Harm reduction
Wodak A, McLeod L. The role of harm reduction in controlling HIV among injecting drug users. AIDS. 2008;Suppl 2:S81-92.
Injecting drug users now account for one in 10 new HIV infections world wide. Yet it has been known since the early 1990s that HIV among injecting drug users can be effectively, safely and cost-effectively controlled by the early and vigorous implementation of a comprehensive package of strategies known as 'harm reduction'. This concept means that decreasing drug-related harms is accorded an even higher priority than reduction of drug consumption. Strategies required involve: explicit and peer-based education about the risk of HIV from sharing injecting equipment; needle syringe programmes; drug treatment (including especially opiate substitution treatment), and community development. Many countries experiencing or threatened by an HIV epidemic among injecting drug users have now adopted harm reduction but often implementation has been too little and too late. Although coverage is slowly improving in many countries, HIV is still spreading faster among injecting drug users than harm reduction programmes while coverage in correctional centres lags far behind community settings. The scientific debate about harm reduction is now over. National and international support for harm reduction is growing while almost all the major UN organizations responsible for drug policy now support harm reduction. Only a small number of countries, led by the USA, are still vehemently opposed to harm reduction. Excessive reliance on drug law enforcement remains the major barrier to increased adoption of harm reduction. Sometimes zealous drug law enforcement undermines harm reduction. A more balanced approach to drug law enforcement is required with illicit drug use recognized primarily as a health and social problem.
Editor’s Note: With injecting drug use reported from 144 countries, of which 128 have detected HIV among injecting drug users, the pragmatic approach of harm reduction must be scalled-up deliberately and rapidly around the world. It is no longer conscionable to deny access to sterile needles and syringes and to substitution treatment for injecting drug uses in the face of the evidence of their effectiveness in reducing HIV infection. Promotion and protecting the human rights of injecting drug users underpin effective public health responses to stem the HIV epidemic among them. There is no time to lose.
Gowing L, Farrell M, Bornemann R, Sullivan L, Ali R. Substitution treatment of injecting opioid users for prevention of HIV infection. Cochrane Database Syst Rev. 2008;(2):CD004145.
Injecting drug users are vulnerable to infection with HIV and other blood borne viruses as a result of collective use of injecting equipment as well as sexual behaviour. Gowing and co-authors aimed to assess the effect of oral substitution treatment for opioid-dependent injecting drug users on rates of HIV infections,and high risk behaviours. They searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and PsycINFO to March 2007. They also searched reference lists of articles, reviews, and conference abstracts. Studies were required to consider the incidence of risk behaviours, or the incidence of HIV infection related to substitution treatment of opioid dependence. All types of original studies were considered. Two reviewers independently assessed studies for inclusion. One reviewer extracted data from included studies, assessed quality, and confirmed decisions by consulting with all other reviewers. The authors included thirty-three studies, involving 10,400 participants. The majority were not randomised controlled studies and there were problems of confounding and bias. The studies varied in several aspects limiting the extent of quantitative analysis. Studies consistently showed that oral substitution treatment for opioid-dependent injecting drug users was associated with statistically significant reductions in illicit opioid use, injecting use, and sharing of injecting equipment. It was also associated with reductions in the proportion of injecting drug users reporting multiple sex partners or exchanges of sex for drugs or money, but had little effect on condom use. It appears that the reductions in risk behaviours related to drug use do translate into reductions in cases of HIV infection. The authors conclude that oral substitution treatment for injecting opioid users reduces drug-related behaviours with a high risk of HIV transmission, but has less effect on sex-related risk behaviours. The lack of data from randomised controlled studies limits the strength of the evidence presented in this review.
Post new comment