Neil McKeganey

Mortality among injecting drug users: a critical reappraisal.

STUDY OBJECTIVE--The aim was to quantify all cause mortality among injecting drug users. DESIGN--This was a retrospective analysis of 1989 data on injecting drug users and mortality obtained from three independent agencies: the Procurator Fiscals Office, the General Register Office, and the Scottish HIV-test register. SETTING--Greater Glasgow, Scotland. SUBJECTS--Drug injectors, estimated population 9424. MAIN RESULTS--81 names were found using the three sources to identify deaths. After removing duplicates, 51 deaths were found. This represented a mortality rate of 0.54% in the estimated population. Among female injectors the mortality rate was 0.85%, significantly higher than the rate of 0.42% among male injectors (95% CI for the true difference in mortality rates between female and male injectors was 0.31%-0.55%). Over 90% of deaths were attributed to overdose or suicide. Although AIDS caused only one death, 19% of cases (5/27) whose HIV antibody status could be ascertained were positive. The mortality rate among HIV positive injectors (3.8%) was significantly higher than among HIV negative injectors (0.49%). CONCLUSIONS--Comprehensive coverage using three data sources revealed a far greater annual number of all cause deaths among injectors than would have been expected from previous research. The observed mortality rate was lower than in previous studies where the denominators used to calculate rates had an element of underenumeration. For the foreseeable future it is unlikely that AIDS will have much impact on mortality among injectors in Glasgow, because of the low prevalence of HIV infection among injectors in the city, and because HIV positive injectors are dying for reasons other than AIDS; rather, overdose and suicide will continue to be the main causes of death.

The rise and rise of peer education approaches.

Over the last decade there has been a major growth in the use of peer education projects in response to a wide range of problems. The proliferation of peer education projects has not been commensurate with the limited evidence available as to the effectiveness of such approaches. This paper provides a short history of peer education techniques and outlines some of the definitional diversity in attempts at characterizing peer education projects. The paper reviews the limited evidence on the effectiveness of peer education projects seen in terms of the impact upon peer educators themselves and the target group of their educational efforts. The paper describes the results of this work and identifies the need to develop a model of peer education evaluation which, whilst being true to the nature of such projects, can also identify effectiveness of peer education in the short, medium and long term.

Female streetworking prostitution and HIV infection in Glasgow.

OBJECTIVES--To identify the extent of HIV infection and injecting drug use among female streetworking prostitutes in Glasgow; to estimate the size of the female streetworking prostitute population in the city; and to estimate the number of HIV positive women working as prostitutes on the streets in Glasgow. DESIGN--Observation and interviewing of female prostitutes over seven months in red light district; analysis of saliva samples for presence of antibodies to HIV; capture-recapture approach to estimating the size of the female streetworking prostitute population. SETTING--Glasgow. SUBJECTS--206 female streetworking prostitutes. MAIN OUTCOME MEASURES--Number of women with antibodies to HIV, self reported use of injecting drugs, history of contact with 206 women. RESULTS--Saliva samples were requested from 197 women; 159 (81%) provided samples. Four (2.5%, 95% confidence interval 0.7%-6.3%) of the samples were positive for HIV, all of which had been provided by women who injected drugs. Of the 206 streetworking women contacted 147 (71%) were injecting drug users. About 1150 women are estimated to work on the streets in Glasgow over a 12 month period. CONCLUSIONS--HIV is not as widespread among female prostitutes as many reports in the tabloid press suggest. A greater proportion of female streetworking prostitutes in Glasgow are injecting drugs than has been reported for other British cities.

Prostitution and HIV: what do we know and where might research be targeted in the future?

A review of the literature indicates that the association between human immunodeficiency virus (HIV) and prostitution varies by geographic region and can be altered substantially by well-planned public health interventions. In most African countries and in Asian countries such as Thailand, the rate of HIV infection among female prostitutes is substantially higher than the rate in the general population. Relatively few commercial sex workers in South and Central America are HIV-positive; however, their extremely high rates of infection with sexually transmitted diseases indicates the potential for future epidemic spread of HIV. In Europe and North America, HIV infection is most prevalent among drug-injecting or crack-using prostitutes. Neglected has been research on the high incidence of HIV among male transvestite and transsexual prostitutes. The lowest levels of condom use in commercial sex encounters have been recorded in regions in developing countries with the highest HIV prevalence. Also of concern are high condom breakage rates (20-50%) among female prostitutes who use petroleum-based lubricants and male prostitutes who practice anal sex. Valuable would be quantification of the additional HIV risk resulting from sex with a prostitute. Other recommended research areas include estimates of the number of male and female prostitutes working in certain geographic areas, mechanisms for monitoring condom use and substance abuse among prostitutes, the impact of HIV infection on movement into and out of prostitution, the dynamics of prostitute-client condom negotiation, and profiles of the clients of male prostitutes.

Abstinence and drug abuse treatment: Results from the Drug Outcome Research in Scotland study

Aims: To identify the proportion of drug users contacting drug treatment services in Scotland who were able to become abstinent 33 months after having started a new episode of treatment and to identify which services were most closely associated with such abstinence. Design: Follow-up survey of 695 of the Drug Outcome Research in Scotland respondents 33 months following recruitment into the study. Setting: Scotland. Participants: Injecting drug users who were initially contacted at drug treatment services and then followed up for 33 months post-recruitment. Measurements: Self-reported drug use and service usage. Findings: Although becoming drug free was the expressed goal of the majority of drug users recruited into the Drug Outcome Research in Scotland study, at 33 months following recruitment only 5.9% of females and 9.0% of males had been totally drug free (excluding possible alcohol and tobacco use) for a 90-day period in advance of being interviewed. There was considerable variation within this study in the proportion of drug users becoming drug free dependent upon the services they had been in contact with. The level of achieved abstinence in this Scottish study was substantially lower than that identified in the National Treatment Outcomes Research Study in England. Conclusions: There is a need to establish why so few drug users in contact with the methadone programme in Scotland appear able to become drug free 33 months after having contacted this service. On the basis of the results presented in this paper there is a need to ensure that drug users seeking help in becoming drug free are able to access residential rehabilitation services although at the present time such services are relatively rare within Scotland.

Estimating the prevalence of drug misuse in Dundee, Scotland: an application of capture-recapture methods.

STUDY OBJECTIVES: To apply capture-recapture methods to provide an estimate of the prevalence of opiate and benzodiazepine misuse in Dundee, Scotland. DESIGN: A four sample capture-recapture method using data from both statutory and non-statutory data sources to estimate drug misuse prevalence in Dundee between January 1990 and December 1994. PARTICIPANTS: Users of benzodiazepines or opiates residing within Dundee. RESULTS: Altogether 855 drug misusers were identified from various sources within Dundee; many were identified from more than one source. Using this data, the estimated unknown population was 1702, giving a total population of 2557 (95% confidence interval (CI) 1974, 3458) who misuse benzodiazepines or opiates. This represents a prevalence of 28.8 (95% CI 22.3, 39.0) per thousand. CONCLUSIONS: Capture-recapture techniques can be applied to statutory and non-statutory agency data to produce an estimate of at least certain sections of the drug misusing population. However, it is important to recognise the limitations of this methodology and in future to seek to combine a range of approaches to the problem of estimating prevalence rather than sticking rigidly to any single approach.

Quantitative and qualitative research in the addictions: an unhelpful divide

It is an exaggeration, though not an enormous one, to characterize most behavioural research in the addictions as falling on either side of a quantitative/qualitative divide. There are those researchers who favour the use of surveys of preferably randomly selected individuals and statistical methods of data collection, and there are those researchers from the qualitative wing of research who generally eschew such standardized methods in favour of participant observation and face to face interviewing of respondents. I would like to suggest that this divide no longer serves a useful function (if it ever did) and that we should direct our attention to the various ways in which it may be overcome.

Association between illegal drugs and weapon carrying in young people in Scotland: schools' survey

Abstract Objectives: To identify the type and extent of weapons being carried among young people in Scotland, and to determine the relation between use of illegal drugs and weapon carrying. Design: Questionnaire school survey. Setting: Independent schools in central Scotland and schools in Lanarkshire and Perth and Kinross. Participants: 3121 students aged 11 to 16 in 20 schools. Main outcome measures: Self completion questionnaire reporting history of drug use and weapon carrying. Results: Overall, 34.1% of males and 8.6% of females reported having carried a weapon (P<0.0001), ranging from 29.2% of boys aged 11-13 (classes S1 to S2) to 39.3% of boys aged 13-15 (S3 to S4). These values are higher than those in a recent survey of young people in England. Weapon carrying in Lanarkshire was 70% higher for males than in the rural area of Perth and Kinross. Both males and females who had taken drugs were more likely to carry weapons (63.5% of male drug users versus 20.5% of non-users and 22.8% of female drug users versus 3.7% of non-users; both P<0.0001). The proportions of males carrying weapons who used none, one, two, three or four, or five or more illegal drugs were 21%, 52%, 68%, 74%, and 92% respectively. A similar trend was found among females. Conclusions: Better information is needed on the nature and extent of weapon carrying by young people in the United Kingdom, and better educational campaigns are needed warning of the dangers of carrying weapons.

Contribution of problem drug users' deaths to excess mortality in Scotland: secondary analysis of cohort study

Objectives To examine the “Scottish effect”—namely, the growing divergence between mortality in Scotland and England that is not explained by national differences in levels of deprivation—and, more specifically, to examine the extent to which the Scottish effect is explained by cross national differences in the prevalence of problem drug use. Design Secondary analysis of cohort study (the DORIS study). Participants 1033 Scottish drug users recruited to the cohort study in 33 drug treatment facilities across Scotland in 2001-2 and followed up 33 months later in 2004-5. Results 38 deaths occurred in the cohort, giving a standardised mortality ratio for the cohort of 1244 (95% credible interval 876 to 1678). Only 22 of the 38 deaths in drug users were classified as drug related deaths. From estimates of the size of the problem drug using populations in both England and Scotland, the contribution of deaths in drug users to national death rates can be estimated: the attributable risk fraction for Scotland is 17.3% (12.3% to 22.8%) and that for England is 11.1% (7.8% to 14.8%). Excluding estimated numbers of deaths in drug users would bring down age standardised mortality at ages 15-54 years from 196 to 162 per 100 000 in Scotland and from 138 to 122 per 100 000 in England; 32.0% (22.3% to 43.0%) of the excess mortality in Scotland is due to drug use. Conclusion Although problem drug use is a low prevalence risk behaviour, it carries a high mortality; the standardised mortality ratio for Scottish drug users is 12 times as high as for the general population. The higher prevalence of problem drug use in Scotland than in England accounts for a third of Scotland’s excess mortality over England. Successful public health efforts to reduce the prevalence of problem drug use in Scotland or deaths in Scottish drug users would have a dramatic impact on overall mortality in Scotland.

Selling sex: Female street prostitution and HIV risk behaviour in Glasgow

Female prostitutes have often been seen as a major source of HIV infection. In this paper we report on a study of HIV-related risk behaviour among street prostitutes in Glasgow. This paper is based on street interviews using a standardized schedule with 68 women. We focus on the extent of HIV testing amongst the women, travel, the sexual services provided, the use of condoms with clients and private partners, and the extent of drug injecting and equipment sharing by the women. It is shown that female street prostitution within Glasgow is, at present, unlikely to be associated with significant heterosexual spread of HIV as most commercial sex is with a condom. However, some risk activities are continuing. Additionally, prostitutes report worrying rates of condom failure with clients. It is suggested that attention should switch away from an exclusive focus on women selling sexual services to target the men who purchase sex. These data indicate that much of the pressure for these women to provide unprotected sex comes from their clients.