OBJECTIVES: HIV/AIDS surveillance methods are under revision as the diversity of HIV epidemics is becoming more apparent. The so called "2nd generation surveillance (SGS) systems" aim to enhance surveillance by broadening the range of indicators to prevalence, behaviors and correlates, for a better understanding and a more complete and timely awareness of evolving epidemics. METHODS: Concepts of HIV SGS are reviewed with a special focus on injecting drug users, a major at-risk and hard to reach group in Europe, a region with mainly low or concentrated epidemics. RESULTS: The scope of HIV/AIDS surveillance needs to be broadened following principles of SGS. Specifically for IDUs we propose including hepatitis C data as indicator for injecting risk in routine systems like those monitoring sexually transmitted infections and information on knowledge and attitudes as potential major determinants of risk behavior. CONCLUSIONS: The suggested approach should lead to more complete and timely information for public health interventions, however there is a clear need for comparative validation studies to assess the validity, reliability and cost-effectiveness of traditional and enhanced HIV/AIDS surveillance systems.
The aim of the study was to investigate present and past morbidity in drug addicts, 25 years after hospitalisation for acute hepatitis B or hepatitis nonA-nonB. The hospital records for 214 consecutively admitted patients were analysed, and a follow-up study on 66 of the 144 patients still alive was performed. At follow-up, 1 of 54 (1.8%) hepatitis B patients was still HBsAg positive. Twelve patients originally diagnosed as hepatitis nonA-nonB were all among 54 found to be anti-hepatitis C virus (anti-HCV) positive, and the total anti-HCV prevalence was 81.8%. Twelve (22.2%) of the HCV cases were unknown before the follow-up examination. Four (6.1%) participants were anti-human immunodeficiency virus positive, only 1 was on antiretroviral therapy, and none had developed AIDS. Other chronic somatic diseases were a minor problem, whereas drug users reported skin infections as a frequent complication. Forty-three patients (65%) had abandoned addictive drugs since the hospital stay. Serious mental disorders were reported by 19 patients (28.8%), and 17 (25.8%) regarded themselves as present (9) and former (8) compulsive alcohol drinkers. A large proportion of the participants were granted disability pension (39%), a majority because of psychiatric disorders, drug and alcohol abuse.
Buprenorphine (Subutex) is widely abused in Finland. A combination of buprenorphine plus naloxone (Suboxone) has been available since late 2004, permitting a comparison of the abuse of the two products among untreated intravenous (IV) users. A survey was distributed to attendees at a Helsinki needle exchange program over 2-weeks in April, 2005, At least 30% were returned anonymously. Survey variables included: years of prior IV opioid abuse, years of buprenorphine abuse, frequency, dosage, route of administration and reasons for use, concomitant IV abuse of other substances and amount paid on the street for both buprenorphine and buprenorphine+naloxone. Buprenorphine was the most frequently used IV drug for 73% of the respondents. More than 75% said they used IV buprenorphine to self-treat addiction or withdrawal. Most (68%) had tried the buprenorphine+naloxone combination IV, but 80% said they had a "bad" experience. Its street price was less than half that of buprenorphine alone. The buprenorphine+naloxone combination appears to be a feasible tool, along with easier access to addiction treatment, for decreasing IV abuse of buprenorphine.
To explore convergence and divergence in ethical stances of public health and of members of the population regarding acceptability of harm reduction interventions, in particular needle exchange programs.
Forty-nine semi-structured interviews were conducted with French-speaking residents of Quebec City. Content analysis was done to explore the views of the respondents with regard to injection drug users (IDUs) and interventions addressed to them, as well as Quebec policies on harm reduction.
Four main categories of social representations about IDUs have emerged from the discourses of the respondents. IDU were represented as: suffering from a disease (n = 17); victim of a situation that they could not control (n = 14); having chosen to use drugs (n = 12); or delinquent people (n = 6). Those social representations were associated with different ethical stances regarding acceptability of harm reduction interventions. Main divergences between respondents' ethical positions on harm reduction and public health discourses were related to the value of tolerance and its limits.
The Quebec City population interviewed in this study had a high level of tolerance regarding needle distribution to drug addicts. Applied ethics could be a useful way to understand citizens' interpretation of public health interventions.
Awareness of drug use in rural communities and small towns has been growing, but we know relatively little about the challenges injection drug users (IDUs) living in such places face in accessing harm reduction services. Semi-structured interviews were conducted with 115 IDUs in urban and non-urban areas of Atlantic Canada. In many instances, geographic distance to a needle exchange program (NEP) meant that individuals living outside of urban areas and who were not provided services through an NEP's outreach program were at a disadvantage in terms of an array of supports offered through many NEPs. These include access to free clean injecting equipment, and such ancillary services as clothing, food, referrals, information and social support. The integration of the services and approaches provided by NEPs into mainstream health services in non-urban places is one possible model for improving such access.
Injection drug users (IDU) often experience barriers to conventional health-care services, and consequently might rely on acute and emergency services. This study sought to investigate IDU perspectives regarding the impact of supervised injection facility (SIF) use on access to health-care services.
Semi-structured qualitative interviews were conducted with 50 Vancouver-based IDU participating in the Scientific Evaluation of Supervised Injecting cohort. Audio-recorded interviews elicited IDU perspectives regarding the impact of SIF use on access to health and social services. Interviews were transcribed verbatim and a thematic analysis was conducted.
Fifty IDU, including 21 women, participated in this study. IDU narratives indicate that the SIF serves to facilitate access to health care by providing much-needed care on-site and connects IDU to external services through referrals. Participants' perspectives suggest that the SIF has facilitated increased uptake of health and social services among IDU.
Although challenges related to access to care remain in many settings, SIF have potential to promote health by facilitating enhanced access to health-care and social services through a model of care that is accessible to high-risk IDU.
Awareness of hepatitis C virus (HCV) infection status is expected to influence risk behaviors. In 2004-2005, injection drug users (IDUs) recruited from syringe exchange programs (SEPs) and methadone clinics in Montreal, Canada, were interviewed on drug use behaviors (past 6 months) and HCV testing. Subjects (n = 230) were classified as low/intermediate risk (20.4% borrowed drug preparation equipment only) and high risk (19.6% borrowed syringes), and 54.5% reported being HCV positive. Logistic regression modeling showed that compared to no risk (60% borrowed nothing), low/intermediate risk was associated with fewer noninjecting social network members, poor physical health, and problems obtaining sterile injecting equipment. High risk was associated with all of these factors except social networks. HCV status was not associated with any level of risk. Improved access to sterile injecting equipment may be more important than knowledge of HCV status in reducing injection risks among this IDU population. The study limitations are noted and recommendations discussed.