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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 users—epidemiology G. Hart
a
a
Department of Genito-Urinary Medicine , University College and Middlesex Schools of Medicine , London, UK Published online: 25 Sep 2007.
To cite this article: G. Hart (1990) Drug users—epidemiology, AIDS Care: Psychological and Sociomedical Aspects of AIDS/HIV, 2:4, 395-397, DOI: 10.1080/09540129008257761 To link to this article: http://dx.doi.org/10.1080/09540129008257761
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
395
AIDS CARE, VOL. 2, NO.4,1990
Drug users-epidemiology G. HART
Downloaded by [Universite Laval] at 05:30 03 March 2015
Department of Genito- Urinary Medicine, University College and Middlesex Schools of Medicine, London, UK
As the epidemic of HIV infection and AIDS has developed over the years since the first International Conference the emphases in the social, behavioural and epidemiological studies that are reported change concomitantly. This year, for example, there were over twice the number of studies concerned with drug users than those relating to behaviour in homosexual men. For the first time there was a recognizable strand of papers on the natural hstory of HIV dsease in injecting drug users (IDUs) and progression to AIDS and a small, but again identifiable, section on treatment and prophylaxis. In t h i s report from the Conference the major focus will be on the epidemiology of HIV and AIDS; Christina Hartgers will discuss studies concerned with prevention in the following section. The message from the United States was fairly promising. Prevalence of HIV infection seems to be levelling out for the most part, and in New York there was even a reduced incidence of AIDS in the city, a peak having been reached in 1988 (Thomas et al., ThC707). Unfortunately, in six South Eastern states there was a raised incidence of AIDS amongst heterosexual IDUs and their sexual partners (Berkelman et al., ThC706), reinforcing the fact that regional variations do exist. A massive study of HIV infection in 16,941 IDUs at 65 sentinel drug treatment c h c s in 27 metropolitan areas reported prevalences ranging from 0% to
47.7%, with the highest being found in the North East of the country as compared to 2.5% for the rest of the U.S. as a whole ( M e n et d., FC551). Despite no apparent major behavioural changes there was still no increase in the overall prevalence in New York, New Jersey, Baltimore, Chicago, Texas and Los Angeles during the course of a year, with hopes that this does signify a levelling out of the infection (Battjes et al., FC552). Watters et al. (FC106) suggested reasons for a constant prevalence of just over 11% since 1987 in San Francisco were the reduction in needle-sharing, generally safer needle use, and the use of bleach by those who continue to share. Moss, reporting from the same city, confirmed that the infection rate has continued to fall, but noted that new infections were likely to be related to sexual risk amongst IDUs; following 604 drug users over the period 1985-90 who were seen twice, 15 seroconverted, giving an incidence of 1.9% per person year. Risk factors for seroconversion included reporting five or more sexual partners in the last year, use of crack cocaine, shooting gallery use and cocaine injection (FC553). Payment for participation is one of the means by which these American studies succeed in attracting such large numbers to antibody testing; alternatively, acceptance onto methadone maintenance programmes is often predicated upon willingness to also
Downloaded by [Universite Laval] at 05:30 03 March 2015
396
SAN FRANCISCO SUMMARIES G . HART
undergo antibody testing. Wiebel et af. (FC556) paid street-recruited IDU’s in Chicago to be tested, and found 127 of 548 (23.2%) to be antibody positive; at followup 6 months later 27 of 421 participants who had been antibody negative sero-convened, giving an incidence of 9.32% per person year, the highest in the U.S.A. Further outreach attempts are being made to contact those most at risk. Whilst many of the American studies described variation between regions, one reported substantial differences in a dmrete geographical area. Rates varied in methadone treatment populations in and around Boston according to location; 30 miles outside the city it was 4%, at a privately owned cenue it was 1446, but in the inner city (serving a predominantly black population) it was 31%. Much of the dfference was accounted for by reference to ethnicity and unequal access to treatment and prevention services (Steger et al., FC558). By way of contrast, IDUs in Minnesota have access to low threshold methadone maintenance programmes and needles and syringes are available without prescription, and here prevalance has remained consistenly low, and was 2.2% in 1989. Thomas et af. (FC559) also suggested that infrequent needle sharing and behaviour mdfication have also contributed to &IS. Although we are sadly not surprised at a prevalence of 47% in New Jersey amongst injectors, particularly of cocaine and speedballs (cocaine/heroin mix) (Iguchi et al., FC561), it is surprising to see a 7% prevalence amongst non-injectors in the city; Pate1 et af. (FC560) suggest sexual risk as a likely cause of infection amongst this group of non-injecting drug users. Reports from Europe were also tentatively optimistic, with no major increases reported in Antwerp (4%) (Todts et ol., FC618), Berlin (17%) (Stark et al., FC618) and Athens (1.1%) (Papaevangelou et af., FC627); in London, there has been no increase in infection amongst attenders at a needle-exchange over an 18-month period (2.4%) (Hart et af., SC745). In Italy 32% of
new entrants to methadone programmes were antibody positive as compared to 45% of subjects already in treatment. These levels have remained constant since 1985, although incidence has been 6.9% per person year (Zaccarelli et al., FC631). Two more Italian studies, from Verona (Lugoboni et al., FC633) and Turin (Sciandra et al., FC634) found reductions in the prevalence of anti-HIV, and maintained that this was associated with the availability of methadone treatment and health education campaigns. Hangers et al. (FC638) from Amsterdam, however, suggest that although low threshold access to methadone has been beneficial from a public order and general health perspective, it has not had any great effect on prevalence; long-term recipients of methadone were just as likely to have HIV infection as other IDUs in the city. Until 1987 there were no identified cases of HIV infection among IDUs in Poland, but by 1989 11.2% of 5,351 drug users in treatment were antibody positive; in 1990 the prevalence was 11.9%. Stapinska et al. (FC640) hope that no further increases will be seen as a result of intensive education, increased needle availability and the distribution of condoms. Reporting from Spain, Delagado-Rodriguez et af. (SC559) found an overall prevalence in 1,233 IDUs from 83 treatment centres throughout the counuy of 40%, although this varied by region and city in the period April to September 1989. Muga et al. (FC643) confirmed the 69% prevalence previously reported in Barcelona, although in Northern Spain there has been a reduction in the incidence of new infections between 1984 and 1989 (Merino et af., FC644). Finally, and less positively, Vanichseni and Sakuntanaga (FC105) reported from Bangkok that the prevalence amongst IDUs has risen during an 18 month period from 15.6% to 44.6%, reminding us that, conditions permitting, the introduction of this infection can result in massive spread in a remarkably short period. Overall, the epidemiological section of
DRUG USERS-EPIDEMIOLOGY
Downloaded by [Universite Laval] at 05:30 03 March 2015
the conference did demonstrate a levelling out of the epidemic in some of the larger populations of drug users. However, whilst it was clear that cautious optimism may be expressed that behavioural change and preventive programmes instituted in the mid- to
397
late-eighties are reaping limited rewards now, it was also evident that vigilant and persistent efforts are still required if we are to maintain the momentum of reduced incidence.
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 users—epidemiology G. Hart
a
a
Department of Genito-Urinary Medicine , University College and Middlesex Schools of Medicine , London, UK Published online: 25 Sep 2007.
To cite this article: G. Hart (1990) Drug users—epidemiology, AIDS Care: Psychological and Sociomedical Aspects of AIDS/HIV, 2:4, 395-397, DOI: 10.1080/09540129008257761 To link to this article: http://dx.doi.org/10.1080/09540129008257761
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
395
AIDS CARE, VOL. 2, NO.4,1990
Drug users-epidemiology G. HART
Downloaded by [Universite Laval] at 05:30 03 March 2015
Department of Genito- Urinary Medicine, University College and Middlesex Schools of Medicine, London, UK
As the epidemic of HIV infection and AIDS has developed over the years since the first International Conference the emphases in the social, behavioural and epidemiological studies that are reported change concomitantly. This year, for example, there were over twice the number of studies concerned with drug users than those relating to behaviour in homosexual men. For the first time there was a recognizable strand of papers on the natural hstory of HIV dsease in injecting drug users (IDUs) and progression to AIDS and a small, but again identifiable, section on treatment and prophylaxis. In t h i s report from the Conference the major focus will be on the epidemiology of HIV and AIDS; Christina Hartgers will discuss studies concerned with prevention in the following section. The message from the United States was fairly promising. Prevalence of HIV infection seems to be levelling out for the most part, and in New York there was even a reduced incidence of AIDS in the city, a peak having been reached in 1988 (Thomas et al., ThC707). Unfortunately, in six South Eastern states there was a raised incidence of AIDS amongst heterosexual IDUs and their sexual partners (Berkelman et al., ThC706), reinforcing the fact that regional variations do exist. A massive study of HIV infection in 16,941 IDUs at 65 sentinel drug treatment c h c s in 27 metropolitan areas reported prevalences ranging from 0% to
47.7%, with the highest being found in the North East of the country as compared to 2.5% for the rest of the U.S. as a whole ( M e n et d., FC551). Despite no apparent major behavioural changes there was still no increase in the overall prevalence in New York, New Jersey, Baltimore, Chicago, Texas and Los Angeles during the course of a year, with hopes that this does signify a levelling out of the infection (Battjes et al., FC552). Watters et al. (FC106) suggested reasons for a constant prevalence of just over 11% since 1987 in San Francisco were the reduction in needle-sharing, generally safer needle use, and the use of bleach by those who continue to share. Moss, reporting from the same city, confirmed that the infection rate has continued to fall, but noted that new infections were likely to be related to sexual risk amongst IDUs; following 604 drug users over the period 1985-90 who were seen twice, 15 seroconverted, giving an incidence of 1.9% per person year. Risk factors for seroconversion included reporting five or more sexual partners in the last year, use of crack cocaine, shooting gallery use and cocaine injection (FC553). Payment for participation is one of the means by which these American studies succeed in attracting such large numbers to antibody testing; alternatively, acceptance onto methadone maintenance programmes is often predicated upon willingness to also
Downloaded by [Universite Laval] at 05:30 03 March 2015
396
SAN FRANCISCO SUMMARIES G . HART
undergo antibody testing. Wiebel et af. (FC556) paid street-recruited IDU’s in Chicago to be tested, and found 127 of 548 (23.2%) to be antibody positive; at followup 6 months later 27 of 421 participants who had been antibody negative sero-convened, giving an incidence of 9.32% per person year, the highest in the U.S.A. Further outreach attempts are being made to contact those most at risk. Whilst many of the American studies described variation between regions, one reported substantial differences in a dmrete geographical area. Rates varied in methadone treatment populations in and around Boston according to location; 30 miles outside the city it was 4%, at a privately owned cenue it was 1446, but in the inner city (serving a predominantly black population) it was 31%. Much of the dfference was accounted for by reference to ethnicity and unequal access to treatment and prevention services (Steger et al., FC558). By way of contrast, IDUs in Minnesota have access to low threshold methadone maintenance programmes and needles and syringes are available without prescription, and here prevalance has remained consistenly low, and was 2.2% in 1989. Thomas et af. (FC559) also suggested that infrequent needle sharing and behaviour mdfication have also contributed to &IS. Although we are sadly not surprised at a prevalence of 47% in New Jersey amongst injectors, particularly of cocaine and speedballs (cocaine/heroin mix) (Iguchi et al., FC561), it is surprising to see a 7% prevalence amongst non-injectors in the city; Pate1 et af. (FC560) suggest sexual risk as a likely cause of infection amongst this group of non-injecting drug users. Reports from Europe were also tentatively optimistic, with no major increases reported in Antwerp (4%) (Todts et ol., FC618), Berlin (17%) (Stark et al., FC618) and Athens (1.1%) (Papaevangelou et af., FC627); in London, there has been no increase in infection amongst attenders at a needle-exchange over an 18-month period (2.4%) (Hart et af., SC745). In Italy 32% of
new entrants to methadone programmes were antibody positive as compared to 45% of subjects already in treatment. These levels have remained constant since 1985, although incidence has been 6.9% per person year (Zaccarelli et al., FC631). Two more Italian studies, from Verona (Lugoboni et al., FC633) and Turin (Sciandra et al., FC634) found reductions in the prevalence of anti-HIV, and maintained that this was associated with the availability of methadone treatment and health education campaigns. Hangers et al. (FC638) from Amsterdam, however, suggest that although low threshold access to methadone has been beneficial from a public order and general health perspective, it has not had any great effect on prevalence; long-term recipients of methadone were just as likely to have HIV infection as other IDUs in the city. Until 1987 there were no identified cases of HIV infection among IDUs in Poland, but by 1989 11.2% of 5,351 drug users in treatment were antibody positive; in 1990 the prevalence was 11.9%. Stapinska et al. (FC640) hope that no further increases will be seen as a result of intensive education, increased needle availability and the distribution of condoms. Reporting from Spain, Delagado-Rodriguez et af. (SC559) found an overall prevalence in 1,233 IDUs from 83 treatment centres throughout the counuy of 40%, although this varied by region and city in the period April to September 1989. Muga et al. (FC643) confirmed the 69% prevalence previously reported in Barcelona, although in Northern Spain there has been a reduction in the incidence of new infections between 1984 and 1989 (Merino et af., FC644). Finally, and less positively, Vanichseni and Sakuntanaga (FC105) reported from Bangkok that the prevalence amongst IDUs has risen during an 18 month period from 15.6% to 44.6%, reminding us that, conditions permitting, the introduction of this infection can result in massive spread in a remarkably short period. Overall, the epidemiological section of
DRUG USERS-EPIDEMIOLOGY
Downloaded by [Universite Laval] at 05:30 03 March 2015
the conference did demonstrate a levelling out of the epidemic in some of the larger populations of drug users. However, whilst it was clear that cautious optimism may be expressed that behavioural change and preventive programmes instituted in the mid- to
397
late-eighties are reaping limited rewards now, it was also evident that vigilant and persistent efforts are still required if we are to maintain the momentum of reduced incidence.
