12th World AIDS Conference
  
back to front page      All the news, as it happens  aids98.ch
back to today's front page

...bridging the gap

LAST UPDATE: Monday, 29 June, 1998 00:16 GMT     F E A T U R E   S T O R Y            ...all the news, as it happens

"Political Will" Lags Behind Need for Action
Harm Reduction for IDUs

BY CHRIS WONG

28 June, 1998

"Amazing." That’s how Don des Jarlais characterises the extremes in the HIV epidemic among intravenous drug users (IDUs). At one extreme, des Jarlais cites Glasgow, Scotland, where HIV prevalence among IDUs is approximately one per cent. At the other end, he points to areas of Myanmar (formerly Burma), where 90 per cent of IDUs are HIV-positive.

How can such disparate realities co-exist? Des Jarlais, Research Director at the Chemical Dependency Institute of Beth Israel Medical Centre in New York City, thinks the answer relates more to politics than science. He contends that the absence of "political will" to expediently implement comprehensive harm reduction programmes is a major factor influencing growth of the epidemic in certain regions.

Declining IDU and HIV?

"It looks like it’s possible to reverse a high seroprevalence epidemic."

--Des Jarlais, Research Director at the Chemical Dependency Institute of Beth Israel Medical Centre in New York City

There are some examples, from the Canadian context, of HIV spreading despite harm reduction efforts that include needle exchange. The HIV outbreaks among IDUs in Vancouver and Montreal, in which injectable cocaine has been a factor, have shown that half measures are often not enough. And these outbreaks have shown that policy decisions can be central to the high rate of infection.

But researchers like des Jarlais believe the evidence is strong that harm reduction strategies, in the vast majority of settings, can effectively prevent the spread of HIV. And they think it’s crucial that more harm reduction programmes be put in place, given the overall status of the epidemic among the estimated 10 million people in the world currently using drugs intravenously. "The global perspective is somewhere between pretty bad to catastrophic," says des Jarlais. "Things are getting worse fast."

Sessions at the 12th World AIDS Conference will spotlight research examining harm reduction in its various forms. They’ll look at the key role of the strategy, which places a priority on reducing harm associated with drug use rather than ensuring abstinence, in HIV prevention. A number of sessions will focus on programmes in Europe, an important testing ground for the development of harm reduction.

One study, jointly conducted by the University Hospital of Geneva and the Phoenix Foundation, measured prevalence and incidence of HIV, hepatitis B and hepatitis C in a cohort of IDUs enrolled in Geneva’s largest methadone maintenance program. Barbara Broers, of the University Hospital’s Substance Abuse Division and principal investigator of the study, says the research documented a high HIV prevalence rate at entry to the program, which reflected out-of-treatment risk-taking. But a significant decrease in HIV infection occurred over time. Because there was no control group of non-methadone users, the study didn’t identify a correlation between methadone maintenance and HIV risk reduction. But Broers says the study’s data suggests IDUs changed behaviour in response to HIV prevention campaigns involving harm reduction. "To me, it’s a sign that the global harm reduction program has been effective."

Broers says the "global" program she’s referring to has incorporated a breadth of measures ranging from needle exchange to addictions treatment. In Amsterdam, a similar broad approach has been taken. Erik Van Ameijden, with Amsterdam’s Municipal Health Service, says a combination of harm reduction measures — not needle exchange alone — has been an important factor in reducing HIV prevalence among IDUs.

Van Ameijden will present a poster at the Conference examining high risk injection behaviours in Amsterdam. His research looked at why there was a major reduction in these behaviours, but only to a certain point. A conclusion of the study was that despite the abundance of harm reduction initiatives in Amsterdam, there’s still a "residual risk" of unsafe behaviour. "There appears to be a maximum [risk reduction] you can achieve," says Van Ameijden, Project Leader of the Amsterdam Cohort Study of IDUs. Therefore a lesson to be learned from the Amsterdam experience is not that new harm reduction measures are necessarily needed, but that existing measures need to at least be maintained, he adds. "It can take a lot of years before interventions have their maximum effect."

 



One of the most controversial harm reduction interventions involves prescription of addictive drugs. With the World AIDS Conference being held in Switzerland, attention will likely turn to the Swiss Programme for a Medical Prescription of Narcotics, also known as PROVE. The study looked at the impact of prescribing heroin to IDUs, with medical and social deficiencies, who were previously difficult to treat. The PROVE research team, from the Addiction Research Institute in Zurich and University of Zurich, will present a poster at the conference documenting changes in addictive behaviour and HIV risk resulting from the treatment.

The poster concludes that study participants significantly reduced their risk for HIV, as they substantially lowered their consumption of heroin and cocaine obtained outside of carefully controlled PROVE treatment. The proportion of participants connected to the illegal drug scene went from 86 per cent to 55 per cent after one year in treatment, says Thomas Steffen, a project leader of the study. "For this group of hardcore users, this treatment is very important," says Steffen, who adds that future research will analyse the treatment’s specific effect on HIV incidence.

Broers, from the University Hospital of Geneva, thinks heroin maintenance will have only a minor impact on HIV rates. The treatment is appropriate for a small group of severely addicted individuals who have failed with more conventional approaches such as methadone maintenance, she says. "This is a very particular population." Broers adds that the PROVE research lacked a control group of IDUs obtaining illicit drugs outside of the treatment being studied. She says there’s a need for more heroin maintenance trials incorporating control groups. Steffen agrees but says it would be "very hard" to set up such a group.

Harm reduction can also benefit another sub-group of the general population: individuals in prisons. Dina Zeegers Paget, Health Promotion Coordinator for prisons in the Swiss Federal Office of Public Health, will present a poster on pilot needle exchange programs in prisons. According to the poster, there have been positive results from the pilot projects, including a decrease in needle sharing and a improvement of health status. The poster notes that a 1997 statement from the Swiss Federal Office of Justice, establishing the legality of needle exchange in prisons, has been a significant development. But prison officials still have difficulty reconciling a situation in which IDUs are incarcerated for drug involvement, yet are given the means to continue drug use, says Zeegers Paget.

In the United States, the "war on drugs" ideology prevents the funding of innovative harm reduction programs with public health value, says des Jarlais. He argues that drug-related law enforcement may be contributing to the growth of intravenous drug use itself. The "zero tolerance" approach drives up the cost of illicit drugs and makes injection the most "cost-efficient" method of drug administration, des Jarlais says. This policy continues, despite the mounting evidence that the absence of programmes that include needle exchanges contributes to skyrocketing infection rates.

So how do you contain the spread of HIV among IDUs in that context? Des Jarlais will present research at the Conference suggesting that harm reduction programs, if they’re allowed to operate, can work. He says these recent findings, based on 10 studies, show declining HIV incidence and prevalence among IDUs in New York where there has been extensive needle exchange. "It looks like it’s possible to reverse a high seroprevalence epidemic."

The reversal in New York, and a similar turnaround in Northern Thailand, offer hope for other areas. But timing is crucial. Des Jarlais says the epidemic among IDUs in Eastern Europe is "a catastrophe well underway." In particular, there’s an "explosion" of HIV related to intravenous drug use in parts of the former Soviet Union, says Lars O. Kallings, Secretary-General of the International AIDS Society. The possibility of serious outbreaks among IDUs in other regions, including Africa, also exists.

With that troubling backdrop in mind, research presented at the 12th World AIDS Conference strives to address both the political and scientific issues affecting the ability of harm reduction programmes. Mobilising the political will of governments remains the work for all delegates following this week together in Geneva.


help!
this story can also be found on pages 4-5 of  The Bridge, the onsite print newspaper


Back to Today's Front Page back