Evaluation of a cognitive-behavioural intervention for pregnant injecting drug users at risk of HIV infection

Pregnant injecting drug users were randomly assigned to: (i) individually receive a six-session cognitive-behavioural intervention in addition to their usual methadone maintenance treatment (intervention condition (I) (n = 40)); or (ii) their usual methadone maintenance treatment only (control condition (C) (n = 40)). There was no change in drug use per se in either group after the intervention. However, at 9-month follow-up the I group had significantly reduced some HIV risk-taking behaviours (in particular injecting risk behaviours). The I group reduced the needle risk associated both with "typical" use (drug use in the month before interview) and "binge" use (drug use in the month nominated as the heaviest month of drug use in the previous 6 months). The intervention had no effect on sexual risk behaviours. The finding of reduced injecting risk behaviour following the six-session intervention suggests that such an intervention may be of benefit for individuals persisting with injecting risk behaviours despite methadone maintenance treatment and the availability of sterile injection equipment.

Managing HIV. Part 6: People living with HIV. 6.5 HIV and injecting drug use

Injecting drug use can not only lead to HIV infection via the sharing of injecting equipment, it can also complicate the course and management of infection.

General practitioners' promotion of healthy life styles: what patients think

The study examined the prevalence of cigarette smoking, alcohol consumption, exercising to keep fit and dieting to lose weight among general practice patients, and patients' perceptions of the role of the general practitioner in advising about life style. A cross-sectional survey using a self-administered questionnaire was completed by 13,017 patients aged 18 to 70 years who were attending one of 119 general practitioners from 40 group practices in metropolitan Sydney over a six- to eight-week period. More women than men reported dieting to lose weight, just over half of the men and women were exercising regularly to keep fit, 35 per cent of men and 29 per cent of women reported smoking, and 12 per cent of men and 10 per cent of women were drinking alcohol at levels considered hazardous or harmful. More young people were smoking, drinking hazardously or harmfully, dieting to lose weight and exercising than the older age groups, and their smoking rates exceeded those of the general population. Most patients reported that general practitioners should be interested in their life-style behaviours, particularly smoking. Substantially fewer patients (particularly women who drank excessively) reported receiving advice about their habits. General practitioners were more likely to give advice when smoking and drinking levels were very high. There were discrepancies between patients' expectations of the doctor's role in promoting healthy life styles, and their likelihood of receiving advice. Doctors could reduce the diseases associated with unhealthy practices. Developments in medical training in the 1990s may extend the way they engage in advising on issues of life style.

Managing HIV. Part 1: Principles. 1.2 Strategies of care in managing HIV

Apply the science, use a team approach, help patients to promote their own health, ensure access to support and accept a public health role. These are the practical lessons of our experience in HIV medicine.

Maintaining low HIV seroprevalence in populations of injecting drug users

OBJECTIVES

To describe prevention activities and risk behavior in cities where human immunodeficiency virus (HIV) was introduced into the local population of injecting drug users (IDUs), but where seroprevalence has nevertheless remained low (< 5%) during at least 5 years.

DESIGN AND SETTING

A literature search identified five such cities: Glasgow, Scotland; Lund, Sweden; Sydney, New South Wales, Australia; Tacoma, Wash; and Toronto, Ontario. Case histories were prepared for each city, including data on prevention activities and current levels of risk behavior among IDUs.

PARTICIPANTS

Injecting drug users recruited from both drug treatment and non-treatment settings in each city.

INTERVENTIONS

A variety of HIV prevention activities for IDUs had been implemented in each of the five cities.

RESULTS

There were three common prevention components present in all five cities: (1) implementation of prevention activities when HIV seroprevalence was still low, (2) provision of sterile injection equipment, and (3) community outreach to IDUs. Moderate levels of risk behavior continued with one third or more of the IDUs reporting recent unsafe injections.

CONCLUSIONS

In low-seroprevalence areas, it appears possible to severely limit transmission of HIV among populations of IDUs, despite continuing risk behavior among a substantial proportion of the population. Pending further studies, the common prevention components (beginning early, community outreach, and access to sterile injection equipment) should be implemented wherever populations of IDUs are at risk for rapid spread of HIV.

Reliability of interview responses of injecting drug users

We compared 23 injecting drug users (IDUs) who were part of a larger study at retest periods of less than or greater than one month for test-retest reliability of their responses to a detailed questionnaire covering demographics, drug use, HIV risk behavior and attitudes and knowledge about HIV. Data indicated that there was high test-retest reliability for demographic characteristics, and for the social context of drug use for the shorter retest duration.

HIV risk-taking behaviour among injecting drug users currently, previously and never enrolled in methadone treatment

This study compares the injecting and sexual risk-taking behaviour among injecting drug users (IDUs) currently, previously and never enrolled in methadone maintenance treatment (MMT). All subjects had injected during the 6 months prior to the day of interview. The current MMT group showed significantly lower injecting risk-taking behaviour subscale scores on the HIV Risk-taking Behaviour Scale (HRBS) of the Opiate Treatment Index than the previous MMT and non-MMT groups together. The current MMT group differed from the other two groups in the frequency of injecting and cleaning of injection equipment with bleach. There was no difference between the current MMT group and the other two groups combined in sexual risk-taking behaviour scores on the HRBS. There were no differences between the previous MMT and non-MMT groups in injecting and sexual risk-taking behaviour. HIV seroprevalence was low and there was no difference in seroprevalence between groups. Thus, IDUs currently enrolled in MMT are at reduced risk for HIV infection when compared with IDUs who have previously or never been enrolled in MMT. However, the absence of a difference between the current MMT and other two groups in frequency of sharing behaviours suggests the need for additional strategies among MMT clients to reduce needle-sharing. Possible strategies include the application of relapse prevention interventions and the availability of sterile injecting equipment in MMT clinics. Further research is needed to identify factors which increase attraction and retention of IDUs to MMT.

Controlled evaluation of a general practice-based brief intervention for excessive drinking

In a controlled evaluation of general practitioner (GP)-based brief intervention, 378 excessive drinkers identified opportunistically by screening in 40 group practices in metropolitan Sydney were assigned to groups receiving: (i) a five-session intervention by the GP (the Alcoholscreen Program); (ii) a single session of 5 minutes' advice by the GP plus a self-help manual (minimal intervention); (iii) an alcohol-related assessment but no intervention; (iv) neither intervention nor assessment. Among all patients allocated to receive it, the Alcoholscreen Program did not result in a significantly greater reduction in consumption at follow-up than control conditions but patients offered Alcoholscreen reported a significantly greater reduction in alcohol-related problems in the period to 6 months follow-up. A greater proportion of patients who returned for the second Alcoholscreen visit were drinking below recommended levels at follow-up than in the remainder of the sample. There was no evidence that minimal intervention or alcohol-related assessment were effective in reducing alcohol consumption or problems. Implications for further research into GP-based brief interventions are discussed.

Harm reduction: Australia as a case study

This paper explicates the term, "harm reduction"; demonstrates that harm reduction has a long tradition; and uses one country, Australia, as a case study. Harm reduction can be understood as "policies and programs which are designed to reduce the adverse consequences of mood altering substances without necessarily reducing their consumption"; it is consistent with the best traditions of both medicine and public health. Although it is difficult to interpret trends in mortality from alcohol, tobacco, and illicit drugs to determine whether harm reduction in Australia "worked", the effectiveness of harm-reduction policies and programs in controlling HIV among injecting drug users (IDUs) seems extremely strong and suggests that benefits of harm-reduction programs for other drugs will become apparent in time.

A comparison of HIV risk between women and men who inject drugs

Although there is growing evidence of differences between women and men who inject drugs (IDUs) in terms of level of risk for HIV infection, very little research has been conducted specifically addressing the risk practices of women IDUs. This study formed part of a national study of HIV infection risks in IDUs and the purpose of the present analysis was an exploration of gender differences in HIV risk practices, focusing on the HIV risk practices of IDU women. 1,245 IDUs from the inner city area of Sydney took part in this study. Of these, 908 were men and 331 were women. Notable results were that female respondents were more likely to report sharing needles, they injected heroin more times in a typical using month and were more likely to have shared with someone they later found out was HIV seropositive. Female respondents also reported more sexual partners than men, were more likely to engage in prostitution, and were more likely to have sexual partners who were themselves IDUs. The results provide support for the proposition that women who inject drugs may be at greater risk of HIV infection through both their drug taking and their sexual practices. Further research is needed to explore the reasons underlying the risk practices of women who inject drugs and an understanding of these factors needs to be incorporated into HIV risk-reduction and drug harm-reduction policies and programs.

Whose territory is it anyway? Should psychiatry own alcohol and drugs in Australia?

Surely alcohol and drug matters in Australia should be regarded as the province of psychiatry? Decades before any other branch of medicine displayed any interest in the subject and long before alcohol and drugs were considered even remotely respectable, numerous Australian psychiatrists provided inspiration and leadership in this Cinderella field. Drs Bartholomew, Bell, Buchanan, Chegwidden, Dalton, Drew, Ellard, Lennane, Milner, Milton, Waddy and Pols are some of the best known among the many Australian psychiatrists who pioneered efforts to improve treatment for patients with alcohol and drug problems. The NHMRC Committee on Alcohol and Drug Dependence, which has a considerable potential for influencing the field in Australia, has always been dominated by psychiatrists. In the United Kingdom and the United States, countries which often serve as models for much of Australian medical and other practice, alcohol and drug matters are determined almost exclusively by psychiatrists. Is there any evidence that they have been held back by a psychiatric hegemony on alcohol and drug's? For many decades (and until quite recently), alcohol and drug matters were handled for the World Health Organisation by its Mental Health Division. Did we suffer globally because WHO placed alcohol and drugs under the control of psychiatry?

Controlled evaluation of a brief intervention for HIV prevention among injecting drug users not in treatment

This study evaluated the effectiveness of a brief intervention (BI), a one-session motivational interview, in reducing HIV risk-taking behaviour among injecting drug users (IDU) not enrolled in any form of treatment for drug dependence. IDU were randomly assigned to either BI or a non-intervention control condition (NIC). One hundred and twenty-one subjects were successfully contacted for a 3-month follow-up and 88 subjects were followed up at 6 months. There were significant reductions for the sample as a whole for injecting risk-taking subscale scores on the HIV Risk-taking Behaviour Scale between pre-treatment and follow-up. There was no significant change in sexual risk-taking behaviour. There were no significant differences between groups on any measure at 3- and 6-month follow-up. There are a number of possible reasons why the sample as a whole showed significant improvements from initial to follow-up assessments. It is possible that, having had their attention directed to their risk-taking behaviour, subjects attempted to reduce their injecting risk-taking behaviour. If this is the case and subjects in the NIC condition can be considered as having received a BI, this suggests that BIs involving a personal risk assessment are effective in reducing risk behaviours associated with injecting. However, this suggestion could only be confirmed by comparison with a non-assessment control group.