Romance y corrido discográfico de Delgadina

have been realised in former years and many are ongoing. Examples are: peer support for drug-using immigrants; drug consumption rooms, HIV counselling and HIV tests; HIV treatment; hepatitis B vaccination and prophylactic vaccination of early stage syphilis among (drug-using) sex workers. On the website www.infectieziekten.net this informa- tion and several fact sheets in Dutch are downloadable (hepatitis B and C, HIV and tu- berculosis) that give basic information about these diseases, do’s and don’ts, and infor- mation about treatment.

In the Netherlands, the organisation of prevention and treatment of infectious diseases is rather complex. Activities for all those who are (at risk of becoming) infected, thus en- compassing a much broader group than drug users, are within the remit of the Municipal Health Services (GGDs) and its National Coordinating Agency (GGD Nederland). Activities targeted specifically at drug users are often offered by organisations for addiction care, because these organisations are the primary agents in motivating addicts to join preven- tive and treatment activities. Co-operation in this domain is crucial, especially for drug dependent groups. To date the Prevention and Brief Interventions Centre (LSP) coordi- nates the National Network Infectious Diseases and Drug Use. Most Organisations of Ad- diction Care and some Municipal Health Services that feel responsible for drug users are members of this network. A recent survey (response > 90%) showed that more than 90% of the organisations of addiction care cooperate with the municipal health services on issues of infectious diseases. Frequent mutual contacts exist but in some cases coop- eration still appears to be difficult. Explicit work plans are necessary, specifying responsi- bilities and divisions of tasks between the two sectors. More exchange of knowledge is needed as well as additional training (personal communication Hoogenboezem). A feasi- bility study on the screening and treatment of hepatitis C among drug users in three or- ganisations for addiction care, also showed that there are still some important limiting factors that have to be overcome before these interventions can be implemented suc- cessfully.

HIV-treatment among drug users

Of the 607 known injecting drug users that were HIV-positive, 488 started Highly Active AntiRetroviral Therapy (HAART) between 1996 and 2005. Over the period 2002-2005, only 96 drug users received HAART. A large number of HIV-infected drug users eligible to initiate HAART are still not receiving this therapy. This is despite the fact that drug users who are treated with HAART are shown to have a similar early response to HAART (mea- sured as the effect on HIV RNA levels and CD4 count) as homosexual men and can be treated effectively. Furthermore, drug users who are treated with HAART do not increase their risk behaviour. Nevertheless, in the long run it is likely that therapy will be less ef- fective, since drug users in this cohort study started HAART at higher HIV RNA levels and lower CD4 cell counts than homosexual men, and only 36-55% of drug users were fully adherent to therapy (Smit et al. 2006a).

National hepatitis B vaccination campaign

In line with a recommendation of the Dutch Health Council, free vaccination of behav- ioural risk groups (drug users, men having sex with men, heterosexuals with multiple sex partners, including commercial sex workers) is taking place nationwide since 2002. Since 2004, there is a formal cooperation with penitentiary institutions, which also provide vac- cinations. This cooperation has proven to be very fruitful, since 12% of the total number of participants has been vaccinated in the 50 participating penitentiary institutions. In 2005, the World Health Organization awarded the WHO Award Health in Prisons Project (HIPP) to the national hepatitis B vaccination campaign. See also § 6.3

• From November 2002 until the end of September 2006, 10,502 drug users received a

first vaccination. Compliance of those drug users with the indication for a second vac- cination (susceptible, and the first vaccination more than a month ago) was 82.5%. Compliance for the third vaccination (six months after the first vaccination) is cur- rently 57.4%. These data imply that the protection rate of the 10,502 drug users tak- ing part in the campaign until now is 64%, including individuals receiving the full vac- cination schedule and those tested as either immune or carriers. As it is currently un- clear whether an incomplete series of vaccinations - two or one vaccination(s) - may also be effective, the actual number of protected drug users may be higher. The data presented are preliminary and subject to change, since the campaign is ongoing (data are provided by M-L Heijnen, Netherlands Association for Community Health Services).

• To assess the effectiveness of the hepatitis B vaccination campaign the number of re-

ported acute hepatitis B infection cases in Amsterdam has been compared in the 6 years before and 6 years during the implementation of the vaccination programme (Houdt 2006). Overall, a significant decrease was observed in the incidence of re- ported acute hepatitis B infection patients in Amsterdam, which was largely due to a reduction of transmission through injecting drug use and heterosexual contacts. The contribution of the vaccination programme to the decrease in acute hepatitis B infec- tion in drug users may be limited though, since only 16% of the estimated total popu- lation of 4,500 drug users in Amsterdam was reached by the program. A more likely explanation is the decreased popularity of injecting drug use in the same period. Needle exchange

There are only limited data on needle exchange. Data from Amsterdam show that from 1990 to 1993 around one million needles were exchanged. After that this number gradu- ally declined to some 500,000 in 1999, more than 300,000 in 2003 and only around 200,000 in 2004 and 2005 (M. Buster, personal communication). The total number of needle exchange programmes in the Netherlands is not known, nor are there national registration data on the number of exchanged syringes or needles. The website of

Mainline (the grassroots organisation of drug users in Amsterdam) only presents some 120 exchange points in different cities (www.mainline.nl; updated in January 2005).