Curriculum vitae

What science tells us about needle exchange programs
(taken from PowerPoint presentation)

HIV and Injecting Drug Use (IDU)

• an epidemic of IDU, starting in the developed world after WW II, now spreading in producing countries and along transit lines
• an epidemic of HIV among IDUs, also starting in the developed world in late 1970’s, now hitting hardest in the developing countries and former Soviet Union

WHO Strategy to Fight HIV among IDUs

• Preventing drug abuse
• Facilitating entry into drug treatment
• Establishing effective outreach to engage IDUs in HIV/AIDS prevention strategies that protect them and their partners and families from exposure to HIV and encourage the uptake of drug dependence treatment and health care
• National policies should be based upon local circumstances
• Policies employed should be evidence based

WHO/UNAIDS Guidelines

• “Unfortunately, certain effective but controversial elements are neglected in many countries. … Important service elements that tend to be neglected include drug dependence treatment, outreach activities and needle and syringe programmes.”
• In this document HIV-testing and counselling is not even mentioned in any project.
• In fact, NEP and substitution treatment are the main elements suggested to combat HIV among IDUs in all WHO/UNAIDS documents, suggesting that these are indeed evidence based methods to do this.
• All successful examples mentioned include either or both and most often needle exchange.

The Swedish Example

• In 1985 HIV prevalence among IV heroin users was over 50% in Stockholm.
• The debate on how to meet the epidemic of HIV among IDUs resulted in: Continued fight against drugs; HIV testing, counselling and education to fight HIV among drug users.
• The fight against drugs should have priority as a means to minimise the vulnerable population.
• If HIV-prevention policy comes in conflict with anti-drug policy, it should not be implemented.
• Needle exchange was seen as coming into conflict with the policy to discourage young people from trying drugs and particularly injecting drugs.
• Thus it was not implemented on a national basis and particularly not in Stockholm, where the majority of the HIV infected IDUs lived.
• This was in conflict with WHO recommendations, and we have been much criticised for this. In Sweden it is still under debate.
• Many other HIV-prevention policies were, however, employed:
• Free HIV testing and counselling in prison, hospitals and treatment units
• Increased possibilities for methadone maintenance treatment with priority for HIV positive heroin users
• Special hospital units for drug users with infectious diseases
• Increased possibilities for drug treatment

The Remand Prison Study

• In 1987 a study of HIV and HIV risk behaviour of IDUs was initiated in Stockholm. It closed in 1998 and then reopened in March 2002.
• An independent team performs a structured interview of risk behaviour and takes an HIV test of IDUs entering Remand Prison in Stockholm.
• 1987-98: 3,657 IDUs participated, some of them many times. 53 new cases were detected
• 2002-2004: 1,031 IDUs participated. 4 new cases detected
• Some may have participated during both periods
• The total number of IDUs in Stockholm is estimated to be 5-10,000

Yearly incidence (%) of HIV among IDUs at Remand Prisons in Stockholm

• The new HIV cases in recent years are mainly older, heavy, male IDUs, often homeless with multiple problems
• No indication of spread among young new IDUs
• The willingness to test is high as well as the interest in information about HIV and hepatitis

Conclusion

• Paradox of continued high risk behaviour but decreased HIV spread
• The most important factor in the reduction of HIV incidence seems to have been the testing and counselling among IDUs in combination with
• The openness of IDUs among themselves about HIV status. They avoid sharing with HIV positive users.

The Swedish Experience

• Since the strategy has been relatively successful we have so far not found reason to change it
• Since the discussion on needle exchange has once again come up, we decided to look at the scientific data collected on needle exchange programmes (NEP)

A NEP a Literature Review

• A total of 143 articles were found by data base searching and reference lists
• 2 criteria: some effect measure of NEP and some sort of control/comparison group
• 69 articles met these criteria and were included

NEP - Randomised Controlled Studies (RCS)

• Only two randomised controlled studies were found, both from Anchorage, Alaska (2002 and 2003)
• The first study looked at needle sharing and cleaning; the other at injection frequency
• No significant difference between study and control groups were detected, but both groups in each study improved their habits
• The authors conclude that the initial HIV information given to all was the effective measure

NEP - Non-randomised Studies

• Effect on HIV spread - 13 studies
• 7 reported no significant effect on HIV incidence
• 3 studies reported positive effects but without specifying possible confounding factors
• 2 studies found higher HIV spread in NEP group
• One study found other factors (mainly HIV testing and counselling) more effective in reducing HIV incidence
• Effect on hepatitis spread or awareness - 5 studies
• 1 reported reduced incidence of hepatitis
• 1 reported increased incidence (same authors - different method)
• 2 reported no effect
• 1 reported no increased awareness of hepatitis
• Effect on self reported risk behaviour - 31 studies
• 15 reported positive results, mainly reduced needle sharing
• 16 reported no significant effect
• 5 studies reported negative effect
• Note that some studies reported both positive, negative and non-significant results for different subgroups
• Effect on drug use, treatment seeking and treatment retention - 13 studies
• 3 reported less drug use in non-users of NEP
• 3 reported no effect (including one randomised)
• 1 reported less drug use in users of NEP
• 2 reported initial increase in treatment seeking, but opposite after two years
• Effect on hepatitis spread or awareness - 5 studies
• 1 reported reduced incidence of hepatitis
• 1 reported increased incidence (same authors - different method)
• 2 reported no effect
• 1 reported no increased awareness of hepatitis
• Effect on self reported risk behaviour - 31 studies
• 15 reported positive results, mainly reduced needle sharing
• 16 reported no significant effect
• 5 studies reported negative effect
• Note that some studies reported both positive, negative and non-significant results for different subgroups
• Effect on drug use, treatment seeking and treatment retention - 13 studies
• 3 reported less drug use in non-users of NEP
• 3 reported no effect (including one randomised)
• 1 reported less drug use in users of NEP
• 2 reported initial increase in treatment seeking, but opposite after two years
• 1 found no difference in users and non-users of NEP in drug treatment seeking behaviour
• 1 found less treatment seeking among users of NEP
• 1 found that retention in treatment was lower among NEP-users and drug positive urine tests were more frequent
• 1 found no difference in positive urine tests
• Effects on other physical conditions than HIV and hepatitis
• 1 found higher incidence of deep skin infections among NEP users than non-users
• 1 found an initial decrease in need for emergency treatment, levelling out with time
• 1 found no significant difference in mortality between NEP users and non-users
• Effects over time
• Some studies show an initial positive effect of NEP on HIV prevalence, need of emergency care, treatment seeking behaviour and risk behaviour which levels off with time and, in some studies, even turns into a negative effect.
• Unfortunately, relatively few studies do follow up over time, particularly long follow ups.
• Alternatives to NEP in comparison -12 studies
• 2 compared NEP users with methadone patients - one positive for methadone, one not significant (outcome: HIV incidence)
• 1 compared NEP with methadone + addiction treatment and found no difference in risk behaviour
• 1 found that NEP-users who were not also receiving methadone more often lent needles to others
• 1 found the opposite: NEP had a more positive effect on risk behaviour than methadone
• 1 found that previous hospital treatment was more predictive than NEP use for seeking drug treatment
• 1 found that NEP did not, whereas drug treatment did, increase hepatitis awareness
• 1 found NEP users were less likely to be tested for HIV, tuberculosis and hepatitis than a comparison group of methadone patients
• 4 studies suggest that the HIV testing and counselling is more effective than NEP, in itself supporting the Swedish experience

NEP Review - Shortcomings of Studies

• Inadequate outcome measures. Few measure HIV incidence. Most often self reported change of risk behaviour
• Often systematic control for covariates is lacking
• NEP use vs. non-use often poorly defined. Sometimes “ever used” vs. “never used”

Conclusions

• The collected evidence for NEP’s effect on HIV incidence among IDUs is at best inconclusive
• The same is true for the effect on the spread of drug addiction/injection
• So hopefully NEP does not produce harm but it is very uncertain whether it does any harm reduction
• The evidence rather points to the fact that other measures like HIV testing and counselling may be more efficient
• The early acceptance of NEP as the “golden bullet” to fight HIV among IDUs may have delayed efficient strategies, particularly in poor countries where you may have to choose between HIV testing and NEP

 
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