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PubMed2000

Evaluation of the AIDS Prevention Street Nurse Program: one step at a time.

The AIDS Prevention Street Nurse Program uses specially prepared community health nurses to focus on HIV and STD prevention with marginalized, hard-to-reach and high-risk clients within a broader context of harm reduction and health promotion. Street nurses (n = 17), service providers (n = 30), representatives of other HIV/STD programs in the province of British Columbia, Canada (N = 5), and clients (n = 32) were interviewed during an evaluation for the purpose of describing the nurses' work, the challenges the nurses' face, the fit of the program with other services, and the impact of the nurses' work. This article describes the impact of the nurses' work on clients. Impact/outcome changes reflected a progression from knowledge to behavioural levels and to major indicators of health/illness. Impact on clients included: knowing more about HIV/AIDS, their own situation, and options; receiving essential supplies to reduce harm and promote health; changing behaviour to reduce disease transmission, improve resistance, and promote health; connecting with help; feeling better about themselves and others; feeling supported; influencing others; receiving earlier attention for problems; being healthier with or without HIV; making major changes in drug use; and likely decreasing morbidity and mortality. The Program was found to be clearly effective in making a positive impact on clients.

Acquired Immunodeficiency Syndrome↗

PubMed2007

Physicians' knowledge of and willingness to prescribe naloxone to reverse accidental opiate overdose: challenges and opportunities.

Naloxone, the standard treatment for heroin overdose, is a safe and effective prescription drug commonly administered by emergency room physicians or first responders acting under standing orders of physicians. High rates of overdose deaths and widely accepted evidence that witnesses of heroin overdose are often unwilling or unable to call 9-1-1 has led to interventions in several US cities and abroad in which drug users are instructed in overdose rescue techniques and provided a "take-home" dose of naloxone. Under current Food and Drug Administration (FDA) regulations, such interventions require physician involvement. As part of a larger study to evaluate the knowledge and attitudes of doctors towards providing drug treatment and harm reduction services to injection drug users (IDUs), we investigated physician knowledge and willingness to prescribe naloxone. Less than one in four of the respondents in our sample reported having heard of naloxone prescription as an intervention to prevent opiate overdose, and the majority reported that they would never consider prescribing the agent and explaining its application to a patient. Factors predicting a favorable attitude towards prescribing naloxone included fewer negative perceptions of IDUs, assigning less importance to peer and community pressure not to treat IDUs, and increased confidence in ability to provide meaningful treatment to IDUs. Our data suggest that steps to promote naloxone distribution programs should include physician education about evidence-based harm minimization schemes, broader support for such initiatives by professional organizations, and policy reform to alleviate medicolegal concerns associated with naloxone prescription. FDA re-classification of naloxone for over-the-counter sales and promotion of nasal-delivery mechanism for this agent should be explored.

Attitude of Health Personnel↗

PubMed1997

Injecting nation: achieving control of hepatitis C in Australia.

Since Australia banned heroin in 1953 consumption of illicit drugs, deaths, crime and corruption related to drugs have steadily increased. Injecting drug use (IDU) in Australia is now a significant public health problem linked each year to approximately 500 overdose deaths and more than 6000 hepatitis C infections. At least 85% of prevalent and incident hepatitis C cases in Australia are injecting drug users (IDUs) with annual incidence estimated at 15%. Although poorly documented, increasing numbers of patients with end-stage liver disease from hepatitis C now appear to present in Australia. This reflects a heroin-injecting epidemic commencing a quarter of a century ago, the close association between drug injecting and hepatitis C and the long delay between hepatitis C infection and complications. The overall health and economic burden of hepatitis C may soon exceed HIV. Control is far more difficult to achieve for hepatitis C than HIV because of much higher baseline prevalence levels and far greater infectiousness by blood to blood spread. Transmission appears to follow minimal breaches of infection control guidelines. Hepatitis C has not yet become a priority public health issue in Australia. No national prevention strategy has been proposed. Prevention strategies (such as needle exchange or methadone) which controlled HIV among IDUs should be expanded, with the expectation of some useful reduction of spread but without achieving control of hepatitis C. Other options for control must be considered. Eradicating illicit drug use in Australia is unachievable. Virtually eradicating injecting drug use by facilitating a switch to non-injecting routes of administration (NIROA) is achievable (although difficult) and this could control hepatitis C. NIROA will have the probable additional benefit of reducing drug overdose deaths. NIROA has begun recently to replace injecting in several countries without government intervention. Powerful cultural, pharmacological and economic factors strongly reinforce drug injecting. Economic impediments to NIROA could be reduced by drug policy reform. Facilitating a switch to NIROA carries some risk of increased discrimination directed against an already marginalized population. A major obstacle to harm reduction is the common assumption that any relaxation of drug policy invariably leads to increased consumption. Switching the predominant route of administration of illicit drugs from IDU to NIROA should be the major focus of national efforts to control hepatitis C and overdose deaths in Australia.

Journal Article↗

PubMed2001

One-, three-, and six-month outcomes after brief inpatient opioid detoxification.

The purpose of this study was to investigate short-term outcomes of a 3-day inpatient medical detoxification. Heroin abusers (n = 116; 66% male, 77% African-American, X = 38 years old), completed the Addiction Severity Index during detoxification, and at 1, 3, and 6 months after detoxification; 94.5% of the postdetoxification interviews were completed. During the 30 days before detoxification, mean days of self-reported use for heroin was 28, for cocaine 19, and for alcohol 14; a mean of $1,975 was spent on drugs. Across the postdetoxification interviews, mean days of reported heroin use ranged from 11 to 14; 21-30% of patients reported no heroin use, whereas 25-36% reported almost daily use. Reported use of cocaine and alcohol showed similar reductions from pre- to postdetoxification. Reports of heroin and cocaine abstinence were generally verified through urine tests. Other psychosocial factors improved as well from pre- to postdetoxification (e.g., employment increased and needle use decreased). During the 6-month evaluation, at least 41% reported engaging in formal inpatient or outpatient treatment; another 25-33% reported attending self-help groups. Engaging in formal treatment (at least 7 days duration) was associated with significantly better outcome. Nevertheless, pre- to postdetoxification changes were significant and robust for the entire study sample. These findings demonstrate that brief inpatient detoxification is followed by reduced drug use over several months and is accompanied by substantial treatment-seeking behavior. Thus brief detoxification may serve as an effective harm-reduction intervention.

Adult↗

PubMed1997

Population level policies on alcohol: are they still appropriate given that "alcohol is good for the heart'?

The research finding that a reduced risk of coronary heart disease is associated with alcohol use has been widely disseminated. This paper addresses the significance of this research finding for decisions about what kind of alcohol harm reduction policies it is appropriate to implement. The public policies of greatest concern to the vested interest groups are population-based policies such as taxation and restrictions on availability. Other public policies which impact on the drinkers' environment are minimum drinking age laws, drink drive deterrence, prevention of intoxication in public drinking places and restrictions on advertising. A review of the effectiveness of the available strategies provided strong support for environmentally focused approaches rather than education targeting high-risk drinkers. Many of these environmental strategies seem unlikely to have a significant direct effect of reducing "heart healthy' drinking by older people. Furthermore, the impact of alcohol on premature mortality among the older sectors of the population has to be weighed against any possible impact on younger drinkers resulting in loss of or disability in many years of life. Given the relative effectiveness of environmental strategies for reducing harm and the likely low level of impact of these strategies on the heart healthy drinking of older people it is concluded that the evidence of reduced risk of coronary heart disease does not preclude their implementation.

Alcohol Drinking↗

PubMed2006

Young people: the centre of the HIV epidemic.

OBJECTIVES: This chapter reviews data on the situation of young people and HIV/AIDS. It assesses whether young people have access to the information, skills and services required to reduce their vulnerability and whether there has been any reduction in HIV prevalence among 15--24-year-olds. METHODS: We reviewed the data on knowledge, behaviour, life skills, access to services and HIV prevalence among young people from nationally representative household surveys, antenatal care surveillance reports, behavioural surveillance surveys, a global coverage survey and other special studies. FINDINGS: In countries where HIV is concentrated among sex workers, injecting drug users or men who have sex with men, high-risk behaviour commences for most during adolescence, and large proportions of these high-risk populations are younger than 25 years. In countries with generalized epidemics, the epidemic is also driven by young people. Half of all new infections in sub-Saharan Africa occur among this group. Many young people do not have the basic knowledge and skills to prevent themselves from becoming infected with HIV. Young people continue to have insufficient access to information, counselling, testing, condoms, harm-reduction strategies and treatment and care for sexually transmitted infections. Other socioeconomic factors beyond the control of individuals need to be addressed. Countries that have reported a decline in HIV prevalence have recorded the biggest changes in behaviour and prevalence among younger age groups. CONCLUSIONS: The epidemic varies greatly in different regions of the world, but in each of these epidemics young people are at the centre, both in terms of new infections as well as being the greatest potential force for change if they can be reached with the right interventions.

Adolescent↗

PubMed1996

Cost implications of random mandatory drugs tests in prisons.

BACKGROUND: Compulsory urine testing of prisoners for drugs, a control initiative, was introduced in eight prisons in England and Wales early in 1995. Despite no evidence of effectiveness, testing was extended to all prisons in England and Wales by March 1996. We consider the cost of testing. METHODS: We combined the costs of refusals, confirmatory tests, punishment of confirmed positives for cannabis or for class A drugs to estimate the average costs of random compulsory drugs testing. These costs were then compared to: i) the healthcare budget for a prison; and ii) the cost of putting in place a credible prisons' drugs reduction programme. We then used Scottish data on incarceration and regional prevalence of injecting drug users to estimate the extent of the injecting drug use problem that prisons face. FINDINGS: Costs per 28 days of the random mandatory drugs testing control initiative in an establishment for 500 inmates where refusal rate is a) 10% or b) nil; and 35% of urine samples test positive, one tenth of them for class A drugs were estimated at between a) 22,800 UK pounds and b) 16,000 UK pounds per 28 days [a) $US35,100 and b) $US24,600]. This cost was equivalent to twice the cost of running a credible drugs reduction and rehabilitation programme, and around half the total healthcare expenditure for a prison of 500 which averaged 41,114 UK pounds per 28 days [$US64,860]. Major cost-generating events were the punishment of refusals--over one third of cost a)--and testing positive for cannabis--over 50% of cost a). In Scotland, around 5% of injecting drug users (IDUs) are incarcerated at any time: 5% of Lothian's drugs care, treatment and prevention costs and 2.5% of its HIV/AIDS prevention budget in 1993-94 amounted to 101,300 UK pounds per annum--or 7770 UK pounds per 28 days ($US11,970)--and about 35% of monthly MDT costs. INTERPRETATION: We suggest that 5% of current resources for drugs prevention and treatment and for IDU-targetted HIV/AIDS prevention should be directed towards the prisons because in the prisons, where 5% of the clients are at any time, injectors have less access to harm reduction measures than on the outside.

Costs and Cost Analysis↗

PubMed2004

Sustained moderate reductions in arterial CO2 after brain trauma time-course of cerebral blood flow velocity and intracranial pressure.

OBJECTIVE: In healthy volunteers cerebral blood flow starts to recover towards baseline within a few minutes of continued hyperventilation due to normalisation of perivascular pH. We investigated the time-course of changes in middle cerebral artery mean flow velocity (FVm) and intracranial pressure (ICP) in head-injured patients during sustained moderate reductions in arterial partial pressure of CO(2) (PaCO(2)). DESIGN: Observational study. PATIENTS: Twenty-seven sedated, mechanically ventilated patients with severe head injury. INTERVENTIONS: Measurements were made during and after routine determination of CO(2)-reactivity: an acute 20% increase in respiratory minute volume was followed by a 10-min stabilisation period and 50 min of continued moderate hyperventilation at a constant PaCO(2) (>3.5 kPa). MEASUREMENTS AND RESULTS: FVm was monitored with transcranial Doppler, ICP was monitored with intraparenchymal probes. During the 50-min period with stable PaCO(2) FVm increased in 36% of patients. All other patients showed a decline in FVm over the same time period. Overall FVm recovery was -0.03+/-0.14%.min(-1). The time-course of ICP changes was significantly different from that of FVm, with ICP reaching its lowest value earlier than FVm (23+/-12 vs 37+/-20 min; P = 0.001) and returning more rapidly towards baseline than FVm (0.23+/-0.23 vs -0.03+/-0.14%.min(-1); P< 0.0001). CONCLUSIONS: Head-injured patients may adapt differently to hyperventilation than healthy volunteers. Potentially harmful reductions in cerebral blood flow may persist beyond the duration of useful ICP reduction.

Adolescent↗

PubMed2000

Feasibility in needle exchange programme: an evaluation of a pilot programme in Catania, Sicily.

INTRODUCTION: Intravenous drug use (10 V) is a primary transmission route for HIV and other blood borne disease. A criminal approach to illicit drug use leads to aggressive attitudes towards drug users and forces them underground, thus hindering their access to Health Service outlets. A 6-month pilot Needle Exchange Programme was set up in Catania, with the aim of reducing the negative effects and consequences of drug use, preventing the spread of blood borne diseases by encouraging the use of clean needles and reduction of needle sharing. To establish contact with the hidden population of the city's, intravenous drug users (IDUs) and promote condom use and safer sex. METHOD: An equipped camper was parked daily in two of the city's main public squares according to a preset timetable, morning and afternoon. A flexible needle exchange policy, i.e. free clean needles given out regardless of those returned, was adopted as a strategy considered necessary in order to, ensure maximum user-friendliness. Safer shooting information leaflets were given out alongside material for the correct use of the condom and condoms. RESULT: The number of IDUs, contacted who had previously been referred to a National Health Service Drug Unit (Ser.T.) and not, and number of syringes exchanged were low but increased month by month. CONCLUSION: Future projects should be undertaken after building up, a collaborative network between Street Unit and local courts; the city police force; social service outlets; hospitals and other health outlets; Ser.T. units and local pharmacies. In the light of our current experience, the one to one strategy instead to the flexible strategy could lead to stricter adherence to harm reduction strategies amongst IDUs.

Journal Article↗

PubMed2004

Efficacy of tobacco dependence treatment in the context of a "smoke-free grounds" worksite policy: a case study.

BACKGROUND: Smoking restrictions provide opportunities to modify smoking behavior. A large insurance company implemented a smoke-free grounds policy at two of their office complexes in January, 2000. METHODS: This cohort study evaluated the impact of the smoke-free grounds policy on abstinence among 128 employees who participated in a tobacco dependence treatment program. RESULTS: The overall quit rate at 6 months was 44.5%. The larger complex showed a trend for higher quit rates compared to the smaller complex (46.5 vs. 28.6%). Post-ban participants had higher quit rates than pre-ban participants (52.4 vs. 43.0%). The probability of abstinence at 6 months follow-up was higher for post-ban compared to pre-ban participants (P = 0.03). Post-ban participants were 80% less likely to relapse than pre-ban participants. Non-quitters decreased their consumption by 6.6 cigarettes/day (39.1% decrease). CONCLUSIONS: A "smoke-free grounds" policy encourages abstinence and may play a significant role in harm reduction among continuing tobacco users.

Adult↗

PubMed2000

The influence of early and frequent use of marijuana on the risk of desistance and of progression to marijuana-related harm.

BACKGROUND: A significant minority of lifetime marijuana users will eventually receive a diagnosis of abuse or dependence. Yet little is known regarding the effect of age at onset and frequency of lifetime marijuana use on desistance from use and on progression to marijuana disorders. METHODS: To address this issue, data were obtained from a community sample of 2,729 lifetime marijuana users participating in the Ontario Mental Health Supplement. RESULTS: Early and frequent lifetime marijuana use was associated with highly persistent use and rapid progression to marijuana-related harm. Multivariate analyses revealed a monotonic increase in the risk of desistance with less frequent categories of use and later ages of onset. Results also indicated a threshold of use (100-199 times) associated with an elevated risk of developing marijuana disorders. A lower threshold of risk for marijuana problems was observed for females (50-99 times). CONCLUSIONS: Early and frequent marijuana use are potent risk factors for prolonging desistance and hastening marijuana-related harm. Required are prevention programs aimed at delaying the onset of first use as well as harm reduction strategies that encourage cessation or reduced levels of consumption among those already using.

Adolescent↗

PubMed2003

Early intervention strategies in substance abuse.

Since the mid-eighties many efforts have been made to develop spezialized intervention strategies and interview techniques aiming at harm reduction and motivational enhancement in patients with substance related disorders. Firstly, the "Transtheoretical Model of Change" by Prochaska and DiClemente, which defines motivation as a dynamic process with several stage dependent intervention possibilities. Secondly, the "Motivational Interviewing" technique by Miller and Rollnick, who strongly suggest an empathic communication style deriving from humanistic psychology. It has been shown that especially persons in early stages of substance related disorders profited very well from such early interventions. Psychiatric institutions not involved in specialized addiction treatment have to face frequent comorbid substance abuse among their patients. Findings of the efficacy of early interventions in general psychiatry are encouraging. Despite there is strong evidence of efficacy of early and motivational intervention strategies in several medical fields, their implementation tends to be very difficult.

Humans↗

PubMedDate not supplied

Blood-borne infections in Dublin's opiate users.

BACKGROUND: Injecting drug users are at high risk of acquiring blood-borne infections. Ireland has had a harm reduction policy of methadone maintenance and needle exchange since 1992. AIM: To estimate prevalence of hepatitis B, hepatitis C and HIV infection and appropriate uptake of hepatitis B vaccine in methadone attendees and to make recommendations for a simple record-based surveillance system. METHOD: Retrospective study of 138 client records for evidence of laboratory tests or test results for blood-borne viruses and appropriate immunisation against hepatitis B. RESULTS: A total of 60% of clients had evidence of one or more laboratory tests in their notes. Of those tested for individual viruses, 5.1% were positive for hepatitis B surface antigen, 78.8% had antibodies to hepatitis C and 16.7% were HIV positive. Nearly two-thirds of clients had no evidence of vaccination or information on prior immunity in their records. CONCLUSIONS: A standardised written protocol for screening for blood-borne viruses and for immunisation against hepatitis B in methadone service attendees was clearly needed, and was subsequently introduced by the Eastern Region Health Authority.

HIV Infections↗

PubMedDate not supplied

Bloodborne virus infections among drug users in Ireland: a retrospective cross-sectional survey of screening, prevalence, incidence and hepatitis B immunisation uptake.

BACKGROUND: Injecting drug users are at high-risk of bloodborne virus infections including hepatitis C (HCV), hepatitis B (HBV) and HIV. AIMS: To document screening for and immunisation against bloodborne viruses and to determine the known prevalence and incidence of these infections. METHODS: A cross-sectional survey of clients attending 21 specialist addiction treatment clinics in one health board area in greater Dublin. Data collected on demographic characteristics, serology for HCV, HBV and HIV and immunisation against HBV. RESULTS: A total of 316 (88%) had been tested for anti-HCV antibody, 244 (68%) had been tested for anti hepatitis B core antibody (anti-HBc), 299 (84%) had been tested for hepatitis B surface antigen (HBsAg) and 307 (86%) had been tested for anti-HIV antibody. The prevalence of anti-HCV, anti-HBc, HBsAg, and anti-HIV were: 66%, 17%, 2% and 11% respectively. The incidence of HCV, HBV and HIV infections were: 24.5, 9.0 and 3.4 per hundred person years respectively. Eighty-one per cent of those in whom it was indicated, had started a targeted HBV immunisation programme in the clinics. CONCLUSION: The proportion of clients screened for HCV, HBV and HIV infection has increased since the introduction of a screening protocol in 1998. Targeted vaccination for opiate users against hepatitis B is more successful than previously shown in Ireland. The prevalence and incidence of bloodborne viruses remains high among opiate users attending addiction treatment services, despite an increase in availability of harm reduction interventions.

Antibodies, Viral↗

PubMed2005

Epidemiological study of hepatitis B virus infection in Manitoba, Canada, 1992-2003.

In comparison with other Canadian provinces and most Western countries, the province of Manitoba maintains a different vaccination policy for hepatitis B. This policy provides selective antenatal screening for hepatitis B in women and an inoculation program for hepatitis B vaccination for fourth-grade pupils. There has been increasing concern for this policy with regard to its influence on secular trends of acute hepatitis B incidence in Manitoba. This created a need to summarise the epidemiological characteristics of hepatitis B virus (HBV) infection in Manitoba and to allocate finances and human resources for future prevention programs. The Cadham Provincial Laboratory in Winnipeg, a Canadian Public Health Laboratory, is responsible for testing all specimens for diagnosis of various common infectious diseases in Manitoba. During the period from 1 January 1992 to 31 December 2003, a total of 285,946 clinical specimens were submitted to this laboratory, which confirmed 310 cases of acute HBV and 7,556 cases of chronic HBV infection. A total of 18,168 individuals were identified as having vaccine-induced immune status. The incidence rate of acute HBV infection has significantly decreased from 6.52/100,000 person-years in 1996 to 0.86/100,000 person-years in 2003. Annual prevalence rates of chronic HBV infection in Manitoba increased slightly from 42.96 cases/100,000 population in 1992 to 71.47 cases/100,000 population in 2003. Incidence rates were generally higher in men than in women at all age groups, with values of 2.65 and 1.65 per 100,000 population, respectively (chi-square=15.768, p value <0.001). The highest incidence rate for both males and females was observed in the age group 30-34 years. The North Eastman and Winnipeg Regional Health Authorities showed significantly higher incidence rates of acute hepatitis B compared with the other nine Regional Health Authorities. Selective hepatitis B vaccination programs for children in Manitoba had achieved the greatest success in the prevention of vertical and horizontal transmission. There is an urgent need to develop cost-effective harm-reduction strategies for hepatitis B prevention among adults (aged 30-34) and groups at risk in Manitoba.

Adolescent↗

PubMed2006

Conflicting messages: how criminal HIV disclosure laws undermine public health efforts to control the spread of HIV.

Twenty-three U.S. states currently have laws that make it a crime for persons who have HIV to engage in various sexual behaviors without, in most cases, disclosing their HIV-positive status to prospective sex partners. As structural interventions aimed at reducing new HIV infections, the laws ideally should complement the HIV prevention efforts of public health professionals. Unfortunately, they do not. This article demonstrates how HIV disclosure laws disregard or discount the effectiveness of universal precautions and safer sex, criminalize activities that are central to harm reduction efforts, and offer, as an implicit alternative to risk reduction and safer sex, a disclosure-based HIV transmission prevention strategy that undermines public health efforts. The article also describes how criminal HIV disclosure laws may work against the efforts of public health leaders to reduce stigmatizing attitudes toward persons living with HIV.

Criminal Law↗

PubMed2007

Strategies to reduce HIV risk behavior in HIV primary care clinics: brief provider messages and specialist intervention.

Reducing HIV transmission is a critical goal worldwide, prompting new strategies to slow the spread of the virus. This paper describes the theoretical underpinnings of the Comprehensive Harm Reduction Protocol (CHRP) and the process of its implementation in one large urban HIV clinic and two smaller rural primary care clinics. Patients enrolled in CHRP complete the Risk Diagnostic Questionnaire (RDQ), self-reporting HIV transmission risk behavior at most clinic visits. Clinicians review RDQs to trigger dialogue using motivational interviewing and the stages of health behavior change to reduce high-risk behaviors (drug use, alcohol use, or high-risk sexual behavior). In the ongoing evaluation study, CHRP patients receive two provider-only visits before being randomized to continue with provider brief prevention messages only or to receive additional intensive counseling with a risk-reduction specialist following the provider visit. If outcome data support one or both interventions, CHRP could be a useful model for widespread adoption. Observations from the implementation of this protocol are presented in order to facilitate the adoption of this protocol in interested clinics. Later, results of the evaluation of the implementation of the protocol may have value in developing prevention policy in HIV treatment clinics.

Ambulatory Care Facilities↗

PubMed2006

Developing a partnership model for cancer screening with community-based organizations: the ACCESS breast cancer education and outreach project.

There is growing enthusiasm for community-academic partnerships to promote health in underserved communities. Drawing upon resources available at a comprehensive cancer center, we developed the ACCESS program to guide community based organizations through a flexible program planning process. Over a three-year period, ACCESS partnered with 67 agencies serving various medically underserved populations. Organizations included hospitals, parishes, senior centers, harm reduction programs, and recreational facilities. Program outcomes at the organizational level were quantified in terms of introduction of new cancer information, referral or screening programs, as well as organizational capacity building. ACCESS represents a viable model for promoting partnership to transfer behavioral health programs and adapt interventions for new audiences. Plans to further evaluate and enhance this model to promote cancer screening efforts are discussed. We argue that, ultimately, formation and development of community partnerships need to be understood as a fundamental area of practice that must be systematically integrated into the mission of major academic medical institutions in every area of public health.

Academic Medical Centers↗