The World Health Organisation has reported and highlighted ...
Draft: 4th November 2003
A situation assessment and review of the evidence for interventions for the prevention of HIV/AIDS among Occasional, Experimental and Young Injecting Drug Users
Background Paper prepared for:
UN Interagency and CEEHRN Technical Consultation on Occasional, Experimental and Young IDUs in the CEE/CIS and Baltics
by:
John Howard, Neil Hunt and Anthony Arcuri
John Howard and Anthony Arcuri Neil Hunt
Ted Noffs Foundation Honorary Research Fellow
PO Box 120 Centre for Research on Drugs and Health
Randwick Behaviour, Imperial College
NSW 2031 C/o 55 Mackenders Lane
Australia Eccles
Kent ME20 7JA
United Kingdom
Phone: + 61 2 9310 0133 Phone: +44 1622 716012
Fax: + 61 2 9310 0020 Mobile: +44 7780 665830
Email: howardj@.au neil@dadden.demon.co.uk
arcuria@.au
This background paper draws heavily on a document prepared by John Howard and Anthony Arcuri, titled “Review of Evidence for Harm Reduction Interventions among Young Drug Users to provide Prevention of HIV/AIDS”, prepared for the WHO Department of Child and Adolescent Health and Development, for a WHO/UNAIDS/UNFPA/UNICEF/YouthNet “global consultation on the health services response to the prevention and care of HIV/AIDS among young people: accelerating country level action”, held in March, 2003 at Montreux, and on an unpublished manuscript towards an uncompleted PhD by Neil Hunt.
Introduction 2
Rationale 4
Section 1: A brief review of relevant national level data on the extent of injecting and HIV/AIDS with special reference to people aged under 25 4
UKRAINE 5
RUSSIAN FEDERATION 5
BELARUS 5
MOLDOVA 5
LATVIA 6
LITHUANIA 6
ESTONIA 6
CAUCASUS REPUBLICS – (ARMENIA, AZERBAIJAN, GEORGIA) 6
CENTRAL AND SOUTH EAST EUROPE 6
BULGARIA 7
POLAND 7
SERBIA and MONTENEGRO 7
ROMANIA 7
CENTRAL ASIAN REPUBLICS 7
KAZAKHSTAN 7
KYRGYZ REPUBLIC 8
TAJIKISTAN 8
TURKMENISTAN 8
UZBEKISTAN 8
Section 2: A summary of what is known about the nature of injecting among young people, transitions into and out of injecting, relevant risk behaviours and contact with prevention and treatment services 8
Transition 10
First Injection 10
Section 3: Identification and consideration of relevant macro-level risk and protective factors 11
Section 4: A review of existing and potential interventions and commentary on their advantage and disadvantages and factors that may affect their adoption and implementation 18
Needle and Syringe Programmes (NSPs) 23
Outreach services 24
Linking Information, Education and Communication (IEC) with service provision 24
Substitution Programmes 25
Strength of evidence 27
IV Evidence obtained from case series, wither post-test or pre-test and post-test 27
Other potential approaches to preventing and curtailing injecting 28
Evidence that providing harm reduction services to young people engages or encourages their utilisation of health services. 28
Legal and Policy Considerations 30
Section Five: Avenues for future research 31
References 35
Introduction
The HIV/AIDS epidemic in Central and Eastern Europe (CEE)/the Commonwealth of Independent States (CIS) and the Baltic States is believed to be the fastest growing in the world, with injecting drug use as the dominant mode of transmission (UNAIDS/WHO 2002). While the limitations of HIV/AIDS surveillance and reporting in Central and Eastern Europe and the Central Asia Republics are well known, all countries in the region report substantial and increasing numbers of young people (defined here as those who are aged from 12 to 24) who are HIV infected. Behavioural surveillance of young people in general is poorly developed and young drug users, especially occasional and experimenting drug injectors, are particularly hard to reach populations. Nevertheless, the limited evidence available suggests that these same young people may be especially vulnerable to HIV infection
The presence of substantial proportions of young people among injection drug user (IDU) populations is of great concern. The World Health Organization (2002a) has highlighted explosive HIV epidemics among IDUs. Broadly speaking IDU related epidemics have rapidly developed in a number of countries (most notably in Belarus, Estonia, Russia and Ukraine) and in specific geographic locations in those countries (for example: Odessa and Nikolaev (Ukraine), Svetlogorsk (Belarus), Moscow, Rostov-on-Don, Kaliningrad, Togliatti City and Irkutsk (Russian Federation), Narva (Estonia), Termitau (Kazakhstan), (Kroll, 2003; Rhodes et al., 2002; WHO, 2002b, 2002c). Injecting drug use, the sharing of injecting equipment and associated risks of HIV infection, has also been increasing in countries throughout Central and Eastern Europe (CEE) and the Central Asian Republics (CAR) since the mid-1990s. It is estimated that up to 1 per cent of the population in some countries in the region (and up to 5% in some cities in Eastern Europe) are injecting drugs. Many of these HIV+ IDUs are young people; how many is not clear.
However, the limited evidence suggests that young people are especially vulnerable to HIV infection. Experimental or occasional drug use and drug injecting among young people is reported to be common in many countries in the region; the number of young people in the region injecting drugs is increasing and young people are initiating injecting drug use at increasingly younger ages. Increases in IDU also relate to the availability of readily injectable drugs, or injectable forms of available drugs, and local rituals and traditions. While there have been interruption to drug markets, the opioid group of drugs remain as the major substances injected (whether produced in ‘home laboratories/kitchens from pharmaceuticals or as heroin). However, there is evidence of increased use of Amphetamine-type Stimulants (again, home made or imported ready to use) both within ‘club’/dance and other settings. While much of this use might be occasional and cause few difficulties for this group of possibly ‘functional users’, within some of these ‘scenes’ there are concerning trends. For example, 41% of a sample of about 200 ‘clubbers’ in Moscow indicated they saw a possibility of transitioning to IDU. In addition, while most were in ‘relationships’, 60% indicated that they had sex with others while in these relationships (Khachatrian, 2003).
The limited evidence available indicates: increasing numbers of young people seeking treatment for their drug use (in Estonia 71% of people in drug treatment are under the age of 25 years), that many of those who inject drugs are young, and the average age at first injection in CEE/CARs is between 16 and 19 years (Rhodes et al., 2002). For example, in Russia, the age at first injection has been decreasing (Rhodes et al. 1999) and that some young people begin injecting at ages less than 15 years. In Moscow, 6% of 15-16 year-old high school students report a history of heroin use (Dehne, 2002). An estimated 70 per cent of IDUs across central Asia, the Russian Federation and central and Eastern Europe are under 25 years of age (UNICEF, UNAIDS, WHO, 2002).
However, there are indications, for example from Russia, that not all IDUs are frequent injectors, and that for some young people, drug injection may be experimental and a passing phenomenon. Where HIV prevalence and incidence rates are high and where risk behaviour is common during initiation into injecting - as in many countries and cities in the region - the risk of HIV infection per sharing act is increased so that young, and recent injectors become infected very quickly. Therefore, it is of concern that little attention appears to have been given to the specific needs of occasional and young IDUs in the prevention of HIV/AIDS,
Important interactions also arise between drug use and sexual risk. Drug operates as a mediating or co-factor for sexual risk taking, social network effects (in which drug using networks and sexual contacts overlap) along with sex work, which is a feature of some young people’s lives. Understanding the immediate risk and protective factors for initiating, continuing and ceasing injection drug use and the associated sharing of injecting equipment and sexual risk behaviours is crucial for effective HIV/AIDS prevention
It is important to note that many other macro-level factors are also thought to increase the vulnerability of young people including: social and economic disadvantage, poverty, unemployment, changing social controls and values, failing education and health systems, changing trafficking routes for drugs, arms and people, imprisonment and detention, marginalization and discrimination, migration, civil and armed conflict. Various corresponding protective factors are thought likely to make initiation into drug use, injecting and the risk of infection with HIV/AIDS less likely. These extend the range of potential interventions and intervention points that warrant consideration in any comprehensive appraisal of how injecting and the spread of HIV/AIDS can best be minimised among young people in CEE/CIS and the Baltic States, which – with as much of a focus on occasional, recent and experimental injectors as we have been able to bring - is the topic of this paper.
The paper is organised as follows:
• A brief review of relevant national level data on the extent of injecting and HIV/AIDS with special reference to people aged under 25;
• A summary of what is known about the nature of injecting among young people, transitions into and out of injecting, relevant risk behaviours and contact with prevention and treatment services;
• Identification and consideration of relevant macro-level risk and protective factors;
• A review of existing and potential interventions and commentary on their advantage and disadvantages and factors that may affect their adoption and implementation;
• Provisional proposals for a programme of research and responses across the region, which will be refined through the consultation process.
It is important to note that the authors do not claim any special expertise with the issues as they particularly affect the region and that this paper is offered very much as a departure point to facilitate a refining of our understanding of the situation in partnership with local experts and not as a definitive account of it.
Rationale
Why do occasional, recent, experimental and young IDUs require special attention?
• Young people account for the greatest number of people in developing countries where the epidemic is concentrated, and if not protected from HIV their nations will face staggering human and economic costs.
• Of those infected with HIV after infancy, at least 50% are young people under 25 years of age.
• Young IDUs may have limited awareness of risks due to limited education about and knowledge of HIV and other Blood Borne Viruses (BBVs)
• Young people are curious and can be easily influenced by peers and/or are reactive to or sceptical of adult warnings about risk.
• Young people may feel they are resilient and invulnerable to harm.
• Young people have less economic security and access to resources.
• Risks to health may be perceived at quite distant and remote and mainly affecting older IDUs.
• Young people may have limited capacity to identify with older IDUs who they believe to be ‘losers’ and that they will be able to stop IDU when they choose.
• Young people may feel unwanted or have had negative experiences at adult services, especially if such services primarily cater to adult men who have sex with men (MSMs) and rarely to IDUs of whatever age.
• Due to age and youth ‘status’, young people may be denied access to certain services by policy or legislation.
• Young people may believe that adult services will not respect their privacy and right to confidentiality.
• Young people may be unaware of the right to health and access to health services.
• The young age at which IDU begins and is established, the greater likelihood of later poly-substance use and chronic and life-threatening health illness.
• Early IDU is associated with early school leaving and difficulties in gaining and maintaining employment and stable accommodation.
• Young people in prison or refugee camps, immigrant and minority youth, those working in forced labour or as child/adolescent soldiers, those displaced by natural disasters or civil or armed conflict, and street children and young MSMs are among those at increased vulnerability.
• Young girls may be at greater risk, due to an increased likelihood that they will engage in commercial sex to finance their drug use and living situation.
• Congregating with peer and/or older IDUs can tend to reinforce risky health behaviour (including limited attention to nutrition and self-care) and marginalisation.
• Young people are a force for change. (developed from UNAIDS, 1999; UNODC/The Global Youth Network, 2003).
Section 1: A brief review of relevant national level data on the extent of injecting and HIV/AIDS with special reference to people aged under 25
This section is largely adapted from the work of Grund (2001) and attempts to provide a brief overview of the regional situation. It needs to be noted that drug use and IDU and HIV/AIDS are not equally distributed across the region or within countries.
UKRAINE
• Between 1988-1994 less than 100 registered HIV infections, mainly among foreigners.
• 1995 - more than 1000 cases detected among drug injectors in Odessa and Nikolayev, producing a population prevalence among drug injectors of 31% and 57% in each city respectively.
• HIV infection reported among drug injectors in all 25 regional capitals within 12 months and continued spread into rural areas and cities in the eastern and central parts of the country.
• By the end of 2001 UNAIDS estimated between 180,000 and 320,000 cases of HIV infection of which 50-80% are among people who inject.
• HIV prevalence among IDUs tested in sentinel surveillance studies in 2002 ranged from 17% in Kharkiv to 58% in Odessa
• By April 2003 54,680 HIV cases were reported, 71% attributed to injection drug use
RUSSIAN FEDERATION
• Fewer than 1100 cases of HIV infection registered until the end of 1995 with very few injecting drug users.
• 1995 – rapid escalation of infection among injecting drug users (IDUs) in Kaliningrad
• 1996/7 – IDU infections spread to Krasnodar, Nizhnyi Novgorod, Rostov Na Donu, Saratov, Tula, Tumen and Tver
• 1998/9 - average age 18-25. Nine cases of HIV infection arising from injecting among 11-14 year olds
• 1999 – epidemic detected in Moscow
• 2000 – epidemic spread to 30 cities and 82/89 oblasts. 130,000 people infected with HIV
• Studies in thirteen cities between 2000 and 2002 found HIV prevalence rates among IDUs ranging from 0% among treatment seeking IDUs in Archangelsk to 64% among syringe-exchange clients in Irkutsk
• By August 2003 248,000 HIV cases were reported, 90% attributed to injection drug use
BELARUS
• 1996 – HIV infection among IDU found in resident of Svetlogorsk. Subsequent targeted screening found prevalence of 88% among IDUs.
• 1997 – 67% prevalence of HIV found in syringes exchange returns in Svetlogorsk.
• 1997 – HIV found in IDUs in all oblasts in Belarus.
• 1999 - UNAIDS estimate 14,000 people with HIV and more than 80% associated with injecting.
• By the end of 2002 5,101 HIV cases were reported, 76% attributed to injection drug use.
MOLDOVA
• More limited outbreaks largely restricted to Chisinau and Baltsi
• Rapid increase in new cases in 1997 and 1998
• 1999 - 1034 registered infections. UNAIDS estimate 4,500 cases.
• 80% associated with injecting.
• By the end of 2002 1,691 HIV cases were reported, 82% attributed to injection drug use.
LATVIA
• 1996 – Only seventeen new cases
• 1998 – 163 new cases (122 among IDUs)
• 1999 – 241 new cases
• 2001 – 807 new cases
• By mid-July 2003 2,540 HIV cases were reported, 84% attributed to injection drug use. Most cases are concentrated in Riga and a few other towns in western Latvia.
• Although the numbers are comparatively small this is one of the highest incidence rates in the region.
LITHUANIA
• Until 2002 Lithuania was spared the explosive HIV epidemics reported elsewhere in the region
• In May-August 2002 284 prison inmates were diagnosed HIV positive
• Initial outbreak in Klaipeda seems to have been contained however by mid-July 2003 805 HIV cases were reported, 84% attributed to injection drug use.
ESTONIA
• Reported annual number of HIV infections soared from eight in 1996 to 1,474 in 2001
• 2000 – outbreak among Russian speaking IDUs in Narva, eastern Estonia followed by rapid spread among IDUs in other parts of the country
• 2001 – highest annual incidence of new infections with 1071 cases per million population.
• By end of March 2003 2,845 HIV cases were reported, 84% attributed to injection drug use
CAUCASUS REPUBLICS – (ARMENIA, AZERBAIJAN, GEORGIA)
• Infections rising
• Transmission category often unknown but suspected to be largely associated with injecting.
• In Armenia 234 HIV cases reported by July 2003, 54% attributed to injection drug use.
• In Azerbaijan 556 HIV cases reported by July 2003, 62% attributed to injection drug use.
• In Georgia, there are 9000 officially registered drug users of whom 60-70 percent inject. This estimate is supposed to underestimate by 12 –15 times the magnitude of the problem (World Bank, 2003). Levels of needle syringe sharing are as high as 72.9%. Steady increase of newly reported HIV cases since 1997. 409 HIV cases reported by the end of 2002, 72% attributed to injection drug use.
CENTRAL AND SOUTH EAST EUROPE
• Epidemic HIV not reported in most countries with the exception of Poland and Serbia/Montenegro which have mature epidemics closely related to injection drug use and dating back to the mid-1980s.
BULGARIA
• Data provided by the National Drug Addiction Centre showed that 94% of all drug use involved heroin, with intravenous introduction accounting for 74% (UN, 2000). More than two-thirds of IDUs were between 15 and 19 years old, and 24% between 20 and 24 years old. The average age of IDUs in Bulgaria was 18.4 years.
• As elsewhere in South Eastern Europe HIV is predominately sexually transmitted with the majority of a relatively small number of infections attributed to heterosexual transmission.
POLAND
• Outbreak in late 1980s.
• 1989 - 411 infections reported.
• 1995/1999 – between 539 and 638 new infections annually, largely associated with injecting.
• 2000 – UNAIDS estimate 13,000 infections
• By August 2003 8,300 reported cases of HIV, 59% attributed to injection drug use
SERBIA and MONTENEGRO
• Similar outbreak to Poland driven by injecting drug use.
• By the end of 2002 1,427 reported HIV cases.
ROMANIA
• In 1989 a unique, major nosocomial HIV epidemic in which several thousand institutionalised young children were infected with HIV through micro-transfusion of blood and multiple unsafe injections.
• Poor case reporting creates problems with determining the number of reported HIV infections (with more AIDS cases reported than HIV cases)
• The estimated number of HIV infections ranges from 5,500 to 14,000 cases.
• At present the HIV/AIDS epidemic in Romania is largely characterised by heterosexual spread.
• Sentinel testing in 2002 found four cases of HIV within a sample of 152 IDUs suggesting a rate of 26.3 per 1000 but a high rate of needle sharing suggests that the pre-conditions for rapid spread exist. (Novotny et al 2003)
CENTRAL ASIAN REPUBLICS
A World Bank report (Godinho et al 2003) updates this information as follows:
KAZAKHSTAN
• Kazakhstan has the oldest epidemic in the Central Asian Republics
• 2000 – 302 IDUs among 347 cases of HIV
• 2001 - 1050 IDUs among 1175 cases of HIV
• 2002 –Number of IDUs may exceed 250,000.
• An official estimate that 3% of population may inject drugs would put this at 450,000.
• Age of drug users decreasing – mainly 20-25 and 85% male
• Little awareness of HIV infection risk and injecting equipment sharing is commonplace.
• By June 2003 3,648 HIV cases reported, 90% attributed to injection drug use
KYRGYZ REPUBLIC
• The smallest Central Asian republic but now thought to be experiencing rapid increases in HIV infection.
• 410 cases of HIV infection by 2003. Mainly among males (74%) and people aged under 30 (64%) and substantially identified among prison inmates (56%).
• 83% of cases report injecting as main risk factor.
• Sentinel studies found 12-19% HIV prevalence among IDUs in Bishkek and 32-50% on Osh. 96% of drug users share syringes. Average age of drug users is 14 to 15 years. Heroin is cheaper than vodka or beer.
TAJIKISTAN
• 2003 – Official statistics report 92 cases of HIV infection (at least 65% associated with injecting)
• Estimates of the number of drug users range from 30,000 to 100,000. behavioural surveys suggest 93% share needles and syringes.
• Important interactions with commercial sex work for women. Average age of commercial sex workers (CSWs) is 20-25 but females as young as 12-13 years are involved. 20% of CSWs inject drugs.
TURKMENISTAN
• Official statistics suggest that the country has been largely unaffected by the spread of injecting and HIV infection, with only two HIV cases reported.
• An as-yet-unpublished situation assessment seems likely to indicate that this is now changing.
• 50% of prisoners are thought to inject.
• UNODCCP estimates suggest that there are 50,000 drug users of whom 15% inject.
UZBEKISTAN
• Local epidemiology is thought to seriously under-estimate the size of the problem.
• 2001 - 800 cases of HIV infection registered rising to 2,209 by April 2003. 84% attributed to injecting.
• More than 50% of known cases are among prisoners with the highest number of cases found in Tashkent.
• UN estimates that there are 60,000 drug users of whom 60-70% inject.
Section 2: A summary of what is known about the nature of injecting among young people, transitions into and out of injecting, relevant risk behaviours and contact with prevention and treatment services
The available data indicates that substantial proportions of young IDUs engage in behaviours that place them at risk of HIV infection (Friedman et al., 1998; Kudriavtseva, 2000; McKeganey, Friedman, & Mesquita, 1998; Miller et al., 2002a, 2002b; Rhodes et al., 1998; Stimson & Choopanya, 1998; UNODC, 2003; Welp et al., 2002). In Serbia, the Rapid Assessment and Response (RAR) project found that injection equipment was shared by 57% of the IDU group, 44% of the young MSM and 85% of the young sex workers (Cucic, 2002). In the Ukraine, 50-70% of all HIV infections are among IDUs (Ukrainian Institute for Social Research, 2001), and in Minsk about 20% (WHO, 2001). These figures are much higher than national prevalence rates. In other parts of the world there are some similarities. In Nepal in 1998, for example, 50 per cent of the nation’s IDUs were HIV positive, half of whom, as mentioned earlier, were 16 to 25 years of age (UNICEF, UNAIDS, WHO, 2001, 2002). In Glasgow, Scotland, increases in the number and proportion of young injectors, particularly females, were observed between 1990 and 1997 (Mullen & Barry, 2001; Taylor et al., 2000).
Indeed, young people have been found to engage in risky needle-sharing behaviours, which appear to be maintained, at least in part, by a belief held by young people that their chosen needle-sharing practices leave them with little or no risk of HIV infection (Deslandes et al., 2002; Loxley & Ovenden, 1995). For example, Louie, Rosenthal, and Crofts (1996) found that, in a sample of 300 peer-interviewed young IDUs in Melbourne, Australia, 44 per cent had ever reused a needle that they knew somebody else had previously used, while 56 per cent of a youth sample in Los Angeles, USA, believed that they had engaged in behaviours that put them at risk of becoming HIV infected (Children’s Hospital Los Angeles, 1996). Furthermore, in a non-youth-specific multi-site survey of 1214 IDUs in England, 78 per cent of respondents reported sharing injecting equipment (Hunter et al., 2000). In addition, there are anecdotal reports from Eastern Europe that where clean water is not available, drugs are mixed for injection in blood provided by one or more of those about to inject (UNICEF, 2003).
One seemingly important feature of the way that people begin injecting concerns the role of current injectors in the initiation process and the role of social exposure to injecting. Wherever the question has been examined, current injectors have been found to play an important role in giving or guiding novices through their first injection (Stenbacka 1990; Crofts et al 1996; Stillwell et al 1999). Furthermore, rather than it being a process characterised by pressure to begin injecting, it is more commonly one in which the non-injector actively seeks the experience of injecting because of a desire to experience ‘the rush’ or more general curiosity about injecting (Crofts et al 1996; Shelley et al. 1993; Stillwell et al 1999). For the majority of people, social exposure – seeing people inject or talking with injectors about what injecting is like – is instrumental in the decision to try injecting (Stillwell et al. 1999); an understanding which underpins the ‘Break the cycle’ intervention developed from work of Hunt et al. (1998) which seeks to interrupt non injectors’ social exposure to injecting and which is used across Great Britain. There may be other ways in which interventions can be developed to affect these processes and further reduce the number of people who begin injecting. These will need to be developed in ways that are sensitive to the local cultural contexts in which injecting occurs.
The Children’s Hospital Los Angeles (1996) stresses that despite the view that adolescents are relatively well informed about HIV transmission and prevention, there is evidence that they are not sufficiently prepared to protect themselves from infection. Developmental and social-environmental factors appear to influence youth in relation to both risky and more protective behaviour.
Social contexts and rituals also perpetuate risk behaviour. The following was documented during an observation of young IDUs in Serbia. “Heroin is boiled with tap water in a common spoon. Boiling of the drug in a dirty bottle cap was also observed wherefrom it is filtered through cotton with a shared needle, into a shared gun, and only then it is shot into other syringes. The cotton balls are not wasted. They are routinely put aside in a box and stored for a time when there is no drug available, when these are boiled over again in an attempt to drain the last droplets out of them” (Cucic, 2002, p.46). These rituals may be eroding, but were also reported by a number of participants from the Ukraine (WHO, 2001).
Transition
A recent literature review on initiation and transition to injecting (Treloar et al., 2003) and RAR summaries from 6 countries of South Eastern Europe, identified the following (Cucic, 2002; Wong, 2002);
- There is often some move back and forth between IDU and non-IDU at different times in a person’s life
- Transitioning is often a process, not just a one-off event
- Patterns of use and routes of administration are sensitive to drug availability, cultural, social, economic and law enforcement factors, and regional (and within region) and cultural variations are evident
- If one route of administration is dominant, new drugs are more likely to also be used the same way (thus, there is a risk of IDU of Amphetamine Type Stimulants [ATS] if heroin IDU has been established)
- Market forces – if injectable drugs are cheap and readily available injection use is more likely, as it is if the drugs available are not so suitable for smoking/inhaling (eg low quality/potency or composition)
- The improved ‘high’ that is often reported with IDU
- ‘Cost effectiveness’
- Curiosity may entice some to injection drug use
- Rituals may develop – a group mix, etc. – and this can be a ‘pull’ to join in the group rituals to ensure membership of the group
- Peer pressure and/or modelling can also be a ‘pull’
- If there is a lot of interaction with injectors, injecting may be more likely (subtle modelling)
- There may be an identification with ‘injector identity’, as being ‘cool or chic’. Also the young person may already be seen as ‘deviant’ because of their temperament, delinquency, etc.
First Injection
The following are characteristics of the first injection:
- They are mostly unplanned
- It is usually not alone
- Women are often given their first injection by sexual partners
- Men are most likely to be first injected by a friend
- If vomiting occurs (if an opioid is used), this soon stops, the analgesic effect of the drug may reduce discomfort anyway, and peer information is usually given about how this reaction is usually short-lived
- Equipment sharing is common as new and infrequent injectors may find it harder to access sterile equipment, have less contact with health services, and may lack money to buy new equipment, if it is not free
- The young initiate may be told that the equipment was ‘clean’ and not be aware of how to know if this is true
- Use of a new equipment can be seen as ‘bad luck’.
The Treloar et al. (2003) study of 336 young people with a mean age 21.2 years (range 16-25 years) comprised 59.2% young males and 40.8% young females from two cities and one rural area in Australia. The first drug injected was heroin for 51.8% of the sample and (meth)amphetamines for 47.6%.
Key findings from the Treloar et al. (2003) study:
- 50.3% of the sample were aged between 12 and 18 at their first injection
- 94% had used alcohol or cannabis prior to their first injection 58% not planned
- The reasons given for IDU were: experimentation, fun, the ‘rush or high’, and then ‘availability’
- 2 or more persons were present at first injection
- For 83% they were the only person having their first injection at that time, but most others present were also injecting
- Those younger at first injection were more likely to have left school early, be more frequent injectors, be risk takers, have less stable accommodation, share equipment, and be unaware of HCV status or be HCV positive
- Fear of BBVs did not seem to be a reason for reducing IDU, nor being HCV+
- Differences between cities and types of drugs emerged.
In summary, Treloar et al. Concluded: ‘Our data characterise initiation of injecting drug use as occurring after a history of illicit drug use, in a social setting with friends and/or partner present, typically with little planning in the injector’s own home or the home of a friend, and with limited awareness and perception of risk at the time….drug injection is typically initiated for reasons of experimentation, fun and availability …. And to be accepted as part of social network activities..’ (p. 51).
The recommendations from this study were:
- Keep young people in school – and work with drug users who are students to help them remain in education
- Use peers to reach networks which include new and near-initiates
- Target ‘older injectors’ and attempt to encourage them to be responsible
- Work with families to be better able to cope and assist their children/siblings (this includes poverty alleviation)
- Provide practical safe injecting information and equipment
Section 3: Identification and consideration of relevant macro-level risk and protective factors[1]
A range of macro-level risk and protective factors have been suggested that might mediate the transition into and out of injecting and the likelihood of acquiring HIV infection. However, although many of these are generally accepted there is far less empirical research focusing on them than one would like. Where there is attention to these questions the focus is almost invariably on the much more diffuse relationship with drug use in general (as in the following summary), rather than the specific focus of this review – young and occasional injectors, which may substantially limit the applicability of the following discussion to the question in hand.
Drug production
Morrison (1997) has described the relationship between the production of both organic and synthetic drugs with the occurrence of:
• Insurgency
• Armed conflict
• Weak/Corrupt government
• Economic dependence on agricultural commodities
• The existence of chemical industries
• Isolated rural regions
• Unemployment
• Being in receipt of economic aid.
As drug use frequently (though not invariably) shadows production, this suggests that these factors might all be associated with rates of injecting wherever drugs that are potentially injectable are produced.
Poverty, employment and social inequalities
The influence of poverty and social inequalities are generally accepted but have much less systematic, empirical support than might be supposed[2] and some contradictory data also exists. For example, Silbereisen et al. (1995) discuss effects on employment in Germany. Within former East Germany, political integration with West Germany initially increased youth employment. This is despite a fall in the aggregate level of employment for the population in East Germany as a whole. Contrary to the commonly supposed effects of poverty, the associated increase in young people’s affluence is suspected to be driving an increase in drug use; as a group of the population that are disposed towards using drugs have a larger amount of disposable income than before. Their greater spending power coincides with the increased mobility that has already been discussed and the two processes seem to have the potential to reinforce each other. Distinguishing drug use in general (e.g. cannabis use and recreational stimulant use) from more problematic and hazardous patterns of drug use such as injecting may be critical for understanding the influence of poverty, income inequalities and (un)employment.
Silbereisen and colleagues (1995) identify the importance of social and political change in Europe as both a putative causal factor for changes in drug use. They allude to several possible mechanisms by which such change may influence levels of drug use. Several possible mechanisms are discussed below. Although Silbereisen et al. Discuss changes within Europe, it seems possible that the mechanisms associated with social and political change in Europe may also be applicable in the CEE/CIS and Baltic region.
Increased mobility
The relaxation of border controls between European Union (EU) member states resulting from the Schengen Agreement (1985) mean that mobility is increasing within the EU. Over the same period, major political changes in eastern Europe have meant that travel in and out of the EU from east European countries has also become easier. Mahajan and Muller (1994) have compared the diffusion of a technological innovation – the videocassette recorder – in Europe between member and non-member states of the European Community and found that diffusion occurred more quickly between member states. It seems possible that such processes are similarly applicable to drug use and the diffusion of drug injecting within the CCE/CIS and Baltic regions.
Availability
Some factors are virtually truisms: injected drug use is more likely where injectable drugs are produced or along transit points for their distribution. Increased mobility can also increases opportunities for trafficking and influence drug transit routes. Not only can this affect the destination market, but also the transit countries or areas, in which increased drug availability may arise. An important consequence of the political changes in Eastern Europe has been the opening up of drug supply routes from Central and Eastern Europe. This is now an important route for both amphetamine-type stimulants produced within Europe and heroin from Afghanistan and Pakistan (EMCDDA 1997: 121: UNDCP 1997: 28): the ‘Balkan route’ as it is often known. At the same time, changes within youth culture across Europe have favoured diffusion of drug use. In particular the emergence of the ‘Balearic beat’ from Ibiza, with its original association with ecstasy use, has been influential across the continent. As the EMCDDA summarise:
The new drug trend rapidly transcended Europe’s previously less pervious national borders. Advances in communications technology meant young people across the Community increasingly had access to the same information sources. Rapidly they became directly aware of rave culture and indirectly aware of ecstasy use, aided by astute marketing. Advertisers responsive to young and relatively affluent consumer markets adopted dance culture’s sounds and images and now use these to market products from soft drinks to sportswear across Europe. Much of the marketing is implicitly or explicitly drug-related; international corporations appear to have become increasingly blasé about ads with explicit drug imagery.
(EMCDDA 1997: 72).
In the Caucuses, increased production of drug s in Afghanistan coupled with unprotected Georgian borders (due to Abkhaz, Ossetian and Chechen ethnic conflicts) appears to be making young people more vulnerable to drug use, particularly injection drug use. However, this relationship appears to be far from perfect, which also begs the question of what protective factors still operate in drug-rich environments?
Break up of mechanisms of social control and increased racial and religious tension
Sudden political and social changes may precipitate a breakdown in social order and the mechanisms of social control. The introduction of alternative, competing value systems, challenges to the authority of those who were previously in power with a consequent transfer or erosion of that power, and the disruption of established social ties, may all accompany sudden political and social change. In turn, this may act both to reduce existing checks and controls on drug use, and by increasing anomie, potentially leading to increased drug use as a reaction. Jablensky (1992) identifies the particular contribution of increased racial and religious tension, that can accompany this process, as a further factor that may increase levels of drug use.
In the example of German unification Silbereisen et al. Draw attention to factors such as the breakdown of the state youth organization and the way “adolescent’s value orientations have gradually come closer to those in the west” to illustrate changes that may alter the way that leisure time is occupied. The processes described here such as changing norms and the erosion of old certainties can be seen to be closely related to those discussed by Egger (1980) that he attributes to ‘rapid economic change’.
Rapid economic change
Egger (1980) has suggested two mechanisms that connect economic growth with drug use. There has already been mention of the way that increased prosperity may enable increased drug use. However, Egger also discusses possible mechanisms by which rapid economic change may cause an increase in drug use. When growth occurs at such a pace that social structures are eroded, he proposes that this contributes to alienation, helplessness and a reduction in meaning, for which increased drug use is a response. Egger cites examples from rural Greece and of the indigenous people of North America and Australia, as well as increased drug use among US military personnel during the Vietnam war, to support this argument.
Changes in leisure
Silbereisen et al. (1995) Refer briefly to changes in the use of leisure time. These changes, and some of the particular ways in which drug use has been ‘normalised’ within young people’s leisure are documented in a five year longitudinal study of young people in north west England by Parker Aldridge and Measham (1998). They conclude that the largely recreational use of the less physically addictive drugs has been “accommodated because most adolescents and young adult users merely fit their leisure into busy lives and then in turn fit their drug use into their leisure and ‘time out’ to compete alongside sport, holidays, romance, shopping, nights out drinking and, most important of all, having a laugh with friends” (pp.156-157). The relationship between ‘leisure’ and drug use is a recurring topic within the drug misuse literature. Although trend data that would allow drug use to be investigated with respect to changes in the amount and nature of leisure are largely elusive.
Studies of drug use and leisure are mostly cross-sectional, with the evident limitations of such designs. Grieco and Lichstein (1981) have suggested that unstructured or empty leisure time is a stressor and that “a rational technology of leisure skill training is needed”. Some support for this view derives from a small study by Iso-Ahola and Crowley (1991) in which drug use was associated with ‘leisure boredom’. In this investigation 39 ‘substance abusers’ overall engagement in leisure activities was greater than a comparison group of 81 non-users. In a way that is consistent with a strand of the literature that pathologises young drug users, this work views drug users as having a “personality predisposition towards sensation seeking and low tolerance for constant experiences”. They conclude, somewhat melodramatically, that “if leisure activities fail to satisfy their need for optimal arousal, leisure boredom results and drug use may be the only alternative”.
However, in a more elaborate consideration of the possible relationships between leisure and drug use, Agnew and Petersen (1994) have examined opportunities for influencing drug use through a number of possible mechanisms. These include:
involvement – structured activities may reduce the time available for drug use,
supervision – where adult supervision of the leisure activity restricts opportunities for drug use,
strengthening the bond to family and school – leisure activities with parents and attached to school may strengthen such ties and prevent deviance,
fostering conventional beliefs – organised leisure activities may increase exposure and attachment to people with conventional (anti-drug) values,
exposure to peers who foster drug use – leisure activities such as ‘hanging out’ may increase access to drugs and a peer group that endorses drug use,
reducing frustration – certain types of leisure activity may relieve tension and frustration caused by an inability to achieve life goals.
They found only weak evidence at best for the proposed mechanisms, indicating that the potential for intervening through programmes that manipulate young people’s leisure time may be limited.
Interactions between work and drug use as leisure have also been discussed by Grieco and Lichstein (1981) where they consider drug use as one possible self-reward within a sequence of work and leisure activity. This would appear to have relevance for the following study. A cross-sectional analysis of aggregated data from the Monitoring the Future project conducted by Bachman and Schulenberg (1993) has investigated the relationship between part-time work intensity among school students and drug use. Along with a range of psychosocial problems, use of cigarettes, alcohol, marijuana and cocaine all increase linearly with hours worked per week. Conversely, leisure satisfaction decreased as hours spent in part-time work increased. One possible interpretation of this is that increased part-time work and the associated disposable income leads to drug use as a self-reward. The converse could also be argued; that drug consumption necessitates increased part-time working. However, Parker, Aldridge and Measham’s (1998) work suggest that most drug use among this age group is better regarded as a leisure choice and cannot be characterised as dependent, in a way that would necessitate work or other forms of funding drug use. Together with the previous indications of the role of general economic growth and increasing youth employment in East Germany, this points to important interactions between spending power, patterns of leisure and drug use among young people.
Risk and protective factors – a perspective from young people’s drug services within the UK
The main governmental reference point for young people’s drug services in the UK (HAS 1996) highlights the deficiency in our general understanding of risk and protective factors for young people’s drug use in general but also provides some points for consideration. It acknowledges the limited research that is specific to drug use and largely infers the likely risk and protective factors from elsewhere. It is crucial to note that this review is not in any way specific to injecting or even drug use. In fact it draws primarily on the general adolescent mental health literature. Nevertheless, it provides a succinct framework from which consideration of risk and protective factors for drug use may be further developed.
The review discusses risk and protective factors in three groups and with a number of sub-headings as follows:
Social and cultural risk factors
• The law and societal norms
• Substance availability
• Extreme economic deprivation
• Neighbourhood disorganisation
Individual and interpersonal risk factors
• Physiological factors
• Family attitudes to substance use and misuse
• Use of substances by parents
• Poor and inconsistent family management practices
• Family conflict
• Early and persistent behaviour problems
• Academic problems
• Low commitment to school
• Early peer rejection
• Association with peers who use drugs
• Alienation
• Attitudes favourable to drug use
• Early onset of drug or alcohol use
Protective factors
• Positive temperament
• Intellectual ability
• A supportive family environment
• A social support system that encourages personal efforts
• A caring relationship with at least one adult.
Whether or how these observations might apply to the situation in the CEE/CIS and Baltic region is clearly open to debate.
Risk and protective factors specific to injecting and HIV (adapted from Grund, 2001)
We have been unable to review the entire literature relevant to this consultation in the time available and so this background paper is inevitably partial. A particular deficiency has been our inability to refer properly to any of the literature published in languages other than English. Nevertheless, among the documents that we have had sight of we consider that Grund’s paper on HIV infection in Central and Eastern Europe (2001) is especially worthy of attention regarding risk and protective factors implied within his paper, which are therefore summarised here:
Risk factors:
• Imprisonment – in several countries across the region the epidemic of HIV appears to be clustered among IDUs within prisons. Although this may partially be an epidemiological artefact of the HIV testing regimes that have been applied it also implies that imprisonment should itself be examined as a risk factor.
• The culturally normative nature of injecting – in many states injecting is described as something which is normal (for the administration of both medicinal and recreational drugs) to a degree that greatly exceeds norms in most other regions of the world. Among many drug users there appears to be a view that recreational drugs (with the exception of cannabis) should invariably be injected. There may be opportunities to promote alternative, non-injected routes of administration, which, - although they would fall short of more absolute drug prevention aspirations - may nevertheless be achievable and might have a valuable impact on HIV infection and the various other harms that are specific to injecting. It further suggests that the population’s attitudes to medical treatment and the general way in which injecting is preferred for administering medical treatment might be a broader long-term target for attention within policy in this area.
• State repression of drug users – as part of understandable efforts to discourage drug use at a time when it has expanded epidemically across the region Grund describes many ways by which drug injectors are repressed. In many ways these drive IDUs deeper underground and away from the very treatment and social welfare services from which they might benefit. They also seem likely to conflict with the promotion of human rights and tolerance identified by UNAIDS as an important feature of efforts to reduce HIV. Consequently, it seems important continuously to critically consider the impact of legislation and other drug control measures intended to alleviate drug problems in case they inadvertently produces unintended and undesirable results.
• Economic collapse – the substantial problems of the legal economy have allowed a huge ‘shadow economy’ to flourish, in which illegal drugs comprise an important sector. Implicitly, measures that restrict the shadow economy and promote participation in the licit economy for the whole population across the region are likely to diminish the use of drugs, injecting and the HIV problem.
• The treatment of ethnic minorities – the examples are given of a) Russians within Narva, Estonia and b) extensive examples involving Roma people highlight the way that drug use, injecting and HIV may disproportionately affect some ethnic groups and the likely role that discrimination may play in this process.
• Complex and competitive relationships between government agencies – Noting the importance of effective multi-sectoral and multi-level approaches in the response to injecting and HIV, Grund describes a residual effect of the highly hierarchical, multi-layered Soviet system which makes the relationships between the government health structures at the local, state and federal level highly complex. Collaboration seems comparatively lacking and a culture of secrecy and competition has been observed, all of which is a risk factor - of a rather different kind - for the development of effective responses. Allied to this he notes the considerable funding shortages and unfavourable climate for NGOs.
• Beliefs in the ‘differentness’ of the region and the inability of drug users to change – these conspiring factors are thought to inhibit the adoption of interventions that have been used successfully elsewhere because they are thought to be inapplicable across the region because IDUs are more intractable than those elsewhere around the world. Whilst it is clearly important for people from outside of the region to be open to the possibility of local differences that limit the applicability of learning elsewhere, it is nevertheless important to identify ill-founded obstacles to the adoption of interventions that might otherwise work.
Protective factors:
• More persistent integration of IDUs within family and social networks – contrary to the situation in many industrialised countries IDUs in the CEE/CIS and Baltic region generally remain integrated within families and social networks to a greater extent and in a way that usefully preserves social relationships that are not exclusively drug related and may enhance social reintegration.
• Lesser levels of social stigma – contrary to the heightened levels of state repression that IDUs experience in many countries within the region, IDUs are otherwise thought to experience less stigma arising from their injecting within their other social relations.
Section 4: A review of existing and potential interventions and commentary on their advantage and disadvantages and factors that may affect their adoption and implementation
So far, HIV/AIDS interventions among young people have primarily focused on prevention in the general population of young people using information campaigns (including use of mass media), school and life-skills based education, health promotion and, to a lesser extent, peer education and youth friendly services. To a lesser extent, targeted interventions for vulnerable or high risk groups, particularly prevention, treatment and harm reduction programmes for injecting drug users have also been put into place. Such interventions in general may not adequately address the specific risk behaviours and risk environments of young drug users, young injectors and other especially vulnerable young people. While drug education campaigns aimed at young people in general may appeal to young people who do not use drugs and to parents, they may have little impact on the actual behaviour of current users. Even though peer-outreach is recognised as an effective approach for reaching especially vulnerable young people, evidence suggests that the majority of peer-led programmes in CEE/CAS/CIS are aimed at reaching mainstream young people in formal settings, such as schools and youth clubs.
At the same time, interventions that target IDUs (e.g. needle syringe exchange, methadone treatment) may be inappropriate and/or inaccessible to young people, especially those who are injecting only occasionally. A needle and syringe exchange may have little to offer young non-injecting drug users. Methadone treatment may not be appropriate for young non-dependant drug injectors. Some HIV/AIDS and drug services are not available to persons under eighteen years of age, because of laws, local policies and formal and informal guidelines. Young drug users may be reluctant to access adult services because of concerns about privacy and confidentiality. Young drug users may also not be engaged in networks of older and more experienced users and injectors. Peer education messages designed for older users may be inappropriate or not reach younger users. Young drug users may not identify with older dependent IDUs and conclude that HIV prevention messages do not apply to them. Furthermore, very few interventions specifically target young drug users who are: recent initiates to injecting drug use, and/or inject occasionally; young non-injecting drug users vulnerable to initiating drug injection, and/or sexual risk associated with their drug use.
The purpose of this section is to:
• review the evidence for the effectiveness of various interventions including harm reduction measures designed to reduce young people’s risk behaviour for HIV transmission and acquisition, especially for new and occasional young injectors;
• explore evidence suggesting that providing harm reduction services for young people engages or encourages their utilisation of a variety of health services;
• discuss major policy or legal implications that need considering.
Evidence and materials for this paper were gathered through MEDLINE and PSYCInfo literature searches, WHO, UNODC, UNAIDS and UNICEF documents, and e-mail and telephone contact with relevant practitioners and researchers (key informants), and meeting participants. Most of the available research is in English and from developed countries, and little specifically concerns young, new or occasional IDUs. Many studies do not appear to have analysed for age effects, despite a multi-city WHO study revealing that between 72 and 96 per cent of 6,436 IDUs across 12 cities in five continents reported that their age of first injection was less than 25 years (Malliori et al., 1998). Likewise, virtually no information has been reported on young recent, occasional and experimental IDUs.
Nonetheless, due to the presence of substantial proportions of young people (defined in this paper as individuals between 10 and 24 years of age) throughout these studies, it is possible to extrapolate the findings to young people with some confidence. However, at least one study (Welp et al., 2002) indicates significant differences in a sample of drug users divided into two categories; i.e. those under and over 25 years of age. Thus, the impact of age cannot be ignored.
Of late, a number of RARs have been undertaken among young people, and especially vulnerable young people (eg in Albania, Bosnia and Herzegovina, Croatia, Federal Republic of Yugoslavia, Former Yugoslav Republic of Macedonia and Serbia) which include young people, young people who use drugs, young sex workers, young men who have sex with men, young sailors, out of school and minority groups, such as Roma youth, and young offenders (Cucic, 2002; Wong, 2002). These valuable and significant studies, some of which have targeted and engaged very hard to reach and hidden sub-populations of young people, are starting to fill in some gaps, and raise many more questions, and demonstrate some regional and within region variations in drug availability, patterns of drug use, drugs used, risk behaviours and service provision and interventions available and used.
While much of the identified literature comprises programme descriptions or uncontrolled studies, which do not meet ‘gold standard’, there is a large degree of consistency in findings between the more robust and predominant adult studies, and the less plentiful youth-focussed evidence.
The World Health Organisation and other international agencies identify the following for the effective prevention of HIV/AIDS among IDUs:
• Use of information, education and communication (IEC) materials to create awareness about the need to address HIV among IDUs, and for health education and motivation among IDUs and their communities. The evidence suggests that IEC interventions are more effective when implemented in conjunction with the provision of sterile injecting equipment and condoms.
• Outreach to IDUs for face-to-face education about HIV risks and prevention measures, and for distribution of IEC materials and the means of prevention. Together with other activities, outreach is most effective if started when HIV seroprevalence among IDUs is low (that is, less than 5%), when linked with other services (especially needle exchange and condom provision), and when IDUs are involved in planning and service provision.
• Providing sterile injecting equipment and disinfecting materials such as bleach. Together with condoms and robust health promotion, these are the main means of prevention of HIV transmission among and from IDUs. Many reviews conclude that Needle and Syringe Programmes (NSPs) are effective and do not lead to increases in the numbers of people injecting drugs. Evidence for disinfection programmes is mixed; some evaluations found a protective effect, others did not. It appears that effectiveness relates more to the circumstances in which the bleach is distributed and used, and may be viewed as a second line strategy to the more effective NSPs.
• Providing substitution treatment to assist IDUs to reduce or stop injecting. Methadone maintenance and other substitution programmes have been associated with lower rates of HIV prevalence and reduction in HIV risk related to injection drug use in opioid users. However, little research has been conducted in developing and transitional countries where availability of substitution is limited. In addition to the rapid increase in the use of amphetamine-type stimulants (ATS) in many regions of the world, anecdotal evidence indicates an increase in the injection of these substances, particularly in developed and some developing countries such as Thailand.
• Supportive policy, legislation and targeted advocacy have contributed to reducing marginalization, and increased IDU access to HIV prevention services (WHO, 2002b, 2002c).
Each of these principles fit within the parameters of a broad view of the ‘harm reduction’ approach to the prevention and control of HIV among IDUs. However, agreement on a universally accepted definition of harm reduction remains elusive. According to WHO (2002b), “the traditional definition refers to attempts to primarily reduce adverse health, social, and economic consequences of drugs rather than maintaining the major focus on reducing consumption of these drugs” (p. 9). However, it is also emphasised that in a number of cases, ‘harm reduction’ also includes abstinence. That is, for people of any age where significant organ and other health and social damage has occurred, the only acceptable recommendation to reduce further harm may be abstinence. It is also not inconsistent that reduction or elimination of drug use can fit within a broad harm reduction approach, in addition to safer means of use and promotion of health among those who choose to continue to use. Nonetheless, due to its predominance throughout the substance use literature, the term ‘harm reduction’ has been adopted for the purposes of this paper.
While still not universally embraced, the harm reduction approach is associated with the most significant reductions in HIV and other BBVs among IDUs. Thus, it deserves some consideration alongside other approaches. ESCAP (1999) has identified a rationale for harm reduction in the context of HIV:
• drug users are hard to reach;
• young drug users may be ignorant of or indifferent to the risks of IDU;
• they may not know how to avoid the harmful consequences of IDU;
• they may share contaminated equipment;
• they may not have access to youth-friendly services;
• they may not have access to safe injecting equipment and sufficient information about cleaning equipment;
• they may not have easy access to condoms nor encouragement to practice safe sex.
ESCAP (1999) also identified the basic assumptions that underlie harm reduction in the context of HIV:
• “Some non-medical or illicit drug use is inevitable in most societies where drugs are available;
• Drug use in the community will inevitably cause harm to the community and to the individual;
• Drug misusers are members of the community. Ensuring that they do not become infected with HIV benefits the whole community;
• Although it is desirable to have a drug free society, it is possible to reduce the potential harms caused by drug taking without necessarily reducing the actual levels of drug use; and
• As some drug users are unable or unwilling to abstain from drugs (at least in the short term), achievable alternative goals that reduce the potential risks should be available.” (p.75).
Usually, a hierarchy of goals is pursued:
• Reduce the incidence of sharing injecting equipment
• Reduce the incidence of injecting
• Reduce the use of street drugs
• Reduce the use of prescribed drugs
• Increase abstinence from all drug use. (Hunt, 2003).
ESCAP (1999) has also listed what harm reduction is not:
• “It is not a soft option on drugs;
• It is not a step toward the legalization of drugs;
• It does not encourage or condone drug use;
• It is not a new method of prevention and treatment for drug misuse; and
• It is not in conflict with the objectives of law enforcement.” (p.76).
Despite the reported trends in risk-taking behaviour, many regions have been successful in preventing HIV epidemics among IDUs (Bastos et al., 1998; Keyl et al., 1998; van Ameijden & Coutinho, 1998). Des Jarlais et al. (1998a, 1998b) explored the prevention activities of five cities in which HIV has been introduced, but where seroprevalence has remained low and stable, at levels of less than five per cent of IDUs. Prevention activities for the five cities - Glasgow (Scotland), Lund (Sweden), Sydney (Australia), Tacoma (USA), and Toronto (Canada) - are presented in Table 1. Common across each of the cities was relatively early initiation of prevention, which included the provision of sterile injecting equipment, community outreach, and greatly expanded drug treatment. Bleach distribution was common across three of the five cities.
Additionally, Wodak (1995) attributed the consistently low levels of HIV infection among Australian IDUs to the early availability of sterile injecting equipment in all major cities and large towns, HIV awareness initiatives in the 1980s, and IDU involvement in the identification and implementation of prevention policies. Similarly, Loxley (2000) proposed that partnerships are important between the IDU community and health educators, researchers and policy makers in the fight against HIV infection. While there appear to be reductions of HIV incidence in some CEE/CARs, it is unclear as yet whether this can be linked, at least in part, to the increased availability of sterile injecting equipment.
Table 1. Prevention activities of cities in which HIV prevalence has remained low and stable
|Cities |Began |Provided |Community Outreach|Greatly |Extensive HIV |Bleach |Self-reported |
| |early |Sterile | |expanded drug |testing |Distribution |behaviour change |
| | |Equipment | |treatment | | |among IDUs |
|Glasgow |X |X |X | | | |X |
|Lund |X |X |X | |X | |X |
|Sydney |X |X |X |X | |X |X |
|Tacoma |X |X |X | | |X |X |
|Toronto |X |X |X | | |X |X |
Adapted from Des Jarlais et al. (1998)
It appears, then, that spread of the HIV epidemic among IDUs can be effectively curbed by prevention activities that:
• begin early;
• include the provision of sterile injecting equipment and disinfecting agents;
• include community outreach;
• involve IDUs in the identification and implementation of prevention policies; and
• are tolerated by local authorities.
However, some interventions on their own are not always enough. A number of regions in which harm reduction strategies were utilised report persistent and even increasing syringe sharing behaviours and HIV infections (Hope et al., 2002). For example, in Dublin, Ireland, where harm reduction interventions are utilised, syringe sharing was reported by 70.3 per cent of a sample of 246 treated IDUs with a mean age of 22 years (Fitzgerald et al., 2001; Smyth & Keenan, 1996, 2001). Syringe sharing was found to be associated with early school leaving, parental unemployment, long history of infrequent injecting, injecting more than one substance, more intimate social relationships with other IDUs, less perceived risk in borrowing from acquaintances, and usually opting to inject in the company of other IDUs.
In addition, McElrath (2001) proposed that risk behaviours among IDUs in Northern Ireland were associated with scarcity of new needles and a general lack of knowledge about injection practices that reduce risk for infectious diseases. In Montreal, Canada, Brogley et al. (2000) found that harm reduction strategies were effective in changing risk behaviours only in IDUs who adopt and maintain low-risk practices. A survey of 6,387 IDUs in Eastern Central Canada revealed that HIV prevalence ranged from 4.7% in semi-urban areas to 20.1% in Ottawa (Hawkins et al., 2002).
These marked variations in the success of harm reduction strategies in effectively preventing and controlling the spread of HIV among IDUs reflect, at least in part, the variations in time, place, trends and culture in which different groups of IDUs live, especially local sero-prevalence rates and drug availability and purity. Degenhardt, Gascoigne and Howard (2002) found, like others, a move toward injection of ATS during a period of reduced heroin availability.
Thus the provision of injection equipment may not be sufficient for effective HIV prevention. It is also probable that risk-taking behaviour is characteristic of some young people generally, and not just associated with injection equipment sharing. It is thus important to explore and address other risk behaviours among occasional and young IDUs, including risky sexual practices, especially given that sexual contact is sufficient for the transmission of HIV.
The following section contains an exploration for effectiveness of various harm reduction interventions aimed at IDUs. Table 2 summarises international evidence for the effectiveness of NSPs, peer education and community outreach programmes, and substitution programmes.
Needle and Syringe Programmes (NSPs)
The term Needle and Syringe Programme (NSP) includes interventions that either exchange or provide sterile injecting equipment. NSPs are operated by a selection of agencies, including government health services, NGOs and pharmacies, and by various means, including fixed-site vending machines and community outreach. Some NSPs require the return of used equipment prior to the provision of new equipment (sometimes specifically one for one). Most provide equipment free of charge or at minimal cost, but, at some pharmacies, they may be relatively expensive and concerns about confidentiality can be a barrier.
In a review of the NSP literature, Gibson, Flynn and Perales (2001) found evidence supporting the effectiveness of NSPs in reducing syringe sharing and risk of HIV infection across several regions of the USA, Netherlands, Scotland, Wales, England and Nepal. Favourable outcomes, which were not listed in the review, have also been reported in Germany, Russia, and Northern Thailand (Gray, 1998; Paone et al., 1995; Starke et al., 1995; WHO 2001). It is noted that, in Thailand, the NSP at that time operated contrary to Thai law, which led to shortages in supply of needles and syringes and consequent sharing of injecting equipment, and, more importantly, young IDUs experiencing difficulties in accessing the NSP (Gray, 1995, 1998).
Outcomes are mediated by many variables (Parsons et al., 2002; Schoenbaum, Hartel, & Gourevitich, 1996). For example, a pilot NSP conducted in Catania, Sicily, demonstrated low success rates (only 6.7 per cent of syringes were exchanged), which were attributed to illegality of syringe possession and general lack of support from other drug agencies and other organisations, including the police. However, results improved over time, which indicates that persistence serves to improve the effectiveness of seemingly unsuccessful NSPs (Nigro et al., 2000).
Several of the less effective NSPs have been criticised for not being adequately linked to other services, such as treatment, education and social services, which indicates that NSPs might be necessary but not sufficient for change (Loxley, 2000). Furthermore, according to Hilton et al. (2001), there is a need to understand what happens to dispensed needles and why IDUs use contaminated rather than sterile needles, when they are readily available. However, it is important to consider that some NSPs may attract higher risk IDUs than do other NSPs. Likewise, the disposal of used injection equipment can be a major issue of concern to
communities, governments and service providers and, unless considered and planned for, be a barrier to the establishment or expansion of NSPs.
However, NSPs can save scarce health resources. Claims have been made that, between 1990 and 2000, Australia’s investment of $150 million in NSPs resulted in:
• An estimated 25000 cases of HIV being avoided;
• An estimated 21000 cases of Hepatitis C being avoided;
• An estimated saving of over 5000 lives by 2010; and
• An estimated return on investment of between $2.4 billion, and $7.7 billion (Office of Drug Policy, 2002).
Similarly, the results of a Canadian study suggest that an annual investment of $1 million per year over five years could result in a return on investment or savings in subsequent costs of as much as $24 million” (Health Canada, 2001, p. 5).On balance, then, the available evidence suggests that NSPs, when linked with other services, are effective (even cost-effective) in reducing the rates of needle sharing and HIV infection among IDUs.
The following is a rare example of an evaluated youth-specific NSP.
A peer-run secondary NSP was established in San Francisco, USA, to cater to the needs of injection drug using street youth aged 15 to 25 years. Street youth are at risk of a variety of health compromising behaviours and negative health outcomes. The service provided syringes, cookers, cotton and other injecting equipment, and coordinated subculture specific activities and materials for the target population. Structured interviews with 122 users of the service revealed that the use of the intervention was associated with reduced syringe sharing, syringe reuse, cotton sharing, and inconsistent condom use with casual partners. However, there were no reductions in back loading (that is, dividing drugs) (Sears et al., 2001).
Outreach services
In a review of the harm reduction literature, Hilton et al. (2001) concluded that observational and quasi-experimental studies of outreach services strongly indicate that they effectively reach IDUs and assist in the reduction of risk taking behaviour and HIV incidence, particularly where they are peer driven. More specifically, Birkel et al. (1993) found that, for indigenous IDUs in the USA and Puerto Rico, significant improvements in HIV knowledge and a reduction in injecting risk behaviours were evident when indigenous outreach workers delivered HIV prevention messages.
A street outreach project (AESOP) in San Francisco, USA, initially involved outreach workers entering the community and providing condoms, bleach and information to street youth. A storefront centre was later established to engage young people in discussions and group activities on blood-borne viral infections (BBVIs), drug problems and other concerns. Finally, youth subculture-specific materials were developed through peer focus groups and informal input, including specific designs for posters, t-shirts, condom packets, and a video on prevention. A youth needle exchange not officially related to the programme was operating in the area. The evaluation of the project reported on 1146 participants and revealed that higher levels of outreach worker contact were associated with following through on HIV-related referrals, and five times the likelihood of use of a new needle/syringe at last injection, but no differences in condom usage. Use of the youth needle exchange was associated with three times the likelihood of use of a new needle/syringe at last injection (Gleghorn et al., 1997).
Outreach programmes often include peer educators. This can be a bonus and/or a liability. Some peers, when ‘educated’, may want to leave behind IDU and, in some cases, commercial sex. Being ‘trained’, they may no longer be recognised as ‘peers’, nor wish to remain in activities they may want to leave behind.
Linking Information, Education and Communication (IEC) with service provision
IEC interventions are included among WHO’s methods for the effective prevention of HIV/AIDS among injecting drug users. Bonomo and Bowes (2001) purport that education campaigns on safe injecting, along with needle exchange programmes, are effective for controlling the spread of HIV among young IDUs. It is important to note that the success of IEC interventions in reducing risky injecting practices is dependent upon the concurrent availability of clean injecting equipment, with which young IDUs can implement their newly acquired knowledge. The provision of equipment may be provided by the IEC programme, but, more likely, by another programme – a health service or NGO.
A recent KAP evaluation of interventions engaging young IDUs in 10 sites in the Ukraine (KAP, 2002) has demonstrated reductions in risk behaviour (i.e. sexual and injecting risk) and improvements in knowledge, attitudes and practice at the individual, social and political level. Whether there will be an impact on incidence of HIV and other BBVs remains to be seen.
The RAR reports on especially vulnerable young people from South Eastern Europe (Cucic, 2002 and Wong, 2002) and those on whole populations (eg Russian Federation in UNODC, 2003) clearly demonstrate that young people require more than just injection equipment. Many who are regular drugs users have multiple heath and social needs. Given difficult economic conditions, unstable governments, high youth unemployment, living in areas where drugs, people and weapons are trafficked, civil conflict, armed conflicts, exposure to violence and crime, discrimination, minority status, high level family stress, abuse low expectations, struggling education systems and lack of adequate health system coverage life can be very difficult for many and their needs great. All this and rapid exposure to, and demand for, ‘Western’ youth culture, some of which has strong associations with drug use.
Substitution Programmes
Although there is currently little published youth-specific research examining the effectiveness of substitution programmes in reducing HIV-related harm in IDUs, the available published adult literature is favourable. However, while there is increasing acceptance and initiating of substitution programmes in a number of developing and transitional countries, they are most commonly established in developed countries, and may not be feasible or affordable for all developing countries (Ball, 1998).
Studies have consistently shown that methadone programmes (and, in one case, a Swiss heroin prescription programme) reduce the frequency of injection drug use, sharing of injecting equipment, sex risk behaviours and HIV infections (Ball, 1998; Camacho et al., 1997; Loxley, 2000; Somaini et al., 2000; Stimson, Des Jarlais, Ball, 1998; van Ameijden & Coutinho, 2001). The use of Buprenorphine has produced similar results (Gowing et al, 2001). However, Hilton et al. (2001) argue that methadone maintenance programmes may be less successful for young people. Furthermore, young IDUs are frequently users of other injectable drugs, such as ATS, for which methadone programmes are not indicated or appropriate. Currently, evidence for the effectiveness of ATS substitution programmes is limited (Ball, 1998; Shearer et al., 2002).
Disinfection Programmes
Disinfection programmes, in which bleach is provided to IDUs and/or IDUs are educated on effective disinfection techniques, are able to either supplement NSPs or operate in their absence, particularly where sterile needles and syringes are not readily available or affordable, such as in developing countries. Disinfection programmes most commonly operate where NSPs are restricted by government policy, and among prison systems in several developing countries, such as Malaysia, Vietnam, India and Thailand. Methods for disinfecting injection equipment include boiling of needles and syringes, cleaning with bleach or other decontaminants, and rinsing with water. The effectiveness of disinfection programmes in reducing HIV transmission has been questioned (Ball, 1998).
Ball (1998) argues that the questionable effectiveness of disinfection programmes may be a result of various factors, including:
• Confusing messages to IDUs about proposed decontaminants and concentrations;
• IDUs not having the time or opportunity to effectively implement recommended sterilisation procedures;
• Boiling often damaging or reducing the useful life of the equipment;
• IDUs fearing the effect of injecting residual bleach after flushing with the agent;
• Unavailability of bleach in many areas; and
• Bleach being rejected because of its ‘evil’ smell, in communities including those in Nepal, India and Thailand.
In order to counter some of these barriers to the effectiveness of disinfection programmes, Ball (1998) recommends that efforts should be made to identify other decontaminants that are acceptable, effective, simple to use and affordable.
Table 2. International evidence for the effectiveness of harm reduction programmes
|Programme/intervention |Strength of evidence |
| | |
|Needle and Syringe Programmes | |
|Needle and syringe programmes have reduced the transmission of HIV, hepatitis B and |((( |
|hepatitis C. | |
|Needle and syringe programmes do not increase injecting drug use or the number of |(( |
|inappropriately discarded needles and syringes. | |
|Amongst people attending needle and syringe programmes, levels of risk behaviour |(( |
|decrease or at least do not increase. | |
| | |
|Peer education and Community Outreach Programmes | |
|Peer education and community outreach programmes promote entry to treatment and |(( |
|encourage a degree of behaviour change. | |
| | |
|Substitution Programmes | |
|Methadone maintenance treatment protects treatment recipients from HIV/AIDS and |((( |
|reduces HIV risk behaviours | |
|Compared to methadone maintenance treatment, buprenorphine has similar or slightly |((( |
|less retention in treatment, but reduces illicit drug use to an equivalent or greater | |
|extent. | |
|Long-term treatment with high doses (>250mg/week) of Levo alpha acetyl methadol (LAAM)|(((( |
|is at least comparable to methadone maintenance treatment in terms of effectiveness in| |
|reducing illicit drug use. | |
|Treatment combining intense psychosocial support with prescribed heroin reduces |(( |
|illicit drug use and criminal behaviour, and improves physical health and social | |
|functioning. | |
|Patient acceptance of naltrexone is poor, resulting in high rates of drop-out from |((( |
|treatment. | |
|Outcomes for naltrexone appear best with people who are highly motivated, are employed|(( |
|and have good social support, are older, and have had prior treatment experience. | |
|Prescription of oral amphetamines is of potential value as substitution treatment for |( |
|dependent, injecting amphetamine users. | |
Adapted from Gowing et al. (2001)
(((( Strong Evidence: Supported by a systematic review that includes randomised controlled trials OR more than one properly conducted (unconfounded) randomised controlled trial.
((( Moderate Evidence: Supported by qualified evidence from reviews limited by research factors OR one properly controlled randomised control trial OR more than one qualified randomised control trial limited by research factors OR more than one well-conducted level III-1 or III-2 study.
(( Some evidence: Supported by one qualified randomised control trial limited by research factors OR more than one level III-2 or level IV study from different research teams OR one or more level III-1 studies limited by research factors.
( A little evidence: Based on opinion (clinical anecdote or editorial) OR reviews unsubstantiated by data OR a single level III-3 or level IV study OR level III-3 or level IV studies limited by research factors.
? Unable to assess: No, insufficient or conflicting evidence preventing any conclusion from being drawn.
Levels of Evidence
I Evidence obtained from a systematic review of all relevant randomised controlled trials
II Evidence obtained from at least one properly designed randomised controlled trial
III-1 Evidence obtained from well-designed, pseudo-randomised controlled trials (alternate allocation or some other method)
III-2 Evidence contained from comparative studies with concurrent controls and allocation not randomised (cohort studies), case-control studies, or interrupted time series with a control group
III-3 Evidence obtained from comparative studies with historical control, two or more single-arm studies, or interrupted time series without a parallel control group
IV Evidence obtained from case series, wither post-test or pre-test and post-test
Other potential approaches to preventing and curtailing injecting
Beyond the need to continually refine our understanding of how conventional harm reduction practice can be optimised and applied in different settings, there is also a developing interest in interventions that reduce initiation into injecting itself or increase the speed with which people stop injecting within their drug using ‘career’ (Hunt et al 1999). These approaches often best regarded as adjuncts to other harm reduction work. Often they are designed to augment or be delivered as part of needle and syringe schemes, substitution or other drug treatment programmes.
The evidence base for these approaches is generally weak. They may nevertheless have potential that should be considered in some circumstances. At the time when these were reviewed by Hunt et al (1999) the following interventions were identified:
• Group work with non-injecting or experimental/occasional injectors,
• Interventions with existing injectors to reduce their propensity to initiate others e.g. the ‘Break the cycle’ campaign now operating across Great Britain,
• Highly targeted social marketing of non-injected means of administration e.g. the Healthy Option Team’s chasing and ‘Up yer bum’ campaign, and Lifeline’s subsequent ‘smoking brown’ campaign,
• Broader based social marketing campaigns that focus on injecting prevention rather than drug prevention,
• Other substitution programmes for which there is weaker validation within the evidence base e.g. prescribing heroin reefers and dexamphetamine sulphate.
• Targeted interventions with drug production and distribution systems that focus on disrupting supplies of more readily injected heroin (diamorphine hydrochloride) rather than the more readily smoked ‘base’ heroin.
Evidence that providing harm reduction services to young people engages or encourages their utilisation of health services.
An example of an evaluated youth-specific harm reduction service that linked its clients to primary health care is Harm Reduction Central (HRC), which was developed through collaboration between the Division of Adolescent Medicine of the Children’s Hospital Los Angeles (CHLA) and Clean Needles Now (CNN) (Weiker, Edgington & Kipke, 1999). HRC targeted injection drug using youth, their sexual partners, and other high-risk drug using youth, and provided the following services in a safe, comfortable, ‘drop-in-centre’ environment:
• Adolescent needle exchange/distribution;
• Distribution of kits/information, which included bleach, distilled water, 100% pellet cotton, latex tourniquets, alcohol wipes, antibacterial cream, “cookers”, and condoms and lubricant;
• Creative Arts programming, as an alternative to substance use;
• Substance use counselling; and
• Peer case management, which linked IDUs with other services, including health care services.
Youth feedback during evaluation of the programme, and records of patterns of service utilisation, revealed that although needle exchange was the core component of the programme, “youth who initially came in because they needed clean injecting equipment became more engaged with CNN/HRC over time” (Weiker et al., 1999, p. 219). This suggests that young people who increasingly engaged with HRC were more likely to utilise the available peer case management service, which served to link them with outside health care services. It is important to note that the services provided by HRC are expensive, and thus may not be easily implemented in developing or transitional countries (Merson, Dayton, & O’Reilly, 2000).
An additional example of a comprehensive harm reduction service is the Kirketon Road Centre (KRC), which targets street youth, sex workers, and IDUs in Sydney, Australia (van Beek, 1998). KRC provides primary health care, needle exchange, and community outreach services, via medical, nursing, counselling, social work and support staff. In a case study of the programme, van Beek reported that the non-threatening initial point of contact provided by the NSP at KRC further encouraged access to KRC’s broader range of health care services. Furthermore, “integrating the outreach into the fixed site service…provided familiar faces in both settings, enabling more effective referral of the more difficult-to-reach outreach clients to KRC where appropriate and vice versa” (p. 4).
While it is assumed that many harm reduction services are provided in ‘health settings’, the evidence base for effective approaches to ensuring that harm reduction services are available in a variety of health settings for young people is extremely limited. It was not possible in the time allowed for this review to find entry points to gain information on programmes that may shed light on this topic, such as those that are unreported, reported in a language other than English, reported in an obscure journal, or documented but not published.
It is important to consider that the available evidence indicates that effective harm reduction services are those that are linked to, or contain, health and other services for young people. The evidence reveals that, within developed countries, special purpose stand-alone NSPs and substitution programmes are rare, with most operating from within pre-existing drug services. Furthermore, a number of NSPs operate in collaboration with other health facilities, such as pharmacies and sexual reproductive health services, including genito-urinary medicine (GUM) clinics (Stimson et al., 1991).
According to WHO (2002d), “health services need to link with other key services for adolescents, so that they become part of a supportive structure that protects young people against dangers, and helps them to build knowledge, skills and confidence” (p. 4). The majority of harm reduction services have various attachments. Many are located within a government health system or operate through NGOs or pharmacies. Those that are or do not, tend to form links with health service provision from government and other organisations.
Evidence suggests that young people are attracted to and maintain contact with adolescent friendly services that provide for a broad range of adolescent concerns, and are characterised by the following:
• Adolescent friendly policies that maintain confidentiality, promote autonomy, and are sensitive to gender, disability, ethnic origin, religion, age, and the special needs of different sectors of the population;
• Adolescent friendly procedures, including short waiting times and ease of consultation;
• Adolescent friendly health care providers, who are easy to relate to, non-judgemental, considerate and trustworthy;
• Adolescent friendly support staff;
• Adolescent friendly health facilities;
• Adolescent involvement, including involvement in service assessment and provision;
• Community involvement and dialogue to encourage parental and community support;
• Appropriate and comprehensive services that address each adolescent’s physical, social and psychological health and development needs;
• Effective health services for adolescents that are guided by evidence-based protocols and guidelines, and have equipment, supplies and basic services necessary to deliver the essential care package; and
• Efficient services (WHO, 2002d).
Legal and Policy Considerations
Those attempting to implement and maintain harm reduction programmes throughout the world have encountered a number of legal, community-based, personal and ideological barriers (Incaiardi & Surratt, 2001). WHO (2002b) report that, on a general level, “vigorous opposition to the introduction and maintenance of effective programmes” has taken the form of:
• Concern, unsupported by any evidence, that effective prevention activities increase illicit drug use;
• Concern that methadone maintenance and other effective programmes are not appropriate forms of drug treatment because cessation of drug use is not their primary goal;
• Criticism that effective measures are too liberal and should be replaced by punishment of drug users;
• Police opposition to NSPs, which may be considered to conflict with law enforcement attempts to restrict drug supply or restrict availability of injecting equipment;
• Opposition from city administration and neighbourhood groups to the establishment of sites for effective programmes on the grounds that these services attract IDUs, do not take care to dispose of discarded or returned used injection equipment, diminishing the amenity of the neighbourhood;
• Perception by some health staff that medical treatment for IDUs wastes scarce resource on “worthless” drug users; and
• Criticism, often based on limited or no knowledge of effective programmes, that such programmes go against the culture of a country or tenets of a prevailing religion.
Legal and policy barriers have also been experienced by programmers of youth-specific harm reduction services. For example, the Concerned Youth Promoting Harm Reduction (CYPHR) project, which involved street youth in peer harm reduction education in Toronto, Canada, faced political, professional and community pressures in response to the launch of a youth-produced harm reduction video (Poland, Tupker & Breland, 2002).
It is also important to consider that, around the world, there are marked variations in the legal ability of young people to, for example, consent to sexual intercourse, vote, consent to and be guaranteed confidentiality of medical treatment, and so on. These limitations impact on the ability of young people to access certain harm reduction interventions.
Interpretation of international treaties and conventions can also create barriers. Part 1 Article 33 of the Convention of the Rights of the Child states that: “State Parties shall take all appropriate measures, including legislative, administrative, social and educational measures, to protect children from the illicit use of narcotic drugs and psychotropic substances as defined in the relevant international treaties, and to prevent the use of children in the illicit production and trafficking of such substances.” Some interpretations of this article can be used to prevent young people from accessing harm reduction services, such as NSPs.
In almost all countries around the world, drugs are available in prisons and other custodial settings, and safe usage is compromised. In relation to young people in custody, Viet (2000) has argued that, ethically, young people have a right to “the highest standard of health care that is available in the community” (p. 463). This could include the availability of sterile injecting equipment for custodial clients. The available evidence from Switzerland, Spain and Germany suggests that adult prison based harm reduction interventions are effective, with favourable outcomes including dramatic reductions in syringe sharing, no cases of acquired HIV, HBV or HCV, and no further injection initiation (Dolan, Rutter, & Wodak, 2003). Nonetheless, prison-based harm reduction, particularly for young people, remains a contentious area.
In NSW, Australia, recent guidelines (NSW Health, 2000) have drawn upon a child protection framework to override age or other barriers to the access of sterile injecting equipment: “It is important to note that sterile injecting equipment should be made available to any person who is currently involved in injecting drugs, regardless of their age" (p. 10). The guidelines also require those who make such equipment available to abide by child protection guidelines, which would require the notification to child protection authorities of those young people ‘at risk’.
Section Five: Avenues for future research
What follows are some recommendations from the Consultation.
It is recommended that the following be considered:
Young people making the transition to injecting (listed in order of priority given by consultation participants):
Research, in the Short Term, Research:
1. Qualitative studies, similar to those planned for Ukraine, to develop a clearer ‘social portrait’ of relevant groups of young people and better understand the social and risk context of transition to injecting, and directly inform interventions that aim both to prevent initiation and reduce risk where it does occur.
2. Identifying achievable changes to legislation that hinders harm reduction efforts for lobbying – and making more widely available UNODC and Temple University reviews.
3. Identifying and better publicising/sharing the components of good practice interventions for young IDUs across the region (e.g. programme components, staff composition, inter-agency and other necessary links). This would include gathering descriptions of how apparently effective harm reduction services for young people who use drugs have been developed within a variety of health settings, including government and private health centres, NGO health and youth centres, outreach settings, pharmacies, and schools
4. Developing better ‘granularity’ regarding the ages of people within: a) epidemiological research and b) process evaluations of interventions (e.g. who do they reach and benefit)? This may include secondary analyses of existing adult data sets to explore for any effects of age and sex, and, in any future research, include these two variables. In these analyses, it is important to identify any significant difference between younger (i.e. under 18) and older (i.e. 18-24) young IDUs and any gender/sex differences.
5. Illustrative studies which explore the links between young(er) and older injecting scenes and drug use and sexual risk (eg social network mapping). This may include mapping the spread of IDU among young people and attempting to identify significant location for interventions, and whether some youth sub-populations are more at risk (eg street youth, same-sex attracted youth, those in the armed forces, students in hostels, migrants (legal and illegal), refugees, minority groups.
6. Studies which aid the local prioritisation of groups with high vulnerability (eg Roma youth, street children and youth (especially female street children), young offenders, those in institutional care, young MSMs, and young CSWs.
7. Identifying what can be influenced and by whom? Ascertaining ‘points/systems of leverage’ and likely allies – eg in schools, health services, pharmacies, sporting groups/organizations, organised religion, work sites, armed forces, youth groups/organizations.
Research, in the Longer Term:
1. Evaluating the impact of intervention programmes that target risk/protective factors.
2. Evaluating the effectiveness of harm reduction programs.
3. Differentiating the influence of different risk and protective factors on transitions to injecting across the region.
Interventions, in the Short Term:
1. Action research focusing on both a) preventing injecting and b) reducing risks for those people who do start injecting (especially during the first injection and early injecting career). These should focus on opportunities for intervention associated with social transitions to/from:
o Custody/prison
o Institutional care
o Army (especially if involved in actual conflict)
o Secondary education
o Unemployment
o Work
o Student hostels
o Further education
2. Action research focussed on increasing the safety and support available within the micro-environments within which young people begin to inject (e.g. apartments, basements, hostels).
3. Training school health (and drug) educators.
4. Development of interventions to influence the media to produce a more supportive environment for harm reduction approaches.
5. Developing models of working with the police to maximise support for harm reduction interventions, and minimise interference.
Interventions, in the Longer Term:
1. Programmes for better supporting families.
2. Programmes for enhancing engagement and retention in education.
3. Increasing access to a developing, broader range of appropriate treatment interventions (especially for young ATS users).
4. Improving access to adequate medical and psychological interventions.
5. Community development.
6. Lobbying against legislation that most clearly impedes harm reduction.
7. Influencing the media to produce a more supportive environment for harm reduction approaches.
Occasional/intermittent injectors (listed in order of priority given by consultation participants):
Short Term:
1. Development of improved case definitions of terms including: ‘occasional’, ‘intermittent’ and ‘experimental’ injector.
2. Development of a resource of existing and potential questions to support the investigation of occasional/intermittent injecting and promote comparability of data across studies.
3. Secondary analyses of existing data sets to explore for any effects of age and sex. In these analyses, it is important to identify any significant difference between younger (i.e. under 18) and older (i.e. 18-24, 25 and over) IDUs and any gender/sex differences.
4. Collect and disseminate any identifiable good/best practice descriptions of interventions for working with occasional/intermittent IDUs to increase safety.
5. Improve the exploitation of existing and newly arising indicators that relate to occasional, intermittent IDUs to better inform what priority to attach to work targeted at this group.
6. Studies - possibly as part of Rapid Assessment and Response studies (RARs) - that attempt to ascertain any differences between new/recent and occasional IDUs. What differentiates those who remain as ‘occasional’ IDUs from those who become ‘regular’ IDUs? Are the former more ‘functional’? Are they better protected from BBVs, such as HIV, HCV?
Longer Term:
Where there is moderately good evidence that occasional IDUs comprise a significantly sized or culturally distinct sub-group of the populations, undertake targeted action research.
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[1] This section draws extensively on an unpublished manuscript towards an uncompleted PhD by Neil Hunt and should not be re-published without his prior consent.
[2] Recent recognition of this gap in the literature has led the Joseph Rowntree Foundation to commission a review of the existing evidence in this area within the UK.
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