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Tuesday 13 May 2008 – DAY THREE –
Daily Update
– 3
‘From the outset we were operating in a
highly politicised environment,’ assistant
professor in the University of British
Columbia’s department of medicine,
Thomas Kerr, told delegates in his sess-
ion on the science and politics of evaluat-
ing Vancouver’s safer injection facility.
Opened in 2003, Insite was North America’s
first supervised injection facility. Launched as a
pilot, it was allowed to operate as long as it was
robustly evaluated and, given the controversy
surrounding the venture, every possible step
was taken to ensure scientific rigour and
maximum transparency. ‘There was a require-
ment that all data be peer reviewed,’ he said.
‘But before the evaluation produced any results
the political fireworks started.’ There were even
accusations of ‘state sponsored suicide.’
Research, however, showed that the
facility did ‘everything people expected it to’,
with reductions in HIV risk behaviour and
public disorder, increased uptake of detox
programmes and no increase in drug-related
crime. Furthermore there was successful
management of more than 1,000 overdoses
with no deaths.
‘We held a press conference in 2006 and
said that based on the evidence the facility
should remain open,’ he said. ‘This is when
things really got ugly.’ An application was
made for funding for a further three and a half
years, but by now Drug Free America, the
International Narcotics Control Board, the
Canadian Police Association and the Royal
Canadian Mounted Police and others had
become involved, the latter going so far as to
fund its own reports which were then leaked to
the media. The Canadian Police Association
issued a press release calling for the facility to
be closed, while The International Narcotics
Control Board declared that supervised
injection facilities were in violation of
international drug laws.
Despite the fact that polls showed that more
than 70 per cent of the local population
supported it, the health minister elected not to
renew funding. There was an outcry from the
scientific community, with the decision branded
a ‘policy horror story’ and claims that funding
had been discontinued for political purposes.
‘We have documented examples of interfer-
ence in the independent peer review process,’
he said. ‘There was a halting of research, the
placement of gag orders on new research and
the government worked to manufacture
uncertainty and create “paralysis by analysis”.’
People had questioned whether it was right for
him to comment on the political wranglings, he
told delegates. ‘But scientists have a right and
an obligation to enter the political debate.’
‘Paralysis by analysis’ derailed injection facility
‘We need to do more than give out syringes and verbal
messages,’ executive director of the US Harm Reduction
Coalition Allan Clear told delegates at Monday’s
evidence in
harm reduction
session. His presentation focused on the
reduction of HIV and hepatitis C following the implementation
of a large scale needle exchange programme in New York.
The study had looked at 600 subjects per year between 1990,
when the exchange had begun, and 2007. ‘We ran underground
exchange programmes before being legalised by the state department
of health in 1992,’ he said. ‘It was scaled up in 1995.’ While hep C
prevalence among HIV positive subjects in the early 1990s was 100
per cent, this had reduced to 82 per cent by the start of the 21st
century. ‘Still way too high,’ he said. Among the HIV negative
population, however, it fell from 91 per cent to 62 per cent in the same
period and among new injectors – those injecting for six years or less –
there was a dramatic fall from 80 per cent to 38 per cent.
‘Trends of hep C went down when we started to scale up the
needle exchange and there was more liberal access to syringes,’
he said. ‘The best measure of how to go forward is to look at new
injectors since the scale up and keep monitoring them, as they will
have spent their entire injection careers in an environment with
relatively good access to legal syringes.’ Social marketing with hep
C rather than HIV at its core was essential, he stressed. ‘If you can
prevent the spread of hep C, you can prevent the spread of HIV.’
Senior lecturer at the London School of Hygiene and Tropical
Medicine, Peter Vickerman, focused on the joint impact of hep C
and HIV harm reduction interventions across the globe. ‘There is
evidence that harm reduction interventions reduce HIV transmission
but little evidence that they reduce hep C transmission,’ he said.
His study had compared the impact of interventions in Dhaka,
Moscow, Rawalpindi, Togliati and Svetlogorsk – areas ranging from
low prevalence of HIV and hep C to almost saturation point, and
including sub groups of high, low and non frequency sharers.
‘The greatest impact you can achieve is early in the epidemic for
both HIV and hep C. However, the cost effectiveness of
interventions will be highly context-specific.’
The modelling had been limited by data uncertainty, he said, but
despite this it gave interesting insights. ‘The impact on HIV and hep
C incidence and cost effectiveness is highly variable,’ he said. ‘You
can’t expect the same impact every time.’ Far greater coverage
and activity would be required to reduce HIV prevalence and
incidence, he stressed.
How effective are interventions in
cutting HIV and hep C prevalence?
‘If you can prevent the
spread of hep C, you can
prevent the spread of HIV.’