence was considerably higher in London (3.8%) than elsewhere.

Whereas survey results in 2006 and 2007 suggested that prevalence might be decreasing, this now appears not to be the case. Prevalence in 2008 was exactly the same as that recorded in 2005.

Turning now to HIV prevalence in those who began injecting in the past three years, it remained below 0.5% from 1991 to 2002. However, in the 2008 study it was 1.3% (5 of 391 people).

Another key indicator is prevalence among people who have injected in the past month. In London, which has the greatest concentration of infection, this has remained stable. However, elsewhere in England and Wales it increased from 0.25% in 2003 to 1.1% in 2008 (18 of 1604 people).

In addition, prevalence of hepatitis C remained high. Among those who began injecting in the past three years, 22% had hepatitis, half of whom were aware of their infection.

On a more optimistic note, the numbers reporting sharing equipment are lower than earlier in the decade. A total of 19% reported sharing needles or syringes, and 37% reported sharing spoons, mixing containers, filters or water.

Source:
Shooting Up. Infections among injecting drug users in the United Kingdom 2008, an update: October 2009. London: Health Protection Agency, 2009.

Key Messages
1. Needle and syringe sharing has declined in recent years, however with around a quarter of injecting drug users continuing to share the level remains higher than in the mid-1990s.

2. Injecting into the groin and the injection of crack cocaine, which are associated with higher levels of
infection and risky injecting, have become more common.

3. Injecting site infections are common, with around one third of injecting drug users reporting having had an
abscess, sore or open wound at an injecting site in the last year.

4. Transmission of HIV and HCV infection through injecting drug use remains higher than in the late 1990s, with a fifth of recent initiates having hepatitis C and around one in 100 having HIV. Overall almost half of injecting drug users are now infected with hepatitis C and about one in 90 with HIV.

5. There has been a marked increase in the number of injecting drug users receiving the hepatitis B vaccine,
with two-thirds now reporting vaccination.

6. Services to reduce injecting related harms and support for those who want to stop injecting should continue to be developed in line with published guidance.

Key Findings
Behaviours: Levels of reported needle and syringe (direct) sharing have declined in recent years, following an increase in the late 1990s. In 2007, around a quarter of injecting drug users (IDUs) reported direct sharing in the previous month; this level remains higher than in the mid-1990s when about a sixth reported this. The sharing of other injecting equipment remains even more common. There are also indications that
two other factors associated with a greater risk of infection have become more common, with almost one in three IDUs now reporting injecting into the groin (femoral vein) and athird reporting the injection of crack-cocaine.

Hepatitis C: Overall, almost half of IDUs in the UK have been infected with hepatitis C. However, there are marked variations in hepatitis C prevalence within the UK, with low prevalences found in some areas. The overall prevalence of hepatitis C infection among IDUs has probably increased in recent years. Current levels of hepatitis C transmission remain higher than in the late 1990s with a fifth of IDUs becoming
infected within three years of starting to inject.

HIV: The incidence of HIV among IDUs is higher than in the late 1990s with around one in 100 now becoming infected within three years of starting to inject. The overall prevalence of HIV infection among IDUs however remains low compared to many other countries. In England & Wales, the overall HIV
prevalence among IDUs is currently around one in 90. Within England and Wales prevalence has increased amongst IDUs outside London: where it has risen from around one in 400 in 2002 to about one in 150 in 2007. However, the prevalence is higher in London, with around one in 20 HIVinfected. In Scotland, the prevalence of HIV among IDUs was around one in 350 in 2007, which is the lowest level reported
since this was first measured in 1989.

Voluntary confidential diagnostic testing: Uptake of testing for hepatitis C among IDUs in contact with drug services, after increasing markedly, now appears to be levelling off with around three-quarters having ever had a test. It is estimated that around half of IDUs with hepatitis C in contact with these services remain unaware of their infection, and that this proportion has not changed in recent years. There are also likely to be many current and former IDUs not in contact with services that will be unaware they have hepatitis C. Whilst most IDUs in contact with services report having had a test for HIV at some point, only two thirds
of those with HIV are aware of their infection.

Vaccination: The proportion of IDUs reporting uptake of hepatitis B vaccination has increased in recent years, with around two-thirds now reporting accepting at least one vaccine dose. However, the transmission of hepatitis B continues among IDUs.

Bacterial infections: Injecting site infections, which may cost the NHS as much as £47 million per annum, remain common with around one-third of IDUs reporting having had an abscess, sore or open wound at an injecting site in the last year. There are continuing problems ranging from localised injection site infection through to invasive disease associated with meticillin resistant Staphylococcus aureus and severe
group A streptococcal infection. The ongoing occurrence of wound botulism and tetanus cases also remains a concern.

 

HIV rates rising amoung newer injection drug addicts who utilize needle exchange in the U.K.; Almost half infected with hepatitis C and many still sharing needles.
Needle exchange was first introduced in the United Kingdom (UK) in 1985 in response to the AIDS epidemic.  Most areas within the UK have pharmacy-based needle-exchange programs (NEPs).  Mobile, agency-based and automated needle exchange programs also exist.Despite this widespread availability of free needles, HIV infection among newer UK injection drug users (IDUs) is rising, according to the Health Protection Agency.  The data comes from samples taken of addicts who accessed services provided by NEPs and methadone treatment programs.

The new report also found that around one quarter of IDUs reported sharing of needles and syringes and almost half have been infected with hepatitis C, with one fifth becoming infected within three years of starting to inject.

Source:  ‘Shooting Up’, Health Protection Agency  October 2008

 

Filed under: HIV/Injecting-Drug-Users :

30 June 2009 – Injecting drug use is responsible for an increasing proportion of HIV infections in many parts of the world. It is estimated in the World Drug Report 2009 that between 11 and 21 million people worldwide inject drugs, and of those, between 0.8 and 6.6 million are infected with HIV.
Brazil, China, the Russian Federation and the United States of America are estimated to have the largest populations of injecting drug users (IDUs), and together account for 45 per cent of the estimated total worldwide population of IDUs. In addition, injecting drug use appears to be an emerging phenomenon in many countries where it had not been reported previously. By 2008, injecting drug use had been reported in 148 countries and territories together accounting for 95 per cent of the world’s population.
HIV infection among people who inject drugs has been reported in 120 countries, and the prevalence of HIV among IDUs varies dramatically. Regions with the largest numbers and highest concentrations of HIV-positive IDUs include Eastern Europe, East and South-East Asia and Latin America. In those regions, the prevalence of HIV is higher than 40 per cent among many national and subnational injecting drug user populations.
Except for sub-Saharan Africa, IDUs account for a sizeable proportion of the total number of people living with HIV. In Eastern Europe and Central Asia, more than half of those living with HIV are IDUs.
The dynamics of the spread of HIV infection are notable. A decade ago, HIV had not been detected among IDUs in Estonia. By contrast, a more recent estimate now suggests that the prevalence of HIV infection in that country has, in one sample, increased to 72 per cent of IDUs. Yet in Australia and New Zealand, levels of HIV infection have remained very low (1.09 and 0.73 per cent, respectively), despite the fact that the prevalence of injecting drug use is higher there than in some other countries.
This difference has been attributed to the geographic isolation of those two countries, as well as to their swift introduction of needle and syringe programmes and the expansion of opiate substitution treatment programmes after HIV infection was first documented in 1984.
The increase in the spread of HIV among IDUs calls for investment in comprehensive public health interventions.
UNODC is helping countries to review and develop laws, policies and standards of care that enable them to put in place effective services for IDUs. It also encourages greater proactive involvement of law enforcement agencies in HIV prevention and care and promotes collaboration among the health and criminal justice sectors and community-based and civil society organizations.
In addition, UNODC helps countries to expand evidence-informed drug dependence treatment services, particularly opioid maintenance therapy for IDUs, and to raise awareness among drug dependence treatment services regarding the need to address HIV prevention and care issues and to develop interventions to prevent the transition from non-injecting drug use to injecting drug use.
UNODC promotes services such as voluntary and confidential HIV counselling and testing, the treatment of sexually transmitted infections, the provision of antiretroviral therapy and interventions for specific sub-groups, including prisoners, sex workers who inject drugs and IDUs who may exchange sex for drugs or money.
Source eNews@UNODC July 2009

From 1999 to 2001 an annual average of 338.000 persons aged 12 or older used a needle to inject cocaine, heroin, or stimulants during the past  year. Young adults aged 18 to 25 were more likely to have injected drugs in the past year compared with youths aged 12 to 17 or adults aged 26 or older.
The last time injection drug users used a needle for injecting drugs, 14 percent of past year injection drug users knew or suspected someone else had used the needle before them and 16 percent used a needle that someone used after them.

Source: http://www.samhsa.gov/, Mar 2003
Filed under: HIV/Injecting-Drug-Users :

SASKATOON – A study of homeless youth in Saskatoon has come up with some disturbing findings.

Nearly 10% of the young people who took part in the research tested positive for hepatitis C. That’s more than double the rate of any other Canadian city where the disease has been studied. The research was conducted by Saskatoon community health nurse Jocelyn Andrews. It was the first study to focus on street kids rather than all drug users in the community.

Andrews also discovered that a drug routinely prescribed for children with an attention deficit disorder was abused by many of the 186 homeless kids who were studied. “What we saw in this subset of this street youth population is injection drug use is a risk for hep C, but what we found in Saskatoon is that use of Ritalin by injection was strongly associated with the hepatitis C virus.”

Andrews says the jury is still out on the role a needle-exchange program could play in reducing infection in youth. Most users of needle exchanges are in their 20s or older – and just having a clean needle is not the answer. “The needle-exchange service offers just the needle,” Andrews says. “With hep C we know it’s readily transmitted through not only the syringe that people are using to inject, but also the other paraphernalia that goes on with that practise: the water, the filter, the spoon.”

Andrews says there’s a positive spinoff from this study. Those who tested positive for hepatitis C have now been told where they can get medical help.
Source:CBC Saskatchewan – Saskatchewan,Canada
Apr 23 2004 http://sask.cbc.ca/regional/servlet/View?filename=hepcyouth04232004

Studies have found that cities with needle exchange programmes , show an increase in blood borne diseases, an increase in the number of new young intravenous drug users, an increase in drug dealing, and an increase in crime. There is the continued habit of sharing needles, unprotected and “risky sex” continues unabated, and ‘shooting up triples the death risk’ with approximately 80% of all addicts dying from an overdose—-not AIDS. Less than half of all needles being distributed by existing NEPs are ever returned .

“Government supplying an implement to anyone to inject a highly addictive controlled substance that is potentially lethal, is a form of assisted suicide. The fact that overdosing kills more intravenous drug users (80%) than any blood borne disease is a a real sticking point that should have all of us supporting education, prevention, early intervention and treatment for addicts not a weapon to commit suicide” said Geraldine Mullins from Western Australia.

Sources: Pulse Checks: Trends in Drug Abuse, January 2004, Dr. Fred Paynes; Evidence Based Review of Needle Exchange Programs; the study by DAWN; the study by the New York Academy of Medicine reviewing Baltimore’s Needle Exchange Program, August 19, 2004;

Filed under: HIV/Injecting-Drug-Users :

Edwin J. Bernard, Friday, July 15, 2005

New HIV infections via injecting drug use (IDU) appear to be on the increase in England and Wales, according to a collaborative study from the UK’s Health Protection Agency (HPA) and Imperial College London, published in the July 22nd issue of the journal AIDS. The study, which combines anonymous HIV testing data with community surveys for the first time, suggests that recent increases in HIV IDU transmission are most pronounced in younger, recent IDUs, in London. This increase in new infections coincides with a shift in UK drugs policy away from public health concerns towards a stronger focus on crime.

In the UK, harm reduction initiatives such as the provision of clean needles through needle exchange programmes (NEPs) have been relatively effective in limiting the spread of HIV among injecting drug users (IDUs). By the end of 2002, only 7% of the 56,000 diagnosed HIV infections were associated with IDU. However, there has been some recent evidence of an increase in risky injecting practices suggesting that new HIV infections amongst IDUs may be on the increase.

In order to examine trends in HIV prevalence amongst IDUs, researchers from the HPA and Imperial College, London combined data from two voluntary unlinked-anonymous survey programmes that included adults (aged 15-49) who had injected drugs in the previous four weeks.

The first is an annual survey of IDUs via drug agencies in England and Wales (ranging in number over the years between 29-59; providing advice, support, harm-reduction and/or treatment services) has been ongoing since 1990, and includes a brief self-completed questionnaire and oral fluid samples for HIV testing.

The second was a series of community-based surveys in London (1990-1993); London and seven other English cities (1997-1998); and London and Brighton (2001-2002). This was conducted in the field (e.g. street locations, homes and social venues) and included an interviewer-administered questionnaire and oral fluid samples for HIV testing. This provided the researchers with a cross-sectional data set, including almost 28,000 oral fluid samples on which to test anonymously for HIV.

Evidence of increase in HIV prevalence

HIV prevalence among IDUs in England and Wales declined from a peak of 5.9% (67 positive HIV antibody tests out of a total of 1132 samples) in 1990 to a low of 0.6% (14/2270) in 1996. It then remained stable until 2000, after which there was, say the researchers, “some evidence of an increase” to 1.4% (21/1529) in 2003.

Individuals who had been injecting for the shortest period of time (less than three years; 1.2%) and those who had been injecting for the longest period of time (more than twelve years; 2.9%) had the highest HIV prevalence in 2003. In contrast, those who had been injecting drugs between three and five years, or six and eleven years, had lower HIV prevalence (0.3% and 0.7%, respectively).

HIV prevalence was found to be higher in London (5%) compared with elsewhere in England and Wales (0.4%) and similar in women (1.8%) and men (1.6%).

Five factors were included in multivariate modelling after adjustment: survey year; recruitment location; length of injecting career; recruitment setting; and having had a voluntary confidential HIV test.

The odds of being HIV-positive were higher for the survey years 1990-95 and 2001-2003 compared with 1996 (p=0.001); higher for recruitment in London compared with outside London (Adjusted Odds Ratio 7.33; 95% CI, 5.60-9.59); highest for those injecting for 15 years or more (AOR 2.3; 95% CI, 1.61-3.28); higher for those recruited in the community versus those from the agency survey (AOR 1.76; 95% CI, 1.37-2.24); and higher for those who had ever had a voluntary HIV test outside of the survey (AOR 2.49; 95% CI,1.95-3.18).

Younger IDUs in London at highest risk of new HIV infection

The investigators used an adjusted model (adjusted for number of years injecting, recruitment setting and having had a voluntary HIV test outside of the survey) to fit location and survey year together, and the results suggested that the recent increase in HIV prevalence was mainly occuring in London (p=0.025).

To examine this futher, force of infection in and outside of London, defined as the yearly rate at which HIV-negative IDUs become HIV-positive, was estimated by fitting a model to prevalence data by calendar year and injecting career length. The results suggest that force of infection in London is higher amongst novice IDUs (those injecting for less than one year) and has increased over time.

Between 1992-1997, the force of infection amongst novice IDUs in London was 0.008 (95% CI, 0.002-0.02), whereas between 1998-2003 it was 0.028 (95% CI, 0.016-0.045), or almost 3% per year. For IDUs who had been injecting for more than a year, the force of infection was 0.13 lower across all time periods. Since age and length of injecting habit were found to be highly correlated (p=0.001), this suggests younger IDUs in London are acquiring HIV more rapidly than older IDUs in London or elswhere.

This increase in new HIV infections is similar to the 3.4% rate found in a recent London-based cohort study.

Awareness of HIV infection

Overall, 54% of the total cohort had ever taken an HIV antibody test outside of the surveys.

Of those testing HIV-positive, 81%( 371/461) reported ever having taken an HIV antibody test. Of those who reported the results of their last HIV test, 75% (193/259) were aware of their infection.

In 2002-2003, however, only 69% (25/36) of those who were HIV-positive and who reported the results of their HIV antibody test were aware of their infection.

Is UK policy to blame?

Although the combined surveys found that reported needle- and syringe-sharing in the previous month remained uniformly high both in London (31%) and outside London (29%) in 2002, the higher force of infection in London may reflect higher HIV prevalence amongst IDUs in London compared with those outside London, as well as an increased prevalence of injecting drugs, crack cocaine in particular.

However, the authors point out that in 1998, the UK’s national drug strategy changed its focus from harm-reduction and the reduction of blood-borne viruses to “wider social harms, in particular drug-related crime.” They suggest that this “simultaneous shift in the focus of policy and service provisioning for drug users in England and Wales” may have “unintentionally hindered the development and re-invigoration of harm reduction measures in response to evolving patterns of drug use and risk behaviours.”

In addition, younger IDUs would not have been exposed to either national or targeted HIV prevention campaigns that took place earlier in the HIV epidemic.

It also appears that many of the recently-infected IDUs are foreign nationals. “Data on country of birth from clinicians’ reports of newly diagnosed HIV infections indicate that two-thirds of HIV-infected IDUs diagnosed in the UK in 2003 were born in another country,” the authors write. Thus the recent increase in HIV prevalence in London may reflect recent patterns of emigration to London, particularly from south-western and eastern Europe where the prevalence of HIV is higher among IDUs than in other risk groups.

Reference

Hope VD et al. HIV prevalence among injecting drug users in England and Wales 1990 to 2003: evidence for increased transmission in recent years. AIDS 19:1207-14, 2005.

Source: Press Association November 12, 2004
Filed under: HIV/Injecting-Drug-Users :

Researchers at the University at Buffalo have presented the first evidence that the addictive drug methamphetamine, or meth, also commonly known as “speed” or “crystal,” increases production of a docking protein that promotes the spread of the HIV-1 virus in infected users.

The investigators found that meth increases expression of a receptor called DC-SIGN, a “virus-attachment factor,” allowing more of the virus to invade the immune system.

“This finding shows that using meth is doubly dangerous,” said Madhavan P.N. Nair, Ph.D., first author on the study, published in the online version of the Journal of Neuroimmune Pharmacology. The study will appear in print in the September issue of the journal.

“Meth reduces inhibitions, thus increasing the likelihood of risky sexual behavior and the potential to introduce the virus into the body, and at the same time allows more virus to get into the cell,” said Nair, professor of medicine and a specialist in immunology in the UB School of Medicine and Biomedical Sciences.

His research centers on dendritic cells, which serve as the first line of defense again pathogens, and two receptors on these cells — HIV binding/attachment receptors (DC-SIGN) and the meth-specific dopamine receptor. Dendritic cells overloaded with virus due to the action of methamphetamine can overwhelm the T cells, the major target of HIV, and disrupt the immune response, promoting HIV infection.

“Now that we have identified the target receptor, we can develop ways to block that receptor and decrease the viral spread,” said Nair. “We have to approach this disease from as many different perspectives as possible.

“If we could prevent the upregulation of the meth-specific dopamine receptor by blocking it, we may be able to prevent the interaction of meth with its specific receptors, thereby inhibiting the virus attachment receptor,” said Nair.

“Right now, we don’t know how the virus-attachment receptor and meth-specific receptors interact with each other, leading to the progression of HIV disease in meth-using HIV-infected subjects. That is the next question we want to answer.

“Since meth mediates its effects through interacting with dopamine receptors present on the cells, and meth increases DC-SIGN, which are the HIV attachment receptors, use of dopamine receptor blockers during HIV infection in meth users could be beneficial therapeutically to reduce HIV infection in these high-risk populations,” Nair said.

Additional researchers on the publication, all from the UB Department of Medicine, are Supriya Mahajan, Ph.D., research assistant professor; Donald Sykes, Ph.D., research associate professor; Meghana V. Bapardekar, Ph.D., postdoctoral associate, and Jessica L. Reynolds, Ph.D., research assistant professor.

Source: www. Medical News Today Aug.17th 2006

A 10-year study has found that the biggest predictor of HIV infection for both male and female injecting drug users (IDUs) is high-risk sexual behavior, not sharing needles used to inject drugs.  High- risk homosexual activity was the most important factor in HIV transmission for men; high-risk heterosexual activity was most significant for women.  Risky drug-use behaviors also were strong predictors of HIV transmission for men but were less significant for women, the study found.
“In the past, we assumed that IDUs who were HIV-positive had been infected with the virus through needle-sharing,” says Dr. Steffanie Strathdee of the Johns Hopkins University Bloomberg School of Public Health in Baltimore, who conducted the NIDA-funded study.  Our analysis indicates that sexual behaviors which we thought were less important among IDUs really carry a heavy weight in terms of risks for HIV seroconversion for both men and women.”
In the study, Dr. Strathdee led a team of researchers who analyzed data collected every 6 months from 1,800 IDUs in Baltimore from 1988 to 1998.  Participants had to be at least 18 years of age when they entered the study, have a history of injecting drug use within the previous 10 years and not have HIV infection or AIDS.  More than 90 percent of the participants said they had injected drugs in the 6 months prior to enrolling in the study.  In their semi-annual interviews, study participants reported their recent drug use and sexual behavior and submitted blood samples to determine if they had become HIV-positive since their last visit.

Researchers analyzed the role of homosexual activity in HIV seroconversions among male IDUs in the study.  After taking into account other factors that increased their risk of acquiring HIV, such as their drug injection practices.  This analysis revealed that the incidence of HIV infection among male IDUs who had engaged in homosexual activity with in the previous 6 months was 10.44% a year, compared to 3.01% among men who did not report having homosexual sex.   Visiting ‘shooting galleries,” where drug abusers gather to obtain and inject drugs, sharing needles used to inject drugs with multiple partners, and injecting drugs daily also were independently linked to significantly higher rates of HIV infection among men in the study.  Men who said they had used shooting galleries had an HIV incidence rate of 6.28% per year and men who shared needles with more than one partner had a rate of 5.52% per year.  These infection rates were more than double those found among men who had not engaged in these behaviors.  Men who injected drugs at least once a day had HIV infection rates of 4.68% more than one and one-half times the rate among men who had injected less than once a day.
Sharing needles also increased risk of HIV infection among women IDUs.  However, high-risk heterosexual activity was a much more important risk factor for these women, the study found.  In fact, other than being younger than 30 years – which independently predicted HIV infection for both sexes – high-risk heterosexual activity was the main predictor of HIV seroconversion among women.  Women who reported having a recent sexually transmitted disease (STD), an indicator of unprotected sex, had more than 2.5 times the rate of HIV infection of women who did not have an STD.
“Both homosexual men and heterosexual women IDUs appear to be at dual risk for becoming infected with HIV,” Dr. Strathdee says. “In previous studies by our group, being a gay male IDU was closely linked to visiting shooting galleries and sharing needles.  Heterosexual women IDUs tend to have more of an overlap in their sexual partners and their drug use than men do.  This puts them at increased HIV risk because they are sharing needles and having unprotected sex with a partner who is more likely to be infected with the virus.
“HIV prevention programs have done a good job in reducing needle – sharing and other drug-use behaviors that spread the virus among IDUs,” Dr. Strathdee says.  “However, our study indicates that HIV prevention programs can achieve better results by also addressing sexual risk behaviors among IDUs.  A multifaceted approach is needed that screens both men and women IDUs for STDs at places where they go, such as needle – exchange programs and methadone treatment programs and provides comprehensive treatment at those sites.
HIV prevention efforts also should be gender-specific, targeting the important differences we have found in sexual and drug-use behaviors among men and women that increase their risk of acquiring and transmitting HIV,” DL Strathdee says.
“For example, women IDUs in stable relationships could be shown how to negotiate condom use with their partners and offered couple counseling to educate both partners about HIV risks associated with their drug use and sexual behaviors.  We need more research to identify and evaluate HIV prevention approaches for male IDUs who have sex with men to determine what kinds of interventions might work.”Strathdee. S.A. et al. Sex differences in risk factors for HIV seroconversion among injection drug users. Archives of Internal Medicine; 2001

Filed under: HIV/Injecting-Drug-Users :

While needle exchange advocates claim that such programs effectively prevent the spread of blood borne diseases such as HIV and hepatitis, the latest report from Vancouver, which boasts the largest needle exchange program (NEP) in North America, suggest otherwise. In fact, this report’s ‘smoking gun’ is its finding that both HIV and Hepatitis C have reached ‘saturation’ among the injection drug using population, meaning few if any of who are not already infected are left to become newly infected.
Here are some of the reports specific findings: In 2002, nearly 3 million needles were distributed by NEPs in the City. Injection drug use was the main mode of HIV transmission in British Columbia from 1994 to 2000. Today injecting drug use and men having sex with men tie as the top risk factors for new HIV cases.

Vancouver began its NEP in 1988, and the number of new HIV infections among injecting drug users (IDUs) increased every year thereafter until peaking in 1996. A 1997 study of more than 1,400 Vancouver IDUs revealed an annual HIV infection rate of 18 percent– the highest level anywhere in the developed world and one of the highest incidence rates reported anywhere worldwide The number of new positive tests began to increase again in 2002 and estimates for 2002 anticipate a further increase. This report notes that many infected injecting drug users have not been tested, so these rates are likely to be higher. The current HIV prevalence among Vancouver IDUs is 35 percent.
The report attributes the HIV incidence peak in 1996 not to the success of needle exchange, but rather to ‘the near saturation’ of HIV infection among IDUs, meaning after 1996 there were few drug addicts left to become newly infected. Needle exchange not only failed to prevent HIV from reaching a saturation point among Vancouver IDUs, but also had the same lack of effectiveness if preventing the spread of hepatitis C (HCV). This report notes that like HIV, HCV has also reached a saturation point among Vancouver IDUs with over 80 percent infected with the incurable and deadly blood borne disease. Nearly two-thirds of Vancouver HCV cases are attributable to injection drug use with Vancouver’s HCV rate being nearly four-times higher than the rate for Canada as a whole.

In 1997, the reported rate of newly identified hepatitis B infections another blood born disease often spread by needle sharing– in Vancouver was eight times the rate for the rest of British Columbia and the highest rate in Canada. The leading cause of death of Vancouver drug addicts is overdose, accounting for 25 percent of deaths among those who are HIV-positive and 42 percent among those who are HIV-negative. Although the overall British Columbia crime rate has decreased over the past decade, drug offenses have increased by 63%. A study by the Canadian centre on Substance Abuse estimated that half of gainful crimes such as theft, break and enter, and robberies were attributed to substance abuse.
Source: Vancouver drug Epidemiology report 2003, Posted on www.ccsa.ca/ccendu/pdf/report

Marijuana use and Trends

What’s Down with Marijuana?

What has the latest research shown us about marijuana? Among other things, marijuana has now been linked to violent teen behaviour, may be responsible for youth tongue cancer, and has been shown in weekly users to trigger suicidal depression. For those with a disposition toward other serious mental illness, marijuana has been found to unleash it.

Marijuana usage up somewhat

The myth among youth is that ‘everyone is doing it.’ In fact, the majority is not – 51 percent of high school seniors have never tried marijuana even once. However, 22 percent of seniors are ‘current’ (past month) users of marijuana. The hard-core, or daily marijuana users (20 or more times in the past 30 days) remain a small portion of youth: 5.8 percent of seniors, 4.5 percent of sophomores, and 1.3 percent of eighth graders.

New use and historical patterns

There have been ebbs and flows in use of marijuana over the past 40 years. About 2.4 million Americans tried marijuana for the first time in 2000. This was a substantial increase from 600,000 new users in 1965, However, initiation in the marijuana world peaked in 1976-1977 at 3.2 million, and dipped to its lowest figure in decades at 1.4 million in 1990. New users rose from there until hitting 2.5 million in 1996, where it has remained for half a decade.

Marijuana has been on the American scene for at least a century. In 1906, it was proscribed under the Pure Food and Drug Act. In 1914, Utah was the first state to pass anti marijuana legislation; by 1931, 29 states had prohibited the medical use of marijuana. In 1936, the government film, ‘Reefer Madness’ was released; it is still a cult film. In 1970. the Federal Government eliminated mandatory sentencing for possession of small amounts of marijuana.

The peak year for teen use of marijuana was 1979. In 1985, synthetic THC, or Marinol, was produced to relieve the nausea of cancer patients undergoing chemotherapy. In 2001, the U.S. Supreme Court unanimously voted down medical marijuana laws. That same year, the #1 rap song “Because I Got High” by Afroman spoke about the destructive effects of marijuana

Helsinki City has trained 40 drug addicts to assist their drug colleagues with supplying clean needles and giving first aid. This idea is from Belgium where it all started already in 1987. These addicts are called ‘jobist’ and their activities are funded by the support from the European Union. After their training. 5 evenings, they also get a small reward of abt US $200. The work is otherwise on a voluntary basis and they get 100 needles/day when looking for their friends. These jobists seem to be well motivated which is of course might be a first preliminary step towards seeking rehab. On the other hand it shows how cheap the society wants treat seriously ill people. This all seems again to fall under the popular theme of harm reduction.
The authorities are scared of next year when Estonia will join EU and the Estonians have a very serious HIV and Hepatitis problem. As you know the drug smuggling is taken care by the Estonians, who today even transport drugs to Finland via Sweden.

Souce: Botho Simolin, Drug Watch International delegate, Finland.


The transmission of drug-resistant HIV among intravenous drug users (IDUs) who participate in high-risk behaviors is high, according to a new study. In addition, such drug users were often prescribed less effective and not recommended HIV drugs.

Evidence of increasing rates of drug resistance among those recently infected with HIV “indicates a growing public health concern and warrants an examination of the problems from a prevention perspective write the Journal of Acquired Immune Deficiency Syndromes.

The researchers examined predictors of unprotected sex and needle sharing among 638 HIV-infected drug users who completed 2731 visits between 1996 and 2000 in an ongoing study in Baltimore, Maryland.

“After taking account other factors, HIV-infected individuals were significantly more likely to engage in unprotected sex if their sexual partners were also HIV-infected,” Dr. Sethi said in an interview with Reuters Health. “Also, HIV-infected women were twice as likely as men to report unprotected sex.”

Among IDUs who had injected recently, there was an independent association between sharing needles and homelessness, daily injection, and trading sex for drugs. “IDUs were at higher risk of HIV and drug-resistant HIV transmission at 19 percent and 6 percent of all visits, respectively,” the investigators write. Among subjects who were at high risk of HIV transmission, significant drug-resistant HIV was found at 14 percent of visits.

“Although highly active antiretroviral therapy (HAART) was widely available during the study period, less effective and not recommended regimens were prescribed to nearly half of IDUs who were potential transmitters of drug-resistant HIV,” Dr. Sethi told Reuters Health. “Transmission of resistance is one consequence of continued wide-use of non-HAART regimens.”

“It is likely that reducing high-risk behaviors by HIV-infected individuals would reduce the transmission of HIV, including drug-resistant HIV, to uninfected individuals,” Dr. Sethi said. “Clinicians can play an important role by counseling HIV-infected patients about the importance of reducing high-risk behaviors.”

SOURCE: Authors: Dr. Ajay K. Sethi, of Case Western Reserve University School of Medicine,Cleveland, Ohio, and colleagues. Published in Journal of Acquired Immune Deficiency Syndromes, April 15, 2004.

Harm reduction advocates claim that needle exchange programs reduce HIV risk by allowing injection drug users to continue to abuse drugs with clean needles, rather than sharing needles that may be infected with HIV. A new study finds that drug abuse may actually increase HIV infection risk by compromising the immune system, and thereby making it easier for HIV and other infectious disease to take hold. This new data potentially explains why drug abusers have higher rates of infection than other at risk groups and why areas with long-standing and high volume needle exchanges– such as Vancouver, British Columbia and Baltimore, Maryland– have failed to curtail the spread of HIV and hepatitis among the injection drug using population. Prevention and treatment for drug abuse, therefore, remain the only proven and scientifically sound prevention strategies against HIV and the other health risks associated with drug abuse. Needle exchange merely allows addicts to continue the very behavior that comprises their immune system and makes them more susceptible to HIV infection.

Source:http://www.drugabuse.gov/NIDA_notes/NNvol18N6/Cocaine.html

Distributing nearly 3 million needles a year to drug addicts, Vancouver, Canada boasts the largest needle exchange program in North America. The program was established in 1988– 16 years ago– to prevent the spread of HIV and hepatitis C (HCV). A new study finds that co-infection with these two deadly viruses is “shocking” with 16% of study participants co-infected at the beginning of the study and 15% more becoming co-infected over the course of the study. The researchers note it took a median of 3 years for seroconversion to secondary infection.

NEW YORK (Reuters Health) Jun 28 – Coinfection with Hepatitis C virus (HCV) and HIV is prevalent in a “shocking” number of young injection drug users, according to Canadian researchers.

In the June 1st issue of the Journal of Acquired Immunodeficiency Syndromes, Dr. Carl L. Miller of the University of British Columbia, Vancouver and colleagues note that they sought to determine the incidence of such coinfections and to compare the socioeconomic characteristics of those infected.

The researchers used data from the Vancouver Injection Drug Users Study to identify 479 subjects aged 29 years or less. At baseline, 78 (16%) were coinfected and a further 45 (15%) became so over the course of the study.

Baseline infection was independently associated with factors including being female, being of aboriginal ancestry, being older and with the number of years of injecting.

Borrowing needles and injecting cocaine more than once a day were both among the factors associated with the time to secondary infection seroconversion. Having recently attended a methadone maintenance program was protective.

Across the categories of coinfected, monoinfected and HIV and HCV negative injection drug users, say the investigators, there were “clear trends for increasing proportions” of women, aboriginals, daily cocaine users and inhabitants of Vancouver’s 10-block injection drug use epicenter.

The researchers, who note that it took a median of 3 years for seroconversion to secondary infection, conclude that “appropriate public health interventions should be implemented immediately.”

Source:Journal of  Acquired  Immune Deficiency Syndrome 2004;36:743-749.

Patterns of HIV transmission among different classes of injection drug users have been characterized.

In a recent study from the United States, the “prevalence of HIV and associated risk behaviors were assessed among three groups of heroin users: long term injection drug users (LTIDUs), new injection drug users (NIDUs), and heroin sniffers (HSs) with no history of injection.”

“HIV seroprevalence was similar among NIDUs (13.3%) and HSs (12.7%),” while “LTIDUs had almost twice as high a level of HIV infection (24.7%),” reported D.D. Chitwood and coauthors at the University of Miami. “After including drug use and sex behavior variables in logistic regression models, both drug and sexual risk factors remained in the models.”

“Attributable risk percent (APR) from injection for HIV infection among injection drug users was estimated to be 55.7% for LTIDUs and 5.8% for NIDUs,” published data indicated. “High-risk sex behavior plays an important role in the prevalence of HIV among drug users and accounts for nearly all the infection among NIDUs.”

“Both injection and sexual risk behaviors need to be stressed in HIV prevention and intervention programs aimed at drug users,” the researchers concluded.

Chitwood and colleagues published their study in the Journal of Psychoactive Drugs (Prevalence and risk factors for HIV among sniffers, short-term injectors, and long-term injectors of heroin. J Psychoactive Drug, 2003;35(4):445-453).

Source: Health & Medicine Week March 1, 2004

But a new study published in the Journal of Psychoactive Drugs finds that sex “accounts for nearly all the infection among” new injection drug users. Likewise, nearly half of HIV infections among long term injection drug users, (44.3 percent) are not attributed to sharing dirty needles. New injection drug users, in fact, had a similar rate of HIV infection as non-injection drug users.

Studies have found that substance abuse is a significant factor for high risk sexual behavior and HIV acquisition. Needle exchange, therefore, does not eliminate the risks for HIV infection for drug abusers, but rather enables addicts to abuse the drugs that impair their judgment, thereby increasing risk for HIV infection. The debate over needle exchange distracts from the real HIV prevention issues for drug abusers, which is preventing substance abuse and treating addiction.

Source: Health & Medicine Week March 1, 2004

WA has one of Australia’s highest rates of illicit drug use. The most common drug was cannabis which was used reularly by 16.5 per cent of people aged 16-24. WA also had the biggest number of injecting drug users – almost 20,000 people. After cannabis the drugs most commonly used by young people were amphetamines (8 per cent) and ecstasy (7 per cent) – BUT THE USE OF HEROIN WAS NEGLIGIBLE! ( Two things here: So why would anyone want to set up a Heroin Clinic in WA ?  Prohibition works, albeit through natural drought, with the very hard work of our Federal Police. Illicit drugs were responsible for one per cent of deaths in WA in 2001 and drug-related visits to Perth hospital emergency departments more than doubled from 1993 to 1998.

The one per cent of deaths from illicit drugs is very serious because that means that, contrary to tobacco harm, 36 years of life is lost for each deceased person.

Drugs such as cannabis, heroin and amphetamines cost the State $610 million a year, according to a new WA Health Dept and Drug and Alcohol Office report. So how did we get to be in this shocking mess? I know that it is through an unholy inter-sectoral Partnership with all Health, Crime Research, Law Enforcement and Epidemiology. The evidence of deception and Public Health corruption lies within the 1997 NDS Evaluation by Single and Rohle. At a cost of over $20 million to Australian taxpayers nearly 32 million needles were distributed in “That’s not to say the problem is limited to the United States or North America,” he added. “It’s a problem found in a number of countries around the world.”

Source:To-days “West” reports; March 2004

ATLANTA — Twenty-five years after the first AIDS cases jolted the world, scientists think they soon may have a pill that people could take to keep from getting the virus that causes the global killer.

Two drugs already used to treat HIV infection have shown such promise at preventing it in monkeys that officials last week said they would expand early tests in healthy high-risk men and women around the world.

“This is the first thing I’ve seen at this point that I think really could have a prevention impact,” said Thomas Folks, a federal scientist since the earliest days of AIDS. “If it works, it could be distributed quickly and could blunt the epidemic.”

Condoms and counselling alone have not been enough HIV spreads to 10 people every minute, 5 million every year. A vaccine remains the best hope but none is in sight. If larger tests show the drugs work, they could be given to people at highest risk of HIV from gay men in American cities to women in Africa who catch the virus from their partners.

People like Matthew Bell, a 32-year-old hotel manager in San Francisco who volunteered for a safety study of one of the drugs. “As much as I want to make the right choices all of the time, that’s not the reality of it,” he said of practicing safe sex. “If I thought there was a fallback parachute, a preventative, I would definitely want to add that.”

Some fear that this could make things worse. “I’ve had people make comments to me, ‘Aren’t you just making the world safer for unsafe sex?'” said Dr. Lynn Paxton, team leader for the project at the Centers for Disease Control and Prevention.

The drugs would only be given to people along with counseling and condoms, and regular testing to make sure they haven’t become infected. Health officials also think the strategy has potential for more people than just gay men, though they don’t intend to give it “to housewives in Peoria,” as Paxton puts it. Some uninfected gay men already are getting the drugs from friends with AIDS or doctors willing to prescribe them to patients who admit not using condoms. This kind of use could lead to drug resistance and is one reason officials are rushing to expand studies.

“We need information about whether this approach is safe and effective” before recommending it, said Dr. Susan Buchbinder, who leads one study in San Francisco.

The drugs are tenofovir (Viread) and emtricitabine, or FTC (Emtriva), sold in combination as Truvada by Gilead Sciences Inc., a California company best known for inventing Tamiflu, a drug showing promise against bird flu.

Unlike vaccines, which work through the immune system the very thing HIV destroys, AIDS drugs simply keep the virus from reproducing. They already are used to prevent infection in health care workers accidentally exposed to HIV, and in babies whose pregnant mothers receive them. Taking them daily or weekly before exposure to the virus the time frame isn’t known yet may keep it from taking hold, just as taking malaria drugs in advance can prevent that disease when someone is bitten by an infected mosquito, scientists believe.

Monkeys suggest they are right. Specifically, six macaques were given the drugs and then challenged with a deadly combination of monkey and human AIDS viruses, administered in rectal doses to imitate how the germ spreads in gay men. Despite 14 weekly blasts of the virus, none of the monkeys became infected. All but one of another group of monkeys that didn’t get the drugs did, typically after two exposures.

“Seeing complete protection is very promising,” and something never before achieved in HIV prevention experiments, said Walid Heneine, a CDC scientist working on the study.

What happened next, when scientists quit giving the drugs, was equally exciting.

“We wanted to see, was the drug holding the virus down so we didn’t detect it,” or was it truly preventing infection, said Folks, head of the CDC’s HIV research lab. It turned out to be the latter. “We’re now four months following the animals with no drug, no virus. They’re uninfected and healthy.” Years of previous monkey studies using tenofovir alone had shown partial protection. The scientists thought to add the second drug, FTC, when Gilead’s combination pill, Truvada, came on the market last year.

The results, announced at a scientific meeting last month in Denver, so electrified the field that private and government funders alike have been looking at ways to expand human testing. “This is an approach we’ve considered for a long, long time,” but didn’t try sooner because AIDS drugs had side effects and risks unacceptable for uninfected people, said Dr. Mary Fanning, director of prevention research at the National Institute of Allergy and Infectious Diseases.

Tenofovir changed that when it came on the market in 2001. It is potent, safe, stays in the bloodstream long enough that it can be taken just once a day, doesn’t interact with other medicines or birth control pills, and spurs less drug resistance than other AIDS medications. The CDC last year launched $19 million worth of studies of it in drug users in Thailand, heterosexual men and women in Botswana, and gay men in Atlanta and San Francisco. A third U.S. city, not yet identified, will be added, CDC announced last week.

Because of the exciting new monkey results, the Botswana study now will be switched to the drug combination; the others are well under way with tenofovir alone. Farthest along is a study of 400 heterosexual women in Ghana by Family Health Initiative. The Bill & Melinda Gates Foundation funded it and others in Cambodia, Nigeria, Cameroon and Malawi, but the rest were doomed by rumours, including fears that scientists wanted to deliberately expose people to HIV or that study participants who got infected might not have access to treatment. In other cases, activists demanded better health care or clean needles for drug users as a condition for allowing the studies to proceed.

Such problems are “part of the HIV prevention landscape” in many foreign countries, said Dr. Helene Gayle, who formerly oversaw AIDS research for the Gates Foundation. Expense also could limit use of the drugs. Gilead donated them for the studies and sells them in poor countries at cost _ 57 cents a pill for tenofovir and 87 cents for Truvada, the combination drug. That’s more than the cost of condoms, available for pennies and donated by the truckload in Africa, but often unused. In the United States, wholesale costs are $417 for a month of tenofovir and $650 for Truvada. Still, health officials are hopeful the drugs could fill an important gap.

The National Institutes of Health is starting a tenofovir study in 1,400 gay men in Peru. Private and government funders are considering others. Tenofovir also is being tested in microbicide gels that women could use vaginally to try to prevent catching HIV. “If you’re in an area where there’s a really high HIV incidence, something that’s even 40 percent effective could have a huge impact,” Paxton said. And in the Atlanta labs where Heneine, Folks and others are still minding the monkeys, “the level of enthusiasm is pretty high,” Heneine said. “This is very promising. For us to be involved in a potential solution to the big HIV crisis and pandemic is very exciting.”
Source:www.chron.com March 2006

The number of HIV-positive drug users who inject has reached its highest level for more than a decade.

Official data from 2005 shows that one in 62 injecting drug users (1.6%) in England and Wales are HIV-positive. This compares with one in 110 in 2002.

Last year the number of HIV diagnoses among injecting drug users rose and rates among new users are also up.

The Health Protection Agency said the rise was partly due to an increase in the numbers injecting crack cocaine.

The level of HIV infection among injecting drug users remained stable in London but saw a six-fold increase in areas outside the English capital from one in 500 (or 0.2%) in 2002 to one in 83 (1.2%) in 2005.
Source: BBC News 17th March 2006

“Drug abuse treatment can have important positive public health benefits even if the outcomes are less than perfect,” lead study author DL George Woody told Reuters Health. “The 12-step oriented combination of group and individual counselling worked the best, though all patients reduced their risk.”

Woody urged everyone to “support substance abuse treatment. It can do a lot of good both in the short and long term.”

In an article in the Journal of Acquired Immune Deficiency Syndromes, Dr. Woody who is at the University of Pennsylvania in Philadelphia and his colleagues report on changes in HIV risk among 487 people undergoing treatment for cocaine addiction.

Treatment was associated with an average reduction of cocaine use from 11 days per month to one day per month after six months, the authors report, with participants who received both individual and group drug counselling faring best.

Treatment participation was also associated with significant reductions in risky sex and the total risk of HIV infection, the report indicates.

Those who completed treatment showed a trend toward less sex risk and significantly less total risk than did patients who dropped out before completing their program, the researchers note.

HIV risk reduction corresponded to reductions in drug use and to improvements in psychiatric symptoms, the results indicate. This improvement was similar regardless of race, gender, sexual orientation or the presence of antisocial personality disorder.

“The fact that all treatments consisted of no more than three weekly outpatient sessions that included risk reduction counselling is worth noting,” the authors conclude, “because it suggests that reductions in cocaine use and HIV risk can be achieved at a relatively low cost, at least for a portion of the patients who seek treatment for cocaine dependence.”

SOURCE: Journal of AIDS (news -web sites) 2003;33:82-87.

By MIRIAM TUCKER, Senior Writer The annual incidence of HIV/AIDS among African Americans dropped significantly between 2001 and 2004, the Centers for Disease Control and Prevention reported.

As a result of advances in treatment with highly active antiretroviral therapy, individuals with HIV infection are living longer than before, and progression to AIDS has declined sharply. AIDS surveillance no longer provides an accurate estimate of HIV infection rates, so the CDC now recommends that all states and territories adopt confidential name based surveillance systems to report HIV infection.

Data from 33 state and local health departments with name-based reporting indicate that the incidence of HIV infection among blacks declined about 5% per year, from 88.7/ 100,000 in 2001 to 76.3 in 100,000 in 2004. Nonetheless, the HIV/AIDS rate among blacks in 2004 was still 8.4 times higher than that of whites, the CDC said (MMWR 2005;54:1149-53).

In addition to the statistically significant decline among blacks, there was a significant 9.1% annual drop among injection drug users. Overall, the average annual rate of HIV/AIDS diagnoses dropped in significantly, from 22.8/100,000 in 2001 to 20.7/100,000 in 2004.

An estimated 157,252 individuals were diagnosed with HIV/AIDS in the 33 states during 2001-2004, of whom 71% were male. Blacks accounted for 51 % of those diagnosed with HIV/AIDS, whites 29%, Hispanics 18% and Asian/Pacific Islanders 1%.

Among males, the route of HIV infection was male-to-male contact for 61 %, high-risk heterosexual contact in 17%, and injection drug use in 16%. For females, on the other hand, the majority (76%) were exposed through high-risk heterosexual contact and 21 % through injection drug use. Among black males, approximately one-fourth of HIV transmission occurred via high-risk hetero sexual contact, the CDC noted.

A significant 9% annual increase in HIV/AIDS diagnosis rates occurred among Asian/ Pacific Islanders, from 5.6/100,000 in 2001 to 7.2/100,000 in 2004, although this group continues to racial/ethnic populations.
Source: Internal Medicine News, January 1, 2006

Filed under: HIV/Injecting-Drug-Users :

Imaging studies in humans suggest that the amygdala plays an important role in craving elicited by cocaine and cocaine-conditioned environmental stimuli. The research examined the relationship between neurochemical changes in the amygdala and cocaine-seeking behavior following exposure to a cocaine-paired environment or a cocaine priming injection. It measured cocaine-seeking behavior by assessing the persistence of lever-pressing in the absence of cocaine reinforcement in animals previously trained to press a lever for cocaine infusions. Lever-pressing under these conditions is thought to reflect the incentive motivational properties of cocaine and cocaine-associated stimuli. It first investigated whether the pattern of changes in cocaine-seeking behavior corresponded with changes in concentrations of dopamine in dialysates obtained from the amygdala during the course of cocaine withdrawal.

There were concomitant changes in cocaine-seeking behavior and dialysate dopamine following the cocaine priming injection, but not following exposure alone to the cocaine self-administration environment. It next investigated changes in Fos protein expression as a general marker for neuronal activation. Exposure to the cocaine self-administration environment, but not the cocaine priming injection, elicited Fos expression in the basolateral nucleus of the amygdala, nucleus accumbens shell, and cingulate cortex. In contrast, the cocaine priming injection, but not the environmental stimuli, elicited Fos expression in the central nucleus of the amygdala and dorsolateral caudate-putamen.

The findings suggest that different neural mechanisms mediate cocaine-seeking behavior elicited by cocaine conditioned environmental stimuli and those elicited by a priming injection of cocaine. Increases in extracellular dopamine may be critical for the induction of cocaine-seeking behavior elicited by cocaine but may not be elicited by cocaine-conditioned environmental stimuli.

Source: Janet Neisewander, Ph.D., Arizona State University

The Swedish epidemic of intravenous amphetamine injection, which started in 1945, was surveyed annually in Stockholm from 1965 to 1987. During that period, approximately 250.000 arrestees were examined for needle marks from intravenous drug injections that they presented in their cubital regions. The progression or regression of the epidemic was gauged by calculating the percentage of addicts (marked with needle scars) among the population arrested for any kind of criminal or civil offense. This epidemiological study using an objective marker demonstrated that a permissive drug policy leads to a rapid spread of drug use. A restrictive policy not only checks the spread of addiction but brings about a considerable reduction in the rate of current consumption. The restrictive policy is based on a general consensus of social refusal of illicit drug use, and strict law enforcement. All countries which have adopted this model such as China, Japan, Korea, Singapore and Taiwan have succeeded in controlling epidemics of amphetamine or heroin addiction. By contrast, Western industrialized nations which have accepted permissive policies have seen their epidemics of drug addiction grow steadily since World II War and erode their democratic institutions. The author concludes that such a trend may only be reversed by adopting a restrictive model validated by epidemiological and historical facts.

Professor Nils Bejerot
The Swedish Carnegie Institute, Stockholm
Presented at an International Colloquium held in Paris at the French Senate in March 1998

Needle exchange programs (NEPs) are designed to prevent human immunodeficiency virus (HIV) transmission among Injecting drug users. Although most studies report beneficial effects in terms of behavior modification, a direct assessment of the effectiveness of NEPs in preventing HIV infection has been lacking. A cohort study was conducted to assess the association between risk behaviors and HIV seroprevalence and seroincidence among injecting drug users in Montreal, Canada. The association between NEP use and HIV Infection was examined in three risk assessment scenarios using intensive covariate adjustment for empirical confounders: a cross-sectional analysis of NEP use at entry as a determinant of seroprevalence, a cohort analysis of NEP use at entry as a predictor of subsequent seroconversion, and a nested case-control analysis of NEP participation during follow-up as a predictor of seroconversion. From September 1988 to January 1995, 1,599 subjects were enrolled with a baseline seroprevalence of 10.7%. The mean follow-up period was 21.7 months. The adjusted odds ratio for HIV seroprevalence in injection drug users reporting recent NEP use was 2.2 (95% confidence interval 1.5-3.2). In the cohort study, there were 89 incident cases of HIV infection with a cumulative probability of HIV seroconversion of 33% for NEP users and 13% for nonusers (p <0.0001). In the nested case-control study, consistent NEP use was associated with HIV seroconversion during follow-up (odds ratio = 10.5. 95% confidence interval 2.7-41.0). Risk elevations for HIV infection associated with NEP attendance were substantial and consistent in all three risk assessment scenarios in our cohort of injecting drug users, despite extensive adjustment for confounders. In summary, in Montreal, NEP users appear to have higher seroconversion rates then NEP nonusers.

Am J Epidemiol 1997;146:994-1002.
cohort studies; HIV; needle exchange programs; substance abuse; substance abuse, intravenous
Julie Bruneau, Francois Lamothe, Eduardo Franco, Nathalie Lachance, Marie Desy, Julio Soto, and Jean Vincelette. American Journal of Epiderniology vol. 146. No. 12

Objective: to describe prevalence and incidence of HIV-1, hepatitis C virus (HCV) and risk behaviours in a prospective cohort of injecting drug users (IDU).

Setting: Vancouver, which introduced a needle exchange programme (NEP) in 1988, and currently exchanges over 2 million needles per year.

Design: IDU who had injected illicit drugs within the previous month were recruited through street outreach. At baseline and semi-annually, subjects underwent serology for HIV-1 and HCV, and questionnaires on demographics, behaviours and NEP attendance were completed. Logistic regression analysis was used to identify determinants of HIV prevalence.
Results: Of 1006 IDU, 65% were men, and either white (65%) or Native (27%). Prevalence rates of HIV-1 and HCV were 23 and 88%, respectively. The majority (92% had attended Vancouver’s NEP, which was the most important syringe source for 78%. Identical proportions of known HIV-positive and HV-negative IDU reported lending used syringes (40%) Of HIV negative IDU. 39% ,.. borrowed used needles within the previous 6 months. Relative to HIV-negative lDU, HIV-positive IDU were more likely to frequently inject cocaine (72 versus 62%; p <0.001). Independent predictors of HIV-positive serostatus were low education, unstable housing, commercial sex, borrowing needles, being an established IOU, injecting with others, and frequent NEP attendance. Based on 24 seroconversions among 257 follow-up visits, estimated HIV incidence was 18.6 per 100 person-years (95% confidence interval, 11.1—26.0).

Conclusions: Despite having the largest NEP in North America, Vancouver has been experiencing an ongoing HIV epidemic. Whereas NEP are crucial for sterile syringe provision, they should be considered one component of a comprehensive programme including counseling, support and education.

Strathdee Patrick Currie, et al –
AIDS 1997. 11:F59—F65

Researchers have now discovered another danger of cocaine use. For the first time, scientists have found cocaine significantly accelerates HIV infection. After infecting mice with the HIV virus, UCLA researchers injected half with liquid cocaine daily, while the other half received a placebo injection. Researchers counted the HIV-infected cells after 10 days and found a 200-fold increase in AIDS viral load in mice injected with cocaine compared to those that did not receive the drug. Gayle Baldwin, MD., from the UCLA AIDS Institute, says, ‘In only two weeks, the drug radically stimulated the production and spread of HIV.” In addition, mice with cocaine in their system had more than double the number of HIV-infected cells than cocaine-free mice.

Another significant finding shows a nine-fold decrease in immune cells in the cocaine-exposed mice. Dr. Baldwin says the drug increased HIV’s efficiency so much it nearly destroyed the immune cells HIV targets to destroy the immune system. She says, “Not only did the drug double the number of HIV-infected cells, it produced a nine-fold plunge in the number of T-cells that fight off the virus.” Researchers believe the animal study could lead to additional studies to examine the effects of diet, alcohol and other drugs on the spread of HIV infection.

Source: Author Dr. G. Baldwin. Published in Journal of Infectious Diseases, 2002

Although methadone maintenance is an effective therapy for heroin dependence, some patients continue to use heroin and may benefit from therapeutic modifications. This study evaluated a behavioural intervention, a pharmacological intervention, and a combination of both interventions.

Methods
Throughout the study all patients received daily methadone hydrochloride maintenance (initially 50 mg/d orally) and weekly counselling.
Following baseline treatment patients who continued to use heroin were randomly assigned to 1 of 4 interventions:
(1) contingent vouchers for opiate-negative urine specimens (n29 patients);
(2) methadone hydrochloride dose increase to 70 mg/d (n=31 patients);
(3) combined contingent vouchers and methadone dose increase (n=32 patients); and
(4) neither intervention (comparison standard; n=28 patients). Methadone dose increases were double blind.

Vouchers had monetary value and were exchangeable for goods and services.
Groups not receiving contingent vouchers received matching vouchers independent of urine test results.
Primary outcome measure was opiate-negative urine specimens (thrice weekly urinalysis).

Results
Contingent vouchers and a methadone dose increase each significantly increased the percentage of opiate-negative urine specimens during intervention.
Contingent vouchers, with or without a methadone dose increase, increased the duration of sustained abstinence as assessed by urine screenings.
Methadone dose increase, with or without contingent vouchers, reduced frequency of use and self-reported craving.

Conclusions
In patients enrolled in a methadone-maintenance program who continued to use heroin, abstinence reinforcement and a methadone dose increase were each effective in reducing use.  When combined, they did not dramatically enhance each other’s effects on any one outcome measure, but they did seem to have complementary benefits.
Source: Author Kenzie et al published in Arch Gen Psychiatry. 2000;57:395-404

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