Abstract: OBJECTIVES. The sharing of contaminated injection equipment is the primary mode of human immunodeficiency virus (HIV) transmission for injection drug users. This study examined demographic factors, life events, and drug use practices that are potential risk factors for sharing injection equipment. METHODS. Between February 1988 and March 1989, 2921 active injection drug users were interviewed and questioned about their backgrounds, life-styles, and patterns of injection drug use. RESULTS. Of 2524 participants who reported injecting drugs within the 6 months prior to study enrollment, 70.4% reported recent needle sharing. A multivariate analysis found needle sharing to be more frequent among those with a history of arrest and lower socioeconomic status, even after accounting for other demographic and drug use variables. In addition, recent needle sharing was higher in male homosexual or bisexual men than in their heterosexual counterparts. CONCLUSIONS. These data suggest that injection drug users have an economic motive to share needles and that the availability of free and legal needles may reduce levels of needle sharing.

Abstract: OBJECTIVE:To compute the burden of cancer attributable to current and former alcohol consumption in eight European countries based on direct relative risk estimates from a cohort study. DESIGN: Combination of prospective cohort study with representative population based data on alcohol exposure. Setting Eight countries (France, Italy, Spain, United Kingdom, the Netherlands, Greece, Germany, Denmark) participating in the European Prospective Investigation into Cancer and Nutrition (EPIC) study. PARTICIPANTS: 109,118 men and 254,870 women, mainly aged 37-70. MAIN OUTCOME MEASURES: Hazard rate ratios expressing the relative risk of cancer incidence for former and current alcohol consumption among EPIC participants. Hazard rate ratios combined with representative information on alcohol consumption to calculate alcohol attributable fractions of causally related cancers by country and sex. Partial alcohol attributable fractions for consumption higher than the recommended upper limit (two drinks a day for men with about 24 g alcohol, one for women with about 12 g alcohol) and the estimated total annual number of cases of alcohol attributable cancer. RESULTS: If we assume causality, among men and women, 10% (95% confidence interval 7 to 13%) and 3% (1 to 5%) of the incidence of total cancer was attributable to former and current alcohol consumption in the selected European countries. For selected cancers the figures were 44% (31 to 56%) and 25% (5 to 46%) for upper aerodigestive tract, 33% (11 to 54%) and 18% (-3 to 38%) for liver, 17% (10 to 25%) and 4% (-1 to 10%) for colorectal cancer for men and women, respectively, and 5.0% (2 to 8%) for female breast cancer. A substantial part of the alcohol attributable fraction in 2008 was associated with alcohol consumption higher than the recommended upper limit: 33,037 of 178,578 alcohol related cancer cases in men and 17,470 of 397,043 alcohol related cases in women. CONCLUSIONS:In western Europe, an important proportion of cases of cancer can be attributable to alcohol consumption, especially consumption higher than the recommended upper limits. These data support current political efforts to reduce or to abstain from alcohol consumption to reduce the incidence of cancer.

Abstract: Objective: To determine whether frontloading (i.e., syringe-mediated drug-sharing) is a risk factor for HIV, hepatitis B virus (HBV) and hepatitis C virus (HCV) infection among injecting drug users (IDU). Design: Cross-sectional study. Data on sociodemographic and behavioural characteristics were obtained by a standardized questionnaire. Serum samples were tested for seromarkers for HIV, HBV and HCV. Setting and participants: IDU were recruited at ’low-threshold’ storefront agencies (out-of-treatment sample), and at a centre for long-term drug use treatment (in-treatment sample). Individuals were included in the study if they had injected drugs within the previous 3 months. Main outcome measures: Serological evidence for HIV, HBV, HCV exposure. Results: Of all IDU (n = 324), 84% had ever practised frontloading with non-sterile injecting equipment, and 46% had done so more than 100 times; 32% had front-loaded during the 6 months prior to the interview. The crude seroprevalence rates for HIV, HBV and HCV increased with the overall frequency of frontloading, and reached 22, 71 and 94%, respectively, among IDU who had frontloaded more than 100 times. After controlling for confounding effects by logistic regression, having practised front-loading more than 100 times was significantly associated with HIV infection [adjusted prevalence odds ratio (POR) 3.5; 95% confidence interval (CI), 1.4-9], and HCV infection (adjusted POR, 5.4; 95% CI, 2.3-12), but not with HBV infection. Another independent risk factor for all three virus infections was needle-sharing in prison. Conclusions: In communities where sterile injection equipment is readily available, and IDU have substantially reduced their overall levels of needle-sharing, the practice of frontloading appears to be a major risk factor for infections by blood-borne viruses among IDU. Prevention activities should specifically address this risk behaviour.

Abstract: Objective To test whether the Communities That Care (CTC) prevention system reduces adolescent alcohol, tobacco, and other drug use and delinquent behavior communitywide. Design The Community Youth Development Study is the first randomized trial of CTC. Setting In 2003, 24 small towns in 7 states, matched within state, were randomly assigned to control or CTC conditions. Participants A panel of 4407 fifth-grade students was surveyed annually through eighth grade. Intervention A coalition of community stakeholders received training and technical assistance to install the CTC prevention system. They used epidemiological data to identify elevated risk factors and depressed protective factors in the community, and chose and implemented tested programs to address their community’s specific profile from a menu of effective programs for families, schools, and youths aged 10 to 14 years. Main Outcome Measures Incidence and prevalence of alcohol, tobacco, and other drug use and delinquent behavior by spring of grade 8. Results The incidences of alcohol, cigarette and smokeless tobacco initiation, and delinquent behavior were significantly lower in CTC than in control communities for students in grades 5 through 8. In grade 8, the prevalences of alcohol and smokeless tobacco use in the last 30 days, binge drinking in the last 2 weeks, and the number of different delinquent behaviors committed in the last year were significantly lower for students in CTC communities. Conclusion Using the CTC system to reduce health-risking behaviors in adolescents can significantly reduce these behaviors communitywide.

Abstract: Objective To examine the effectiveness of needle exchange programs (NEPs) in modifying HIV-related outcomes in injection drug users (IDUs). Methods On-line computer searches of six electronic databases, hand searches of core journals and relevant studies, combined with key informant suggestions at the federal and front line level for potentially relevant studies, and review of local and community publications, resulted in the retrieval of 84 studies from 1997 to 1999 related to the effectiveness of needle exchange programs. The HIV-related outcomes of interest examined were behavioural (modifications in HIV-risk-related injection practices) and end-point physical health status outcomes (changes in rates of HIV, hepatitis B (HBV) and hepatitis C (HCV) seroprevalence or incidence) at either the population (most frequently, city; less frequently, country) or individual level. Results Relevance and quality assessment reviews resulted in the inclusion in this review of 21 relevant but largely methodologically weak primary studies. From the evidence of these primary studies, NEPs appear to continue to be effective in modifying most HIV risk-related injection practices although engagement in sharing drug preparation equipment continues. The earlier protective effect of NEP attendance against HIV, HBV and HCV seroconversion has not been consistently sustained. However, NEPs appear to be effective in attracting a group of IDUs experiencing higher HIV risk conditions and who are thereby at increased risk for HIV infection. Conclusions NEPs appear well positioned, as an accessible service, to continue to offer the knowledge and the means to modify engagement in HIV-risk-related injection practices. Enhanced programming is needed to address the documented continued sharing of injection preparation equipment, to modify engagement in a potentially effective, yet largely unrecognized, method of HIV transmission. The potential role of NEPs to expand and diversify as an acceptable comprehensive health resource for a marginalized group of people for whom mainstream health care has not always been easily accessible must be realized.