Injecting drug users and the Human Immunodeficiency Virus: what do we know?

The Australian Study of HIV and Injecting Drug Use. Part II: Predicting exposure to hepatitis C and hepatitis B

Researchers agree that while hepatitis B maybe in control, hepatitis C is present in epidemic proportions among injecting drug users and that current HIV prevention strategies have not been sufficient to halt the spread of this hepatitis virus, although there is some evidence to suggest that incidence rates are stabilizing. Since there is no effective cure and it is unlikely that a vaccine will become available in the foreseeable future all efforts to control the spread of hepatitis C must rely on education and prevention strategies. The Australian Study of HIV and Injecting Drug Use is a cross-sectional national study designed to investigate exposure to and risks for infection with bloodborne viruses. Of those volunteering a usable blood sample for hepatitis C antibody and hepatitis B core antibody testing 55% and 19%, respectively, returned reactive test results. Logistic regression statistical models were used to identify risk factors for hepatitis C and hepatitis B. Risk factors for hepatitis C were identified as duration of use, use of opiates on last injecting occasion, education level, treatment status and having a history of sexually transmissible diseases. Risk factors associated with hepatitis B were duration of use, and use of opiates on last injecting occasion. The lack of identifiable risk factors for hepatitis B suggest that past rather than current injecting and sexual behaviour patterns are required to predict accurately risk of exposure to hepatitis B. In addition to this, one-third of respondents reported being vaccinated against hepatitis B. Respondents perceived themselves to be at greater risk from hepatitis C than from hepatitis B or HIV. A discussion of strategies needed to prevent the spread of the hepatitis viruses will be presented along with recommendations for further research.

The general practitioner pharmacotherapy prescribing workforce: examining sustainability from a systems perspective

As prescribers of opioid pharmacotherapies, general practitioners (GPs) are pivotal to the sustainability of opioid pharmacotherapy treatment services. The goal of this study was to examine the nature and sustainability of the Australian GP prescriber workforce in order to inform future programmes and policy development in this area. Data were collected from four Australian states: South Australia, Queensland, Victoria and New South Wales. Key features of the available data were: a heavy client load carried by a small number of prescribers, a high proportion of trained but inactive prescribers, and a high proportion (one-third to two-thirds) of medical practitioners who undertake training but do not take up prescribing, i.e. a high attrition rate. Available data indicate significant shortfalls in the number of prescribers available in each state to service this patient population. Across all states a relatively small number of prescribers were providing services for the majority of methadone clients. In order to achieve sustainable, high quality prescriber service provision, workforce development strategies are needed which focus on recruitment of new prescribers, and the support and retention of existing and inactive prescribers. Establishment of systematic and detailed data collection systems should also be considered a priority.

AIDS and injecting drug use: very risky behaviour in a Perth sample of injecting drug users

This research was carried out in 1990 to examine high-risk injecting and sexual behaviour in a sample of injecting drug users (IDUs) in Perth. The study was a cross-sectional survey with a convenience sample drawn from drug treatment (54%) and non-treatment (46%) populations. In the sample of 150 IDUs, there were 11 very risky drug behaviour (VRDB) and 63 very risky sex behaviour (VRSB) respondents. Four respondents fell into both categories. Independent comparisons were made between each risk group and the rest of the sample. The VRDB respondents were heterosexual men, most of whom were in long-term monogamous relationships, with heavier levels of drug use than the rest of the sample. The VRSB respondents were largely single and mainly heterosexual, with more sexual partners than the rest of the sample. It was concluded that there was little evidence that very risky behaviour was related to a general risk-taking dimension, to inadequate knowledge about AIDS or to a low assessment of personal vulnerability to AIDS. However, situational influences in association with heavy drug use appeared to be a major component of high-risk injecting behaviour, while high-risk sexual behaviour appeared more to be a reflection of community norms about heterosexual sexual behaviour. The study should be replicated with larger samples, particularly as the VRDB group was so small, but if the findings are reproduced in other studies, it suggests that serious attention should be paid to the promotion of safer sex among injecting drug users.

Doing the possible: harm reduction, injecting drug use and blood borne viral infections in Australia

Most surveys show that, other than among men who inject drugs and have a history of homosexual contact, the prevalence of HIV infection among injecting drug users (IDUs) in Australia is about 2%. Rates of needle sharing have also declined greatly in the last decade, although the high prevalence and incidence of hepatitis C infection suggest that existing strategies have not yet brought this epidemic under control. Harm reduction has been the major Australian approach to the reduction of blood borne viral infections (BBVIs) in IDUs. Harm reduction strategies include needle distribution schemes, drug substitution therapies and education about safe administration practices. Importantly, with IDUs as with gay men, the infected and affected communities have been brought into partnership with health educators, researchers and policy makers. This paper will review Australia's approach to the prevention of BBVI in IDUs and the effectiveness of current strategies. I will argue that while HIV/AIDS among heterosexual IDUs appears to have been successfully prevented, international experiences of rapidly emerging epidemics demonstrate there is little room for complacency. Moreover, reducing the incidence of hepatitis C and hepatitis B among IDUs remains a major challenge.

Sexual behaviour and its relationship to drug-taking among prostitutes in south London

The precise manner in which the use of different types of drugs is related to prostitution has not been adequately researched. This study investigates patterns of drug-taking and sexual behaviour among a group of women working as prostitutes in south London; it also looks at prostitution in which sex is offered in return for drugs, at the links between heroin, cocaine and alcohol use and sexual behaviour, and at the association between severity of dependence and sexual behaviour. All of the women in our sample (n = 51) were actively working as prostitutes. More than half of them had given sex for drugs, though this was a relatively infrequent occurrence. The majority of them were using heroin and many of them were moderately or severely dependent upon heroin. More than one-third had shared injecting equipment after it had already been used. Almost two-thirds reported that they only worked as a prostitute in order to fund their use of drugs (predominantly heroin), and that they would not continue working as a prostitute if they were not still using drugs. The more severely dependent upon heroin they were, the more likely they were to report these links between heroin use and prostitution. About half of the women in our sample said that they first started to work as a prostitute in order to pay for drugs. The women who began to use heroin prior to prostitution were more severely dependent on heroin and described themselves as being trapped in prostitution by the need to maintain a supply of heroin. Very few women regularly used cocaine in association with their prostitution. There are grounds for concern about the alcohol consumption of these women. About one-quarter of the women said that they used alcohol every day; some of them reported drinking at levels which greatly exceed recommended limits for women, and some were drinking at levels which were likely to be physically damaging.

Jabs in the dark: injecting equipment found in prisons, and the risks of viral transmission

Injecting drug users in prisons may reuse and share contaminated injecting equipment, increasing their risk of infection with blood-borne viruses. We examined 58 syringes found in three metropolitan Adelaide prisons during a one-year period: 95 per cent were one millilitre volume; blood was visible in 24 per cent; 58 per cent indicated repeated use; 33 per cent were wrapped in plastic; and 26 per cent had detachable needles, allowing more blood to be trapped in the dead space between the syringe barrel and needle than with the fixed-needle variety. The nature and condition of some of these syringes suggested they might transmit contaminated blood. The ineffectiveness of present approaches to keeping injecting equipment out of prisons demands a more enlightened approach to harm minimisation. With doubts cast on the efficacy of bleach, education should be supported by practical means to reduce transmission of viruses. Provision of sterile injecting equipment is a possible option.