HIV prevalence among IDUs in Australia: a methodological review

A review was carried out of Australian studies which have measured the prevalence of HIV infection among injecting drug users (IDUs). The review considered published studies which had reported on serologically-determined HIV prevalence. There were five studies reported from specialized sexually-transmissible disease of HIV clinics, five studies reported from health services aimed at IDUs, three studies reported from other health services and one multi-centre behavioural study. The main findings from the studies were that HIV prevalence in IDUs has been low in Australia, apart from in male IDUs who also had homosexual contact. HIV prevalence ranged from 20 to 24% in male IDUs reporting homosexual contact and from 0 to 5% in other IDUs.The studies, while reflecting a range of research methodologies, are subject to a number of limitations. Most of the studies did not provide detailed analyses of HIV prevalence by age and sex or behavioural factors, and several studies used sampling frames which were not clearly defined. There is little available information on temporal trends in seroprevalence and geographical comparisons are rendered difficult by differences in the study methodology. Adoption of standardized, continuing seroprevalence surveys on IDUs would provide a better means of monitoring the occurrence of HIV infection in this group, which has been a key determinant of the course of the HIV epidemic in a number of Western countries.

Changes in equipment sharing in injecting drug users in Sydney 1989-1990

We investigated levels of equipment sharing in injecting drug users in Sydney, Australia, in two consecutive samples recruited in a non-treatment setting using similar methodology in 1989 (n = 1,245) and 1990 (n = 550). Comparison between the two waves of the study indicated that there were consistent and major reductions in percentage of time used equipment was re-used, and number of people from whom used equipment had been accepted. There was a corresponding significant and major increase in use of sterile injection equipment, obtained more frequently in the second sample from needle and syringe exchanges. The proportion of respondents reporting they had never shared equipment rose significantly. These data suggest that there is a continuing increase in the adoption of safer injecting practices and utilisation of needle and syringe exchanges over time in response to the threat of HIV transmission in injecting drug users.

HIV risk exposure of injecting drug users in Sydney

One thousand two hundred and forty-five Sydney injecting drug users (IDUs) were interviewed by questionnaire in 1989 to determine demographic and behavioural characteristics. One-sixth (16.7%) were considered to be at low risk of HIV from either needle sharing or sexual transmission as they had either never shared injecting equipment, or had not shared for years, or cleaned their injecting equipment effectively on 100% of the occasions when they did share; and were either celibate or monogamous or, if they had multiple partners, had not had unsafe sex in the previous 6 months. Over half (50.7%) had either unsafe injecting or sexual behaviour with the remaining third (32.6%) engaging in both unsafe injecting and sexual practises. Women were more at risk from sharing injection equipment than men but men were more at risk from sexual transmission than women. Increasing age was associated with greater likelihood of safer sex but age had no effect on injecting practises. There was no relationship between unsafe injecting and sexual practises. Amphetamine use was associated with low risk injecting practises while heroin use was associated with low risk sexual transmission. These findings indicate appreciable residual risk behaviour sufficient to allow for at least a slow diffusion of HIV among injecting drug users.

Predictors of unsafe injecting drug use

This paper reports on the incidence of unsafe injecting and the factors which influence this practice in a sample of 1245 Sydney injecting drug users (IDUs). Using a needle and syringe after someone else at some time in the last six months was reported in 41.6% of the sample. Taking into account those who claimed always to clean used needles with virucidal methods, 32.9% had placed themselves at risk of HIV infection from shared needles in the six months prior to interview.Seven factors were predictive of unsafe behaviour. These were (a) the amount spent per week on drugs, (b) the number of times a single needle was used prior to disposal, (c) having shared with a person who is now HIV infected, (d) having a regular sexual partner, (e) the proportion of times high, stoned or drunk when injecting, (f) being part of a group that injects together and (g) having been in prison.

Tobacco in prisons: a focus group study

OBJECTIVE

To examine the role of tobacco use in prison and possible influences of the prison environment on smoking among inmates in the context of developing inmate smoking cessation programmes.

METHOD

Qualitative study based on seven focus groups with prisoners and ex-prisoners.

SETTINGS

A maximum security prison in rural New South Wales (NSW), Australia, and a community justice restorative centre and accommodation service for ex-prisoners in Sydney, NSW, Australia.

PARTICIPANTS

40 participants (28 men and 12 women) comprising nine prisoners (including four Indigenous inmates) and 31 ex-prisoners.

RESULTS

Prisoners reported that tobacco serves as a de facto currency in correctional settings and can be exchanged for goods, used to pay debts and for gambling. Smoking helps manage the stressful situations such as transfers, court appearances and prison visits. Inmate smoking cessation programmes need to address the enmeshment of tobacco in prison life, improve availability of pharmacotherapies (for example, nicotine patches, bupropion) and the quitline (a free telephone helpline providing information on stopping smoking), provide non-smoking cells and areas within prisons, encourage physical activity for inmates and maintain monitoring of smoking cessation status after release.

CONCLUSIONS

Tobacco is integrally bound up in the prison "culture". Our findings are relevant to inform prison health authorities concerned with improving the health of prisoners, and for support organisations attempting to facilitate smoking cessation both in prison and after release. Smoking cessation programmes in prisons should be tailored to the unique stresses of the prison environment. Programmes need to acknowledge the difficulties of quitting smoking in prison arising from the stresses posed by this setting.

Going soft on evidence and due process: Canada adopts US style harm maximization

After recently adopting a US style drug policy, the Canadian government rejected the recommendations of an independent review of Vancouver's Safer Injecting Facility and ignored the compelling supportive evidence in apparent readiness to close the centre.

Injecting nation: achieving control of hepatitis C in Australia

Since Australia banned heroin in 1953 consumption of illicit drugs, deaths, crime and corruption related to drugs have steadily increased. Injecting drug use (IDU) in Australia is now a significant public health problem linked each year to approximately 500 overdose deaths and more than 6000 hepatitis C infections. At least 85% of prevalent and incident hepatitis C cases in Australia are injecting drug users (IDUs) with annual incidence estimated at 15%. Although poorly documented, increasing numbers of patients with end-stage liver disease from hepatitis C now appear to present in Australia. This reflects a heroin-injecting epidemic commencing a quarter of a century ago, the close association between drug injecting and hepatitis C and the long delay between hepatitis C infection and complications. The overall health and economic burden of hepatitis C may soon exceed HIV. Control is far more difficult to achieve for hepatitis C than HIV because of much higher baseline prevalence levels and far greater infectiousness by blood to blood spread. Transmission appears to follow minimal breaches of infection control guidelines. Hepatitis C has not yet become a priority public health issue in Australia. No national prevention strategy has been proposed. Prevention strategies (such as needle exchange or methadone) which controlled HIV among IDUs should be expanded, with the expectation of some useful reduction of spread but without achieving control of hepatitis C. Other options for control must be considered. Eradicating illicit drug use in Australia is unachievable. Virtually eradicating injecting drug use by facilitating a switch to non-injecting routes of administration (NIROA) is achievable (although difficult) and this could control hepatitis C. NIROA will have the probable additional benefit of reducing drug overdose deaths. NIROA has begun recently to replace injecting in several countries without government intervention. Powerful cultural, pharmacological and economic factors strongly reinforce drug injecting. Economic impediments to NIROA could be reduced by drug policy reform. Facilitating a switch to NIROA carries some risk of increased discrimination directed against an already marginalized population. A major obstacle to harm reduction is the common assumption that any relaxation of drug policy invariably leads to increased consumption. Switching the predominant route of administration of illicit drugs from IDU to NIROA should be the major focus of national efforts to control hepatitis C and overdose deaths in Australia.

Pilot randomized controlled study of dexamphetamine substitution for amphetamine dependence

AIMS

To test the feasibility of conducting a definitive randomized controlled trial of dexamphetamine substitution for amphetamine dependent people and provide preliminary data.

DESIGN

An open, two-group pre-post randomized controlled trial.

PARTICIPANTS

Forty-one long-term, dependent amphetamine users seeking treatment.

INTERVENTION

Twenty subjects were offered weekly counselling. Twenty-one subjects were, in addition, prescribed up to 60 mg dexamphetamine daily.

MEASUREMENTS

Immunoassay and mass spectrometric urinalysis techniques were used to identify the presence of amphetamine and methylamphetamine in urine. The Opiate Treatment Index and Severity of Dependence Scale were used to collect pre- and post-self-report data. Subjects were screened using the Composite International Diagnostic Interview.

FINDINGS

Reduced street amphetamine use and amphetamine dependence was observed both in subjects prescribed dexamphetamine and subjects receiving counselling only. Treatment subjects appeared more likely to attend counselling.

CONCLUSIONS

A definitive randomized controlled trial of dexamphetamine substitution using the techniques and instruments piloted in this study is feasible. Users appeared to be attracted and retained in substitution treatment. The intervention also appeared to be acceptable to clinicians.

Evaluation of a workplace brief intervention for excessive alcohol consumption: the workscreen project

BACKGROUND

The workplace provides a useful setting for early identification and intervention with individuals who have unhealthy lifestyles. The objective was to evaluate the effects of a workplace-based lifestyle intervention (Workscreen) to reduce excessive drinking.

METHOD

There were eight Australia Post networks randomly allocated to experimental and control conditions, comprising 67 worksites and 1206 employees. The experimental condition involved a broad spectrum lifestyle campaign, incorporating support from management, employee awareness of health, and brief interventions for high-risk behaviors, including excessive alcohol use. Focus groups identified relevant cultural factors. Changes in workplace culture and employee behavior were assessed 10 months after baseline. Males and females were analyzed separately.

RESULTS

Over half of APOST employees participated at each screening point. In the experimental condition 61% of employees overall and 58% of those identified as excessive drinkers in Phase 1 responded to the lifestyle campaign by attending health assessments. Analyses focusing on the organization as a whole did not reveal significant reductions in excessive alcohol consumption among men or women. However, a significant reduction in number of drinks was observed in the experimental condition among women for whom completion of baseline and follow-up could be confirmed (P < 0.001).

CONCLUSIONS

The present study indicates that a workplace-based lifestyle campaign can assist self-selected employees in reducing their alcohol consumption. There was a moderately high level of participation among those identified as drinking excessively, which supports our approach of embedding a low-intensity alcohol program within the context of a broader health promotion campaign.

Quantitative and qualitative evaluations of brief interventions to change excessive drinking, smoking and stress in the police force

AIMS

To evaluate the effects of a brief intervention to reduce excessive drinking, smoking and stress among police.

DESIGN

(1) Controlled intervention trial with pre and post-intervention assessment approximately 8 months apart; (2) focus group identification of relevant factors).

SETTING, PARTICIPANTS

Assessment was carried out of 954 NSW (Australia) police at 19 stations within two matched districts in the Sydney metropolitan area. Five focus groups were carried out with 43 randomly selected police from the matched districts.

MEASUREMENTS

Weekly alcohol consumption and binge drinking, smoking and symptoms of stress were measured by a self-administered Health and Fitness Questionnaire. Recorded responses to set questions provided qualitative data.

RESULTS

Participation was high (89%) at both quantitative assessments. Alcohol consumptions, particularly among men, was high at both baseline and follow-up assessments, although comparisons between groups across occasions showed no significant intervention effects. Excessive drinkers and those reporting moderate to severe stress levels reported more sick leave days (p < 0.05, p < 0.05). A significant increase in awareness of alcohol policies in the work-place showed in both experimental and control groups over time (p < 0.01). The percentage of smokers declined significantly in both intervention and control groups. Overall, women had significantly more symptoms of stress than men. Only 20% of police thought they would seek advice from work-place staff about alcohol consumption, 14% for smoking and 61% for stress. In the qualitative study, employees generally distrusted their organization's involvement in health unless work performance was affected. Seeking professional assistance for life-style issues was viewed as a sign of weakness. Alcohol use was seen as a way of obtaining information or group membership, self-medication and socializing.

CONCLUSIONS

The brief interventions did not produce significant improvements in three life-style factors beyond positive trends in alcohol consumption among women and general reductions in smoking among both study groups. Combining quantitative and qualitative approaches helped identify interactive individual and organizational factors which influence behavioural and cultural norms.

HIV transmission in a prison system in an Australian State

OBJECTIVE

To investigate possible HIV transmission among prison inmates.

SETTING

A prison system in an Australian State.

PARTICIPANTS

13 ex-prisoners and their prison contacts.

METHODS

Ex-prisoners who claimed to have been infected with HIV in prison and their prison contacts were interviewed about HIV risk behaviour. Entries in prison and community medical records were used by a three-member expert panel to establish the likelihood of primary HIV infection and its possible timing and location.

MAIN OUTCOME MEASURES

Determination of whether HIV infection probably occurred in prison.

RESULTS

There was a very high probability that at least four of 13 ex-prisoners investigated acquired HIV in prison from shared injection equipment. Another two ex-prisoners most probably acquired HIV infection outside prison. The location of infection for the remaining seven could not be determined.

CONCLUSIONS

HIV transmission in prison has substantial public health implications as most drug-using prisoners soon return to the community. HIV prevention strategies known to be effective in community settings, such as methadone maintenance treatment and syringe exchange schemes, should be considered for prisoners.

HIV and HCV prevalence among trawler crew

A survey of 51 people who work on trawlers was carried out to describe injecting and sexual behaviour and the prevalence of HIV and HCV antibody. All crew members who were departing from an Australian port during the last week of February 1996 to work on trawlers were asked to complete a brief, self-administered questionnaire and provide a finger prick blood sample. Questionnaires were received from 51 (77%) and blood samples from 45 (68%) of the 66 crew from 15 vessels. Almost half the respondents reported ever injecting illicit drugs. No respondents had HIV antibody while 27% had HCV antibody detected. Among 20 injecting drug user (IDU) respondents, the prevalence of HCV was 55% (95% CI 32%-77%). Twelve respondents reported new sex partners in the past month of whom half reported no condom use with these sex partners. The survey emphasises the diversity of the IDU population in Australia. Yet it would appear that regardless of the sub-population surveyed that HCV is endemic among IDUs in Australia. Effective HCV prevention programs targeted specifically for these (and other) sub-populations of IDUs should be devised.

How healthy are the police? A survey of life-style factors

AIMS

To examine the prevalence of five life-style behaviours among New South Wales police.

DESIGN

A cross-sectional survey using a self-administered questionnaire.

SETTING AND PARTICIPANTS

A total of 852 police were recruited from metropolitan Sydney.

MEASUREMENTS

Prevalence related to age and sex of self-reported alcohol consumption, cigarette smoking, inadequate exercise, perception of overweight and stress symptoms.

RESULTS

A high level (89%) of participation was achieved in the survey. Almost half (48%) of males and more than two-fifths (40%) of females consumed alcohol excessively including continuous hazardous or harmful consumption and binge drinking. Excessive drinking was more prevalent among younger police. There were 8% of male and 15% of female police who reported that they did not drink alcohol. Over one-quarter (27%) of male and one-third (32%) of female respondents reported smoking. Almost half (46%) of men and women (47%) believed that they were overweight. More than one-fifth (21%) of men and less than one-quarter (24%) of women reported that they did not exercise. Finally, 12% of men and 15% of women reported feeling moderate to severe symptoms of stress.

CONCLUSIONS

The police work-force offers an opportunity to screen for a large number of healthy, young and high risk individuals (particularly men) who are hard to reach in other settings and who rarely visit their general practitioner. A sizeable majority (83%) of NSW police had at least one unhealthy life-style behaviour with 19% reporting 3-5 unhealthy factors. The high prevalence of excessive alcohol consumption among police is of particular concern. More active health promotion and provision of brief interventions among police may reduce morbidity and mortality associated with unhealthy life-styles.

Aspects of care for the hepatitis C positive patient

BACKGROUND

With almost 200,000 infected Australians, hepatitis C is Australia's commonest life threatening chronic infection.

OBJECTIVE

Over 90% of the 11,000 new infections in Australia each year are associated with injecting drug use. Australia does not have a national plan for achieving control of hepatitis C. Treatment at present is expensive, less effective than many other conditions and associated with considerable side effects.

DISCUSSION

Most people with chronic hepatitis C infection have a normal life expectancy with good quality of life. The role of general practitioners in prevention and treatment is increasing.

Screening for unhealthy lifestyle factors in the workplace

OBJECTIVE

To examine (1) the prevalence of four lifestyle behaviours among Australia Post employees and (2) employees' perceptions of the role of the workplace in promotion of lifestyle change.

DESIGN

A cross-sectional survey using a self-administered questionnaire involved 688 employees working in Australia Post throughout metropolitan Sydney.

MAIN OUTCOME MEASURES

Prevalence related to age and sex of alcohol consumption, cigarette smoking, inadequate exercise, perception of excessive weight.

RESULTS

36% of men and 11% of women reported drinking alcohol at levels considered hazardous or harmful; 33% of men and 25% of women reported smoking; 51% of men and 62% of women thought they were overweight; 30% of men and 39% of women did not exercise regularly. Younger respondents were more likely to report drinking hazardously or harmfully, were smokers and had multiple risk factors. A majority of respondents thought that their employer should be interested in employee's lifestyle issues, particularly excessive drinking (63%). However, few considered seeking advice from the workplace regarding smoking (16%), weight (25%) and excessive alcohol consumption (12%).

CONCLUSIONS

These results show that many of Australia Post employees have unhealthy lifestyle behaviours. While employees perceive that the workplace has an important role in promoting healthy lifestyles among staff, few are presently willing to seek advice from the workplace regarding these issues. Promotion of healthy lifestyles in Australian workplaces is a potentially important public health advance that could reduce the incidence of diseases associated with high-risk lifestyle behaviours.

A mathematical model of HIV transmission in NSW prisons

A mathematical model was developed to estimate HIV incidence in NSW prisons. Data included: duration of imprisonment; number of inmates using each needle; lower and higher number of shared injections per IDU per week; proportion of IDUs using bleach; efficacy of bleach; HIV prevalence and probability of infection. HIV prevalence in IDUs in prison was estimated to have risen from 0.8 to 6.7% (12.2%) over 180 weeks when using lower (and higher) values for frequency of shared injections. The estimated minimum (and maximum) number of IDU inmates, infected with HIV in NSW prisons was 38 (and 152) in 1993 according to the model. These figures require confirmation by seroincidence studies.

Effect of training on general practitioners' use of a brief intervention for excessive drinkers

OBJECTIVE

To determine among general practitioners (GPs) the effect of three different types of training on utilisation of a brief, controlled drinking intervention.

DESIGN

A non-randomised intervention study. Setting, participants: 96 GPs (64%) within the South Eastern Sydney Division of General Practice participated; 35 chose workshop training, 39 one-to-one training and 22 received a special kit by mail.

MAIN OUTCOME MEASURES

Identification by GPs of excessive drinkers by practice audits; use of the program determined by the number of patients recruited in 3 months and by GPs' use of the intervention 6 months after training.

RESULTS

41 (43%) GPs conducted practice audits, identifying 15.1% of males and 6.6% of females as excessive drinkers (regular excessive weekly consumption and/or binge). 179 patients were recruited by 36 GPs over 3 months, and 32% of these patients reported a reduction of alcohol consumption. 63% who attended workshop training, 57% who received one-to-one training, and 36% who received the kit by mail reported they were current users of the program at 6 months. Significantly fewer GPs who received the kit by mail reported ever using the program (59%) compared to the other groups (p < 0.01).

CONCLUSION

This naturalistic study found that workshops and one-to-one training sessions in doctors' surgeries achieved greater uptake of a brief intervention for problem drinkers than distribution of a special kit by mail.

Epidemiology of hepatitis C virus infection among injecting drug users in Australia

STUDY OBJECTIVE

To review the epidemiology of hepatitis C virus (HCV) infection among injecting drug users (IDUs) in Australia, and consider needs for further research and prevention policies and programmes.

DESIGN

(1) Review of the results of surveillance for HCV; (2) review of published literature on prevalence, incidence, and risk factors for HCV among IDUs; and (3) reconstruction of incidence rates from prevalence studies of HCV in IDUs.

SETTING AND PARTICIPANTS

Field and clinic based studies of IDUs in Australia.

MAIN RESULTS

HCV has been present at high prevalences (of the order of 60-70%) in populations of Australian IDUs since at least 1971. Duration of injecting and main drug injected were the main predictors of seropositivity, the latter possibly a surrogate for frequency of injecting and both together as surrogate for cumulative numbers of times injected. Risk of infection begins with first injection and continues as long as injecting does. Current incidence is approximately 15 per 100 person years, and up to 40 per 100 person years in some subpopulations. Incidence may have decreased through the 1980s as a result of behaviour change in relation to HIV, as it has for hepatitis B, but not significantly so.

CONCLUSIONS

Control of HCV infection in Australia will depend on effectiveness of measures to control HCV spread among IDUs. This will be a greater challenge than the control of HIV in this population has been. Needs identified include improved surveillance, especially for recently acquired infection, better understanding of exact transmission modes, and urgent improvement in prevention strategies.

Pharmacokinetic and pharmacodynamic principles of illicit drug use and treatment of illicit drug users

Many clinicians are confronted by the use of illicit drugs on a daily basis. The unsanctioned use of opioids, psychostimulants, benzodiazepines, alcohol and nicotine is a major cause of morbidity and mortality. Multiple factors have inhibited the scientific study of these agents including prohibition, public denial and lack of commercial interests. In dealing with problems related to these drugs, clinicians need a scientific understanding of their pharmacology, quantifiable effects and potential adverse effects. Illicit drug users select drugs with particular pharmacokinetic parameters and pharmacodynamic properties. Generally, rapid absorption, rapid entry into the central nervous system, high bioavailability, short half-life, small volume of distribution and high free drug clearance are pharmacokinetic characteristics which predict a high potential for harmful use because these factors increase positive reinforcement. Drug users adapt the method and route of drug administration to optimise the delivery of the drug to the brain while attempting to maximise the bioavailability of the drug. Inhalation and smoking are the routes of administration which allow the most rapid delivery of drug to the brain, while intravenous injection maximises the bioavailability of an administered drug. Each route of administration results in attendant complications related to mucosal damage, carcinogenesis and risk of infection. Negative reinforcement or withdrawal is a major drive to recurrent use. Many illicit drugs have pharmacological features that promote dependence, including long half-life, low free drug clearance and sufficient drug exposure to allow development of tolerance. The preventive or reductive pharmacotherapeutics of illicit drug use makes use of several subsets of agents: those which act on the same receptor or system as the illicit drug (such as methadone), those which produce an adverse reaction on consumption of the illicit drug (such as disulfiram) and those which symptomatically attenuate illicit drug withdrawal symptoms (such as clonidine). Many new agents are being trialled as potential preventive or reductive agents. It is important to consider pharmacotherapy as only one potential part of the treatment of illicit drug users. The complications of illicit drug use present many therapeutic challenges. As with all patients consuming multiple drugs, illicit drug users are prone to developing drug interactions. The most common interactions seen in practice are pharmacodynamic in nature, most often due to the additive effects of different drugs on the central nervous system. However, alcohol, cocaine, disulfiram, methadone and tricyclic antidepressants may be involved in important pharmacokinetic interactions. Of these the effect of long term alcohol consumption in increasing the hepatotoxicity of paracetamol and of cytochrome P450 3A microsomal enzyme stimulating drugs in diminishing the efficacy of methadone are the most commonly encountered.

Managing HIV. Part 8: Controlling an epidemic. 8.5 HIV prevention in the community: injecting drug users

Increasing HIV transmission among drug users has often been the prelude to a wider epidemic in the community, but not in Australia, where successful preventive strategies have been applied. The weak link in these efforts has been in the prisons, which may become epidemic hotspots.