A woman injecting drug user argued articulately that it is not realistic or acceptable to expect all IDUs to stop injecting altogether, that the alternative to the prohibitionist approach is harm reduction, based on:

1. the recognition that the demand and supply for drugs is never going to end and

2. the goal of reducing the negative consequences of drug injection:

• When there is diffusion of injection drug use, HIV is never far behind. Of 128 countries reporting injection drug use in 1998, 103 now report HIV infection among drug users.

• Political, social and economic unrest, as experienced recently in countries of the former Soviet Union, has lead to rapid increases in IDU and HIV among IDUs in Belarus, Moldova and the Ukraine. In the Ukraine, 100,000 HIV infections were estimated to have occurred in 1997, mostly among IDUs and in the Russian Federation, the median age of first injection is as low as 11 years, underscoring the need to study factors related to initiation of drug injecting, and ways to discourage injection in favour of other forms of drug use. In light of disturbing reports of IDUs injecting home-made drug preparations using human blood as a clarifying agent, there is a need to undertake widespread outreach efforts to promote safe injection practices.

• A combination of interventions, such as needle exchange programmes (NEP), outreach, HIV counselling and testing, methadone maintenance programmes, and network-oriented interventions can reduce needle sharing and HIV infection risk among IDUs. Huge variations exist with respect to implementation of harm reduction programmes world-wide. NEP and methadone maintenance programmes have been in place in Kathmandu (Nepal) for 5 years, and NEP and methadone detoxification have been implemented among hill tribes in Northern Thailand. In contrast, many countries, such as the US, have failed or delayed harm reduction programmes with the opportunity to prevent new HIV epidemics among IDUs having been missed.

• Rapid Situation Assessment and Response, which addresses the individual, micro and macro-level aspects of drug-related harms and risks that can lead to infection speeds up the process of assessment and allows for the implementation of effective, feasible, culturally acceptable interventions, tailored to the local environment.

• A successful community based intervention including NEP, a drop-in centre, counselling, STD treatment, condom distribution and education aimed at IDUs in Bangladesh was based on an 18 month period of situation assessment which involved the entire community, (IDUs, their families, religious and political leaders, and police) in a "best practice" case story from which other countries may gain valuable experience.

• Another exciting example of a set of community based interventions for IDUs was in Madras (India). A randomized controlled trial of a personal network intervention was shown to reduce injection in shooting galleries, and sharing of injection equipment. NEP was also used as a vehicle to encourage supportive networks between ex-IDUs and current injectors, to reduce high risk behaviour and facilitate referrals to drug treatment.

• Fears in developed countries that NEP may inadvertantly facilitate high risk social networks were not supported by studies from Montreal, Vancouver (Canada) and Baltimore (USA) which consistently showed that very few NEP attenders met new needle sharing partners at the exchange. There was continued evidence that NEP was associated with reductions in high risk behaviours and HIV incidence, with former NEP attenders more likely to reduce or cease injecting, and to enter drug treatment programs.

• Despite considerable success in implementing interventions aimed at IDUs, there is clear lack of formal evaluation of many programs, especially in resource poor countries. An elegant approach to evaluating NEP involves studying the "life cycle" of NEP syringes, rather than the people who use them, labelling and tracking NEP syringes to evaluate syringe coverage and syringe circulation time.

• Reports from Thailand and from Zimbabwe of the acceptability of female condoms emphasised the importance of including men in social marketing approaches. In Zimbabwe, 40 per cent of sales were to men and there were indications that men liked the female condom because it felt more natural and transmitted heat and because women took over responsibility.

• Re-use of the female condom could increase accessibility, decrease cost and would increase convenience for women, but questions of durability and safety need to be answered. Preliminary findings on structural integrity, microbial retention and HIV permeability after rewashing with a variety of agents suggest that the female condom can be safely washed up to ten times.

• Work in progress on cost-effectiveness of the female condom using cost per disability adjusted life year (DALY) and cost per case averted point to significant savings when the cost of HIV medical care in developing countries is factored into the calculations.

• Further research is required to assess the efficacy of female condoms in reducing HIV transmission along with research on sexual practices in populations, which might derive maximum benefit from female condom use.

• Sexual network analysis is a promising tool to increase understanding of: centrality of the infected person; change in risk structure, change in risk configuration and risk behavior, change in microstructure, mixing patterns and matrices. In the future their use should be expanded to mapping, evaluation and in the exploration of network concept in modeling.

• The "first generation " public health surveillance had some disadvantages such as representativity and not reaching all vulnerable populations. A Zambian study compared the sentinel surveillance system to population based HIV surveys in the same population and found that antenatal sentinel surveillance provides a close match to overall prevalence but may overestimate prevalence due to high levels of infection in women age 15-19 as a result of the tendency for women to be infected at a younger age than men.

• Second generation surveillance systems should be country specific, move from prevalence data to incidence data, collect behaviour data, provides adequate coverage and where possible, and calibrate sentinel sites.

• Public policy issues that were highlighted included external factors such as debt crisis, changes in the international leadership for AIDS and internal country factors including the type of political leadership.

• Strong political commitment is mandatory for effective and sustainable programmes. It is time to adopt public health approaches that facilitate the application of effective interventions based on research evidence in order to make prevention programmes more effective and realistic to domestic conditions.

• Methods for increasing access to STD treatment in developing countries include the development of diagnostic and treatment modalities, which do not rely on expensive and technological intensive methods; integration of STD management into Primary Health Care and Family Planning programmes. The main challenges facing all countries include achieving integration, implementing innovations, reaching undeserved populations, mobilising and securing community involvement and political will and dealing with specific implementation issues.