PUBLIC HEALTH by Ross ColquhounNews Weekly
Needle exchange a nonstarter for prevention
, August 15, 2015
Since the early 1980s there has been a largely uncritical acceptance among health authorities that harm-reduction measures among intravenous drug users is an important strategy to prevent the transmission of blood-borne viruses.
The main motivation for the urgent implementation of these policies was the feared transmission of HIV and hepatitis C virus (HCV) among intravenous drug users through unsafe injecting practices, mainly via sharing of needles and injecting equipment, and the wider community with whom they interacted.
Needle-exchange programs were introduced on the basis that intuitively they made sense. When the programs were introduced there was no evidence to support their efficacy nor were there any assurances that they would not cause more harm than good.
Central to harm-reduction thinking was that these strategies did not necessarily seek to reduce the frequency with which users injected drugs but merely to minimise the harm those who continued to practise these risky behaviours did to themselves.
The spread of infectious diseases such as HIV and HCV is mostly associated with groups adopting behaviours in situations where the means not to do so is compromised by ignorance and poverty.
Unsafe drug use is often due to attitudinal factors and lack of exposure to or access to preventive measures, and is often associated with addiction to a drug.
In the cases of HIV and HCV, the incentive to change behaviour has been undermined by the harm-reduction message that the transmission of these diseases can be stopped without people having to cease injecting drugs.
As with most chronic diseases, lifestyle factors play a big role and can be changed. For example, to contain the infection rates of hepatitis A requires changes in hygiene practices. A complicating factor is the extent to which these prevention and treatment strategies infringe on personal rights.
Not only must individuals make changes to protect their own health, but they must act responsibly towards those who might acquire a disease from them through their risky behaviour.
The customary emphasis on each person taking responsibility for protecting their own health has a tendency to reinforce HIV-related stigma, potentially discouraging those persons at risk from taking preventative measures or seeking treatment. Often, though, they do not change their behaviours as the messages they receive reinforce the notion that it is a matter of individual rights and to require change is an infringement of those rights.
Surveys of intravenous drug users and other at-risk groups in Australia clearly demonstrate that HIV is primarily transmitted through unsafe sexual activity and that injecting drug use has minimal if any impact on infection rates. HCV, on the other hand, is almost exclusively transmitted by unsafe drug injecting.
Furthermore, reviews of the studies in needle and syringe programs (NSPs) show that there is insufficient evidence to demonstrate any benefit of such programs in relation to the transmission of HCV, and that the transmission of HIV is primarily due to risky sexual behaviours.
Despite this, advocates for harm reduction continue to claim that the evidence is “substantial” and that needle and syringe programs are effective – and cost-effective – even when no evidence is cited.
Attention therefore needs to shift to other preventative strategies, including community education and to treatment. Despite the clear differences in the means of transmission of HIV and HCV, the factor that was common to both groups was persistent risky behaviours, behaviours that have been found to result in cross-infection of up to 80 per cent among some groups.
Accordingly, prevention should be directed at those at risk of acquiring the viruses and should involve providing education, risk-reduction counselling, HIV and HCV screening, and substance-abuse treatment.
For HCV, counselling should be focused on drug treatment, while for HIV the focus of prevention should be on safe-sex practices. In both cases those found to have viral infections need to be counselled to reduce the risk of HIV and HCV transmission to others.
Policies that have been effective have been neglected, while harm-reduction policies driven by a political agenda and showing no demonstrable effect on HIV and HCV rates have been the main focus in the last 30 years or more. In other words, the funds spent on harm-reduction programs would be more effectively spent on adequately funding policies that actually do prevent risky behaviours and treat drug addiction.
Dr Ross Colquhoun is an executive member of Drug Free Australia and research fellow, and a member of the Drug Advisory Council of Australia (daca.org.au).