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HIV Prevention & Injecting Drug Use
How many people are injecting drug
users?
How can these risks be reduced?
What do syringe and needle exchange
schemes involve?
Do syringe and needle exchange schemes
increase drug use?
Globally, sex between men and women is by far the
most common way of passing on HIV. But a second transmission route
drives the epidemic in many, if not most, countries outside Africa.
That is transmission among men and women who inject drugs.
Injection of any sort is an even more efficient way
of spreading HIV than sexual intercourse. Since injecting drug users
are often linked in tight networks and commonly share injecting
equipment with other people without cleaning it, HIV can spread very
rapidly in these populations. Also, like other sexually active
people, people who inject drugs may acquire HIV infection through
their sexual partners if they have unprotected sex.
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Because injecting drug use is illegal in most
countries, it is hard to know exactly how many people inject drugs
and how many share their equipment. It is even harder to know how
many are infected with HIV. Whilst precise figures may be hard to
come by, it is clear that HIV can explode through drug-using
populations with remarkable speed and can stabilise at very high
levels.
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In relation to sexual transmission, the main means
of risk reduction are similar to those that should be adopted by all
sexually active people-namely, the consistent and proper use of
condoms, or the avoidance of penetrative sex.
In relation to transmission through the sharing of
needles, syringes and other equipment, several options are
available. Some of these offer better means of protection than
others. In order of efficacy they include:
1. Stopping injecting drug use
2. Using sterile needles, syringes and other
equipment every time
3. Not sharing injecting equipment
4. Cleaning equipment between use
Without doubt, the most effective way of reducing
the risk of HIV infection is to give up using drugs, but where this
is not possible, changing from injecting to non-injecting drug use
can significantly reduce the risk of HIV transmission by non-sexual
means. For those who inject opioid drugs such as heroin, this may be
achieved through participation in a non-injectable drug substitution
programme in which a drug such as methadone is administered orally.
An important way of making clean syringes and
needles more readily available is through needle and syringe
exchange programmes. These have been shown to be effective in
preventing the transmission of HIV, and do not increase the use of
illegal drugs. Studies in the Netherlands, Britain, Australia and
many other countries have shown that syringe and needle exchange
programmes significantly reduce the risk of HIV infection through
injecting drug use
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Syringe and needle exchange schemes aim to increase
the availability of sterile injecting equipment and removing
contaminated syringes from circulation. Some of them also refer
injecting drug users to appropriate services. They may also provide
information and advice on safer sex, and may distribute condoms for
use by injecting drug users and their sexual partners. They also
access more marginalised and vulnerable drug using populations. In
Belarus, an HIV prevention programme among drug users in Svetlogorsk,
which included education about safe injecting and safe sex and which
provided clean syringes, seems to have led to far safer behaviour
among drug users. The prevention programme also included the
distribution of condoms to help reduce HIV transmission from
infected drug users to their sex partners.
Such schemes have several benefits. For injecting
drug users using such programmes, they decrease the proportion of
needles and syringes that are contaminated, reducing the likelihood
of HIV transmission. For injecting drug users not using such
programmes, they lower the proportion of contaminated needles in
circulation, thus lowering the risk of new HIV infections more
generally. They also reduce sharing and re-use occasions. The
Belarus prevention programme reduced the usage of shared syringes
dramatically. In 1997, before the prevention programme started, 92%
of those surveyed said they shared syringes. 1999, the percentage
dropped precipitously to 35%.
Syringe and needles exchange schemes have also been
shown to be cost effective. By preventing infections among programme
users, their sex partners and their children, and by avoiding the
lifetime costs associated with the treatment and care of such
infections, exchange schemes can enable health authorities to make
important budgetary savings. The Belarus prevention programme is
estimated to have prevented over 2000 cases of HIV infection by its
second year of operation. At a cost of around US$0.36 per disposable
syringe distributed and around US$29 per infection prevented, this
is far below the cost of an AIDS case to a family or a health
system.
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There is clear evidence that syringe and needle
exchange schemes neither increase drug use as a result of providing
access to sterile equipment, nor increase the frequency of injection
among those using such schemes, or the number of new initiates to
injecting drug use.
At least six government-funded studies of HIV
infection among drug users in the USA concluded that needle exchange
programmes significantly reduce new HIV infections without
encouraging drug use. Despite these results, however, federal
funding of needle exchange- programmes is still prohibited in the
USA because of political opposition. In one study it was estimated
that failure to implement widespread needle- exchange programmes in
the USA between 1987 and 1995 will cost the country at least US$244
million in medical care for HIV cases that could have been
prevented.
In the US, there is evidence to suggest that syringe
and needle exchange schemes report increased referrals to drug
treatment services, including those services that aim to help
injecting drug users stop injecting. This may have an additional
benefit in that as a result of such referral some drug users at
least may cease to inject thereby reducing the risk of other kinds
of drug-related harm.
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