Montreal Needle Exchange Participant's HIV Sero-Conversion Rate Twice That of Non-Exchange Participants, Says St. Luc Hospital Study; Health Officers Say More Programs, Services Are Needed

HARM REDUCTION January 1998

Needle-exchange participants in Montreal are more than twice as likely to get HIV than those who do not use such programs, according to a report in the American Journal of Epidemiology (Julie Bruneau, et al., "High Rates of HIV Infection Among Injection Drug Users Participating in Needle Exchange Programs in Montreal: Results of a Cohort Study," American Journal of Epidemiology, December 15, 1997, Vol. 146, No. 12, pp. 994-1002; Jeff Heinrich, "Needles Trade-In Failing," Montreal Gazette, December 15, 1997, p. A1; Catherine Porter and Jeff Heinrich, "Needle study backs B.C. experience," Vancouver Sun, December 15, 1997, p. B1).

Known as the St. Luc Hospital Study, this report says of 974 addicts studied between September 1988 and January 1995, 5.1% became infected with HIV each year. The yearly infection rate was 7.9% for those in exchange programs, compared with 3.3% for those who did not attend needle exchanges.

The study contradicts previous studies which found that needle-exchange programs are an effective way of limiting the spread of HIV because they reduce sharing of infected syringes. Scientific reviews of needle exchange studies by the federal Centers for Disease Control and Prevention, the Institute of Medicine, the National Institute of Health and the General Accounting Office have concluded that needle exchange programs effectively reduce HIV transmission without increasing drug use (see "Needle Exchanges Endorsed by NIH Panel, Federal Officials," NewsBriefs, March-April 1997).

According to the study, Montreal is an exception mainly because of a large increase in cocaine (instead of heroin) as the drug of choice of intravenous drug addicts. Researchers believe requent cocaine injectors are more likely to use each other's HIV-infected syringes when their supply of clean ones runs out or when they get too high to care. In the period studied before 1995, Montreal needle exchange programs only supplied a maximum of 15 syringes per individual a day. That number was far below demand, but since 1995, there has been no limit. Vancouver may have a similar problem. "The problem is the patients are using them 15 to 20 times a day, in runs of five to six days in a row, fixing the entire time,'' Dr. Stan de Vlaming, head of addictions medicine at St. Paul's Hospital, said. "You can bet at day two or day three they are not capable of making rational decisions."

In Vancouver, where HIV infection rates are high and 2.3 million syringes a year are given to addicts, experts say that more services are needed. Vancouver/Richmond regional medical health officer Dr. John Blatherwick said, to be effective, needle exchanges have to be complemented by other programs. "The needle exchange on its own means that's all the [services] addicts have, so over time they will end up getting AIDS. So that will be the impression -- that the needle exchange people have a higher percentage of AIDS than non-users,'' Blatherwick said. "Basically what we've said, though, is it isn't enough -- you have to have some treatment programs, outreach programs, methadone alternatives, all the things we're about to do in the Vancouver/Richmond health board.''

Lou Demerais, on the advisory committee of the Vancouver needle-exchange program, agreed. "Maybe we're now talking along the lines of medically supervised injection,'' said Demerais, also executive director of the Vancouver Native Health Society.

An American Journal of Epidemiology editorial and the St. Luc hospital report's authors agree that the solution to Montreal's problem is an increased number of needle-exchange programs. "What is needed to reduce the terrible toll of HIV among Montreal intravenous-drug users is not less needle exchange, but more," the editorial said. Principal author Julie Bruneau, a psychiatrist in St. Luc's detox center, said by not expanding the program earlier "we may have created problems as well.''

One problem suggested is a "networking" effect, whereby needle-exchange programs create meeting grounds for addicts who wind up sharing scarce needles. However, most of the clientele already know each other from the street, say Judy McGuire, who manages the Downtown Eastside Youth Activities Society's needle-exchange program in Vancouver, and Montreal needle-exchange director Mario Bilodeau.

Dr. Julie Bruneau - (514) 281-2121, ext. 5882.