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Commentary on Vorobjov et al., "Comparison of injection drug users who obtain syringes from pharmacies… Werb, Daniel; Wood, Evan Nov 27, 2009

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ralssBioMed CentHarm Reduction JournalOpen AcceCommentaryCommentary on Vorobjov et al., "Comparison of injection drug users who obtain syringes from pharmacies and syringe exchange programs in Tallinn, Estonia"Daniel Werb1,2 and Evan Wood*1,2Address: 1British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada and 2School of Population and Public Health, University of British Columbia, Vancouver, CanadaEmail: Daniel Werb - dwerb@cfenet.ubc.ca; Evan Wood* - uhri-ew@cfenet.ubc.ca* Corresponding author    AbstractRecent data suggest that globally, between 5% and 10% of all new HIV cases are the result of unsafeinjecting practices, and experts agree that reducing these practices is key to tackling the spread ofHIV. And yet, despite the overwhelming evidence that providing sterile syringes to injection drugusers (IDU) through syringe exchange programs (SEPs) or other means is an effective way ofreducing HIV transmission among high-risk subpopulations, IDU in most settings still do not haveaccess to sterile injecting equipment or if they do, access remains too restricted to effectivelyreduce the risk of HIV transmission. Vorobjov and colleagues have presented in this journal aninteresting and timely study from Estonia comparing individuals who obtain syringes from SEPs andthose who obtain syringes from pharmacies. As the authors point out, Estonia faces anunacceptably high HIV incidence rate of 50 new HIV cases per 100,000, this rate driven primarilyby injection drug use. As such, the authors argue that Estonia's SEP network does not have thecapacity to serve a growing IDU population at risk of transmitting HIV and pharmacy dispensationof clean syringes may be one potential approach to decreasing syringe sharing among high-riskinjectors. It may be overly optimistic to consider the impact of higher threshold interventions suchas pharmacy-based SEPs, given that IDU populations that engage in HIV risk behaviours such assyringe sharing are often hidden or hard to reach. Despite the need for a cautious approach,however, the findings presented by Vorobjov et al. may chart one potential course towards a morecomprehensive societal response to reducing the health harms associated with injection drug use.A global consensus has been reached regarding the pri-mary role of syringe sharing in driving the HIV epidemicamong injection drug users (IDU), and there is growinginternational recognition of the interventions required toaddress this public health crisis. Recent data suggest thatglobally, between 5% and 10% of all new HIV cases arespread of HIV. Despite this scientific consensus, there stillexists a shortage of resources allocated towards the scale-up of interventions to address the harms associated withsyringe sharing. For instance, while approximately 83% ofall countries reporting HIV-infection among IDU subpop-ulations have at least one syringe exchange programPublished: 27 November 2009Harm Reduction Journal 2009, 6:33 doi:10.1186/1477-7517-6-33Received: 22 July 2009Accepted: 27 November 2009This article is available from: http://www.harmreductionjournal.com/content/6/1/33© 2009 Werb and Wood; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 2(page number not for citation purposes)the result of unsafe injecting practices [1,2], and expertsagree that reducing these practices is key to tackling the(SEP), certain regions such as Eastern Europe and theformer Soviet Union continue to report that 70% to 90%Harm Reduction Journal 2009, 6:33 http://www.harmreductionjournal.com/content/6/1/33of all HIV infections are the result of injection drug use[2]. This problem persists despite the fact that the WorldHealth Organization and a number of other multilateralorganizations and national public health authorities haveendorsed SEPs as a simple method of reducing the risksfor HIV transmission associated with syringe sharing [1].And yet, despite the overwhelming evidence that provid-ing sterile syringes to IDU through SEPs or other means isan effective way of reducing HIV transmission amonghigh-risk subpopulations [3], IDU in most settings still donot have access to sterile injecting equipment or if theydo, access remains too restricted to effectively reduce therisk of HIV transmission [4].This is of concern, particularly in light of the many inter-ventions available to policymakers considering how bestto distribute sterile syringes to different IDU subpopula-tions. For example, Riley and colleagues found that first-time syringe exchange participants who acquired sterilesyringes from mobile sites (i.e., syringe exchange vans) inBaltimore were more likely to be frequent injectors, sug-gesting that these interventions may effectively targethighly dependent individuals [5]. Other researchers haveconfirmed that, while IDU accessing SEPs often havehigher risk profiles for the transmission of HIV and otherblood-borne diseases, SEPs themselves are an efficientmeans of reducing health risks among hard-to-reach, stig-matized, and hidden populations [6,7].Vorobjov and colleagues have presented in this journal aninteresting and timely study from Estonia comparing indi-viduals who obtain syringes from SEPs and those whoobtain syringes from pharmacies [8]. As the authors pointout, Estonia faces an unacceptably high HIV incidencerate of 50 new HIV cases per 100,000, this rate driven pri-marily by injection drug use. As such, the authors arguethat Estonia's SEP network does not have the capacity toserve a growing IDU population at risk of transmittingHIV. Within this context, the study investigated whetherpharmacies that dispensed sterile injecting equipmentcomplement SEPs in serving the needs of Estonian IDU,and whether differences exist between individuals thatprimarily use SEPs compared with those that primarilyuse pharmacies to acquire sterile injecting equipment.In their analysis, Vorobjov and colleagues found that indi-viduals who reported using pharmacies as their primarysource of sterile equipment exhibited lower risks of HIVtransmission than IDU who primarily used SEPs. Likemany studies of IDU, this study is limited by its cross-sec-tional design and its use of non-random sampling. Aswell, the possibility exists that the merging of users ofSEPs and pharmacies within the sample may have led tomacies in playing an early preventive role in limiting therisk trajectory of IDU, and it does so in a region that ishard hit by an injection-fuelled HIV epidemic and is inneed of epidemiologic research. If, as the authors suggest,IDU who visit pharmacies represent a subpopulation atan earlier stage of their injecting careers, pharmacies couldplay a key role in connecting IDU to treatment such asmethadone and preventive services prior to a transition toriskier use of injection drugs [9]. If feasible, pharmaciescould also be potential locales for the provision of addic-tion treatment, counseling, detoxification referral, orsocial services. Further longitudinal research in this area istherefore needed.The limits of SEPs in servicing IDU are well-known [10].As such, it may be overly optimistic to consider the impactof higher threshold interventions such as pharmacy-basedSEPs. Despite the need for a cautious approach, however,the findings presented by Vorobjov et al. may chart onepotential course towards a more comprehensive societalresponse to reducing the health harms associated withinjection drug use, and could also hold lessons for policy-makers and health authorities in other settings that maybe struggling to reduce the transmission of HIV amonghard to reach IDU populations.References1. World Health O: Harm reduction approaches to injecting druguse.  Geneva: World Health Organization; 2006. 2. Aceijas C, Hickman M, Donoghoe M, Burrows D, Stuikyte R: Accessand coverage of needle and syringe programmes (NSP) inCentral and Eastern Europe and Central Asia.  Addiction 2007,102:1244-1250.3. Cooney A, Wodak A: Effectiveness of sterile needle and syringeprogramming in reducing HIV/AIDS among injecting drugusers.  2004.4. Wolfe D, Malinowska-Sempruch K: Illicit drug policies and theglobal HIV epidemic: Effects of UN and national governmentapproaches.  New York: Open Society Institute; 2004:1. 5. Riley ED, Mahboobeh S, Strathdee SA, Marx MA, Huettner S, Beilen-son P, Vlahov D: Comparing new participants of a mobile ver-sus a pharmacy-based needle exchange program.  JAIDS 2000,24:57-61.6. Broadhead RS, Kerr TH, Grund J-pC, Altice FL: Safer InjectionFacilities in North America: their Place in Public Policy andHealth Initiatives.  Journal of Drug Issues 2002, 32:329.7. Jurgens R, Kerr T, Lines R, Stover H, Laticevschi D, Nelles J: Prisonneedle exchange: Lessons from a comprehensive review ofinternational evidence and expertise.  Toronto: Canadian HIV/AIDS Legal Network; 2006:1. 8. Vorobjov S, Uuskula A, Abel-Ollo K, Talu A, Ruutel K, Des Jarlais D:Comparison of injecting drug users who obtain syringesfrom pharmacies and syringe exchange programs in Tallinn,Estonia.  Harm Reduction Journal 2009:6.9. World Health Organization UNOoDaCU: Substitution mainte-nance therapy in the management of opioid dependence andHIV/AIDS prevention: position paper.  2004.10. Jurgens R, Ball A, Verster A: Interventions to reduce HIV trans-mission related to injecting drug use in prison.  Lancet Infect Dis2009, 9:57-66.Page 2 of 2(page number not for citation purposes)unmeasured confounders. Nevertheless, it presentsimportant new data and highlights the potential of phar-


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