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Abstract
In France a harm-reduction policy was implemented in the late 1980s with the aim of reducing the prevalence of HIV and hepatitis C virus (HCV) infection among drug users. The ANRS-Coquelicot survey was designed to measure the prevalence of HIV and HCV infection among drug users and to examine determinants of at-risk behaviors. In 2002, information was collected from 166 drug users recruited in all types of services specializing in drug use intervention and harm reduction in Marseille, France. Self-reported HIV and HCV serostatus was compared with the results of serological tests done on capillary blood collected on filter paper. The self-reported and biologically documented prevalence rates of HIV infection were identical (22%). In contrast, the self-reported prevalence of HCV infection was 52%, whereas the biologically documented prevalence was 73%. Overall, 30% of HCV-infected drug users were unaware of their status. Forty-four percent of drug users under 30 years of age were HCV seropositive, suggesting that they had been infected early during drug use. The harm-reduction policy seems to have had a marked impact on HIV transmission among drug users but a much more limited impact on HCV transmission. The limitations and implications of the study are discussed.
Notes
Drug users are defined here as “problem drug users” who take heroin or cocaine. “Problem drug users” are defined as individuals who seek health care or who are arrested by the police. This estimate is based on a capture-recapture study conducted in 5 cities (Toulouse, Lille, Lens, Marseille, and Nice) by the French Observatory on Drugs and Drug Users (OFDT) in 1999.
The relevant law, passed on 31 December 1971, is still in force and governs issues relating to illicit drug use in France. It is among the most repressive in Europe. It punishes the sale of drugs, without distinguishing between the different products. Personal use can lead to up to a year in prison but is generally punished by a fine or a community work order. “User-dealer” status, which includes people who buy small amounts of drugs for their friends, is more severely reprimanded.
Drug users were no longer obliged to accept withdrawal therapy to gain access to care facilities.
We do not deal here with the various European models of harm reduction.
This article is based on an epidemiological study restricted to the health impact of this public policy. The social, economic, and ethical aspects of the policy also need to be evaluated and analyzed but are not dealt with in the present article.
The French National Agency for AIDS Research (ANRS) is a publicly funded body created in 1992. It organizes, coordinates, and finances research on AIDS and hepatitis B and C in France and developing countries.
Sleep-ins are emergency accommodation centers reserved for drug users.. They are publicly funded and managed by associations. The staff include doctors and social workers.
Boutiques are daytime low-threshold centers where users can rest, eat, wash their clothes, and take a shower without being required or asked to give up drugs or seek employment. The only rules prohibit violence toward the staff and other users and drug consumption on the premises.
The scientific committee (see member list in the Acknowledgments) was composed of sociologists, anthropologists, epidemiologists, and statisticians.
SIAMOIS is a database managed by the French National Institute of Public Health Surveillance and designed to monitor pharmacy sales of opiate replacement therapy (methadone and Subutex) and syringes.
“Shooting rooms” are specially created places where drug users can go to inject in hygienic conditions, in order to avoid HIV and HCV infection, abscesses, etc. Clean materials are provided and medical staff are on hand. Such places exist notably in Germany and Switzerland.