Other examples of harm reduction
Like needle exchanges, other harm reduction measures exist to minimise the harmful consequences associated with drug use. The provision of these programmes is often hindered by laws which prohibit carrying drug paraphernalia and the fear of discrimination brought by the association with such programmes.33
Maintenance therapy. Maintenance therapy, or opioid substitution treatment, involves the provision of drugs such as methadone or buprenorphine, in pill or liquid form, to drug users as a way of minimising risks associated with injecting. These programmes aim to curb needle sharing, the use of contaminated street drugs, overdoses, and crimes associated with funding drug addiction. Methadone or buprenorphine substitution therapy exists in just over 60 countries worldwide.34
Drug substitution treatment has proven effective in rehabilitating and stabilising IDUs, and in reducing HIV infection rates.35 36 For example, researchers from the University of Philadelphia monitored 152 injecting users receiving methadone maintenance treatment and 103 injecting users on no treatment over a period of 18 months, all of whom were HIV negative at the beginning of the study. The results showed that over the 18 months, only 3.5% of those receiving methadone became infected with HIV, in contrast to 22% not on treatment.37
Another study in Amsterdam followed a group of 582 IDUs on methadone maintenance therapy for an average of three years. The HIV infection rate among those who continued injecting throughout the treatment was 30 times higher than in those who stopped injecting while on treatment. These results revealed that oral methadone treatment is critical in stopping drug users injecting, though a small minority will later revert to high-risk behaviour.38
A report by the WHO in March 2005 reviewed many global studies and concluded that substitution treatment is a ‘critical component’ of HIV prevention policy, significantly reducing opioid dependency and HIV infection rates.39 In addition, studies have also found a decline in crime rates and commercial sex work when IDUs no longer have to find ways to fund their expensive addictions.40 41
Several studies have shown that prescribing injectable opiates – including heroin – can help heroin addicts who have failed on traditional maintenance therapy. The Randomised Injectable Opioid Treatment Trial (RIOTT), which took place in three UK cities, targeted the 5% of addicts who were not benefiting from existing treatments and were continuing to inject street heroin despite receiving oral methadone. Individuals in all three groups – those receiving injectable heroin, injectable methadone, or oral methadone – decreased their consumption of street heroin, with the biggest decrease among those receiving injectable heroin. Programmes such as these would be beneficial for HIV prevention among ‘problem’ drug users as reducing their use of street heroin also reduces the likelihood of using contaminated needles. This was in addition to a substantial reduction in crime.42
The risk of HIV infection through the use of methamphetamine ('crystal meth') is high yet substitution treatment for meth addiction does not currently exist. As well as the HIV risk associated with injecting meth, one effect of the drug is a high sex drive, which can lead to an increase in sexual partners and riskier sexual behaviour. In the United States the use of meth by men who have sex with men (MSM) is 20 times higher than in the general population and is believed to be a major cause of new HIV infections among MSM.43 If substitution treatment was made available to meth users the risks associated with this drug could be substantially reduced.44
Safer injection facilities (SIFs). These provide an environment where drug users can inject in a safer manner and under medical supervision. Like needle exchange programmes they may offer drug education and referral for treatment. They also aim to reduce public disorder issues and risks associated with injection drug use such as large congregations of injectors in public places and litter, particularly syringes. Such facilities exist in only a few countries including Germany, Switzerland, the Netherlands, Spain, Australia and Canada.
After Frankfurt introduced SIFs in the early 1990s, cases of HIV among IDUs declined, as did overdose cases in the city which dropped dramatically from 147 in 1991 to 22 in 1997.45 46 This decline can be attributed to the city’s overall harm reduction approach, though overdose cases dropped steeply in the year following the introduction of SIFs.47 Furthermore, IDUs who overdose in safer injection facilities are 10 times less likely to require hospitalisation.48 Research of Vancouver's Insite, North America’s first SIF, found there was no association between the facility and the rate of drug trafficking or other crimes linked to drug use.49
The Insite facility had faced pressure by Canada’s Conservative government, and was threatened with closure under drug trafficking and possession laws. However, a 2008 ruling allowed it to remain open.50 In the judge’s opinion, Canada’s Controlled Drugs and Substances Act violated individuals' constitutional rights:
“It denies the addict access to a health care facility where the risk of morbidity associated with infectious disease is diminished, if not eliminated… While there is nothing to be said in favour of the injection of controlled substances that leads to addiction, there is much to be said against denying addicts health care services that will ameliorate the effects of their condition.”51
Safer crack smoking resources. Like needle exchange programmes they distribute clean crack-smoking implements in order to curb the risks associated with sharing of equipment.
These have not been implemented on as wide a scale as needle exchange programmes but have shown to be effective in cutting behaviours associated with HIV transmission. An Ottowan needle exchange that also began providing sterile crack-smoking equipment, such as glass stems and rubber mouthpieces, found the proportion of participants sharing implements decrease from 85% six months prior to implementation, to 77% 12 months after. Of those who still shared just 12% did so every time, compared with 37% previously.52
Pharmacy sale of syringes. Non-prescription over-the-counter sale of syringes is another way to allow drug users access to sterile needles. In the US, some states have amended drug paraphernalia laws to exclude syringes. Pharmacies that provide clean injecting equipment may also offer similar secondary services as needle exchanges such as providing information and referrals. In Australia, pharmacy-based needle and syringe programmes account for 15% of all syringes used for injecting drugs.53
An examination of the 96 largest metropolitan areas in the United States found both the proportion of IDUs living with, and becoming infected with, HIV, was lower in the 60 areas that permitted the purchase of syringes without prescription compared to the 36 metropolitan areas that did not allow this.54
Supplying tin foil to deter injecting. One method of helping habitual drug users avoid the harms of injecting is supplying tin foil to encourage smoking of drugs instead. Heroin can be boiled on a piece of foil and then its vapours inhaled. Some countries such as Holland and Spain supply foil through their needle exchanges. In England, however, it is illegal to do so, though it is believed that around 100 of the known 1300 needle exchanges break the law and supply foil.55 An Early Day Motion in the British Parliament aims to overturn section 9A of the Misuse of Drugs Act which restricts the supply of tin foil.56
Again, while no one would claim that smoking heroin is a healthy activity, for people who are addicted to the drug and normally inject, smoking can be a preferable option:
"Smoking drugs is by no means safe, but is a great deal safer than injecting drugs – which is particularly associated with overdose, blood-borne viruses, drug-related litter, greater dependency, abscesses and vein damage." - Jamie Bridge, International Harm Reduction Association57
Safe needle disposal. Various disposal methods exist so contaminated needles are unable to injure another person. These include, drop-off points located in buildings such as police departments, clinics, community organisations or medical waste facilities; mail-back programmes where used needles are sent in a special container to a collection site; residential pick-up services; and in-home disposal services that safely destroy the needle.58 Programmes that offer safer syringe disposal may well be part of a general needle exchange service.
Community-based outreach programmes. These work with injecting drug users (IDUs) to distribute clean equipment, promote condom use and provide information about prevention and rehabilitation. Injecting communities are often secretive and distrustful of authorities. Outreach programmes focus on accessing these hidden groups, opening an important route to providing support. In some cases, former IDUs are recruited and trained as peer-outreach workers. Some IDUs are likely to be involved in sex work to fund their expensive addiction, so provision of sexual health information and condom promotion play key roles in preventing HIV transmission through other routes.
A report from the WHO reviewed data from over 40 studies on outreach prevention methods and concluded that these significantly reduce high-risk behaviour in IDUs and are successful in directing them to rehabilitation services.59
In 2006, UNAIDS published a report that reviewed several ‘high coverage’ prevention programmes (50% of local IDU population accessing more than one prevention initiative) in transitional and developing countries. The inclusion of harm reduction measures was one of the key factors in achieving hi
gh coverage.
It's alarming that crystal meth is one of the factors that trigers for a person to have HIV. I've read an article about a gay that uses meth while having sex with different guys and now both of them acquired HIV. They should seek crystal meth treatment before it took his whole body, mind, and life.
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