NDARC Technical Report No. 37 (1996)
This study involved a quite significantly disadvantaged population. The typical respondent was a thirty year old single, unemployed male who had limited schooling, lived in eastern Sydney at the time of the study but was also highly mobile. It is encouraging that the prevalence of HIV infection among female and heterosexual male respondents was only 3%. This is in line with numerous other studies in Sydney and elsewhere in Australia. However, more than two thirds of the Sydney respondents were infected with hepatitis C and almost one quarter have been exposed to hepatitis B. These figures are higher than other parts of Australia. They may reflect the fact that the Sydney sample was somewhat older and started injecting at a younger age. It is clear from this study that much more effort will be required to overcome the challenge of controlling hepatitis C infection in this population.
The Sydney respondents were more likely to have began injecting earlier than their counterparts in other cities and more likely to inject heroin or cocaine rather than amphetamines. Almost all respondents were polydrug users. The high prevalence of tobacco use in this population will undoubtablly worsen their health outcomes. It is encouraging that the Sydney respondents had a significantly lower prevalence of alcohol use than respondents from other cities.
In this study, respondents injected drugs on average 46±61 occasions during the previous month. It is particularly gratifying that this study demonstrates a continuing decline in the proportion of injections involving unsafe practices. In 1985, two studies were conducted in Sydney with sharing of injection equipment reported by about 95% of respondents (Crofts et al, 1996). In this study conducted in Sydney about a decade later, almost 90% of Sydney IDUs reported not sharing injection equipment. This suggests that the norm of sharing injecting equipment in 1985 has changed in a decade to a norm of not sharing injecting equipment. Although some of this change may represent the difficulty injecting drug users have admitting to sharing today, there can be little doubt that a major reduction in risk behaviour has occurred. This reduction appears to be more marked in Sydney than elsewhere in Australia, possibly because of the many years of intensive education and early and extensive implementation of prevention measures.
Sydney respondents were more likely to inject alone than their counterparts in other cities. This may reflect an attempt to reduce the risk of sharing and becoming infected with blood borne viruses. However, injecting alone may increase the risk of a fatal outcome from an overdose.
An higher proportion of Sydney injecting drug users reported injecting in public places and injecting rooms than their counterparts in other cities. One in four respondents in Sydney reported that their last injection took place in a street, park or injecting room. It is possible that the establishment of legally sanctioned injecting rooms, as recently recommended for consideration by the NSW Premier (Sharp, 1996) could result in a further reduction in risk behaviour. Major reductions in risk taking practices by IDUs are required not just to keep HIV under control but to substantially reduce and possibly control the spread of hepatitis C in this population.
The high utilisation of needle exchanges and pharmacies is very gratifying and consistent with the reduction in risk behaviour documented in this population. These facilities seem to provide a good service. In general, IDUs appear to be well aware of their responsibilities when disposing of used injection equipment.
It is curious that these major reductions in risk behaviour have occurred among injection drug users in Sydney even though most respondents in this study greatly under estimated their risk of becoming infected with either HIV, hepatitis B or hepatitis C. Some perceived correctly that they were more at risk of hepatitis B and hepatitis C than HIV.
The high level of testing for HIV provides further confidence that a major undetected outbreak of HIV in this population is unlikely to occur. However, the high level of testing for HIV, hepatitis B, and hepatitis C suggest that either the respondents are more concerned about their risk of blood borne viral infections than they are prepared to own up to or the health care system they interact with encourages regular and possibly excessive testing. It is disappointing that the rate of hepatitis B vaccination in this population is still so low. With such a high prevalence of hepatitis B and such low levels of hepatitis B vaccinations, substantial sexual transmission of this virus is inevitable.
Sydney IDUs according to the data in this study mainly live in fairly impoverished circumstances. Although supported by reasonable social networks, many of their close friends are also IDUs. Few have encountered more than a handful of other IDUs infected with HIV. Yet their evidence of close linkages between respondents in this study and homosexual male IDUs suggests the possibility of a bridge for HIV infection ultimately reaching the general population.
The respondents in this study had an average annual income of $36,000 of which they spent about $16,000 on illicit drugs. In total, the 219 respondents spent over $3.5 million a year on illicit drugs and derived about $2.7 million from property crime, fraud and the sale of drugs. If this is extrapolated to the estimated 172,000 heroin injectors nation wide, annual expenditure on illicit drugs would be $2.7 billion and an annual income of $2.1 billion would be derived from crime.
Almost three quarters of respondents had attended a doctor in the previous month. Many had attended health and welfare professionals. About 90% had wanted to change their drug use with three quarters reported that their drug use had caused problems. Over half were in treatment with 90% of these in methadone treatment which had lasted, on average, for two and a half years. Another (almost) one third had previously been in methadone treatment. The reported doses of methadone received was well in the effective range. These results suggest that there is a major demand for treatment which is currently being met mainly by methadone. Law enforcement seems to have provided little impetus to change or enter drug treatment. Almost one third had tried self-help to improve their situation while over one in five have undergone detoxification. Family and friends were clearly another important source of assistance.
Contact with other drug users was the most commonly cited single factor which precipitated a decision to leave treatment among both those who regarded treatment as being helpful as well as those who regarded it as unsuccessful. This raises the possibility that increasing the provision of methadone in general practice and community pharmacies will improve outcomes from this treatment. Lack of follow up was identified by one in six respondents as a major factor for their lack of success. This is remediable at least potentially. It is difficult to avoid the conclusion that a large proportion of these respondents are unhappy about their drug use and have tried many times and in many ways to bring their lives under control. The many IDUs who have benefited from interacting with treatment (or self help) and have not relapsed would not, of course, be eligible for recruitment in this study.
This study also adds further confirmation that drug overdose is a very common experience among drug users. Two thirds have personal experience with a previous overdose. It is disappointing that only one in eight attribute a previous overdose to polydrug use. These data also suggest that official statistics under represent the incidence of overdose as a considerable proportion of these events were not reported to officials. One third of respondents had been present at a previous fatal overdose.
Over half the respondents reported switching from non-injecting routes of administration to injecting but only one in five of the total population reported a transition in the reverse direction. The factors responsible for a transition to injecting seem powerful and easily identifiable while the factors responsible for a reverse transition seem less powerful and more difficult to identify.
Only one in three respondents were aware of the existence of an organisation for drug users while only half of these respondents had come into contact with a user organisation. However, those who had contacted their local drug user organisation reported benefit in general.
Two thirds of these respondents had experienced imprisonment before turning twenty. The most recent imprisonment had lasted for almost one year. Over half had been imprisoned for an offence directly related to drugs while the remainder was imprisoned for offences that were indirectly related to drug use. Over one third of respondents with a prison history had been on methadone treatment when last in prison. Of those who had previously been in prison, over 40% reported injecting during their last period of incarceration. 56% of those who had injected during their last period in prison reported sharing. While the practice of sharing is becoming much less common among IDUs in the community, the prevalence of injecting inside prison remains very high. It is also known that drug injectors sharing in prison do so with a much larger number of partners than in the community.
In summary, this study documents the reduction in risk behaviour which has enabled tight control to be kept over HIV infection in this population. However, the prevalence of hepatitis C and hepatitis B among injecting drug users in Sydney and elsewhere in Australia remains unacceptably high. The incidence and outcome from drug overdose are disturbing. These data show much cause for concern. The provision of sterile injection equipment appears to be working well. Drug treatment is clearly reasonably available and relatively attractive. Nevertheless, this study points to some grounds for improvement.
Major studies of this kind are now being done less frequently in Australia. They are being supplemented by more frequent but far less detailed studies which help to monitor risk behaviour and the prevalence of blood borne viral infections. Although these major and more detailed studies consume considerable resources, they also provide a large quantity of very valuable information which is not other wise obtainable.