AIDS Care

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HIV among drug injectors: The epidemic and the response S. R. Friedman & D. C. Des Jarlais To cite this article: S. R. Friedman & D. C. Des Jarlais (1991) HIV among drug injectors: The epidemic and the response, AIDS Care, 3:3, 239-250, DOI: 10.1080/09540129108253069 To link to this article: http://dx.doi.org/10.1080/09540129108253069

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AIDS CARE, VOL. 3, NO. 3,1991

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HIV among drug injectors: the epidemic and the response S. R. FRIEDMAN & D. C. DESJARLAIS’

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Narcotic and Drug Research, Inc. & * Beth Israel Medical Center, New York, USA

Introduction

As of 31 December 1990, over 60,000 AIDS cases among drug injectors had been reported from more than 25 countries. These included 34,398 heterosexual and 10,557 homosexual/ bisexual drug injectors from the United States, as well as 14,808 heterosexual and 905 homosexual/bisexual drug injectors from Europe. Drug injectors accounted for the majority of reported cases in Italy and Spain.

Risk factors for HIV seropositivity Behavioural risk factors for HIV infection among IV drug users include frequency of drug injection (especially cocaine injection in some US studies), sharing injection equipment and injecting in shooting galleries; some studies have also revealed sexual behaviours to be significant risk factors (Caussy et al., 1990; Chaisson et al., 1989; D’Aquila et al., 1989; Friedman et al., 1989b;Marmor et al., 1987; Muga et al., 1990;Page, Smith & Kane, 1990; Sasse et al., 1989; Schoenbaum et al., 1989;van den Hoek et al., 1988;Vlahov et al., 1990; Williams, 1990). A history of syphilis or other STDs has also been found to be a risk factor in some studies, although evidence exists that this may reflect lifestyle rather than a biological factor (Williams 1990; Friedman, Kleinman 81 Des Jarlais, in press). Social and biographical risk factors that have been reported include socioeconomic status, racelethnicity, years of injection, imprisonment, and perhaps gender (Caussy et al., 1990; Chaisson et al., 1989; D’Aquila et al., 1989;De Rossi et al., 1988; Friedman et al., 1989a;Lewis & Watters, 1988; Marmor et al., 1987; Muga et al., 1990; Page, Smith & Kane, 1990; Sasse et al., 1989; Schoenbaum et ul., 1989; van den Hoek et al., 1988;Vlahov et ul., 1990; Williams, 1990). Seroprevalence over time

Table 1 (page 241) presents data for seroprevalence over time among drug injectors in 20 localities. Since these data come from a number of disparate studies with varying numbers of subjects their comparability and representativeness are not high. Nonetheless they provide a broad outline of the development of the epidemic among injecting drug users. Even before

Address for correspondence: Professor S. R. Friedman, Narcotic and Drug Research Inc., 11 Beach Street, New York, NY 10013, USA.

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the first published report of AIDS in 1981, HIV was widespread among drug injectors in New York City and also present in Milan and Padua. It had spread to South America by 1983 (Sao Paul0 1983 [Secretaria de Estado da Saude, 19901, Rio de Janeiro 1986 [Bastos et al., 1988]), Australia by 1985 (Arachne & Ball 1986; Blacker et al., 1986), and Asia by 1987 (Bangkok 1987 [Phanuphak et al., 1989]), Manipur late 1989 [Naik et al., 19911). The rate of spread varied among cities. Figure 1 presents data on seroprevalence in the year prior to, and then the year during which seroprevalence reached 10%.Seroprevalence in this second year is thus an indicator of the speed with which HIV was spreading among drug injectors. In half of the cities, seroprevalence was 15% or less in the second year. On the other hand, seroprevalence was over 35% in Bangkok, Bologna, Edinburgh, and Manipur. The reasons for the variations in rate of spread have not been fully determined, and additional research into this question is sorely needed. The World Health Organization is presently sponsoring studies in cities in Asia, Australia, Europe, North America and South America that may help us better understand this phenomenon. Particularly puzzling is the fact that all four cities where seroprevalence reached 35% or more in the second year are cities in which most drug injecting is heroin injection. Yet individual risk factor studies in San Francisco and New York indicate that in cities where both cocaine and heroin are widely used, cocaine injection presents a greater risk than heroin injection (Chaisson et al., 1989; Friedman et aZ., 1989). It is possible, however, that there may be cocaine-dominant cities in Latin America in which similar rates of spread have occurred without full documentation. 100-

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Francisco Data lor Edinburgh compare first half-years of 1983 and 1984; for Bangkok. the second half-years of 1987 and 1988: and for Manipur, Januarythrough September 1989 and October 1989 through June 1990.

FIG. 1. HIV seroprevalence among drug injectors in the year before (0) and the year in which it reached 10%

(.).

In a number of cities seroprevalence seems to have levelled off. The level at which this has occurred varies: about 12% for San Francisco, 32% for Amsterdam and 55% for New York. The reasons for these different levels of stabilization have not been determined, but may include a combination of factors: differences in prevention programme effects; variations in the degree of drug injectors’ autonomous risk-reduction efforts; differences in the

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For footnotes 1-25 see Appendix at end of article.

New York’ Sardinia2 San Francisco’ Rio de Janiero4 Bangkok5 Bologna6 Milan I-hepatitis’ Milan 11-MMTP* Padua I--bepatitis9 Padua 11-detox’O Rome’l Geneva I-outpatients12 Geneva II-hospita113 Berlin I-drug deaths14 Berlin II-treat~nent~~ Hamburg I-drug deathsI6 Hamburg 11-treatment” Vienna18 Edinburgh19 BilbaoZ0 Tours*’ Amsterdamz2 London2’ Manipur (India)24 Detroitz5

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1987

Table 1. Time-Sm’es Data on HIV Seroprevalence among injecting drug users b city figures are percentages).

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16

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1989

54

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242 S. R. FRIEDMAN & D. C. DES JARLAIS

stage of the epidemic at which widespread risk reduction began among drug injectors in various localities; and variations in drug injectors’ pre-existing behaviours or network structures.

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Risk reduction among drug injectors Considerable risk reduction has been reported by both surveys and ethnographic studies of drug injectors. There have been increases in the demand for new syringes, in syringe cleaning and to a lesser extent, in condom use. Reductions in sharing used works and sharing syringes during initiation into drug injection have also been reported (Friedman et al., 1987; Des Jarlais, Friedman & Hopkins 1985; Neaigus et al., 1991; Abdul-Quader et al., 1990; Power et al., 1988; Chitwood & Comerford, 1990.) In general, however, risk reduction rather than risk elimination has predominated. Maintaining these gains remains problematic. Risk reduction has been greatest among those whose peer-group norms support this (Friedman et al., 1987; Abdul-Quader et al., 1990; Magura et al., 1989a; Huang et al., 1989a, 1989b) and among those with close social ties to non-injectors (Klee et al., 1990; Neaigus et al., 1990).

HIV prevention programmes A brief theoretical discussion may help focus our understanding of programmes aimed at reducing the transmission of HIV from one drug injector to others, or to their sex partners. A useful starting point is understanding that HIV transmission is a form of interaction among two or more persons-and that individuals engage in such interactions as the result of a lifelong series of social relationships. Attempts to reduce the risk posed by this interaction can focus on: (i) the individual drug injector; (ii) the dyads (or larger groups) who share injection equipment or have sex with each other; (iii) the wider drug-injection subculture; or (iv) larger social processes or structures including both the relationships between drug injectors and society at large as well as the cumulative social forces that may influence some persons to inject drugs in high-risk settings. To date, however, most AIDS prevention projects have focused primarily on the drug injector as an individual. These include health education, antibody testing and counselling, drug abuse treatment, providing physical means to individuals to facilitate risk reduction (syringes, bleach, condoms), and skills training programmes to teach individuals how to handle interactions so that they are more likely to avoid risk. Only a few projects have focused on changing drug-user subcultures. Almost none have targeted the relationship between society at large and drug users, much less the surrounding social relationships or structures, such as racism, gender inequality, or poverty. Yet doing so may be a prerequisite for successful implementation of harm reduction strategies in some countries. A second consideration that should guide our understanding of prevention programmes involves the nature of the agent of intervention and the different kinds of social relationships which each mode of intervention entails. The great majority of projects have involved ‘outside’ agencies intervening for the good of the drug injectors. Often these have been health departments or drug abuse treatment agencies. A smaller number have involved drug users themselves setting up groups to respond to the epidemic in their own way. Such selforganization against AIDS has of course been more widespread and successful among gay men in many cities. These two approaches-the ‘outside’ agency versus self-organizationcan be viewed as poles of a continuum, with programmes varying in the extent to which drug

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users are approached as objects to be acted upon, or as subjects who can contribute ideas and actions on their own. With this theoretical overview informing our discussion, we proceed to specific assessments of the major interventions to date.

Drug abuse treatment

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Drug abuse treatment has provided individuals who remain in it with some protection against HIV infection (Abdul-Quader et al., 1987; Blix & Gronbladh, 1988; Schoenbaum et al., 1989) and has led to less HIV risk behaviour (Hartel et al., 1989; Ball et al., 1988).

HIV testing HIV testing has been implemented on a wide scale under the assumption that people who learn they are carrying the virus win act to prevent transmission to others. Studies have generally shown that both seropositives and seronegatives do reduce high-risk behaviour after HIV testing (Higgins et al., 1990). The strongest case for the utility of HIV testing comes from Sweden, where an unusually high percentage of the drug injectors in the country have been tested. A new norm of social interaction has developed, in which seropositive drug injectors warn others against borrowing injection equipment and stabilization of seroprevalence has occurred (Kall & Olin 1990). Yet despite the generally positive results from studies of HIV testing of drug injectors, there is still much to be learned about the potential role of testing in reducing HIV transmission. First, the causal mechanisms through which testing might lead to risk reduction have not been determined. Counselling is generally considered to be an essential part of HIV testing, yet there has been very little research to identify the criteria for good HIV counselling. There have also been wide individual variations in response to HIV counselling and testing, but the determinants of these variations have not been identified. Finally, now that there are treatments available to retard the development of HIV-related disease among seropositives, the perceived availability of medical treatment may be a new factor affecting the usefidness of HIV testing in reducing viral transmission.

The provision of risk reduction materials The provision of risk reduction materials is a major emphasis of many projects. These are distributed to drug injectors both as an educational device and as an immediate way to reduce the probability that HIV will be transmitted due to the lack of non-contaminated injection equipment or condoms. Perhaps the most widespread of these projects are syringe exchanges, along with deliberately increased over-the-counter sales of syringes, which have emerged as major new approaches to reducing HIV spread in the Netherlands, England, Scotland, Australia, and elsewhere. Syringe exchanges were initiated in the Netherlands at the instigation of drug users’ own organizations, and have often been started in various cities by unofficial bodies or by individual clinics. In several cities in the United States, syringe exchanges function on a quasi-legal or illegal, but tolerated, basis. Syringe exchanges vary in the extent to which they insist upon participants returning syringes as a way of getting potentially infectious materials off the streets. In most cases syringe exchanges have functioned as fixed-site, indoor activities, although efforts have been made to distribute syringes to dealers’ houses or other places where drug injectors gather.

244 S. R. FRIEDMAN & D. C. DES JARLAIS

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Although most are conducted by ‘outside’ groups some have been conducted by drug users’ organizations. Evaluation of syringe exchanges has found that: exchangers reduce high-risk behaviour more than non-exchangers; in some cases, the exchangers may be persons who had reduced their risk prior to coming to the exchange, but who rely upon the exchange to enable them to maintain their reduced risk; exchanges can reduce the number of used syringes left lying in the streets; the presence of an exchange in a city does not lead to any increase in the number of persons who begin to take or inject drugs; and in Amsterdam, at least, the expansion of an exchange has been followed by a decline in seroconversion rates for both HIV and HBV (Des Jarlais et al., 1989; Fuchs et al., 1988; Hagan et al., 1989; Hartgers et al., 1989; Ljungberg et al., in press; Oliver, 1990; Stimson et al., 1988; van Haastrecht et al., 1989; Wolk et al., 1988.)

Educational outreach Educational outreach by persons who can function effectively on the streets has been the major non-treatment AIDS prevention approach for drug injectors in the United States. Although some projects have used only ex-users as outreach workers, there is some evidence that ex-users may be less effective than was originally thought (Rivera-Beckman et al., in press). Current users have been incorporated in outreach efforts conducted by drug users’ unions and other groups in the Netherlands (de Jong, 1991) and elsewhere. In most cases outreach in the United States has involved bleach and condom distribution, although state or local government policies have sometimes prevented this. Outreach in the Netherlands, on the other hand (and in some local efforts in the United States) has included syringe distribution or exchange. Although these projects have usually focused on individual education, in San Francisco, Chicago and some other locations they have also attempted to influence the drug-user subculture so that it incorporates bleach use as the norm. Considerable reduction in drug-related risk and some reduction in unsafe sex have been reported in evaluation of outreach projects (Feldman et al., 1989; Moss & Chaisson, 1988; Neaigus et al., 1990; Wiebel et aL, 1989; Wiebel, 1990).

Self-organization In the early 1980s, there was an outburst of collective self-organization by drug users in the Netherlands who wanted acceptance and better treatment by their society. The junkiebonden that were formed became involved in AIDS education and the distribution of syringes to drug injectors. These organizations, however, remained limited in size and tended to vary over time in their effectiveness, with periods of high activity interspersed with periods in which little was done (Friedman, De Jong & Des Jarlais, 1988). In the last two years there has been renewed self-organization, particularly in Germany, where at least 25 cities now have chapters of JES (Junkies, Ex-users, Substitutionists) and in Australia, where organizations exist in several cities which combine the efforts of current and former drug injectors. In the United States, efforts have been made to organize drug injectors against AIDS in New York City and in Minneapolis-St Paul (Carlson & Needle, 1989). The New York effort has met with only moderate success in establishing organization, but an evaluation study indicates that considerable risk reduction has resulted among drug injectors in the neighbourhood (Friedman et al., in press), with one third reporting that they always use condoms during sex (Jose et al., in press).

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In summary, available data indicate that a wide range of interventions can lead to risk reduction by many drug injectors, and the levelling off of seroprevalence in San Francisco, New York, Amsterdam and other cities may indicate that these efforts have limited the spread of HIV. However, some seroconversions continue to be reported in these cities. Hence further work will be needed in order to find ways to broaden and deepen the impact of interventions, so they produce a greater degree of drug-related and sex-related risk avoidance that lasts for a lifetime. It is our opinion that such changes would necessarily require changes in the subculture of drug use and in society at large-not just individual change. Even more pressing is an intensification of existing programmes. Bleach use has become much more widespread in San Francisco, with about 50 outreach workers for around 15,000 drug injectors, than in New York which has never had more than 100 workers for 200,000 drug injectors. Thus, new approaches to intervention need to be developed alongside considerable increases in the scale of already existing programmes.

Sociopolitical issues In the ten years of the epidemic, official responses to AIDS prevention among drug injectors have been disappointing in the United States and elsewhere. The epidemic spread for several years after it was discovered-before any sizable programmes began. Although there has been some willingness to experiment with new approaches (such as outreach programmes and syringe exchanges) the funding for these programmes has remained woefully inadequate in most cities with large concentrations of drug injectors. The ten years of the AIDS epidemic have been marked by the crystallization of two broad political approaches to issues of drug use. One of these is the harm-reduction approach, which advocates a public-health paradigm that aims to minimize the damage that drug users do to themselves, other persons and society by working with users. The other approach, far more politically influential, has been the ‘War on Drugs’ in the United States and elsewhere. This advocates the punishment and stigmatization of drug users through a ‘zero tolerance’ approach. Many of its supporters view harm minimization through bleach or syringe distribution as ‘sending the wrong message’. Advocates of the war on drugs approach have succeeded in obstructing many AIDS initiatives that would prevent the spread of HIV. Los Angeles County, for example, forbade distribution of condoms or bleach, much less syringes, in its AIDS programmes and a small experimental syringe exchange in New York City was first crippled, then stopped, by opposition. Although some, but not all, opponents of such projects say they would favour an expansion of drug abuse treatment, the actual extent of such expansion has been limited. In the United States, for example, National Institute on Drug Abuse data indicate that the patient census increased between 1982 and 1987 from 71,000 to 81,000 for methadone clients; from 74,000 to 144,000 for other outpatients; from 15,000 to 27,000 for residential treatment; and from 3,000 to 11,000 for special in-hospital programmes (Gerstein & Harwood, 1990). Yet this increase of 100,000 is comparatively small given the estimated total of 5.5 million persons in the US who need treatment, including approximately one million drug injectors (Spencer, 1989), particularly if we exclude the 70,000 increase in ‘other outpatients’. In New York City, the epicentre of the HIV epidemic among drug injectors, the number of persons in treatment only increased from 30,535 in 1981 to 35,192 in 1991 (New York State Division of Substance Abuse Services, unpublished data.) One aspect of the response to the AIDS epidemic among drug injectors that has been disappointing in almost all countries has been the lack of a concerted effort to reduce the numbers of persons who start injecting drugs. There may be a common assumption that

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knowledge of AIDS will in itself reduce the number of persons who start to inject illicit drugs, but so far there has been no evidence that this has happened (Des Jarlais & Friedman, 1988). The United States, the United Kingdom and Australia have all conducted mass media anti-drug campaigns since AIDS was discovered among drug injectors. These campaigns have been against illicit drug use in general, and have merely included AIDS as one reason not to use drugs, without emphasizing AIDS as such. Evaluation of the campaign in the United States has shown an association between the amount of media campaign exposure and more negative attitudes towards illicit drugs across different geographic areas (Black, 1991). Whether these negative attitudes in the population as a whole will affect the number of persons who begin injecting illicit drugs remains to be determined. A comprehensive campaign to reduce the number of persons who begin to inject drugs would have to include changes in the socioeconomic and social structural factors which have led to the concentration of drug injection among economically disadvantaged groups in many countries. Whether the threat of AIDS among drug injectors will lead to programmes at this level remains to be seen but very little has even been proposed at this level of intervention. Indeed, the international AIDS community has been too slow to suggest programmes to target these ills. In the early years of the epidemic this disregard could be defended on the basis that efforts needed to concentrate on programmes to spread the word about AIDS and how it is transmitted to drug injectors and their sexual partners. Ten years into the epidemic, however, we need to find ways to combine short-term urgency (projects directly targeting AIDS risk behaviours and interactions) with other, longer-term programmes that target some of the social roots of drug injection and needle sharing.

Acknowledgements The research in this paper was supported by National Institute on Drug Abuse grants DA05283, DA03574, and DA06723. The views expressed in this paper do not necessarily reflect the positions of the granting agencies or of the institutions by which the authors are employed.

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(1989) Determinants of needle sharing among intravenous drug users, American Journal of Public Health, 79(4), pp. 459-462. -OR, M., DESJ W S , D.C., COHEN,H. et al. (1987) Risk factors for infection with human immunodeficiency virus among intravenous drug abusers in New York City, AIDS, 1(1), pp. 39-44. MOSS, A.R. & CHAISSON,R. (1988) AIDS and intravenous drug use in San Francisco, AIDS and Public Policy, 3, pp. 37-41. MUGA,R., TOR, J., LLIBRE,J., SORIANO, V., REY-JOLY, C. & FOZ, M. (1990) Risk factors for HIV-1 infection in parented drug users. AIDS, 4, pp. 259-260. NAIK, T.N., S W , S., SINGH,H.L. et al. (1991) Intravenous drug users-a new high-risk group for HIV infection in India, AIDS, 5, pp. 117-1 18. M., FRIEDMAN, S.R. et al. (1990) Effects of outreach intervention on risk reduction among NEAIGUS,A., SU~AN, intravenous drug users, AIDS Education and Prevention, 2, pp. 253-271. D.C. (1991) Declines in NEAIGUS, A., FRIEDMAN,S.R., STEPHERSON, B., JOSE,B., SUFIAN,M. & DES JARLAIS, syringe sharing during the first drug injection. Seventh International AIDS Conference, Florence. OLIVER,K. (1990) Presentation on evaluation of the Portland, Oregon, syringe exchange. North American Syringe Exchange Convention, Tacoma, Washington. October 26. PAGE,J.B., SMITH,P.C. & KANE,N. (1990) Shooting galleries, their proprietors, and implications for prevention of AIDS, Drugs and Society, 5, pp. 69-85. T. & ROJANAPITHAYAKORN, ‘$7. (1989) HIV transmission among PHANuPHAK,P., POSHYACHINDA, V., UN-EKLABH, intravenous drug abusers. Read before the Fifth International Conference on AIDS, Montreal, June 6, 1989. E. (1988) Drug injecting, AIDS, and risk behaviour: potential for change POWER,R., HARTNOLL, R. & DAVIALID, and intervention strategies, British Journal of Addiction, 83, pp. 649-654. S.R., C L A ~M.C. , & CURTIS,R. (1991) ‘Inside’-‘Outside’: Social process in RIVERA-BECKMAN, J., FRIEDMAN, AIDS outreach. Proceedings of the Second National AIDS Demonstration Research Conference, National Institute on Drug Abuse (in press). SASSE, H., SALMASO,S., CONTI,S . et al. (1989) Risk behaviors for HIV-1 infection in Italian drug users: report from a multicenter study, Journal of Acquired Immune Dejiciency Syndromes, 2, pp. 486-496. SCHOENBAUM, E.E., HARTEL,D., SELWYN,P.A. et al. (1989) Risk factors for human immunodeficiency virus infection in intravenous drug users. New EnglandJournal of Medicine, 321, pp. 874-879. DE ESTADODA SAUDE.(1990) AIDS no Estado de Sao Paulo. (September). Centro de Vigilancia SECRETARIA Epidemio1ogica. SPENCER, B.D. (1989) On the accuracy of current estimates of the numbers of intravenous drug users, in: C. F. TURNER, H. G. MILLER& L. E. MOSES (Eds) AIDS: Sexual Behavior and Intravenous Drug Use (Washington, National Academy Press). M.C. & LART, R.A. 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WILLIAMS, M.L. (1990) HIV seroprevalence among male IVDUs in Houston, Texas, American Journal of Public Health, 80, pp. 1507-1509. WOLK,W.S., WODAK,A., GUINAN,J.J. et al. (1988) HIV seroprevalence in syringes of intravenous drug users using syringe exchange in Sydney, Australia, 1987. Paper presented at the Fourth International Conference on AIDS, Stockholm.

Appendix

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Footnotes to Table 1: [I] New York-50% figure for 1990 is from preliminary unpublished data. Total number of subjects: 1978-1983(110); 1986(65); 1987(294). Source: DES JARLAIS, D.C., FRIEDMAN, S.R. et al. (1989) J A M , 261(7), pp. 1008-1012. [2] Sardinia-Sample drawn from medical evaluations of methadone maintenance patients. Total number of subjects each year: 1978(88); 1979(112); 1980(129); 1981(257); 1982(70); 1983(66); 1984(75); 1985(70); 1986(98). Source: FARCI,P., NOVICK, D.M. et al. (1988) American Journal of Epidemiology, 127(6), pp. 1312-1314. [3] San Francisco-Six cross-sections of IVDUs: convenience samples from three 21-day detoxification clinics; targeted samples from three inner-city street locations. Total number of subjects each year: Jan 1986(363); Feb 1987(478); Mar 1987(368); Apr 1988(345); May 1988(332); June 1989(228). Source: WATTERS, J.K., CHENG, Y. et al. (1990) Sixth International Conference on AIDS, San Francisco (F.C. 106). S.R. (1991) Bulletin on Narcotics, in press. [4] Rio de Janiero-Source: LIMA,E.S., BASTOS,F.I. & FRIEDMAN, [5] Bangkok-Data are for last halves of 1987 and 1988. Samples drawn from hospital inpatient drug abusers and K. Paper clinic outpatients. Total number of subjects: 1987(1,649); 1988( 1,811). Source: CHOOPANYA, prepared for WHO Multi-Center Study, May 1989. [a] Bologna-Sample drawn from drug abusers hospitalized for acute viral hepatitis, mostly type B. Total number tested each year: 1979(21); 1980(26); 1981(11); 1982(67); 1983(61); 1984(93). Source: TITTI, F., LAZZARIN, A. et al. (1987) Journal ofMedical Virology, 23, pp. 241-248. [7] Milan I-Sample drawn from drug abusers hospitalized for acute viral hepatitis, mostly type B. Total number tested each year: 1978(15); 1979(28); 1980(64); 1981(121); 1982(123); 1983(90); 1984(140); 1985(120). Source: T m , F. et al., ibid. [El Milan 11-Methadone maintenance treatment patients. Total number tested each year: 1981(45); 1982(72); F. et al., ibid. 1983(218); 1984(64); 1985(75); 1986-6 months(37). Source: TITTI, [9] Padua I-Sample drawn from drug injectors hospitalized with acute viral hepatitis B. Total number in sample each year: 1978(7); 1979(15); 1980(37); 1981(59); 1982(68); 1983(45); 1984(39); 1985(22); 1986(20); 1987(3); 1988(6). Source: BORTOLOTTI,F., CADROBBI, P. ef al. (1989) Infection, 17(6), pp. 364-368. [lo] Padua 11-Detoxification patients with a drug-abuse history of greater than 2 years. Total number of subjects F. et al. examined each year: 1983(55); 1984(42); 1985(491); 1986(565). Source: DE ROSSI,A., BORTOLOTI?, (1988) European Journal of Cancer and Clinical Oncology, 24(2), pp. 279-280. [ l l ] Rome-Sample drawn from new entrants into largest drug dependency unit in metropolitan Rome. Total M., number tested each year: 1985(251); 1986(247); 1987(238); 1988(223); 1989(221). Source: ZACCARELLI, REZZA,G. et al. (1990) AIDS, 4, pp. 1007-1010. [ 121 Geneva I-Ambulatory IVDUs requesting or already receiving methadone maintenance treatment. Total number tested each year: 1981(63); 1982(34); 1983(191); 1984(142); 1988(154). Source: ROBERT,C-F., DEGLON, J-J. et al. (1990) AIDS, 4, pp. 657-660. [13] Geneva 11-Hospitalized heroin addicts. Total number tested during each phase of study: 1981(69); 1982/83( 1 15); 1984/85(97). Source: HIRSCHEL, B., CARPENTIER, N. et al. Second International Conference on AIDS, Paris, 1986 (Poster 166). [14] Berlin I-Sample drawn from HIV-antibody screening of drug-related deaths. 1988 figure is for first six months of the year. Total number screened each year: 1985(35); 1986(51); 1987(39); 1988(35). Source: BSCHOR,F., SCHNEIDER, V., et al. Paper presented at 35th ICAA Congress, Oslo, August 3, 1988. [15] Berlin 11-Sample drawn from drug-injecting clients in treatment. Total number tested each year: 1985(45); 1986(79); 1987(404). Source: BSCHOR,F. et al., ibid. [16] Hamburg I-Sample drawn from HIV-antibody screening of drug-related deaths. 1988 figure is for first six months of the year. Total number screened each year: 1985(8); 1986(22); 1987(51); 1988(32). Source: BSCHOR,F. et al., ibid. [17] Hamburg 11-Sample drawn from drug-injecting clients in treatment. Total number tested each year: 1985 and 1986 (not available); 1987 (approx. 100). Source: BSCHOR,F. et al., ibid.

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I181 Vienna-Sample

[19]

[20]

[21]

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[22]

drawn from drug addiction outpatient ward. Figures for 1988-1990 follow the introduction of a methadone maintenance program in late 1987 which attracted an increased number of patients seeking treatment. Total number of subjects tested each year: 1986(82); 1987(159); 1988(119); 1989(195); 1990(156). Source: LOW, N., PRESSLICH, 0. et al. (1990) AIDS Care, 2(3), pp. 281-286. Edinburgh-Sample drawn from patients attending the Royal Infirmary. Total number of sera collected each year: 1982(182); 1983(124); 1984(205); 1985(178). Source: PEUTHERER,J.F., EDMOND,E. et al. Second International Conference on AIDS, Paris, 1986 (Poster 167). Bilbao-Sample drawn from patients in a drug dependency unit. No year-by-year figures on the number of subjects are available but, over the course of the study (1984-1989), sera were collected from 1,504 drug injectors. Source: MERINO,F., AIZPIRI, J. e l al. Sixth International Conference on AIDS, San Francisco, 1990 (Poster F.C. 644). Tours-Sample drawn from patients in Tours University Hospital. Total number tested each year: 1982(22); A., DUBOIS,F. et al. Second International Conference on 1983(30); 1984(40); 1985(125). Source: GOUDEAU, AIDS, Paris, 1986 (Poster 169). Amsterdam-Subjects recruited from six methadone maintenance outreach sites and from one STD clinic for drug-using prostitutes. Total number tested each year: 1986(220); 1987(178); 1988(133); 1989(91). Source: VANHAASTRECHT, H.J.A., VAN DEN HOEK,J.A.R. et al. (1991) American Journal of Public Health, 81(1), pp.

59-62. [23] London-Sample

drawn from drug injectors attending clinics and General Practitioners in the South London area. Total number tested each year: 1985(19); 1986(293); 1987(313); 1988(216). Source: SUTHERLAND,S., MCMANUS,T.J. Fifth International Conference on AIDS, Montreal, 1989 (Poster T.A.P. 55). [24] Manipur (India)-Sample drawn from treatment centers, jail, and the general population. Number of IVDUs in total sample before October, 1989, is not reported. From October 1989 to June 1990, the serum samples of 1,412 drug injectors were screened. Source: NAIK, T.N., SAW, S. et al. (1991) AIDS, 5(1), pp. 117-118. [25] Detroit-Sample drawn from ‘serologically unknown’ drug injectors seeking hospital care for conditions unrelated to HIV. Total number tested during each of the study’s three phases: 1985-86(96); 1987-88(70); 1988-89(71). Source: OGNJAN,A., MARKOWZ,N. et al. Fifth International Conference on AIDS, Montreal, 1989 (Poster Th.A.P. 10).

HIV among drug injectors: the epidemic and the response.

AIDS Care ISSN: 0954-0121 (Print) 1360-0451 (Online) Journal homepage: http://www.tandfonline.com/loi/caic20 HIV among drug injectors: The epidemic...
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