Needleexchange programs

Prevention and harm-reduction strategies face many of the same obstacles as drug treatment strategies. In general, harm reduction refers to strategies for reducing the harm associated with drug use, with emphasis on HIV and hepatitis. Central to the principle of harm reduction is that this is possible without requiring abstinence or a reduction in drug use itself (Heather et al, 1993). Harm-reduction programs have been increasingly seen in developing countries, where a range of differing activities to decrease needle sharing and other unsafe injecting behavior has been developed (Crofts, 1999). Harm-reduction programs have typically been accompanied by reductions in rates of HIV transmission, and are more cost-effective than interdiction or incarceration of addicts, yet these programs remain controversial and present challenges to communities and governments (Crofts, 1999; Deany and Crofts, 2000). For example, there is consistent evidence that provision of clean needles and injecting equipment can halt or even reverse HIV/AIDS epidemics among injection drug users (Hurley et al, 1997; Drucker et al, 1998). Examples of effective programs come from Sydney, Glasgow, and Toronto. Needle-exchange programs reduce disease transmission directly by lowering rates of needle sharing and decreasing the prevalence of HIV among needles available for sharing, and also indirectly through provision of services including bleach distribution, referrals to drug treatment, provision of condoms, and education about risk behavior. An ecological study of 81 cities worldwide comparing those with and without needle-exchange programs found that the average seroprevalence increased by 5.9 percent per year in 52 cities without such programs, and decreased by 5.8 percent per year in 29 cities with programs (Hurley et al., 1997). Further evidence suggests that HIV epidemics have been less explosive in cities and countries where needle-exchange programs have been established earlier in the epidemic. The role of such programs in preventing both HCV and HBV transmission has been far more controversial. Since most injection drug users acquire HCV and HBV earlier than HIV, in many places needle-exchange programs were established too late to be effective against HBV and HCV (Hagan et al, 1999). However, in places where programs were established early, some success against HBV and HCV has been observed (Taylor et al, 2000; Hope et al, 2001). This is evidenced by a study in Glasgow, where the prevalence of HCV was significantly lower among injectors who initiated injection after rather than before the establishment of the needle-exchange program (Taylor et al, 2000).

Yet despite this overwhelming evidence, the establishment of needle-exchange programs has often occurred too late in the course of an epidemic - well after the explosive spread of HIV - when reversal of the epidemic may not be possible. This has been the case in many countries in Eastern Europe. In 2002 in Togliatti City, Russia, where a dramatic increase in HIV prevalence between 2000 and 2002 was observed, less than 8 percent of injection drug users in one study obtained needles from the needle-exchange program (Rhodes et al., 2002).

Safe injection facilities represent yet another effective harm-reduction tool. While these programs were initiated in Europe as early as 1970, in Amsterdam, the first safe injection facility in North America was opened in Vancouver in 2003 (Kerr, 2003; Kimber et al., 2003). Within this facility, injection drug users can access sterile injection equipment, inject pre-obtained illicit drugs under the supervision of nurses, and also access nursing care and addiction counseling. These facilities enable use of pre-obtained drugs in a safe and anxiety-free atmosphere under hygienic and low-risk conditions (Kerr, 2003). A study from Vancouver showed that the use of medically supervised safer injection facility was associated with reduced syringe sharing in a community-based sample of injection drug users who reported similar rates of needle sharing before the opening of the facility (Kerr et al., 2005, 2006). These facilities exist in Canada and some parts of Europe and Australia, but to date have not been adopted elsewhere and are likely to face the same type of political resistance encountered by MMT and needle-exchange programs.

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