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International Journal of Drug Policy 14 (2003) 359–360

Response
Ecological analyses and the evaluation of needle
and syringe programmes
Waleska Teixeira Caiaffa∗ , Fernando Augusto Proietti
Department of Preventive and Social Medicine, School of Medicine, Federal University of Minas Gerais (UFMG),
Av. Alfredo Balena 190 10o. andar, MG 30130-100 Belo Horizonte, Brazil

Received 1 December 2002; received in revised form 15 March 2003; accepted 2 July 2003

Needle/syringe exchange programmes (NSP), despite jection seems mainly attributable to ecological factors
some controversies, are recognised as a successful interven- rather than individual ones (van Ameijden & Coutinho,
tion in several countries based on a consistent association 2001).
reported in a myriad of observational studies. Results from In this context, we should reflect about costs and feasi-
the ecological study done by MacDonald, Law, Kaldor, bility of cohort studies, especially in developing countries
Hales, and Dore (2003) add an additional piece of evidence where the rapid spread of HIV infection and increases in
about NSP effectiveness in preventing HIV infection jigsaw IDU populations in many countries call for scaling up of
puzzle. Drawing on an extended data from a previous pa- harm reductions strategies. As a consequence, in this sce-
per published by Hurley, Jolley, and Kaldor in The Lancet nario, cross sectional data are helpful and timely. Ecological
(1997), the study confirmed the findings previously reported studies looking at trends over time, especially in the con-
showing a meaningful correlation: HIV seroprevalence de- text of a possibility of comparison between an existing NSP
creased in cities with NSP and increased in cities that had intervention are well justified, especially since randomised
never introduced NSP. trials of the efficacy of NSP in preventing HIV transmission
Ecological studies have received a negative press and rep- is considered not ethically acceptable in light of their proven
utation. For the past 50 years, as compared to the individual effectiveness (Caiaffa & Bastos, 1998).
level based designs, ecological studies have been consid- Finally, what are the implications of these findings? Along
ered suspect and inferior. Fortunately, ecological studies are with numerous recommendations, this article reinforces the
nowadays re-emerging as important analytical tools to bet- need to pursue an aggressive global approach on harm re-
ter understand the interdependence between healthy related duction related to injecting drugs given that they represent a
events and habits, modes of life and relationships to their wise global investment strategy, providing both human and
surroundings (Berkman, 2000; Morgenstern, 1998; Susser, fiscal resource benefits and showing that public health in-
1994). In this context, the paper by MacDonald et al. (2003) vestments in vulnerable populations will lead to healthier
is a welcome addition. lives.
The public health implications of these findings are strik-
ing because it is well known that HIV infection related to
injecting drug use is a typical combination of individual References
behaviour (such as needle/syringe sharing) and contextual
factors (for example, drug culture and/or drug market) (Des Berkman, L., Kawachi, I. (2000). Social epidemiology. New York: Oxford
Jarlais, Courtwright, & Joseph, 1991; Nelson et al., 1998). University Press.
Caiaffa, W. T., & Bastos, F. I. (1998). Usuários de droga injetável e in-
Recently, cohort studies assessing the impact of NSPs fecção pelo HIV: epidemiologia e perspectivas de intervenção. Revista
based on self-reported risk behaviours have showed that Brasileira de Epidemiologia, 1, 2–16.
large scale needle exchange programmes do not lead to Des Jarlais, D. C., Courtwright, D. T., & Joseph, H. (1991). The transition
an increase in injecting drug use, and that decline in in- from opium smoking to heroin injection in the United States. AIDS
& Public Policy Journal, 6(2), 20, 88–90.
Hurley, S., Jolley, D. J., & Kaldor, J. M. (1997). Effectiveness of needle
∗Corresponding author. and syringe exchange programs for prevention of HIV transmission.
E-mail address: wcaiaffa@medicina.ufmg.br (W.T. Caiaffa). Lancet, 349, 1797–1800.

0955-3959/$ – see front matter © 2003 Elsevier B.V. All rights reserved.
doi:10.1016/S0955-3959(03)00134-8
360 W.T. Caiaffa, F.A. Proietti / International Journal of Drug Policy 14 (2003) 359–360

MacDonald, M., Law, M., Kaldor, J., Hales, J., Dore, G. (2003). Ef- immunodeficiency virus infection and risk behavior among injection
fectiveness of needle and syringe programmes for preventing HIV drug users in Baltimore, MD, 1988–1998.
transmission. International Journal of Drug Policy, 14, 353–357. Susser, M. (1994). The logic in ecological: I. The logic of analysis.
Morgenstern, H. (1998). Ecological studies. In K. J. Rothman & S. American Journal of Public Health, 84, 825–829.
Greenland (Eds.), Modern epidemiology (2nd ed.). Philadelphia: van Ameijden, E. J., & Coutinho, R. A. (2001). Large decline in injecting
Lippincott-Raven. drug use in Amsterdam 1986–1998: Explanatory mechanisms and
Nelson, K. E., Galai, N., Safeian, M., Strathdee, S. A., Celentano, D. determinants of injecting transitions. Journal of Epidemiology and
D., Vlahov, D. (1998). Temporal trends in the incidence of human Community Health, 55, 356–363.

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