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• W2140047650 abstract "The effectiveness of needle and syringe exchange programmes (NSP) to prevent HIV infection among intravenous dug users (IDUs) has been discussed intensely for 20 years. A recent WHO summary of evidence for prevention of HIV transmission concludes in favour of NSP [1], as did Gibson et al. [2] in a review from 2001. In neither reviews were studies in favour of NSPs scrutinized to check if the authors’ conclusions were sound. A cornerstone in both reviews was a paper by Hurley et al. [3], which has been cited 90 times [4]. Two later studies used the same design as Hurley et al. [5-7]. If these studies are not altogether scientifically rigorous, the impact on the conclusions in the World Health Organization (WHO) summary may be noticeable. These studies examine changes in seroprevalence among IDUs over time, comparing cities with and without NSP. An average increase in such seroprevalence for cities without NSP, and an average decrease in cities with NSP, were interpreted as evidence for a positive effect of NSP. However, the ecological studies did not control for two possibly important confounders: the stage of the epidemic among IDUs and the level of knowledge of the participants’ HIV status. A careful reading suggests that weaknesses of the design and the measurements regarding the strength in the conclusions in favour of NSP were, perhaps, not addressed adequately in those studies. Studies concerning HIV incidence in European countries by back-calculation indicate that the incidence of HIV among IDUs was highest in the mid-1980s, with fairly short peaks [8, 9]. HIV among IDUs was, from the start, a big-city phenomenon, so the epidemic depicted for a country also depicted the situation in one or more big cities in that country. For an HIV epidemic with peaked incidence, both incidence and prevalence in an IDU population increase before the peak. Thus, up to the mid-1980s we should find an increase in prevalence in most big cities. This was also the period with very few NSPs. Most decision-makers used a considerable amount of time before any NSPs were established due to the fear that NSPs would enhance injecting drug use, even though the demand for NSPs rose drastically after the first HIV test became available in 1985. After the peak the incidences decrease and the prevalence may develop in many ways, depending on the relative size of new cases of HIV versus deaths among HIV-positive IDUs. Recruitment to injecting drug use in general may also have an effect on the prevalence. The three studies [3, 5, 6] compared the change of HIV seroprevalence in cities with NSP versus cities without NSP. Because NSPs were established in many places after the peak, the stage of the epidemic could be an important confounder in the analysis. This can be seen as a lack of adequate controls that are necessary in observational studies. A city without an NSP may also have been a city in the early stages of the epidemic, while a city with an NSP may have been a city where the problem was identified and where the HIV epidemic was past the peak period. A visual examination of Figs 1 and 2 in Hurley et al. [3] reveals that this may be a tendency in the measurements for the cities shown. In Fig. 1, it is shown that Bern had an increasing seroprevalence in 1981–85 and Glasgow had a decreasing prevalence in 1985–91. This is an illustration of a general epidemic situation, and does not illustrate any effect of NSPs. In Fig. 2, during the period 1980–84 of increasing epidemics, measurements were mainly for cities without NSPs. In the period 1985–92 measurements for cities both with and without NSPs were included. The second possible confounder, the level of known HIV seropositivity among IDUs, is not recognized in the studies. Regardless of mode of transmission, HIV counselling and testing has been suggested as a tool to reduce risk practice [10-12]. HIV testing and counselling practice regarding IDUs was present in most cities after 1985, often combined with an NSP. This makes it difficult to identify which measure was most important for the reduction in HIV seroprevalence, or the contribution of each. The three studies recognize the identification problems by saying that implementation of NSPs was almost certainly confounded by implementation of other HIV prevention strategies, Hurley et al. [3] mentioning the sale of injection equipment through pharmacies as a possible competitor and MacDonald et al. [5] mentioning provision of condoms, education about minimizing risk and referrals to drug treatment centres. A study of HIV among IDUs in the three Scandinavian countries, the only study that compares several parallel prevention measures, suggests that a high level of testing and counselling was more efficient to reduce HIV transmission than free and legal access to needles and syringes/NSP [9]. In Norway and Sweden IDUs were tested frequently from 1985 onwards and the level of known HIV seropositivity was high. In Denmark, IDUs were not as willing to take HIV tests and the level of known seropositivity was lower. After the peak in 1985/86 in all three countries the epidemic stabilized at a higher level in Denmark compared with Norway and Sweden, even though Denmark had free and legal access to needles and syringes. There was no legal access to needles and syringes in Sweden. The study by Hurley et al. [3] comprised 81 cities, while MacDonald et al. studied 99 cities and the HOI report [6] 103 cities. The criticism presented is relevant for all reports. Including more cities does not render superfluous the lack of controlling for the stage of the epidemic or the level of known seropositivity. Based on these aspects or shortcomings, the published conclusions are probably too strong and not justified in the articles. A reanalysis should be performed, removing the cities where the measurements were made before 1985. In this period hardly any knew their HIV status and an increasing incidence/prevalence was associated most probably with no NSP; otherwise, the stage of the local epidemic at the time the NSP was introduced should be controlled for in a reanalysis. The level of known HIV seropositivity for the NSP attendees or, alternatively, the level of HIV testing activity among IDUs should also be controlled for. So far, however, this scientific criticism cannot be interpreted in favour of a lack of effect of NSPs. The problem of identification of the working mechanism(s) in NSPs and HIV testing and counselling to reduce risk behaviours should be acknowledged more fully. More effort should be used in establishing relevant study designs and better specifications of hypotheses. Perhaps HIV testing and counselling is a better tool? We simply do not know. While waiting for new knowledge, NSPs should certainly be on the harm reduction palette of possible measures preventing HIV, but its status as the superior tool may be questioned." @default.
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• W2140047650 date "2006-07-01" @default.
• W2140047650 modified "2023-09-26" @default.
• W2140047650 title "Measuring effectiveness of needle and syringe exchange programmes for prevention of HIV among injecting drug users" @default.
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