Evidence for what? That sterile equipment does not transmit bloodborne viruses? For the number of transmissions after the injections of the products you are interested in? For the frequency of transmission-prone behaviour in those people, or the prevalence of blood-borne viruses in this specific population?

I suggest you look for evidence on the risk side; this will by itself answer the public health benefits question.

Interesting question. I must say in the cultural environment where I work in, the questions have been raised whether such needle-providing services are ethical in the first place. One generic difference I would like to point out in IVDU vs performance enhancer abusers is that the former are prone to share needles to a greater extent and for a larger number of times thus exposing them to a greater risk. These are just conjectures though. Also, depending on the country where the athlete works in, the legal environment, and the hush-hush nature of the act, risks of virological disease transmission appears low as it is!

G'day Pranab,

The ethical or moral discussion about needle and syringe programs (NSP) will continue as long as use of some drugs is illegal and socially disapproved of, however the scientific argument as to their effectiveness is well and truly over.

In Australia we have been operating NSP since 1987, and the programs have been credited with saving our public health systemn billions of dollars. Here are return on investment studies examining Australian NSP;

http://www.health.gov.au/internet/main/publishing.nsf/Content/E1027EFEC83DA846CA257650007AC419/$File/roisum.pdf

.

http://www.kirby.unsw.edu.au/sites/hiv.cms.med.unsw.edu.au/files/hiv/attachment/RO-2ReportLQ.pdf

.

Here's the UNODC assessment of NSP;

http://www.unodc.org/documents/hiv-aids/EFA%20effectiveness%20sterile%20needle.pdf

.

In the first 10 years of NSP in Australia, we spent $150million (Australian). The lowest estimate of savings (in terms of prevented cases of HIV and HCV) was $2.5bilion, the highest estimate was about $7.5billion.

Even at the lowest end of this range, that makes NSP the single most cost effective public health initiative ever. The HIV rate amongst our injecting drug using population has never risen above 1%, (currently 0.8%), and we have correspondingly low levels of HIV in the general population as well. Public Health initiatives (NSP and safe sex education) implemented in the mid to late 1980s averted the HIV epidemics that have ravaged most of our neighbour countries.

The sum of scientific evaluations clearly demonstrate that NSP does not increase the per-capita rate of injecting, but it does dramatically reduce the incidence of blood-borne virus (BBV) transmission and of non-viral infections and injuries. It also links people engaging in an illicit and secretive activity with health workers, drug treatment and welfare agencies. That's why the World Health Org recommends that any country with an injecting drug-using population should implement NSP;

http://ecdc.europa.eu/en/publications/Publications/111012_Guidance_ECDC-EMCDDA.pdf

.

Hi Jim,

Thanks for posting this. This is a timely question for me, as we are currently seeing an emerging trend in most western countries of steroid use amongst some young men who do not use any other injecting drugs. These are not the stereotypical "juicers" or "gym-junkies", they are almost always men, mostly in their early to mid twenties, who are planning on doing one or two courses of steroids to "tone up". They are well groomed and obviously very concerned with body-image. It appears that amongst this cohort steroid use is becoming as normalised as collagen injections or botox has become amongst some young women.

We have very little information about this emerging population, or about the possible implications of this trend. All of our research about injecting drug use focuses on users of psychoactive drugs like heroin, morphine, cocaine and methamphetamine.

Pranab is correct in stating that intravenous drug users typically have longer injecting careers than steroid users. However our research in Australia shows that most people who contract HCV do so in the first 18 months of that injecting career.

And contrary to Pranab's comments, in a country like Australia where we have been running NSP and harm reduction education for many years, and where we have quite good coverage geographically with our NSPs, most injecting drug users are well educated about BBVs and are very reluctant to share equipment. Conversely, the young steroid users I am seeing in my work are generally very poorly educated about the risks of injecting. Most of them are buying the steroids on-line, and sourcing all their advice about how to use them etc in the same way. Generally they are complete new comers to injecting, and have little or no knowledge about how to do it aseptically etc. They also tend to think of what they are doing as being very different to what "junkies" do, and they tend to be reluctant to engage with NSP services because of the prejudices people have against injecting drug users.

In terms of the effectiveness of NSP for this cohort;

I would point out that steroids are administered via intramuscular injection, (IM), not intravenous injection, (IV), and that IM has a somewhat lower chance of transmitting any BBV than IV. However there is still a real risk of BBV transmission if steroid users are sharing equipment, and there is also a risk of serious fungal or bacterial infection when people re-use their own equipment.

I would also point out that if NSP can effectively engage with this population, we can better educate them about the risks involved in the practice and how to minimise them. We can teach them how to perform intramuscular injection without risking nerve injury or infection and we can ensure that they understand how steroids work and the importance of cycling the 'roids and good nutrition.

So as well as reducing the incidence of BBV transmission, if NSP can effectively engage with these populations there will be other public health cost benefits.

This study comes from BBV and injecting behaviour surveillance conducted annually in Australian NSPs.

http://content.ebscohost.com/pdf9/pdf/2008/57J/01Sep08/33622461.pdf?T=P&P=AN&K=33622461&S=R&D=aph&EbscoContent=dGJyMMTo50SeqK44v%2BbwOLCmr0qep69Ssq%2B4SLWWxWXS&ContentCustomer=dGJyMPGssk2xqLJNuePfgeyx44Hy

.

Between 1995 and 2004 only 1.6% of surveyed NSP users were identified as steroid users, and this proportion remained stable over this 10 years.

I have been working in the largest NSP in Western Australia since 1999, and this is consistent with our experience. However we have seen a very significant increase in the last three years. (Oil based steroids are injected with a much larger gauge needle than water-soluble drugs like opioids or amphetamines. We can judge the percentage of steroid users by examining the through-puts of our needle exchange).

Over the past six months the %age of interactions where people were buying or exchanging equipment for steroid use has ranged between 9 and 12%.

I would be very grateful of links to any international research into addressing this issue.

Cheers,

Paul.

I would add perhaps an additional perspective in that: 1. There are some data about hormone injection among transgender populations which is different than the typical IDU injecting other illicit drugs. Also the hormones may not be illegal for the individual. The problem is that transgenders may be at higher risk for HIV infection through sexual risk behavior so it is difficult to tease out the residual effect of hormone injection. The second issue is that we did publish the results (at least some of the results) of the only randomized clinical trial of needle exchange ever conducted. We found that use of the needle exchange was not associated with any increase in injection drug use frequency. Not even a little bit., HTH

Paul,

Fascinating data and information. Thanks for the detailed answers and brilliant arguments. I do agree that NSP is a great public health initiative, but I just wanted to point out that the cultural environment in India is a little hostile for the wholesale implementation of this program.

The "tone-up" gym-goers that you speak of, who are poorly documented and researched, is also very interesting. Their injection practices also need to be looked into. I did some searching on this but the evidence lies thin. Some anecdotal evidence I heard from my colleagues in sports medicine would indicate that a bigger menace is post-injection abscess and simple local bacterial infections rather than the systemic BBV.

Poor injection methods, leading to inoculation of skin commensal onto injection site will not be solved by NSPs. In fact, this being a largely illegal or barely-legal activity, the surreptitious administration of the juice-drugs by complicit, poorly-trained personnel is to blame for these complications.

Thanks for the stimulating discussions. I plan to put up the topic of NSP in our department for debate and discussion at our brown bag club, and your arguments have really bolstered my knowledge of the issue.

Cheers!

Hi Pranab,

Thanks- it's always nice to get positive feedback.

Historically, non-viral infection and injury caused by injecting drug use (IDU) has been relatively neglected by researchers and by policy makers. Attention has been almost entirely focused on HIV and other BBVs, and on cns depressant overdoses and stimulant toxicity.

Non-viral (bacterial or fungal) IDU related infections include;

“DIRTY” HIT,

CELLULITIS,

ABSCESSES,

SEPTICAEMIA,

GANGRENE,

ENDOCARDITIS,

OSTEOARTICULAR INFECTION

ENDOPHTALMITIS

IDU related injuries include;

NERVE DAMAGE

PULMONARY or CARDIAC TALCOSIS,

THROMBOSIS/THROMBOPHLEBITIS,

BRUISING/TRACK MARKS,

INTERNAL BLEEDING,

ANAPHYLAXIS

(Sorry for the caps- I'm not shouting, I just cut and paste this text from one of my powerpoint presentations that we use when training health workers about IDU).

Some of the injuries and infections I've listed above, if untreated, can kill you a lot faster than HIV or HCV will.

If you can access the full text of this article it contains a concise overview of viral, bacterial and fungal infection associated with injecting drug use;

http://www.ncbi.nlm.nih.gov/pubmed/21389334

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Here is an attempt to measure the public health costs of non-viral infections and injury caused by IDU;

http://www.ncbi.nlm.nih.gov/pubmed/19689596

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The cost of treating a case of (say) infective endocarditis is much less than that of treating a case of chronic HIV or HCV, but it is not negligible- (treating endocarditis typically requires ~8 weeks hospitalisation, and often by the time the infection is diagnosed the top right heart valve is damaged and requires repair or replacement).

http://archinte.jamanetwork.com/article.aspx?articleid=585127

I tend to agree that for most steroid injectors, bacterial infection may be more likely than BBVs, but we are aware of people who use steroids and IV drugs as well, or who have a previous history of IV use, and we are also aware of some cohorts of steroid users who inject each other and reuse each others' equipment.

Some of these problems (like pulmonary or cardiac talcosis http://www.ajronline.org/content/174/3/789.full) are not going to occur in people who only inject IM.

Others, (like endocarditis or osteoarticular infections) are less likely in IM injectors than IV users, but can still occur as a sequelae to bacterial abscess.

When researchers have phage-typed bacteria sampled from injection-related infections, they are almost always commensal strains from the patient's skin, mouth or nasal cavity, (as you have pointed out, above). The most common bacteria in these infections are types of staph or strep, the most common fungal infection is candida.

I will disagree with Pranab on one point;

These types of infections are not an unavoidable consequence of non-medical injecting. They are caused by poor injecting hygiene and by use of equipment that is not sterile.

NSP services (including peer-education) are cheap to implement and can have a very dramatic impact on the incidence of these sorts of problems.

If someone is taught how to inject in an aseptic fashion, and has ready access to sterile equipment, they are extremely unlikely to suffer any form of bacterial or fungal infection.

And if someone is taught to identify abscesses and seek antibiotic treatment promptly, infections will not progress to the point where the bugs are forming colonies in organs or joints etc.

Dependent injecting drug users may occasionally resort to "second best" practice and re-use or even share equipment out of desperation (when in withdrawal, or when in prison where sterile equipment can't be found).

In contrast, steroid users are following a plan. They know how many injections they are going to have, and when, well in advance. Well designed interventions targeting this cohort of drug users should be able to dramatically reduce the harms and hazards associated with "juice".

Paul.

Re: N+S programs, HIV and HCV transmission, there is a good discussion here;

http://findings.org.uk/count/downloads/download.php?file=Kwon_JA_2.txt

.

If you haven't been to "Findings" before, it's an excellent resource. The site summarizes the scientific literature on a whole range of alcohol and drug issues, and it's quite easy to search specific topics. Check out the links to "top 10 most closely related documents" that follow the entry.

Also see;

http://www.health.gov.au/internet/main/publishing.nsf/Content/E1027EFEC83DA846CA257650007AC419/$File/roisum.pdf

.

and

http://www.unodc.org/documents/hiv-aids/EFA%20effectiveness%20sterile%20needle.pdf

.

Paul.

Magdalena Zimová [email protected]

It's an interesting question. Exchange of needles and syringes in terms of public support in this area do not deal . Needles and syringes are exchanged only for drug addicts

Hi Magdalena,

I work in the largest needle exchange in Western Australia. We don't care what substance someone is injecting- we just want them to have access to appropriate equipment and education.

I also have to point out that not all people who inject drugs illegally are dependent on those drugs- so they are not all "drug addicts", they are just people who use injecting drugs.

However the vast majority of research in the published literature is examining injecting use of psychoactive drugs, not of substances such as anabolic steroids, and this is the focus of almost all published evaluations of n+s programs. Most n+s programs have been set up to engage with people who inject psychoactive drugs, and most are set up to target the most dependent and most marginalised injecting drug users, so they may need to take different approaches to engage with steroid users.

In places where injecting use of steroids is becoming more common, we need to research the scale of the issue, and gather the data that will allow us to set up projects that will engage effectively with steroid users, (examples might include recruiting and training peer educators who have used steroids, using on-line forums and other approaches etc).

Paul.

Paul, I am not aware of any active NSP in my country/area of practice. so I was wondering about a legal question: how do we approach a situation where we know that someone is using an illegal substance (that we need to report to the police or other authorities) who needs to be a part part of an NSP? I know I am possibly digressing from the main question (in fact I am quite sure I am), but I was just thinking about what would be the way to go...

Hi Pranab,

I'm always happy to digress tangentially!

Are you based at UCMS in Delhi?

>>

http://www.unodc.org/documents/southasia//publications/research-studies/NSEP_print_ready_file.pdf

.

siteresources.worldbank.org/.../Resources/AnandGrover.pps

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This document examines recent progress in the region, (although confusingly the HIV prevention strategies are called "National Strategic Plans+ or NSP, which is also the abbreviation for Needle and Syringe Programs, it does talk about N+S Ps as part of seven of the ten countries' NSPs).

http://aidsdatahub.org/dmdocuments/NSP_Review_10_Countries_Aug_2012.pdf

.

Australians tend to be pragmatic rather than idealistic- we introduced N+S programs in the mid to late 1980s and the vast majority of Aussies approve of N+S provision and methadone/buprenorphine programs, even though the majority of us disapprove of injecting drug use.

In Australia, only trained and licensed people can legally distribute injecting equipment, but possession of sterile equipment is not an offence.

Possession of any illicit drug (even the traces of drug left in a used syringe), and self administration of non-prescribed drugs remain criminal offences, but Police never charge people for these offences any more (unless there are very unusual circumstances) because prosecutors and judges tend to see it as a waste of time and resources to pursue.

Police have policies of not targeting n+s programs, again because it is viewed as not productive in terms of preventing serious crime, and as counterproductive in terms of improving public health.

Here in Western Australia, we operate drug courts and Police also have the option of diverting people caught with small amounts of drugs into treatment, rather than laying criminal charges.

Drug courts;

http://www.courts.dotag.wa.gov.au/D/drug_court.aspx

.

http://www.dao.health.wa.gov.au/Informationandresources/WADiversionProgram/DrugCourt.aspx

.

Cannabis Infringement Notices are civil penalties, not criminal ones, that WA Police can employ instead of a criminal charge for possession of small amounts of cannabis;

http://ndri.curtin.edu.au/local/docs/pdf/publications/T177.pdf

.

WA Police also have the discretion to refer people to treatment, rather than charge them with possession of other drugs;

http://www.dao.health.wa.gov.au/Informationandresources/WADiversionProgram/AllDrugDiversion.aspx

All of these policies required considerable advocacy and education with key stakeholders, especially police, to implement.

Paul.

This is such a brilliant example of law and public health coming together to complement each other! Yes, I am based in New Delhi.

The Honorable Health Minister Shri Ghulam Nabi Azad, in a World AIDS Day press release gave out the numbers related to HIV/AIDS and though India has substantially reduced the new case incidence and all other parameters (including "high risk" groups like MSM and CSW), the prevalence of HIV in the IVDU has not been reduced significantly. If anything, there may be an overall increase in numbers despite a small reduction in the prevalence. This has been attributed to poor planning and implementation of the needle sharing and other preventive programs.

I am not sure whether illicit drug use is a civil offense in India. Given my limited knowledge, it might be a criminal charge, and non-reporting, in that case, would also mean harboring, aiding and abetting a criminal!

If India has to make a positive dent in the HIV numbers, especially in the iVDU, then, we need to quit the squeamishness and take bold steps.

However, I wonder how this radical step will affect a multi-ethnic, multi-cultural, multi-party-politics nation as India! Interesting outcomes in Sociology of Public Health!

Regards.

Thank you for all your responses to the question. We are about to conduct a systematic review on behalf of NICE in the UK on the optimal provision of needle and syringe programmes for people who inject anabolic steroids and associated drugs. I will post the results on here when the work is completed.

Thanks again

Jim

Thanks Jim,

Anything you can share would be very useful for us here at WASUA.

Paul.

I have done research in the area of return rates of used needles associated with the use of needle exchange programs. Also, I conducted a meta-analysis of a variety of risk reduction benefits associated with needle exchange programs, which speaks to the public health benefits. You might want to check out the follwing articles:

Ksobiech, Kate. (2004). Return rates for needle exchange programs: A common criticism answered. Harm Reduction Journal, 1(2), http://www.harmreductionjournal.com/content/1/1/2.

Ksobiech, Kate. (2003). A meta-analysis of needle sharing, lending, and borrowing behaviors of needle exchange program attenders. AIDS Education and Prevention, 15, 257-268.

Regards,

Kate Ksobiech

Thanks Kate,

Paul.