Transmission of HIV among drug addicts in three French cities: implications for prevention

Sections

ABSTRACT
Introduction
Methodology
Description of the population
Health data
Practices relating to syringe use
Sexual behaviour
Serological status and changing risk behaviours
Qualitative results
Discussion
Conclusion

Details

Author: F. R. INGOLD , M. TOUSSIRT
Pages: 117 to 134
Creation Date: 1993/01/01

Transmission of HIV among drug addicts in three French cities: implications for prevention *

F. R. INGOLD
M. TOUSSIRT **
Institute for Epidemiological Research on Drug Dependence, Paris

ABSTRACT

In 1988, the Institute for Epidemiological Research on Drug Dependence conducted an ethnographic study designed to assess the results of liberalization of the sale of syringes. In that study, drug addicts were found to have gradually altered their customary practices by limiting the sharing of syringes. Two years later, a second study was conducted to further assess the behavioural changes under way. The whole survey covered 359 subjects - 165 in Paris, 110 at Marseille and 93 at Metz.

Almost all the subjects stated that they knew about the risks of transmission of the human immunodeficiency virus (HIV) by needle and during unprotected sexual intercourse. Almost all of them (98 per cent) knew that syringes were freely sold at pharmacies. Most of them (84 per cent) felt that they were generally well informed on the subject of AIDS and the ways in which the virus was transmitted. Prostitutes accounted for17 per cent of the sample, with more women (32 per cent) than men (13 per cent) included in that category.

The overwhelming majority of the subjects bought their syringes at pharmacies, and the trend towards the non-sharing of syringes was confirmed, a change in behaviour that has emerged mainly since 1987. Among the "new generation" of drug addicts, namely those who began to inject after 1987, the changes are reflected in a much lower rate of infection - 2 per cent instead of 28 per cent of the total.

About a third of the subjects, however, continued to engage in practices involving a certain level of risk. In a global context, including subjects who do not know how to properly clean a syringe, a variety of usually ineffective practices are followed, for example rinsing with water, lemon juice, or scent.

* Study financed by the agency national de recherche sur le SIDA (National Aids Research Agency) of France.

** The study was carried out in cooperation with C. Jacob (Centre hospitalier spcialis), P. Petit (Charonne Association, Paris) and M. Prat (Intersecteur spcialis). The field study was conducted with contributions from M. Bolinches (Marseille), D. Bombardier (Metz) and A. Chaoui (Paris).

The use of bleach remained limited, and few people considered cleaning with it.

Liberalization of the sale of syringes seems to be essential to the prevention of AIDS among drug addicts. But this measure is not enough in itself. Apart from the overall problems of looking after the health of drug addicts and ensuring access to medical care, certain specific measures remain highly desirable. Of particular importance is the dissemination of information clearly describing effective methods of sterilizing syringes (including the use of bleach).

Introduction

In France, the first effective measure taken to prevent AIDS among drug addicts was the liberalization of the sale of syringes in pharmacies (introduced in May 1987). A preliminary evaluation of the impact of liberalization of the sale of syringes was conducted in 1988, on the basis of a survey carried out in five French cities [ 1] .

The work described in the present paper constitutes a follow-up to the preliminary evaluation. It was carried out in 1990/91 in three French cities, Marseille, Metz and Paris. The purpose was to study the present situation as regards the practices, attitudes and perceptions of drug addicts in connection with the risk of RIV transmission. Two features were singled out, the use of syringes and sexual behaviour. Both studies were conducted using the same methods. In each of the cities concerned, two sectors were investigated: an institutional sector (specialized health- care facilities at Marseille and Metz and at the Charonne Association in Paris) and a street sector. The studies were thus based on a double sample: one for addicts undergoing or starting treatment, and one for active addicts encountered in the street.

Methodology

The study conducted in 1990/91 was performed in three cities, Marseille, Metz and Paris. The methodology used was comparable to that applied in 1987/88 in Paris and at Bordeaux, Marseille and Metz: the subjects studied were taken from the streets and from the treatment centres involved; the sample related only to consumers of illicit drugs using syringes; the questionnaires used were identical in all cases.

The 1990/91 study involved 359 subjects: 156 in Paris, 110 at Marseille and 93 at Metz. Of these, 156 were interviewed in medical institutions (specialized joint services at Metz and Marseille, and the Charonne Association in Paris), while 203 were encountered in the streets.

The questionnaire used was intended to gather general data on the subjects (age, sex, social and cultural background, financial and professional status, drugs consumed, frequency of use, legal record etc.), together with more specific information on current practices regarding purchase and use of syringes and condoms.

The qualitative approach centred mainly on semi-structured interviews. In the interviews, the subject was encouraged to recall the principal stages of his or her history of drug consumption and addiction; the subject was then questioned on individual practices relating to the purchase and use of syringes and condoms, on sexual practices and, in a more general manner, on the topic of "risk reduction". Finally, a. large number of field observations were carried out, imparting a largely ethnographic dimension to the study.

Description of the population

Age and sex

The data for 1987/88 and 1990/91 covered almost identical samples: 73 per cent of men and 27 per cent of women, with an average age of 27.5 years (ranging from 17 to 48). The distribution was approximately the same for the three cities and the two sectors (street and establishment).

Nationality

Eighty-eight per cent of the subjects were French, most of the rest being Algerian (4.5 per cent), Moroccan (2.2 per cent), Italian (1.7 per cent) and Portuguese (1.1 per cent). There was no significant difference in sampling between the 1987/88 and the 1990/91 studies, or between the cities.

Residence

Thirty-one per cent of the subjects had their own home and 35.2 per cent lived with their relatives. In one third of the cases (33.8 per cent), the subjects were without any fixed abode.

Educational level

A majority of the subjects (85.5 per cent) had received secondary education. However, as with the 1987/88 study, the lower echelon of secondary education predominated, covering about two thirds of the sample.

Family status

Most of the subjects were unmarried (62.7 per cent), persons living together accounted for 27.9 per cent, and 9.4 per cent were divorced or separated. In 29 per cent of the cases, they had one or more children. in the 1987/88 study, a similar proportion (26 per cent) of subjects had one or more children. The family status of the subjects was characterized by broken relationships and the need to live with relatives (45 per cent of the cases).

Social and professional status

A substantial number (35 per cent) of subjects were unemployed or drawing unemployment benefits (34 per cent). The most frequent social background of the parents and relatives was that of worker and employee in a disadvantaged social context: 33 per cent of the fathers were unemployed, retired or disabled. In 29 per cent of the cases the father was dead or unknown.

Drugs consumed

Among the drugs consumed at the time of the survey, heroin predominated (91 per cent), followed by cannabis (48 per cent) and cocaine (22 per cent). The subjects were "active" addicts, that is, persons taking drugs at the time of the survey and for the most part on a daily basis. Among the substances consumed, pharmaceuticals (40 per cent) played a significant part.

Treatment

In the medical history of the subjects, rehabilitation treatments were mostly undergone in specialized establishments (35 per cent of the cases), in psychiatric hospitals (27 per cent), and in internal medicine clinics (22 per cent). Use of health centres by subjects from the streets was less than that by subjects lodged in institutions at the time of the survey.

Imprisonment

Out of all the subjects, 196 (or 54 per cent) had been imprisoned at least once, 69 of whom (or 35 per cent) were HIV-infected. On the other hand, among the subjects who had not been in custody, HIV seroprevalence was 20 per cent. This represents a significant difference.

Health data

Subjects' knowledge of AIDS

Almost all subjects stated that they were aware of the risks of the transmission of HIV by needle and during unprotected sexual intercourse. Nearly all (98 per cent) were familiar with the free sale of syringes in pharmacies. Most of them considered that in general they were well- informed (84 per cent), their sources of information being most frequently the media (46 per cent), the medical world (19 per cent) and by word of mouth (11 per cent).

Principal disorders

Taken as a whole, the subjects were highly prone to illnesses and accidents. Two thirds of them (65.7 per cent) mentioned at least one illness in the recent past. Overdoses and comas affected 42 per cent of the sample, and 27 per cent had attempted suicide. The illnesses most frequently mentioned were as follows: dental problems (60 per cent); various forms of hepatitis (41.5 per cent); abscesses (18 per cent); and sexually transmitted diseases (8.6 per cent). Traffic accidents were also frequent: 30 per cent.

Such problems occurred much more frequently among seropositive and AIDS subjects than among seronegative persons. Hepatitis (57 per cent as against 36 per cent), abscesses (29 per cent as against 14 per cent), sexually transmitted diseases (13 per cent as against 6 per cent) and dental problems (69 per cent as against 57 per cent) represented the most significant disorders.

Serological status

The great majority of subjects (82.5 per cent of the total sample) had undergone a screening or detection test, 95 of whom were seropositive, or 26.5 per cent of all subjects and 32.1 per cent of the subjects screened. Taking into account the seven AIDS patients, a seroprevalence of 28.5 per centof the total sample, and of 34.5 per cent of those who had undergone a screening test, was thus recorded.

The seroprevalence in the second study was comparable to that of 1987/88, or even slightly less: out of a sample of 280 subjects, 28 per cent were seropositive, or 36 per cent in relation to only the subjects having been screened, and 40 per cent if the AIDS patients are added. However, for a significant number of subjects (68, or 19 per cent), the last screening test was already old, having taken place more than a year earlier. For 63 subjects (17.5 per cent), moreover, the screening test had never been carried out. Therefore, for 36.5 per cent of the sample, the serological status was in fact uncertain (29 per cent in 1987/88).

In the streets, seroprevalence was lower (21.7 per cent) than in specialized establishments (37.2 per cent). Small regional variations were observed: 33.6 per cent at Marseille, 29.5 per cent in Paris and 20.4 per cent at Metz (see table 1).

Table 1. Seroprevalence in sample by city and by sector

 

Seropositives and AIDS patients

Uncertain serological status

Seronegatives

City

Sample Size

Percentage

Number

Percentage

Number

Percentage

Number

Marseille
110 33.6 37 38.2 42 28.2 31
Metz
93 20.4 19 46.3 43 20.4 31
Paris
156 29.5 46 29.5 46 41 64
Total
359 28.4 102 36.5 131 35.1 126

Practices relating to syringe use

Purchase

Most subjects (95 per cent) stated that they themselves bought their syringes at pharmacies (compared with 89 per cent in 1987/88). Of that number, 80 per cent always went to pharmacies to purchase their syringes, and 15 per cent did so occasionally (see table 2).

Table 2. Purchase of syringes in pharmacies

 

Cases observed

Percentage by sector

Practice described

Number

Percentage of sample

Street

Institution

Purchase at pharmacy
334 95.4 98.0 92.0
Always
280 80.0 79.0 81.3
Occasionally
50 14.3 18.0 9.3
Once or twice
4 1.1 1.0 1.3
Never
16 4.6 2.0 8.0
Do not lend
225 67.4 66.3 68.8
Lend
35 10.5 7.6 14.5
Give away
25 7.5 9.7 4.3

Sharing

In the case of 67.3 per cent of the subjects, purchase of the syringe was accompanied by its strictly personal use; they never lent or gave away their syringes. Hence, there has been some progress as regards "non-sharing" by comparison with 1987188, namely from 52 per cent to 67.3 per cent. Moreover, lending, giving and borrowing are somewhat infrequent practices. Those (38.4 per cent) who stated that they used or had used syringes which they had not purchased themselves did or had done so rarely (21.7 per cent), from time to time (12.8 per cent) or regularly (3.9 per cent). The estimate of 67.3 per cent for "non-sharing" is therefore a realistic figure which clearly indicates "non-sharing" of syringes in the case of a majority of subjects, and a tendency on the part of subjects to reduce both "sharing" practices and the frequency of "sharing".

There were no regional differences with regard to the frequency of "non-sharing", neither was there any very significant difference between the two sectors, that of the street (66..3 percent) and that of establishments (68.8 per cent). However, the frequency of "non-sharing" differed somewhat, depending on serological status: it was 77.3 per cent with seronegatives, 61.2 per cent with persons whose status was uncertain, and 62.3 per cent with seropositive subjects and patients.

Precautions taken

As in 1987/88, syringes were subjected to various kinds of treatment, indicating a general consciousness of hygienic considerations. Most subjects (67 per cent) claimed to take such precautions. Most frequently (41 per cent of cases), the syringe was simply rinsed with water. In a small number of cases, the syringe was cleaned with bleach (18 per cent) or boiled (6 per cent). These more effective practices (use of bleach or boiling water) were encountered most frequently among seronegative persons (20 and 10 per cent respectively), and less frequently among seropositives and AIDS patients (9 and 3 per cent) (see table 3).

Table 3. Precautions taken

Cleaning method or agent

Number

Percentage of sample

Seropositives and AIDS patients (Percentage)

Uncertain serological status (Percentage)

Seronegatives (Percentage)

Washing in water
100 41.5 40.9 44.6 39.1
Alcohol, perfume
46 19.1 12.1 22.9 20.7
Bleach
43 17.8 9.1 21.7 20.7
Boiling
15 6.2 3.0 4.8 9.8
Lemon and water
7 2.9 3.0 4.8 1.1

Trends

Among those who claimed to have given up any sharing of needles, such abandonment had occurred mostly since 1987 (51 per cent). Hence, there has been a repetition of the 1988 findings, namely that behavioural changes set in fairly recently, having started in 1983, and having gained considerably in momentum since 1985, 1986 and 1987. This applies in general to the entire sample, irrespective of age, sex, drugs used or serological status.

Sexual behaviour

Sexual partners

The majority of subjects (57 per cent) stated that they had a regular sexual partner. There were no differences between the regions, the sectors or the three groups broken down by serological status. The partners were addicts in 39.6 per cent of the cases, most of them practising intravenous injection (33.8 per cent). In 11.6 per cent o cases the partners were seropositive or ill. In 10.1 per cent of cases the serological status of the partner was unknown.

Sexual relations

In most instances the subjects were leading an active sexual life (78 per cent), and only 15 per cent were totally abstinent. Abstinence was mainly encountered among seropositives and AIDS patients (21 per cent), and less frequently among seronegatives (9 per cent). Homosexual relations were reported in the case of 15 per cent of subjects, mainly men (10 per cent). Such relations were most frequently described as occasional (10 per cent).

Purchase and use of condoms

In 1987/88 a small proportion of subjects stated that they bought or had bought condoms (22 per cent), but that the practice was recent (80 per cent as from 1986) and usually occasional. In 1990/91, the corresponding proportion of subjects purchasing condoms had increased to 45 per cent; half of them (23 per cent) used them regularly. The practice of purchasing condoms was fairly recent: 70 per cent since 1987. There has thus been a very clear development in behaviour, particularly in the case of seropositives and AIDS patients; regular use was encountered in 43 per cent of this group, and in 15 per cent of those who were seronegative or whose serological status was uncertain.

Prostitution

Prostitution [ 2] , [ 3] affected 17 per cent of the subjects, being more frequent among women (32 per cent) than men (13 per cent). In 50 per cent of case6 it was being currently practised, mostly on a casual basis. Of this group, 56 per cent claimed always to take precautions, and in this case condoms were always used (100 per cent). Insistence on the use of condoms appears to be more frequent in the case of women (59 per cent) than in that of men (41 per cent). These observations therefore confirm what is generally thought about prostitution among drug addicts: it affects both sexes, tends to be casual, and frequently (44 per cent of cases) takes place without the use of a condom.

Prostitution was found more often in the street sample (21 per cent) than in the establishments sample (11 per cent). Broken down by region, it was more frequent in Paris (25 per cent of subjects) than at Marseille (12 per cent) or Metz (8 per cent). It affected to the same degree both seropositives and seronegatives (23 and 19 per cent, respectively).

Serological status and changing risk behaviours

Subjects who had begun to practice intravenous injection since 1987 numbered 77, representing 21 per cent of the sample (see table 4). They were the younger generation of addicts, differing significantly from older heroin users as regards their serological status: in the group of subjects having the needle for only a few years, HIV seroprevalence was only 3 per cent. In the others it was considerably higher, 48 per cent for those practising intravenous injection in 1977 and earlier, 44 per cent for those practising it between 1978 and 1981, and 27 per cent for those practising it between 1982 and 1986.

Table 4. Date of first Injection and serological status (vertical distribution)

 

Seropositives and AIDS patients

Uncertain serological status

Seronegatives

Date of first injection

Percentage

Number

Percentage

Number

Percentage

Number

Before 1987
97 95.1 86 65.6 92 73.0
After 1987
2 2.0 42 32.1 33 26.2
No reply
3 2.9 3 2.3 1 0.8
Total
102 100 131 100 126 100

However, the low rate of HIV infection in the younger generation of addicts must be placed in proper perspective by another consideration: the number of subjects whose serological status was uncertain was particularly high - 55 per cent. Those subjects, having undergone one detection test, did not repeat it.

It is in connection with their sexual practices that certain differences in attitude emerge: there were more subjects never using condoms in their private sexual practices (63 per cent as against 47 per cent on average), and only 13 per cent claimed to use a condom regularly (as against 24 per cent on average). However, it is also in the younger generation that attitudes favouring risk reduction were most frequent: this group contained the largest number having only one regular sexual partner (60 per cent) and the lowest number (19 per cent) having a sexual partner who was a drug addict. Moreover, when not engaged in prostitution, this group contained the largest number making regular use of condoms (86 per cent).

Qualitative results

Information status of addicts

The great majority of addicts were provided with basic information on the transmission of HIV by blood and sperm. They paid close attention to everything said and done on the subject of AIDS. The addicts encountered in the streets were eager for information about the epidemic, which was a major subject of discussion for them. The desire for information reflected the anxiety which reigned among them.

Seropositives and AIDS patients seek further information on facilities for looking after infected addicts, on access to care, and on the effectiveness of medicaments. They want to know the distinguishing features of the various stages of the disease, and are interested in the problem of reinfection.

Seronegative subjects, many of whom have a friend or relative who is HIV- positive, are equally concerned. They know that they themselves may be at risk.

The sources of information to which addicts most frequently have recourse are specialized establishments, the media and anyone who appears to them to represent a potentially reliable source - general practitioners, pharmacists, nursing staff, social workers etc.

It remains nevertheless true that a substantial proportion of drug users have only vague information on the disease and the risks of its transmission. Furthermore, addicts do not always obtain precise replies to their questions from those concerned with addiction, general practitioners and other sources, particularly as regards methods of sterilizing injection equipment.

Purchases of syringes and condoms

Since the 1987 decree on liberalization of the sale of syringes in pharmacies [ 4] , a new relationship has been established between the pharmacist and the drug addict, and transactions between them proceed in a more relaxed climate. The addict has become a customer who is known and recognized by the pharmacist.

Although a customer among many others, the addict is given special treatment. It was observed during the survey that a number of pharmacists have a special drawer containing syringes and medicaments (such as Neocodion, the most commonly used codeine) sought by addicts. This makes it possible to serve them rapidly.

Such an attitude is not universal, however, and some pharmacists reject addicts out of hand. Nevertheless, refusal to sell a syringe applies only to a minority, as was pointed out with respect to certain suburban or rural pharmacies.

A relationship exists today between the syringe and the condom, to the extent that both are associated in the effort to combat the spread of AIDS through the use of a new syringe to avoid infection via the blood, and a condom to prevent infection by sexual contact. However, on the list of priorities of the addict, condoms come far behind the syringe.

Description of the shot

The preparation for "shooting" and the shot itself are delicate operations. When addicts are at home they take the time to make the preparations and to "shoot". In the streets, however, the various stages of the operations are frequently marked by incidents.

Whatever the place - cafe, car park, squatters' premises - the addict is always frightened of being disturbed. He speeds up the movements and gestures for preparation of the shot, puts the substance into a spoon, adds a little water, squeezes a little lemon, warms the mixture with a cigarette lighter, installs the filter, takes up the liquid with the syringe, searches for the vein, makes sure that he is into it, and injects the drug. All these operations must be done rapidly.

When in a group (two or three) and there are communal preparations, addicts share out the tasks among themselves in order to speed things up. While one puts the drug into the receptacle, the second takes care of the water. While one squeezes the lemon, the other ignites the cigarette lighter and warms the mixture. These movements have to be precise and synchronized. Any clumsiness during preparation or injection may have consequences for the progress of the other stages, all of which are equally delicate. Communal preparation means sharing the liquid when mixed and ready for injection. The lemon, the water and the cotton swabs are also shared. When the shot is finished, the addict disposes of everything and keeps nothing that might compromise him.

Practices associated with injection

After the shot, the addict disposes of the needle or hides it for later recovery, a dangerous practice, since the secrecy of hiding-places can never be guaranteed, and re-use of equipment is always risky. The addict who spends his life with other users cannot be entirely sure that his equipment has not been borrowed without his knowing it.

Furthermore, while many addicts use only their own needles, they do not exercise the same caution with the rest of the injection equipment, the water and the receptacle for preparation. Also, sterilization of injection equipment by means of disinfectants is unusual or even unknown.

Disposable needles have made it possible for those who so wish to exercise iron discipline. For them each shot is performed with new equipment. However, there is a grading of risk. Thus, some addicts use only their own equipment. They also never lend their syringes, but are prepared to give them away. Then there are those who agree to share only in cases of force majeure, while taking precautions to sterilize the equipment. After that come those who share all or part of their equipment with persons close to them (friends, partners) and disinfect it. On down the scale, there are those who tend, borrow and share injection material with any chance companion. At the end of the scale, some addicts question their partners regarding their serological status before borrowing their equipment.

For the above -mentioned reasons, through accident and ignorance of methods of disinfection, many factors can be the cause of infection. One addict has spoken thus: "I always take my precautions, I conceal the needles which I have used in various hiding-places. When I am in a jam I recover them and re-use them. I put a bit of cotton wool on a needle, and if the cotton wool is still there that means that no one has used the needle. I rinse the syringe with water and lemon. Lemon is an effective disinfectant."

AIDS awareness

In the view of addicts, transmission of HIV is primarily associated with the intravenous consumption of drugs [ 5] . A change in behaviour regarding the use of syringes is accompanied by a change in behaviour regarding use of the drug itself. A seropositive diagnosis is frequently followed by cessation of the use of heroin. Such abstinence does not last, but there is often a reduction in the frequency of intake, irrespective of the status of the subjects, whether seropositive, seronegative or ignorant of their serological status. The reduction in frequency has a twofold importance: on the one hand, there is the possibility of changing from intake by intravenous injection to intake through nasal passages; on the other hand, there may be an improvement in the conditions under which injections are carried out, that is, a reduction in the number of occasions when drugs are taken without having clean needles available.

In 1988 AIDS was not considered by addicts as a disease fundamentally connected with addiction. Now the conception seems to prevail that a relationship does exist between HIV infection and addiction, which is not the same as the relationship between HIV infection and drug use by intravenous injection. That could be a result of the data identifying addicts as the group at greatest risk as regards transmission of HIV. Whereas in 1988 AIDS was often compared to cancer as a disease liable to strike randomly at anybody, frequently with a fatal prognosis but leaving some possibility of remission, it is now more generally associated with leprosy or plague, which are diseases with a fatal prognosis and involving rejection on the part of the community. In the words of a seropositive person: "It's like the plague, makes me think of lepers ... Everybody who knows me, those with whom I am in close contact, are aware of it. I make no secret of it. But at work I certainly do not mention it". It might be that this conception of the situation has been brought about by the reaction of society to infected persons. While in their circle of family or friends most subjects treat the fact that they are seropositive with a certain nonchalance, this is not the case in social and professional relationships.

As a reaction to their being seropositive, subjects attempt to reintegrate themselves socially and professionally. They try to achieve stability by seeking accommodation and a job. The seropositive subject is more marginalized than the addict; this radicalization of his situation is due to the proximity of death. One spoke thus: "Now I am working hard, I can't afford to take a day's holiday every six months in order to have tests that won't tell me very much ... When I start not to feel well anymore, I'll give up everything, I'll sell everything and clear of f. I've no time for AZT or anything like that ... I feel well, in fact I feel in grand form. I have never worked as I do so now. I plan to take up karate again next season."

Discussion

The study shows a distinct change in the attitude of addicts to the needle since the mid-1980s: needle-sharing, which was practised by a majority of drug users during the 1970s, has considerably diminished since the period from 1987 to 1988. The strong impact of AIDS, together with the liberalization of the sale of syringes, has made a substantial contribution to the change in behaviour [ 6] , [ 7] .

Although sharing practices have not entirely disappeared, needle- sharing has become the exception, and use of a personal syringe the rule. From this point of view, addicts emerge as a risk group that has distinguished itself by the speed of its modifications in behaviour aimed at reducing the risk of infection, at least via the blood [ 8] .

As regards risk-reduction practices, there is still a lag between attitudes to drug use, on the one hand, and to sexual habits, on the other. The gap is probably not measurable solely on the basis of the criterion of use of the condom. Other factors tending to a reduction in risk are also at work, ranging from wise choice of partner to a change in sexual practices. Use of the condom can also be highly selective, applying to particular partners or particular circumstances. Sexual practices, and the risks associated therewith, should be further studied. It should be stressed, however, that risk does not affect only users of the needle, and that preventive action should necessarily aim at a broad target, including users of non-injectable drugs.

A detailed examination of practices and habits clearly shows that these can in no way be correlated with factors such as age, sex, social background, the drugs consumed, the length of time during which the addiction has lasted, or any other social factor. Overall, addicts behave in a similar manner, and the authors are inclined to doubt the existence of a subgroup among them, said to be characterized by an attitude of negligence or intractability. It would be more correct to say that all addicts behave in the same manner, that all attempt to reduce the risks of infection, and that if some subjects are less successful in this respect than others, it is mainly due to their immediate environment.

The three cities. In each of the cities, the behaviour of addicts emerges as substantially the same, although there are a few differences to be observed between Marseille and Paris, on the one hand, and Metz, on the other. Risk - enhancing behaviour appears to be more frequent at Metz than at Marseille and Paris, which had comparable findings.

A number of reasons can be adduced to explain such findings. First of all, AIDS appeared later at Metz than in Paris or at Marseille, and hence changes in behaviour showed a certain lag at Metz by comparison with the other two cities. Apart from that primary governing factor, the smaller size of Metz and the lesser degree of anonymity enjoyed by users may have inhibited the acquisition of certain practices such as the regular personal purchase and rapid replacement of syringes through a pharmacy.

However, it should be immediately added that Metz also has the lowest infection rate, a fact which leads the authors to question the importance of the environment as regards the actual risk of infection. The risk is probably indeed less at Metz than at Marseille or in Paris, as a result not only of the pattern of development of the epidemic itself, but also of the existence of a more favourable social and health environment, with easier access to care and less serious conditions at the street level and in terms of squatting practices.

Availability of syringes. Syringes are not distributed free of charge; they are obtained from the pharmacist against payment in cash. The sums involved, although not much, may represent a problem for users, for whom a few francs means a lot, even to secure the required access to public toilets or to those of a caf to prepare for injection following the purchase of a syringe and the drug.

The life of the drug addict is usually marred by hardship and severe financial constraints. Drug money, or rather money used for drugs, cannot be budgeted in the same way as money that might be used for food or housing. Offences are committed to obtain the desired dose or packet. When the dose has been obtained, there are no resources left for anything else. One subject reported that he had stolen - and sold - that very day a coat for 300 francs. Another said that he had offered his "services" for purchasing boxes of medicine. Thus, an addict can easily spend 300 or 600 francs per day for drugs, and yet never have a penny in his pocket. The one-hundred franc note is his basic monetary unit; nothing less is of any value.

Shortage of money is accompanied by problems in many other areas, particularly hygiene and health. Thus, if precautions are neglected in the use of syringes, such neglect is reflected in the overall hygienic practices (attitudes to health) of the subjects concerned. The distinctly higher incidence of illness in general among seropositives and AIDS patients than among seronegatives would also appear to indicate wider differences of attitude with respect to health and hygiene. The difference observed, in terms of serological status, between addicts who have been imprisoned and those who have not points in the same direction. Addiction management that is less medically oriented and more directed towards punishment would make it much more difficult, if not impossible, to provide for the health care of the subject.

The first overall results highlight the decisive role played by the availability of syringes in pharmacies following the liberalization of the sale of syringes in 1987. That was the central factor which made possible the changes in behaviour described, and above all which has contributed to maintaining them, as part of a whole range of new attitudes relating to risk reduction, including risks associated with sexual behaviour, through the use of condoms and the careful choice of a partner.

In short, the problems associated with syringe use no longer concern availability; if a needle is shared, it is more the result of an unfavourable or an insecure environment than of a scarcity of needles.

Information.As noted earlier, addicts are eager for information about everything concerning AIDS. However, they find it difficult to understand the somewhat contradictory and obscure information made available to them concerning needle sterilization. Thus, when the circumstances of drug use encourage needle-sharing, users are often at a total loss as to what they should do. Only a few will boil the needle, and others will wash it with bleach, but the methods used. will often be completely ineffective. There is a clear need for information based on easily comprehensible and realistic principles. It would thus be better to advise the use of disinfectants or detergents - preferably bleach - rather than boiling the needle. Indeed, the question of needle-sharing arises most frequently under insecure conditions when the subjects are in a hurry. Boiling a needle for 30 minutes then becomes too much to expect. By contrast, the use of household materials is fairly straightforward, and once aware of what is required, users could make arrangements to obtain the necessary materials.

Conclusion

An intense effort has been made in recent years to induce addicts to reduce the risk of infection through changes in behaviour. It remains to be seen whether the impetus for change has reached its limits, and whether the improvements that have occurred will prove permanent. The new generation of drug abusers seems to have looked after itself much better than its seniors. Infection among subjects who began injection after 1987 is very low (2per cent), and most of the subjects infected (95 per cent) began injecting before 1987. However, these findings will have to stand the test of time. The length of the intoxication period remains an important factor in this connection, if only because of the numerous high-risk situations to which drug abusers are exposed.

The risks of transmission are now determined by the living conditions and the general hygiene of drug abusers. Information is provided, non-sharing of needles has become routine, and the use of condoms has become somewhat more frequent. However, an adequate sanitary environment is lacking for the maintenance or consolidation of the new habits. Phases of crisis, poverty, street life, difficulty of access to treatment and the sporadic nature of the provision of health care are all factors which erode or curtail the effects of risk reduction. The limited use of condoms, which are highly unpopular as a means of risk reduction, is significant in this regard.

The present study suggests that emphasis should be placed on the need to address a wide public, not limited to drug injectors, to promote preventive measures, and on the importance of additional action to strengthen the beneficial effects of liberalization of the sale of syringes, including, in particular, the encouragement of the use of bleach by addicts who re-use or share injection equipment.

References

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