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First, do harm reduction

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Science  11 Jul 2014:
Vol. 345, Issue 6193, pp. 156-158
DOI: 10.1126/science.345.6193.156

Australia's aggressive efforts to stop HIV's spread via injecting drugs averted a catastrophe.

Shortly after a test for HIV came to market in 1985, researchers at St. Vincent's Hospital in Sydney looked for the virus in 200 people receiving treatment for addiction to heroin and other injection drugs. At that point, the small but frightening AIDS epidemic was concentrated in gay men, and only one drug user tested positive. But a closer examination of this man's sexual and needle-sharing contacts, who were not in the initial study, told a more unsettling story: Four of six people tested had the virus. “That study was a real call to action,” says Alex Wodak, director emeritus of the hospital's alcohol and drug service. “We knew that we had to do something quickly and what we did had to work.”

Wodak convened a meeting of people who injected drugs and professionals who worked with them. “Everybody in the room had exactly the same focus and obsession,” Wodak says. “We all wanted to stop the epidemic. And we were all prepared to do whatever it took.” They collectively agreed on what was then a radical plan: They would launch needle and syringe exchange programs as widely as they could to provide clean equipment to users. This was in violation of the country's drug laws, but they so fervently believed in what today is called harm reduction that they decided to take the risk.

The program began in November 1986, and the police vice squad soon called in Wodak, the public face of the effort, for a grilling. “I spoke without pausing for breath and explained to them that this was a serious issue,” Wodak recalls. He barraged the police with statistics about how quickly HIV can spread among people who inject drugs, infecting 50% of a needle-sharing population within 6 months and dramatically accelerating sexual spread. Contaminated needles and syringes, not drugs, transmit viruses, he stressed. A senior policeman then pulled Wodak aside and told him that they wouldn't be pressing charges. “I knew then that we had won,” Wodak says.

Had they ever.

When it comes to HIV infections in people who inject drugs, “we have the most boring graph in the world,” says epidemiologist John Kaldor of the Kirby Institute for Infection and Immunity in Society, a branch of the University of New South Wales in Sydney. In many of Australia's neighboring countries, including Indonesia and Malaysia, people who inject drugs account for a high percentage of infections. But in Australia, only 17 out of 3490 injecting drug users who received yearly HIV tests between 1995 and 2012 became infected, Kaldor and his colleagues reported in the 14 January issue of AIDS. The Kirby Institute's latest annual HIV surveillance report found that between 2008 and 2012, injecting drug use accounted for just 2% of new HIV diagnoses in Australia. Men having sex with men accounted for most new diagnoses (67%), followed by heterosexual sex (25%).

By 1987, the state of New South Wales endorsed needle and syringe programs, and in 1989, the first national HIV/AIDS strategy plan said this would be a key component of the country's response. Overall, needle and syringe programs had averted more than 57,000 HIV infections by 2009, according to Australia's Department of Health and Ageing. Between 2000 and 2009, the country's investment of just over US$200 million had saved US$1.2 billion in health care costs.

Today, Australia has more than 3000 sites that distribute some 30 million needles and syringes to drug users each year. The U.S. government, in contrast, bans funding of similar programs, although about 200 sites operate legally in various states. According to the U.S. Centers for Disease Control and Prevention, 16% of the people living with HIV in the country were infected by sharing needles and syringes.

Australia's early embrace of HIV harm reduction strategies was sparked in no small part by a “national psychodrama” that was playing out at the time, Wodak says: When the AIDS epidemic emerged in Australia, the prime minister's daughter was battling heroin addiction. Other factors entered in as well. Neal Blewett, the minister of health, rallied bipartisan support for a strong HIV/AIDS response and included representatives from the drug-using community in the discussions. And Wodak believes that Australia's history as a British penal colony helped, too. “Convicts are practical people—they're not ideologues,” he says.

The Australian government soon went beyond its support of needle and syringe programs, allowing a center to open in 2001, under the auspices of a church group, where users could inject drugs with clean equipment under medical supervision—without fear of prosecution. Located near a busy subway stop, the Sydney Medically Supervised Injecting Centre (MSIC) was the first facility of its kind outside of a few European countries, and the feedback from clients has been overwhelmingly positive, says the center's medical director, Marianne Jauncey. “The single starkest, most commonly repeated phrase is, ‘Thank you for treating me like a human being,’” Jauncey says.

Marianne Jauncey, a physician, oversees an injection center where people can fix in a safe environment.

PHOTO: MALCOLM LINTON

A series of independent reviews has found that MSIC has delivered on its promise. The latest, published by the accounting firm KPMG in 2010, found that the center had supervised more than 600,000 injections, referring about one-third of its clients to drug treatment. It managed nearly 3500 overdoses without a single death and saved the health system some US$600,000 per year. Since the site's opening, HIV infection rates have dropped in the nearby neighborhoods, although the review did not have enough data to link MSIC to the decline.

Video

Harm reduction in Australia, http://scim.ag/hiv2014.

Australia's harm reduction effort has had its limits, which the hepatitis C virus (HCV) spotlights. HCV is transmitted by needle and syringe sharing much more easily than HIV is, and it was already widespread when harm reduction efforts began for HIV. According to Department of Health and Ageing estimates, this liver-damaging virus had infected more than 80,000 people by 1986. That number grew to 200,000 by 2000, despite needle and syringe programs. Yet, without those programs, the country would have faced a much larger HCV epidemic: The health department estimates that they prevented more than 100,000 new HCV infections.

Harm reduction programs for both HIV and HCV also overlooked some marginalized populations for a time. A study published in the October 2006 issue of Addiction found few services were available for “ethnic minorities”—a group that included indigenous Australians and immigrants from Vietnam and other Southeast Asian countries—who injected drugs in Sydney and in less urban sites around New South Wales. “It was a harm reduction nightmare,” says Lisa Maher, an epidemiologist at the Kirby Institute who led the study. Over 3 years, 31% of the ethnic minorities in the 368-person study became infected with HCV, a rate three times higher than seen in the non–ethnic minority group. Needle and syringe programs and the accompanying health services for people who inject drugs have since expanded to these communities.

Wodak stresses that harm reduction can only do what its name implies. “We're happy to make a bad problem less bad,” Wodak says. “We don't have to eradicate the problem in order to feel that we've succeeded.”

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