Drug and Alcohol Elsevier
Scientific
Dependence,
29 (1991)
Publishers
Ireland
171-
171
181
Ltd.
AIDS among drug users in Europe H. Brennera, “North-Western
He&h
P. Hernando-Briongos”
and C. GoosC
Board, Sligo (Republic of Ireland), bMinistry oJ‘Health nrtd Consumer A,fitiCfnirs,Mndrid ‘World Health Organization, Regional Q[fiw ,for Europr. CopPnhrrgrrr (Dvnmtrrk/
(Accepted
August
2nd,
(Spuin)
u~(d
1991)
This study was carried out by the Regional Office for Europe of the World Health Organization. It contains information ob tained by 31 December 1990 from 31 countries under the headings: illegal use of drugs; AIDS among intravenous drug users; HIV seropositivity among drug users; measures to prevent HIV infection among drug users; training programmes for tlrug workers. Key words:
drug
abuse;
AIDS;
Europe
Introduction
request from the WHO regional programme for abuse of psychoactive drugs, as well as from other documents available in the programme. The information presented has its shortcomings: accurate and reliable data is very difficult to obtain. The situation is changing rapidly, different sources provide different opinions and data, and frequently little or no information is available. In anticipation of a forthcoming review we would appreciate receiving comments or further information.
Of the 45 361 cases of AIDS reported by 31 December 1990, the proportion among drug users has increased from 20.5% in 1986 to 33.1% in 1990. The Global Commission on AIDS has therefore called for close monitoring of the spread of HIV among drug abusers and recomefforts to increased integrate mended HIV/AIDS programmes with drug abuse treatment and prevention. A symposium was held in Stockholm in September 1989 at which the experience of many European countries with AIDS and drug abuse was described [ 11. This report provides, as an updated review on far as possible, developments in the European countries where information is available. The report includes statistics of HIV infection among drug users, and data on drug abuse, on the implementation of preventive strategies and on training programmes for drug workers. Much of the information comes in response to a
Illegal Use of Drugs The need for valid epidemiological information on the use of iiiegal drugs is heightened by the emergence of injecting drug users as an increasingly significant risk group in the AIDS pandemic. The scale of drug abuse in Europe is unknown: although data are being collected and reported from many countries the gathering of them is subject to limitations. It is generally accepted that there is a lot of non-recognition and underreporting of the use of illicit drugs. The difficulty in collating these data is compounded by several factors, e.g. different ter-
Correspondence to: C. Goos, World Health Organization, Regional Office for Europe, Copenhagen, Denmark.
0376-8716/91/$03.50 Printed
and Published
01991
Elsevier
in Ireland
Scientific
Publishers
Ireland
Ltd.
172 Table I.
Estimated
number of drug users.
Country
Number
Category
Comment
Austria Czechoslovakia Denmark France Germany Greece Ireland
18 389
6814 6000 - 10 000 80 000 - 120 000 50 000 - 80 000 40 000-50 000 4454
Registered Registered Estimated Estimated Estimated Estimated
Italy Netherlands
100 000 15 000-20
IHegaI drug users Drug users Injecting drug abusers Drug users (65% IV)a Drug addicts (90% IV) Drug dependents Addicts presenting for treatment 1983 - 1988 IV drug users Drug addicts (40% IV)
Norway Poland Portugal Spain
4000 - 6000 5000b 40 000-50 000 80 000 - 100 000
Sweden Switzerland USSR United Kingdom
10 ooo9500 61 086 75 ooodrugs 13 000-
Yugoslavia bThe number of drug-abusing
000
14 000
150 000 (50% IV variable) 16 000
Drug users (15% IV)
Registered
people needing medical care is 20 000-30
minologies, sources of data, reporting systems and ethical and legal considerations. Table I gives an indication of the extent of the use of illicit drugs in countries for which there is available data. Most figures are based on estimates but some are derived from official registers or enquiries. These figures have to be used with utmost caution as in no way are they derived from scientific research. A common characteristic of many reporting countries is that a high proportion of drug users
Table II.
Injecting users Addicts tested for HIV Drug dependents Heroin users (estimated) Drug abusers (75% IV) Heroin dependents Drug dependents Misusers of notifiable
Estimated Estimated. High percentage in touch with care Estimated Minimum number Estimated In 1988, 16 481 initiated treatment Official enquiry Approximate number Registered Registered + estimated
000.
live either in or near the capital or other big cities. Trends in drug abuse are reported from some countries with well developed reporting systems. Austria reports a decreasing use of heroin and an increasing use of cocaine. Similar trends seem to occur in some other western European countries. An important finding in Sweden is that the use of intravenous drugs has not apparently increased in recent years. Guidelines have been developed for initiating
AIDS among injecting drug abusers.
Reported cases of AIDS among injecting drug abusers 1987
1988
No.
%
No
1340
23.4
2860
Percentage increase in number of cases 1989
%
No.
Y0
32.2
4547
36.6
1987 - 1988
1988 - 1989
113
59
and operating drug abuse reporting systems. In view of the increasing number of countries using drug abuse registers and reporting systems and reporting their data to WHO, these systems should now develop along formal lines while recognizing individual country requirements. The abuse of psychoactive drugs programme in the Regional Office has started a project to produce a European Summary on Drug Abuse on a regular basis in conjunction with monitoring Health For All in the European Region. AIDS Cases Abusers
Among
Intravenous
injecting drug users among the reported cases. Intravenous drug users as a risk group constitute 33.1% of the 45 361 cases of AIDS reported from 32 European countries up to 31 December 1990. The male to female ratio of cases is significantly different (3.3 : 1) among the drug users when compared with the ratio of 6.5 : 1 in all cases. Fifty-six percent of all females reported with AIDS are drug users, and just over one-third of all paediatric AIDS cases are the children of female drug users. The 43rd World Health Assembly in May 1990 urged Member States to recognize the close link between HIV infection/AIDS and the use of drugs or similar substances for recreational purposes which increases the risk of mother-to-fetus transmission. Mortality associated with HIV infection in drug users may have been underestimated owing to surveillance definitions being inappropriate for this group. The number of AIDS cases among drug users in European countries is shown in Table III. The high percentage of drug users among the total cases of AIDS is notable in Italy, Spain and Yugoslavia and to a somewhat lesser degree in France and Switzerland. Countries with a
Drug
The WHO collaborating centre on AIDS in Paris is responsible for AIDS surveillance in Europe. Their data clearly illustrates the continuing rapid spread of HIV infection among drug users and underlines the need for an immediate expansion of prevention programmes and treatment facilities at international, national and local levels. Table II shows the percentage change in the number of AIDS cases among drug users reported annually from 32 European countries (1987- 1989) and the increasing percentage of
Table III. Country
Drug
abusers-AIDS Drug
No. Albania Austria Belgium Bulgaria Czechoslovakia Denmark Finland France Germany Greece Hungary Iceland Ireland Israel Italy
cases
by country
user
Homo/Bisex. Drug user %
0
118 22 0 0 23 1 1804 565 9 0 II 48 12 4012
(31 countries
No. 0
28
4 2 19 12 3
3 4 0 0 7 0 203 43 1
34 11 66
0 0 7 3 167
3
reported
by 31 March
Country
70
1990). Drug
No. Luxembourg Malta Monaco Netherlands Norway Poland Portugal Romania San Marino Spain Sweden Switzerland Turkey USSR ITnited Kingdom Yugoslavia
5 0 0 85 8 7 43 0 1 3326 11 413 5 0 99 43
Homo./Bisex. user
user
‘81
No.
“70
174
relatively low percentage (predominantly northern European) are Belgium, Denmark, Finland, Greece, Israel, Netherlands, Norway, Poland, Portugal, Sweden and the United Kingdom. Several countries have reported no cases among drug users: Albania, Bulgaria, Czechoslovakia, Hungary, Iceland, Malta, Monaco, Romania and the U.S.S.R. Geographical differences in the prevalence of AIDS (and HIV seropositivity) occur within countries between different regions and cities. In the Canary Islands region of Spain, for example, there is a higher percentage of AIDS cases among homosexuals than among drug users, unlike the rest of the country. Similarly, most countries have demonstrated differences in prevalence within their borders, notably France, Italy, Sweden and the United Kingdom. Several explanations have been advanced, including the time of introduction of HIV into the community at risk and differing patterns of drug use. Projections have been made for 1991 for new cases of AIDS among drug users in Europe. The lowest among several predictive models shows 13 000 new cases of AIDS in this risk group before the end of 1991. HIV Seropositivity
Among Drug Users
Tests for HIV seropositivity among drug users are now offered in most countries. The test is usually offered to everyone who contacts a caring agency, and despite its voluntary nature, the uptake in this risk group is higher than in others. There are ethical dilemmas in HIV seroprevalence studies, but these are more readily resolved in groups in which the risk of aequiring and transmitting the virus is high. Table IV shows percentages of seropositivity among drug users in those countries for which data are available. Since those tested have usually contacted caring agencies, testing is necessarily of selected groups and the data are not representative of the drug using population. Even so, they are of interest both for public health initiatives and health services planning. Explanatory notes follow the table.
Measures to Prevent Drug Users
HIV Infection
Among
In January 1988 the Global Programme on AIDS recommended a new approach to the prevention of HIV infection related to drug inof the increasing jecting in recognition magnitude of drug injecting behaviour and its implication for HIV infection and AIDS. This review sees how far selected European countries where information is available have educational developed programmes for outreach, needle and syringe exchange, specific subgroups of drug users, substitution therapy in drug treatment services and training for drug treatment staff. It includes a short commentary on the philosophy of intervention. Educational
Outreach Programmes
The AIDS pandemic has motivated an increasing number of intravenous drug users to attend drug treatment centres, even if only to be tested for HIV infection. However, drug users who do not come to centres must be contacted so as to provide information on the risk of HIV infection and a service to these people who, with some justification, feel that established health services are unsympathetic to their needs. Outreach programmes are being tried out and are well established in several European countries. Experience shows that drug users can be attracted to drug abuse services and helped to take fewer risks. A report on stimulating outreach activities has been prepared by the programme on abuse of psychoactive drugs of the WHO and will be reviewed before publication. Needle and Syringe Exchange
Programmes
Some of the above outreach activities include needle and syringe exchange programmes. However, these programmes are also available in other contexts and in countries where there is no policy of easy access to needles and syringes. There is no evidence that needle and syringe exchange programmes have either caused an in-
Table IV.
HIV seroprevalence-selected
Country
Seropositive
Austria Belgium
see note 2
Denmark France Germany Greece
5-18 up-58 15-20 4
Ireland Italy Luxembourg Netherlands
14.2 30-80 3-4 30
groups (%)
of intravenous
drug
abusers.
Country
Seropositivr
Norway Poland Portugal Spain Sweden Switzerland
5-8 7 2 40-60 10-15 37-15
USSR United Kingdom Yugoslavia
0.0007 see note 27.5
(%) -
Austria. An increase of HIV infection among drug users has been noted since November 1987, although no exact figure is available. HIV-infected drug users account for 44.5% of all seropositives. Czechoslovakia. No HIV seropositives have been found among drug users in screening up to 31 October 1990. Denmark. One study indicates a seroprevalence of 18%. In Copenhagen 200 injecting drug users are seropositive. an estimated prevalence of 5 - 13%. France. Data based on four studies. Wide regional variations. Gemnany. A study in 1988- 1989 found a prevalence of 20% seropositives in over 1000 drug users. For Berlin (West) the figurr was 26%). A study in drug treatment centres revealed a 15% prevalence. Greece. Data based on two studies. Ireland. Drug users make up 57% of all people found to be seropositive on testing. Italy. HIV prevalence among drug users varies widely: 30 - 80% in Roman methadone centres, 6OW in Lombardy and 20% in Sicily. Luxembourg. Since 1985, four out of 105 drug users tested were seropositive. During 1989 no new positive tests were found among 42 drug users tested. Netherlands. Studies since 1986 have shown a 30% stable HIV seroprevalence among injecting drug users in Amsterdam. The prevalence is smaller in smaller cities - 3.6% in Arnhem for example. Norway. At the most visited test centre in Oslo and at other agencies, the HIV seroprevalence among drug users is .I - 8’/11. Approximately 75% of the drug using population has been tested at least once. Potand. From 1986- 1989 over 5000 drug users were tested and 353 found to be seropositive. This represents 65% of all people found to be HIV seropositive. PortUgaI. Out of 1127 drug users tested since 1988,22 were found to be seropositive. One of these was also seropositive for HI\?. Spain. Of more than 1000 drug abusers who sought treatment in 1989, about 40”s) were HIV seropositive. Seroprevalence among prisoners who had injected drugs at least once was 60%. Sweden. A majority of injecting drug users has been tested. In Gothenburg and Malmo, HIV seroprevalence is approximately 1% compared with an estimated lo- 15% among drug users in Stockholm. Switzerlnnd. Data based on seven studies. United Kingdom. The rates of HIV infection among groups of drug users varies widely, from over 60% in some parts of Scotland to up to 3OYo found in small-scale studies in England. Not all regions with high rates of drug among drug users. Yugosloria. Since 1984, 4443 drug users were tested revealing a 27.5% HIV seroprevalence. tested were HIV seropositive.
crease in the number of drug users or in the number of injections by users using the schemes. Studies have shown that these programmes reduce risk behaviour in relation to shared or dirty syringes and needles, and that they can provide information about AIDS and other health matters.
abuse have high rates In Belgrade,
of‘ infection
44”iis of 758 usc’rs
Users of intravenous drugs are generally well aware of the risk of HIV transmission from sharing contaminated equipment, but the unavailability of clean needles and syringes contributes to the continuation of the practice; and unless guidelines are properly applied, cleaning of needles and syringes will not protect against
176
transmission of HIV or other viruses which are important in the context of injecting drug abuse - notably the hepatitis viruses. Needle and syringe programmes have been set up in several European countries, often requiring changes in legislation and policy agreements between public health and judicial departments (France, Netherlands, Sweden, Switzerland and the United Kingdom). Information follows regarding selected European countries.
Netherlands
Austria
Norway
Exchange schemes are available in some health institutions. Others provide free needles and syringes not necessarily in the context of exchange. Needles and syringes can be bought at low cost in all pharmacies without medical prescription.
Needles and syringes are freely sold in pharmacies and there are vending machines in 10 towns. In Oslo a bus provides free syringes, among other drug-related health services. They are also provided free of charge by the municipal HIV clinic and some treatment centres and outreach agencies. There are exchange schemes in some towns.
Czechoslovakia No special measures
The Amsterdam needle and syringe exchange programme began in 1984, and subsequent positive evaluations encouraged the spread of the schemes which are now available in over 40 municipalities. Needles and syringes are also available on the ‘methadone buses’. Recently a needle and syringe exchange machine has been installed in one drug agency, and the first evaluation of its use is encouraging.
have been taken yet. Poland
Denmark
The need for needle exchange programmes has been obviated by the easy accessibility of needles and syringes. In Copenhagen these have been supplied free from chemists’ shops since 1988. Vending machines also operate in some communities. France
Two pilot exchange schemes have been initiated. Amendments to the legislation now allow unrestricted sales of needles and syringes from pharmacies and other retail sources. Germany Needle exchange programmes and other ways of providing clean equipment are under consideration, but implementation is considered inappropriate in many parts of the country. Vending machines have been introduced in some cities. Ireland
A syringe and needle exchange scheme associated with counselling has been introduced as part of the Dublin outreach programme.
A programme of free exchange syringes and needles has started.
of disposable
Switzerland
Exchange and distribution schemes have been initiated on a large scale in Switzerland. One evaluating study showed that only those drug users actively engaged in treatment programmes reduced needle sharing. United Kingdom
There are over 100 needle exchange programmes in the United Kingdom, and 15 of the pilot schemes launched in April 1987 are being evaluated by a monitoring research group. Initiatives were taken in Liverpool and Scotland. One of the largest programmes is a store-front needle exchange scheme at the London Middlesex Hospital, where an average of nearly 9000 syringes are dispensed each month to an average of 257 injecting drug users; there is a return of used equipment of nearly 80%. Another well known project, the Central London Action on Street Health, is also involved in needle exchange programmes. General practitioners and pharmacists are encouraged to
177
cooperate with needle exchange programmes and the sale of injecting equipment is unrestricted. Syringes and needles are increasingly available in Portugal (not free) and Spain, although not in the context of exchange programmes. The sale of needles and syringes is also unrestricted in Italy. It was feared that there would be an increased danger to the general public from discarded contaminated needles and syringes when needle exchange programmes were being developed, especially if there was not a strict one-to-one exchange. Most programmes give advice about this: in Norway leaflets have been produced and in Denmark special bins are provided for disposing of contaminated equipment. However this is regarded to be a problem of significance in communities in many countries. Some countries provide information about and supply material for needle and syringe cleaning. This is specifically mentioned in a report from Norway. In Germany, it is planned to provide information to drug users about effective needle sterilization techniques. In other countries this information is often included in health education and counselling to drug users. An interesting phenomenon reported from Glasgow is the use of vinegar for dissolving heroin prior to injection, which may be a factor in maintaining a relatively low HIV infection prevalence (6%) among drug users there. A survey of the practical availability of needles and syringes at street level is currently being carried out by the regional programme on abuse of psychoactive drugs of the WHO and will be reported on later this year. Programmes Users
for
Subpopulations
of
Drug
Several subpopulations of drug users are important in relation to the spread of HIV infection, either among themselves or to the general population. Two groups - people in prisons and prostitutes - are considered here, but the use of intravenous drugs in others, for example ethnic minorities and refugees, is also significant.
P?iwn inmates In some countries many prison inmates have had previous experience of injecting illegal drugs. The risk of spread of HIV infection is potentially high since opportunities exist for the smuggling of drugs into prisons, clandestine sharing of injecting equipment and homosexual activity. In the United Kingdom, an AIDS video teaching pack has been made available to prison staff including a video for viewing by prisoners. In England and Wales, since 1985, viral infectivity regulations can be applied at the discretion of the prison medical officer. These include HIV seropositive prisoners being moved into single cells or sharing a cell with another seropositive inmate, the reason for the move not being disclosed. In some countries (e.g. Austria, France, Germany, Norway and Spain) all drug users in prisons are offered the opportunity to be tested for HIV infection and condoms are available to inmates free of charge. In Belgium and Greece an HIV test is mandatory for prison inmates. In Italy, Norway and Spain, bleach is available to prisoners for the disinfection of drug injecting brochures are In Norway, equipment. distributed in prisons with information about cleaning syringes and needles, and this information is also given by health personnel in prisons. There are support groups for HIV seropositive persons in Oslo prisons, and in Austria outreach workers with special training are encouraged to go into prisons to support and counsel injecting drug users. In Portugal, educational programmes arranged by local hospital staff are available to prisoners as well as to prison staff. In Luxembourg, a special project for prisoners has started aiming at informing prisoners about HIV infection and at motivating them towards treatment. Information leaflets about the availability of condoms are being distributed as part of the project. Brief talks are given at regular intervals to remind prisoners of the threat of AIDS. In Sweden, prison staff are encouraged to consider the personal lives of the inmates. In one
178
large detention unit where more than one-third of the prisoners are injecting drug users, there is considerable peer pressure for HIV testing and a strong programme of counselling and support. In this unit a major research project is looking at the effects of the prison policy on the spread of HIV infection. Denmark, Norway and Sweden permit regular conjugal visits in prison, which are thought to reduce the level of homosexual activity and hence the attendant risk of HIV transmission. In the Netherlands and Sweden, continuity of care for those leaving prisons is arranged with the appropriate social and health services. Guidelines for the prevention and control of AIDS in prisons have been developed by the WHO Global Programme on AIDS, and are available from WHO free of charge. Prostitutes
Female prostitutes who are injecting drug users present a serious potential for the spread of HIV infection. They are themselves doubly at risk because of their injecting habit and their multiple sexual encounters. Several countries have initiated special programmes for prostitutes, who are approached in non-threatening ways with information, advice and counselling. In the United Kingdom, outreach workers have been trained to work with prostitutes, them on the streets. often approaching Outreach workers have also been involved in street-work contact with prostitutes in Luxembourg as part of the ‘AIDS-Berbding’ programme initiated in 1988 by the Red Cross. In the Netherlands, open-door centres have been opened in those city areas with many drugusing prostitutes. A mobile centre was opened in Utrecht in 1986 creating a friendly environment for prostitutes to come in, have a cup of tea, a shower, and consult a doctor if they wish. They are provided with condoms, and are given safesex advice and counselling as opportunity permits. Interestingly, clients of prostitutes use the facility, and they are provided with condoms as well as AIDS-related information. In Norway, there is a pilot project in which
two active prostitutes have undertaken to provide appropriate information to other prostitutes, especially those who are drug users. A pilot project is also in progress to determine the sexual behavioural patterns of male prostitutes. The different municipal outreach agencies are also doing HIV-prevention work among people who sell sex. In Yugoslavia, prostitutes (many of them addicts) receive information but little is known as to how far they comply with advice. In Czechoslovakia, prostitutes who are registered at sexually transmitted disease clinics are compulsorily tested for HIV. If they are seropositive they are told about measures to avoid the further spread of infection. Testing is also compulsory for prostitutes in Austria and Greece. In Austria prostitutes are prohibited from working if found to be HIV seropositive. Little work appears to have been done in the area of male homosexual prostitution, and the degree of drug abuse in the people involved is not known. However, the widespread involvement of young ‘rent-boys’ in some major cities and their potential for HIV infection is causing serious concern. Substitution services
programmes
in drug treatment
Many treatment modules are used in drug abuse programmes throughout Europe. One approach to diminishing the risk of transmitting HIV infection is the substitution of prescribed drugs for illicit injected drugs. Methadone substitution and maintenance for the treatment of heroin addicts has been used in many countries for about 25 years; the options for the use of methadone are reviewed, based on international experience, in a recent WHO position paper 121. Information on methadone programmes is available from the following European countries. Austria
Since 1987 a pharmacological substitution treatment programme (mostly using metha-
done) has been implemented. By September 1989, 891 people were in the programme, which is under evaluation. Conditions for entering the programme include being aged over 18, previous unsuccessful drug-free treatment and/or HIV seropositivity. Although methadone is available, the number of drug users seeking drug-free treatment increased in 1988 compared to previous years. Czechoslovakia No substitution
programmes
are available.
Denmark
Recent initiatives have made participation in methadone maintenance treatment programmes easier. From 1982 to 1989 the number of people in the Copenhagen programme increased from 269 to 1131 and similar increases have been noted in other parts of the country. There are no entry conditions to a programme for HIVseropositive people who would benefit from participation. France
Two Paris hospitals are running pilot programmes of methadone substitution for small numbers of drug users. The treatment is not aimed at maintenance but at drug discontinuance. The programmes are being evaluated and will probably not be extended. Any further proposals for methadone projects will be within a formal framework with a precise protocol and follow-up. Germany
The older countrywide policy of prohibiting substitution therapy is being challenged and in a number of Lander experimental substitution programmes have been initiated over the past year. Ireland
A recent pilot programme of methadone maintenance has been evaluated in the National Drug Treatment Centre in Dublin. Just over twothirds of addicts who entered treatment in a 6-month period have benefited from the pro-
gramme. A relatively large number of pregnant opiate users attend the Centre for treatment. Netherlands
In all major cities in the Netherlands lowthreshold methadone drug programmes are available. Contact is made with a large proportion of heroin users through the easy access to programmes. One example is the Amsterdam ‘methadone bus’ project in which two buses travel routes through known drug scenes. The few conditions for participation are introduction to the central methadone register, regular contact with a doctor and no take-home doses. Methadone is used not only to stabilize, but also to detoxify and treat heroin users. Approximately 1500 heroin users make use of the bus facility each year, and the opportunity occurs to give information about AIDS, exchange needles, provide condoms and arrange assistance with social problems. Norway
Methadone is offered as part of the medical treatment to HIV infected drug users, but there is no formal methadone substitution programme. Portugal
Methadone is used on a small scale as treatment in drug abuse programmes. The effect on HIV prevalence among participants in the programme is being studied. Sweden The majority of drug users in Sweden use amphetamines. However in the Stockholm area and in the southern part of the country about onequarter of the injecting drug users are using heroin. The oldest methadone programme in Europe was implemented in Uppsala. It has now also departments in Stockholm and Lund. Approximately 300 persons are involved. Currently 95% of patients in the Stockholm methadone programme are HIV seropositive. Switzerland
The regulations of previously existing methadone substitution therapy programmes have been revised to make it available to an increasing number of drug users.
180
United Kingdom Substitution has long been available in the United Kingdom, but the emphasis is now shifting to the increased use of longer-term methadone prescription. This apparently encourages drug users to take treatment and maintain contact and compliance. Yugoslavia Drug users attending the Institute for Drug Abuse in Belgrade and fulfilling certain basic criteria of opium dependence are entered into a strictly controlled methadone programme with treatment based on a careful assessment of each individual. This is being evaluated. The existence of methadone maintenance programmes appears to attract drug users into therapy. Uchtenhagen 131 has concluded that a reduction of HIV seroconversion rates has been observed whenever behavioural changes have taken place during methadone substitution therapy. Training Programmes
for Drug Workers
The need for personnel in drug treatment centres and other health workers who work with drug users to be trained in relation to HIV infection needs no justification other than the projection that there will be a minimum of 23 000 cases of AIDS among drug users in Europe by the end of 1991. In Norway, different groups of personnel have received training about HIV infection and AIDS. In the first phase the emphasis was on giving factual information, but in the last 3 years it has been on methods for changing sexual behaviour. Another training programme directed at the leaders of drug abuse treatment agencies deals with such issues as burn-out, the provision of support, training of staff and recent developments in the HIV pandemic. In Spain, efforts have been made to ensure that general practitioners are aware of drug-related programmes in the country, since many drug users go to them for medical reasons before seeking treatment for their dependency. There is a special programme to contact all physicians in the country on this issue.
In France, a high priority is given to training and programmes are of health workers, developed locally and nationally. The first national programme was started in 1987 and aimed to train motivated health professionals for each of France’s 22 health areas. After receiving the training they commit themselves to becoming regional training leaders. The second national training programme was developed in 1988 for participants working exclusively in drug addiction. They are given information about AIDS and coping with the particular problems of HIVinfected drug users. In the United Kingdom, training courses for drug workers in relation to AIDS are open to both statutory and nonstatutory personnel. Service training needs are coordinated in England by AIDS prevention coordinators in the 200 district health authorities. In Austria, specialized information is given to drug treatment personnel, and in Portugal trainers themselves are now being trained to give this information. Other European countries have similar training courses which are often a priority. In some countries courses, meetings and seminars are available for personnel who work in outreach agencies and prisons. A WHO report on training on AIDS for drug workers [4] discusses the development of training guidelines in this area. Acknowledgement We thank the collaborators in the countries who furnished information for incorporation in this review, and hope that in the light of the expected worsening position as regards HIV infection in drug users in Europe this report will stimulate the further development of programmes for prevention and care and the expansion of training programmes for drug workers. Another review will be attempted shortly. References 1
AIDS among drug abusers in Europe: report on Symposium. Copenhagen, WHO Regional Office for Europe, 1991 (unpublished
document
EURlICPlGPA
049).
1x1
2
Options for the use of methadone in the treatment of drug dependence. Geneva, World Health Organization, 1989 (unpublished document WHOIMNH/DAT/89.2).
3
A. Uchtenhagen. Drug abuse policies against the background of the AIDS epidemic. Copenhagen, WHO
Regional Office for Europe, EUR/ICP/GPA 04917). 4
1991 (unpublished
document
Training on AIDS for personnel in drug treatment tres: report on a WHO Meeting. Copenhagen, Regional Office for Europe, 1988.
crnWHO
Scientific
Dependence,
29 (1991)
Publishers
Ireland
171-
171
181
Ltd.
AIDS among drug users in Europe H. Brennera, “North-Western
He&h
P. Hernando-Briongos”
and C. GoosC
Board, Sligo (Republic of Ireland), bMinistry oJ‘Health nrtd Consumer A,fitiCfnirs,Mndrid ‘World Health Organization, Regional Q[fiw ,for Europr. CopPnhrrgrrr (Dvnmtrrk/
(Accepted
August
2nd,
(Spuin)
u~(d
1991)
This study was carried out by the Regional Office for Europe of the World Health Organization. It contains information ob tained by 31 December 1990 from 31 countries under the headings: illegal use of drugs; AIDS among intravenous drug users; HIV seropositivity among drug users; measures to prevent HIV infection among drug users; training programmes for tlrug workers. Key words:
drug
abuse;
AIDS;
Europe
Introduction
request from the WHO regional programme for abuse of psychoactive drugs, as well as from other documents available in the programme. The information presented has its shortcomings: accurate and reliable data is very difficult to obtain. The situation is changing rapidly, different sources provide different opinions and data, and frequently little or no information is available. In anticipation of a forthcoming review we would appreciate receiving comments or further information.
Of the 45 361 cases of AIDS reported by 31 December 1990, the proportion among drug users has increased from 20.5% in 1986 to 33.1% in 1990. The Global Commission on AIDS has therefore called for close monitoring of the spread of HIV among drug abusers and recomefforts to increased integrate mended HIV/AIDS programmes with drug abuse treatment and prevention. A symposium was held in Stockholm in September 1989 at which the experience of many European countries with AIDS and drug abuse was described [ 11. This report provides, as an updated review on far as possible, developments in the European countries where information is available. The report includes statistics of HIV infection among drug users, and data on drug abuse, on the implementation of preventive strategies and on training programmes for drug workers. Much of the information comes in response to a
Illegal Use of Drugs The need for valid epidemiological information on the use of iiiegal drugs is heightened by the emergence of injecting drug users as an increasingly significant risk group in the AIDS pandemic. The scale of drug abuse in Europe is unknown: although data are being collected and reported from many countries the gathering of them is subject to limitations. It is generally accepted that there is a lot of non-recognition and underreporting of the use of illicit drugs. The difficulty in collating these data is compounded by several factors, e.g. different ter-
Correspondence to: C. Goos, World Health Organization, Regional Office for Europe, Copenhagen, Denmark.
0376-8716/91/$03.50 Printed
and Published
01991
Elsevier
in Ireland
Scientific
Publishers
Ireland
Ltd.
172 Table I.
Estimated
number of drug users.
Country
Number
Category
Comment
Austria Czechoslovakia Denmark France Germany Greece Ireland
18 389
6814 6000 - 10 000 80 000 - 120 000 50 000 - 80 000 40 000-50 000 4454
Registered Registered Estimated Estimated Estimated Estimated
Italy Netherlands
100 000 15 000-20
IHegaI drug users Drug users Injecting drug abusers Drug users (65% IV)a Drug addicts (90% IV) Drug dependents Addicts presenting for treatment 1983 - 1988 IV drug users Drug addicts (40% IV)
Norway Poland Portugal Spain
4000 - 6000 5000b 40 000-50 000 80 000 - 100 000
Sweden Switzerland USSR United Kingdom
10 ooo9500 61 086 75 ooodrugs 13 000-
Yugoslavia bThe number of drug-abusing
000
14 000
150 000 (50% IV variable) 16 000
Drug users (15% IV)
Registered
people needing medical care is 20 000-30
minologies, sources of data, reporting systems and ethical and legal considerations. Table I gives an indication of the extent of the use of illicit drugs in countries for which there is available data. Most figures are based on estimates but some are derived from official registers or enquiries. These figures have to be used with utmost caution as in no way are they derived from scientific research. A common characteristic of many reporting countries is that a high proportion of drug users
Table II.
Injecting users Addicts tested for HIV Drug dependents Heroin users (estimated) Drug abusers (75% IV) Heroin dependents Drug dependents Misusers of notifiable
Estimated Estimated. High percentage in touch with care Estimated Minimum number Estimated In 1988, 16 481 initiated treatment Official enquiry Approximate number Registered Registered + estimated
000.
live either in or near the capital or other big cities. Trends in drug abuse are reported from some countries with well developed reporting systems. Austria reports a decreasing use of heroin and an increasing use of cocaine. Similar trends seem to occur in some other western European countries. An important finding in Sweden is that the use of intravenous drugs has not apparently increased in recent years. Guidelines have been developed for initiating
AIDS among injecting drug abusers.
Reported cases of AIDS among injecting drug abusers 1987
1988
No.
%
No
1340
23.4
2860
Percentage increase in number of cases 1989
%
No.
Y0
32.2
4547
36.6
1987 - 1988
1988 - 1989
113
59
and operating drug abuse reporting systems. In view of the increasing number of countries using drug abuse registers and reporting systems and reporting their data to WHO, these systems should now develop along formal lines while recognizing individual country requirements. The abuse of psychoactive drugs programme in the Regional Office has started a project to produce a European Summary on Drug Abuse on a regular basis in conjunction with monitoring Health For All in the European Region. AIDS Cases Abusers
Among
Intravenous
injecting drug users among the reported cases. Intravenous drug users as a risk group constitute 33.1% of the 45 361 cases of AIDS reported from 32 European countries up to 31 December 1990. The male to female ratio of cases is significantly different (3.3 : 1) among the drug users when compared with the ratio of 6.5 : 1 in all cases. Fifty-six percent of all females reported with AIDS are drug users, and just over one-third of all paediatric AIDS cases are the children of female drug users. The 43rd World Health Assembly in May 1990 urged Member States to recognize the close link between HIV infection/AIDS and the use of drugs or similar substances for recreational purposes which increases the risk of mother-to-fetus transmission. Mortality associated with HIV infection in drug users may have been underestimated owing to surveillance definitions being inappropriate for this group. The number of AIDS cases among drug users in European countries is shown in Table III. The high percentage of drug users among the total cases of AIDS is notable in Italy, Spain and Yugoslavia and to a somewhat lesser degree in France and Switzerland. Countries with a
Drug
The WHO collaborating centre on AIDS in Paris is responsible for AIDS surveillance in Europe. Their data clearly illustrates the continuing rapid spread of HIV infection among drug users and underlines the need for an immediate expansion of prevention programmes and treatment facilities at international, national and local levels. Table II shows the percentage change in the number of AIDS cases among drug users reported annually from 32 European countries (1987- 1989) and the increasing percentage of
Table III. Country
Drug
abusers-AIDS Drug
No. Albania Austria Belgium Bulgaria Czechoslovakia Denmark Finland France Germany Greece Hungary Iceland Ireland Israel Italy
cases
by country
user
Homo/Bisex. Drug user %
0
118 22 0 0 23 1 1804 565 9 0 II 48 12 4012
(31 countries
No. 0
28
4 2 19 12 3
3 4 0 0 7 0 203 43 1
34 11 66
0 0 7 3 167
3
reported
by 31 March
Country
70
1990). Drug
No. Luxembourg Malta Monaco Netherlands Norway Poland Portugal Romania San Marino Spain Sweden Switzerland Turkey USSR ITnited Kingdom Yugoslavia
5 0 0 85 8 7 43 0 1 3326 11 413 5 0 99 43
Homo./Bisex. user
user
‘81
No.
“70
174
relatively low percentage (predominantly northern European) are Belgium, Denmark, Finland, Greece, Israel, Netherlands, Norway, Poland, Portugal, Sweden and the United Kingdom. Several countries have reported no cases among drug users: Albania, Bulgaria, Czechoslovakia, Hungary, Iceland, Malta, Monaco, Romania and the U.S.S.R. Geographical differences in the prevalence of AIDS (and HIV seropositivity) occur within countries between different regions and cities. In the Canary Islands region of Spain, for example, there is a higher percentage of AIDS cases among homosexuals than among drug users, unlike the rest of the country. Similarly, most countries have demonstrated differences in prevalence within their borders, notably France, Italy, Sweden and the United Kingdom. Several explanations have been advanced, including the time of introduction of HIV into the community at risk and differing patterns of drug use. Projections have been made for 1991 for new cases of AIDS among drug users in Europe. The lowest among several predictive models shows 13 000 new cases of AIDS in this risk group before the end of 1991. HIV Seropositivity
Among Drug Users
Tests for HIV seropositivity among drug users are now offered in most countries. The test is usually offered to everyone who contacts a caring agency, and despite its voluntary nature, the uptake in this risk group is higher than in others. There are ethical dilemmas in HIV seroprevalence studies, but these are more readily resolved in groups in which the risk of aequiring and transmitting the virus is high. Table IV shows percentages of seropositivity among drug users in those countries for which data are available. Since those tested have usually contacted caring agencies, testing is necessarily of selected groups and the data are not representative of the drug using population. Even so, they are of interest both for public health initiatives and health services planning. Explanatory notes follow the table.
Measures to Prevent Drug Users
HIV Infection
Among
In January 1988 the Global Programme on AIDS recommended a new approach to the prevention of HIV infection related to drug inof the increasing jecting in recognition magnitude of drug injecting behaviour and its implication for HIV infection and AIDS. This review sees how far selected European countries where information is available have educational developed programmes for outreach, needle and syringe exchange, specific subgroups of drug users, substitution therapy in drug treatment services and training for drug treatment staff. It includes a short commentary on the philosophy of intervention. Educational
Outreach Programmes
The AIDS pandemic has motivated an increasing number of intravenous drug users to attend drug treatment centres, even if only to be tested for HIV infection. However, drug users who do not come to centres must be contacted so as to provide information on the risk of HIV infection and a service to these people who, with some justification, feel that established health services are unsympathetic to their needs. Outreach programmes are being tried out and are well established in several European countries. Experience shows that drug users can be attracted to drug abuse services and helped to take fewer risks. A report on stimulating outreach activities has been prepared by the programme on abuse of psychoactive drugs of the WHO and will be reviewed before publication. Needle and Syringe Exchange
Programmes
Some of the above outreach activities include needle and syringe exchange programmes. However, these programmes are also available in other contexts and in countries where there is no policy of easy access to needles and syringes. There is no evidence that needle and syringe exchange programmes have either caused an in-
Table IV.
HIV seroprevalence-selected
Country
Seropositive
Austria Belgium
see note 2
Denmark France Germany Greece
5-18 up-58 15-20 4
Ireland Italy Luxembourg Netherlands
14.2 30-80 3-4 30
groups (%)
of intravenous
drug
abusers.
Country
Seropositivr
Norway Poland Portugal Spain Sweden Switzerland
5-8 7 2 40-60 10-15 37-15
USSR United Kingdom Yugoslavia
0.0007 see note 27.5
(%) -
Austria. An increase of HIV infection among drug users has been noted since November 1987, although no exact figure is available. HIV-infected drug users account for 44.5% of all seropositives. Czechoslovakia. No HIV seropositives have been found among drug users in screening up to 31 October 1990. Denmark. One study indicates a seroprevalence of 18%. In Copenhagen 200 injecting drug users are seropositive. an estimated prevalence of 5 - 13%. France. Data based on four studies. Wide regional variations. Gemnany. A study in 1988- 1989 found a prevalence of 20% seropositives in over 1000 drug users. For Berlin (West) the figurr was 26%). A study in drug treatment centres revealed a 15% prevalence. Greece. Data based on two studies. Ireland. Drug users make up 57% of all people found to be seropositive on testing. Italy. HIV prevalence among drug users varies widely: 30 - 80% in Roman methadone centres, 6OW in Lombardy and 20% in Sicily. Luxembourg. Since 1985, four out of 105 drug users tested were seropositive. During 1989 no new positive tests were found among 42 drug users tested. Netherlands. Studies since 1986 have shown a 30% stable HIV seroprevalence among injecting drug users in Amsterdam. The prevalence is smaller in smaller cities - 3.6% in Arnhem for example. Norway. At the most visited test centre in Oslo and at other agencies, the HIV seroprevalence among drug users is .I - 8’/11. Approximately 75% of the drug using population has been tested at least once. Potand. From 1986- 1989 over 5000 drug users were tested and 353 found to be seropositive. This represents 65% of all people found to be HIV seropositive. PortUgaI. Out of 1127 drug users tested since 1988,22 were found to be seropositive. One of these was also seropositive for HI\?. Spain. Of more than 1000 drug abusers who sought treatment in 1989, about 40”s) were HIV seropositive. Seroprevalence among prisoners who had injected drugs at least once was 60%. Sweden. A majority of injecting drug users has been tested. In Gothenburg and Malmo, HIV seroprevalence is approximately 1% compared with an estimated lo- 15% among drug users in Stockholm. Switzerlnnd. Data based on seven studies. United Kingdom. The rates of HIV infection among groups of drug users varies widely, from over 60% in some parts of Scotland to up to 3OYo found in small-scale studies in England. Not all regions with high rates of drug among drug users. Yugosloria. Since 1984, 4443 drug users were tested revealing a 27.5% HIV seroprevalence. tested were HIV seropositive.
crease in the number of drug users or in the number of injections by users using the schemes. Studies have shown that these programmes reduce risk behaviour in relation to shared or dirty syringes and needles, and that they can provide information about AIDS and other health matters.
abuse have high rates In Belgrade,
of‘ infection
44”iis of 758 usc’rs
Users of intravenous drugs are generally well aware of the risk of HIV transmission from sharing contaminated equipment, but the unavailability of clean needles and syringes contributes to the continuation of the practice; and unless guidelines are properly applied, cleaning of needles and syringes will not protect against
176
transmission of HIV or other viruses which are important in the context of injecting drug abuse - notably the hepatitis viruses. Needle and syringe programmes have been set up in several European countries, often requiring changes in legislation and policy agreements between public health and judicial departments (France, Netherlands, Sweden, Switzerland and the United Kingdom). Information follows regarding selected European countries.
Netherlands
Austria
Norway
Exchange schemes are available in some health institutions. Others provide free needles and syringes not necessarily in the context of exchange. Needles and syringes can be bought at low cost in all pharmacies without medical prescription.
Needles and syringes are freely sold in pharmacies and there are vending machines in 10 towns. In Oslo a bus provides free syringes, among other drug-related health services. They are also provided free of charge by the municipal HIV clinic and some treatment centres and outreach agencies. There are exchange schemes in some towns.
Czechoslovakia No special measures
The Amsterdam needle and syringe exchange programme began in 1984, and subsequent positive evaluations encouraged the spread of the schemes which are now available in over 40 municipalities. Needles and syringes are also available on the ‘methadone buses’. Recently a needle and syringe exchange machine has been installed in one drug agency, and the first evaluation of its use is encouraging.
have been taken yet. Poland
Denmark
The need for needle exchange programmes has been obviated by the easy accessibility of needles and syringes. In Copenhagen these have been supplied free from chemists’ shops since 1988. Vending machines also operate in some communities. France
Two pilot exchange schemes have been initiated. Amendments to the legislation now allow unrestricted sales of needles and syringes from pharmacies and other retail sources. Germany Needle exchange programmes and other ways of providing clean equipment are under consideration, but implementation is considered inappropriate in many parts of the country. Vending machines have been introduced in some cities. Ireland
A syringe and needle exchange scheme associated with counselling has been introduced as part of the Dublin outreach programme.
A programme of free exchange syringes and needles has started.
of disposable
Switzerland
Exchange and distribution schemes have been initiated on a large scale in Switzerland. One evaluating study showed that only those drug users actively engaged in treatment programmes reduced needle sharing. United Kingdom
There are over 100 needle exchange programmes in the United Kingdom, and 15 of the pilot schemes launched in April 1987 are being evaluated by a monitoring research group. Initiatives were taken in Liverpool and Scotland. One of the largest programmes is a store-front needle exchange scheme at the London Middlesex Hospital, where an average of nearly 9000 syringes are dispensed each month to an average of 257 injecting drug users; there is a return of used equipment of nearly 80%. Another well known project, the Central London Action on Street Health, is also involved in needle exchange programmes. General practitioners and pharmacists are encouraged to
177
cooperate with needle exchange programmes and the sale of injecting equipment is unrestricted. Syringes and needles are increasingly available in Portugal (not free) and Spain, although not in the context of exchange programmes. The sale of needles and syringes is also unrestricted in Italy. It was feared that there would be an increased danger to the general public from discarded contaminated needles and syringes when needle exchange programmes were being developed, especially if there was not a strict one-to-one exchange. Most programmes give advice about this: in Norway leaflets have been produced and in Denmark special bins are provided for disposing of contaminated equipment. However this is regarded to be a problem of significance in communities in many countries. Some countries provide information about and supply material for needle and syringe cleaning. This is specifically mentioned in a report from Norway. In Germany, it is planned to provide information to drug users about effective needle sterilization techniques. In other countries this information is often included in health education and counselling to drug users. An interesting phenomenon reported from Glasgow is the use of vinegar for dissolving heroin prior to injection, which may be a factor in maintaining a relatively low HIV infection prevalence (6%) among drug users there. A survey of the practical availability of needles and syringes at street level is currently being carried out by the regional programme on abuse of psychoactive drugs of the WHO and will be reported on later this year. Programmes Users
for
Subpopulations
of
Drug
Several subpopulations of drug users are important in relation to the spread of HIV infection, either among themselves or to the general population. Two groups - people in prisons and prostitutes - are considered here, but the use of intravenous drugs in others, for example ethnic minorities and refugees, is also significant.
P?iwn inmates In some countries many prison inmates have had previous experience of injecting illegal drugs. The risk of spread of HIV infection is potentially high since opportunities exist for the smuggling of drugs into prisons, clandestine sharing of injecting equipment and homosexual activity. In the United Kingdom, an AIDS video teaching pack has been made available to prison staff including a video for viewing by prisoners. In England and Wales, since 1985, viral infectivity regulations can be applied at the discretion of the prison medical officer. These include HIV seropositive prisoners being moved into single cells or sharing a cell with another seropositive inmate, the reason for the move not being disclosed. In some countries (e.g. Austria, France, Germany, Norway and Spain) all drug users in prisons are offered the opportunity to be tested for HIV infection and condoms are available to inmates free of charge. In Belgium and Greece an HIV test is mandatory for prison inmates. In Italy, Norway and Spain, bleach is available to prisoners for the disinfection of drug injecting brochures are In Norway, equipment. distributed in prisons with information about cleaning syringes and needles, and this information is also given by health personnel in prisons. There are support groups for HIV seropositive persons in Oslo prisons, and in Austria outreach workers with special training are encouraged to go into prisons to support and counsel injecting drug users. In Portugal, educational programmes arranged by local hospital staff are available to prisoners as well as to prison staff. In Luxembourg, a special project for prisoners has started aiming at informing prisoners about HIV infection and at motivating them towards treatment. Information leaflets about the availability of condoms are being distributed as part of the project. Brief talks are given at regular intervals to remind prisoners of the threat of AIDS. In Sweden, prison staff are encouraged to consider the personal lives of the inmates. In one
178
large detention unit where more than one-third of the prisoners are injecting drug users, there is considerable peer pressure for HIV testing and a strong programme of counselling and support. In this unit a major research project is looking at the effects of the prison policy on the spread of HIV infection. Denmark, Norway and Sweden permit regular conjugal visits in prison, which are thought to reduce the level of homosexual activity and hence the attendant risk of HIV transmission. In the Netherlands and Sweden, continuity of care for those leaving prisons is arranged with the appropriate social and health services. Guidelines for the prevention and control of AIDS in prisons have been developed by the WHO Global Programme on AIDS, and are available from WHO free of charge. Prostitutes
Female prostitutes who are injecting drug users present a serious potential for the spread of HIV infection. They are themselves doubly at risk because of their injecting habit and their multiple sexual encounters. Several countries have initiated special programmes for prostitutes, who are approached in non-threatening ways with information, advice and counselling. In the United Kingdom, outreach workers have been trained to work with prostitutes, them on the streets. often approaching Outreach workers have also been involved in street-work contact with prostitutes in Luxembourg as part of the ‘AIDS-Berbding’ programme initiated in 1988 by the Red Cross. In the Netherlands, open-door centres have been opened in those city areas with many drugusing prostitutes. A mobile centre was opened in Utrecht in 1986 creating a friendly environment for prostitutes to come in, have a cup of tea, a shower, and consult a doctor if they wish. They are provided with condoms, and are given safesex advice and counselling as opportunity permits. Interestingly, clients of prostitutes use the facility, and they are provided with condoms as well as AIDS-related information. In Norway, there is a pilot project in which
two active prostitutes have undertaken to provide appropriate information to other prostitutes, especially those who are drug users. A pilot project is also in progress to determine the sexual behavioural patterns of male prostitutes. The different municipal outreach agencies are also doing HIV-prevention work among people who sell sex. In Yugoslavia, prostitutes (many of them addicts) receive information but little is known as to how far they comply with advice. In Czechoslovakia, prostitutes who are registered at sexually transmitted disease clinics are compulsorily tested for HIV. If they are seropositive they are told about measures to avoid the further spread of infection. Testing is also compulsory for prostitutes in Austria and Greece. In Austria prostitutes are prohibited from working if found to be HIV seropositive. Little work appears to have been done in the area of male homosexual prostitution, and the degree of drug abuse in the people involved is not known. However, the widespread involvement of young ‘rent-boys’ in some major cities and their potential for HIV infection is causing serious concern. Substitution services
programmes
in drug treatment
Many treatment modules are used in drug abuse programmes throughout Europe. One approach to diminishing the risk of transmitting HIV infection is the substitution of prescribed drugs for illicit injected drugs. Methadone substitution and maintenance for the treatment of heroin addicts has been used in many countries for about 25 years; the options for the use of methadone are reviewed, based on international experience, in a recent WHO position paper 121. Information on methadone programmes is available from the following European countries. Austria
Since 1987 a pharmacological substitution treatment programme (mostly using metha-
done) has been implemented. By September 1989, 891 people were in the programme, which is under evaluation. Conditions for entering the programme include being aged over 18, previous unsuccessful drug-free treatment and/or HIV seropositivity. Although methadone is available, the number of drug users seeking drug-free treatment increased in 1988 compared to previous years. Czechoslovakia No substitution
programmes
are available.
Denmark
Recent initiatives have made participation in methadone maintenance treatment programmes easier. From 1982 to 1989 the number of people in the Copenhagen programme increased from 269 to 1131 and similar increases have been noted in other parts of the country. There are no entry conditions to a programme for HIVseropositive people who would benefit from participation. France
Two Paris hospitals are running pilot programmes of methadone substitution for small numbers of drug users. The treatment is not aimed at maintenance but at drug discontinuance. The programmes are being evaluated and will probably not be extended. Any further proposals for methadone projects will be within a formal framework with a precise protocol and follow-up. Germany
The older countrywide policy of prohibiting substitution therapy is being challenged and in a number of Lander experimental substitution programmes have been initiated over the past year. Ireland
A recent pilot programme of methadone maintenance has been evaluated in the National Drug Treatment Centre in Dublin. Just over twothirds of addicts who entered treatment in a 6-month period have benefited from the pro-
gramme. A relatively large number of pregnant opiate users attend the Centre for treatment. Netherlands
In all major cities in the Netherlands lowthreshold methadone drug programmes are available. Contact is made with a large proportion of heroin users through the easy access to programmes. One example is the Amsterdam ‘methadone bus’ project in which two buses travel routes through known drug scenes. The few conditions for participation are introduction to the central methadone register, regular contact with a doctor and no take-home doses. Methadone is used not only to stabilize, but also to detoxify and treat heroin users. Approximately 1500 heroin users make use of the bus facility each year, and the opportunity occurs to give information about AIDS, exchange needles, provide condoms and arrange assistance with social problems. Norway
Methadone is offered as part of the medical treatment to HIV infected drug users, but there is no formal methadone substitution programme. Portugal
Methadone is used on a small scale as treatment in drug abuse programmes. The effect on HIV prevalence among participants in the programme is being studied. Sweden The majority of drug users in Sweden use amphetamines. However in the Stockholm area and in the southern part of the country about onequarter of the injecting drug users are using heroin. The oldest methadone programme in Europe was implemented in Uppsala. It has now also departments in Stockholm and Lund. Approximately 300 persons are involved. Currently 95% of patients in the Stockholm methadone programme are HIV seropositive. Switzerland
The regulations of previously existing methadone substitution therapy programmes have been revised to make it available to an increasing number of drug users.
180
United Kingdom Substitution has long been available in the United Kingdom, but the emphasis is now shifting to the increased use of longer-term methadone prescription. This apparently encourages drug users to take treatment and maintain contact and compliance. Yugoslavia Drug users attending the Institute for Drug Abuse in Belgrade and fulfilling certain basic criteria of opium dependence are entered into a strictly controlled methadone programme with treatment based on a careful assessment of each individual. This is being evaluated. The existence of methadone maintenance programmes appears to attract drug users into therapy. Uchtenhagen 131 has concluded that a reduction of HIV seroconversion rates has been observed whenever behavioural changes have taken place during methadone substitution therapy. Training Programmes
for Drug Workers
The need for personnel in drug treatment centres and other health workers who work with drug users to be trained in relation to HIV infection needs no justification other than the projection that there will be a minimum of 23 000 cases of AIDS among drug users in Europe by the end of 1991. In Norway, different groups of personnel have received training about HIV infection and AIDS. In the first phase the emphasis was on giving factual information, but in the last 3 years it has been on methods for changing sexual behaviour. Another training programme directed at the leaders of drug abuse treatment agencies deals with such issues as burn-out, the provision of support, training of staff and recent developments in the HIV pandemic. In Spain, efforts have been made to ensure that general practitioners are aware of drug-related programmes in the country, since many drug users go to them for medical reasons before seeking treatment for their dependency. There is a special programme to contact all physicians in the country on this issue.
In France, a high priority is given to training and programmes are of health workers, developed locally and nationally. The first national programme was started in 1987 and aimed to train motivated health professionals for each of France’s 22 health areas. After receiving the training they commit themselves to becoming regional training leaders. The second national training programme was developed in 1988 for participants working exclusively in drug addiction. They are given information about AIDS and coping with the particular problems of HIVinfected drug users. In the United Kingdom, training courses for drug workers in relation to AIDS are open to both statutory and nonstatutory personnel. Service training needs are coordinated in England by AIDS prevention coordinators in the 200 district health authorities. In Austria, specialized information is given to drug treatment personnel, and in Portugal trainers themselves are now being trained to give this information. Other European countries have similar training courses which are often a priority. In some countries courses, meetings and seminars are available for personnel who work in outreach agencies and prisons. A WHO report on training on AIDS for drug workers [4] discusses the development of training guidelines in this area. Acknowledgement We thank the collaborators in the countries who furnished information for incorporation in this review, and hope that in the light of the expected worsening position as regards HIV infection in drug users in Europe this report will stimulate the further development of programmes for prevention and care and the expansion of training programmes for drug workers. Another review will be attempted shortly. References 1
AIDS among drug abusers in Europe: report on Symposium. Copenhagen, WHO Regional Office for Europe, 1991 (unpublished
document
EURlICPlGPA
049).
1x1
2
Options for the use of methadone in the treatment of drug dependence. Geneva, World Health Organization, 1989 (unpublished document WHOIMNH/DAT/89.2).
3
A. Uchtenhagen. Drug abuse policies against the background of the AIDS epidemic. Copenhagen, WHO
Regional Office for Europe, EUR/ICP/GPA 04917). 4
1991 (unpublished
document
Training on AIDS for personnel in drug treatment tres: report on a WHO Meeting. Copenhagen, Regional Office for Europe, 1988.
crnWHO
