Exposure to HIV risks among young people who use drugs (YPUD) in three cities in Vietnam: time to develop targeted interventions.

INTRODUCTION: The aim of this study is to identify the profiles of young people who use drugs (YPUD) and their exposure to HIV risks in the 3 main cities of Vietnam, Haiphong, Hanoi, and Ho Chi Minh City (HCMC), in order to design a community-based intervention to prevent HIV. METHODS: A survey using respondent-driven sampling (RDS) was conducted among YPUD aged 16-24. Participants were eligible if they reported drug use, confirmed by a urine test. After obtaining informed consent, they were screened for HIV/HCV and assessed using face-to-face questionnaires and self-report. A cluster analysis was conducted, taking into account risk behaviors and confirmed HIV-positive status. RESULTS: Seven hundred and three YPUD aged 16-24 were recruited between October 2016 and February 2017, 584 of whom were included in the final analysis. Median age was 21 (17.7, 23.0); 79% were male, 18% female, and 2% transgender. Methamphetamines use was reported by 77%, followed by cannabis (51%) and heroin (17%); polydrug use was common; 15% had "ever" injected drugs. HIV prevalence was 7%. Among all participants, 48% reported non-consistent condom use and 1% reported needle/syringe sharing during the previous month. Four distinct profiles of HIV risk behaviors were identified: The high multiple-risk group mixed unsafe drug use with unsafe sexual practices and had higher prevalence of HIV; the second group practiced high-risk sex with non-consistent condom combined with methamphetamine use; the third group was a moderate-risk group with limited unsafe sexual practices; and the fourth was considered at "low-risk" as reportedly, most never had sex and never injected. The highest risk group included more female YPUD, living in HCMC, who used heroin and had unsafe sex with their regular partners. The second high-risk group included most of the MSM and all transgender people and frequently reported mental health disorders. CONCLUSIONS: The profiles of YPUD who are at risk of HIV vary according to age, location, and population group. Injecting YPUD are the most exposed to risk and need immediate attention. Sexual exposure to HIV is very common. Mental health is a major concern. Interventions need to be integrated in a differentiated but holistic approach.

Interactive Versus Video-Based Training of Police to Communicate Syringe Legality to People Who Inject Drugs: The SHIELD Study, Mexico, 2015-2016.

Objectives. To assess how instructional techniques affect officers' intent to communicate syringe legality during searches in Tijuana, Mexico, where pervasive syringe confiscation potentiates risk of HIV and HCV among people who inject drugs (PWID) and of occupational needle-stick injury among police. Methods. Using the SHIELD (Safety and Health Integration in the Enforcement of Laws on Drugs) model, Tijuana police underwent training to encourage communication of syringe possession legality to PWID. Trainees received either passive video or interactive role-play exercise on safer search techniques. We used logistic regression to assess the training's impact on self-reported intent to communicate syringe legality by training type and gender. Results. Officers (n = 1749) were mostly men (86%) assigned to patrol (84%). After the training, intent to communicate the law improved markedly: from 20% to 39% (video group) and 20% to 58% (interactive group). Gender and training type significantly predicted intent to communicate syringe legality. Male and female officers' adjusted odds ratios in the interactive group were 5.37 (95% confidence interval [CI] = 4.56, 6.33) and 9.16 (95% CI = 5.88, 14.28), respectively, after the training. Conclusions. To more effectively persuade police to endorse harm reduction and occupational safety practices, police trainings should include interactive elements.

Differences in polysubstance use patterns and drug-related outcomes between people who inject drugs receiving and not receiving opioid substitution therapies.

AIMS: To test if polysubstance use profiles and drug-related outcomes differ between those receiving and not receiving opioid substitution therapies (OST) among people who inject drugs (PWID). DESIGN: An annual cross-sectional, sentinel sample of PWID across Australia. SETTING: Data came from 3 years (2011-13) of the Illicit Drug Reporting System (IDRS). PARTICIPANTS: A total of 2673 participants who injected drugs from the combined national IDRS samples of 2011 (n = 868), 2012 (n = 922) and 2013 (n = 883). MEASUREMENTS: Latent class analysis (LCA) was used to summarize participants' self-reported use of 18 types of substances, with the resulting polysubstance use profiles then associated with participant experience of a number of drug-related outcomes. FINDINGS: Polysubstance use profiles exhibiting a broad range of substance use were generally at increased risk of negative drug-related outcomes, whether or not participants were receiving OST, including thrombosis among OST receivers [odds ratio (OR) = 2.13, 95% confidence intervals (CI) = 1.09-4.17], injecting with used needles among OST receivers and non-receivers, respectively (OR = 2.78, 95% CI = 1.50-5.13; OR = 2.15, 95% CI = 1.34-3.45) and violent criminal offences among OST receivers and non-receivers, respectively (OR =2.30, 95% CI = 1.16-4.58; OR = 1.87, 95% CI = 1.14-3.07). An important exception was non-fatal overdose which was related specifically to a class of PWID who were not receiving OST and used morphine frequently (OR = 1.83, 95% CI = 1.06-3.17) CONCLUSION: Regardless of opioid substitution therapies usage, people who inject drugs who use a broad-range of substances experience greater levels of injecting-related injuries and poorer health outcomes and are more likely to engage in criminal activity than other groups of people who inject drugs.

Profile of People Who Inject Drugs in Tehran, Iran.

The marked shift in the patterns of drug use in Iran, from opium smoking to injecting drug use, has led to serious health-related outcomes. This study was designed to explore characteristics of people who inject drugs (PWID) in Tehran, Iran. Nine hundred and four PWID were recruited from treatment and harm reduction facilities, as well as drug user hangouts in public areas in Tehran. Participants were interviewed using the Persian version of the World Health Organization Drug Injecting Study Phase II questionnaire. The median age at the time of the first illegal drug use, at the time of the first injection and current age was 20, 24 and 32, respectively. In more than 80% of the cases, the first drug used was opium. The transition from the first drug use to the first drug injection occurred after an average of 6.6 and 2.7 years for those who had started drug use with opium and heroin, respectively. Two-thirds of the participants shared injecting equipment within the last 6 months. Difficulty in obtaining sterile needles and thehigh cost of syringes were reported as the major reasons for needle/syringe sharing. Approximately 80% of community-recruited PWID reported difficulties in using treatment or harm reduction services. Self-detoxification and forced detoxification were the most common types of drug abuse treatment in alifetime. Despite a dramatic shift in drug policy in Iran during the past few years, wider coverage of harm reduction services, improvement of the quality of services, and education about such services are still necessary.

The impact of buprenorphine/naloxone treatment on HIV risk behaviors among HIV-infected, opioid-dependent patients.

BACKGROUND: Opioid dependence is a major risk factor for HIV infection, however, the impact of buprenorphine/naloxone treatment on HIV risk behaviors among HIV-infected opioid-dependent patients is unknown. METHODS: We conducted a longitudinal analysis of 303 HIV-infected opioid-dependent patients initiating buprenorphine/naloxone treatment. Outcomes included self-reported past 90-day needle-sharing and non-condom use. We assessed trends over the 12 months using the Cochran-Armitage trend test. Using generalized estimating equations, after multiple imputation, we determined factors independently associated with needle-sharing and non-condom use, including time-updated variables. We then conducted a mediation analysis to determine whether substance use explained the relationship between time since treatment initiation and needle-sharing. RESULTS: Needle-sharing decreased from baseline to the fourth quarter following initiation of buprenorphine/naloxone (9% vs. 3%, p<0.001), while non-condom use did not (23% vs. 21%, p=0.10). HIV risk behaviors did not vary based on the presence of a detectable HIV-1 RNA viral load. Patients who were homeless and used heroin, cocaine/amphetamines or marijuana were more likely to report needle-sharing. Heroin use fully mediated the relationship between time since treatment initiation and needle-sharing. Women, patients who identified as being gay/lesbian/bisexual, those married or living with a partner and who reported heroin or alcohol use were more likely to report non-condom use. Older patients were less likely to report non-condom use. CONCLUSIONS: While buprenorphine/naloxone is associated with decreased needle-sharing among HIV-infected opioid-dependent patients, sexual risk behaviors persist regardless of viral load. Targeted interventions to address HIV risk behaviors among HIV-infected opioid-dependent populations receiving buprenorphine/naloxone are needed.

Access to harm reduction and HIV-related treatment services inside Indian prisons: experiences of formerly incarcerated injecting drug users.

PURPOSE: The authors aimed to examine the incarceration experiences of injecting drug users in accessing harm reduction, and HIV-related services inside prisons in India. DESIGN/METHODOLOGY/APPROACH: The authors conducted three focus groups with a purposive sample of 23 formerly incarcerated male IDUs and four key informant interviews with a former police official, a drug dealer and service providers. Data were analyzed using a constant comparative method. FINDINGS: Participants reported availability of alcohol and injectable or oral drugs such as heroin, dextropropoxyphene, and marijuana inside prisons. Inmates obtained drugs and clean syringes (one syringe bought for 2.5-4 USD) through prison staff, and collected used syringes and needles from the dustbins in prison sickrooms. Needles and syringes were reused and shared. Prisons did not have needle and syringe programmes, detoxification, overdose management or opioid substitution treatment. Drug-using prison inmates faced several challenges in accessing antiretroviral treatment and HIV testing. PRACTICAL IMPLICATIONS: The authors' findings emphasize the need to protect the health of injection drug-using inmates by introducing harm reduction programmes and removing barriers to HIV testing and antiretroviral treatment. ORIGINALITY/VALUE: This study illustrates, for the first time, the contexts behind high risk injecting drug use behaviours among prison inmates in India. It also highlights the lack of availability of harm reduction services such as needle and syringe programmes, drug detoxification and opioid substitution treatment inside prisons. Further, it demonstrates the difficulties faced by HIV-positive prison inmates in getting timely and uninterrupted antiretroviral treatment.

The Golden Crescent and HIV/AIDS in Central Asia: deadly interactions.

Afghanistan has become the world's largest producer of illicit opiates. Opium and its derivative heroin are widespread substances of use, abuse and dependency in Central Asia. The region is currently undergoing expanding HIV epidemics driven largely by needle sharing among people who use drugs, in contexts where public health interventions to reduce the harms associated with substance use are limited by policy, law and legalistic and repressive approaches to drug users. Evidence-based approaches to drug treatment are lacking or limited in multiple states. Urgent reform is needed. The massive volumes of Afghan's illicit opiate exports are having serious impacts on the health of the region.

Participant characteristics and HIV risk behaviors among individuals entering integrated buprenorphine/naloxone and HIV care.

OBJECTIVE: This study was part of a national, multisite demonstration project evaluating the impact of integrated buprenorphine/naloxone treatment and HIV care. The goals of this study were to describe the baseline demographic, clinical, and substance use characteristics of the participants and to explore HIV transmission risk behaviors in this group. METHODS: Nine sites across the United States participated. Data obtained by interview and chart review included demographic information, medical history, substance use, and risk behaviors.We performed a descriptive analysis of patient characteristics at entry and used logistic regression to evaluate factors associated with 1) unprotected anal or vaginal sex; and 2) needle-sharing within the previous 90 days. RESULTS: Three hundred eighty-six individuals were included in the study: 303 (78.5%) received buprenorphine/naloxone; 41 (10.6%) received methadone; and 42 (10.9%) received another form of treatment. The analysis of risk behaviors was limited to those in the buprenorphine group (n = 303). Among those reporting vaginal or anal sex in the previous 90 days, 24% had sex without a condom. Factors significantly associated with unprotected sex were: having a partner; female gender; and alcohol use in previous 30 days. A total of 8.9% of participants shared needles in the previous 90 days. Factors significantly associated with needle-sharing were: amphetamine use; marijuana use; homelessness; and anxiety. CONCLUSIONS: Addressing transmission risk behaviors is an important secondary HIV prevention strategy. In addition to treatment for opioid dependence, addressing other substance use, social issues, particularly housing, and mental health may have important implications for reducing HIV transmission in HIV-infected opioid-dependent patients.

Injection drug use in Rural Iran: integrating HIV prevention into iran's rural primary health care system.

Major opium trafficking routes traverse rural Iran, but patterns of drug use and HIV infection in these areas are unknown. In 2004, Iran's Ministry of Health integrated substance use treatment and HIV prevention into the rural primary health care system. Active opium or heroin users (N = 478) were enrolled in a rural clinic. Participants received counseling for abstinence from substances, or daily needle exchange and condoms. On enrollment, 108 (23%) reported injecting; of these, 79 (73%) reported sharing needles. Of 65 participants tested for HIV, 46 (72%) tested positive. Participants who received daily needle exchange/condoms stayed in the program longer than those who did not (AOR 2.08, 95% CI 1.1-3.88). This project demonstrates that HIV risks exist in rural Iran and suggests the innovative use of Iran's rural health care system to extend prevention and treatment services to these populations.

Integrating multidimensional HIV prevention programs into healthcare settings.

Effective secondary prevention programs to reduce HIV transmission risk-relevant behaviors among HIV-infected individuals must go beyond the traditional, common sense prevention components to develop biomedically and epidemiologically informed behavioral interventions as part of comprehensive, integrated, multidisciplinary HIV care. Incorporating and expanding on the Serostatus Approach to Fighting the Epidemic, a five-pronged strategy set forth by the Centers for Disease Control and Prevention in 2001, we discuss recent findings from the biomedical sciences on viral and host factors that influence infectiousness to support the idea that the most proactive prevention programs will explicitly integrate biomedical interventions and approaches designed to reduce infectiousness, and thus the sexual transmission of HIV. Based on studies of emerging and spreading drug-resistant HIV variants, we have posited the potential development of biodisparity as the biological entrenchment of disparities in socioeconomic status, access to care, and HIV risk-relevant behaviors that differentially affect minorities living with HIV in the US. It is clear that creative approaches based on an expanded behavioral medicine interface with the latest HIV biomedical and epidemiological research are needed to enhance the efficacy of HIV secondary prevention.

Cannabis abuse is not a risk factor for treatment outcome in methadone maintenance treatment: a 1-year prospective study in an Israeli clinic.

OBJECTIVE: We addressed the following questions. What are the current and lifetime prevalence of cannabis abuse in an Israeli methadone maintenance treatment (MMT) clinic? Does cannabis abuse change over time during MMT? Is cannabis abuse related to treatment outcome measures such as retention rate and the abuse of drugs? Is the abuse of cannabis related to psychopathology, HIV/HCV risk-taking and infectious diseases? Do cannabis abusers (CAs) have a different psychosocial and demographic profile than nonabusers (NCAs)? Is cannabis abuse part of a polydrug abuse tendency or a distinct substance of abuse? METHOD: Overlapping samples of either the entire clinic population (n = 283) or all the patients who had completed 1 year of MMT treatment (n = 196 of which 20 were re-entering) underwent random and twice-weekly observed urine analysis for various drugs of abuse, responded to self-report questionnaires (SCL-90-R; HIV/HCV risk-taking behaviours; n = 164), interviews (ASI, n = 176; SCID, n = 151) and hepatitis C and HIV testing (n = 149). RESULTS: Lifetime abuse prevalence was found in 75% and current abuse at MMT intake in 25%. Abuse did not increase significantly over a 1-year period. Cannabis abusers were found to be more often polydrug abusers than NCAs. Cannabis abusers did not suffer from more psychological distress, infectious diseases, and did not engage in more HCV/HIV risk-taking behaviour, nor did they leave treatment earlier than NCAs. CONCLUSIONS: Cannabis abuse MMT patients should be treated as polydrug abusers, although no specific influences of cannabis abuse on psychological and medical conditions of MMT patients have been observed. Treatment policy should take these results into consideration.

Vulnerable among the vulnerable: drug users in situations of poverty and indigence in Argentina.

To study drug use in the context of poverty, it is necessary to undertake a complex analysis of various perspectives to understand the dense interweaving of socioeconomic, political, and cultural factors involved in the problem. The analysis of this social scenario was our starting point in planning holistic actions for the prevention of human immunodeficiency virus/acquired immunodeficiency syndrome and other illnesses related to drug use. Merely copying successful models from developed countries, which are designed for other contexts and populations, would result in insufficient and ineffective actions. The Asociación Civil Cristiana Recuperación Atención de Drogadependientes (ACCRAD), also known as "El Retoño" ("sprout"), is a nongovernmental organization that has been working since 1985 to consolidate a model of analysis and intervention that considers this complex framework and seeks to meet the needs of drug users from the poorest sectors of society. Our research on the use of drugs and its relationship to poverty, together with the documentation of harm-reduction interventions, has been carried out since 1997.

Drug use, harm reduction, and health policies in Argentina: obstacles and new perspectives.

High human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) incidence among injection drug users (IDUs) shows the failure of traditional health policies. The preference of IDUs for injected cocaine exposes them to high risks for contracting HIV because of the frequency of drug use. The correlation of poverty with the selling of drugs, especially the so-called "drugs of poverty"--freebase cocaine and crack--is a consequence of prohibitions against drug use and of urban unemployment. In Argentina, "zero-tolerance" approaches and punishment for personal drug use tend to exclude IDUs from the country's health care system. A historical perspective is presented regarding approaches to the prevention of HIV/AIDS and harm reduction in Latin America and Argentina, where, despite isolated efforts, IDUs had no free access to sterile needles until the end of the 1990s. We present the impact of programs and campaigns of the Argentinean Harm Reduction Association, showing how and why, even with obstacles, harm reduction is possible and necessary.

Hepatitis C in methadone maintenance patients: prevalence and public policy implications.

OBJECTIVE: This study measured the extent and examined implications of hepatitis C (HCV) infection in a methadone maintenance treatment (MMT) population. METHOD: Four hundred and sixty patients were tested for HCV-Ab, hepatic enzymes and bilirubin, HCV-RNA, and hepatitis B antibody. RESULTS: Overall, 87% of this population had evidence of HCV-Ab. Among drug injectors (IDU), 96% were HCV-Ab positive. Among a subset of Laotian opium-smoking patients prevalence was only 11%. Sixty-two percent of patients with HCV-Ab had detectable HCV-RNA. Only 41% had elevated hepatic enzymes, and 5% had elevated bilirubin levels. All age groups were equally infected. Systemic problems in screening and treating HCV in drug users were identified. CONCLUSION: HCV infection poses significant long-term health risks for this population. Harm reduction interventions aimed at reducing transmission of HCV and other needle-related infectious disease deserves more consideration.

Lay injection practices among migrant farmworkers in the age of AIDS: evolution of a biomedical folk practice.

The practice of injecting vitamins and antibiotics by lay people is common among Hispanic migrant farmworkers in the U.S.A. This practice has recent roots in the Latin American cultures from which these farmworkers originate, but it presents a public health concern in its new context because of the high prevalence of HIV infection among this disenfrachised population. Reasons for use of lay injections include cultural beliefs about the superiority of injections over oral forms of medications, perceived irrelevance of a professional diagnostician in prescribing empirical treatment, and a multitude of barriers to access to Western medicine. Although HIV educational materials directed at migrant farmworkers do not address the issue of sharing needles for these types of injections, some farmworkers indicated they had already modified their injection techniques in response to simple directives from physicians in their home country. In contrast to other folk treatment practices that have been resistant to change mediated solely through the provision of information, lay injection is such a new development that considerable experimentation and incorporation of new knowledge are still actively shaping its use. In this process, physicians are seen as legitimate sources of information about the use of Western pharmaceuticals; they should use this role to discourage unsafe injection practices. Efforts to extinguish the practice of lay injection entirely are less likely to meet with success so long as other means of accessing Western medicine are limited.

The HIV/AIDS epidemic: its evolutionary implications for human ecology with special reference to the immune system.

The epidemiology of AIDS in Africa is discussed. Serological and clinical data on virology and population genetics are related to current theories of heterosexual transmission and to cultural practices involving the exchange or transmission of body fluids between individuals, such as female and male genital mutilation and indigenous or 'folk' medicine, as well as non-Western medical uses of medical syringes. A review of the relationship of autoimmune conditions, graft-vs-host disease and the retrovirus/oncogene involvement is presented. These data place in a new perspective concepts of widespread heterosexual infection and transmission of HIVs as well as their relation to AIDS in the context of the evolution of the human immune system.

Hepatitis C virus infection in a male homosexual cohort: risk factor analysis.

BACKGROUND: Hepatitis C virus (HCV) infection is a major cause of morbidity throughout the world. Parenteral exposure to infected blood accounts for the majority of cases. Sexual transmission is suggested by the higher prevalence of infection in sex workers and homosexual men. Sexual practices which contribute to HCV infection need to be identified. METHODS: The social and medical history, and HCV serostatus of 1058 homosexual men in the Pittsburgh arm of the Multicenter AIDS Cohort Study were analysed. Multivariate analysis was used to determine risk factors for HCV seropositivity. RESULTS: 31 men were HCV seropositive by enzyme immunoassay and recombinant immunoblot assay (2.9%). They were more likely to be HIV seropositive (39%) than the HCV seronegative men (19%). Needle sharing and illegal drug use were the most important risk factors for HCV seropositivity. Statistically significant sexual factors (p < 0.05) included a history of syphilis, rectal gonorrhea, anal insertive intercourse with ejaculation, and douche or enema use before anal receptive intercourse. The number of sexual partners was not a significant risk factor. CONCLUSIONS: HCV infection is associated with specific sexually transmitted diseases (STDs) and sexual practices in the male homosexual population. The evidence of high risk behavior should be incorporated into ongoing educational efforts to decrease the incidence of STDs.

HIV infection and AIDS risk behaviors among injecting drug users entering methadone treatment: an update.

Trends in HIV infection and AIDS risk behaviors among injecting drug users (IDUs) were assessed through a series of nonblinded point-prevalence surveys conducted between 1987 and 1991 with admissions to methadone treatment in eight areas, including New York City; Asbury Park and Trenton, New Jersey; Philadelphia; Baltimore; Chicago; San Antonio, Texas; and Los Angeles County. Over the 5-year period, significant changes in HIV seropositivity were found in two of the eight cities, with seroprevalence decreasing in Asbury Park from 43.1 to 21.2% and increasing from 10.1 to 17.6% in Chicago. Initially high levels of injection-related risk behaviors decreased substantially across cohorts in most cities, except for San Antonio and Los Angeles, where risk levels remained high. Sexual risk behaviors continued at high levels in all cities, suggesting relatively little sexual risk reduction during the course of the study.

Operating needle exchange programmes in the hills of Thailand.

Injecting drug use is increasingly markedly amongst the ethnically distinct Hilltribe peoples of northern Thailand in the notorious 'Golden Triangle'. This paper reports on the establishing of needle exchanges in three remote Hilltribe villages, examining the success and the failure. Up to 60% of adult males and a smaller percentage of adult females in these villages are habitual users of opium and/or heroin. Overcoming initial concern that needle distribution would encourage increased use, the villagers themselves have assumed responsibility for much of the needle exchange operation. Prior to the introduction of the needle exchanges all the injecting drug users were sharing needles. This behaviour changed significantly with the introduction of the exchanges. Reluctance on the part of locally-based government officials to participate fully in the programme created difficulties in maintaining needle supplies which saw some resumption in needle sharing. HIV seroprevalence rates amongst the tested injecting drug users remained fairly stable at 33% in February 1993 and 32% in February 1994. The conclusion can be drawn that needle exchange programmes are operable in the Hilltribe context and that they are the best means of limiting HIV/AIDS transmission amongst injecting drug users and the wider community. The success of needle exchange programmes, however, is dependent upon co-operation from various government agencies and non-government agencies, in addition to the local communities. To this end mechanisms ensuring co-operation, training, monitoring and evaluation need to be developed alongside the introduction of needle exchanges.

PIP: Injecting drug use is increasing markedly among the ethnically distinct Hilltribe people of northern Thailand in the notorious Golden Triangle. This paper reports on the establishment of needle exchanges in 3 remote Hilltribe villages. The needle and syringe exchanges were established in 3 villages: Anamai Village 1, 2, and 3, each with an average of 47 households and 5-6 people per household. Altogether there were 46 injecting drug users participating: 16 from Anamai Village 1; 12 from Anamai Village 2; and 18 from Anamai Village 3. Up to 60% of adult males and a smaller percentage of adult females in these villages were habitual users of opium and/or heroin. Through a series of meetings in the villages various means available to prevent the transmission of HIV/AIDS in an injecting drug use context were discussed. The villagers themselves have assumed responsibility for much of the needle exchange operation. The sharing of needles by injecting drug users changed significantly with the introduction of the exchanges. Reluctance on the part of local government officials to participate in the program created difficulties in maintaining needle supplies, which led to some resumption in needle sharing. The needle and syringe exchanges in November 1992 supplied 5000 1 cc needle and syringe fits, a 1-years' supply. HIV seroprevalence rates among the tested injecting drug users remained fairly stable at 5 cases (33%) of 15 IDUs tested in February 1993. In February 1994, 8 (32%) of 25 IDUs tested were found to be HIV seropositive. The 17 men found to be HIV negative in February 1994 despite their injecting behavior would seem to indicate that the needle exchange programs in the Hilltribe context are effective in limiting HIV/AIDS transmission among injecting drug users and the wider community. The success of needle exchange programs is dependent upon cooperation from various government agencies and nongovernment agencies as well as the local communities.