INTERNATIONAL EVALUATIONS OF NEEDLE EXCHANGE PROGRAMS



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Proceedings Workshop on Needle Exchange and Bleach Distribution Programs INTERNATIONAL EVALUATIONS OF NEEDLE EXCHANGE PROGRAMS

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Proceedings Workshop on Needle Exchange and Bleach Distribution Programs EVALUATION OF THE NEEDLE/SYRINGE EXCHANGE IN AMSTERDAM, THE NETHERLANDS ANNEKE VAN DEN HOEK and ROEL COUTINHO Municipal Health Service, Department of Public Health and Environment, The Netherlands AIDS AND HIV IN THE NETHERLANDS AND AMSTERDAM Through June 1993 a cumulative total of 2678 cases of AIDS have been reported in the Netherlands (circa 15 million inhabitants). Homosexual men are the most important risk group (78%), followed by injecting drug users (9%); 93% of the cumulative AIDS cases are men. In 1992 481 new cases were diagnosed and in 1991 437. Most of the AIDS cases in the Netherlands were reported from Amsterdam (700,000 inhabitants). The total number of HIV infected persons in the Netherlands is estimated at 6,000-10,000. In Amsterdam the total number of homosexual men between 18 and 55 is estimated at 20,000 of whom 2,000-4,000 are infected with HIV. The number of drug users in the city is estimated at 7,000 of whom approximately 800 are HIV infected. BACKGROUND INFORMATION ON AMSTERDAM DRUG POLICY The estimate of the number of hard drug users in Amsterdam is based on a capture-recapture method and is a year prevalence. The estimated number of drug users staying on a regular day in Amsterdam is lower, approximately 5,500. This smaller number is due to the large number of foreign drug users who only stay briefly in Amsterdam. Based on data of participants of the low threshold methadone programs, it is estimated that about 40% of the drug users in Amsterdam inject their drugs. The prevalence of the current injection of drugs among drug users differs according to country of origin: circa 40% of the Dutch drug users inject their drugs, compared to circa 70% of drug users of foreign origin (mainly German and South-European) and circa 5% of the ethnic drug users (from Surinam, the Netherlands Antilles, Morocco, and Turkey). The assistance system for drug users in Amsterdam can be described in three phases: getting in contact, harm reduction and treatment. Contact with drug users is made by 1) street corner workers, 2) physicians visiting drug users arrested in police-cells and 3) social nurses visiting all hospitalized drugs patients.

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Proceedings Workshop on Needle Exchange and Bleach Distribution Programs Through regular contact appropriate medical and social care can be given, which is considered "to be beneficial for drug users themselves and the society at large". This policy is called the harm reduction approach. The main instrument for harm reduction (as long as the drug user is not able or willing to stop his/her drug use) is the large methadone program with a low level of threshold. Another activity of the harm reduction approach is the needle and syringe exchange program, aimed at the reduction of the harm by injecting. This program was initially started in 1984-through an initiative of the drug users organization, the "Junkiebond"-to prevent hepatitis B, but was soon overshadowed by the more important goal of AIDS prevention. In 1985, 100,000 needles and syringes were handed out and this number has gradually risen to circa 700,000 in 1988 and to approximately one million in 1991 and 1992. In 1992, 92% of the distributed needles/syringes had been exchanged for a used needle/syringe. Presently Amsterdam has 14 needle exchange locations. It is possible to exchange needles and syringes from 10 a.m. till 4 a.m. the next day. During the night, two slot machines are in operation for purchasing syringes. Participation in the exchange program does not require identification or registration. For this reason, no information is available on the number of participants or on their demographic characteristics. As the needle/syringe exchange program is a low threshold project, there is no registration or monitoring of clients. Evaluation of the impact of the exchange program on injecting behavior and the spread of HIV, has therefore mainly taken place in our cohort study on HIV infection and AIDS. THE AMSTERDAM COHORT STUDY ON HIV INFECTION AND AIDS AMONG DRUG USERS The open cohort study started at the end of 1985. At that time only one drug user with AIDS had been reported in the Netherlands. The aims of the study are to study the prevalence and incidence of HIV infection and AIDS in relation to (changes in) drug use and sexual behavior; to evaluate the impact of various HIV-prevention programs for drug users; to study determinants of risky injecting and sexual behavior; and to study the natural history of HIV infection. Participants are recruited at methadone outposts, the special STD clinic for drug using prostitutes and by word of mouth. Eligible for the study are men and women who use or have used drugs, either by injection or otherwise. Blood samples for serology, virology and immunology are taken and participants are interviewed using a standard questionnaire which includes questions concerning clinical symptoms, medical history, lifestyle, use of oral and intravenous drugs (methadone included), and

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Proceedings Workshop on Needle Exchange and Bleach Distribution Programs prostitution. Participants are asked to return for a follow-up visit every four months. Twenty five Dutch guilders are paid per follow-up visit to encourage continued participation. PREVALENCE AND INCIDENCE OF HIV INFECTION Through July 1993 a total of 1,012 drug users had entered the study, 258 HIV positives and 754 HIV negatives. The HIV prevalence among drug users with a history of injecting drug use was approximately 30% (1) and remained more or less stable among new intakes in this group in following years (2). The annual HIV incidence per 100 person-years was 9.2 in 1986, varied between 2 and 5% in the years 1987-1991 (3) and was 2.5 in 1992. To date a total number of 52 seroconversions have occurred. RISK REDUCTION AND THE EXCHANGE PROGRAM The first study on risk reduction among the participants (December 1985-April 1988) showed that during follow-up, a strong reduction in borrowing and lending occurred, and that this behavioral was not dependent on being informed of HIV serostatus (4). Over time, the use of the needle and syringe exchange program increased. However, reduction in needle sharing was not seen among new entrants to the study. Therefore, we concluded that the risk reduction observed during follow-up was mainly an effect of the study (with counselling), with the exchange program only having a limited effect. The next study (5) looked into factors related to regular participation in the exchange program and the borrowing of syringes in 131 HIV seronegative current injecting drug users (1989-1990). A total of 29% of the users reported borrowing syringes in the past 4-6 months. Users at increased risk of borrowing are previous borrowers, long term moderate-to-heavy alcohol users, current cocaine injectors, and drug users without permanent housing. Regular clients of the syringe exchange, when compared with other injecting drug users, were found more often to be frequent, long term injectors. They borrowed slightly less often than other users, but this was not statistically significant, even after controlling for frequency of injecting or other potential confounders. These results suggest that 5 years after the start of the exchange program, drug use characteristics govern an individual injecting drug user's choice of exchanging or not exchanging. We concluded that it seems more important to direct additional preventive measures at injecting drug users with an increased risk of borrowing rather than at users who do not participate in the syringe exchange or who do so irregularly. Another study (3) assessed risk factors for seroconversion to HIV, between December 1985 and November 1991. The behaviors of 31 seroconverters were compared with those of 202 seronegative injecting drug users (controls). Three

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Proceedings Workshop on Needle Exchange and Bleach Distribution Programs independent risk factors for seroconversion were found in logistic regression: 1) living > 10 years in Amsterdam (OR=2.45, 95%CI 1.09-5.53); 2) first injection < 2 years ago (OR=3.43, 95%CI 1.20-9.81); and 3) injecting mainly at home (OR=0.39, 95%CI 0.18-0.88). No evidence was found that obtaining new needles/syringes via the exchange program was protective. However, the data suggest that exchanging needles/syringes may have been protective at the start of this program. In the discussion of this finding we mentioned that this may be explained by an overall increased availability of needles/syringes, which enabled non-exchangers to more easily obtain new needles/syringes. Another explanation we mentioned was that, at the beginning of the program, a desire for risk reduction was the motive for exchanging, while later on exchanging became just a way to obtain injection equipment. The methodological problems encountered in evaluating prevention programs are many. In general, little is known about the representativeness of the study sample of drug users. Furthermore, participants are self selected, and self-selection occurs again with respect to participation in the follow-up study. Self-reports on injecting and sexual behavior may be unreliable and are difficult to validate. To evaluate the impact of prevention-programs, random allocation of drug users to the various programs would be the best study design. However, this allocation would be in conflict with the harm reduction policy which includes large accessibility of the programs for all drug users. Another problem in evaluating the impact of the programs on risk reduction is that drug users may attend programs for other reasons than risk reduction and the longer low threshold programs exist, the more this may be the case. On the other hand, health education messages have also reached drug users who do not want to use the needle and syringe exchange program to obtain clean needles and syringes and prefer to buy their needles and syringes at pharmacies and certain shops. These considerations may imply that the impact of a prevention-program cannot be assessed by studying differences in risk behavior between attenders and non-attenders. Indeed, a last study (6) that studied serial, cross-sectional trends in injecting behavior from 1986 to 1992 showed that the proportion of drug users who reported borrowing and lending used injection equipment and re-using needles/syringes (in the 6 months preceding intake) continuously declined from 51% to 20%, from 46% to 10% and from 63 to 39%, respectively and that non-attenders of exchange programs reduced their risk behavior to the same extent as attenders. This finding explains why, in comparing attenders with non-attenders we were not able to demonstrate any impact of the exchange (and other prevention) programs on risk reduction*. *   For a part of the Amsterdam drug users the exchange program may have started too late, shown by the fact that in 1986 already 30% of the drug users in Amsterdam appeared to be infected with HIV. But for the rest of the Netherlands the exchange programs may have been in time. Recent HIV prevalence studies among drug users in four other cities (only 1 to 2 hours' drive from Amsterdam), showed that the prevalence of HIV among drug users outside Amsterdam is still low (less than 4%).

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Proceedings Workshop on Needle Exchange and Bleach Distribution Programs CONCLUSIONS We conclude, therefore, that the evaluation of specific measures is difficult. Although we have not been able to demonstrate any impact of specific prevention measures, we think that all prevention activities taken together in Amsterdam (exchange programs, over-the-counter sales of needles/syringes by pharmacies, low threshold methadone programs, counselling projects, and information campaigns) have been responsible for the decline in high-risk injecting behavior. However, it must be realised that a considerable number of drug users from time to time borrow an used needle/syringe and that transmission of HIV among drug users still occurs. LITERATURE 1. van den Hoek JAR, Coutinho RA, van Haastrecht, van Zadelhoff AW, Goudsmit J. Prevalence and risk factors of HIV infections among drug users and drug using prostitutes in Amsterdam. AIDS 1988;2(1):55-60 2. Van Haastrecht HJA, van den Hoek JAR, Bardoux C, Leentvaar-Kuijpers, Coutinho RA. The course of the HIV epidemic among intravenous drug users in Amsterdam, The Netherlands. Am J Public Health 1991;81:59-62 3. Van Ameijden EJC, van den Hoek JAR, van Haastrecht HJA, Coutinho RA. The harm reduction approach and risk factors for HIV seroconversion in injecting drug users, Amsterdam. Am J Epidemiol 1992;136:236-43 4. Van den Hoek JAR, Van Haastrecht HJA, Coutinho RA. Risk reduction among intravenous drug users in Amsterdam under the influence of AIDS. Am J Public Health 1989;79:1355-1357 5. Hartgers C, van Ameijden EJC, van den Hoek JAR, Coutinho RA. Public Health Reports 1992;107:675-682 6. van Ameijden EJC, van den Hoek JAR, Coutinho RA. A substantial decline in injecting risk behavior among drug users in Amsterdam from 1986 to 1992, and its relationship to AIDS-prevention programs. Am J Public Health 1994;84:275-281.

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Proceedings Workshop on Needle Exchange and Bleach Distribution Programs EVALUATION OF HUMAN IMMUNODEFICIENCY VIRUS PREVENTION PROGRAMS FOR INJECTION DRUG USERS IN CANADA MARGARET MILLSON, Department of Preventive Medicine and Biostatistics, University of Toronto, Canada, and City of Toronto Department of Public Health; and CATHERINE HANKINS Centre for AIDS Studies, Montréal-Centre Regional Public Health Team, Canada THE PILOT PROGRAMS The first official HIV prevention program for injection drug users in Canada which included needle exchange opened in Vancouver in January 1989. It was quickly followed by programs in Montreal, Toronto, and several other major cities, so that by the end of 1990 there were 8 such publicly-funded programs involving needle exchange in operation. These programmes had not seen the light of day spontaneously but rather, with the exception of the Vancouver needle exchange, were part of a federal government strategy to stimulate the development of pilot intervention programmes for injection drug users. The overall objectives for this initiative on the part of Health Canada were twofold. First, the federal government aimed to collaborate with provincial governments in the support of pilot prevention programmes designed to reduce the transmission of HIV among injection drug users and their sexual partners. The second objective was to acquire national data concerning the risk of HIV infection among injection drug users and the efficacy of prevention strategies. The funding criteria for the pilot prevention programmes were clearly spelled out. In order to be eligible, pilot studies had to take place within the context of a collaborative multidisciplinary network involving local public health officials, addiction treatment agencies, law enforcement, community groups and, where possible, academic or research institutions. A variety of collaboration mechanisms were considered to be acceptable, ranging from inter-agency committees to direct multi-agency programme delivery. In addition to this multidisciplinary context, pilot studies had to embody a multifaceted approach to prevention.1 Proposed programs had to include risk reduction education and counselling, as well as linkage to addiction treatment services and to other existing health and social services. Prevention programs could opt to include a carefully monitored needle-syringe exchange component. With respect to evaluation, in order to be eligible for funding, pilot studies were required to include a comprehensive and methodologically sound as well as ethically approved evaluation component. The evaluation research protocols had to receive the approval of a constituted ethics review committee and follow the Medical Research Council of Canada's guidelines on research involving human subjects, 1987.2

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Proceedings Workshop on Needle Exchange and Bleach Distribution Programs With respect to the funding strategy, the federal government of Canada offered to cost-share the service delivery component on a 50-50 basis with the provinces during the pilot study period, up to a maximum of two years. The federal share of the programme funding was completely administered through those provinces agreeing to participate. The federal government bore the full cost of the programme evaluation component during the same pilot period. What was the outcome of Health Canada's initiative to support pilot intervention programs for injection drug users? Five provinces participated with federal funding for the last of the pilot projects ending in March of 1993. Recognizing the importance of a long term integrated HIV prevention strategy in the injection drug using population, many provincial and local governments not only assumed the responsibility for ongoing funding but proceeded to increase the number of outreach programmes. More than 30 intervention projects are now operating and an additional 10 projects are slated to come on stream by the spring of 1994. Publically funded programmes involving needle exchange in Montréal, Toronto, Vancouver and several major cities were opened in 1989 and 1990, eight of which form the basis for this national evaluation. Although a series of meetings was held to discuss evaluation of the projects and promote the use of common methodology and instruments in order to seek comparability, there were significant differences in the evaluation approaches utilized, and to some extent these have limited the ability to compare and attempt to generalize findings. This paper will provide a brief overview of key program features, evaluation methodologies employed, their strengths and limitations, and the major findings so far. This overview will be followed by a more detailed description of the evaluations carried out in Montreal and Toronto. The programs which were established in different cities varied substantially in their organizational features. Although all were required to be multiagency collaborations, some programs were established within agencies already serving the target population, with pre-established credibility with their clients, while others were established as new services which needed to become known and accepted by potential clients. The cities involved also varied in the degree of acceptance by the police, politicians, and the public of the services, particularly of needle exchange. There were also important differences in the size and characteristics of the client population and in the drugs being used. For example, at the outset of these programs, injection of a combination of talwin and ritalin (''T and Rs") was very common in Western Canada, but was almost unheard of in Toronto and Montreal, where heroin and especially cocaine were the drugs of choice. There were police reports of shooting galleries in Montreal, but these were said to be quite uncommon in Toronto. Therefore each city represented a unique set of circumstances which influenced both the program and the evaluation undertaken. An important difference among different services was the mix of outreach services undertaken. Some services relied heavily on a mobile van to reach potential clients, others conducted considerable street outreach on foot, while others relied primarily on a fixed site in a location judged to be appropriate for attracting potential service users. In

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Proceedings Workshop on Needle Exchange and Bleach Distribution Programs some cities these fixed site(s) were in pre-existing agencies, in others they were newly established locations. A common feature of all services was the effort to provide a range of services, including counselling and referral to drug treatment. In some sites where the volume of clients seen was high, the ability to carry out in-depth counseling may sometimes have been compromised. EVALUATION APPROACHES All the evaluations undertaken as part of these projects attempted to collect process measures documenting numbers of clients served, numbers of needles given out and exchange rates, client characteristics including age, sex, drugs used and frequency, length of time injecting, needle-sharing frequency, reasons for needle-sharing, disinfection techniques used when taking used needles and their frequency of use, as well as frequency and gender of sexual partners, condom use, how the client heard of the service, and distance traveled to the service. Evaluators agreed to ask questions in a standardized way as much as possible, based on questionnaires developed for the World Health Organization/European Economic Community collaborative studies, which have been used in several cities, including New York, for research on the epidemiology of HIV and injection drug use. Several of the evaluations undertaken attempted to measure impact through tracking individuals in some fashion to allow for one or more follow-up comparisons over time looking for reported behaviour change as well as repeated measures of HIV status using saliva +/fingerprick blood samples. Generally speaking these approaches included a comparison group of injection drug users who were not in treatment and not attending needle exchange. Most of the evaluations using this approach experienced difficulty following up individuals, due in part to the policy of allowing participants to remain anonymous, which made repeated participation dependent on the individual to return, or workers/interviewers to recognize previous participants and encourage them to participate again. From the beginning, there was agreement that studies requesting lengthy interviews would need to pay participants; most studies such as the one in Toronto have paid $20 for a personal interview requiring 45 minutes or more; the payment is given to those completing the interview regardless of whether they agree to provide samples for testing. Despite this incentive, this study and some others had difficulty obtaining follow-up data on the same individuals; in the first year of the study, 3 month follow-up rates were only 20%, so that it was necessary to modify the design to focus on repeated cross-sectional measures of the population as a whole rather than individual follow-up. The implications of this will be discussed further below. In general, researchers who were external to the program and trying to collect impact measures in some cases experienced difficulties in collaborating effectively with project staff who were asked to collect process measures. In some instances, staff considered collecting even minimal information such as age or drug of choice to be too intrusive to clients, and feared that clients would be driven away be being asked any

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Proceedings Workshop on Needle Exchange and Bleach Distribution Programs questions. In many instances this problem was more acute at the beginning when programs were being launched, and became less problematic once client comfort with the service was established. SELECTED FINDINGS OF PROCESS EVALUATIONS Table 1 summarizes the findings of a key impact measure, numbers of needles distributed annually by some of the larger programs. It should be noted that each of these cities was estimated to have several thousand injectors at the time these programs were undertaken. TABLE 1 Needles Given Out by Year by 5 Urban Canadian Needle Exchange Programs YEAR       CITY                 Toronto Montreal Vancouver Winnepeg Edmonton Total 1989 4,387 24,267 127,806         156,460 1990 58,281 146,211 343,995 616 15,000 564,103 1991 130,442 169,423 527,248 36,624 183,000 1,046,737, 1992 120,637 193,740 607,385 24,831 (to Aug) 392,080 1,338,673 In addition to needles, most programs provided alcohol swabs, sterile water for injection, and condoms; many also provided bleach kits and instructions on needle disinfection for use in situations where sterile needles were not immediately available. Some programs found a very high demand for condoms, in some cases by clients who did not request needles, reflecting the mix of sex trade workers attending services. Another key measure was demand for referral to other services, in particular to drug treatment. Some programs, for example Vancouver, reported that requests for treatment outstripped availability, and pressed for more treatment to be made available. In Toronto, experiences of the needle exchange and other community services in seeking treatment for their clients lead to concern about difficulty in finding treatment slots. The Ministry

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Proceedings Workshop on Needle Exchange and Bleach Distribution Programs IDU representatives are invited to actively participate in policy development and implementation. National efforts were made to increase bleach availability and utilisation. Many NSEPs had difficult distributing bleach to IDUs as sterile injection equipment was so available there was little interest in obtaining alternatives. Since the biological effectiveness of bleach as a decontamination agent began to be questioned publicly in the US in 1993 (National Institute on Drug Abuse. Community Alert Bulletin, March 1993), the wisdom of advocating bleach decontamination has been reviewed. Decontamination practices of IDUs in Australia fall far short of acceptable and are a further reason for reviewing exhortations to IDUs to use bleach. EVALUATION There is some evidence that high risk injecting practices are becoming less common but as in other counties, baseline levels of unsafe injecting practices were very high and unsafe sexual practices appear to have declined only slightly. HIV prevention policies are widely regarded as having successfully prevented the spread of HIV among IDUs although rigorous scientific proof of their effectiveness is unavailable, probably unobtainable and was wisely not regarded as a prerequisite for adoption and expansion of prevention programmes. HIV prevention policies for IDUs continue to have very strong community and political support. In 1989, one sixth of a Sydney sample (17%) were at low risk of HIV infection as they had never shared injection equipment, cleaned injecting equipment effectively 100% of the time it was shared, and were celibate, monogamous, or had not had unsafe sex in the past six months (Wodak, in press). Half (51%) had either unsafe injecting or sexual behaviour, with the remaining third (33%) engaging in both unsafe injecting and sexual practices. Comparison of two large and consecutive (1989 and 1990) samples of Sydney IDUs recruited in non-treatment settings were consistent with major risk reduction (Ross, in press) (see Table 4). These data are drawn from two cross-sectional samples and therefore the possibility that the differences observed were due to sampling cannot be discounted. Nevertheless, the strength and consistency of the behavioural differences, the similarities in demographic characteristics and drug use of the two samples, and the similarity of findings in comparable studies in other countries suggest that these behavioural differences are real. They are all the more remarkable when it is considered that the two samples were recruited less than twelve months apart. Attributing benefit to any single intervention is impossible when multiple strategies have been implemented at about the same time, the intensity of implementation is difficult if not impossible to measure, and the effect of interventions is in all likelihood synergistic. In a categorical sense, these methodological problems can not be resolved without a controlled trial of communities randomly allocated to a single intervention or no intervention. The ethical, logistic, financial and public health problems of attempting such a study are such (Des Jarlais, 1993) that there is no alternative, especially given the

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Proceedings Workshop on Needle Exchange and Bleach Distribution Programs urgency of the epidemic, to making a judgement on the grounds of plausibility, feasibility, cost and international experience. At issue is whether authorities in a particular country prefer to be roughly right or precisely wrong. Australian authorities, perhaps reflecting a characteristically pragmatic and non-ideological national approach, preferred the former option. So too did most other developed countries. LOOMING PROBLEMS Hepatitis C and Other Blood Borne Viruses Continuing high levels of unsafe injecting practices and international spread of the HIV epidemic within and to an increasing number of countries suggest that complacency about the possibility of future spread of HIV among (and from) Australian IDUs is unwarranted. There is increasing concern in Australia that the magnitude of the Hepatitis C (HCV) epidemic and its consequences has been seriously underestimated. High incidence levels of HCV in Australian IDUs, especially young IDUs, evidence of annual incidence rates for Hepatitis B and C of between 10 and 20 % in Victorian inmates with more than one occasion of prison entry (Crofts, 1993a), and recent estimates that there are five times more people in Australia infected with HCV than HIV and at least a fifteen times higher incidence of HCV than HIV (Crofts, 1993b) may lead to a reassessment of the public health threat of IDU-related blood borne viruses. Evidence of continuing high incidence levels of Hepatitis B and C among IDUs in Australia also indicates the potential for spread of other blood borne viruses including HIV. Although the morbidity and mortality associated with HIV exceeds that of HCV, the much larger pool size and higher incidence of HCV in Australia suggests that far greater attention needs to be directed in the future to the containment of blood borne viruses in addition to HIV. It is estimated that at least 20% of HCV infected individuals will develop cirrhosis within 5-10 years with up to 5% developing a hepatocellular carcinoma. Prisons There is some evidence that HIV spread in prisons has been underestimated in terms of documented seroconversions. The relatively short mean duration of imprisonment in relation to the "window period" for seroconversion suggests that entry-exit testing of HIV infection underestimates the extent of the problem. A network of IDUs who became infected with HIV while in prison is currently being investigated with at least one of these cases being virtually certain (K. Dolan, personal communication). There are about a dozen published cases of HIV infection in prison world-wide but none of these cases can be regarded as definite.

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Proceedings Workshop on Needle Exchange and Bleach Distribution Programs IDUs enter correctional facilities from diverse geographic and social backgrounds. They usually remain within correctional facilities for relatively brief periods during which time they are often moved frequently mixing with many other prisoners. In contrast, unsafe injecting practices among IDUs in the community are increasingly restricted to small social networks. HIV infection within such a network has far less public health impact than infection of a prison inmate with the potential for wide dissemination of HIV within correctional facilities and subsequently following release. Unsafe injecting practices in prison are less frequent than in the community but may be more hazardous for several reasons. Injecting equipment is less available in prison and is therefore likely to be shared between a larger number of partners. Bleach is also less available inside prison. Drug injecting and equipment decontamination is also likely to be more furtive with less opportunity to carefully decontaminate injecting equipment. Evidence of an unofficial needle and syringe exchange programme successfully conducted for almost a year in several prisons in NSW has emerged recently and has been presented to a committee of inquiry. This unofficial strictly "one for one" trial involved over 100 prisoners and was conducted by an HIV infected prisoner with covert assistance of some health professionals and possibly with the knowledge of some correctional staff. The existence of a prison NSEP lasting almost twelve months raises the possibility of considering this intervention more widely at a time when the effectiveness of current decontamination strategies relying on bleach have been called into question. In 1990, an HIV infected prisoner stabbed a NSW prison officer with a syringe filled with the inmate's blood. The prison officer seroconverted over the next months becoming the first documented case of occupational exposure of a prison warder. It is anticipated that recommendations to consider a pilot NSEP in an Australian prison will therefore meet much resistance and accordingly should not be supported at the risk of endangering more likely interventions. PROHIBITION UNDER INCREASING SCRUTINY The Australian experience with HIV prevention among IDUs has stimulated a more critical appraisal of prohibition. There has been increasing support for the view that prohibition is expensive, ineffective, counter-productive and impairs the effectiveness of efforts to control the spread of HIV. The number of influential members of the community calling for a review of drug policy in recent years has been steadily growing. The Australian Parliamentary Group for Drug Law Reform was established in 1993 and includes representatives of the major parties with members drawn from Commonwealth, State and local levels of government. A debate about the fundamental nature of drug policy has been slowly intensifying with fundamental reform strongly supported by many leaders of the medical and legal professions and most doctors involved in delivering HIV prevention or treatment services. The National Centre for Epidemiology and Population Health, Canberra, is investigating the possibility of a trial of controlled availability of currently illicit drugs

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Proceedings Workshop on Needle Exchange and Bleach Distribution Programs and was awarded a grant of A$0.5 million by the Australian National University to further this work. This trial followed from a recommendation made by an Australian Capital Territory Legislative Assembly official enquiry into HIV, illicit drugs and prostitution. Whether a debate about drug policy reform would have developed in the absence of adoption of needle and syringe exchange programmes is arguable. However, the fact that liberalisation of availability of injection equipment has been so beneficial and virtually unaccompanied by unintended negative consequences has certainly drawn attention to the lack of evidence of effectiveness, high costs and major adverse consequences associated with prohibition. Prohibition is seen by some to keep street drug prices high and purity of street drugs low and thus reduce the possibility of IDUs making a transition to non-parenteral modes of administration. Prohibition also delayed the adoption and slowed expansion of NSEPs and also impeded the implementation of many other programmes needed to control the HIV epidemic. RELEVANCE TO OTHER COUNTRIES These conclusions may be of interest to other countries especially those which share many similar characteristics such as the United States. However, the many major differences between Australia and the United States must also be borne in mind. The United States and Australia were both colonised by Great Britain. When the United States declared independence, Great Britain lost a favoured storage site for surplus prisoners. The search for a new gulag lead to the establishment of a colony in Australia. The two countries have similar political systems and the curses and blessings of a federal system of government. The Australian political system is sometimes referred to as Washminster reflecting the debt to both Westminster and Washington. The United States and Australia have been parliamentary democracies without interruption. English is the main language spoken in both countries. The area of the continental United States is only fractionally larger then Australia. Both countries have populations drawn from diverse cultures. US drug policies have been a dominant influence on Australia drug policies since soon after the turn of the century. In both countries, the drug policy is essentially prohibition although this takes a kinder and gentler form in Australia. However there are many differences between Australia and the United States. Australia only has about 6% of the population of the United States. Like most other western countries, Australia has a universal health care system. A policy of harm minimization for illicit drugs has been adopted at the highest political level in Australia. This policy states that the aim "is to minimize the harmful affects of drugs on Australian society". In contrast, US drug policies has been dominated (explicitly) by attempts to reduce drug use. Although poverty and severe social disadvantage exist in both countries, Australia has never had a large urban under-class as is seen in a number of major US cities. Furthermore, policy makers and injecting drug users in Australia come from the same racial group and speak the same language. Moreover, injecting drug

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Proceedings Workshop on Needle Exchange and Bleach Distribution Programs users and policy makers in Australia are in contact with one another. In recent years, some injecting drug users have been employed on Government projects because they were currently injecting drug users. Social policies are markedly different in Australia and the United States. In Australia, abortion is readily available and ceased to be an issue several decades ago. Capital punishment was last carried out decades ago. In 1992, it was decided that sexual orientation of male and female military recruits would no longer be taken into account (despite strenuous opposition of the military). All Australian jurisdictions have laws restricting the availability of guns which are much stricter than in the United States. Crime rates and rates of imprisonment are much lower in Australia than the United States. In most western countries including Australia, the questions policy makers ask about the availability of sterile injection equipment for injecting drug users is not whether this is a legitimate strategy to prevent the spread of HIV infection or even whether this policy contributes to improved control of the epidemic. Improving the availability of sterile injection equipment is assumed to make a most important contribution to the control of the epidemic even in the absence of categorical proof. In Australia, the standard of proof required for evaluating the contribution of needle and syringe exchange programmes to improve control of the epidemic was commensurate with the speed of spread of the epidemic and the magnitude of the consequences of an uncontrolled epidemic. The critical question for policy makers in Australia regarding needle and exchange is how needle and syringe availability can be implemented more effectively and at lower cost. There is a strong desire to focus on improving availability particularly for groups of major public health importance such as homosexual/bisexual male injecting drug users. After seven years of needle and syringe availability, political, bureaucratic and community support is still overwhelming. REFERENCES Australian National AIDS and Injecting Drug Use Study (1992). Not in a Fit. Third Report of the Australian National AIDS and Injecting Drug Use Study (ANAIDUS), 1990 Data collection. Sydney. Australian National AIDS and Injecting Drug Use Study (ANAIDUS). (1991) Neither a borrower nor a lender be. First Report of the Australian National AIDS and Injecting Drug Use Study (ANAIDUS), 1989 Data collection. Sydney. Blacker P, Tindall B, Wodak AD, and Cooper D. (1986) Exposure of Intravenous Drug Users to AIDS Retro Virus Sydney, 1985. Aust and N. Z. Med J 686-690. Crofts N, Hearne P, Stewart T, Breschkin AM, Locanini SA. (1993a). HCV Among Prison Entrants in Victoria. Abstract. National Symposium on Hepatitis C. St. Vincent's Hospital. Melbourne. October 8th. Crofts N, Wodak A. (1993b). Prevalence, carriage and incidence of HCV among IDUs in Australia. Abstract. National Symposium on Hepatitis C. St. Vincent's Hospital.

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Proceedings Workshop on Needle Exchange and Bleach Distribution Programs Melbourne. October 8th. Department of Community Services and Health, National HIV/AIDS Strategy. (1989) A policy information paper. Australian Government Publishing Service. Canberra. Des Jarlais DC, Friedman SR. (1993) Research. Dimensions of HIV prevention: Needle Exchange. (eds) J. Stryker, MD Smith. pp 63-75. Des Jarlais, DC, Hagan H, Friedman SR, Friedman P, Goldberg D, Frischer M, Green S, Tunving K, Ljunberg B, Wodak A, Ross M, Purchase D, Millson ME, Myers T. Maintaining low HIV seroprevalence in populations of injecting drug users. (submitted for publication) Dolan, K, Hall W, Wodak A, Gaughwin M. (1994) (letter) Evidence of HIV transmission in an Australian prison. Med J. Aust 160: 734. Douglas R. (1991) AIDS in Australian Prisons. What are the challenges? in ''HIV/AIDS and Prisons". (eds) J. Norberry, M. Gaughwin, S-A. Gerull. Australian Institute of Criminology. Canberra. pp 23-30. Duckett M, Moore T, Ramsay J, Wodak A. (1993) Review of Western Sydney HIV/AIDS prevention and Outreach Service. May, 1993. Gaughwin M, Kliewer E, Ali R, Faulkner C, Wodak A, Anderson G. (1993) The prescription of methadone for opiate dependence in Australia, 1985-1991. Med J Aust 159: 107-108. Inter Governmental Committee on AIDS. (1992) The final report of the legal working party of the Inter Governmental Committee on AIDS. Australian Government Publishing Service. Canberra. Kaldor J, Elford J, Wodak A, Crofts JN, Kidd S. (1993) HIV prevalence among IDUs in Australia: a methodological review. Drug and Alcohol Review. 12: 175-184. National Centre in HIV Epidemiology and Clinical Research, Australian HIV Surveillance Report. Volume 9, Number 3. July 1993 National Centre in HIV Epidemiology and Clinical Research. National Working Group on HIV projections; Estimates and Projections of the HIV Epidemic in Australia, 1981-1994. Internal Technical Report 1 April 1992. National Institute on Drug Abuse. (1993) Community Alert Bulletin, March. Inter Governmental Committee on AIDS. Report on HIV/AIDS in Australia 1990-91 . (1992) Australian Government Publishing Service. Canberra. Ross MW, Stowe A, Wodak A, Gold J. (1993) Changes in equipment sharing in injecting drug users in Sydney 1989-1990. Drug and Alcohol Review 12: 277-281. Wodak A, Stowe A, Dolan K, Ross MW, Gold J. (1993) Comparison of characteristics and HIV risk behaviours of injecting drug users attending needle and syringe exchange programs and pharmacies. Submitted for publication. Wodak A, Stowe A, Ross MW, Gold J, Miller ME. (in press) Extent of HIV risk exposure of injecting drug users in Sydney. Drug and Alcohol Review. Wodak A. (1992) HIV infection and injecting drug use in Australia: responding to a crisis. Journal of Drug Issues 22 (3): 547-560. Wolk J, Wodak A, Guinan J, Macaskill P, Simpson JM. (1990) The Effect of a Needle and Syringe Exchange on a Methadone Maintenance Unit. Brit J Addict 85: 1445-1450.

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Proceedings Workshop on Needle Exchange and Bleach Distribution Programs TABLE 1 Percentage New Needles and Syringes Were Easily Obtained in Four Cities, 1989 (ANAIDUS, 1991)   Median Mean SDD n Sydney 95.0 84.3 20.7 1,225 Brisbane 50.0 58.6 27.6 582 Perth 90.0 83.4 20.0 194 Melbourne 75.0 72.0 24.4 349 TABLE 2 Usual Source of New Needles and Syringes (n = 2,422)(ANAIDUS, 1991)   Source (%) Response (%) Drug store 47.9 70.9 Needle exchange 22.0 32.6 After hours drug store 14.3 21.2 Using friends 9.21 3.6 Non-using friends 1.2 1.8 Hospitals 1.2 1.8 Dealers 1.1 1.6 Doctors 0.9 1.4 Veterinary surgeons 0.5 0.8 Other 1.7 25 TABLE 3 Percentage New Needles and Syringes Were Easily Obtained in Two Cities, 1990 (ANAIDUS, 1992)   Median Mean SDD n Sydney 99.0 93.0 14.3 544 Perth 90.0 85.5 17.1 148

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Proceedings Workshop on Needle Exchange and Bleach Distribution Programs TABLE 4 Differences in Risk Behaviour (Ross, 1993) Variable 1989 1990 n 1,245 550 # of times N & S used 2.9 +/-3.1 1.9 +/-2.3** % time use new N & S 735 +/-26.284.8 +/ 21.8**     % of times easy to get new N & S 84.3 +/-20.7 93.0 +/-14.3** % of times N & S used after     someone else 19.0 +/-25.8 9.7 +/-18.5** # of people accepted used N & S     from in last 6 months 1.8 +/-6.6 0.9 +/-3.9*       # of people who use a N & S     before being discarded 2.0 +/-4.2 1.2 +/-1.1**       share because withdrawal, intox. 5.1 +/-1.7 6.0 +/-1.6**       share because N & S unavailable 0.3 +/-0.6 0.1 +/-0.4**       share because risk low 0.5 +/-0.7 0.2 +/-0.5**       % new N & S from drug store 65.8 47.6**       % new N & S from after hours drug store 19.7 10.8**       % new N & S from NSEP 34.8 575**       % new N & S from IDU 9.9 11.9         p < 0.01 ** p < 0.001

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Proceedings Workshop on Needle Exchange and Bleach Distribution Programs Figure 1: Estimated incidence of HIV infection in Australia, 1981-1990 for selected back-projection model Source: National Centre in HIV Epidemiology and Clinical Research. National Working Group on HIV Projections: Estimates and Projections of the HIV Epidemic in Australia, 1981-1994. Internal Technical Report 1, April 1992, Figure 3, p. 26.

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Proceedings Workshop on Needle Exchange and Bleach Distribution Programs DISCUSSION: INTERNATIONAL EVALUATIONS OF NEEDLE EXCHANGE PROGRAMS PETER SELWYN Peter Selwyn noted that a large number of studies from the United States and many other countries throughout the world have provided generally consistent data about needle exchange programs. Nevertheless, underlying social and political dynamics in the United States seem to be requiring a standard of scientific proof for such programs that is much higher than that usually required of other preventive, or even clinical, interventions. The more important underlying dynamic appears to be the social context for policy concerning drug injection and related preventive interventions. The tendency to respond to drug injection within a criminal justice as opposed to a medical public health context inhibits responses that are truly preventive and educes instead responses that are more proscriptive and punitive. Thus, he observed, there is the irony that the United States, which is both heavily affected by injection drug use and by the AIDS epidemic, has served as an alarming negative example to other countries around the world. Other countries have gone on to develop comprehensive AIDS prevention programs targeted on drug users; in the United States, however, similar steps have not been taken in any systematic way, notwithstanding the many important steps undertaken in selected individual cities and communities. He commented that it may be helpful to separate the issues that surround needle exchanges into three categories: (1) the data that exist, (2) the limitations of the data, and (3) the political, cultural, and often emotional issues that underlie the data. As for the data that exist, he said, it is clear that virtually all of the research that has looked at outcomes of needle exchange programs around the world points in the same direction-that is, toward no evidence of significantly increased use of drugs, initiation of drug use, or drug injection at an earlier age. There is also evidence of reductions in needle sharing among participants in needle exchange programs and lower or stable HIV seroprevalence. The importance of increased access to drug treatment and other medical interventions for active injectors is also a consistent finding. Selwyn noted the methodological limitations of the data that have already been discussed—sampling frames, nonrandomized designs, inability to separate needle exchange effects from other program effects and secular changes over times, validity of self-report data, and so on. An important point that bears repeating is that use of HIV seroconversion as an outcome measure may not be feasible or even relevant to the evaluation of needle exchanges. In most of the studies that were presented, needle exchanges were being introduced into populations that were either already heavily saturated with HIV infection or still at a very low level of seroprevalence. Thus, statistically demonstrating a reduction in seroconversion would have been a priori difficult, just from the standpoint of sample size. Another important limitation is the inability to separate easily the effects of other behavioral factors, such as sexual risk behavior, from the effects of needle exchanges. Finally, not so much from a data

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Proceedings Workshop on Needle Exchange and Bleach Distribution Programs standpoint, but perhaps more conceptually, there is the difficulty of proving that something did not happen. As the presentation on Australia's experience made clear, one cannot say that something would have happened otherwise had it not been for the programs that were implemented. Turning to the underlying political and cultural framework, he noted, the social acceptability of a behavior, in general, lends itself proportionately to preventive, as opposed to punitive or proscriptive, approaches to that behavior. Thus, there has been less reluctance in the United States to introduce behavioral interventions aimed at reducing heterosexual transmission of HIV than transmission among homosexuals or bisexuals and injecting drug users. In conclusion, Selwyn observed, based on the existing data and leaving aside the policy and underlying social dimensions for the moment, needle exchange programs do not make things any worse and there are some data—e.g., from Kaplan in New Haven-that they may make things better. They do not cause people to use drugs, they seem in many instances to promote positive behavioral change, they definitely help provide access to vulnerable and sometimes otherwise inaccessible populations, and they may reduce the risk of transmission of HIV. But, as all of the preceding presenters noted, needle exchange programs should not be looked at as a single or simple solution. The data from Amsterdam that were presented are an interesting reflection of this point. The fact that cocaine use, alcohol use, and homelessness were the factors that predicted HIV seroconversion, even among people who used the needle exchange, suggests that it is not simply a matter of handing out clean needles. The behavioral and social factors underlying drug use must also be addressed.