Don DesJarlais, PhD, from the Albert Einstein College of Medicine in New York opened the session on combination prevention for injection drug users (IDUs) by identifying syringe exchange programs (SEPs) as the “foundation for combination HIV prevention” in this population. To an audience Tuesday afternoon at the International AIDS Conference in Rome, he pointed out that risk elimination is not necessary because sharing syringes is still inefficient for HIV transmission. You do, however, need to reach a majority of IDUs in the population to have a real and measurable impact on HIV incidence among the population. Locations with large syringe exchange programs are associated with lower levels of HIV infection and Hepatitis C among the entire IDU population in terms of both incidence and prevalence—including among IDUs who do not use the exchanges. The challenge is to distribute enough needles and syringes to drug users at the right time and in the right places.
DesJarlais, a long-time researcher and advocate in this arena, outlined best practices for effective syringe exchange programs:
- Begin programs early when HIV prevalence is low; if you start when it is low, you can keep it low.
- Programs should be large-scale with no limits on the number of syringes distributed and no requirements for one-to-one exchange.
- Provide services at convenient locations with convenient hours of operation.
- Provide multiple services at exchange locations—testing, condom distribution, etc.
- Involve drug injectors as experts to assist with site operations.
- Work to ensure cooperation with local law enforcement.
Dr. Koran Beck from the British Columbia Center for Excellence in AIDS reported on the success of the multiple interventions that have led to dramatic reductions in HIV incidence among IDUs in British Columbia. In response to an explosion of HIV infections among IDUs in Vancouver in 1996, a number of key actions were taken. Access to syringes was improved by eliminating one-to-one syringe exchange, engaging peer drug users in the program and decentralizing distribution of syringes. Access to drug treatment, especially methadone maintenance was expanded. In 2003, a supervised injecting facility was opened in Vancouver. Use of this site was associated with less likelihood of syringe sharing and reductions in overdose mortality. The injecting facility also offered linkages to drug detoxification services, contact with addiction counselors onsite and access to residential drug treatment. The final important intervention was expanded access to antiretroviral therapy for IDUs.
There are a number of barriers remaining to effective HIV prevention among IDUs, including overuse of the criminal justice system to manage drug addiction. Research has demonstrated that the more frequently IDUs with HIV infection are incarcerated, the less likely they are to adhere to therapy. There have also been concerning changes in drug use practices, particularly increases in the use of crack cocaine. Finally, the national government in Canada appears interested in increasing criminal penalties for drug-related offenses, including the potential imposition of mandatory minimum sentences.