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October 18, 1995, Vol 274, No. 15 >
ARTICLE | October 18, 1995

Maintaining Low HIV Seroprevalence in Populations of Injecting Drug Users FREE

Don C. Des Jarlais, PhD; Holly Hagan, MPH; Samuel R. Friedman, PhD; Patricia Friedmann, MS; David Goldberg, MD; Martin Frischer, PhD; Steven Green, MD; Kerstin Tunving, MD; Bengt Ljungberg, MD; Alex Wodak, MD; Michael Ross, PhD; David Purchase; Margaret E. Millson, MD; Ted Myers, PhD
[+] Author Affiliations

Deceased.

The views expressed in this article do not necessarily reflect the positions of the granting agencies or of the institutions by which the authors are employed.

Reprint requests to BIMC/NDRI, 11 Beach St, New York, NY 10013 (Dr Des Jarlais).


JAMA. 1995;274(15):1226-1231. doi:10.1001/jama.1995.03530150050033
Text Size: A A A
Published online
Article
References

Objectives.  —To describe prevention activities and risk behavior in cities where human immunodeficiency virus (HIV) was introduced into the local population of injecting drug users (IDUs), but where seroprevalence has nevertheless remained low (<5%) during at least 5 years.

Design and Setting.  —A literature search identified five such cities: Glasgow, Scotland; Lund, Sweden; Sydney, New South Wales, Australia; Tacoma, Wash; and Toronto, Ontario. Case histories were prepared for each city, including data on prevention activities and current levels of risk behavior among IDUs.

Participants.  —Injecting drug users recruited from both drug treatment and non-treatment settings in each city.

Interventions.  —A variety of HIV prevention activities for IDUs had been implemented in each of the five cities.

Results.  —There were three common prevention components present in all five cities: (1) implementation of prevention activities when HIV seroprevalence was still low, (2) provision of sterile injection equipment, and (3) community outreach to IDUs. Moderate levels of risk behavior continued with one third or more of the IDUs reporting recent unsafe injections.

Conclusions.  —In low-seroprevalence areas, it appears possible to severely limit transmission of HIV among populations of IDUs, despite continuing risk behavior among a substantial proportion of the population. Pending further studies, the common prevention components (beginning early, community outreach, and access to sterile injection equipment) should be implemented wherever populations of IDUs are at risk for rapid spread of HIV.(JAMA. 1995;274:1226-1231)

REFERENCES

1 +
Stimson GV. The health and social costs of drug injecting: the challenge to developing countries. Presented at the Sixth International Conference on the Reduction of Drug-Related Harm; March 26-30, 1995; Florence, Italy.
2 +
Des Jarlais DC, Friedman SR, Goldberg D, et al. Final Report of the World Health Organization Programme on Substance Abuse Multi-City Study of HIV Infection Among Injecting Drug Users . Geneva, Switzerland: World Health Organization; May 1994;.
3 +
Des Jarlais DC, Friedman SR, Novick D, et al.  HIV-1 infection among intravenous drug users in Manhattan. JAMA . 1989;;261:1008-1012.
4 +
Robertson JR, Bucknall ABV, Welsby P, et al.  Epidemic of AIDS-related virus (HTLV-III/LAV) infection among intravenous drug users. BMJ . 1986;; 292:527-529.
5 +
Vanichseni S, Sakuntanaga P. Results of three seroprevalence surveys for HIV in IVDU in Bangkok. In: Program and abstracts of the Sixth International Conference on AIDS; June 20-23,1990; San Francisco, Calif. Abstract FC 105.
6 +
Naik TN, Sarkar S, Singh HL, et al.  Intravenous drug users: a new high-risk group for HIV infection in India. AIDS . 1991;;5:117-118.
7 +
Friedman SR, Des Jarlais DC.  HIV among drug injectors: the epidemic and the response. AIDS Care . 1991;;3:239-250.
8 +
Lamothe F, Bruneau J, Soto J.  Progression of prevalence of HIV-1 infection among injection drug users in Montreal, Quebec. Can Commun Dis Rep . 1992;;18:98-101.
9 +
Lampinen TM, Joo E, Seweryn S, Hershow RC, Weibel W.  HIV seropositivity in community-recruited and drug treatment samples of injecting drug users. AIDS . 1992;;6:123-126.
10 +
Lurie P, Reingold AL, Bowser B, et al. The Public Health Impact of Needle-Exchange Programs in the United States and Abroad, Volume 1 . Atlanta, Ga: Centers for Disease Control and Prevention; September 1993;.
11 +
Stimson GV. The prevention of HIV infection in injecting drug users: recent advances and remaining obstacles. In: Program and abstracts of the Sixth International Conference on AIDS; June 20-24, 1990; San Francisco, Calif.
12 +
Frischer M, Green S, Goldberg D, et al.  Estimates of HIV infection among injecting drug users in Glasgow from 1985-1990. AIDS . 1992;;6:1371-1375.
13 +
Frischer M, Floor M, Green S, et al.  Reduction in needle sharing among community-wide samples of drug injectors. Int J STD AIDS . 1992;;3:288-290.
14 +
Frischer M, Haw S, Bloor M, et al.  Modelling the behaviour and attributes of injecting drug users: a new approach to identifying HIV risk practices. Int J Addict . 1993;;28:129-152.
15 +
Hagan H, Hale CB. HIV-1 Seroprevalence Surveys in Pierce County, June 1988 to December 1992 . Tacoma, Wash: Tacoma-Pierce County Health Department; 1993;.
16 +
Millson P, Myers T, Rankin J, Major C, Fearon M, Rigby J. Trends in HIV seroprevalence and risk behaviour in IDUs in Toronto, Canada. In: Program and abstracts of the Ninth International Conference on AIDS; 6-11,1993; Berlin, Germany. Abstract PO-C15-2936.
17 +
Kaldor J, Elford J, Wodak A, Crofts JN, Kidd S.  HIV prevalence among IDUs in Australia: a methodological review. Drug Alcohol Rev . 1993;;12: 175-184.
18 +
Ljungberg B, Christensson B, Tunving K, et al.  HIV prevention among injecting drug users: three years of experience from a syringe exchange program in Sweden. J AIDS . 1991;;4:890-895.
19 +
Tunving K, Nyholm K, Andersson B. Two successful syringe- and needle-exchange programs in Lund/Malmö, Sweden: their effects on the help-seeking drug-using communities and the surrounding drug treatment facilities. In: Program and abstracts of the Eighth International Conference on AIDS; July 19-24, 1992; Amsterdam, the Netherlands. Abstract PuC 8231.
20 +
Papaevangelou G, Ancelle-Park R, Seyrer Y. HIV prevalence and risk factors for infection among intravenous drug users in the European Community. In: Program and abstracts of the Seventh International Conference on AIDS;June 16-21,1991; Florence, Italy. Abstract MD 4074.
21 +
Hagan H, Des Jarlais DC, Purchase D, et al.  An interview study of participants in the Tacoma, Washington syringe exchange. Addiction . 1993;;88:1691-1697.
22 +
Ross MW, Wodak A, Gold J, Miller ME.  Differences across sexual orientation on HIV risk behaviours in injecting drug users. AIDS Care . 1992;; 4:139-148.
23 +
Ross MW, Stowe A, Wodak A, Miller ME, Gold J.  Predictors of HIV status among injecting drug users, and health promotion. J R Soc Health . In press.
24 +
Millson P, Myers T, Rankin J, et al. Descriptive epidemiology of injection drug users in Toronto. Presented at the Second Annual Canadian National Conference on HIV/AIDS; May 28-29, 1992; Vancouver, British Columbia.
25 +
Hagan H, Des Jarlais DC, Purchase D, Reid T, Friedman SR.  The Tacoma syringe exchange. J Addict Dis . 1991;;10:81-88.
26 +
Frischer M, Elliot L.  Discriminating needle-exchange attenders from non-attenders. Br J Addict . 1993;;88:681-687.
27 +
Friedman SR, de Jong W, Wodak A.  Community development as a response to HIV among drug injectors. AIDS . 1993;;7( (suppl 1) ):S263-S269.
28 +
Des Jarlais DC, Friedman SR.  AIDS prevention programs for injecting drug users.  In: Wormser GP, ed. AIDS and Other Manifestations of HIV Infection . 2nd ed. New York, NY: Raven Press Ltd; 1992;: 645-658.
29 +
Millson P, Coates R, Rankin J, et al. Evaluation of a Programme to Prevent Human Immunodeficiency Virus Transmission in Injection Drug Users in Toronto: Final Report to the National Health Research and Development Programme, Health and Welfare Canada . Ottawa, Ontario: National Health Research and Develoment Programme; December 1991;. NHRDP grant 6606-4333-AIDS.
30 +
Taylor A, Frischer M, McKeganey N, Platt S, Goldberg D, Green S.  HIV risk behaviours among female prostitute drug injectors in Glasgow. Addiction . In press.
31 +
Carr S, Green S, Goldberg D, et al.  HIV prevalence among female street prostitutes attending a health care drop-in centre in Glasgow. AIDS . 1992;; 6:1553-1554.
32 +
Christensson B, Ljungberg B.  Syringe exchange for prevention of HIV infection in Sweden: practical experiences and community reactions. Int J Addict . 1991;;26:1293-1302.
33 +
Neaigus A, Friedman SR, Curtis R, et al.  The relevance of drug injectors' social networks and risk networks for understanding and preventing HIV infection. Soc Sci Med . 1994;;38:67-78.
34 +
Stall R, Ekstrand ML, Pollack L, McKusick L, Coates TJ.  Relapse from safer sex: the next challenge for AIDS prevention efforts. J Acquir Immune Defic Syndr . 1990;;3:1181-1187.
35 +
Ekstrand ML, Coates TJ.  Maintenance of safer sexual behaviors and predictors of risky sex: the San Francisco Men's Health Study. Am J Public Health . 1990;;80:973-977.
36 +
Osmond DH, Page K, Wiley J, et al. Human immunodeficiency virus infection in homosexual/ bisexual men, ages 18-29: the San Francisco Young Men's Health Study. In: Program and abstracts of the Ninth International Conference on AIDS; June 6-11, 1993; Berlin, Germany. Abstract WS-C07-3.
37 +
Office of National Drug Control Policy (ONDCP). Needle Exchange Programs: Are They Effective? Washington, DC: Executive Office of the President, Office of National Drug Control Policy; July 1992;. ONDCP Bulletin No. 7.
38 +
Stimson GV.  AIDS and injecting drug use in the United Kingdom, 1988 to 1993: the policy response and the prevention of the epidemic. Soc Sci Med . In press.
39 +
Dolan KA, Stimson GV, Donoghoe MC.  Reductions in HIV risk behaviour and stable HIV prevalence in syringe-exchange clients and other injectors in England. Drug Alcohol Rev . 1993;;12:133-142.
40 +
Baker M, Tobias M, Brady H. Detection of HIV antibodies in used syringes in New Zealand. In: Program and abstracts of the Seventh International Conference on AIDS; July 16-21, 1991; Florence, Italy. Abstract WC 3364.
41 +
Brown BS, Beschner GM, eds. Handbook on Risk of AIDS . Westport, Conn: Greenwood Press; 1993;.
42 +
DiClemente R, Peterson J, eds. Preventing AIDS: Theories and Methods of Behavioral Interventions . New York, NY: Plenum Press; 1994;.
43 +
Anderson RM, May RM, Boily MC, Garnett GP, Rowley JT.  The spread of HIV-1 in Africa: sexual contact and the predicted demographic impact of AIDS. Nature . 1991;;352:581-589.
44 +
Cordray DS.  Quasi-experimental analysis: a mixture of methods and judgment. New Dir Prog Eval . 1986;;31:9-28.
45 +
Des Jarlais DC, Choopanya K, Vanichseni S, et al.  AIDS risk reduction and reduced HIV seroconversion among injecting drug users in Bangkok. Am J Public Health . 1994;;84:452-455.
46 +
Chitwood DD.  HIV risk and injection drug users: evidence for behavioral change. Am J Public Health . 1994;;84:350.
47 +
Des Jarlais DC, Hagan H, Friedman SR, et al. Biological validation of self-reported behavior change among IDUs. In: Program and abstracts of the 10th International Conference on AIDS; August 7-12,1994; Yokohama, Japan. Abstract PD0495.
48 +
Des Jarlais DC, Friedman SR, Choopanya K, et al.  International epidemiology of HIV and AIDS among injecting drug users. AIDS . 1992;;6:1053-1068.

Figures

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Stimson GV. The health and social costs of drug injecting: the challenge to developing countries. Presented at the Sixth International Conference on the Reduction of Drug-Related Harm; March 26-30, 1995; Florence, Italy.
2 +
Des Jarlais DC, Friedman SR, Goldberg D, et al. Final Report of the World Health Organization Programme on Substance Abuse Multi-City Study of HIV Infection Among Injecting Drug Users . Geneva, Switzerland: World Health Organization; May 1994;.
3 +
Des Jarlais DC, Friedman SR, Novick D, et al.  HIV-1 infection among intravenous drug users in Manhattan. JAMA . 1989;;261:1008-1012.
4 +
Robertson JR, Bucknall ABV, Welsby P, et al.  Epidemic of AIDS-related virus (HTLV-III/LAV) infection among intravenous drug users. BMJ . 1986;; 292:527-529.
5 +
Vanichseni S, Sakuntanaga P. Results of three seroprevalence surveys for HIV in IVDU in Bangkok. In: Program and abstracts of the Sixth International Conference on AIDS; June 20-23,1990; San Francisco, Calif. Abstract FC 105.
6 +
Naik TN, Sarkar S, Singh HL, et al.  Intravenous drug users: a new high-risk group for HIV infection in India. AIDS . 1991;;5:117-118.
7 +
Friedman SR, Des Jarlais DC.  HIV among drug injectors: the epidemic and the response. AIDS Care . 1991;;3:239-250.
8 +
Lamothe F, Bruneau J, Soto J.  Progression of prevalence of HIV-1 infection among injection drug users in Montreal, Quebec. Can Commun Dis Rep . 1992;;18:98-101.
9 +
Lampinen TM, Joo E, Seweryn S, Hershow RC, Weibel W.  HIV seropositivity in community-recruited and drug treatment samples of injecting drug users. AIDS . 1992;;6:123-126.
10 +
Lurie P, Reingold AL, Bowser B, et al. The Public Health Impact of Needle-Exchange Programs in the United States and Abroad, Volume 1 . Atlanta, Ga: Centers for Disease Control and Prevention; September 1993;.
11 +
Stimson GV. The prevention of HIV infection in injecting drug users: recent advances and remaining obstacles. In: Program and abstracts of the Sixth International Conference on AIDS; June 20-24, 1990; San Francisco, Calif.
12 +
Frischer M, Green S, Goldberg D, et al.  Estimates of HIV infection among injecting drug users in Glasgow from 1985-1990. AIDS . 1992;;6:1371-1375.
13 +
Frischer M, Floor M, Green S, et al.  Reduction in needle sharing among community-wide samples of drug injectors. Int J STD AIDS . 1992;;3:288-290.
14 +
Frischer M, Haw S, Bloor M, et al.  Modelling the behaviour and attributes of injecting drug users: a new approach to identifying HIV risk practices. Int J Addict . 1993;;28:129-152.
15 +
Hagan H, Hale CB. HIV-1 Seroprevalence Surveys in Pierce County, June 1988 to December 1992 . Tacoma, Wash: Tacoma-Pierce County Health Department; 1993;.
16 +
Millson P, Myers T, Rankin J, Major C, Fearon M, Rigby J. Trends in HIV seroprevalence and risk behaviour in IDUs in Toronto, Canada. In: Program and abstracts of the Ninth International Conference on AIDS; 6-11,1993; Berlin, Germany. Abstract PO-C15-2936.
17 +
Kaldor J, Elford J, Wodak A, Crofts JN, Kidd S.  HIV prevalence among IDUs in Australia: a methodological review. Drug Alcohol Rev . 1993;;12: 175-184.
18 +
Ljungberg B, Christensson B, Tunving K, et al.  HIV prevention among injecting drug users: three years of experience from a syringe exchange program in Sweden. J AIDS . 1991;;4:890-895.
19 +
Tunving K, Nyholm K, Andersson B. Two successful syringe- and needle-exchange programs in Lund/Malmö, Sweden: their effects on the help-seeking drug-using communities and the surrounding drug treatment facilities. In: Program and abstracts of the Eighth International Conference on AIDS; July 19-24, 1992; Amsterdam, the Netherlands. Abstract PuC 8231.
20 +
Papaevangelou G, Ancelle-Park R, Seyrer Y. HIV prevalence and risk factors for infection among intravenous drug users in the European Community. In: Program and abstracts of the Seventh International Conference on AIDS;June 16-21,1991; Florence, Italy. Abstract MD 4074.
21 +
Hagan H, Des Jarlais DC, Purchase D, et al.  An interview study of participants in the Tacoma, Washington syringe exchange. Addiction . 1993;;88:1691-1697.
22 +
Ross MW, Wodak A, Gold J, Miller ME.  Differences across sexual orientation on HIV risk behaviours in injecting drug users. AIDS Care . 1992;; 4:139-148.
23 +
Ross MW, Stowe A, Wodak A, Miller ME, Gold J.  Predictors of HIV status among injecting drug users, and health promotion. J R Soc Health . In press.
24 +
Millson P, Myers T, Rankin J, et al. Descriptive epidemiology of injection drug users in Toronto. Presented at the Second Annual Canadian National Conference on HIV/AIDS; May 28-29, 1992; Vancouver, British Columbia.
25 +
Hagan H, Des Jarlais DC, Purchase D, Reid T, Friedman SR.  The Tacoma syringe exchange. J Addict Dis . 1991;;10:81-88.
26 +
Frischer M, Elliot L.  Discriminating needle-exchange attenders from non-attenders. Br J Addict . 1993;;88:681-687.
27 +
Friedman SR, de Jong W, Wodak A.  Community development as a response to HIV among drug injectors. AIDS . 1993;;7( (suppl 1) ):S263-S269.
28 +
Des Jarlais DC, Friedman SR.  AIDS prevention programs for injecting drug users.  In: Wormser GP, ed. AIDS and Other Manifestations of HIV Infection . 2nd ed. New York, NY: Raven Press Ltd; 1992;: 645-658.
29 +
Millson P, Coates R, Rankin J, et al. Evaluation of a Programme to Prevent Human Immunodeficiency Virus Transmission in Injection Drug Users in Toronto: Final Report to the National Health Research and Development Programme, Health and Welfare Canada . Ottawa, Ontario: National Health Research and Develoment Programme; December 1991;. NHRDP grant 6606-4333-AIDS.
30 +
Taylor A, Frischer M, McKeganey N, Platt S, Goldberg D, Green S.  HIV risk behaviours among female prostitute drug injectors in Glasgow. Addiction . In press.
31 +
Carr S, Green S, Goldberg D, et al.  HIV prevalence among female street prostitutes attending a health care drop-in centre in Glasgow. AIDS . 1992;; 6:1553-1554.
32 +
Christensson B, Ljungberg B.  Syringe exchange for prevention of HIV infection in Sweden: practical experiences and community reactions. Int J Addict . 1991;;26:1293-1302.
33 +
Neaigus A, Friedman SR, Curtis R, et al.  The relevance of drug injectors' social networks and risk networks for understanding and preventing HIV infection. Soc Sci Med . 1994;;38:67-78.
34 +
Stall R, Ekstrand ML, Pollack L, McKusick L, Coates TJ.  Relapse from safer sex: the next challenge for AIDS prevention efforts. J Acquir Immune Defic Syndr . 1990;;3:1181-1187.
35 +
Ekstrand ML, Coates TJ.  Maintenance of safer sexual behaviors and predictors of risky sex: the San Francisco Men's Health Study. Am J Public Health . 1990;;80:973-977.
36 +
Osmond DH, Page K, Wiley J, et al. Human immunodeficiency virus infection in homosexual/ bisexual men, ages 18-29: the San Francisco Young Men's Health Study. In: Program and abstracts of the Ninth International Conference on AIDS; June 6-11, 1993; Berlin, Germany. Abstract WS-C07-3.
37 +
Office of National Drug Control Policy (ONDCP). Needle Exchange Programs: Are They Effective? Washington, DC: Executive Office of the President, Office of National Drug Control Policy; July 1992;. ONDCP Bulletin No. 7.
38 +
Stimson GV.  AIDS and injecting drug use in the United Kingdom, 1988 to 1993: the policy response and the prevention of the epidemic. Soc Sci Med . In press.
39 +
Dolan KA, Stimson GV, Donoghoe MC.  Reductions in HIV risk behaviour and stable HIV prevalence in syringe-exchange clients and other injectors in England. Drug Alcohol Rev . 1993;;12:133-142.
40 +
Baker M, Tobias M, Brady H. Detection of HIV antibodies in used syringes in New Zealand. In: Program and abstracts of the Seventh International Conference on AIDS; July 16-21, 1991; Florence, Italy. Abstract WC 3364.
41 +
Brown BS, Beschner GM, eds. Handbook on Risk of AIDS . Westport, Conn: Greenwood Press; 1993;.
42 +
DiClemente R, Peterson J, eds. Preventing AIDS: Theories and Methods of Behavioral Interventions . New York, NY: Plenum Press; 1994;.
43 +
Anderson RM, May RM, Boily MC, Garnett GP, Rowley JT.  The spread of HIV-1 in Africa: sexual contact and the predicted demographic impact of AIDS. Nature . 1991;;352:581-589.
44 +
Cordray DS.  Quasi-experimental analysis: a mixture of methods and judgment. New Dir Prog Eval . 1986;;31:9-28.
45 +
Des Jarlais DC, Choopanya K, Vanichseni S, et al.  AIDS risk reduction and reduced HIV seroconversion among injecting drug users in Bangkok. Am J Public Health . 1994;;84:452-455.
46 +
Chitwood DD.  HIV risk and injection drug users: evidence for behavioral change. Am J Public Health . 1994;;84:350.
47 +
Des Jarlais DC, Hagan H, Friedman SR, et al. Biological validation of self-reported behavior change among IDUs. In: Program and abstracts of the 10th International Conference on AIDS; August 7-12,1994; Yokohama, Japan. Abstract PD0495.
48 +
Des Jarlais DC, Friedman SR, Choopanya K, et al.  International epidemiology of HIV and AIDS among injecting drug users. AIDS . 1992;;6:1053-1068.

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