Needle and syringe exchange and working with injecting drug users ‘Doing it Down Under’: Critical reflections on Australia’s HIV response 4th IAS Conference on HIV Pathogenesis, Treatment and Prevention Sydney, Australia, 22-25 July 2007 Dr. Alex Wodak, St. Vincent’s Hospital, Sydney NSW Health and National Centre in HIV Social Research, UNSW, Sydney

Outline: The initial problem Principles of the response What was done and when Overcoming barriers Did it work Lessons learnt

The initial problem: Early 1980s: HIV prevalence ~ 35% large population MSM eastern Sydney Large population injecting drug users living in same area High risk: HIV spreading from MSM  MSM/IDUs  heterosexual IDUs  general population Urgent need action: prompt, effective

Principles of the response: New problem: no off-the-rack solutions Major need: interrupt needle transmission HIV Need to work closely with population most at risk on design & implementation Amsterdam, Liverpool started needle syringe programmes early 1980s Methadone treatment likely to work

What was done and when: Discussion group formed about 1984 in Sydney: ‘ADIC’ Advocacy for needle syringe programmes and expanded methadone 13 submissions to NSW Health permission start pilot NSP First NSP Australia started 13 November 1986: civil disobedience

What was done: 2 NSP breached 1985 law Uproar By 1988 all Australia had NSP coverage Now 32 million needles & syringes/year Methadone also rapidly expanded Explicit, peer based harm reduction education: ‘Never, ever share needles’

What was done: 3 Government funded organisation IDUs started 1989, now most of country Emphasis on HIV prevention in prisons - little achieved Important support from police: development operational guidelines Harm reduction package: needle syringe programmes drug treatment (especially methadone) explicit education community development

Overcoming barriers: Ferocious battle fought out in media Accusation: ‘condoning drug abuse’ Powerful supporters of harm reduction Turning point: no prosecution Vigorous debate = huge free HIV education campaign Australia’s adoption harm minimisation official national drug policy April 1985 critical, fortuitous

Did it work: HIV prevalence among IDUs Australia consistently 1-2% across many data sets community, prisons, STI clinics Few IDUs (5%) among HIV or AIDS cases Parsimony: HIV epidemic among/from IDUs averted

HIV and hepatitis C prevalence1 in needle and syringe programs by year and sex 1 HIV and hepatitis C prevalence adjusted by estimated prevalence of injecting drug use in each State/Territory Source: Collaboration of Australian Needle and Syringe Programs

HIV prevalence in prison entrants by year and sex Source: State and Territory Departments of Corrections

Did it work: HIV prevalence among IDUs consistently 1-2% across many data sets community, prisons, STI clinics Few IDUs among HIV or AIDS cases 3% HIV diagnoses 2001-2005 IDUs 4% HIV diagnoses 2001-2005 IDUs + MSM Parsimony: HIV epidemic among/from IDUs averted

Lessons learnt: Public health HIV prevention among IDUs not difficult, elements well understood ~ 1990 Harm reduction now supported by copious high quality evidence effective safe cost effective beyond scientific debate

Lessons learnt: 2 Early, vigorous action: small cost, huge benefit 1988-2000 cost NSP $A 130 million Benefit: prevented by 2000: 25,000 HIV infections; 21,000 HCV infections saved by 2000: $A 2.4-7.7 billion prevented by 2010: 4,500 AIDS, 90 HCV deaths ‘Return on Investment in Needle and Syringe Programs in Australia’

Lessons learnt: 3 Politics difficult: major problem entrenched opposition from drug law enforcement Opposition mostly inspired by USA: millions infected HIV needlessly Partnership critical: officials, community groups, researchers, clinicians, police Don’t cut and run – stay the course