Misadventure in Muirhouse. HIV infection: a modern plague and persisting public health problem.

This story is of particular interest and importance to Edinburgh and Scottish medicine. It describes the events in one general medical practice in Edinburgh, the Muirhouse Medical Group, and their impact and relationship to the AIDS pandemic. For many, the origin of HIV in the UK is now history. Since the introduction of HIV/AIDS into the intravenous illegal drug using community, much has changed but problems remain that should concern policy makers and clinicians. Reflections on the recent history of the HIV epidemic among drug users in the UK provide important insights into risks for current policy making and the potentially problematic direction that policy has taken. Rather than starting from a pragmatic baseline of harm minimisation, with its low cost, high impact, prevention approach, the emphasis, and consequently the resources, has been on a model of recovery which fails to acknowledge the fragile control maintained by early intervention and supporting treatments. In 2015, the re-emergence of HIV in a vulnerable inner city population of people who inject drugs highlighted a policy failure. An ongoing epidemic could and should have been prevented, as should several other recent epidemics of other viral or bacterial infections in urban populations in Scotland. The story of HIV is full of controversy, denial, prejudice and stigma. At all levels across the world from national presidents, governments and public opinion, progress has been impeded by these problems. People using drugs have an additional set of problems: criminality, poverty and marginalisation from education and the supports of main stream society. These continue to hamper efforts to improve lives and prevent disease.

Pence, Putin, Mbeki and Their HIV/AIDS-Related Crimes Against Humanity: Call for Social Justice and Behavioral Science Advocacy.

Indiana, a large rural state in the Midwestern United States, suffered the worst North American HIV outbreak among injection drug users in years. The Indiana state government under former Governor and current US Vice President Mike Pence fueled the HIV outbreak by prohibiting needle/syringe exchange and failed to take substantive action once the outbreak was identified. This failure in public health policy parallels the HIV epidemics driven by oppressive drug laws in current day Russia and is reminiscent of the anti-science AIDS denialism of 1999-2007 South Africa. The argument that Russian President Putin and former South African President Mbeki should be held accountable for their AIDS policies as crimes against humanity can be extended to Vice President Pence. Social and behavioral scientists have a responsibility to inform the public of HIV prevention realities and to advocate for evidence-based public health policies to prevent future outbreaks of HIV infection.

Methadone maintenance treatment: disciplining the 'addict'.

This article examines key aims, objectives, technologies, strategies, and procedures utilised in Australian methadone maintenance programs over the past thirty years. An examination of the major policy documents reveal that, in addition to medico-health concerns, methadone programs have been strategically deployed to manage specific sociopolitical problems including illicit drug use, crime, and the spread of infectious diseases. The techniques, technologies, and procedures utilised in methadone programs and the 'disciplinary monotony 'of the methadone regime itself aim to produce a more compliant, conforming, and self-regulating subject. It is argued that the promotion of methadone maintenance as a 'treatment' modality obscures these disciplinary objectives and the political goals that have fostered them.

Fools rush in where angels fear to tread Playing God with Vancouver's Supervised Injection Facility in the political borderland.

Healthcare does not exist in a social vacuum. Nowhere is this more obvious than in the case of people living with active addiction who are treated as social lepers: feared, despised and socially banished from the wider human family. People with addictions, and their families, fight for survival in the moral borderland between two competing understandings of their condition. According to one understanding, addiction is a concern for the criminal justice system while according to the other it is primarily a population health issue. In one orientation, addicts are troublesome offenders, while in the other they are wounded persons in need of medical attention. These competing values form a cultural web of belief that extends far beyond healthcare to the highest political office of Canadian society. This paper examines the politics of addiction over a 6-year period beginning at the municipal level in Vancouver and culminating with a confrontation between the Prime Minister of Canada and the tiny neighbourhood that provides a home for North America's only Supervised Injection Facility. Not wanting to let the medical facts get in the way of a political stand, Prime Minister Stephen Harper and his Health Minister, Tony Clement, played God this summer by playing politics with the lives of people in the shadows of Canadian society.

Merseyside, the first harm reduction conferences, and the early history of harm reduction.

In the mid 1980s, Liverpool implemented pioneering approaches to dealing with the problems caused by the use of drugs. The Mersey Harm Reduction Model concentrated on reducing the harms rather than, as previously was the case, trying to reduce drug use itself. This policy was given great impetus by the emergence of HIV and the danger of infection from using contaminated injection equipment. It became imperative to reduce this kind of risk behaviour by providing clean injecting equipment, prescribing methadone (and in a small percentage of cases, heroin) and by using outreach workers to go into the community and help people where they lived and to attract them into services. The police played a key role. Service uptake was rapid and included many who had never had previous contact with services. An HIV epidemic did not happen amongst injecting drug users in Mersey. In 1991, the approach was applied to the new phenomenon of the use of MDMA with the publication of the leaflet 'Chill Out'. The First International Conference on the Reduction of Drug Related Harm took place in Liverpool in 1990 as a response to the interest shown in what was happening in the region and the International Harm Reduction Association was born out of these conferences.

Harm reduction and HIV-prevention among injecting drug users in Australia: an international comparison.

In response to the threat of HIV transmission via drug injection with shared needles, Australia developed a needle and syringe exchange program that became one of the most comprehensive in the world. Originally health professionals and pharmacists were given the responsibility of implementing the program. However, community-based AIDS organizations were soon also funded to distribute sterile injecting equipment, alcohol swabs, puncture-proof disposable containers, condoms, and safe sex information. Nearly all of the programs operated on a no-need-for-exchange basis, during hours and from outlets (both fixed and mobile) that were convenient for users. Their success in preventing the widespread transmission of HIV among injecting drug users was demonstrated in international studies that found a large discrepancy between the rates of HIV infection in cities with, and without, needle and syringe exchange programs, and was reflected in the continued low level of HIV infection among injecting drug users in Australia. Australia's success in preventing HIV transmission among drug users suggests the merits of the "harm reduction" approach to controlling drug use as well as funding community-based needle and syringe exchange programs.

The impact of New York City's 1975 fiscal crisis on the tuberculosis, HIV, and homicide syndemic.

In 1975, New York City experienced a fiscal crisis rooted in long-term political and economic changes in the city. Budget and policy decisions designed to alleviate this fiscal crisis contributed to the subsequent epidemics of tuberculosis, human immunodeficiency virus (HIV) infection, and homicide in New York City. Because these conditions share underlying social determinants, we consider them a syndemic, i.e., all 3 combined to create an excess disease burden on the population. Cuts in services; the dismantling of health, public safety, and social service infrastructures; and the deterioration of living conditions for vulnerable populations contributed to the amplification of these health conditions over 2 decades. We estimate that the costs incurred in controlling these epidemics exceeded 50 billion US dollars (in 2004 dollars); in contrast, the overall budgetary saving during the fiscal crisis was 10 billion US dollars. This history has implications for public health professionals who must respond to current perceptions of local fiscal crises.

Historical trends in the production and consumption of illicit drugs in Mexico: implications for the prevention of blood borne infections.

Mexico has cultivated opium poppy since before the 1900's and has been an important transit route for South American cocaine for decades. However, only recently has drug use, particularly injection drug use, been documented as an important problem. Heroin is the most common drug used by Mexican injection drug users (IDUs). Increased cultivation of opium poppy in some Mexican states, lower prices for black tar heroin and increased security at U.S.-Mexican border crossings may be contributing factors to heroin use, especially in border cities. Risky practices among IDUs, including needle sharing and shooting gallery attendance are common, whereas perceived risk for acquiring blood borne infections is low. Although reported AIDS cases attributed to IDU in Mexico have been low, data from sentinel populations, such as pregnant women in the Mexican-U.S. border city of Tijuana, suggest an increase in HIV prevalence associated with drug use. Given widespread risk behaviors and rising numbers of blood borne infections among IDUs in Mexican-U.S. border cities, there is an urgent need for increased disease surveillance and culturally appropriate interventions to prevent potential epidemics of blood borne infections. We review available literature on the history of opium production in Mexico, recent trends in drug use and its implications, and the Mexican response, with special emphasis on the border cities of Ciudad Juarez and Tijuana.

The intravenous injection of illicit drugs and needle sharing: an historical perspective.

This study reviewed the literature on the history of needle sharing and intravenous drug abuse. Reports suggest that needle sharing was practiced by drug abusers as early as 1902 in China and 1914 in the United States. Intravenous drug abuse was first mentioned in the literature in 1925. However other references suggest that some opioid users were injecting intravenously prior to 1920. Outbreaks of malaria in Egypt, the United States, and China between 1929 and 1937 were attributed to needle sharing and intravenous injection of opioids. These reports suggest that both needle sharing and intravenous drug use were common by 1937. Factors such as medical use of intravenous injections, enactment and zealous enforcement of antinarcotic laws, and interactions among drug users in institutional settings such as regional hospitals and prisons may have contributed to the spread of both needle sharing and the intravenous technique among drug abusers.