This article was downloaded by: [Johns Hopkins University] On: 09 January 2015, At: 03:34 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
AIDS Care: Psychological and Sociomedical Aspects of AIDS/HIV Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/caic20
Behavioural change in injecting drug users: Evaluation of an HIV/AIDS education programme a
a
a
a
G. S. Martin , G. Serpelloni , U. Galvan , A. Rizzetto , M. a
a
Gomma , S. Morgante & G. Rezza a
b
HIV Screening Section , USL-25, Verona
b
AIDS Unit , Institute Superiore di Sanità , Viale Regina Elena, 299-00161, Roma, Italy Published online: 25 Sep 2007.
To cite this article: G. S. Martin , G. Serpelloni , U. Galvan , A. Rizzetto , M. Gomma , S. Morgante & G. Rezza (1990) Behavioural change in injecting drug users: Evaluation of an HIV/AIDS education programme, AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV, 2:3, 275-279, DOI: 10.1080/09540129008257740 To link to this article: http://dx.doi.org/10.1080/09540129008257740
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &
Downloaded by [Johns Hopkins University] at 03:34 09 January 2015
Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
AIDS CARE, VOL. 2, NO. 3,1990
275
Downloaded by [Johns Hopkins University] at 03:34 09 January 2015
Behavioural change in injecting drug users: evaluation of an HIVIAIDS education programme G. S. MARTIN,G. SERPELLONI, U. GALVAN, A. RIZZETTO, M. GOMMA, S. MORGANTE, G. REZZA* HIV Screening Section, USL-25 Verona and *AIDS Unit, Instituto Supm'ore di Sanitb, Viale Regina E l m 299-00161 Romq Ifaly
Abstract The results obtained fiom the training and follow-up of 189 IDUs who participated in a programme consisting of an audiovisual presentation, pre-/post-testing and individual counselling are presented. Syringe sharing decreased fiom 35% at initial contact to 12% after 6 months. Sexual behatiour proved more resistant to change. However, condom use in at-risk situations increased from 49% w 70%. IDUs under continuous methadone treatment were less likely to engage high risk drug injecting practices than the other IDUs. Results indicate that an educational programme addressed toward risk reduction may determine relevant behavioural change among IDUs. Introduction
Injecting drug users (IDUs) represent the most important risk group for AIDSIHIV infection in Italy. IDUs account for almost 70% of the total number of AIDS cases reported in Italy. A series of different prevention strategies has been implemented in different countries, and more pragmatic approaches l k e needle syringe schemes have been adopted on a large scale in the UK, Netherlands, Switzerland and Australia (Stimson et al., 1988; Buning et al., 1986; Hausser [personal communication]; Wok et al., 1988). Such programmes have not been utilised in Italy so far. However, the sale of needles and syringes in the pharmacies is free (i.e. no need for medical prescription). The general availability of syringes represents the rationale for the implementation of education programmes based on creating a positive attitude toward behavioural change and adoption of low risk practices. Methods and sample
The study was carried out in Verona, an Italian city close to main transport thoroughfares
Address for correspondence: G. Rezza, AIDS Unit,Istituto Superiore di Smith, Vide Repna Elena 299-00161 Roma, Italy.
Downloaded by [Johns Hopkins University] at 03:34 09 January 2015
276
G.
s.MARTIN ET AL.
and in proximity to border areas. Verona has developed into a narcotics distribution hub for northern Italy and Europe. Easy access to narcotics has no doubt played a part in creating the disproportionately large IDUsing population of 4.25/1,000. Higher rates have been estimated only in Rome and Milan. One hundred and eighty nine IV drug abusers attended a programme consisting of an audiovisual presentation, pre/post testing and individual counselling. Behavioural change was assessed by individual interview using a standardised questionnaire. Differences in the frequency of at-risk behaviours were assessed by chi-square test and chi square for trend. ‘At risk sex’ was defined as sexual intercourse either with other IDUs or with known seropositive partners without use of condom. A series of narrated slides were developed that highlighted important prevention concepts and sought to communicate a positive attitude toward the adoption of risk reduction techniques. The content of the audiovisual, which lasts 25 minutes, dealt with principal AIDS transmission modalities and prevention strategies. The language and images were pre-tested on several groups of IDUs, and appropriate modifications were made. The tone of the production was not one in which the target population was exhorted to change behaviour but rather encouraged to carefully evaluate the risks. In addition to the slides a prelpost test was developed that sought to evaluate three different parameters: informational level, attitude and at-risk behaviours. Two to four weeks after viewing the audiovisual presentation, a psychiatrist recalled all seropositives and those seronegatives still in contact with the centre who reported to have engaged in at-risk behaviour at pre-testing. After 3 and 6 months the participants were recalled and asked to complete the original questionnaire. Beginning in November of 1987, the drug dependency unit in Verona initiated the intervention described above. The following is a report of the more significant results obtained for the 189 patients enrolled in treatment for some period between November 1987 and February 1988 and followed through August 1988. This initial group consisted of 134 males (71%) and 5 5 females (29%). Average age was 27.7 years (SD 5.2 years) for males and 25.9 years (SD 5.5 years) for females. 42 subjects, 26 males and 16 females, comprising 22.8% of the total were seropositive. 147 subjects, 108 males and 39 females, comprising 77.2% of the total were seronegative.
Results Of the 189 subjects who participated in the initial audiovisual training and pre-/post-testing, we were able to retest 81 after three months (drop-out=57.2%) and 73 subjects after 6 months (drop-out = 61.4%). The main results are reported in Table 1. As regards at-risk drug using behviour, at pre-testing, 35% (66/189 subjects) reported having shared needles in the previous 3 months; there was no difference between seronegatives and seropositives as 34.7% (15142) of the seropositives and 34.7% (511147) of the seronegatives reported sharing needles. After 6 months, overall frequency of syringe sharing was observed to decrease to 12.3% (9/73), but the average number of occasions per subject remained at 5.5 during the previous 3-month period. Seropositives reported reducing their syringe-sharing habits more than seronegatives, but the difference was not significant. We defined ‘continuous’ treatment as that which had not been interrupted during the 3 months prior to pre-testing, even if the patient was absent from treatment for 1 or 2 days. Thirty-eight subjects in continuous treatment (at least 3 months) were compared with 151 IDUs in discontinuous methadone treatment. IDUs in continuous methanodone treatment were less likely to share needles than those who were not in continuous treatment
BEHAWOLJRN. CHANGE IN IDUS
277
Table 1. Reported necde sharing habus among rwoposirive and swonegaiive IDUs or inirial conract and or 3 and 6 monrh connols
N
Shared needles
Number of occasions
Report a t risk sex
Av. N . at risk encounters per subject
42 147 189
35.7% 34.7% 34.9%
2.5 6.4
5.5
62.0% 32.0% 38.6%
25.2 22.8 23.7
54.3 43.0 48.7
22 59 81
9% 22% 18.5%
2.5 9.5 8.2
34.5% 27.1 % 34.6%
21.0 18.0 19.3
72.0 37.0 54.6
21
9.5% 13.5% 12.3%
2.5 6.4 5.5
52.0% 25.0% 32.9%
16.3 21.2 18.9
77.3 63.0 70.2
HIV test
he-text connol POS NEG
Downloaded by [Johns Hopkins University] at 03:34 09 January 2015
TOT 3-monrh connol POS NEG
TOT 6-monrh connol POS NEG
TOT
52 73
Av. % condom use
per at risk encounter
( 1 8% versus 3946, p t 0 . 0 3 ) . Not only did significantly fewer persons share needles while in continuous methadone treatment, but those who did share needles while in continuous treatment did so on an average of 1.7 occasions per patient during the previous 3 months, as compared to 6 occasions per patient for those not in continuous treatment. At pre-testing, 38.6% (73/189) reported engaging in at-risk sex during the previous 3 months compared to 34.6% (28/81) at the 3-month control and 32.9% (24173) at the 6-month control. While the percentage of patients engaging in at-risk sexual activity diminished only slightly over the 6months, a decrease in the average number of at-risk occasions per patient can be seen among the seropositives as well as an increase in the use of the condom in at-risk situations.
Discussion Behavioural change may occur in IDUs either as a consequence of AIDS fear or general information programmes (usually short-term change) or more specific and pragmatic approaches (more long-term change)-(Becker & Joseph, 1988). In a previous behavioural study conducted in several Italian drug dependency units, 774 out of 1,285 IDUs admitted to have modified drug injecting behaviour (60.2%), and 359 out of 766 (46.9%) sexual behaviour. However, only 31% IDUs referred to have not shared needles in the last 2 years; 49.9% IDUs affirmed to have never used condoms during the same time period (Sasse, 1989). The assessment of a general information campaign conducted in Padua on a small sample of IDUs showed that needle sharing was reduced from 64% to 20% and condom use increased from 6% to 22% (Bertolotti et al., 1988). We did not use a control group in order to evaluate the prevention approach for ethical reasons. In fact, we considered it mandatory to give detailed information to all IDUs attending our methadone programme. However, our findings confirm that IDUs may modify their behaviour, and suggest that behavioural change is more dramatic as a consequence of educational programmes addressed toward risk reduction. IDUs attending our educational programme reported to have modified both drug injecting and sexual behaviour over the follow-up period. At the 6-month control, 88% of IDUs interviewed reported not to have
Downloaded by [Johns Hopkins University] at 03:34 09 January 2015
278
G. S. h4ARTIN ETAL.
shared needles anymore during the previous 3 months. Condom use increased from 49 to 7096, but only a small minority referred to have modified other sexual behaviour. From our findings, seropositive IDUs seem more likely to change behaviour than seronegative IDUs. Similar findings came from other behavioural studies conducted on IDUs in Italy and on homosexual males in the United States (Sasse et al., 1988; Cates & Handsfield, 1988). However, those findings differ from those coming from the evaluation of the Amsterdam needle exchange schemes in which the extent of behavioural change did not depend on learning one’s infection status (Van den Hock et al., 1989). The relatively high drop-out rate seems to represent a major problem for the education programmes as well as for other prevention strategies (i.e. needle exchange schemes)(Stimson, et al., 1988). The high drop-out rate experienced by our programme in the first 3 months of follow-up reflect the usual turn-over of the subjects undergoing methadone treatment in our drug dependency unit. However, it must counsel caution in the interpretation of the results. Soft data apart, the prevalence of HIV infection in Verona (about 31% in 1,750 IDUs tested) was slightly lower than in Rome and Milan (respectively 35% and over 50%). Furthermore, cohort studies conducted on IDUs attending drug dependency units in these cities over the last three years showed seroconversion rates of 5% in Rome (unpublished data) and 7% in Milan (Nicolosi & Lazzarin, 1989). In Verona, the seroconversion rate observed in the same period was much lower (unpublished data). Even if the reliabdity of these data may be questionable, they seem to represent an indirect confirmation of the impact of the educational programmes implemented in Verona since 1985 which were first addressed towards viral hepatitis B control. Our findmgs seem to support the hypothesis that a patient in long-term treatment with methadone injects less because he/she is less exposed to the situation in which needles might be shared, confirming the role played by methadone programmes in reducing the risk of HIV infection (Ball et d.,1988). One could also imagine that a patient in methadone treatment who does inject does so with much less urgency and, therefore, might be able to plan and provide for the procurement of a clean syringe. At the same time we should note that those who are in continuous treatment with methadone are those who are most exposed to the AIDS prevention message even before audiovisual training. In conclusion, behavioural change may occur in IDUs, but it is more dramatic as a consequence of specific educational programmes. These kind of programmes may be particularly useful in countries in which there are no legal restrictions for syringe availability. Continuous methadone programmes, being able to keep in touch with IDUs, seems to be useful in influencing behavioural change if it is complemented by counselling. However, because of the lmited sexual behavioural change referred by IDUs attending information and education programmes, more emphasis should be given to heterosexual transmission.
Achowldgcments The Authors thank Ms P. Mamxci for secretarial support.
References BALL, J.C., W G E W.R., , MYERS,C.P.& FRIEDMAN, S.R.(1988) Reducing the risk of AIDS through methadone maintenance treatment, Joumal of Health and Social Behavior, 29, pp. 214-226.
Downloaded by [Johns Hopkins University] at 03:34 09 January 2015
BEHAVIOURAL CHANGE IN IDUS
279
BECKER,M.H. & JOSEPH,J.G. (1988) AIDS and behavioral change to reduce risk: a review, American Journal 01 Public Health, 78, pp. 394-410. B E R T O L O ~F.,, S’IIV-LO, A., DU’ARMI, A., RINALDI,R. & LA GRASTA,F. (1988) AIDS information campaign has significantly reduced risk factors for HIV infection in Italian drug abusers, Journal o/ Acquired Immune Deficiency Syndrome, 1, pp. 4 12-4 13. BUNING,E.C., Counmo, R.A., VAN BRUSEL, G.H.A., VAN SANTEN,G.W. & VAN ZADELHOFF,A.W. (1986) Preventing AIDS in drug addicts in Amsterdam, Lancer, i, pp. 1435. CAW, W. & HANDSPIELD,H. (1988) HIV counseling and testing: does it work? Amm’can Journal offibrblic Healrh, 78, pp. 1533-1534. HAUSER, D. [Personal Communication]. NICOLOSI, A. & LAZA”,A. (1989) HIV seroconversion rates in intravenous drug users from Northern Italy, Lancet, ii, p. 269. SASE, H., SALMA~O,S., Corn, S. & Ruu, G. (1988) Significance of HIV antibody testing as a preventive measure in intravenous drug users, AIDS, 2, pp. 403-404. SASE, H., SALMASO, S., CONTI,S. (1989) Risk behaviours for HIV-1 infection in Italian drug users: report from a multicenter study, Journal of Acquired Immune Deficiency Syndrome, 2, pp. 486-496. STIMSON,G.V., ALLDRIT~, L., DOLAN,K. & DONOGHOE, M. (1988) Syringe exchange schemes for drug users in England and Scotland, Bnnjh Medical Journal, 296, pp. 1717-1719. VAN DENHOEK,J.A.R., VAN HMSTRECHT,H.J.A. & COUTINHO,R.A. (1989) Risk reduction among intravenous drug users in Amsterdam under the influence of AIDS, Amm’can Journal of Public Health, 79, pp. 1355-1357. WOLK, J., WODAK,A., MOW, A., GUINAN,J.J., WILSON, E., GOLD,J. & COOPER,D.A. (1988) Syringe HIV seroprevalence and behavioural and demographic characteristics of intravenous drug users in Sydney, Australia, 1987, AIDS, 2, pp. 373-377.
AIDS Care: Psychological and Sociomedical Aspects of AIDS/HIV Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/caic20
Behavioural change in injecting drug users: Evaluation of an HIV/AIDS education programme a
a
a
a
G. S. Martin , G. Serpelloni , U. Galvan , A. Rizzetto , M. a
a
Gomma , S. Morgante & G. Rezza a
b
HIV Screening Section , USL-25, Verona
b
AIDS Unit , Institute Superiore di Sanità , Viale Regina Elena, 299-00161, Roma, Italy Published online: 25 Sep 2007.
To cite this article: G. S. Martin , G. Serpelloni , U. Galvan , A. Rizzetto , M. Gomma , S. Morgante & G. Rezza (1990) Behavioural change in injecting drug users: Evaluation of an HIV/AIDS education programme, AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV, 2:3, 275-279, DOI: 10.1080/09540129008257740 To link to this article: http://dx.doi.org/10.1080/09540129008257740
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &
Downloaded by [Johns Hopkins University] at 03:34 09 January 2015
Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
AIDS CARE, VOL. 2, NO. 3,1990
275
Downloaded by [Johns Hopkins University] at 03:34 09 January 2015
Behavioural change in injecting drug users: evaluation of an HIVIAIDS education programme G. S. MARTIN,G. SERPELLONI, U. GALVAN, A. RIZZETTO, M. GOMMA, S. MORGANTE, G. REZZA* HIV Screening Section, USL-25 Verona and *AIDS Unit, Instituto Supm'ore di Sanitb, Viale Regina E l m 299-00161 Romq Ifaly
Abstract The results obtained fiom the training and follow-up of 189 IDUs who participated in a programme consisting of an audiovisual presentation, pre-/post-testing and individual counselling are presented. Syringe sharing decreased fiom 35% at initial contact to 12% after 6 months. Sexual behatiour proved more resistant to change. However, condom use in at-risk situations increased from 49% w 70%. IDUs under continuous methadone treatment were less likely to engage high risk drug injecting practices than the other IDUs. Results indicate that an educational programme addressed toward risk reduction may determine relevant behavioural change among IDUs. Introduction
Injecting drug users (IDUs) represent the most important risk group for AIDSIHIV infection in Italy. IDUs account for almost 70% of the total number of AIDS cases reported in Italy. A series of different prevention strategies has been implemented in different countries, and more pragmatic approaches l k e needle syringe schemes have been adopted on a large scale in the UK, Netherlands, Switzerland and Australia (Stimson et al., 1988; Buning et al., 1986; Hausser [personal communication]; Wok et al., 1988). Such programmes have not been utilised in Italy so far. However, the sale of needles and syringes in the pharmacies is free (i.e. no need for medical prescription). The general availability of syringes represents the rationale for the implementation of education programmes based on creating a positive attitude toward behavioural change and adoption of low risk practices. Methods and sample
The study was carried out in Verona, an Italian city close to main transport thoroughfares
Address for correspondence: G. Rezza, AIDS Unit,Istituto Superiore di Smith, Vide Repna Elena 299-00161 Roma, Italy.
Downloaded by [Johns Hopkins University] at 03:34 09 January 2015
276
G.
s.MARTIN ET AL.
and in proximity to border areas. Verona has developed into a narcotics distribution hub for northern Italy and Europe. Easy access to narcotics has no doubt played a part in creating the disproportionately large IDUsing population of 4.25/1,000. Higher rates have been estimated only in Rome and Milan. One hundred and eighty nine IV drug abusers attended a programme consisting of an audiovisual presentation, pre/post testing and individual counselling. Behavioural change was assessed by individual interview using a standardised questionnaire. Differences in the frequency of at-risk behaviours were assessed by chi-square test and chi square for trend. ‘At risk sex’ was defined as sexual intercourse either with other IDUs or with known seropositive partners without use of condom. A series of narrated slides were developed that highlighted important prevention concepts and sought to communicate a positive attitude toward the adoption of risk reduction techniques. The content of the audiovisual, which lasts 25 minutes, dealt with principal AIDS transmission modalities and prevention strategies. The language and images were pre-tested on several groups of IDUs, and appropriate modifications were made. The tone of the production was not one in which the target population was exhorted to change behaviour but rather encouraged to carefully evaluate the risks. In addition to the slides a prelpost test was developed that sought to evaluate three different parameters: informational level, attitude and at-risk behaviours. Two to four weeks after viewing the audiovisual presentation, a psychiatrist recalled all seropositives and those seronegatives still in contact with the centre who reported to have engaged in at-risk behaviour at pre-testing. After 3 and 6 months the participants were recalled and asked to complete the original questionnaire. Beginning in November of 1987, the drug dependency unit in Verona initiated the intervention described above. The following is a report of the more significant results obtained for the 189 patients enrolled in treatment for some period between November 1987 and February 1988 and followed through August 1988. This initial group consisted of 134 males (71%) and 5 5 females (29%). Average age was 27.7 years (SD 5.2 years) for males and 25.9 years (SD 5.5 years) for females. 42 subjects, 26 males and 16 females, comprising 22.8% of the total were seropositive. 147 subjects, 108 males and 39 females, comprising 77.2% of the total were seronegative.
Results Of the 189 subjects who participated in the initial audiovisual training and pre-/post-testing, we were able to retest 81 after three months (drop-out=57.2%) and 73 subjects after 6 months (drop-out = 61.4%). The main results are reported in Table 1. As regards at-risk drug using behviour, at pre-testing, 35% (66/189 subjects) reported having shared needles in the previous 3 months; there was no difference between seronegatives and seropositives as 34.7% (15142) of the seropositives and 34.7% (511147) of the seronegatives reported sharing needles. After 6 months, overall frequency of syringe sharing was observed to decrease to 12.3% (9/73), but the average number of occasions per subject remained at 5.5 during the previous 3-month period. Seropositives reported reducing their syringe-sharing habits more than seronegatives, but the difference was not significant. We defined ‘continuous’ treatment as that which had not been interrupted during the 3 months prior to pre-testing, even if the patient was absent from treatment for 1 or 2 days. Thirty-eight subjects in continuous treatment (at least 3 months) were compared with 151 IDUs in discontinuous methadone treatment. IDUs in continuous methanodone treatment were less likely to share needles than those who were not in continuous treatment
BEHAWOLJRN. CHANGE IN IDUS
277
Table 1. Reported necde sharing habus among rwoposirive and swonegaiive IDUs or inirial conract and or 3 and 6 monrh connols
N
Shared needles
Number of occasions
Report a t risk sex
Av. N . at risk encounters per subject
42 147 189
35.7% 34.7% 34.9%
2.5 6.4
5.5
62.0% 32.0% 38.6%
25.2 22.8 23.7
54.3 43.0 48.7
22 59 81
9% 22% 18.5%
2.5 9.5 8.2
34.5% 27.1 % 34.6%
21.0 18.0 19.3
72.0 37.0 54.6
21
9.5% 13.5% 12.3%
2.5 6.4 5.5
52.0% 25.0% 32.9%
16.3 21.2 18.9
77.3 63.0 70.2
HIV test
he-text connol POS NEG
Downloaded by [Johns Hopkins University] at 03:34 09 January 2015
TOT 3-monrh connol POS NEG
TOT 6-monrh connol POS NEG
TOT
52 73
Av. % condom use
per at risk encounter
( 1 8% versus 3946, p t 0 . 0 3 ) . Not only did significantly fewer persons share needles while in continuous methadone treatment, but those who did share needles while in continuous treatment did so on an average of 1.7 occasions per patient during the previous 3 months, as compared to 6 occasions per patient for those not in continuous treatment. At pre-testing, 38.6% (73/189) reported engaging in at-risk sex during the previous 3 months compared to 34.6% (28/81) at the 3-month control and 32.9% (24173) at the 6-month control. While the percentage of patients engaging in at-risk sexual activity diminished only slightly over the 6months, a decrease in the average number of at-risk occasions per patient can be seen among the seropositives as well as an increase in the use of the condom in at-risk situations.
Discussion Behavioural change may occur in IDUs either as a consequence of AIDS fear or general information programmes (usually short-term change) or more specific and pragmatic approaches (more long-term change)-(Becker & Joseph, 1988). In a previous behavioural study conducted in several Italian drug dependency units, 774 out of 1,285 IDUs admitted to have modified drug injecting behaviour (60.2%), and 359 out of 766 (46.9%) sexual behaviour. However, only 31% IDUs referred to have not shared needles in the last 2 years; 49.9% IDUs affirmed to have never used condoms during the same time period (Sasse, 1989). The assessment of a general information campaign conducted in Padua on a small sample of IDUs showed that needle sharing was reduced from 64% to 20% and condom use increased from 6% to 22% (Bertolotti et al., 1988). We did not use a control group in order to evaluate the prevention approach for ethical reasons. In fact, we considered it mandatory to give detailed information to all IDUs attending our methadone programme. However, our findings confirm that IDUs may modify their behaviour, and suggest that behavioural change is more dramatic as a consequence of educational programmes addressed toward risk reduction. IDUs attending our educational programme reported to have modified both drug injecting and sexual behaviour over the follow-up period. At the 6-month control, 88% of IDUs interviewed reported not to have
Downloaded by [Johns Hopkins University] at 03:34 09 January 2015
278
G. S. h4ARTIN ETAL.
shared needles anymore during the previous 3 months. Condom use increased from 49 to 7096, but only a small minority referred to have modified other sexual behaviour. From our findings, seropositive IDUs seem more likely to change behaviour than seronegative IDUs. Similar findings came from other behavioural studies conducted on IDUs in Italy and on homosexual males in the United States (Sasse et al., 1988; Cates & Handsfield, 1988). However, those findings differ from those coming from the evaluation of the Amsterdam needle exchange schemes in which the extent of behavioural change did not depend on learning one’s infection status (Van den Hock et al., 1989). The relatively high drop-out rate seems to represent a major problem for the education programmes as well as for other prevention strategies (i.e. needle exchange schemes)(Stimson, et al., 1988). The high drop-out rate experienced by our programme in the first 3 months of follow-up reflect the usual turn-over of the subjects undergoing methadone treatment in our drug dependency unit. However, it must counsel caution in the interpretation of the results. Soft data apart, the prevalence of HIV infection in Verona (about 31% in 1,750 IDUs tested) was slightly lower than in Rome and Milan (respectively 35% and over 50%). Furthermore, cohort studies conducted on IDUs attending drug dependency units in these cities over the last three years showed seroconversion rates of 5% in Rome (unpublished data) and 7% in Milan (Nicolosi & Lazzarin, 1989). In Verona, the seroconversion rate observed in the same period was much lower (unpublished data). Even if the reliabdity of these data may be questionable, they seem to represent an indirect confirmation of the impact of the educational programmes implemented in Verona since 1985 which were first addressed towards viral hepatitis B control. Our findmgs seem to support the hypothesis that a patient in long-term treatment with methadone injects less because he/she is less exposed to the situation in which needles might be shared, confirming the role played by methadone programmes in reducing the risk of HIV infection (Ball et d.,1988). One could also imagine that a patient in methadone treatment who does inject does so with much less urgency and, therefore, might be able to plan and provide for the procurement of a clean syringe. At the same time we should note that those who are in continuous treatment with methadone are those who are most exposed to the AIDS prevention message even before audiovisual training. In conclusion, behavioural change may occur in IDUs, but it is more dramatic as a consequence of specific educational programmes. These kind of programmes may be particularly useful in countries in which there are no legal restrictions for syringe availability. Continuous methadone programmes, being able to keep in touch with IDUs, seems to be useful in influencing behavioural change if it is complemented by counselling. However, because of the lmited sexual behavioural change referred by IDUs attending information and education programmes, more emphasis should be given to heterosexual transmission.
Achowldgcments The Authors thank Ms P. Mamxci for secretarial support.
References BALL, J.C., W G E W.R., , MYERS,C.P.& FRIEDMAN, S.R.(1988) Reducing the risk of AIDS through methadone maintenance treatment, Joumal of Health and Social Behavior, 29, pp. 214-226.
Downloaded by [Johns Hopkins University] at 03:34 09 January 2015
BEHAVIOURAL CHANGE IN IDUS
279
BECKER,M.H. & JOSEPH,J.G. (1988) AIDS and behavioral change to reduce risk: a review, American Journal 01 Public Health, 78, pp. 394-410. B E R T O L O ~F.,, S’IIV-LO, A., DU’ARMI, A., RINALDI,R. & LA GRASTA,F. (1988) AIDS information campaign has significantly reduced risk factors for HIV infection in Italian drug abusers, Journal o/ Acquired Immune Deficiency Syndrome, 1, pp. 4 12-4 13. BUNING,E.C., Counmo, R.A., VAN BRUSEL, G.H.A., VAN SANTEN,G.W. & VAN ZADELHOFF,A.W. (1986) Preventing AIDS in drug addicts in Amsterdam, Lancer, i, pp. 1435. CAW, W. & HANDSPIELD,H. (1988) HIV counseling and testing: does it work? Amm’can Journal offibrblic Healrh, 78, pp. 1533-1534. HAUSER, D. [Personal Communication]. NICOLOSI, A. & LAZA”,A. (1989) HIV seroconversion rates in intravenous drug users from Northern Italy, Lancet, ii, p. 269. SASE, H., SALMA~O,S., Corn, S. & Ruu, G. (1988) Significance of HIV antibody testing as a preventive measure in intravenous drug users, AIDS, 2, pp. 403-404. SASE, H., SALMASO, S., CONTI,S. (1989) Risk behaviours for HIV-1 infection in Italian drug users: report from a multicenter study, Journal of Acquired Immune Deficiency Syndrome, 2, pp. 486-496. STIMSON,G.V., ALLDRIT~, L., DOLAN,K. & DONOGHOE, M. (1988) Syringe exchange schemes for drug users in England and Scotland, Bnnjh Medical Journal, 296, pp. 1717-1719. VAN DENHOEK,J.A.R., VAN HMSTRECHT,H.J.A. & COUTINHO,R.A. (1989) Risk reduction among intravenous drug users in Amsterdam under the influence of AIDS, Amm’can Journal of Public Health, 79, pp. 1355-1357. WOLK, J., WODAK,A., MOW, A., GUINAN,J.J., WILSON, E., GOLD,J. & COOPER,D.A. (1988) Syringe HIV seroprevalence and behavioural and demographic characteristics of intravenous drug users in Sydney, Australia, 1987, AIDS, 2, pp. 373-377.
