Gillian M. Hunter

Changes in the injecting risk behaviour of injecting drug users in London, 1990-1993

Objective: To describe changes in the injecting risk behaviour of injecting drug users (IDU) in London between 1990 and 1993. Design: Injecting risk behaviour was measured over 4 years (1990‐1993) in a serial point HIV prevalence study of 2062 IDU recruited in both drug treatment and non‐treatment community‐based settings within greater London. The study used a structured questionnaire and common sampling and interview strategy developed by a World Health Organization technical group and implemented in 13 cities. Methods: Log‐linear models were used to assess patterns of change over years and of differences in injecting risk behaviour, including syringe sharing and syringe hygiene between 1990 and 1993. The log likelihood X2 statistic, G2, was used to test statistical significance. Changes in the mean values were assessed first using parametric tests assuming normality and the results were compared with Kruskal‐Wallis (non‐parametric) tests. Pearsons X2 was used to measure differences in frequency of sharing occasions and partner selectivity. Results: An overall reduction in injecting risk behaviour was observed during the first 2 years of this study, including a decline in syringe sharing (both accepting and passing on used syringes), the number of sharing partners and the frequency of sharing occasions. Most sharers restricted sharing to sexual partners and close friends. The majority of sharers reported always cleaning injecting equipment. Main source of sterile equipment was pharmacies and syringe exchanges. Indirect sharing (of spoons, filters, and by front‐ or backloading) was reported. Since 1991 there has been a stabilization in risk behaviour. Conclusions: The data indicate that IDU in London have made positive reductions in risk behaviour. Levels of syringe sharing were substantially lower than those reported up to 1987 before AIDS awareness and the introduction of HIV prevention measures. The majority did not share syringes or confined their sharing to close friends and sexual partners, and if shared, cleaned their syringes. Continuation of indirect sharing indicates the need for more detailed prevention messages. While the initial decline in syringe‐sharing rates may be attributed to the wide availability of sterile injecting equipment and other preventive measures, it may now be necessary to look beyond current intervention initiatives to develop interventions which seek to change the social etiquette of sharing and move towards the long‐term maintenance of low levels of injecting risk behaviour. AIDS 1995, 9:493‐501

Peer education as a means of drug prevention and education among young people: an evaluation

Peer education has become increasingly popular in Britain as a method of drug education and prevention for young people. Few initiatives nave undergone formal evaluation and the extent to which such programmes influence the drug use of young people is consequently unknown. The results from a process evaluation of a community based peer intervention are presented here. Research and evaluation took place between April 1995 and June 1996. Findings show that the intervention was successful in that drug information was disseminated to a wide cross-section of the target population including those who would Otherwise not have access to such information, for example parents and teachers. The evaluation found a considerable number of contacts made by the peer educators were through speaking to friends and distributing drug information leaflets. While it appears that contacts of this nature achieve increased levels of knowledge about drugs, it remains unclear how effective the intervention was in influencing the drug-using behaviour of young people currently involved in drug use. Until impact and outcome evaluations of peer intervention programmes have been completed, there is no clear evidence that peer education is a superior method of drug education and prevention in comparison to other approaches.

HIV prevalence and HIV risk behaviour among injecting drug users in London and Glasgow.

This paper reports on the British findings from a cross-national study of HIV prevalence and HIV risk behaviour among 1,037 injecting drug users (IDUs) recruited from a variety of treatment- and community-based settings during 1990. Confirmed HIV saliva test results show 12.8% (63) of London respondents and 1.8% (8) of Glasgow respondents to be HIV antibody positive. Among London respondents, a higher rate of prevalence was found in those with no experience of drug treatment. A greater proportion of Glasgow respondents (68%) than London respondents (47%) reported sharing used injecting equipment in the 6 months prior to interview. The majority (88% in both cities) attempted cleaning borrowed equipment, although less than a third (31% in London and 30% in Glasgow) usually used bleach. The majority of respondents (71% in London and 82% in Glasgow) were sexually active with partners of the opposite sex in the last 6 months, and respondents had a mean number of 2.4 non-commercial sexual partners in London and 2.1 in Glasgow. Levels of reported condom use were comparable with reports in the heterosexual population as a whole, with 70% of London respondents and 75% of Glasgow respondents never using condoms with primary partners, and 34% of London and 52% of Glasgow respondents never using condoms with casual partners. Half (48%) of London respondents and 42% of Glasgow respondents reported sexual intercourse with non-injecting private sexual partners, while 14% of female respondents in London and 22% in Glasgow had engaged in prostitution. Levels of risk-taking in each of the two cities indicate the potential for further transmission of HIV among drug injectors, and their sexual and sharing partners.

HIV-1 prevalence in community-wide samples of injecting drug users in London, 1990-1993.

Objective To provide time-trend estimates of HIV-1 prevalence among injecting drug users (IDU) in London. Design HIV-1 prevalence and HIV testing behaviour were measured in four serial point prevalence surveys of IDU recruited at multiple sites in community-based non-treatment and drug treatment settings between 1990 and 1993. Methods Community subjects were recruited through social network sampling by trained indigenous interviewers; treatment subjects were interviewed at agencies. With informed consent, subjects responded to a structured questionnaire covering risk behaviour. Volunteered saliva samples were tested anonymously for anti-HIV-1. Statistical comparisons across years were examined using mixed binomial logistic and log-linear models. Pearsons χ2 and Fishers exact tests were also used for some two-group comparisons. Results Similar samples were recruited each year. HIV-1 prevalence rate declined from 12.8% in 1990, 9.8% in 1991, 7.0% in 1992, to 6.9% in 1993. The statistical modelling suggested that the overall trend in prevalence rates was one of decelerating decline. There was no difference in prevalence rate by gender and length of injecting. Less than one-half (46%) had received a named HIV test. Over one-half of the HIV-positive IDU were unaware of their status. Conclusions The pattern of decline in HIV-1 prevalence rate is attributed to changes in risk behaviour following HIV prevention interventions.

Arrest Referral in London Police Stations: characteristics of the first year. A key point of intervention for drug users?

The paper examines the demographic, drug use and offending profile of arrestees in contact with arrest referral (AR) schemes in London, compares these contacts with the arrestee population as a whole, and with drug users presenting to treatment services in the community, and assesses the proportion and characteristics of AR contacts that go on to attend drug-treatment services. Routine monitoring data from AR schemes (April 2000 to March 2001) were analysed and compared with data ( for equivalent time period) on arrestees from the Crime Reporting Information System (CRIS) and data from the National Drug Treatment Monitoring System (NDTMS). AR schemes see about 10% of arrestees in London. Approximately half of those assessed by an AR worker report using heroin (55%) and crack cocaine (49%) with a similar proportion (51%) having no previous contact with drug-treatment services. The large majority (80%) report previous convictions. Of those referred by AR workers (50% of assessments) between 25 and 37% attend a first appointment at a drug-treatment service. Drug users seen by AR workers are younger, more likely to come from ethnic minorities and more likely to be using crack cocaine than those presenting to treatment services in the community. AR is a key point of contact with problem drug users, including those considered under-represented at drug-treatment services. However, to fully assess the effectiveness of AR, further information is required about retention in treatment and its effect on drug use and offending behaviour.

HIV testing and unreported HIV positivity among injecting drug users in London

ObjectiveTo assess the importance of community-recruited drug injectors with no treatment experience and no previous testing history when estimating HIV prevalence among drug injectors. DesignHIV testing behaviour and prevalence were measured in a serial point prevalence study of drug injectors recruited in community-based non-treatment and treatment settings. MethodsPearsons χ2 and Fishers exact tests were used to measure differences between treatment groups and non-treatment groups in demographic characteristics, including age and length of injecting career, recent drug use, recent syringe sharing, uptake of previous HIV testing, confirmed HIV-antibody status by saliva and self-reported HIV status. ResultsRates of HIV-antibody testing were significantly lower in community-recruited drug injectors with no experience of treatment than those previously or currently in treatment. Confirmed HIV prevalence by saliva was highest in drug injectors with no experience of treatment. HIV-antibody-positive drug injectors with no treatment experience were less likely to be aware of their antibody status than injectors who were, or who had been, in treatment. ConclusionsPrevious studies of HIV prevalence among drug injectors may be biased by drawing on samples primarily from treatment settings. Drug injectors with no treatment experience and no previous history of HIV testing should be included in HIV prevalence studies. Regular and repeat HIV testing in low-threshold community-based programmes should be considered a necessary part of interventions which seek to provide better access to treatment and other HIV prevention services.

HIV prevalence and risk behaviour among female injecting drug users in London, 1990 to 1996

OBJECTIVE To describe trends in HIV prevalence among female injecting drug users (IDU) in London between 1990 and 1996. DESIGN HIV prevalence and risk behaviour were measured yearly between 1990 and 1993, and in 1996, in point prevalence HIV surveys of IDU recruited from both drug-treatment and community-based settings within Greater London. Sample sizes were 173 in 1990, 111 in 1991, 128 in 1992, 146 in 1993 and 200 in 1996. METHODS Each survey used structured questionnaires and common sampling and interview strategies. Oral fluid specimens were collected for testing for antibodies to HIV (anti-HIV). Multiple logistic regression was used to assess the trend in HIV prevalence. RESULTS The percentage of female IDU testing positive for antibodies to HIV showed a marked decline over the study period, from 15.0% in 1990 to 1.0% in 1996 (P < 0.001). This trend was independent of all other variables examined. Each year, higher HIV prevalences were found among IDU recruited from community settings compared with treatment agencies. CONCLUSIONS These results concur with those of IDU recruited from treatment sites, although the yearly estimates in this study are higher. London benefits from low prevalence of HIV infection among IDU, coupled with behaviour change facilitated by early intervention. Continued surveillance of injectors recruited from both community and treatment settings is necessary in order properly to assess HIV prevalence among IDU.

HIV prevalence no higher among female drug injectors also involved in prostitution.

To assess the prevalence of HIV infection among female drug injectors involved in prostitution and female drug injectors not involved in prostitution, survey-based interviews were undertaken with 308 female drug injectors in 1990 and 1991. Confirmed saliva test results show 12.9% HIV prevalence among female drug injectors involved in prostitution and 14.4% HIV prevalence among drug injectors not involved in prostitution. This gives an HIV prevalence rate of 14.2% among female drug injectors overall. Findings also show that women not involved in prostitution were less likely to be in contact with a drug treatment or helping agency and were less likely to report having had an HIV test. Respondents in contact with a treatment agency and respondents involved in prostitution were more likely to be aware of their HIV status, and 72% of non-prostitute women confirmed HIV positive were unaware of their positive status. These findings of no higher HIV prevalence among female drug injectors also involved in prostitution lend some support to emerging evidence which associates HIV transmission among women prostitutes with an involvement in injecting drug use rather than with an involvement in prostitution per se. Findings also strengthen the need for greater expansion and greater accessibility of HIV testing, counselling and prevention facilities in community locales where drug injection and prostitution is prevalent.

Interventions with drug injectors in the UK : trends in risk behaviour and HIV prevalence

Experience in the United Kingdom over the past 10 years adds to the growing body of international evidence that injecting drug users have modi® ed their drug injecting behaviour in response to the threat of HIV and AIDS1± 4. Internationally, there is evidence of important changes in injecting practices including less frequent sharing of syringes, greater discrimination in the choice of sharing partners, and the use of bleach and other decontaminants for cleaning syringes. In the UK, there is good reason to link these changes in behaviour with a range of HIV preventive programmes that were introduced from 1986 onwards5. Furthermore, the UK has not experienced the rapid spread of HIV-1 infection among injectors that, back in the mid-1980s, was anticipated. HIV-1 prevalence rates are low by international standards, and appear to be stable. Overall there is evidence that drug injectors are (contrary to earlier beliefs) willing and able to make HIV relevant changes in injecting behaviour, evidence to link this with HIV preventive interventions, and prima facie evidence to link this with continuing low levels of HIV-1 infection.

Research and Development Focusing on Peer Intervention for Drug Users

Peer interventions have been advocated as a means of expanding and consolidating existing HIV interventions among drug users. They have been promoted as having the potential to redress the limitations of traditional outreach by maximizing contacts with hidden populations of drug users, and replacing individually focused health education with efforts to change ‘community norms’ towards safer drug use. Yet, despite such accolades, there has been little published information on the practicalities of implementing or developing such interventions among drug users in the UK. This paper outlines a survey of peer interventions among drug services in North Thames Regional Health Authority. The findings provide some insight into the way in which these interventions are being introduced into the drugs field. The paper also highlights the potential role for local forums of service providers in the management and development of community interventions.