NEEDLE EXCHANGE IS NOT ENOUGH - LESSONS FROM THE VANCOUVER INJECTING DRUG-USE STUDY

Objective: To describe prevalence and incidence of HIV-1, hepatitis C virus (HCV) and risk behaviours in a prospective cohort of injecting d rug users (IDU).Setting: Vancouver, which introduced a needle exchange programme (NEP) in 1988, and currently exchanges over 2 million needl es per year. Design: IDU who had injected illicit drugs within the pre vious month were recruited through street outreach. At baseline and se mi-annually, subjects underwent serology for HIV-1 and HCV, and questi onnaires on demographics, behaviours and NEP attendance were completed . Logistic regression analysis was used to identify determinants of HI V prevalence. Results: Of 1006 IDU, 65% were men, and either white (65 %) or Native (27%). Prevalence rates of HIV-1 and HCV were 23 and 88%, respectively. The majority (92%) had attended Vancouver's NEP, which was the most important syringe source for 78%. Identical proportions o f known HIV-positive and HIV-negative IDU reported lending used syring es (40%). Of HIV-negative IDU, 39% borrowed used needles within the pr evious 6 months. Relative to HIV-negative IDU, HIV-positive IDU were m ore likely to frequently inject cocaine (72 versus 62%; P < 0.001). In dependent predictors of HIV-positive serostatus were low education, un stable housing, commercial sex, borrowing needles, being an establishe d IDU, injecting with others, and frequent NEP attendance. Based on 24 seroconversions among 257 follow-up visits, estimated HIV incidence w as 18.6 per 100 person-years (95% confidence interval, 11.1-26.0). Con clusions: Despite having the largest NEP in North America, Vancouver h as been experiencing an ongoing HIV epidemic. Whereas NEP are crucial for sterile syringe provision, they should be considered one component of a comprehensive programme including counselling, support and educa tion.