Innovative approaches in AIDS prevention among drug users
By Ernst Buning

In the last five years, many initiatives have been undertaken to prevent the further spread of HIV amongst and by injecting drug users. Some of these initiatives were successful, others disappointing. No one initiative has been successful in eliminating all risk behaviour. Therefore a range of interventions, which are complementary rather than mutually exclusive, seems the most appropriate approach. In this brief paper various innovative interventions will be described, problems will be elucidated and finally, suggestions will be made about future action in the AIDS prevention field in the European Region.

Promoting safer sex

At an International workshop + by the Dutch STD Foundation in May 1989, a group of 20 international experts on AIDS prevention among drug users, discussed the area of "promoting safer sex among injecting drug users" (Buning & Des Jarlais, 1990) . In their report they concluded, that "the level of condom use among injecting drug users is still low (although higher than in the general population) and that education programs affect the level of knowledge, yet still lack impact on actual behaviour". Various obstacles in addressing drug users about safer sex were mentioned, such as political, moral and religious issues, resistance among the staff to discuss this topic with their clients and the fact that many drug users don’t see safer sex as a high priority since most of their energy is spent on short term ‘survival’ activities.

Examples of activities aimed at promoting safer sex In Oslo, Norway (Amsterdam Municipal Health Service, 1990), the Directorate of Health employs two women, who themselves sell sex, to do outreach work with prostitutes (including drug injecting prostitutes). Amongst other things, they give information about safer sex and provide condoms. The two women have been very well received by their colleagues.

In Berlin, Germany (Amsterdam Municipal Health Service, 1990), in December 1987 a contact caf‚ called ‘Olga’ was established for drug dependent prostitutes. The caf‚ is close to the drugscene and opens between 17.00 hr and 23.00 hr. The caf‚ has an open atmosphere, where clients can feel welcomed by the staff. ‘Olga’ provides medical and legal assistance and condoms (about 1,000 per month). About 20 to 30 women visit the caf‚ daily, whilst a total of about 100 drug dependent prostitutes are in contact. Two streetworkers are attached to ‘Olga’ as well.

In Utrecht, The Netherlands, a similar project to ‘Olga’ has been in operation since 1986. Every night between 20.30 hr and 1.30 hr, a bus is parked in an area where street prostitutes are active. The activities of this project were described in an earlier paper for the WHO (Buning, 1990). A recent booklet on ‘tips for safe sex’ contains the answers of 28 prostitutes who sent in their reaction to a competition about ‘condom negotiations with your client’. The project also produced a flyer for the clients of prostitutes. This flyer was a photocopy of a 50Dfl bill with the text "a minimum price for maximum safety". Finally, the project hired professionals to provide education about various topics. To emphasize the fact that prostitution is a ‘real job’, a physiotherapist was hired to teach the prostitutes proper standing techniques and to advise them about an ergonomic body posture during their work.

In various projects, the workers accompany the clients to drug stores where they buy condoms. In so doing, it is hoped that embarrassment will be overcome. In some projects, workers show clients how to apply a condom by using a banana. The large number of condoms which burst due to improper or inexperienced use is an indication that such practical skill training is still needed.

Other projects try to eroticize safer sex by teaching sex techniques other than copulation and by teaching techniques on how the application of a condom can be an attractive part of sexual activity.

Problems in promoting safer sex

Sex is a sensitive topic and does not lend itself easily to public discussion. Many workers in the drugs field feel reluctant to openly discuss safer sex with their clients. Nevertheless, safer sex has become a vital issue for many drug injectors. In some countries, part of the embarrassment among the workers has been overcome through training sessions. However, a video, shown in waiting rooms of Amsterdam methadone programmes, with a very explicit safer sex message, was rejected by the clients and some staff members. Some of the clients said that "this is pornography, why don’t you show that to prostitutes?", whilst the staff felt that showing the video was too disruptive to the ongoing activities in the methadone programme.

Sometimes , police regulations can be counterproductive to safer sex education. In areas where prostitution is prohibited, the police may attempt to disperse the ‘prostitution scene’, resulting in an inability for AIDS educators to reach the drug injecting prostitutes and their clients. The most extreme example of a situation where the police frustrated the AIDS interventions of outreach workers was a city where the police used the possession of condoms as evidence for illegal prostitution (Amsterdam Municipal Health Service, 1990).

Another problem in promoting safer sex is the use of cocaine and crack. Especially if it is used without heroin, cocaine/crack can lead to a higher level of sexual activity. In areas with a high HlV-seroprevalence (for example, New York City) relations were found between AIDS infections and cocaine/crack use. Since appropriate treatment for cocaine/crack use is still lacking and cocaine/crack users generally do not see their use as problematic, it is difficult to contact this group and educate them about safer sex. The same can be said of those using Ecstasy (MDMA).

Finally, safer sex among drug users should be mentioned in the light of their sexual contact with non-injectors. These non-injecting sex partners are not reached by the drug helping agencies and depend on their information from campaigns aimed at the general public. Sometimes, these sex partners don’t even know that their partner is (or had been) injecting. In Utrecht, a league of clients of prostitutes is giving AIDS education to other clients. Although this is on a small scale, this approach is successful.

Promoting safer drug use

Promoting safer drug use is almost a contradiction in terms. The best way to avoid infection with HIV and other infections is to refrain from injecting drugs. Since this option only seems to be adopted by a small group of drug injectors, AIDS and drugs experts agree that a range of options should be available, i.e.

1) prevent drug injection

2) stimulate drug users to stop using drugs

3) convert intravenous drug use to oral drug use

4) assist drug injectors to refrain from needle sharing

5) stimulate drug injectors, who share needles, to clean them with bleach.

Points 1 and 2 will not be discussed in this paper, though it should be mentioned that for budgetary reasons in some countries money is shifted from these activities to "harm-reduction" (points 3 to 5) projects.

Convert intravenous drug use to oral drug use Much discussion has taken place about the role of methadone as an oral alternative for opiate injectors. So far, data about AIDS-related risk behaviour among clients in methadone programmes has not been conclusive. Strict methadone programmes which don’t tolerate any use of illegal substances - self-evident - report no risk behaviour among clients who remain in the programme. More relaxed methadone programmes report a significant number of clients who refrain from injecting or who reduce injecting .. considerably. A methadone programme in the Bronx (New York) reported that clients who were on methadone longer than 7 years and clients on a dosage higher than 60 mg. showed a lower HIV seroprevalence (Hartel, Selwyn et al, 1988).

Besides the direct effect of methadone programmes on HIV risk behaviour there may also be an indirect effect. In Amsterdam, only 40% of heroin users inject. The remaining 60% are ‘chasing the dragon’ (a way of smoking heroin). Chasing the dragon is only possible when the purity of heroin is high. Through the ample availability of methadone it is believed that drug users have become very critical buyers from the drug dealers. Why should they spend their money on low quality heroin if they can always fall back on methadone? Whether this can be attributed to the availability of methadone is difficult to prove but, nevertheless, it is a fact that the purity of heroin in Amsterdam has remained stable (around 30% to 40%) since large methadone programmes.were opened.

In an experiment in the Merseyside Health Region, drug users can obtain ‘reefers’ containing a smokeable preparation of the drug of choice.

Heroin, methadone, cocaine and amphetamine is prescribed by a medical doctor. The client brings a packet of their own cigarettes to the pharmacist who injects them with the prescribed drug(s) and the client smokes the cigarettes (reefers) when they feel the need. The number of clients in this programme is still small and scientific data have to prove whether this intervention is useful in preventing AIDS amongst drug users (Marks & Palombella, 1990).

Assist drug injectors to refrain from needle sharing

In the last five years, initiatives in many countries throughout the European Region were undertaken to start needle exchange programmes. In a number of countries, these programmes have been evaluated (Hartgers, Buning et al, 1989; Lart & Stimson, 1989). The general conclusion of these evaluations was that needle exchange programmes assist older drug injectors with a long ‘drug career’ in refraining from needle sharing. Young drug injectors and female injectors were more difficult to reach. Since even amongst clients of needle exchange programmes a small percentage had still shared needles in the month preceding the interview, needle exchange programmes should not be seen as a panacea to change AIDS related risk behaviour.

A conclusion from the British evaluation was that most needle exchange schemes are small and only reach a limited number of drug injectors. The same is true for programmes in the Netherlands where, outside Amsterdam (where 820,000 needles and syringes were exchanged in 1989), projects are generally small.

Outreach workers can play an important role in handing out clean needles and/or referring drug injectors to exchange programmes. Various examples of these sorts of activities were described in a paper prepared for the WHO-Euro (Amsterdam Municipal Health Service, 1990).

Stimulate drug injectors who share needles to clean them with bleach

In San Francisco, USA, a prevention campaign was implemented called "teach and bleach". Since needle exchange programmes were forbidden, prevention workers thought of an alternative. Small bottles of bleach are handed out to drug users. Before injecting they have to rinse the needle and syringe with bleach and water. Studies about the HIV sero-prevalence amongst drug injectors indicate that about 12% of them are infected. This is much lower than in New York, where bleach was never applied on a large scale.

Teaching drug users to clean their needles and syringes with bleach seems to be an acceptable alternative in areas where needle exchange programmes are forbidden or too costly. Since a small number of participants in the Amsterdam needle exchange still report needle sharing, a leaflet has been distributed in which cleaning needles and syringes with bleach is explained. A next step could be to hand out small bottles of bleach to a limited number of drug injectors who remain involved in needle sharing. However, workers in the Amsterdam needle exchange schemes fear giving a double message when handing out bleach in their schemes.

Conclusion

Based on the above, it may be concluded that no one intervention has turned out to be completely effective in stopping AIDS related risk behaviour among drug users. It is therefore necessary to implement various prevention measures. The choice as to which interventions are adopted will depend strongly on the local, cultural and political climate.

WHO-Euro can play a significant role in making expertise on AIDS prevention available for the various Member States. In this regard, expertise on the following issues seems relevant:

 outreach work among drug users;

 methadone programmes as an oral alternative to injecting;

 safer sex campaigns for addicted prostitutes; .

 needle exchange programmes to prevent needle sharing

WHO-Euro is strongly recommended to stimulate the development of a pool of experts who can be consulted whenever a oocal) government wants to initiate AIDS prevention programmes for drug users.

Furthermore, WHO-Euro should stimulate the development of a database of articles, published and unpublished documents about AIDS and drugs. This database should be accessible to all Member States whenever more information is needed on various topics related to AIDS and drugs.

Finally, WHO-Euro should investigate the need for, and feasibility of, a European Newsletter on AIDS and drugs. This newsletter should give concrete descriptions of interesting AIDS and drugs projects throughout the European Region and provide a forum for information exchange.

In so doing, WHO-Euro can contribute considerably to ‘getting the right expertise at the right place’ and in stimulating the development of concrete AIDS intervention projects throughout the European region.

Buning, E., Des Jarlais, D. 1990 Promoting safer sex among injecting drug users. In: Promoting safer sex edited by Maria Paalman.

‘Outreach work among drug users in the light of the AIDS epidemic", 1990. Paper prepared by Amsterdam Municipal Health Service for WHO Regional Office for Europe.

Buning, E.C. 1990 AIDS related interventions in the Netherlands, The International Journal on Drug Policy, Vol I, No 5.

Hartel, D., Selwyn RA. et al 1988 Methadone maintenance treatment (MMTP) and reduced risk of AIDS specific mortality in intravenous drug users. Presentation at IV International Aids Conference, Stockholm.

Marks, J.A., Palombella, A. 1990 Prescribing smokeable drugs", The Lancet.

Hartgers, C., Buning, E.C. et al 1989 The impact of the needle and syringe exchange program in Amsterdam on injecting risk behaviour, AIDS volume 3, page 571-576;

Lart, R., Stimson, G.V. 1989 National survey of syringe exchange schemes in England. Publication by Monitoring Research Group, London, England.