HIV transmission by contaminated needles and syringes among injecting drug users (IDUs) is one of the three main modes of transmission that fuel the HIV pandemic. Needle exchange programmes (NEPs) were adopted to reduce HIV transmission in this risk group. The aim of this review was to investigate evidence for the effectiveness of NEPs.

Literature searches were conducted covering articles published until December 2005. In the final selection only studies using HIV incidence or prevalence data as outcome variables were included. Nine studies presented data addressing the effect of NEPs on HIV incidence. Seven of these studies showed no significant effect, one showed a positive and one an unfavourable effect. Three looked at HIV prevalence at baseline, all showing an unfavourable effect. The method used in three ecological studies that investigated changes in HIV prevalence in cities with and without NEPs have drawbacks, and the results should not be used as evidence for the effectiveness of NEPs.

The effectiveness of NEPs to prevent HIV transmission among IDUs is overrated in previous reviews. The conclusion that NEPs are the superior method for preventing HIV transmission among IDUs may have delayed the implementation of more effective and integrated methods.

Research has overwhelmingly supported the proposition that safe injection facilities (SIFs) are successful in meeting their stated objectives. However, the methodological and analytic approaches used in these studies have not been scrutinized to any significant degree. Previous studies are compromised by an array of deficiencies, including a lack of baseline data, insufficient conceptual and operational clarity, inadequate evaluation criteria, absent statistical controls, dearth of longitudinal designs, and inattention to intrasite variation. This review suggests that much of the commonly-cited evidence regarding the effects of SIFs cannot be substantiated. Disentangling complicated casual mechanisms first requires that the identified shortcomings be addressed.

The Public Health Dangers of Drug Abuse in Prisons
Ian Oliver

Globally, many prisons are failing to ensure adequate policies to deal with health, sexual behaviour and the use of illicit drugs by prisoners with the result that they are little more than incubators for serious diseases such as AIDS/HIV and Hepatitis C. It seems that the individual human rights of prisoners are outweighing the public health interests of the wider communities, and the misuse of harm reduction policies in some prisons gives rise to profound concern and raises the question of State approved drug abuse. This in turn begs the question of whether a policy of zero tolerance of drugs in prisons is possible or desirable and what are the long-term consequences of failing to deal with this problem.

The history of ‘so-called harm reduction’ - starting with its conception in and dissemination from the Liverpool area of Britain in the 1980s - is described in comparison with American liberalisers’ ‘Responsible Use’ stratagem in the 1970s and with subsequent so-called Harm Reduction initiatives in various countries. The text takes extracts from or synopses of papers presented by various writers on both sides of the argument. As the scope of a historical review of Harm Reduction - over several decades and across several countries - is necessarily large, this paper is presented in 3 parts. Part 1 examines the developments in the USA; whilst Part 2 looks at Britain, Canada, and Australia. Part 3 considers mainland Europe, and then goes on to explore reasons why the package called ‘Harm Reduction’ has fared better than ‘Responsible Use’ as well as some possible reasons why the present, Harm-Reduction-biased situation has come about. The paper concludes by suggesting possible ways forward for those advocating a prevention-focused approach – learning from history.

Medical Research
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International Drug Policy
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In the News
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A recent RAND study found that youths who abstain from marijuana use had better outcomes as young adults  More