1. 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, July 2007
Dr. Alex Wodak, St. Vincent’s Hospital, Sydney
NSW Health and National Centre in HIV Social Research, UNSW, Sydney

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

3. 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

4. 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

5. 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

6. 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’

7. 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

8. 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

9. 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

10. 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

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

12. 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 IDUs
4% HIV diagnoses IDUs + MSM
Parsimony: HIV epidemic among/from IDUs averted

13. 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

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

15. 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