S.T. Green

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.

Female streetworker -- prostitutes in Glasgow: a descriptive study of their lifestyle.

The objective of this study is to describe the lifestyle of a group of female prostitutes. The collection of information was achieved by: (i) using a self administered questionnaire; and (ii) conducting conversational type interviews. Of 85 women attending a health care drop-in centre for female street prostitutes in Glasgow, 63 completed the questionnaire and 72 participated in conversational interviews. For 63 women the mean age of commencement of prostitution was 21 years. Fifty-one (81%) were injecting drug users, their most commonly used drugs being heroin and temazepam. They worked a mean of 5.5 evenings per week and provided sexual services to a mean of 6.4 clients per working day. Less than half of these services were estimated to be vaginal intercourse. While 59/60 women indicated that they always used condoms during vaginal intercourse, this only applied to commercial sex; only 8/47 (17%) always used condoms with their regular sexual partners. Unconventional sexual services, e.g. voyeurism and physical abuse, were commonly provided and clients were often violent. A typical female streetworking-prostitute in Glasgow was aged 25, unemployed, an injecting drug user and had commenced prostitution 4 years before. Her knowledge of HIV/AIDS was good and for vaginal intercourse she almost always used condoms with clients, though probably not with her regular partner. Her main concern was likely to be violence from clients.

A primary health care service for Glasgow street sex workers-6 years experience of the 'Drop-in Centre', 1989-1994

In Glasgow, a health and social care centre opened in 1988 principally to facilitate HIV prevention among street prostitutes, most of whom are injecting drug users. During 1992 to 1994, 551 women made 17,554 visits to the medical room which is functional 5 nights per week. The mean age of the sex workers was 26 years (range 15 to 62) and 89% injected drugs. Fifty-five per cent of the attendances were for needle/syringe exchange only whilst the remainder involved other health care provision. Common presenting problems included abscesses, burns and venous thromboses, reflecting the high proportion of sex workers who injected drugs. Most women always used condoms for penetrative commercial sex and symptomatic sexually transmitted disease was seen infrequently. In addition to the provision of injecting equipment and condoms, other key prevention activities included Hepatitis B vaccination and cervical screening. The prevalence of HIV infection amongst the women remains under 5% and most seropositives were known to be infected before the Centre opened. This initiative shows that if multidisciplinary health and social services are provided to street sex workers at a time and place convenient to their work, the benefits are considerable.

HIV AND OROGENITAL TRANSMISSION

It may seem paradoxical that citric acid enhances aluminium gastrointestinal absorption but induces aluminium excretion. However, in biological fluids at various H + and reactant concentrations, distinct aluminium complexes predominated and the same chemical partners induced different clinical effects.9 Although we agree with Hewitt and colleagues that there is a risk in simultaneous therapy with oral aluminium and citrate compounds, intraperitoneal citric acid may prevent aluminium intoxication. We are studying the effects of citric acid in uraemic animals and the effects of long-term administration of citric acid.

Reduction in needle sharing among community wide samples of injecting drug users.

Evidence of reduced levels of needle sharing among injecting drug users (IDUs) has largely been confined to IDUs attending needle exchanges or receiving treatment. In this paper we present the results of a serial cross-sectional study of needle sharing conducted in Glasgow using a multisite sampling strategy. Of the estimated 9400 IDUs in the city, 503 were interviewed in 1990 and 535 in 1991. The proportion of IDUs reporting injecting with, or passing on used needles and syringes in the last 6 months fell significantly as did the number of individuals from whom equipment was received or passed on to. The impact of this level of sharing has been limited in terms of HIV transmission; the prevalence of HIV among the 1990 sample was 2.0% and 1.1% for the 1991 sample. However, the fact that a third of IDUs in Glasgow continue to inject, even occasionally, with used equipment gives cause for concern in view of the other pathologies known to be associated with poor injecting hygiene.

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.

Modeling the Behavior and Attributes of Injecting Drug Users: A New Approach to Identifying HIV Risk Practices

The behaviors and attributes of 503 Scottish injecting drug users were modeled using the linear structural equations program LISREL. Drug use was directly related to prison experience, sexual activity, sharing of injecting equipment, and prostitution. Although the prevalence of HIV among the sample was low (2.0%), the pattern of risk behaviors observed in the data affords potential for future spread of the virus. Harm reduction measures taken by injectors in response to the threat posed by AIDS were inversely related to drug use but, more encouragingly, directly related to awareness of the disease, treatment for drug use, and prostitution.

Low and Stable Prevalence of HIV among Drug Injectors in Glasgow

The first HIV-positive diagnosis among injecting drug users (IDU) in Glasgow was made in 1985. By the end of 1987 prevalence among IDU receiving voluntary attributable tests was 4.8%. Since 1990, an annual cross-sectional survey of HIV prevalence and risk behaviours among 500 current Glasgow IDU has provided a more representative sample. Anonymously-tested saliva samples obtained from respondents revealed prevalence rates of 1.8%, 1.2% and 1.0% in 1990, 1991 and 1992 respectively. Siince 1987 a wide range of measures aimed at reducing HIV-related risk behaviour among IDU has been introduced and maintained in Glasgow. Against this background, there is evidence that IDU in the city have reduced their risk behaviours. The findings reported here suggest that implementing harm-reduction measures when prevalence is low may inhibit the rapid dissemination of HIV.

Increasing Ecstasy Use Among Glasgow Drug Injectors

Although Ecstasy [Methylenedioxymethamphetamine (MDMA)] is known to have adverse health consequences, research has focused exclusively on oral use. An opportunity to determine the prevalence of Ecstasy use among drug injectors was afforded by an ongoing study of HIV related risk behaviour among this population in Glasgow. Five hundred plus injectors per annum were questioned between 1990-1992 on their use of Ecstasy. The proportion of injectors using Ecstasy increased from 4.8% in 1990 to 28.9% in 1992 while the proportion who reported injecting Ecstasy increased from 0.6% to 4.7%. The emergence of injecting as a means of administering Ecstasy adds a new dimension to the growing debate on how to control drugs, abuse of which has hitherto been largely confined to oral usage.

Transmission of HIV in prison. Evidence of risk.

pate but saliva testing is insufficiently sensitive as yet to detect reliably the low levels of antibody associated with recently acquired infections. In the second situation voluntary, named testing of at least two blood samples is required, accompanied by the usual counselling before and after testing. This well established diagnostic procedure ought to be available inside prison on the same basis as it is outside. Outside prison the concerned individual has a choice-to consult his or her own medical practitioner or to attend (anonymously if desired) a specialised counselling clinic or genitourinary medicine clinic. We understand that currently the only option available to inmates of British prisons is to consult either their prison medical officer or a prison officer who has trained as an HIV counsellor. Much depends, therefore, upon the rapport, or lack of it, which exists between these representatives of authority and individual prisoners. The third situation is one to which public health staff are attuned to respond-the identification and control of an outbreak of infection. Sound epidemiology must be applied as an urgent response to safeguard both individuals and the community, rather than at the measured pace of research preceded by ethical clearance. When there is evidence of recent transmission of HIV (as first established at Glenochil through the prisons general practitioner), detection of low concentrations of HIV antibody requires that blood, not saliva, samples be obtained. Necessary, relevant data legitimately collected about individuals and the group are subject to the same general duty of confidentiality that all health care professionals owe to patients.