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Reaching the unreached An outreach model for 'on the spot' AIDS prevention among active, out-of-treatment drug addicts PDF Print E-mail
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Articles - HIV/AIDS & HCV
Written by Jean-Paul Grund   


Around 1985 the spread of HIV among drug addicts in the Netherlands became a serious concern to policy makers, drug service agencies and users themselves, organized in so-called junkie Unions. The first AIDS prevention initiatives, aimed at Injecting Drug Users (IDUs) were established by these pressure or interest groups of drug addicts': In Amsterdam the AIDS-inspired syringe exchange was initiated by the MDHG, a user-based organization, in 1984. The earliest AIDS prevention leaflet for drug users in the Netherlands was produced by the Rotterdam junkie Union. In 1981 this union was already distributing clean syringes at places in the drug scene where EDUs gathered to prevent the spread of hepatitis. When it became apparent that HIV would also mean a menace to Dutch IDUs, the Rotterdam Junkie Union immediately started a syringe exchange. This was long before the municipal syringe exchanges opened. At first, these activities were exposed to firm opposition from the police, the treatment agencies and the municipal authorities. Insight into the magnitude of the AIDS epidemic was yet to come about at these levels. In Rotterdam, where this research was conducted, the municipal syringe exchange system was established in the first half of 1987. This rather late start was due to resistance in some parts of the treatment system. Among other arguments, it was felt that syringe exchange would encourage injecting and undermine drug-free treatment (van Heiningen, 1988). Nowadays, these arguments are generally seen as obsolete and, more important, it has been proved that they have no scientific basis (Buning, 1988). At the end of 1986 HADON, at that time a small and experimental outreach and drug information programme, took the initiative and set up a syringe exchange. Soon the rest of the city was to follow.

In Rotterdam, as in many other Dutch cities, syringe exchanges are predominantly tied to the methadone programmes, mainly methadone maintenance programmes. The advantage of this Rotterdam approach is that these programmes are in contact with approximately 1,000 heroin addicts (both smokers and DU) on a daily basis. However, estimates of the number of heroin addicts in Rotterdam vary between 2,500 and 3,500 (INTRAVAL, 1989), not counting those drug users from the suburbs, that are also oriented on Rotterdam, both for drugs and help. The proportion of IDUs is approximately 25 per cent for both in and out of treatment groups (Grund et al., 1991b). Although the syringe exchanges at the methadone programmes are open to non-clients, few actually use them. This means that on a daily basis at least 60 to 70 per cent of the target group is not reached by the municipal syringe exchange system. Additionally, the composition of the 'in treatment' cohort is often subject to rapid changes (Toet 1989). Furthermore, many addicts have switched from heroin to cocaine as their drug of preference (Grund et a/., 1991a), and for this reason methadone presumably has become less valuable for them. For these reasons, the outreach and information project HADON, which in 1989 fused with the Odyssee foundation, made reaching the active out-of-treatment drug addicts, generally the 'unreached', into its main AIDS prevention priority. This chapter will give a brief description of the working methods of this project and present some results of the pilot evaluation study we conducted.


In this pilot evaluation study, syringe exchange contacts of the HADON programme were registered. For each exchange contact the programme staff registered date, minimal demographics, the number of syringes and containers dispensed, and the number of syringes returned. When syringes were returned in a container, the actual number of syringes was estimated by a weighing procedure (Blanken, 1990). Quantitative data analysis was conducted at the level of (1) the individual exchanger, and (2) the exchange contacts. Staff of the program were questioned on the contents of their work and their knowledge on the attendants and programme routines were observed. Data on how the programme's goals were addressed in the networks of contacted drug users were collected through ethnographic field work in an ongoing research project in the Addiction Research Institute (Grund etal., 1991b).


HADON is a neighbourhood-based information programme providing outreach, prevention and referral services to active out-of-treatment DUs in the north of Rotterdam. The programme started in 1985, before the health implications of the AIDS epidemic among the IDU population was generally acknowledged in Rotterdam. Due to this evolving epidemic, the priority of the programme has been shifted towards the prevention of HIV transmission. Besides the contacts in the project's storefront premises, the outreach workers visit on a regular basis many places in the scene called 'user collectives'. The outreach workers supply clean syringes, condoms and up-to-date information on HIV/AIDS to people who visit these places. The uniqueness of the programme lies in its two-tiered organization of syringe exchange. In addition to supplying these prevention materials in the storefront and while doing outreach, the workers stimulate key people to exchange syringes at their user collectives. The user collectives are frequently visited by other addicts from the same or related networks. Thus, visitors can exchange individual syringes (individual exchange) or, upon special agreement, exchange containers of used syringes for boxes of 100 new syringes (collective exchange). The containers are plastic and can hold approximately 200 used syringes. The HADON collective exchange tier has been experimentally initiated in order to determint if the outreach component of the programme could be extended and improved.

Second, the experiment examined if the motivation of visitors could be reinforced through stimulating a willingness both to exchange and collect used syringes and take more responsibility, not only for their own individual health, but also for the health of their injecting drug-user peers. This second aspect is based on the observation that social support is a common phenomenon in addict networks. The stereotype of addicts is that of ripping each other off as predatory individuals. While this behaviour does indeed occur, a more prevalent pattern seems to be sharing. Addicts share many, for them, important things like housing, food, clothing, etc., and often they help one another with daily problems associated with addict life (Grund et al., 1991b). These sharing behaviours have been documented in many studies in different places and seem universal (Preble and Casey, 1969; Feldman and Biernacki, 1988; Mata and Jorquez, 1988; Des Jarlais et al., 1988). They fit the broader context of addict life and find their function in coping with craving, human contact and needs, and life in the margins of society. Drug use is not the only factor that brings and keeps drug users together. Drug users engage in many common activities and they spend considerable time on social activities (Kaplan et al., 1991).


From May 1988 to June 1989 the HADON syringe exchange project involved 104 regularly registered exchangers, and 1,255 syringe exchange contacts were registered. The collective exchange has been defined as 'making available large amounts of sterile syringes and sharpsafe containers at strategic places in the drug scene in order that there are always clean syringes available at those places where drugs are being used'. Individual exchange has been defined as 'those exchanges and supply transactions concerning small quantities of syringes' (Barendregt, 1989). According to these programme definitions we have defined a collective exchanger as 'an exchanger who has at least once taken out a box with syringes and a container and has at least once returned a container'. Based on this, twenty-five clients (24 per cent) were classified as collective and seventy-nine clients (76 per cent) as individual exchangers. The mean number of supplied syringes over the 595 individual syringe exchange contacts is almost nine. For the 660 collective syringe exchange contacts this number is seventy-nine. Given the above definitions, it is no surprise that this difference is statistically significant (Table 18.1). During the research period a total number of 57,328 syringes were supplied, of which 91 per cent went out through the collective exchange. In total, 46,610 syringes were returned, which gives an exchange rate of 81.3 per cent. Profound differences in exchange rates were found between the two groups: 46.4 per cent for individual and 84.8 per cent for collective exchangers (Table 18.2).

0The programme's holding power was remarkable in retaining especially the collective exchangers. The mean number of contacts of individual exchangers is 73; for the collective exchangers this is 26.4 - a clear and statistically significant difference. Fifty-two per cent of the collective exchangers visited the programme twenty-five or more times. Moreover, the collective exchangers (only 24 per cent of the clients) accounted for 52.6 per cent of the total number of syringe exchange contacts. The mean number of days between each syringe exchange contact is 15.8. A breakdown for the days of the week does not show big differences in contact rate. Individual exchangers have their 'top day' on Thursday and collective exchangers on Friday.


To complement these results, the ethnographic fieldwork data provide insight into how the programme's goals are addressed in the networks of IDUs contacted by the programme. Although during the fieldwork places were visited where hygiene regarding injecting was poor, the impression is that users who are engaged in the collective exchange are more aware of risk behaviours and put more energy in health and hygiene, as can be seen in the following excerpts from fleidnotes:

1 R. is still cleaning up the room: 'It is always possible someone might call and I don't like this stuff laying around.' The syringes, swabs and other papers go into the plastic bag that's already filled with other used spikes, bloody swabs, etc. 'This is for Sak' (= worker of the neighbourhood exchange programme). For extra security C. takes off the needle from the syringe. Then he takes out the piston totally and puts the needle inside the syringe. Then he puts back the piston and presses it so the needle inside crumbles together. C. — 'Now nobody can hurt himself on it. You have to be aware, I think.'

2 When Freek had finished injecting he rubbed some Hyrudoid balsam on the needle wound. 'One of you guys want some too?' He asked Ronald and Frits. Frits took some of the ointment and rubbed it on his arm. 'It's good stuff for your veins,' said Frits. 'Yes, it also disinfects the wound,' Freek replied.

As ast many dealing addresses injecting the purchased drugs on the premises is not allowed, IDUs often go to a friend's place to inject. Karel is participating in the collective exchange and lets his friends 'get off' at his place:

3 Karel agrees to Jerry taking a shot at his place. Jerry wants to shoot up pure cocaine. He puts his spike on the table and asks Karel for a spoon. Karel asks: 'Is that an old spike you want to use ?' J. — 'Well, old, I've used it one time before, so it's still good for usage.' K. -'I've got some new ones left from HADON,' he hands one over to J., 'you want some more for tonight or the weekend ?' J. — 'If you can spare them I'll take some with me.' K. gives him four in total.

The syringes distributed through the collective exchange evidently are distributed beyond the user collectives. As well as for use on the spot they are distributed among other users to take home. There is even an exchange of new syringes between user collectives.

4 Harry left with a bunch of new syringes to go to the dealing place where Ronald and Frits had bought their dope. 'They have a shortage of shooters there,' he said before leaving.


When considering the programme's goals (extending the outreach component of the programme, stimulating the users to take an interest in their own health and that of other users) we feel that the programme is making an important contribution. In the evaluation study of the British syringe exchange schemes, a return rate of 62 per cent was found (Stimson et al., 1988). Often it is felt that a high return rate is due to strict rules regarding a one-for-one transaction. Our findings do not support this thesis. The high return rate of the collective exchange is not accomplished by strict rules but through trust, respect and a shared responsibility in combination with supplying the necessary tools for safe injecting practices. The retention rate of the collective exchangers can be regarded as very high compared to the results of the British evaluation study — 33 per cent over five visits (Stimson et al., 1991). An interesting difference is that between the busiest days of individual and collective exchange. On Thursday most addicts receive their social benefit and the individual exchange rises markedly. Friday, the day before the weekend, when the programme is closed, is the busiest day for the collective exchange. It seems that individual exchangers are driven more by situational determinants (the availability of money) and the collective exchangers have included getting clean syringes in their daily life as a planned activity. The ethnographic data show that the goals of the programme are positively anticipated in the injecting community. Clean syringes are at hand at high-risk places when needed, distributed through IDU networks and even exchanged among user collectives.

A disturbing factor: police raids on dealing addresses

A closer look at Table 18.2 shows that after a steady growth of the issued syringes from June 1988 to January/February 1989, in March/April an immense downfall occurs. This collapse can be attributed to increased police raids on dealing/using addresses in that period. While the collective exchange goes down 60 per cent from January to April, the individual exchange rises by almost 1,000 per cent (see italic numbers). This may be called a short-term effect as in the following months the individually issued syringes join the downward trend of the collective exchange. This is, however, due to the space reallocation of many of the regular visitors of the closed-down addresses towards the west and other parts of Rotterdam. And in this west part of Rotterdam recently history again repeated itself (Grund et al., 1991a). These findings not only support the assumption that many active IDUs are actually reached by the collective exchange; they also show that this kind of repressive police activity has a negative effect on AIDS prevention efforts (Des Jarlais and Friedman, 1990; Chitwood et al., 1990). In the spirit of the theme of the First International Conference on the Reduction of Drug-Related Harm, one might even speak of 'drug enforcement-related harm'. A fine tuning of public health and judicial policy in favour of an effective AIDS prevention policy is urgently needed.

In conclusion, our findings suggest that the exchanging of syringes can be made more effective by employing collective social means in contrast to individualistic psychological strategies. The use of 'naturalistic settings' (e.g., the placing of the plastic container at 'user collectives' and dealing addresses), existing drug user networks and appeals to injecting drug users' responsibility may be more powerful determinants of variations in syringe exchange rates than psychological characteristics of individuals. In any case, engaging drug users themselves as an integral part and partner of the outreach work provides an interesting topic for further investigation and development. In Rotterdam, it will be interesting to see in the future whether this human resource and social manner of exchanging will be more effective than more technologically inspired approaches (e.g. syringe exchanging machines) that are also planned for the city's AIDS prevention efforts.


This research was supported by a grant from the Nederlandse Organisatie voor Wetenschappelijk Onderzoek (Dutch Organization for Scientific Research), MEDIGON, Social Psychiatry Working Group (grant n. 900-556-046). Opinions expressed in the paper do not necessarily reflect the policy of the supporting organization. We thank the drug users who participated in this study for their cooperation.


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Our valuable member Jean-Paul Grund has been with us since Sunday, 19 December 2010.

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