Stimson G V
Department of Psychiatry, Charing Cross and Westminster Medical School, University of London, England.
Soc Sci Med. 1995 Sep;41(5):699-716. doi: 10.1016/0277-9536(94)00435-v.
This paper assesses policy development, service changes and trends in HIV infection and risk behavior among injecting drug users (IDUs) in the United Kingdom. In 1986, the U.K. was faced with the possible rapid spread of HIV infection among IDUs. The combination of an outbreak of HIV infection with prevalence levels of 50% or more in Edinburgh, the recent diffusion of drug injecting, and high levels of syringe-sharing risk behaviour, suggested that HIV infection might spread rapidly through IDU populations. HIV prevention activities commenced in 1986 and developed in 1987. The first report on AIDS and Drugs Misuse by the Advisory Council on the Misuse of Drugs in 1988 was a major catalyst for change. It supported and legitimized emergent views on new ways of working with drug users. Between 1988 and 1993 innovative public health projects increased the ability to target vulnerable populations through syringe distribution, expansion of methadone treatment and outreach to hard-to-reach populations. There were major changes in service philosophy and practices, as ideas of harm minimization, accessibility, flexibility and multiple and intermediate goals were developed. There is evidence that these public health projects encouraged extensive changes in the health behaviour of IDUs. There have been major reductions in syringe-sharing risk behaviour and sharing syringes is no longer the norm. Evaluation of specific interventions (e.g. syringe-exchange) shows their importance in encouraging reductions in risk behaviour. Levels of HIV infection in IDUs remain low by international standards. Outside of London rates of about 1% have been reported; London has a low and declining prevalence of infection to around 7% in 1993; previous high levels in Edinburgh (55%) have since declined to 20%. Britain has to date avoided the rapid increase in HIV infection among injectors that has occurred in many parts of the world. The same period saw the continuation of high prevalence levels in New York and many European cities, and the explosive spread of HIV in many countries in south-east Asia. This paper acknowledges the difficulties is proving links between social interventions and epidemic prevention. It argues that there is prima facie evidence for the success of public health prevention, that the collection of intervention approaches in the U.K. had a significant impact on IDUs behaviour, and that this has helped prevent an epidemic of HIV infection among IDUs. The U.K. experience adds to the growing evidence of the significance of early interventions in encouraging behaviour change and in limiting the spread of HIV infection.
本文评估了英国注射吸毒者（IDU）中艾滋病病毒（HIV）感染及风险行为方面的政策制定、服务变化和趋势。1986年，英国面临HIV感染在注射吸毒者中可能迅速传播的情况。HIV感染疫情在爱丁堡爆发，感染率达50%或更高，加之近期注射吸毒行为的扩散以及注射器共用风险行为的高发，这表明HIV感染可能会在注射吸毒者群体中迅速传播。1986年开始了HIV预防活动，并在1987年得到发展。1988年药物滥用咨询委员会发布的首份关于艾滋病与药物滥用的报告成为变革的主要催化剂。它支持并使关于与吸毒者合作新方式的新兴观点合法化。1988年至1993年间，创新性公共卫生项目通过注射器分发、扩大美沙酮治疗以及向难以接触到的人群开展外展服务，增强了针对脆弱人群的工作能力。随着危害最小化、可及性、灵活性以及多重和中间目标等理念的发展，服务理念和实践发生了重大变化。有证据表明，这些公共卫生项目促使注射吸毒者的健康行为发生了广泛改变。注射器共用风险行为大幅减少，共用注射器已不再是常态。对特定干预措施（如注射器交换）的评估表明了它们在鼓励降低风险行为方面的重要性。按照国际标准，注射吸毒者中的HIV感染水平仍然较低。据报告，伦敦以外地区的感染率约为1%；伦敦的感染率较低且呈下降趋势，到1993年降至约7%；爱丁堡先前的高感染率（55%）此后已降至20%。英国迄今避免了世界许多地区注射吸毒者中HIV感染迅速增加的情况。同一时期，纽约和许多欧洲城市的感染率持续处于高位，HIV在东南亚许多国家呈爆发式传播。本文承认证明社会干预与疫情预防之间联系存在困难。它认为，有初步证据表明公共卫生预防取得了成功，英国所采用的一系列干预措施对注射吸毒者的行为产生了重大影响，并且这有助于预防注射吸毒者中HIV感染的流行。英国的经验进一步证明了早期干预在鼓励行为改变和限制HIV感染传播方面的重要性，并为此提供了越来越多的证据。
