Re-examining blood donor deferral criteria relating to injecting drug use

BACKGROUND AND AIMS

Potential Australian blood donors are deferred indefinitely if they report a history of injecting drug use (IDU), or for 12 months if they report having engaged in sexual activity with someone who might have ever injected. Given incremental improvements in blood safety, this study sought to examine whether Australia's IDU-related eligibility criteria reflected current scientific evidence, were consistent with international best practice and, if current IDU-related policies were to be changed, how this should happen.

METHODS

An expert committee was formed to review relevant literature with a focus on issues including: the epidemiology of IDU in Australia and key transfusion-transmissible infections (TTIs) among Australian people who inject drugs (PWID); and, 'non-compliance' among PWID regarding IDU-related blood donation guidelines. International policies relating to blood donation and IDU were also reviewed. Modelling with available data estimated the risk of TTIs remaining undetected if the Blood Service's IDU-related guidelines were changed.

RESULTS

Very few (<1%) Australians engage in IDU, and IDU risk practices are reported by only a minority of PWID. However, the prevalence of HCV remains high among PWID, and IDU remains a key transmission route for various TTIs. Insufficient data were available to inform appropriate estimates of cessation and relapse among Australian PWID. Modelling findings indicated that the risk of not detecting HIV becomes greater than the reference group at a threshold of non-admission of being an active PWID of around 1.8% (0.5-5.1%). Excluding Japan, all Organisation for the Economic Co-operation and Development member countries permanently exclude individuals with a history of IDU from donating.

CONCLUSION

Numerous research gaps meant that the study's expert Review Committee was unable to recommend altering Australia's current IDU-related blood donation guidelines. However, having identified critical knowledge gaps and future areas of research, the review made important steps toward changing the criteria.

A review of the efficacy and effectiveness of harm reduction strategies for alcohol, tobacco and illicit drugs

Harm reduction is both a policy approach and used to describe a specific set of interventions. These interventions aim to reduce the harms associated with drug use. Employing a strict definition of harm reduction, evidence for the efficacy and effectiveness of alcohol, tobacco and illicit drug harm reduction interventions were reviewed. Systematic searches of the published literature were undertaken. Studies were included if they provided evaluation data (pre-post, or control group comparisons). More than 650 articles were included in the review. The majority of the literature concerned illicit drugs. For alcohol, harm reduction interventions to reduce road trauma are well-founded in evidence. Otherwise, there is limited research to support the efficacy and effectiveness of other alcohol harm reduction interventions. For tobacco, the area is controversial but promising new products that reduce the harms associated with smoking are being developed. In the area of illicit drugs there is solid efficacy, effectiveness and economic data to support needle syringe programmes and outreach programmes. There is limited published evidence to date for other harm reduction interventions such as non-injecting routes of administration, brief interventions and emerging positive evidence for supervised injecting facilities. There is sufficient evidence to support the wide-spread adoption of harm reduction interventions and to use harm reduction as an overarching policy approach in relation to illicit drugs. The same cannot be concluded for alcohol or tobacco. Research at a broad policy level is required, especially in light of the failure by many policy makers to adopt cost-effective harm reduction interventions.

Diffusion of the D.A.R.E and syringe exchange programs

We examined the diffusion of the D.A.R.E program to reduce use of illicit drugs among school-aged children and youths and the diffusion of syringe exchange programs to reduce HIV transmission among injection drug users. The D.A.R.E program was diffused widely in the United States despite a lack of evidence for its effectiveness; there has been limited diffusion of syringe exchange in the United States, despite extensive scientific evidence for its effectiveness. Multiple possible associations between diffusion and evidence of effectiveness exist, from widespread diffusion without evidence of effectiveness to limited diffusion with strong evidence of effectiveness. The decision theory concepts of framing and loss aversion may be useful for further research on the diffusion of public health innovations.

Risk behaviors among injecting drug users in Northern Ireland

Compared to elsewhere in the United Kingdom, drug policy in Northern Ireland has for the most part failed to incorporate harm reduction strategies. In light of the conservative drug policies, the purpose of this study was to investigate the nature and extent of risk behaviors among injecting drug users (IDUs) in Northern Ireland. Data for this study were drawn from in-depth interviews with 39 IDUs in Northern Ireland. The findings suggest that most IDUs engage in extensive risk behaviors that pose risk for HIV, Hepatitis B and C. and other infectious disease. Moreover, these risk behaviors are linked to the scarcity of new needles and a general lack of knowledge about injection practices that reduce risk for infectious disease. These findings are discussed in the context of conservative drug policies.

Evaluating effectiveness of syringe exchange programmes: current issues and future prospects

Although a large body of international literature has found syringe exchange programmes (SEPs) to be associated with reduced incidence of blood borne pathogens among injection drug users, recent studies have fuelled controversy surrounding SEP effectiveness. Existing studies are observational in nature and have seldom considered ecologic aspects affecting SEP functioning and evaluation. The authors apply concepts from infectious disease epidemiology to discuss the direct and indirect effects of SEP upon the spread of blood borne pathogens in drug users, their social networks and the broader community. Further, the authors discuss social policies, particularly drug control policies, which have directly and/or indirectly limited SEP functioning at local and national levels. A critical review of the literature suggests that biases common to observational studies can account for higher HIV incidence among SEP attenders relative to non-attenders. Strong selection factors often lead high-risk drug users to be over-represented among SEP attenders. Failure to account for these factors and the indirect effects of SEPs can bias interpretations of programme effectiveness. Future SEP evaluations should consider behavioural data, the local ethnographic context, the prevalence of infectious disease in the groups under study and the structural components of SEP that are most and least effective at reducing incidence of blood borne pathogens. Hierarchical models that take into account the ecological dimensions of SEP are recommended as an approach for future studies. Beyond methodologic concerns, the authors discuss social, legal and programmatic obstacles that must be overcome in order to maximise SEP effectiveness.

Hepatitis C virus antibody prevalence among injecting drug users at selected needle and syringe programs in Australia, 1995-1997. Collaboration of Australian NSPs

OBJECTIVES

To describe point prevalence of HCV antibody and relevant risk behaviour among people who inject drugs and who attended selected needle and syringe programs throughout Australia in 1995, 1996 and 1997.

DESIGN AND SETTING

Repeated cross-sectional surveys of one week's duration were carried out in 21, 20 and 23 needle and syringe program sites throughout Australia in 1995, 1996 and 1997, respectively.

PARTICIPANTS

All clients attending participating sites during the designated survey week were asked to complete a self-administered questionnaire and provide a finger-prick blood sample for HCV antibody testing.

MAIN OUTCOME MEASURES

Prevalence of HCV antibody.

RESULTS

Survey response was 41% (n = 979) in 1995, 51% (n = 1463) in 1996 and 48% (n = 1699) in 1997. HCV prevalence declined significantly from 63% in 1995 to 51% in 1996 and 50% in 1997 (P < 0.001). Among respondents who reported injecting for less than three years, prevalence declined from 22% in 1995 to 13% in 1996 and 1997 (P < 0.001). Reported use of needles and syringes after someone else in the previous month declined from 31% in 1995 and 28% in 1996 to 15% in 1997 (P < 0.001).

CONCLUSIONS

Despite an apparent decline in HCV prevalence, carriage rates of HCV antibody remain high.

Usuários de drogas injetáveis e infecção pelo Vírus da Imunodeficiência Humana: epidemiologia e perspectivas de intervenção

Dos cerca de 130 mil casos de aids notificados no Brasil entre 1980 e fevereiro de 1998, 21% estão diretamente relacionados ao uso de drogas injetáveis. Este artigo revisa aspectos da epidemiologia da infecção pelo HIV e outros patógenos de transmissão sangüínea, entre usuários de drogas injetáveis (UDI), visando a subsidiar as pesquisas e a implementação de propostas de intervenção em nosso meio. A população de UDI é heterogênea e, ao contrário do estereótipo, nem todos os UDI provêm de minorias masculinas das grandes áreas urbanas. Esta população está em contínua transformação, com mudanças marcantes ao longo do tempo na sua composição, hábitos e padrões de consumo. A estimativa precisa do número de UDI em uma dada localidade constitui tarefa difícil, embora disponha-se de novas metodologias, como o método de captura-recaptura. A combinação de dados provenientes de diversas fontes se mostra também indispensável. Estudos no sentido de monitorizar os padrões e tendências do uso de drogas injetáveis, segundo diferentes níveis de agregação e em intervalos regulares, permitem estimar prováveis aumentos ou decréscimos desta população e detectar mudanças relevantes nos seus comportamentos, contribuindo para orientar as estratégias de intervenção e alocação ótima de recursos. Evidências recentes demonstram que, devido à exposição parenteral e sexual aos diferentes patógenos, as infecções nesta população ocorrem precocemente, demandando intervenções prontas e abrangentes quanto aos UDI em atividade, e esforços no sentido de minimizar a transição para a via injetável e oferecimento de alternativas de tratamento clínico e para o abuso de drogas.