Alex Wodak

Global epidemiology of injecting drug use and HIV among people who inject drugs: a systematic review

BACKGROUND Injecting drug use is an increasingly important cause of HIV transmission in most countries worldwide. Our aim was to determine the prevalence of injecting drug use among individuals aged 15-64 years, and of HIV among people who inject drugs. METHODS We did a systematic search of peer-reviewed (Medline, EmBase, and PubMed/BioMed Central), internet, and grey literature databases; and data requests were made to UN agencies and international experts. 11 022 documents were reviewed, graded, and catalogued by the Reference Group to the UN on HIV and Injecting Drug Use. FINDINGS Injecting drug use was identified in 148 countries; data for the extent of injecting drug use was absent for many countries in Africa, the Middle East, and Latin America. The presence of HIV infection among injectors had been reported in 120 of these countries. Prevalence estimates of injecting drug use could be ascertained for 61 countries, containing 77% of the worlds total population aged 15-64 years. Extrapolated estimates suggest that 15.9 million (range 11.0-21.2 million) people might inject drugs worldwide; the largest numbers of injectors were found in China, the USA, and Russia, where mid-estimates of HIV prevalence among injectors were 12%, 16%, and 37%, respectively. HIV prevalence among injecting drug users was 20-40% in five countries and over 40% in nine. We estimate that, worldwide, about 3.0 million (range 0.8-6.6 million) people who inject drugs might be HIV positive. INTERPRETATION The number of countries in which the injection of drugs has been reported has increased over the last decade. The high prevalence of HIV among many populations of injecting drug users represents a substantial global health challenge. However, existing data are far from adequate, in both quality and quantity, particularly in view of the increasing importance of injecting drug use as a mode of HIV transmission in many regions.

Meth/amphetamine use and associated HIV: Implications for global policy and public health

Amphetamine type stimulants (ATS) have become the focus of increasing attention worldwide. There are understandable concerns over potential harms including the transmission of HIV. However, there have been no previous global reviews of the extent to which these drugs are injected or levels of HIV among users. A comprehensive search of the international peer-reviewed and grey literature was undertaken. Multiple electronic databases were searched and documents and datasets were provided by UN agencies and key experts from around the world in response to requests for information on the epidemiology of use. Amphetamine or methamphetamine (meth/amphetamine, M/A) use was documented in 110 countries, and injection in 60 of those. Use may be more prevalent in East and South East Asia, North America, South Africa, New Zealand, Australia and a number of European countries. In countries where the crystalline form is available, evidence suggests users are more likely to smoke or inject the drug; in such countries, higher levels of dependence may be occurring. Equivocal evidence exists as to whether people who inject M/A are at differing risk of HIV infection than other drug injectors; few countries document HIV prevalence/incidence among M/A injectors. High risk sexual behaviour among M/A users may contribute to increased risk of HIV infection, but available evidence is not sufficient to determine if the association is causal. A range of possible responses to M/A use and harm are discussed, ranging from supply and precursor control, to demand and harm reduction. Evidence suggests that complex issues surround M/A, requiring novel and sophisticated approaches, which have not yet been met with sufficient investment of time or resources to address them. Significant levels of M/A in many countries require a response to reduce harms that in many cases remain poorly understood. More active models of engagement with M/A users and provision of services that meet their specific needs are required.

Should smoking be banned in prisons

Consequences and effectiveness Tobacco smoking is an integral part of prison life and an established part of the prison culture. Tobacco serves a range of functions in prison: as a surrogate currency, a means of social control, as a symbol of freedom in a group with few rights and privileges, a stress reliever and as a social lubricant. Smoking bans in prison have gained favour in recent times, particularly in North America.1–3 Fear of legal action by non-smoking prison staff and other inmates appears to be the main driver rather than public health concerns. Prisons are some of the few places in the Western world where smoking is still allowed in enclosed spaces. More recently, however, moves have been made to bring prisons in line with other public institutions through the use of partial or total smoking bans. While tobacco control strategies have successfully reduced smoking in the general community to below 20% in Australia, the rate among prisoners remains unacceptably high. In 1996 the overall prevalence of smoking among New South Wales (NSW) prisoners was a staggering 88%4 (compared with 27% in the community5) and in 2001 the prevalence was 90%6 (compared with 20% in the community7). Similar rates are reported in overseas prisoner health studies. Smoking is one of the most pernicious public health problems affecting prisons and one that all too often is ignored community based tobacco control strategies. Reasons for smoking rates remaining high in prisoner populations include high nicotine dependency, mental illness, a lack of smoking cessation programmes available to prisoners, a paucity of evidence regarding best practice for smoking cessation in this population segment, confusion over ownership of the problem between health departments and custodial authorities, and poor access by this group to smoking cessation programmes while in …

Hiv Risk Behaviour of Idus Before, During and After Imprisonment in New South Wales

Objectives: To assess risk behaviours of HIV infected and HIV negative Injecting Drug Users (IDUs) in and out of prison in New South Wales in a case control study.Methods: 25 (20 M, 5 F) cases and 160 (135 M, 25 F) controls were recruited in 1993. HIV status was determined by testing dried blood spots.Results: Cases and controls were similar on basic demographic characteristics. Reports of injecting by cases and controls were more common before entry (84%, 90%) and after prison discharge (60%, 80%) than during incarceration (44%, 44%). However, reported syringe sharing was more common during imprisonment (64%, 71%) than before entry (19%, 24%) and after prison discharge (20%, 15%). Male cases were significantly more likely to use condoms outside prison (44% vs 7%) but also to be sexually active in prison (60%, 6%) than male controls.Conclusions: This study indicates the potential for HIV transmission among IDUs in prison and following release. To prevent HIV transmission in prisons, prison methadone progr...

Sexually transmissible diseases in injecting drug users.

Self-reported histories of sexually transmissible diseases (STDs) and HIV serostatus were investigated as part of a study of HIV risk behaviour in a sample of 1245 Syndey injecting drug users (IDUs) (mean age 27.5 years) both in and out of treatment. A high lifetime prevalence of STDs was reported in both men and women. For male IDUs, the lowest reported lifetime prevalence of STDs was in heterosexuals, with bisexuals intermediate and homosexuals reporting the highest prevalence. HIV seroprevalence followed the same pattern. For women, bisexuals had the highest reported STD history, heterosexual women were intermediate and homosexual women reported the lowest prevalence. Over one third of the bisexual women reported having been involved in prostitution. These data indicate that over one third of IDU men and over half of IDU women reported at least one STD in their lifetime. The high lifetime prevalence of STDs in IDUs indicates that this group is at increased risk of sexual transmission of HIV, given the importance of STDs as a cofactor. Reducing the prevalence of STDs in IDUs is a possible additional strategy to diminish the spread of HIV among IDUs and from them to non-IDU sexual contacts.

Census of Patients Receiving Methadone Treatment in a General Practice

Objectives: To describe the demographic characteristics, drug use and treatment outcomes of 121 patients currently receiving methadone treatment in an experienced inner-city general medical practice in Sydney, Australia. Methods: In a cross sectional survey of all patients receiving methadone treatment, self-reported data were collected by administered questionnaire. Results were corroborated with supervised urine tests, medical records and other documentary evidence wherever practicable.Results: Sixty-eight patients (56%) reported no heroin use in the previous six months. The mean duration opi-oid-free was 17 months. Morphine (heroin metabolite) was detected in 75 (7.4%) of 1009 random, supervised urine tests from 114 patients in a six month period. Employment rate increased substantially (28% vs. 56%). Patients age, dose, duration in treatment, prison history and seroprevalence rates of HCV and HIV were found to be comparable with data from other reported experience.Conclusion: Outcomes from general pr...

The Swiss heroin trials

Editor—Farrell and Hall seem to have misunderstood the importance of the Swiss trials of heroin on prescription for addicts. The call for a clinical trial of heroin versus methadone is irrelevant as these drugs cater for different segments of the addict population; no one suggests stopping methadone clinics. It is self evident that prescribing heroin will attract addicts who need the “buzz” and will not switch to methadone. These include dealers and pushers and those who succeed in obtaining funds through crime. Methadone clinics attract newer rather than hard core addicts. A logical policy for decriminalising heroin under medical supervision would have four steps: giving prescriptions of heroin to all addicts in or out of prison (which would gradually put criminals out of business); providing methadone clinics for those who will switch; weaning the addicts off the drugs; and providing a follow up programme to minimise relapse. The trial that is needed would compare a city region or country adopting this approach with a similar community continuing the existing policy of prohibition. This policy has already failed for the same reason that prohibition failed in the United States: it created an opportunity for the criminal mafias who dominate the drug scene. The end points of a comparative trial should not be narrowly defined as conceived by Farrell and Hall; they should include the numbers of new addicts, mortality and morbidity among addicts and former addicts, the impact on spread of HIV infection and hepatitis B both inside and outside prisons, and statistics for drug related crime (allegedly reduced by 60% in the Swiss trials). The economic gain to the community from heroin clinics will include the street price forgone by the clinics’ clients, which would otherwise be stolen from members of the community. This is a massive gain over and above the similar gain from methadone clinics. The time has come for the medical management of heroin addicts to be submitted to the disciplines of clinical pharmacology and epidemiology, including, ideally, randomised controlled trials. Apart from the impact on problems caused by hard drugs, the new approach will be essential for resolving issues surrounding soft drugs. Marijuana is safer than alcohol or tobacco, but legalisation is inhibited by the fear that pushers of hard drugs can recruit users of soft drugs.

Heroin use and HIV risk-taking behaviour among women injecting drug users

This study compares drug use, injecting and sexual risk-taking behaviour among pregnant injecting drug users (IDUs) enrolled in methadone maintenance treatment (MMT), non-pregnant women IDUs enrolled in MMT and women IDUs not enrolled in treatment. There was no significant difference between pregnant IDUs enrolled in MMT and women IDUs not enrolled in treatment in terms of their injecting risk-taking behaviour. Both groups reported significantly higher levels of injecting risk-taking behaviour compared to (non-pregnant) women enrolled in MMT. Pregnant women enrolled in MMT reported a significantly lower methadone dose compared to non-pregnant women in MMT. There was a trend for pregnant women enrolled in MMT to report a higher level of heroin use compared to non-pregnant women in MMT. The lack of evidence for a difference in level of injecting risk-taking behaviour between pregnant IDUs enrolled in MMT and women IDUs not enrolled in treatment suggests the need for additional strategies among pregnant IDUs to reduce IDU and injecting risk-taking behaviour. Possible strategies include maintenance on higher doses of methadone and the application of relapse prevention strategies.

Recommendation by a law body to ban infant male circumcision has serious worldwide implications for pediatric practice and human rights

BackgroundRecent attempts in the USA and Europe to ban the circumcision of male children have been unsuccessful. Of current concern is a report by the Tasmanian Law Reform Institute (TLRI) recommending that non-therapeutic circumcision be prohibited, with parents and doctors risking criminal sanctions except where the parents have strong religious and ethnic ties to circumcision. The acceptance of this recommendation would create a precedent for legislation elsewhere in the world, thereby posing a threat to pediatric practice, parental responsibilities and freedoms, and public health.DiscussionThe TLRI report ignores the scientific consensus within medical literature about circumcision. It contains legal and ethical arguments that are seriously flawed. Dispassionate ethical arguments and the United Nations Convention on the Rights of the Child are consistent with parents being permitted to authorize circumcision for their male child. Uncritical acceptance of the TLRI report’s recommendations would strengthen and legitimize efforts to ban childhood male circumcision not just in Australia, but in other countries as well. The medical profession should be concerned about any attempt to criminalize a well-accepted and evidence-based medical procedure. The recommendations are illogical, pose potential dangers and seem unworkable in practice. There is no explanation of how the State could impose criminal charges against doctors and parents, nor of how such a punitive apparatus could be structured, nor how strength of ethnic or religious ties could be determined. The proposal could easily be used inappropriately, and discriminates against parents not tied to the religions specified. With time, religious exemptions could subsequently be overturned. The law, governments and the medical profession should reject the TLRI recommendations, especially since the recent affirmative infant male circumcision policy statement by the American Academy of Pediatrics attests to the significant individual and public health benefits and low risk of infant male circumcision.SummaryDoctors should be allowed to perform medical procedures based on sound evidence of effectiveness and safety with guaranteed protection. Parents should be free to act in the best interests of the health of their infant son by having him circumcised should they choose.

The US war on harm reduction: fixing policy on intelligence and facts

At a two-day private meeting in Tokyo in June 2005, some of Japans most senior politicians and powerbrokers met to consider the steadily expanding HIV/AIDS epidemic. AIDS has recently become a matter of increasing concern in Japan following an HIV epidemic in several major Japanese cities among Japanese men having sex with men at sex-on-premises venues. The Japanese elites at the Tokyo meeting were shocked to learn that the United States has by far the highest annual AIDS incidence among OECD countries at 15/100,000 [1]. Spain, with an annual AIDS incidence of 3.3/100,000, has the second highest rate among industrialized countries, while Australia was well down the ranking with an incidence only one tenth that of the United States at 1.5/100,000 [1].