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AIDS Care: Psychological and Sociomedical Aspects of AIDS/HIV Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/caic20
Drug user interventions C. Hartgers
a
a
Municipal Health Service, Department of Public Health and Environment , P.O. Box 20244, 1000 HE, Amsterdam, The Netherlands Published online: 25 Sep 2007.
To cite this article: C. Hartgers (1990) Drug user interventions, AIDS Care: Psychological and Sociomedical Aspects of AIDS/HIV, 2:4, 399-402, DOI: 10.1080/09540129008257762 To link to this article: http://dx.doi.org/10.1080/09540129008257762
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 & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
NDS CARE, VOL. 2, NO.4,1990
399
Drug user interventions C . HARTGERS Downloaded by [University of Toronto Libraries] at 18:58 31 October 2014
Municipal Health Senice, Department of Public Health and Environment, P.O. Box 20244, 1000 HE Amsterdam, T%e Netherlands
The best known interventions among injecting drug users (IDUs) to date are needle exchange programmes, mainly in Europe, and programmes w advocate bleach use, mainly in the USA. Although studies in England ( D o h , FC108 and Hart, SC745) indicate that exchangers behave more safely than non-exchangers, still up to 25% of the exchangers recently borrowed an already-used needle. Hart therefore advocates additional interventions such as provision of bleach. In Amsterdam leaflets with information on cleaning with bleach have been distributed since last year, both among attenders and non-attenders of needle exchange programmes, because of risks s t i l l taken by both groups (Hartgers, SC558). In San Francisco in 1988 an-illegalneedle exchange programme was started, while the bleach campaign commenced in 1986. Watters (FC106) reported on the favourable results of this combined approach: the percentage reporting no needle sharing in the past year increased from 9% in 1986 to 35% in 1989, while the percentage who reported bleach use among those sharing increased from 3% in 1986 to 86% in 1989. In Australia (Lowe, SC746) problems were encountered because inadequate measures were taken to ensure return and safe disposal of used injection equipment (2 million in 1989). The introduction of portable needle-containers resulted in an increase in
return rate of used needles from 25% to 64%. However, no mention is made of keeping to a strict I-to-1 exchange rule, which should be the basic rationale of all needle exchange programmes, in order to minimize public health risks. The main purpose of several American studies seemed to be persuasion of politicians that needle exchange programmes are necessary and feasible. From a scientific point of view the studies did not provide much new data. For example, Trapido (ThC592) from Florida cultured HIV from needles collected at a shooting gallery and concluded that HIV is viable within used and shared IV drug equipment. Tross (SC731) concludes that elmhation of injection does not seem to be a realistic goal for HIV-prevention initiatives. Nelson (FC109) finds evidence that diabetic drug users have a lower risk of being HIV-infected, which he thinks is most likely due to their unrestricted access to injection equipment. Several other studies (Arshinoff, SC554; COnnors, SC730; Harris, SC744) present more arguments to install needle exchange programmes. Connors for example describes a user-developed risk-reduction strategy; users keep one ‘personal’ needle and one ‘lendmg’ needle. This reduces their own risk but not that of others. Since users prefer this strategy above bleach use this suggests that assuring access to sterile equipment through needle exchange programmes is necessary.
Downloaded by [University of Toronto Libraries] at 18:58 31 October 2014
400 SAN FRANCISCO SUMMARIES: C. HARTGERS
The European and San Francisco studies suggest that a combined approach (needle exchange programmes and bleach) probably has the best results. Another way to ascertain that IDU’s have access to sterile injection equipment Seems to be through phannucists. Several studies reported on this possibility (McKeganey, SC551; De Muynck, SC734 and Zulaica, SC738). HZV-testing and counselling for IDUs has increased substantially over the past years (Jones, SC659). Although it tends to decrease risky injection behaviour, it does not have the same effect on risky sexual behaviour (Kggins, ThD836). Since many methadone programmes are not especially successful in reaching their original goal of abstinence, goals have changed over the years. Opportunity for medical care (Brenle, SD128; Batki, ThD60), malung contact, methadone maintenance, stabilization of drug use, etc. With HIV a new purpose offered itself; methadone programmes might have a preventive effect! Serraino (SD 125) finds that the proportion of IDUs attending methadone programmes in different Italian regions is inversely related to the cumulative incidence of AIDS-cases among IDUs in these regions. Although he first admits that this findmg does not imply a cause-effect relationship he then concludes that his study confirms previous research demonstrating a beneficial impact of methadone programmes on the control of AIDS in IDUs. A more rigorous study was carried out in San Francisco by Williams (SC748). She found an association between seronegativity and having been more than 60 months in methadone maintenance treatment for white and Hispanic IDUs but not for black IDUs. In Amsterdam, Hartgers (FC638) did not find a lower seroprevalence among long term IDU clients at low threshold methadone programmes. She concluded that HIV-prevention efforts in these programmes, whch do not penalise continuing drug use, seem to have failed so far.
Two studies, Tortu (SC732) and Chitwood (SC763), compared different educational programmes (a standard one-session programme and a three-session programme) by assigtung non-treatment IDUs at random to one of the two risk reduction programmes. Chitwood did not mention in his abstract which programme showed the best results, but concludes that risk reduction is achieved among his sample of non-treatment IDUs. One of his results is not all that favourable; after attending the programme IDUs seem to increase their number of noninjecting sex partners: wise from their point of view but increasing the risk of HIV transmission to non-injectors. Tom found no difference between the two educational programmes and overall she concluded pessimistically that initial positive effects to both programmes may be defeated by lack of community support and by the effects of poverty and addiction. Calsyn (SD126), who included a waiting list condition, could not demonstrate the efficacy of two different one-session programmes among IDUs. Decreased injecting drug use was the only factor associated with a decrease in risk behaviour. According to Calsyn this suggests that drug abuse treatment wdl be superior to education as HIVprevention. This conclusion seems far fetched, as it is well known that many drug users have periods of high frequent and less frequent use. That less frequent use is associated with less risk behaviour does not warrant Calsyns conclusion. A number of studies point to the necessity of aiming interventions to specific groups of drug users, because of the high seroprevalence and/or higher level of risk behaviour in these groups. These specific groups are for example: black and hispanic drug users in the USA (Moss, FC553; Wiebel, SC556 and Goodloe, SC545) young IDUs and IDUs in prison (Stark, FC625) crack users (Abramowitz, FC763; Weissman, SD 124)
DRUG USER INTERVENTIONS 401
Downloaded by [University of Toronto Libraries] at 18:58 31 October 2014
- young
female IDUs because they are at highest risk for crack use in New York (Schoenbaum, ThC103). - parented cocaine users (Amsel, ThC590). - infrequent injectors (often cocaine injectors) (Todts, FC618 and Snyder, FC755). - homeless drug users (Todts, FC618, Klee, SC561) bisexual male IDUs (often self identifying as heterosexual) (Lewis, FC762).
-
Interventions should also aim at certain techniques or be carried out in a specific way. Grund (SC737) finds that Dutch IDUs unknowingly may infect themselves when in preparing their drug they use a technique called ‘frontloading’, which they do not seem to consider as needle sharing. Woody (SC550) found an association between psychological factors and risk behaviour and says that psychological factors should be taken into account in designing interventions. Marusich (SC729) reports on the success of graffiti murals to reach IDUs. Friedman (SC733) tried to stimulate self-organization in drug users, and compared this with an outreach project. Although AIDS-risk behaviour declined in both projects, the organizing-project seemed to have a little better result. However, Friedman told that the organizing project met with a lot of difficulties, among which indirect opposition from workers, and self-organization did not get from the ground. Most studies with regard to sexual risk behaviour (for example Van den Hoek, SD122; Sasse, SC557; Ehrhardt, ThD787; Lauren, SC560; Hwang, SC552, CarballoDieguez, SC547) reported relatively high levels of sexual activity, low levels of safe sex and/or little or no improvement over time, despite AIDS-preventive measures aimed at IDUs. Abu (SC546) and Catanzarite (ThD788) both reported that outreach work tended to increase condom use among IDUs,
especially among those with more than one partner. Related to this McKay (FC765) argues that especially monogamous IDUs should be a focus for safer sex education, since they use condoms less often than IDUs with multiple partners. Pappas (SC750) studied lifestyle patterns of female sexual partners of male IDUs, and made recommendations for interventions. Television and advertisements on public transportation may be useful to reach this group. Furthermore, according to Pappas, since these female partners value their family highly, interventions which refer to or involve family members may be worth trying. Weiner (SC751) presents favourable results of HIV-prevention education among female partners of IDUs; increase in knowledge, positive intentions and skills, etc. However, whether this will result in sizeable behaviour change remains an open question. Choi (FC761), Johnson (FC652) and Tacconi (FC632) for example are not optimistic about this. Sexual risk behaviour and crack use remains a big problem, especially among female drug users. Crack users do not seem to consider themselves especially at risk (Kowalewski, FC759), nor do others. Black male IDUs for example tend to think that heroin users are at greater risk of carrying HIV than crack users (Hasbrouck, SC728). Leeper (SC758) reported satisfactory results of the female condom, which should be commercially available soon. This seems to be an important new means of prevention, since as Ehrhardt (ThD787) pointed out, “it is erroneous to hold women responsible for partner condom use since their control over their male partners’ behaviour is limited”. T o conclude, it seems that researchers are now discovering that IDUs are not a unified group but exhibit endless variety, which makes a wide array of interventions necessary. Furthermore, the period of rapid behavioural changes and dramatic effects has passed. As is well known from other health campaigns, it is much more difficult to pre-
402
SAN FRANCISCO SUMMARIES C . HARTGERS
Downloaded by [University of Toronto Libraries] at 18:58 31 October 2014
vent relapse or to change the behaviour of image of the irrational, risk-loving and antithose IDUs who have not done so by now. social IDUs resurges as an excuse against Continuing effort, expertise and creativity tackling prevention. are necessary, the danger arises that the
AIDS Care: Psychological and Sociomedical Aspects of AIDS/HIV Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/caic20
Drug user interventions C. Hartgers
a
a
Municipal Health Service, Department of Public Health and Environment , P.O. Box 20244, 1000 HE, Amsterdam, The Netherlands Published online: 25 Sep 2007.
To cite this article: C. Hartgers (1990) Drug user interventions, AIDS Care: Psychological and Sociomedical Aspects of AIDS/HIV, 2:4, 399-402, DOI: 10.1080/09540129008257762 To link to this article: http://dx.doi.org/10.1080/09540129008257762
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 & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
NDS CARE, VOL. 2, NO.4,1990
399
Drug user interventions C . HARTGERS Downloaded by [University of Toronto Libraries] at 18:58 31 October 2014
Municipal Health Senice, Department of Public Health and Environment, P.O. Box 20244, 1000 HE Amsterdam, T%e Netherlands
The best known interventions among injecting drug users (IDUs) to date are needle exchange programmes, mainly in Europe, and programmes w advocate bleach use, mainly in the USA. Although studies in England ( D o h , FC108 and Hart, SC745) indicate that exchangers behave more safely than non-exchangers, still up to 25% of the exchangers recently borrowed an already-used needle. Hart therefore advocates additional interventions such as provision of bleach. In Amsterdam leaflets with information on cleaning with bleach have been distributed since last year, both among attenders and non-attenders of needle exchange programmes, because of risks s t i l l taken by both groups (Hartgers, SC558). In San Francisco in 1988 an-illegalneedle exchange programme was started, while the bleach campaign commenced in 1986. Watters (FC106) reported on the favourable results of this combined approach: the percentage reporting no needle sharing in the past year increased from 9% in 1986 to 35% in 1989, while the percentage who reported bleach use among those sharing increased from 3% in 1986 to 86% in 1989. In Australia (Lowe, SC746) problems were encountered because inadequate measures were taken to ensure return and safe disposal of used injection equipment (2 million in 1989). The introduction of portable needle-containers resulted in an increase in
return rate of used needles from 25% to 64%. However, no mention is made of keeping to a strict I-to-1 exchange rule, which should be the basic rationale of all needle exchange programmes, in order to minimize public health risks. The main purpose of several American studies seemed to be persuasion of politicians that needle exchange programmes are necessary and feasible. From a scientific point of view the studies did not provide much new data. For example, Trapido (ThC592) from Florida cultured HIV from needles collected at a shooting gallery and concluded that HIV is viable within used and shared IV drug equipment. Tross (SC731) concludes that elmhation of injection does not seem to be a realistic goal for HIV-prevention initiatives. Nelson (FC109) finds evidence that diabetic drug users have a lower risk of being HIV-infected, which he thinks is most likely due to their unrestricted access to injection equipment. Several other studies (Arshinoff, SC554; COnnors, SC730; Harris, SC744) present more arguments to install needle exchange programmes. Connors for example describes a user-developed risk-reduction strategy; users keep one ‘personal’ needle and one ‘lendmg’ needle. This reduces their own risk but not that of others. Since users prefer this strategy above bleach use this suggests that assuring access to sterile equipment through needle exchange programmes is necessary.
Downloaded by [University of Toronto Libraries] at 18:58 31 October 2014
400 SAN FRANCISCO SUMMARIES: C. HARTGERS
The European and San Francisco studies suggest that a combined approach (needle exchange programmes and bleach) probably has the best results. Another way to ascertain that IDU’s have access to sterile injection equipment Seems to be through phannucists. Several studies reported on this possibility (McKeganey, SC551; De Muynck, SC734 and Zulaica, SC738). HZV-testing and counselling for IDUs has increased substantially over the past years (Jones, SC659). Although it tends to decrease risky injection behaviour, it does not have the same effect on risky sexual behaviour (Kggins, ThD836). Since many methadone programmes are not especially successful in reaching their original goal of abstinence, goals have changed over the years. Opportunity for medical care (Brenle, SD128; Batki, ThD60), malung contact, methadone maintenance, stabilization of drug use, etc. With HIV a new purpose offered itself; methadone programmes might have a preventive effect! Serraino (SD 125) finds that the proportion of IDUs attending methadone programmes in different Italian regions is inversely related to the cumulative incidence of AIDS-cases among IDUs in these regions. Although he first admits that this findmg does not imply a cause-effect relationship he then concludes that his study confirms previous research demonstrating a beneficial impact of methadone programmes on the control of AIDS in IDUs. A more rigorous study was carried out in San Francisco by Williams (SC748). She found an association between seronegativity and having been more than 60 months in methadone maintenance treatment for white and Hispanic IDUs but not for black IDUs. In Amsterdam, Hartgers (FC638) did not find a lower seroprevalence among long term IDU clients at low threshold methadone programmes. She concluded that HIV-prevention efforts in these programmes, whch do not penalise continuing drug use, seem to have failed so far.
Two studies, Tortu (SC732) and Chitwood (SC763), compared different educational programmes (a standard one-session programme and a three-session programme) by assigtung non-treatment IDUs at random to one of the two risk reduction programmes. Chitwood did not mention in his abstract which programme showed the best results, but concludes that risk reduction is achieved among his sample of non-treatment IDUs. One of his results is not all that favourable; after attending the programme IDUs seem to increase their number of noninjecting sex partners: wise from their point of view but increasing the risk of HIV transmission to non-injectors. Tom found no difference between the two educational programmes and overall she concluded pessimistically that initial positive effects to both programmes may be defeated by lack of community support and by the effects of poverty and addiction. Calsyn (SD126), who included a waiting list condition, could not demonstrate the efficacy of two different one-session programmes among IDUs. Decreased injecting drug use was the only factor associated with a decrease in risk behaviour. According to Calsyn this suggests that drug abuse treatment wdl be superior to education as HIVprevention. This conclusion seems far fetched, as it is well known that many drug users have periods of high frequent and less frequent use. That less frequent use is associated with less risk behaviour does not warrant Calsyns conclusion. A number of studies point to the necessity of aiming interventions to specific groups of drug users, because of the high seroprevalence and/or higher level of risk behaviour in these groups. These specific groups are for example: black and hispanic drug users in the USA (Moss, FC553; Wiebel, SC556 and Goodloe, SC545) young IDUs and IDUs in prison (Stark, FC625) crack users (Abramowitz, FC763; Weissman, SD 124)
DRUG USER INTERVENTIONS 401
Downloaded by [University of Toronto Libraries] at 18:58 31 October 2014
- young
female IDUs because they are at highest risk for crack use in New York (Schoenbaum, ThC103). - parented cocaine users (Amsel, ThC590). - infrequent injectors (often cocaine injectors) (Todts, FC618 and Snyder, FC755). - homeless drug users (Todts, FC618, Klee, SC561) bisexual male IDUs (often self identifying as heterosexual) (Lewis, FC762).
-
Interventions should also aim at certain techniques or be carried out in a specific way. Grund (SC737) finds that Dutch IDUs unknowingly may infect themselves when in preparing their drug they use a technique called ‘frontloading’, which they do not seem to consider as needle sharing. Woody (SC550) found an association between psychological factors and risk behaviour and says that psychological factors should be taken into account in designing interventions. Marusich (SC729) reports on the success of graffiti murals to reach IDUs. Friedman (SC733) tried to stimulate self-organization in drug users, and compared this with an outreach project. Although AIDS-risk behaviour declined in both projects, the organizing-project seemed to have a little better result. However, Friedman told that the organizing project met with a lot of difficulties, among which indirect opposition from workers, and self-organization did not get from the ground. Most studies with regard to sexual risk behaviour (for example Van den Hoek, SD122; Sasse, SC557; Ehrhardt, ThD787; Lauren, SC560; Hwang, SC552, CarballoDieguez, SC547) reported relatively high levels of sexual activity, low levels of safe sex and/or little or no improvement over time, despite AIDS-preventive measures aimed at IDUs. Abu (SC546) and Catanzarite (ThD788) both reported that outreach work tended to increase condom use among IDUs,
especially among those with more than one partner. Related to this McKay (FC765) argues that especially monogamous IDUs should be a focus for safer sex education, since they use condoms less often than IDUs with multiple partners. Pappas (SC750) studied lifestyle patterns of female sexual partners of male IDUs, and made recommendations for interventions. Television and advertisements on public transportation may be useful to reach this group. Furthermore, according to Pappas, since these female partners value their family highly, interventions which refer to or involve family members may be worth trying. Weiner (SC751) presents favourable results of HIV-prevention education among female partners of IDUs; increase in knowledge, positive intentions and skills, etc. However, whether this will result in sizeable behaviour change remains an open question. Choi (FC761), Johnson (FC652) and Tacconi (FC632) for example are not optimistic about this. Sexual risk behaviour and crack use remains a big problem, especially among female drug users. Crack users do not seem to consider themselves especially at risk (Kowalewski, FC759), nor do others. Black male IDUs for example tend to think that heroin users are at greater risk of carrying HIV than crack users (Hasbrouck, SC728). Leeper (SC758) reported satisfactory results of the female condom, which should be commercially available soon. This seems to be an important new means of prevention, since as Ehrhardt (ThD787) pointed out, “it is erroneous to hold women responsible for partner condom use since their control over their male partners’ behaviour is limited”. T o conclude, it seems that researchers are now discovering that IDUs are not a unified group but exhibit endless variety, which makes a wide array of interventions necessary. Furthermore, the period of rapid behavioural changes and dramatic effects has passed. As is well known from other health campaigns, it is much more difficult to pre-
402
SAN FRANCISCO SUMMARIES C . HARTGERS
Downloaded by [University of Toronto Libraries] at 18:58 31 October 2014
vent relapse or to change the behaviour of image of the irrational, risk-loving and antithose IDUs who have not done so by now. social IDUs resurges as an excuse against Continuing effort, expertise and creativity tackling prevention. are necessary, the danger arises that the
