Monitoring quality and coverage of harm reduction services for people who use drugs: a consensus study.

BACKGROUND AND AIMS: Despite advances in our knowledge of effective services for people who use drugs over the last decades globally, coverage remains poor in most countries, while quality is often unknown. This paper aims to discuss the historical development of successful epidemiological indicators and to present a framework for extending them with additional indicators of coverage and quality of harm reduction services, for monitoring and evaluation at international, national or subnational levels. The ultimate aim is to improve these services in order to reduce health and social problems among people who use drugs, such as human immunodeficiency virus (HIV) and hepatitis C virus (HCV) infection, crime and legal problems, overdose (death) and other morbidity and mortality. METHODS AND RESULTS: The framework was developed collaboratively using consensus methods involving nominal group meetings, review of existing quality standards, repeated email commenting rounds and qualitative analysis of opinions/experiences from a broad range of professionals/experts, including members of civil society and organisations representing people who use drugs. Twelve priority candidate indicators are proposed for opioid agonist therapy (OAT), needle and syringe programmes (NSP) and generic cross-cutting aspects of harm reduction (and potentially other drug) services. Under the specific OAT indicators, priority indicators included 'coverage', 'waiting list time', 'dosage' and 'availability in prisons'. For the specific NSP indicators, the priority indicators included 'coverage', 'number of needles/syringes distributed/collected', 'provision of other drug use paraphernalia' and 'availability in prisons'. Among the generic or cross-cutting indicators the priority indicators were 'infectious diseases counselling and care', 'take away naloxone', 'information on safe use/sex' and 'condoms'. We discuss conditions for the successful development of the suggested indicators and constraints (e.g. funding, ideology). We propose conducting a pilot study to test the feasibility and applicability of the proposed indicators before their scaling up and routine implementation, to evaluate their effectiveness in comparing service coverage and quality across countries. CONCLUSIONS: The establishment of an improved set of validated and internationally agreed upon best practice indicators for monitoring harm reduction service will provide a structural basis for public health and epidemiological studies and support evidence and human rights-based health policies, services and interventions

Surveillance of HIV-infections in the region of Arnhem. Part 2: Monitoring of laboratory tests for HIV-infection, April 1989-June 1991

In collaboration with the Regional Public Health Laboratory (RPHL), the Rijnstate Hospital and the Monucipal Health Service, a comprehensive program for surveillance of HIV infections in the Arnhem area is carried out. This program consists of three parts: (1) monitoring of laboratory tests for HIV infection, (2) a continuous questionnaire on indications and the risk factors for HIV infection to physicians requesting testing, and (3) surveys on the prevalence and the risk factors for HIV infection in specific populations. More than 40% of HIV tests are done for life assurance purposes. Over half of all tests for clinical purposes are requested for by general practitioners. A large proportion of tested individuals are sexually active heterosexuals without other reported risk factors. Relatively few homo/bisexual men and intravenous drug users are tested, whereas in these groups most infections are found. Data by risk group can be viewed only as estimates of the prevalence among selected subgroups. These data should be interpreted jointly with surveillance data from other sources, such as the surveys among homosexual men, drug users and pregnant women, that are carried out in collaboration with the Municipal Health Services and others. Taken together the surveys and the monitoring system prove to be a powerful means of gaining insight into the spread of HIV infection at the regional level. It is possible to expand the monitoring system in a relatively easy way to other infectious diseases.Programma coordinatiecommissie voor het AIDS-onderzoek van de Raad voor Gezondheids-onderzoek(RGO/PCCAO)

Surveillance van HIV-infecties in de regio Arnhem. Deel 2: Monitoring van laboratoriumdiagnostiek naar HIV-infecties, april 1989-juni 1991

In collaboration with the Regional Public Health Laboratory (RPHL), the Rijnstate Hospital and the Monucipal Health Service, a comprehensive program for surveillance of HIV infections in the Arnhem area is carried out. This program consists of three parts: (1) monitoring of laboratory tests for HIV infection, (2) a continuous questionnaire on indications and the risk factors for HIV infection to physicians requesting testing, and (3) surveys on the prevalence and the risk factors for HIV infection in specific populations. More than 40% of HIV tests are done for life assurance purposes. Over half of all tests for clinical purposes are requested for by general practitioners. A large proportion of tested individuals are sexually active heterosexuals without other reported risk factors. Relatively few homo/bisexual men and intravenous drug users are tested, whereas in these groups most infections are found. Data by risk group can be viewed only as estimates of the prevalence among selected subgroups. These data should be interpreted jointly with surveillance data from other sources, such as the surveys among homosexual men, drug users and pregnant women, that are carried out in collaboration with the Municipal Health Services and others. Taken together the surveys and the monitoring system prove to be a powerful means of gaining insight into the spread of HIV infection at the regional level. It is possible to expand the monitoring system in a relatively easy way to other infectious diseases.<br

Surveillance of HIV infections among drug users; a feasibility study in Deventer

Abstract niet beschikbaarIn the western world, intravenous drug users are the second most important risk group for AIDS after homosexual men with multiple partners. Because of the long incubation period of AIDS, research on the prevalence of HIV in risk groups can lead to a considerable gain in time with regard to the formulation of care and prevention policies. Until now in the Netherlands prevalence studies among drug users have almost exclusively been done in Amsterdam. Therefore, little is known about the spread of HIV among drug users across the country. This study was initiated to investigate the feasibility of (regularly repeated) prevalence studies among drug users. Of special importance was to ascertain to what extent drug users in general and hidden groups in particular could be reached using care facilities as an entrance. Apart from that the study generates data on prevalence of HIV infections and HIV-related risk factors in a population of drug users outside the urbanized Western part of the country. In this study a recently developed saliva test for antibodies against HIV is used. It was attempted to reach all hard-drug users, both injecting and non-injecting, in the population. This was done to be able to study selections, that occur when studying sub-populations, and to be able to study sexual risk behaviour independently of risk related to injection of drugs. Deventer, a provincial town in the Eastern part of the country, was selected as research site on the basis of population size, the number and type of care facilities, and comparability with a simultaneous project among drug users in Alkmaar. The most important findings are: 1 Given the fruitful collaboration prevalence research among drug users, using local care facilities as an entrance is well possible. 2. Prevalence research in collaboration with care facilities can offer advantages with respect to the acceptability for care givers and participants and repeatability. 3. Hidden groups, not reached by care facilities, can still be reached by this approach. Realistic estimates of the number and characteristics of the whole population are possible through nomination techniques. 4. The prevalence of HIV infections among drug users in Deventer is low: 0-2.6% in general and 0-5.3% among intravenous drug users. This low prevalence is probably representative of the prevalence among drug users outside the urbanized Western part of the country. 5. Sharing of needles and syringes is uncommon in Deventer. Sexual risk is more common among women, drug users with little education, and among drug users currently or ever under methadone treatment. Injecting drug users are older, more often have a history of prostitution and make more drug-related travels to other cities.PCCAO WVC (Programma coordinatie Commissie AIDS Onderzoek van de Raad voor Gezondheidsonderzoek

[Laboratory surveillance of HIV infections in the Arnhem region, 1989-1993.]

In the Arnhem area, with 830.000 inhabitants, the RPHL is the only laboratory performing anti-HIV tests. In the automated administration of the RPHL all relevant (standard) information on the HIV test, the physician requesting testing and the tested individual are selected for anonymous analysis. Between April 1989 and July 1993 12,219 anti-HIV tests (252 or 2.1% positive) were performed for 10,972 individuals (86 men and 21 women, i.e. 1.0% positive). In 41.6% testing was done for screening purposes, usually for life assurances (1/3,434 seropositive), and these are disregarded in subsequent analyses. Heterosexual risk behaviour was the reason for the test in 2,477 out of 4,818 tests for clinical purposes ; seven infections were found in this group: 3 out of 47 persons with a seropositive partner, 3 out of 460 with a partner in a risk group and 1 out of 1,970 with multiple heterosexual partners. Although only 13.8% of the tests were performed among homo/bisexual men, 50.7% of all infections were found in this group (34 out of 336 homosexual men tested, seroprevalence 10.1%). Among 169 intravenous drug users, 6 infections were found (3 men and 3 women, seroprevalence 3.6%). Among 312 persons who stayed in HIV-endemic areas, 4 were infected (seroprevalence 1.3%). The methodology used in this surveillance programme allows for extension to other regions and other infectious diseases.RGO/PCCA

Laboratory-based surveillance of HIV-infections in the Arnhem area, 1989-1994

In de regio Arnhem vinden sinds april 1989 een aantal surveillance-activiteiten voor HIV-infecties plaats. Dit rapport presenteert de resultaten van vijf jaar monitoring van laboratoriumdiagnostiek van HIV-infecties aangevuld met een continue enquete naar de indicatie voor de test bij alle aanvragers van deze diagnostiek. Van april 1989 tot en met juni 1994 zijn 16.411 testen verricht voor 14.715 personen uit het verzorgingsgebied van het Streeklaboratorium Arnhem (SLA). Het percentage geinfecteerde personen (1,0%, n=140) was bijna twee keer zo klein als het percentage positieve testen (1,8%, n=303). Het aantal positieve personen nam niet toe in de tijd, alhoewel het aantal aangevraagde testen wel sterk is gestegen. Dit werd hoofdzakelijk veroorzaakt door een stijging in testaanvragen vanwege "wisselende heteroseksuele contacten". Sinds de start van de enquete in 1990 zijn 13.002 personen getest, waaronder 114 seropositieven. Door de enquete is van 88% van deze personen de reden voor testaanvraag bekend. Van de personen werd 38,3% getest op verzoek van derden, meestal in het kader van een keuring voor een (levens)verzekering. Onder deze testen werden twee infecties (0.05%) aangetoond. Er werden 3835 mannen en 3220 vrouwen getest met een medische reden waarvan 1,3% positief werd bevonden. Bij mannen werden de meeste infecties waargenomen onder homo/biseksuelen: 9,7% seropositief. Per kalenderjaar varieerde dit percentage van 6% tot 10%. Ook onder de intraveneuze druggebruikers werden relatief veel infecties aangetoond: 4,2% van de mannelijke druggerbuikers was positief en 5,8% van de vrouwelijke. Circa 44% van de mannen en 59% van de vrouwen met een test op medische indicatie werden getest vanwege heteroseksueel risicogedrag. Het percentage infecties dat in deze groep werd gevonden was echter laag: 0,2% en 0,3% van deze mannen resp. vrouwen. Er was geen trend zichtbaar in de heteroseksuele verspreiding over de 5 jaren. Dit alles wijst erop dat de verspreiding van HIV-infecties zich nog steeds met name in de bekende risicogroepen voordoet ; aanwijzingen voor aanzienlijke transmissie in de algemene bevolking werden niet gevonden.From april 1989, surveillance-activities of HIV infections are carried out in the Arnhem area. This report presents five years of monitoring of laboratory diagnostics of HIV infections, in addition to a continuous questionnaire on the indication for testing sent to the requesting physicians. Between April 1989 and June 1994 16,411 HIV tests were performed in 14,715 individuals living in the service area of the Arnhem Regional Public Health Laboratory (RPHL). The percentage of positive tests (1.8%, n=303) was almost twice the percentage of positive persons (1.0%, n=140). No increase in number of new infections was observed over time, although the number of requested tests dramatically increased. This was mainly caused by a sharp increase in the number of tests for "changing heterosexual contacts". Since the start of the questionnaire in January 1990, 13,002 individuals were tested, of which 114 were HIV-positive. Information about the indication for testing was available for 88% of these individuals. The non-reponse on the questionnaire increased till the second half of 1993, but subsequenltly decreased again. Of individuals, 38.3% were tested due to third party requests, mainly for taking out a life insurance. HIV was demonstrated twice (0.05%). Tests at medical indications were performed for 3835 men and 3220 women, 1.3% of these tests were positive. Most infections in men occurred among homo/bisexuals: 9.7% seropositive. This percentage fluctuated between 6 and 10% in separate calendar years. Among injecting drug users 4.2% and 5.8% of male and female drug users resp. tested positive. About 44% of males and 59% of females tested for medical indications were tested due to heterosexual risk behaviour. However, the number of infections was low: 0.2% and 0.3% of resp. males and females was HIV-positive. No trend in heterosexually acquired infections could be observed over the five years. It appears that the spread of HIV is still restricted to known risk groups: signs for considerable spread in the general population could not be found.RIV

HIV-infection and risk behavior among transvestite and transsexual street prostitutes in Rotterdam

Doel van de studie was het vaststellen van de HIV-prevalentie en de mate van spuitgerelateerd en seksueel risicogedrag, en het verkrijgen van inzicht in de bekendheid met en het gebruik van preventie-activiteiten. Dit onderzoek maakte deel uit van een onderzoek naar de HIV-prevalentie onder druggebruikers in Rotterdam (eind 1994). Daarin werden ook travestieten en transseksuelen in de straatprostitutie die hormonen of siliconen gebruikten opgenomen. Toen bleek dat dit om een behoorlijk grote groep ging is de vragenlijst met enkele voor deze groep specifieke vragen uitgebreid. Bij alle deelnemers zijn speekselmonsters afgenomen en getest op anti-HIV 1/2. Deelname aan het onderzoek was vrijwillig en anoniem. Alle deelnemers waren biologisch van het mannelijk geslacht. De HIV-prevalentie in deze groep bleek laag (8%) vergeleken met studies uit andere landen. Intraveneus druggebruik speelt geen rol in deze groep. Ook bij het spuiten van hormonen/siliconen lijkt riskant gedrag weinig voor te komen. Mogelijk loopt deze groep travestieten en transseksuelen risico door commerciele- en privecontacten met homo/biseksuele mannen. Onbeschermde seks vindt vooral plaats met de vaste partners. De bekendheid met en het gebruik van preventieve maatregelen tegen AIDS zijn hoog.The Objective of the study was to determine the prevalence of HIV infection and the level of injecting and sexual risk behaviour, and to gain insight in the acquaintance with and the use of prevention activities. This study is part of a study on HIV prevalence and related risk behaviours among drug users in Rotterdam (end of 1994). Transvestites and transsexuals working in the street prostitution and reporting use of hormones or silicones were included in the original study. When this appeared to be a sizeable group, the questionnaire was extended with some specific questions. Saliva was collected from all participants and tested for antibodies to HIV-1/2. Participation was on voluntary basis and anonymous. All participants were biologically male. HIV prevalence among these participants showed to be low (8%). This finding contrasts with studies in other countries. In this study risk of HIV infection was not related to injecting drug use. Possibly, these transvestites and transsexuals are at risk for HIV infections through private or commercial sexual contacts with homo/bisexual men. Risk behaviour related to the use of needles for injecting hormones and/or silicones risk is low. Unprotected sexual intercourse with clients is rare, but occurs frequently with steady partners. Knowledge and use of AIDS prevention programmes are high.PccAo VW

Surveillance van HIV-infecties via het laboratorium, regio Arnhem, 1989-1993

In the Arnhem area, with 830.000 inhabitants, the RPHL is the only laboratory performing anti-HIV tests. In the automated administration of the RPHL all relevant (standard) information on the HIV test, the physician requesting testing and the tested individual are selected for anonymous analysis. Between April 1989 and July 1993 12,219 anti-HIV tests (252 or 2.1% positive) were performed for 10,972 individuals (86 men and 21 women, i.e. 1.0% positive). In 41.6% testing was done for screening purposes, usually for life assurances (1/3,434 seropositive), and these are disregarded in subsequent analyses. Heterosexual risk behaviour was the reason for the test in 2,477 out of 4,818 tests for clinical purposes ; seven infections were found in this group: 3 out of 47 persons with a seropositive partner, 3 out of 460 with a partner in a risk group and 1 out of 1,970 with multiple heterosexual partners. Although only 13.8% of the tests were performed among homo/bisexual men, 50.7% of all infections were found in this group (34 out of 336 homosexual men tested, seroprevalence 10.1%). Among 169 intravenous drug users, 6 infections were found (3 men and 3 women, seroprevalence 3.6%). Among 312 persons who stayed in HIV-endemic areas, 4 were infected (seroprevalence 1.3%). The methodology used in this surveillance programme allows for extension to other regions and other infectious diseases.<br

HIV-infection and risk behavior among transvestite and transsexual street prostitutes in Rotterdam

The Objective of the study was to determine the prevalence of HIV infection and the level of injecting and sexual risk behaviour, and to gain insight in the acquaintance with and the use of prevention activities. This study is part of a study on HIV prevalence and related risk behaviours among drug users in Rotterdam (end of 1994). Transvestites and transsexuals working in the street prostitution and reporting use of hormones or silicones were included in the original study. When this appeared to be a sizeable group, the questionnaire was extended with some specific questions. Saliva was collected from all participants and tested for antibodies to HIV-1/2. Participation was on voluntary basis and anonymous. All participants were biologically male. HIV prevalence among these participants showed to be low (8%). This finding contrasts with studies in other countries. In this study risk of HIV infection was not related to injecting drug use. Possibly, these transvestites and transsexuals are at risk for HIV infections through private or commercial sexual contacts with homo/bisexual men. Risk behaviour related to the use of needles for injecting hormones and/or silicones risk is low. Unprotected sexual intercourse with clients is rare, but occurs frequently with steady partners. Knowledge and use of AIDS prevention programmes are high.Doel van de studie was het vaststellen van de HIV-prevalentie en de mate van spuitgerelateerd en seksueel risicogedrag, en het verkrijgen van inzicht in de bekendheid met en het gebruik van preventie-activiteiten. Dit onderzoek maakte deel uit van een onderzoek naar de HIV-prevalentie onder druggebruikers in Rotterdam (eind 1994). Daarin werden ook travestieten en transseksuelen in de straatprostitutie die hormonen of siliconen gebruikten opgenomen. Toen bleek dat dit om een behoorlijk grote groep ging is de vragenlijst met enkele voor deze groep specifieke vragen uitgebreid. Bij alle deelnemers zijn speekselmonsters afgenomen en getest op anti-HIV 1/2. Deelname aan het onderzoek was vrijwillig en anoniem. Alle deelnemers waren biologisch van het mannelijk geslacht. De HIV-prevalentie in deze groep bleek laag (8%) vergeleken met studies uit andere landen. Intraveneus druggebruik speelt geen rol in deze groep. Ook bij het spuiten van hormonen/siliconen lijkt riskant gedrag weinig voor te komen. Mogelijk loopt deze groep travestieten en transseksuelen risico door commerciele- en privecontacten met homo/biseksuele mannen. Onbeschermde seks vindt vooral plaats met de vaste partners. De bekendheid met en het gebruik van preventieve maatregelen tegen AIDS zijn hoog

Prevalence and risk factors of HIV infection among drug users in Rotterdam

DOEL Het vaststellen van de prevalentie van HIV-infectie en risicogedrag onder intraveneuze- (IVDs) en niet-intraveneuze-druggebruikers in Rotterdam. Het onderscheiden van subgroepen IVDs met een verhoogd risico op HIV-infectie. Het inschatten van het risico op verdere verspreiding van HIV. Het vaststellen van de bekendheid en het gebruik van preventie-activiteiten. METHODEN Tussen 6 september en 18 december 1994 is bij 701 druggebruikers (494 IVDs) in Rotterdam een speekselmonster en een vragenlijst naar risicogedrag afgenomen. Deelnemers werden geworven via de methadonverstrekking (67%) en via werving 'op straat' (33%). In de methadonwerving werd ook een bloedmonster verzameld. Deelname was vrijwillig en anoniem. RESULTATEN Van de 492 geteste IVDs waren 57 seropositief (prevalentie 12%, 95%-betrouwbaarheidsinterval [BI] 9-14%), onder de 207 niet-IVDs werden drie infecties gevonden (1.5%, 95%BI 0-4%). Onafhankelijke risicofactoren voor een positieve serostatus onder IVDs waren een jongere leeftijd (34 OR=1), geboorteland (Nederland OR=1, Turkije, Marokko, Suriname, Antillen OR=0.12 [0.02-0.94], overig buitenland OR=1.54 [0.72-3.32]), gevangenisstraf (nooit OR=1, 1 keer OR=1.96 [0.61-6.28], >1 keer OR=3.40 [1.36-8.52]) en een langere spuitcarriere (0-2 jr OR=2.17 [0.65-7.27], 3-10 OR=1, >10 OR=3.05 [1.39-6.71]). Het aantal druggebruikers in Rotterdam wordt geschat op tenminste 3500 op jaarbasis, waarvan 2500 IVDs en 200 tot 300 geinfecteerden. Op basis van zelfgerapporteerde testuitslagen sinds 1991 blijken recent infecties te zijn voorgekomen. Een op de vijf actuele spuiters had in de laatste 6 maanden gebruikte spuiten of naalden van anderen geleend. Van alle IVDs had 9% een vaste seksuele relatie met een niet-intraveneuze druggebruiker en 14% met een niet-druggebruiker. Binnen de meeste vaste seksuele relaties (79%) werden nooit condooms gebruikt. Van de 325 actuele spuiters was 97% bekend met een of meer spuitomruillocaties, 95% had er ooit gebruik van gemaakt. Van alle deelnemers kende 94% een of meer condoomverstrekkingsplaatsen en had 58% daar ooit gebruik van gemaakt. CONCLUSIES De prevalentie van HIV-infecties in Rotterdam wordt geschat op 12% onder intraveneuze-druggebruikers en 1.5% onder niet-intraveneuze druggebruikers. Dit komt naar schatting overeen met 200 tot 300 seropositieve druggebruikers. Risicofactoren voor HIV-infectie onder IVDs zijn een jongere leeftijd, gevangenisstraf en een lange spuitcarriere. IVDs die in Turkijke, Marokko, Suriname of de Antillen zijn geboren zijn minder vaak seropositief. Nieuwe infecties komen onder IVDs nog steeds voor. Verspreiding naar niet-druggebruikers, met name vaste seksuele partners van IVDs, is aannemelijk. De bekendheid met en gebruik van spuitomruil en condoomverstrekking zijn hoog.OBJECTIVES To determine the prevalence of HIV infection and risk behaviours among injecting (IDUs) and non-injecting drug users in Rotterdam. To distinguish subgroups of IDUs with a higher risk of HIV infection. To assess the risk of further spread of HIV. To determine the acquaintance with and use of prevention activities. METHODS Between September 6 and December 18 1994 a saliva sample and questionnaire on risk behaviour were collected from 701 drug users (494 IDUs) in Rotterdam. Participants were recruited through methadone care (67%) and on the street (33%). In methadone care also a blood sample was collected. Participation was on a voluntary basis and anonymous. RESULTS Of 492 tested IDUs 57 were seropositive (prevalence 12%, 95% confidence interval [CI] 9-14%), among the 207 non-IDUs three infections were found (1.5%, 95%CI 0-4%). Independent risk factors for a positive test result among IDUs were a younger age (34 OR=1), country of birth (Netherlands OR=1, Turkey, Morocco, Surinam, Dutch Antilles OR=0.12 [0.02-0.94], other foreign OR=1.54 [0.72-3.32]), imprisonment (never OR=1, once OR=1.96 [0.61-6.28], >1 time OR=3.40 [1.36-8.52]) and a longer injecting history (0-2 yrs OR=2.17 [0.65-7.27], 3-10 OR=1, >10 OR=3.05 [1.39-6.71]). The number of drug users in Rotterdam is estimated at a minimum of 3500 on a yearly basis, of which 2500 IDUs and 200 to 300 infected. On the basis of self-reported negative test results since 1991 infections appear to have occurred recently. One in five current injectors borrowed used syringes or needles in the last 6 months. Of all IDUs 9% had a steady sexual relationship with a non-IDU and another 14% with a non-drug user. Within most (79%) steady relationships condoms were never used. Of the 325 current injectors 97% were acquainted with one or more needle exchange locations and 95% had ever made use of them. Of all participants 94% were acquainted with one or more locations where free condoms are provided and 58% ever got condoms there. CONCLUSIONS The prevalence of HIV infections in Rotterdam is estimated at 12% among intravenous drug users and 1.5% among non-intravenous drug users, corresponding with about 200 to 300 HIV-infected drug users. Risk factors for HIV infection among IDUs are younger age, imprisonment and a longer injecting career. IDUs born in Turkey, Morocco, Surinam or the Dutch Antilles are infected less often. New infections among IDUs still occur. Spread to non-drug users, especially steady partners of IDUs, is likely. The acquaintance with and use of needle exchange and free condom supply are high.PccA