Drug Abuse

In New South Wales radical action is being taken to combat the spread of HIV infection amongst intravenous drug users- even within the prison system

HIV & AIDS

Intravenous drug use in New South Wales, Australia

by Kate Dolan

According to the Sydney Morning Herald, ln November 1988 the number of AIDS cases in Australia was 1,079. The majority of cases occurred in N.S.W., 64.8% (700) and were male 98% (1,039). Although England had approximately twice the number of cases up to this time (1,926), its population is nearly four times that of Australia's. The ratio of AIDS cases per head of population was 2.1 per 100,000 for Australia and 1.1 for the U.K in 1987.

The majority (88%) of all people reported with AIDS in N.S.W. to November 1988 were homosexual or bisexual men. Homosexual or bisexual intravenous drug users accounted for 2.5% and 0.9% were heterosexual intravenous drug users. Heterosexual transmission accounted for 1.3% of cases.

Six studies of the HIV levels amongst intravenous drug users (IVDU) have found the rate of infection is growing at an increasing rate.

1) Blacker and Wodak's study of approximately 200 methadone clients in Sydney in 1985 found only one subject was seropositive (0.5%). A contact trace on the positive subject found four out of six people who had sexual or needle contact were also positive. For one of the four, it was her first injection. (pp 686-690)

2) In 1986, a sample of 300 needles and syringes returned to an exchange scheme were tested for HIV antibodies, three were positive, giving a rate of 1%. (Wodak & Dolan, 1987, p275)

3) Another study in 1987 involved a sample of 1,681 syringes being tested out of 3,704 syringes that were collected at four different exchange schemes. A different level of infection was found at each of the schemes. The scheme mentioned above, in study 2, had a rate of 1.5% (15/999). Scheme B had a rate of 6% (33/545). Scheme C had a rate of 8.6% (3/35) and scheme D didn't have any positive syringes 0% (0/ 103) (Wolk & Wodak, 1988)

4) A study at the Albion Street AIDS Centre of 407 IVDU in June 1987 found 4.2% were HIV positive. (Vumbaca, 1987)

5) A study conducted in 1987 found an HIV infection rate of 9% from a sample of 181 IVDU. More than half of the HIV positive injectors were homosexual. (Wolk, 1988)

6)According to the Quarterly Research Newsletter, by October 1988, 11% of all drug injectors who had been tested at Albion Street AIDS Centre were HIV positive. The 11% is made up to 6% of those who had IV use as an only risk factor and 14% of those who had another risk factor. The total number of IVDU tested was 1,799. (1988)

Funding For AIDS

Funding for AIDS over the past five years has increased dramatically. In 1984, £2.5m was allocated and in 1988 just over £20m was provided by the Commonwealth Department of Community Services and Health. A breakdown of the £10m allocated in 1987 is presented in table 1.

30 %	Community Care/Counselling
25 % % % 5 % % 2.8 %	Laboratory AZT Hospice Evaluation and administration Needle and syringe exchange Education

The Injecting Population

The National Advisory Committee on AIDS (NACAIDS) conducted a survey in 1987 of 2,000 people. It estimated 5% of the adult population have injected drugs at some time in their lifetime. The percentage who reported having injected drugs in the last year was 2%. This gives a national drug injecting population of 300,000. Of those suneyed who had injected, 40% of males and 71% of females had shared a needle and syringe.

The Drug and Alcohol Authority of N.S.W. estimated that there were between 10,000 and 14,000 drug injectors in N.S.W. in 1987. This was based on the number coming to the attention of the drug services and the law. (Sandland, 1986)

The Commonwealth Department of Community Services Health estimated that there are 30,000 to 50,000 regular injectors in Australia and up to 60,000 when casual injectors are included. (Vumbaca, 1989)

The first Australian needle and syringe exchange scheme started in November 1986 in Darlinghurst. At that time in N.S.W. pharmacists could sell needles and syringes at their discretion but it was an offence to possess a needle and syringe for the purpose of self administration of illegal drugs. Legal impediments to the increased availability of needles and syringes, including exchange schemes,

still existed one year later in the Australian Capital Territory, Northern Territory Queensland and Tasmania.

Exchange Schemes

Increased availability of needles and syringes was achieved by three methods in N.S.W.; exchange schemes, outreach services and pharmacy based programmes (distribution and exchange). These approaches are coordinated at a state level by the Health Department.

In N.S.W. there are 56 exchange schemes. A coordinator is employed by the Health Department to help agencies establish schemes, especially in areas where there are no exchanges. He produces a newsletter to inform exchange worXcers of current developments and runs training days for the exchange worErs.

There has been one scheme closure so far. The scheme was located behind a hospital and out of the town centre. To reach the scheme it was necessary to pass security guards with dogs.

Five types of schemes have been approved by the Health Department in N.S.W.

1) Existing agency with existing staff

2) Existing agency with funded staff

3) Primary shopfront exchange

4) Outreach service (mobile)

5) Existing agency - after hours use

To provide a comprehensive syringe exchange service a number of variations on this theme are in operation. for example:

1) Kirketon Road Medical Centre was established to cater for the street kids, drug injectors and prostitutes in Kings Cross. On average the centre exchanges 4,000 needles and syringes a month.

2) Bourke Street Drug Advice Centre in Sydney operates an exchange scheme from Friday to Sunday between 8 p.m. and 1 a.m. The centre is within walking distance of the drug ghetto of Sydney.

3) Ken's Karate Klub, a gay sauna that is open 24 hours, is about to start a syringe exchange for anyone, not just gays.

4) The Albion Street AIDS Centre operates an exchange scheme and testing facilities from a bus. The bus operates late at night and in areas known for drug injectors and prostitutes.

One such scheme is based in Darlinghurst. The scheme, operated by the Alcohol and Drug Information Service, was based in a corridor which led to Victoria Street in Darlinghurst. Darlinghurst and the neighbouring Kings Cross are the prostitution and drug dealing centres of Sydney. The scheme was not funded which restricted the hours it was able to operate and the evaluation of it. It relied on donations from clients. When there were sufficient staff and donations, the scheme operated from 7 a.m. to 11 p.m. seven days a week.

A feasibility study of operating a needle and syringe exchange project was carried out in 1987. In the first 70 days of operation, 512 requests for equipment were made. The return rate of equipment was 67% and 67% of clients were male. In the month before clients attended the exchange 67.5% had shared a needle and syringe. (Dolan, 1987a)

One study in 1987 of 890 exchanges found the rate of returned equipment was 59%, and 64% of the clients were male. The level of syringe sharing in the month prior to interview was 35% and 49% had shared in the previous year. (Dolan, 1987b)

The Darlinghurst pilot needle and syringe exchange programme was last evaluated between 1.6.87 to 30.9.87. and is reported below (Vumbaca et al, 1987)

The sex ratio of clients was 2:1, male to female, which reflects the sex of callers to the Alcohol and Drug Information Service in N.S.W. The mean age for the male clients was 26.8 years and 25.4 years for females.

More than half of the clients take equipment for others, 40% take it for one other, while 11% take it for two or more.

Information about when clients last shared a needle and syringe was collected. It was found that 72.5% had increased the length of time since they had shared a needle and syringe and, in effect, had not shared since they registered with the programme.

Some of the reasons given by those who had shared were:

1) The client was in a stable relationship and shared with their partner.

2) No clean equipment was available when they wanted to inject.

3) Access to equipment was restricted.

4) The exchange programme was closed.

The return rate of used equipment was 45%.

As well as building-based exchange schemes there are also a number of complimentary projects in operation:

There are 26 outreach projects that distribute equipment to IVDU's in N.S.W. The projects have 44 'syringe' outreach workers, with most being employed on a part time basis. The largest service is operated by Langton Clinic, a medical detox unit in Sydney. The average number of needles and syringes distributed by the Langton workers is 10,000 per month.

There are two types of pharmacy based needle and syringe programmes operating in N.S.W.

1) The pharmacy distribution scheme began in 1986 and was administered by the Pharmacy Guild of Australia. IVDU's can purchase an Anti AIDS Kit comprising 5 needles and syringes and an information card on AIDS, all in a plastic bag. The cost is £1.75 which includes a £1.25 optional consultancy fee for the pharmacist. The Health Department provides funding for the plastic bags and information cards that are given to IVDU's purchasing equipment.

Over 300 pharmacies participate in this programme. The average number of needles and syringes distributed per month went from 43,000 in 1987 to 60,000 in 1988.

2) The Pilot Pharmacy Needle and Syringe Exchange Programme began in December 1987. It is administered by the Pharmacy Guild and funded by the Health Department IVDU's are able to purchase a 'Guildpak' which is a plastic container with 10 needles and syringes and a built-in disposal section. The cost of a Guildpak is £2.50, £1.50 for the Guildpak and £1 for the consultancy fee. If an IVDU returns a Guildpak then it costs only £1 for the next 10 as the , Department of Health funds the replacement Guildpak. Over 100 pharmacies are involved in the exchange programme.

The average return rate for the first eight months was 37%, ranging from 2% in the first month to 62% for the last two months. In this period over 45.000 needles and syringes were distributed.

A logo (above) has been designed to indicate that an agency or pharmacy operates a syringe exchange scheme. There is widespread use of the logo in N.S.W. and there are plans to use the same design all over the country.

Despite the above initiatives, it is also felt necessary to provide further access to sterile injecting equipment. These include:

1. Private medical practitioner.

A draft policy has been developed on the role of medical practitioners by the AIDS bureau and will be considered by the AIDS and IV Drug Use Sub-Committee.

2. Vending machines

A pilot study will commence soon on the use of vending machines to distribute needles and syringes.

There are two types of machines that are currently being assessed. One is coin operated and the other requires a needle and syringe to be inserted before a new one is dispensed. The preference is for the exchange machine.

The aim is have 40 machines in place by June 30th 1989, with 25 in Sydney and 15 in the country areas. Apparently the Danish Department of Health has introduced vending machines.

3. One Shot Syringes There are plans to introduce non-reusable syringes and in 2 years they may be the only syringes available in Australia. The AIDS Bureau recently negotiated a grant to allow further research and development of non-reusable needle and syringes. The Medical Devices and Dental Products Branch has carried out a feasibility study of non reusable syringes (1988) If one shot syringes are introduced, it will be vital to increase the supply.

The number of needles and syringes distributed to IVDU in N.S.W. was between 1 and 1.5 million last year. The target is 9 million by 1990, which is the estimated number required for every injector to have a new needle and syringe for every injection. Wit such an increase in supply and less than 100% return rates at exchange schemes, the amount of used equipment discarded could become a major problem.

There is still a possibility of injectors being charged with the self-administration of drugs on the basis of possession of used equipment and so there is a problem of equipment being discarded. A feasibility study is about to be conducted into encouraging injectors to place their used equipment into soft drink cans. Funding has been allocated for a campaign called 'Can Ya Fit' which involves employing four ex users for 12 weeks. (fit is a slang word for injecting equipment)

Often drug injectors will use the bottom of a can to mix their drugs in, so canning one's syringe would seem an accessible option for disposal. However, there is a problem in that many children (and adults) collect and crush cans for money for the recycling industry.

The AIDS Bureau, in the Department of Health, N.S.W. has sponsored the AIDS Council of N.S.W. (ACON) to develop some cartoons for IVDU's and in particular to target casual injectors. The cartoons will be placed in magazines. ACON will help Ken's Karate Klub, a gay sauna, operate an exchange scheme and ACON will operate schemes at their three offices. Also they have workers that visit 'beats' or cottages and these workers will carry injecting equipment.

There is a disproportionate number of gay IVDU's infected, as opposed to heterosexual IVDU's, and they are going to be targeted through networks in the gay community.

Funding has been provided for the establishment of an organisation for injectors, with AIDS being the central concern. One worker was to be employed in Jan 1989 on a part time basis and in July 1989, the funding will be ex-tended to employ two full time workers. There are also plans to set up a National I.V League.

AIDS Campaigns

Before 1987 most advertising and educational material was found in the gay press, bars, saunas and clubs. Now, in recognition of the need for further information (both general and aimed at specific groups) AIDS campaigns have broadened out.

In 1984 there was a 'Rubber me' campaign aimed at the gay community. This was followed by a question and answer series and special seasonal campaigns, targeting visitors to Sydney for summer and the Gay Mardi Gras in February

In April 1987 there was a £1 million 'Grim Reaper' campaign on national television aimed at the general public. Then in October, 1989 another Television campaign referred people to information brochures that were available.

In December 1987, there were national advertisements on television aimed at IVDU's. Also advertisements designed by the 'Get Rear team accompanied movies at the cinema.

The last campaign was entitled 'Cover yourself against AIDS' and advertisements featured two metre long pink condoms on buses and billboards

Prostitutes & Prisoners

The Australian Prostitutes' Collective was founded in 1986. The staff visit brothels and talk to workers on the streets about AIDS. The first National Sex Industry Conference was held in Melbourne 1988. The incidence of STD amongst female sex workers is currently lower than for the general population, suggesting a higher frequency of condom usage. (A1DS Council of NSW, 1989)

The prison population at any one time in N.S.W. is 4,000 and just over 14,000 people pass through prison per year. Condoms are available in some prisons, but in an ad hoc way.

There is AIDS education in 26 prisons in N.S.W. and 8 beds are set aside for prisoners with AIDS in Long Bay, Sydney. There are 20 known HIV positive prisoners. Needles and Syringes are not available. However, prisoners have always had access to bleach and are now educated about the cleaning of needles and syringes

Some prisoners are involved in AIDS education and have written and performed several plays on the subject, which inmates and the public can attend. HIV positive prisoners are not segregated in NSW, but there are plans to test a sample of prisoners anonymously early in 1989.

Research

A study has been carried out looking at the relapse rate of methadone clients at a clinic that was next door to a syringe exchange scheme. The difference in the level of 'dirty' urines, in the three months prior to the scheme starting and three months after its introduction, was examined. There was no significant difference.

CARG (Commonwealth AIDS Research Grant) is involved in a national study looking at drug injectors, in and out of treatment, on a variety of levels. The serostatus of the drug injectors will also be examined by using the finger prick method.

The Questionnaire used is made up of five modules;

1. Attitudes to conception/contraception by women

2. Attitudes to treatment

3. Sources of AIDS information

4. Prisons

5. Sexual transmission (from IV to non-IV).

A pilot study of 107 interviews has already been conducted.

Sydney has been chosen as one of the cities in the World Health Organisation's study of intravenous drug users. A pilot of the questionnaire has taken place with 20 IVDU in and 10 out of treatment being interviewed. There is a possibility that the study will extend beyond Sydney to the country areas.

There are plans to evaluate the schemes before May 1989. The research will be conducted by a Market Research company and will look at, among other things, the differences between the various outlets and regions. The evaluation will also test awareness of IVDU's of the logo used in NSW.

Treatment

There is a proposal for all HIV positive IVDU's to go through a methadone programme. On most methadone programmes, HIV positives are not expelled if they use other drugs but HIV negatives are.

At present in N.S.W. there are 3,800 people on methadone and the target is to have 5,000 by October 1989. The methadone guidelines are about to be reviewed in the light of HIV.

There are plans to introduce Methadone buses, along the lines of the ones used in Amsterdam. They will be in operation by September 1989.

An STD clinic will visit Rankin Court's Methadone clinic and provide regular check ups for the clients.

There are plans to do a pilot study where injectors will be given syringes prefilled with a narcotic. It is undecided whether the syringes will be filled with heroin or a substitute.

Prevention

Syringe exchange schemes operate in all states and territories except Tasmania. The only scheme in Queensland is opened for three hours a day. Vending machines for needles and syringes are also planned for use in Western Australia. A prostitutes' collective and a users' organisation have been established in Victoria.

A survey of gay and bisexual men found that 87% had changed their sexual practices because of AIDS. Most gay men are practising safer sex most of the time. (Connell. 1988)

A study at the Albion Street AIDS Centre found that 31% of gay men presenting were infected. (1988) One AIDS worker said the level of infection amongst gay men was about 60%. Sydney is reputed to be the second largest gay city after San Francisco, on a per capita basis.

A policy discussion paper, 'AIDS: A time to care, a time to act-Towards a strategy for Australians' was recently pro to advise the public on the best way to convey their opinions to the Health Department. In addition, six panels of experts were set up to hear the public's views on AIDS. The panels will consider the following issues:

IV drug use and AIDS

Education and prevention

Aborigines and AIDS

Testing

Treatment, services and care

Discrimination and other legal issues.

Summary

The statistics show Australia has a relatively larger problem with HIV infection than the U.K The rate of infection in gay men is rather high and the rate in IVDU's, is on the increase. Possibly these factors have led to the dramatic increases in funding and to the Department of Health trying every possible option that may limit the spread of HIV. They have estimated the number of needles and syringes needed and are aiming for that target.

There is much more coordination of the syringe distribution in N.S.W. than in the U.K The N.S.W. Health Department has managed to increase the supply and availability of needles and syringes quite dramatically and is aiming for 24 hour access via vending machines. Also when single shot syringes are manufactured, all other multiple use ones may be banned. It was anticipated that this will happen within two years.

Many exchange schemes operate late at night and on weekends. The pharmacy schemes have been coordinated on a state wide basis with hundreds of pharmacies taking part. An aggressive outreach service has been set up, also on a state wide basis.

Although there has been limited research into syringe exchange schemes, in comparison to the U.K, there have been six prevalence studies of HIV levels in intravenous drug users. These studies have documented the increase of HIV infection from 0.5% in 1985 to 14% in 1988.

IVDU are being encouraged to organise themselves by funding a group that will give them representation to advisory groups and a voice on AIDS issues that are relevant to them.

REFERENCES

Albion Street AIDS Centre, November 1988, Quarterly Research Journal Vol 1, No. 3.

Albion St AIDS Centre, November 1988, Quarterly Research Newsletter Vol 1, No. 3.

Blacker P, Wodak A, et al, 1986 Exposure of IVDU to AIDS retrovirus Aust NZ J Med..

Connell R,1988, Social Aspects of the Prevention of AIDS. Report No. 3, School of Behavioural Sciences Macquarie University N.S.W.

Dolan K, 1987, Feasibillty of a needle and syringe exchange Project (Draft) .

Dolan K, 1987, Preliminary results of Survey of Syringe Exchange Participants (Draft) .

Frontline, 1989, AIDS Council of N.S.W newsletter No. 34

Medical Devices and Dental Products Branch, Victoria, 1988 Feasibility Study of Non reusable Syringes.

Sandland R, April 1986, Estimation of the Number of Heroin Users in New South Wales Using police arrest Data: Development of a Statistical model, New South Wales Drug and Alcohol Report B86/1.

Vumbaca G, Milechman B Wodak A, 1987, A report on the Pllot Darilnghurst Needle and Syringe Exchange Programme.

Vumbaca G, 1987, personal communication.

Vumbaca G,1989, personal communication.

Wodak A, Dolan K, et al, 1987 Med J Aust.

Wolk JS, Wodak A, et al, June 1988, HIV seroprevalence in Syringes of intravenous drug users using syringe exchange in Sydney, Australia, 1987.1V International Conference on AIDS, Stockholm, (abstract 8504).

Wolk JS, 1988, personal communication.