AIDS related interventions among drug users in the Netherlands
Adapted from a paper presented to the WHO European Symposium on AIDS and Drug Abuse, Stockholm, 25-28
Ernst Buning Drug Department, City of Amsterdam Health Department, the Netherlands
Pragmatic and nonjudgemental are two words which best describe Dutch AIDS and drugs policy. In their approach, the Dutch have not upheld any one particular ideology, be it heavy law enforcement or total acceptance of drug addiction. Rather, interventions implemented are those which seem to work best in Dutch society.
' Recently, the Ministry of Welfare, Health and Cultural Affairs outlined the Dutch AIDS and drugs policy, as "The main target of our Aids policy is limiting the spread of HIV by means of risk reduction. Risk reduction implies safer sex and safer drug use. Risk reduction means feasible changes of life style. If a reduction of unwanted behaviour is not possible, safer techniques should be learned, with regard to both sexual behaviour and drug taking. When cessation of drug use cannot be achieved, and we all know the limitations of interventions in this regard, taking drugs in a non-intravenous way should be learned. And when this is not feasible, as practice shows, safer injection methods should be promoted. Health education should, therefore, be accompanied by the availability of sterile needles and syringes, as well as condoms" (Wever 1989).
In many Dutch cities, the above described policy resulted in various AIDS related measures being integrated into the existing drug policy.
In Amsterdam, as in many other cities, the measures are carried out along a simple model (Buning et al 1988, Buning 1988, Buning & van Brussel 1988). Firstly, contact is made with as many drug users as possible and secondly, information about safer sex and safer drug use is given. The best way to get this message across proved to be personal counselling, where the drug user and his counsellor discussed safer sex and safer drug use, as well as social skills. To reinforce this personal contact, Amsterdam is developing audio-visual material that can be shown in waiting areas. The European Regional Office of the WHO has identified this activity as a pilot project.
If the inforrnation comes across, the expectation is that drug users will change their attitudes towards sex and drug use.
To reinforce the message and assist the behaviour change, certain conditions are fulfilled:
• condoms are available, free or at low cost, in or near the drug scene;
• drug-free treatment is accessible for those drug users who want to stop using drugs and long waiting lists are avoided;
• methadone is available for those heroin users who want to reduce or stop injecting, but who can't give up their dependence on opiates (yet);
•clean injecting equipment is available, free or at low cost, in or near the drug scene. Since contaminated material could endanger the general public (in parks, playgrounds or plastic garbage bags), the importance of returning their used equipment to needle and syringe exchange schemes is stressed.
Finally, in the larger cities, a good provision of care for injecting drug users with AIDS has been established. This care is integrated into the existing helping organisations and aimed at avoiding further discrimination and marginalisation. Case management is a key word in this regard.
Through this case-management, attempts are made to create supportive conditions that prolong and improve the quality of life of a person with AIDS. This may include a tight methadone programme, AZT prescription and regular checks for TBC. Communication between the hospital specialist, the drug agency, the family, the family doctor and the primary home care is essential.
In the Netherlands, the number of hard drug (heroin, cocaine, etc.) users remains stable at 15-20,000, out of a population of 14.8 million people (Wever 1989). Most of them use heroin in combination with cocaine and/or benzodiazepines. Between 30 and 40% of the drug users live in the capital, Amsterdam. Another 30% live in the other three big cities (Rotterdam, The Hague, Utrecht) and the rest are evenly distributed among 60 other cities.
Some characteristics of drug users in the Netherlands are:
• more than 75% are male;
• up to 30% of the drug-taking population belongs to an ethnic minority (although the Surinamese and Moluccans -from former Dutch colonies- and immigrants from Morocco and Turkey form only 5% of the Dutch population);
• 10 to 20% of the drug users come from other European countries (mostly Germans, living in Amsterdam);
• 40% use drugs intravenously. Intravenous drug use among ethnic minorities groups is a rare phenomenon, contrary to non-Dutch Europeans.
HIV infection among drug users
According to the Medical Officer of Health for Infectious Diseases, by December 31st 1989, 1074 AIDS cases were reported in the Netherlands, 89 of which had intravenous drug use as a risk factor (75 heterosexual and 14 homosexual i.v. drug users).
Although the actual number of AIDS cases among drug users is still relatively low, seroprevalence studies in Amsterdam show that about 30% of the injecting drug users are HIV antibody positive (Coutinho 1989, Van den Hoeck 1988, Van den Hoek 1989). This represents about 800 injecting drug users, an ethnic breakdown of which shows that about 50% are of Dutch origin, 25% German and 25% of other European countries (Buning 1987 & 1988).
The HIV prevalence among 560 injecting drug users tested in Amsterdam over the years 1986-1988, remained stable. Corrected for differences in risk behaviour, the HIV prevalence is 33% in 1986 (N=234), 30% in 1987 (N=191) and 30% in 1988 (N=135). The HIV incidence among seronegative injecting drug users in the follow-up group was 12% in 1986 (95% Cl 2-22), 5% in 1987 (95% Cl 1-9) and 3% in 1988 (Cl 0-7).
Besides HIV incidence, acute hepatitis B incidence among injecting drug users is also an indicator for unsafe drug use (Bardoux et al 1989). The number of reported cases has decreased considerably in Amsterdam since 1985. Studies outside the Amsterdam region are scarce, whilst recent data are hardly available (Houweling 1987). However, in 1986, of 84 drug users in Arnhem, Heerlen and Breda, 3 (3.6%) were found to be infected. In a study in the Karl Hormann Foundation in Rotterdam (a low threshold methadone programme) in 1985, one in 29 were found to be HIV positive. 24 seronegatives were examined again in 1986 and it was found that two of them had seroconverted. In 1986, 113 drug users were investigated in the same institute and 11 (9.7%) were seropositive (Barends 1988).
The Amsterdam study
In 1985, the Amsterdam Municipal Health Service started a longitudinal study to evaluate the impact of the Aids prevention measures among drug users (Coutinho 1989, Van den Hoeck et al 1988 & Van den Hoeck 1989). To date, over 700 drug users have enrolled in the study.
Although the seroprevalence among new intakes in the study has remained stable since 1986 and the HIV incidence has gone down among a follow-up group, data from the interviews is still cause for concern. Drug users recruited into the study in 1988 report almost the same level of risky behaviour (needle sharing, unsafe sex) as the intakes in 1986, indicating that the prevention measures still lack substantial impact. On the other hand, drug users who participated in the follow-up study (about 250) reported a decrease in needle sharing (both borrowing and lending) and an increase in the use of the needle-exchange schemes. The researchers attribute this positive behaviour change to the extensive questioning about risk behaviour, which probably worked like counselling. They therefore recommend systematic AIDS counselling for all the drug users i~n Amsterdam.
Drug users who were tested and found seropositive reported a significantly higher level of condom use than participants who -were negative or who did not want to know lhe results. The researchers conclude that knowledge of antibody status may have a preventive value towards safer sex.
In the Netherlands, various studies have been done to investigate injecting practices in the light of the AIDS epidemic. Most of these studies are related to an evaluation of a needle exchange scheme. Of a sample of 50 drug users in Rotterdam, it was found that participants of the needle exchange were more integrated into both their communities and their respective treatment system than drug users who didn't use the needle exchange (Kaplan 1986). Eighty per cent of the participants of the needle exchange reported a change of life-style.
In Amsterdam, in 1987, a study was undertaken to assess the impact of the needle and syringe exchange schemes (Hartgers et al 1988, Hartgers et al 1989). The interviewed drug users were recruited at the 11 "exchange-locations" in Amsterdam, as well as other places where no exchange was possible (police stations, hospitals and the project for drug users from abroad). Drug users who exchanged regularly ("exchangers",N=72), were compared with drug users who never exchanged or who did so irregularly ("non-exchangers", N=73).
Based on self-reports, only 29% of the "exchangers" indicated an increase in drug use in the six months preceding the interview, whilst 38% reported a reduction in their drug use. In a follow-up study, where 60 drug users were interviewed for a second time, again no evidence could be validated for increase in drug use (Hartgers et al 1989).
Needle-sharing hardly occurred within the group of "exchangers", only 9% indicated that they had been involved in needle-sharing in the last month. The "non-exchangers" reported a higher percentage (22%).
Finally, data about needle-sharing were analysed. No participation in the needle exchange, younger age and male gender were all independently correlated with risky behaviour.
A study conducted in Heerlen also indicated a decrease in daily injecting, from 73.6% to 48%, in the last two years (Paulussen 1988). Needle sharing also went down, from 75% to 53%. However, these behaviour changes were based on self-reports.
Another study, conducted in Rotterdam, revealed an interesting phenomenon. Although drug users were not sharing their needles, they did share their drugs through the technique of "front-loading" (Grund 1989). One drug user would suck up the drug from the spoon into the syringe and subsequently squirt half of the dose into the syringe of the other user. The researchers suggest that it is not unlikely that, as the syringe is not sterile, blood traces could be mixed with the drug and conclude that this "front-loading" may be a risk for HIV infection which has been neglected. Drug agencies in Rotterdam took immediate action in their prevention campaign.
The role of methadone
Although it was initially believed that methadone could block the effects of heroin, later research raised doubts about this hypothesis (Sells et al 1980, van Epen 1983). In the Netherlands, methadone is being used in three different modalities - to contact heroin users, to stabilize heroin users, and to detoxify and treat heroin users (Buning 1987 & 1988).
In all major cities in the Netherlands, low-threshold methadone programmes are available. By providing methadone without too many impediments, contact can be made with large proportions of the heroin-using population.
One example of such a low threshold programme is the Amsterdam "methadone by bus" project. Two converted city buses follow a regular route through Amsterdam, stopping at a total of 8 different places in or near the "drug scene". In these buses, liquid methadone is dispensed to heroin users who have been referred to the buses by one of the Municipal Health Service doctors. Certain pre-conditions for participation in the project are set down, which are:
• regular contact with a medical doctor (a minimum of once every three months);
• introduction into the central methadone registration; . no take home dosages.
Further hassle is avoided (i.e. there is no urine sampling, no mandatory contactw ith counsellor etc.). Besides the methadone, information about AIDS is given, needles can be exchanged and condoms are available. Through the availability of methadone, heroin users tend to become more stable and may more easily resist the temptation to share needles.
Crucial to AIDS prevention is the provision of assistance to injecting drug users who want to quit injecting.
In the Netherlands, a network of Consultation Bureaux for Alcohol and Drugs (CAD) has been established. In these CAD's methadone can be prescribed, but they also provide services which are aimed at helping heroin users to give up their iDegal drug use. Urine samples are taken and medical and psycho-social help is provided.
Clients are assisted if they face problems concerning housing, financial and legal matters. Medical help is given in the form of regular medical examination, providing contraception and referral to hospitals.
Methadone can be prescribed on a long-term basis. In this way an intravenous opiate dependence is substituted by an oral opiate dependence and a first step in stabilizing the use is taken. The risk of contracting AIDS through needle sharing is avoided as long as the client doesn't relapse into intravenous drug use.
Evidence from Sweden (Blix 1988) and the USA (Hartel 1988, Sorensen 1989), indicates that HIV infection is not common among clients who are retained in methadone maintenance programmes.
Another way of applying methadone is to use it as a therapeutic tool. This is especially useful for those drug users who want to kick the habit. The fear of AIDS may be one of the reasons why they are motivated to do so. In this form of out-patient treatment, methadone is prescibed on rather strict conditions.
Most (low-threshold) methadone programmes co-operate very effectively with these drug-free therapeutic treatment programmes. In fact, they are complementary and need one another.
In Amsterdam, the number entering drug-free treatment and resocialisation has more than doubled since the introduction of the methadone buses and the needle exchanges schemes (Buning 1987 & 1988).
Exchanging needles in the Netherlands
To date, needle exchange is available in 40 Municipalities of the Netherlands. The implementation of these exchange schemes was made possible due to two facts.
Firstly, the Ministry of Welfare, Health and Cultural Affairs made money available to support local initiatives. Secondly, the outcome of the evaluation of the Amsterdam exchange schemes allowed for positive expectations concerning their preventive value.
In 1984 the needle and syringe exchange began operating in Amsterdam. It was initially greeted with a certain amount of controversy as objections were made such as:
• it would encourage i.v. use and reduce the incentive to "kick the habit";
• injecting drug users should buy their own equipment;
• a black market in needles and syringes would develop as a way to obtain money for illegal drugs;
• workers in the drug field should be helping addicts to stop, not continue, a dangerous practice;
• pharmacists would be able to use this as an excuse to stop selling needles and syringes;
• it was a misuse of the professional staff's time.
Even though Health Authorities initially shared some of these concerns, it was decided that a small experiment within the building of the Junky Union would be set up. At the outset, approximately 1,000 needles and syringes were exchanged each week. When AIDS became a major concern in 1985, more institutions began to get involved in the exchange system. In 1986, the Municipal Health Service decided to extend this service to the methadone buses as well. In 1989, 820,000 needles and syringes were distributed through the needle exchange at 11 different locations (all low-threshold drug agencies).
More recently, initiatives have been taken to install needle and syringe exchange dispensing machines. A company in Rotterdam has just developed a needle exchange machine, which is presently being tested in a drug agency (Klaassen, 1989).
Although the first results are very positive, it should be stressed that a machine can never replace the personal contact which takes place in the needle exchange.
Another issue to consider in managing the AIDS problem is the fact that in areas with many drug injectors, the general public may accidentally stick themselves with contaminated needles.
In Amsterdam, people who encounter needle stick accidents are requested to report this to the Municipal Health Service. In the period 1984-1988 there was no significant increase in the (low) number of reported needle stick accidents. However, in 1987 complaints were reported about needles in parks and gutters in the inner city. This induced a critical evaluation of the exchange rate by the Municipal Health Service. Buckets with returned needles from the exchange schemes were randomly selected, weighed and disinfected. Subsequently, the number of needles and syringes were counted. Based on this procedure, an estimate was made of the number of returned needles from the various exchange schemes.
The return rate turned out to be 87%. The director of the Municipal Health Service stipulated that all the exchange schemes had to operate on a "one to one" basis and further emphasized that the continuation of the exchange schemes could be jeopardized if no improvement took place. This announcement, combined with the installation of better exchange equipment, led to an icrease in the exchange rate. To date. This exchange rate is 95%.
As an example of how drug-dependent prostitutes could be approached in the light of AIDS, a short description will be given of the Prostitute Contact Centre in Utrecht. In May 1986, a mobile contact Centre (HAP) was opened in the prostitution area in Utrecht, using a large mobile unit Jaarverslag 1987). The goal of this project was to create a place where street prostitutes could come in, have a cup of tea and a chat, take a shower and, when required, consult with the medical doctor. In the unit, the use of drugs, alcohol and/or violence is not permitted. The centre co-operates with the local police, who will assist immediately if women are threatened in the centre. Apart from this, the police play an inactive role.
Safer sex campaigns are organized regularly and women who visit the centre are given a "fun-pack", containing different condoms and a towel with the text "use a condom, practise safe sex".
During these campaigns, clients of prostitutes were approached by a male worker. Discussions about condom use were initiated and condoms were given free. Since 1986 the HAP (prostitution project) distributed over 60,000 condoms to street prostitutes and their clients.
In 1987, 180 street prostitutes in total (mostly drug users) visited the centre, with an average of 20 visitors per night. Seventy-two prostitutes were seen by the doctor and 53 times a sexually transmitted disease was diagnosed.
An interesting fact that came to light was that condoms for anal intercourse (duo-condoms) are bought by female prostitutes as well, although it was always believed that anal intercourse did not occur among this group.
As a form of AIDS education, clients who come in are given a safe-sex message and then asked to tell this to the next person that comes in. In this way, the staff could check if the message came across, while at the same time peer group education was established.
Finally, a campaign in which prostitutes were asked to return condoms which had burst, proved to be very successful. Burst condoms were returned to the supplier and counselling took place about the methods in which the condom had been used. From this it became clear that even some experienced prostitutes lacked knowledge about proper use of condoms.
Drug users of ethnic minority groups
A substantial percentage of the Dutch hard drug users (about 30%) is from an ethnic minority group. The largest group are Surinamese (Dutch Guyana) and a smaller proportion are from Morocco, the Dutch Antilles and Indonesia (Moluccans).
Interestingly, the majority of drug users of these ethnic groups don't inject but smoke their drugs (known as 'chasing the Dragon'), minimising the risk of getting AIDS through needle sharing.
Since they don't inject, many drug users of these ethnic groups don't see AIDS as a problem. Nevertheless, the sexual transmission of HIV cannot be ruled out among these groups.
In terms of sexuality, major differences can be found among various ethnic groups. In the Surinamese and Dutch Antillian culture for example, homosexuality is not accepted. Men who wish to engage in homosexual activities fear marginalisation and conduct their contacts in secret. Openly, they express heterosexual preferences, often resulting in bisexual behaviour. Consequently, campaigns aimed at homosexuals don't come across to this group of men.
Homosexual behaviour in the Moroccan culture, however, varies greatly from the Surinamese culture as it is accepted that boys have sexual contact with men. Nevertheless, this contact is not labelled as homosexual, primarily because homosexuality is not permitted in their religion. Once again, a campaign for homosexual men lacks impact on this group.
The patterns of heterosexual behaviour vary as well. Just looking into the Surinamese subgroup, three major ethnic groups can be identified: Creolen", "Hindoestanen"and Javanen". Monogamous relationships are common among Hindoestanen, whilst this is much less embedded in the culture of the "Creolen" and the "Javanen».
Thus a male Creool" drug user who doesn't inject, may have sexual contact with a white female drug injector, get infected with HIV and further infect other (non-injecting) sex partners.
Most of the drug users from the ethnic minority groups don't consider AIDS a problem, since they don't inject and homosexuality doesn't exist" in their culture - they see AIDS as a white" problem.
The above indicates that it may be extremely difficult to set up a comprehensive AIDS campaign for these subgroups. Given the fact that the groups vary greatly, differentiated campaigns would be the best option. Educational material that has been developed so far for these groups, focusses on heterosexual transmission and the necessity to use condoms.
In the last few years, many activities have been undertaken in the Netherlands to curb the further spread of AIDS among drug users.
Research data indicate that drug users did change their injecting behaviour in various parts of the country. The easy accessibility to methadone, clean injecting equipment, condoms and a dense network of drug helping agencies may have induced these changes.
The wide availability of methadone reinforced a pattern of drug use which differs greatly from other European countries and the USA. Many users don't inject but smoke heroin and/or cocaine and those who do inject know that they can always fall back on methadone, which could make the urge to inject and/or share needles less severe.
However, methadone doesn't provide an answer to the (intravenous) use of other drugs such as cocaine and amphetamines. In areas where heroin is not the predominant drug, methadone may only lay a modest role.
Methadone and needle exchange can not be seen as a panacea. Although safer drug use has been reported by a large percentage of the drug users, some are still involved in needle sharing. If not yet seropositive, this group will probably become infected by HIV sooner or later.
It is, therefore, necessary to combine methadone and needle exchange programmes with other prevention measures, such as providing information, AlDS-counselling, teaching needle cleaning and psycho-social care.
Though changes in injecting behaviour were observed, less drastic changes took place in the field of sexual behaviour. In the near future, more emphasis is needed in promoting safer sex. It is questionable whether these efforts will be very successful. In using condoms in sexual contacts with non-injectors, drug users are primarily protecting their sex partner from HIV infection. Can such an altruistic act be expected from drug users, especially since clear, positive reinforcement to safer sex is lacking? This question still remains unanswered.
Finally, epidemiological research projects outside the Amsterdam region should b; stimulated. Provided that sufficient pre-and post-test counselling is available and that informed consent and protection of privacy is ensured, these studies may produce data which would give us a clearer picture of the progression of the Aids epidemic among drug users in the Netherlands.
Acknowledgement is given to Dr. Henk Rengelink, Municipal Health Service Amsterdam (MHSA), Christina Hartgers (MHSA), Annette Verster (MHSA), Krishne Kanhai (MHSA) and Leon Wever (Ministry of WVC) for reviewing this paper. l am also grateful to Leon Wever for permission to use parts of his presentation Drug abuse from the perspective of Aids, The Hague, June 28th,1989
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