See below a recent speech by a high-level UNAIDS official on IDU and HIV in Asia. Very worth reading. It gives a stark picture of the low rates of coverage of this high priority target group.
I'd like to draw your attention to the conclusion he draws:
"... So our main challenge in the next two years is to increase access from 3% to 80% for all injecting drug users in need of these prevention and treatment services."
Only a small proportion of all IDUs currently have access to urgently needed HIV prevention products and services. Product and service delivery is PSI's forte. PSI should/will have an important role to play in the rapid scale up needed for IDUs in Asia, and beyond.
Rob
Speech delivered by Mr JVR Prasada Rao, Director, Regional Support Team, UNAIDS Regional Support Team, Asia Pacific at the opening ceremony of the 1st Asian Consultation on the Prevention of HIV Related to Drug Use
28 January 2008
It gives me pleasure to address this Consultation for two particular reasons: firstly because it is the first Asia Pacific Consultation on the specific issue of reducing harm related to injecting drug use, including preventing HIV transmission. It is also special as an initiative entirely undertaken by civil society groups and communities and not by formal organizations in the Government or the UN system. I see in this room a dedicated group of individuals who share a common goal of making HIV prevention, treatment and care for drug users a reality. Congratulations to all the sponsoring agencies and individuals.Today, we have the means needed to make a real difference tackling HIV related to injecting drug use. We have high level commitment to address the epidemic; we have the science, meaning we know what works and we have the resources to scale up interventions.Injecting drug use as a catalyst of HIV epidemics and transmission of hepatitis among IDU in AsiaIn the past, HIV responses in the Asia-Pacific region were guided by global strategies on prevention, treatment and care. The global strategies were based on early experiences in high prevalence regions which witnessed extremely high growth rates within a matter of a few years. Only later was there recognition that the risk factors and the underlying social determinants of the epidemic in this region are totally different to those in other parts of the world.Injecting drug use has acted as a catalyst for HIV epidemics at the onset of the pandemic in many Asian countries. Sharing of injecting equipment is a very efficient way to transmit HIV from one person to the next. Once HIV enters the IDU network, it spreads very rapidly and a drug-use related HIV epidemic kicks off in a country. This is what happened in China, Indonesia, Vietnam and the north east of India, to mention a few of the countries thus affected. Soon after that happens, we start finding HIV among sex workers and sexual partners of drug users, as we saw in Manipur, And within five years of the initial epidemic among people injecting drugs, it had spread to children.Already, globally, three million injecting drug users are living with HIV. In our region, prevalence of anywhere between 20% and 85% has been reported among injecting drug users in several of the countries, including China, India, Thailand, Myanmar, Nepal, and Vietnam. And countries, such as the Philippines, which reported no injecting drug use related to HIV transmission before 2005, have since detected HIV among this population.The good news is that we have the science and we know what we have to do. The first golden rule in preventing a fast spreading HIV epidemic in any country is early intervention to halt transmission. Countries that report injecting drug use need to start prevention before HIV is reported among injecting drug users. I cannot stress this fact enough. Countries that waited and hoped that information, education and communication programmes for the general population would show results did not see them. In these countries, HIV prevalence among injecting drug users sky-rocketed up to 90%. On the other hand, countries, such as Bangladesh, that acted early and implemented focused interventions aimed at preventing transmission among people who inject drugs, have been rewarded with prevalence of around five percent or below, a level comparable level to Australia, Europe and the US.Universal Access and barriers to access among drug usersOn the basis of past experience we also have more detailed blueprint for responses to work with. Last year, UNAIDS and its cosponsors endorsed a practical guideline on prevention interventions. It recommends giving priority to interventions reaching people who inject drugs in all countries that report injecting drug use and it provides practical guidance on the core package of interventions for prevention of HIV related to drug use. By a comprehensive package we mean a full range of treatment options and relevant services. These include substitution treatment, needle and syringe programmes, peer education and outreach, voluntary HIV testing and counseling, prevention of sexually transmitted infections, primary health care and anti retroviral therapy.On top of this, we have a more supportive political environment. In the political declaration made at the high level meeting of the UN General Assembly in June 2006, countries committed to developing targets for Universal Access, while recognizing that the targets have to be cognizant of the realities at country level. Supporting countries to meet these targets has become a major focus of the international efforts, led by UNAIDS and its cosponsors.Ladies & gentlemen, with these guidelines and the political commitment we have a strong platform to take action. You might even think we're on course to solve the problem. But let me now give you a brief snapshot of what's actually going on. It's not a comforting picture.Take the latest data on coverage and access to the essential services by people who inject drugs. It shows that only a tiny proportion of injecting drug users in need of harm reduction programs (3% in South-East Asia and 8% (1 country only, China) in East Asia, actually have access to these services.Only a few countries provide access to substitution treatment, and where it is available, it is mostly at a pilot stage, for example in Indonesia, Nepal, Malaysia, and Myanmar. Only one country, China, has demonstrated a significant scale up effort.Even though it has been quite some time ago that WHO included both Methadone and Buprenorphine to the WHO List of Essential Drugs, yet, as of today, Methadone is legally available in only five countries in Asia (China, Hong Kong, Indonesia, Lao PDR, Myanmar) and Buprenorphine is available in only three: (India, Pakistan and Nepal). Moreover in five countries, namely Bangladesh, Bhutan, Cambodia, Japan and Singapore, both Methadone and Buprenorphine are still illegal.The priority now is to see that all countries which report injecting drug use make methadone legal, include it in the list of essential drugs and expand access to drug substitution treatment sites on the ground.However, a comprehensive HIV response also means that drug users have access to needle and syringe exchange and distribution programmes. Scientific evidence shows that easy and consistent access to sterile injecting equipment cuts transmission of HIV and hepatitis. Countries that took the initiative to implement needle and syringe programmes before a drug use related HIV epidemic took off have succeeded to date in averting a generalized epidemic, saving lives and a huge burden of cost.Yet, only 10 countries in Asia and the Pacific have at least one dedicated needle and syringe exchange programme and only two countries (Malaysia and China) have both NSP and substitution treatment programs in place.Countries that report injecting drug use need to significantly scale up the number of needle and syringe program sites if they are to attain the goal of Universal Access.Another issue of concern is equity, or should I say, the lack of equity, in access to HIV treatment by people who inject drugs. Of all injecting drug users receiving treatment globally, an astonishing 90% live in just one country, Brazil (WHO, 2007).Too often people who use drugs are denied the services that they need and have a right to. We hear that drug users are being told by physicians that "as long as you use drugs you cannot have ART". Similarly, we have heard that drug users on methadone treatment have been denied access to ART.I find this situation unacceptable. ,Denial of treatment is a denial of basic human rights. But let us be clear, it is also bad practice. Current or past drug use cannot be used as a criteria for deciding who can and cannot access treatment.To curb and reverse the spread of AIDS, treatment needs to be provided based on clinical criteria, not on moral grounds. Second; health care services need to be comprehensive, with good referral mechanisms between general medical care, drug dependence treatment, harm reduction services, HIV testing and counseling and psycho-social support.Delivery of anti retroviral therapy for IDUs through public healthcare services alone will not work. We need to expand access to anti retroviral treatment through community based organizations and experience shows us that the more we can involve people who use drugs in the design and delivery of treatment and care programmes, the more successful those programmes will be. Treatment services also need to reach HIV positive persons in closed settings, such as prisons and drug rehabilitation centres. Lessons learned from prison in Bali, Indonesia, show that it is feasible to make available comprehensive treatment and care services in a closed setting.Ladies & gentlemen, in 2010 we will take stock of the progress made towards achieving Universal Access. So our main challenge in the next two years is to increase access from 3% to 80% for all injecting drug users in need of these prevention and treatment services. This is a tall order, but unless we have the vision from the beginning, we will not go very far. To be successful, everyone needs to work together to scale up harm reduction programs and make universal access for drug users a reality at country level.Stigma and discrimination, involvement of drug usersBut let us consider some of the obstacles we must tackle to get there. One of the main barriers for access to prevention, treatment and care services by people who inject drugs continues to be the stigma and discrimination associated both with HIV and injecting drug use. The prejudice encountered by people living with HIV is well documented. But people who use drugs also report stigma and discrimination, and being an HIV-positive drug user brings with it a "double-stigma" that makes it all the more difficult to access relevant services.We also know that in several countries drug users and positive people's networks are still not allowed to organize themselves and that drug users and their networks are excluded from decisions that affect them. This needs to change. The stigma and discrimination associated with drug use and HIV need to go, communities and governments need to embrace the reality of what works in curbing the epidemic.By treating drug users and their representatives as equals, by including them in consultative processes and the decision-making and policy-making bodies that shape the HIV, drug, and other relevant policies, we are more likely to succeed. We also need to support direct involvement of drug users in provision of services, such as outreach, substitution treatment, needle and syringe programmes, delivery of anti retro viral treatment, and prevention of overdose due to drug use. After all, who understands the health and social needs of drug users better than the drug user?Legislation and policies; management of national programsBut the one, overarching bottleneck I hear of whenever I meet and work with colleagues who are dedicated to increasing access to the programmes reducing drug related harm, is how current legislation and policies hamper implementation. There is an urgent need to harmonize drug policies with HIV policies. Criminalization of drug users hampers access to treatment and prevention services.In most countries, the HIV program is managed by the Ministry of Health while the national narcotics control bodies have been left out of the response and as a result often lack understanding and ownership of the national HIV programs. Ministries responsible for controlling narcotic drugs should come forward to participate in these programmes and work closely with the national AIDS programs. China is a good example of such collaboration.ConclusionDespite such challenges, we now have a clear roadmap with which to address this crucial but neglected area of the region's epidemic. The Asia AIDS Commission, recognizing the vital importance of tackling the IDU-related spread of HIV, has given priority to a review of this dimension of the Asian epidemic. Its findings and recommendations will be coming out very soon. I strongly believe that if all of us, the Governments, the parliamentarians, the UN agencies, civil society and drug user organizations implement these recommendations as a matter of urgency we can not only change the current ground reality but alter the course of the epidemic in Asia.Call for ActionLadies & Gentlemen, Colleagues,Let us use this consultation as a platform from which to call on all those who are involved in the response to HIV to move for concerted action on the following agenda:? To review and revise laws that criminalize drug use? To tackle the stigma associated with drug use and HIV? To ensure comprehensive coverage of IDUs with prevention, treatment and care interventions? To involve networks of drug users and community based organizations in delivery of prevention, treatment, care and support services? To maximize financial and technical resources for prevention, treatment and care programs for injecting drug users? And finally to promote and facilitate organizations of people who use drugs.We have over 20 years of experience at hand, we have the evidence, we have the resources, we have the commitment. So let us just do it , lets get on and make Universal Access a reality.
Wednesday, February 27, 2008
Monday, February 18, 2008
How many needles?
If you run a needle and syringe distribution project for IDUs, you've likely struggled with the question 'How many needles and syringes should I give to clients each day.'
This is always an important issue for harm reduction programs. There are no simple answers.
Supply and demand factors need to be weighed. For example, on the supply side, your project may not have unlimited access to commodities. And giving out large numbers of free needles may simply result in those commodities being sold to pharmacies.
On the demand side, if your IDU clients are injecting cocaine, they may inject up to 10 times a day or more and thus need more needles, while heroin injectors (due to the longer half-life of opiates) typically inject much less frequently and so need fewer needles.
These are complex issues, but there is a growing evidence base on this issue which teaches us the following 2 general lessons:
Please don't hesitate to contact me (robgray@laopdr.com) or Mariah (mpreston@psi.org) for more guidance on this issue.
Rob
Needle exchange coverage key to reducing infection risk
Findings’ in-depth review1 of needle exchange and hepatitis C highlighted the importance of coverage – the extent to which exchanges approach the ideal of making a sterile set of equipment available for every injection. Two reports2 3 from researchers in California have confirmed that liberal exchange policies improve coverage which in turn reduces visitors’ risks of contracting or spreading blood-borne diseases.Both derive from a study of 24 of the 25 exchanges operating in the state in 2001. Each service’s policies and activity levels were explored in interviews with their directors, while 1577 injectors recruited between 2001 and 2003 as they were leaving the exchanges were asked about their use of the service and their infection risk behaviours.The number of syringes each injector had available to them over the past month was estimated on the basis of their visits during that time and how many syringes for their own use4 they picked up last time. This was divided by the number of times they injected during the month to construct an index of the adequacy of their supplies. On average exchange visitors (who mainly injected heroin and stimulants) needed nearly 90 syringes/needles in the past month to be able to use a fresh set each time.The first report2 showed that the less restrictive was the distribution policy of their exchange, the greater were the chances of reaching this level. Most restrictive was strict one-for-one exchange of new syringes for old with a cap on the quantity issued per visit. Compared to these services, exchanges which simply provided as much as was needed were five times more likely to achieve adequate coverage. Not far behind were services which implemented uncapped one-for-one exchange supplemented by a few extra sets. Further behind were those which did this but capped quantities, then came the strict one-for-one exchanges, bottomed out by the two which also capped quantities.An analysis which statistically evened out caseload differences confirmed that uncapped needs-based distribution was associated with the highest proportion of visitors (61%) receiving adequate supplies and the lowest receiving less than half their needs (19%). Corresponding figures for the next best option (uncapped one-for-one plus extras) were 50% and 34%. Bottom was capped, strict one-for-one exchange, which left most visitors with less than half their needs met. In exchanges which fell short of needs-based distribution, giving extras on top of one-for-one or not imposing caps made significant improvements to coverage. Visitors who received adequate supplies were significantly more likely to supply sterile syringes to other injectors who did not visit the exchange.A second report3 linked coverage to the proportion of injectors who in the past month had risked spreading infection by injecting with a syringe already used by someone else, or by letting someone else inject with their used syringe. On both measures, the more adequately the individual’s needs had been met by the exchange, the less likely they were to have incurred these risks. For example, when less than half their needs had been met, 38% had re-used after someone else. This proportion progressively reduced as coverage improved to just 9% of injectors who had received at least 50% more than they needed.Adequate coverage was also associated with fewer injectors re-using their own equipment (which heightens the risk of damage at the injecting site) and fewer sharing implements used to heat drug solutions. On all these variables there were some statistically significant differences between coverage levels. More adequately supplied injectors were also more likely to always safely dispose of used syringes by returning them to the exchange, though this fell short of statistical significance once other factors had been taken in to account.These results were relatively clear cut, possibly because so few injectors made up for shortfalls by purchasing syringes from pharmacies, which at the time could be supplied only on prescription.Another important finding was that injectors in treatment were twice as likely to be adequately supplied as those who were not. As in other studies,1 5 this probably reflects a synergistic impact, with exchanges facilitating treatment entry and treatment stabilising lives and reducing injection frequency, making it easier for exchanges to meet patients’ remaining needs.The implications of these findings can already be found in guidelines endorsed by the National Needle Exchange Forum for England and Wales.7 These advise allowing injectors "to take all the injecting equipment they need for themselves and the people they inject with" without capping supplies or routinely tying distribution to returns.There is some way to go to meet this standard. In 2004/5 a survey found that exchanges in England rarely operated a strict one-for-one policy, but also that amounts returned were commonly taken in to account in deciding how much to supply.8 A minority had fixed quantity caps. More common was a variable cap, often depending partly on returns. Around 30-40% had no upper limit. The result was wide variation in how much each exchange gave to the average client. Overall this was one syringe every two days, meaning that many customers must have been under-supplied. At the same time in Scotland (where there are legal caps on the quantity which can be supplied at a single visit) the picture was similar, though there the average distributed per client was less.9 Policies on how much to distribute per visit are not the sole reason for shortfalls; opening hours and other accessibility issues also play a role.The featured study concerned itself with only one element of coverage – adequacy of supply of exchange users – not with the extent to which all injectors in the area were adequately supplied.6 In 2000/1 exchanges in Brighton and Liverpool supplied enough equipment for just over 1 in 4 injections in their areas and in London 1 in 5,10 if anything less than a national estimate for England in 1997.11Thanks for their comments on this entry in draft to Ricky Bluthenthal of the RAND Corporation. Commentators bear no responsibility for the text including the interpretations and any remaining errors.1 Ashton M. Hepatitis C and needle exchange: part 4 • the active ingredients. Drug and Alcohol Findings: 2004, 11, p. 25–30.2 FEATURED STUDY Bluthenthal R.N. et al. Examination of the association between syringe exchange program (SEP) dispensation policy and SEP client-level syringe coverage among injection drug users. Addiction: 2007, 102(4), p. 638–646.3 FEATURED STUDY Bluthenthal R.N. et al. Higher syringe coverage is associated with lower odds of HIV risk and does not increase unsafe syringe disposal among syringe exchange program clients. Drug and Alcohol Dependence: 2007, 89, p. 214–222.4 As opposed to those they intended to pass on to someone else.5 Van Den Berg C. et al. Full participation in harm reduction programmes is associated with decreased risk for human immunodeficiency virus and hepatitis C virus: evidence from the Amsterdam Cohort Studies among drug users. Addiction: 2007, 102, p. 1454–1462.6 Burrows D. Rethinking coverage of needle exchange programs. Substance Use & Misuse: 2006, 41(6–7), p. 1045–1048.7 UK Harm Reduction Alliance, National Needle Exchange Forum, Exchange Supplies. Reducing Injecting Related Harm: consensus statement on best practice. London: UKHRA, 2006.8 Abdulrahim D. et al. The NTA’s 2005 survey of needle exchanges in England. National Treatment Agency for Substance Misuse, 2007.9 Griesbach D. et al. Needle exchange provision in Scotland: a report of the National Needle Exchange Survey. Scottish Executive, 2006.This reports (p.24) that 3,553,911 syringes were distributed to 31,955 (14,229 + 17,726) clients which equates to about 1 every 3 days, but many services were unable to estimate the number of clients, suggesting that this is an over-estimate.10 Hickman M. et al. Injecting drug use in Brighton, Liverpool, and London: best estimates of prevalence and coverage of public health indicators. Journal of Epidemiology and Community Health: 2004, 58, p. 766–771.11 Parsons J. et al. Over a decade of syringe exchange: results from 1997 UK survey. Addiction: 2002, 97, p. 845–850.LINKS Hepatitis C and needle exchange: parts one, two, three and four Nuggets 10.7 5.8 Comment on this entry Back to contents list at top of page
This is always an important issue for harm reduction programs. There are no simple answers.
Supply and demand factors need to be weighed. For example, on the supply side, your project may not have unlimited access to commodities. And giving out large numbers of free needles may simply result in those commodities being sold to pharmacies.
On the demand side, if your IDU clients are injecting cocaine, they may inject up to 10 times a day or more and thus need more needles, while heroin injectors (due to the longer half-life of opiates) typically inject much less frequently and so need fewer needles.
These are complex issues, but there is a growing evidence base on this issue which teaches us the following 2 general lessons:
- Programs should simply try to fill their clients' real daily need for needles and syringes
- Imposing low limits on the number of needles and syringes that IDUs can take (i.e. one-for-one needle "exchange") tends to result in more sharing of used needles, and hence more transmission of HIV and other blood-borne viruses
Please don't hesitate to contact me (robgray@laopdr.com) or Mariah (mpreston@psi.org) for more guidance on this issue.
Rob
Needle exchange coverage key to reducing infection risk
Findings’ in-depth review1 of needle exchange and hepatitis C highlighted the importance of coverage – the extent to which exchanges approach the ideal of making a sterile set of equipment available for every injection. Two reports2 3 from researchers in California have confirmed that liberal exchange policies improve coverage which in turn reduces visitors’ risks of contracting or spreading blood-borne diseases.Both derive from a study of 24 of the 25 exchanges operating in the state in 2001. Each service’s policies and activity levels were explored in interviews with their directors, while 1577 injectors recruited between 2001 and 2003 as they were leaving the exchanges were asked about their use of the service and their infection risk behaviours.The number of syringes each injector had available to them over the past month was estimated on the basis of their visits during that time and how many syringes for their own use4 they picked up last time. This was divided by the number of times they injected during the month to construct an index of the adequacy of their supplies. On average exchange visitors (who mainly injected heroin and stimulants) needed nearly 90 syringes/needles in the past month to be able to use a fresh set each time.The first report2 showed that the less restrictive was the distribution policy of their exchange, the greater were the chances of reaching this level. Most restrictive was strict one-for-one exchange of new syringes for old with a cap on the quantity issued per visit. Compared to these services, exchanges which simply provided as much as was needed were five times more likely to achieve adequate coverage. Not far behind were services which implemented uncapped one-for-one exchange supplemented by a few extra sets. Further behind were those which did this but capped quantities, then came the strict one-for-one exchanges, bottomed out by the two which also capped quantities.An analysis which statistically evened out caseload differences confirmed that uncapped needs-based distribution was associated with the highest proportion of visitors (61%) receiving adequate supplies and the lowest receiving less than half their needs (19%). Corresponding figures for the next best option (uncapped one-for-one plus extras) were 50% and 34%. Bottom was capped, strict one-for-one exchange, which left most visitors with less than half their needs met. In exchanges which fell short of needs-based distribution, giving extras on top of one-for-one or not imposing caps made significant improvements to coverage. Visitors who received adequate supplies were significantly more likely to supply sterile syringes to other injectors who did not visit the exchange.A second report3 linked coverage to the proportion of injectors who in the past month had risked spreading infection by injecting with a syringe already used by someone else, or by letting someone else inject with their used syringe. On both measures, the more adequately the individual’s needs had been met by the exchange, the less likely they were to have incurred these risks. For example, when less than half their needs had been met, 38% had re-used after someone else. This proportion progressively reduced as coverage improved to just 9% of injectors who had received at least 50% more than they needed.Adequate coverage was also associated with fewer injectors re-using their own equipment (which heightens the risk of damage at the injecting site) and fewer sharing implements used to heat drug solutions. On all these variables there were some statistically significant differences between coverage levels. More adequately supplied injectors were also more likely to always safely dispose of used syringes by returning them to the exchange, though this fell short of statistical significance once other factors had been taken in to account.These results were relatively clear cut, possibly because so few injectors made up for shortfalls by purchasing syringes from pharmacies, which at the time could be supplied only on prescription.Another important finding was that injectors in treatment were twice as likely to be adequately supplied as those who were not. As in other studies,1 5 this probably reflects a synergistic impact, with exchanges facilitating treatment entry and treatment stabilising lives and reducing injection frequency, making it easier for exchanges to meet patients’ remaining needs.The implications of these findings can already be found in guidelines endorsed by the National Needle Exchange Forum for England and Wales.7 These advise allowing injectors "to take all the injecting equipment they need for themselves and the people they inject with" without capping supplies or routinely tying distribution to returns.There is some way to go to meet this standard. In 2004/5 a survey found that exchanges in England rarely operated a strict one-for-one policy, but also that amounts returned were commonly taken in to account in deciding how much to supply.8 A minority had fixed quantity caps. More common was a variable cap, often depending partly on returns. Around 30-40% had no upper limit. The result was wide variation in how much each exchange gave to the average client. Overall this was one syringe every two days, meaning that many customers must have been under-supplied. At the same time in Scotland (where there are legal caps on the quantity which can be supplied at a single visit) the picture was similar, though there the average distributed per client was less.9 Policies on how much to distribute per visit are not the sole reason for shortfalls; opening hours and other accessibility issues also play a role.The featured study concerned itself with only one element of coverage – adequacy of supply of exchange users – not with the extent to which all injectors in the area were adequately supplied.6 In 2000/1 exchanges in Brighton and Liverpool supplied enough equipment for just over 1 in 4 injections in their areas and in London 1 in 5,10 if anything less than a national estimate for England in 1997.11Thanks for their comments on this entry in draft to Ricky Bluthenthal of the RAND Corporation. Commentators bear no responsibility for the text including the interpretations and any remaining errors.1 Ashton M. Hepatitis C and needle exchange: part 4 • the active ingredients. Drug and Alcohol Findings: 2004, 11, p. 25–30.2 FEATURED STUDY Bluthenthal R.N. et al. Examination of the association between syringe exchange program (SEP) dispensation policy and SEP client-level syringe coverage among injection drug users. Addiction: 2007, 102(4), p. 638–646.3 FEATURED STUDY Bluthenthal R.N. et al. Higher syringe coverage is associated with lower odds of HIV risk and does not increase unsafe syringe disposal among syringe exchange program clients. Drug and Alcohol Dependence: 2007, 89, p. 214–222.4 As opposed to those they intended to pass on to someone else.5 Van Den Berg C. et al. Full participation in harm reduction programmes is associated with decreased risk for human immunodeficiency virus and hepatitis C virus: evidence from the Amsterdam Cohort Studies among drug users. Addiction: 2007, 102, p. 1454–1462.6 Burrows D. Rethinking coverage of needle exchange programs. Substance Use & Misuse: 2006, 41(6–7), p. 1045–1048.7 UK Harm Reduction Alliance, National Needle Exchange Forum, Exchange Supplies. Reducing Injecting Related Harm: consensus statement on best practice. London: UKHRA, 2006.8 Abdulrahim D. et al. The NTA’s 2005 survey of needle exchanges in England. National Treatment Agency for Substance Misuse, 2007.9 Griesbach D. et al. Needle exchange provision in Scotland: a report of the National Needle Exchange Survey. Scottish Executive, 2006.This reports (p.24) that 3,553,911 syringes were distributed to 31,955 (14,229 + 17,726) clients which equates to about 1 every 3 days, but many services were unable to estimate the number of clients, suggesting that this is an over-estimate.10 Hickman M. et al. Injecting drug use in Brighton, Liverpool, and London: best estimates of prevalence and coverage of public health indicators. Journal of Epidemiology and Community Health: 2004, 58, p. 766–771.11 Parsons J. et al. Over a decade of syringe exchange: results from 1997 UK survey. Addiction: 2002, 97, p. 845–850.LINKS Hepatitis C and needle exchange: parts one, two, three and four Nuggets 10.7 5.8 Comment on this entry Back to contents list at top of page
Sunday, February 17, 2008
How many needles?
If you run a needle and syringe distribution project for IDUs, you've likely struggled with the question 'How many needles and syringes should I give to clients each day.'
This is always an important issue for harm reduction programs. There are no simple answers. Supply and demand factors need to be weighed. For example, on the supply side, your project may not have unlimited access to commodities. And giving out large numbers of free needles may simply result in those commodities being sold to pharmacies. On the demand side, if your IDU clients are injecting cocaine, they may inject up to 10 times a day or more and thus need more needles, while heroin injectors (due to the longer half-life of opiates) typically inject much less frequently and so need fewer needles.
These are complex issues, but there is a growing evidence base on this issue which teaches us the following 2 general lessons:
Needle exchange coverage key to reducing infection risk
Findings’ in-depth review1 of needle exchange and hepatitis C highlighted the importance of coverage – the extent to which exchanges approach the ideal of making a sterile set of equipment available for every injection. Two reports2 3 from researchers in California have confirmed that liberal exchange policies improve coverage which in turn reduces visitors’ risks of contracting or spreading blood-borne diseases.
Both derive from a study of 24 of the 25 exchanges operating in the state in 2001. Each service’s policies and activity levels were explored in interviews with their directors, while 1577 injectors recruited between 2001 and 2003 as they were leaving the exchanges were asked about their use of the service and their infection risk behaviours.
The number of syringes each injector had available to them over the past month was estimated on the basis of their visits during that time and how many syringes for their own use4 they picked up last time. This was divided by the number of times they injected during the month to construct an index of the adequacy of their supplies. On average exchange visitors (who mainly injected heroin and stimulants) needed nearly 90 syringes/needles in the past month to be able to use a fresh set each time.
The first report2 showed that the less restrictive was the distribution policy of their exchange, the greater were the chances of reaching this level. Most restrictive was strict one-for-one exchange of new syringes for old with a cap on the quantity issued per visit. Compared to these services, exchanges which simply provided as much as was needed were five times more likely to achieve adequate coverage. Not far behind were services which implemented uncapped one-for-one exchange supplemented by a few extra sets. Further behind were those which did this but capped quantities, then came the strict one-for-one exchanges, bottomed out by the two which also capped quantities.
An analysis which statistically evened out caseload differences confirmed that uncapped needs-based distribution was associated with the highest proportion of visitors (61%) receiving adequate supplies and the lowest receiving less than half their needs (19%). Corresponding figures for the next best option (uncapped one-for-one plus extras) were 50% and 34%. Bottom was capped, strict one-for-one exchange, which left most visitors with less than half their needs met. In exchanges which fell short of needs-based distribution, giving extras on top of one-for-one or not imposing caps made significant improvements to coverage. Visitors who received adequate supplies were significantly more likely to supply sterile syringes to other injectors who did not visit the exchange.
A second report3 linked coverage to the proportion of injectors who in the past month had risked spreading infection by injecting with a syringe already used by someone else, or by letting someone else inject with their used syringe. On both measures, the more adequately the individual’s needs had been met by the exchange, the less likely they were to have incurred these risks. For example, when less than half their needs had been met, 38% had re-used after someone else. This proportion progressively reduced as coverage improved to just 9% of injectors who had received at least 50% more than they needed.
Adequate coverage was also associated with fewer injectors re-using their own equipment (which heightens the risk of damage at the injecting site) and fewer sharing implements used to heat drug solutions. On all these variables there were some statistically significant differences between coverage levels. More adequately supplied injectors were also more likely to always safely dispose of used syringes by returning them to the exchange, though this fell short of statistical significance once other factors had been taken in to account.
These results were relatively clear cut, possibly because so few injectors made up for shortfalls by purchasing syringes from pharmacies, which at the time could be supplied only on prescription.
Another important finding was that injectors in treatment were twice as likely to be adequately supplied as those who were not. As in other studies,1 5 this probably reflects a synergistic impact, with exchanges facilitating treatment entry and treatment stabilising lives and reducing injection frequency, making it easier for exchanges to meet patients’ remaining needs.
The implications of these findings can already be found in guidelines endorsed by the National Needle Exchange Forum for England and Wales.7 These advise allowing injectors "to take all the injecting equipment they need for themselves and the people they inject with" without capping supplies or routinely tying distribution to returns.
There is some way to go to meet this standard. In 2004/5 a survey found that exchanges in England rarely operated a strict one-for-one policy, but also that amounts returned were commonly taken in to account in deciding how much to supply.8 A minority had fixed quantity caps. More common was a variable cap, often depending partly on returns. Around 30-40% had no upper limit. The result was wide variation in how much each exchange gave to the average client. Overall this was one syringe every two days, meaning that many customers must have been under-supplied. At the same time in Scotland (where there are legal caps on the quantity which can be supplied at a single visit) the picture was similar, though there the average distributed per client was less.9 Policies on how much to distribute per visit are not the sole reason for shortfalls; opening hours and other accessibility issues also play a role.
The featured study concerned itself with only one element of coverage – adequacy of supply of exchange users – not with the extent to which all injectors in the area were adequately supplied.6 In 2000/1 exchanges in Brighton and Liverpool supplied enough equipment for just over 1 in 4 injections in their areas and in London 1 in 5,10 if anything less than a national estimate for England in 1997.11
Thanks for their comments on this entry in draft to Ricky Bluthenthal of the RAND Corporation. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
1 Ashton M. Hepatitis C and needle exchange: part 4 • the active ingredients. Drug and Alcohol Findings: 2004, 11, p. 25–30.
2 FEATURED STUDY Bluthenthal R.N. et al. Examination of the association between syringe exchange program (SEP) dispensation policy and SEP client-level syringe coverage among injection drug users. Addiction: 2007, 102(4), p. 638–646.
3 FEATURED STUDY Bluthenthal R.N. et al. Higher syringe coverage is associated with lower odds of HIV risk and does not increase unsafe syringe disposal among syringe exchange program clients. Drug and Alcohol Dependence: 2007, 89, p. 214–222.
4 As opposed to those they intended to pass on to someone else.
5 Van Den Berg C. et al. Full participation in harm reduction programmes is associated with decreased risk for human immunodeficiency virus and hepatitis C virus: evidence from the Amsterdam Cohort Studies among drug users. Addiction: 2007, 102, p. 1454–1462.
6 Burrows D. Rethinking coverage of needle exchange programs. Substance Use & Misuse: 2006, 41(6–7), p. 1045–1048.
7 UK Harm Reduction Alliance, National Needle Exchange Forum, Exchange Supplies. Reducing Injecting Related Harm: consensus statement on best practice. London: UKHRA, 2006.
8 Abdulrahim D. et al. The NTA’s 2005 survey of needle exchanges in England. National Treatment Agency for Substance Misuse, 2007.
9 Griesbach D. et al. Needle exchange provision in Scotland: a report of the National Needle Exchange Survey. Scottish Executive, 2006.This reports (p.24) that 3,553,911 syringes were distributed to 31,955 (14,229 + 17,726) clients which equates to about 1 every 3 days, but many services were unable to estimate the number of clients, suggesting that this is an over-estimate.
10 Hickman M. et al. Injecting drug use in Brighton, Liverpool, and London: best estimates of prevalence and coverage of public health indicators. Journal of Epidemiology and Community Health: 2004, 58, p. 766–771.
11 Parsons J. et al. Over a decade of syringe exchange: results from 1997 UK survey. Addiction: 2002, 97, p. 845–850.
LINKS Hepatitis C and needle exchange: parts one, two, three and four Nuggets 10.7 5.8 Comment on this entry Back to contents list at top of page
This is always an important issue for harm reduction programs. There are no simple answers. Supply and demand factors need to be weighed. For example, on the supply side, your project may not have unlimited access to commodities. And giving out large numbers of free needles may simply result in those commodities being sold to pharmacies. On the demand side, if your IDU clients are injecting cocaine, they may inject up to 10 times a day or more and thus need more needles, while heroin injectors (due to the longer half-life of opiates) typically inject much less frequently and so need fewer needles.
These are complex issues, but there is a growing evidence base on this issue which teaches us the following 2 general lessons:
- Programs should simply try to fill their clients' real daily need for needles and syringes
- Imposing low limits on the number of needles and syringes that IDUs can take (i.e. one-for-one needle "exchange") tends to result in more sharing of used needles, and hence more transmission of HIV and other blood-borne viruses
The study below confirms these general lessons.
Please don't hesitate to contact me (robgray@laopdr.com) or Mariah (mpreston@psi.org) for more guidance on this issue.
Rob
Needle exchange coverage key to reducing infection risk
Findings’ in-depth review1 of needle exchange and hepatitis C highlighted the importance of coverage – the extent to which exchanges approach the ideal of making a sterile set of equipment available for every injection. Two reports2 3 from researchers in California have confirmed that liberal exchange policies improve coverage which in turn reduces visitors’ risks of contracting or spreading blood-borne diseases.
Both derive from a study of 24 of the 25 exchanges operating in the state in 2001. Each service’s policies and activity levels were explored in interviews with their directors, while 1577 injectors recruited between 2001 and 2003 as they were leaving the exchanges were asked about their use of the service and their infection risk behaviours.
The number of syringes each injector had available to them over the past month was estimated on the basis of their visits during that time and how many syringes for their own use4 they picked up last time. This was divided by the number of times they injected during the month to construct an index of the adequacy of their supplies. On average exchange visitors (who mainly injected heroin and stimulants) needed nearly 90 syringes/needles in the past month to be able to use a fresh set each time.
The first report2 showed that the less restrictive was the distribution policy of their exchange, the greater were the chances of reaching this level. Most restrictive was strict one-for-one exchange of new syringes for old with a cap on the quantity issued per visit. Compared to these services, exchanges which simply provided as much as was needed were five times more likely to achieve adequate coverage. Not far behind were services which implemented uncapped one-for-one exchange supplemented by a few extra sets. Further behind were those which did this but capped quantities, then came the strict one-for-one exchanges, bottomed out by the two which also capped quantities.
An analysis which statistically evened out caseload differences confirmed that uncapped needs-based distribution was associated with the highest proportion of visitors (61%) receiving adequate supplies and the lowest receiving less than half their needs (19%). Corresponding figures for the next best option (uncapped one-for-one plus extras) were 50% and 34%. Bottom was capped, strict one-for-one exchange, which left most visitors with less than half their needs met. In exchanges which fell short of needs-based distribution, giving extras on top of one-for-one or not imposing caps made significant improvements to coverage. Visitors who received adequate supplies were significantly more likely to supply sterile syringes to other injectors who did not visit the exchange.
A second report3 linked coverage to the proportion of injectors who in the past month had risked spreading infection by injecting with a syringe already used by someone else, or by letting someone else inject with their used syringe. On both measures, the more adequately the individual’s needs had been met by the exchange, the less likely they were to have incurred these risks. For example, when less than half their needs had been met, 38% had re-used after someone else. This proportion progressively reduced as coverage improved to just 9% of injectors who had received at least 50% more than they needed.
Adequate coverage was also associated with fewer injectors re-using their own equipment (which heightens the risk of damage at the injecting site) and fewer sharing implements used to heat drug solutions. On all these variables there were some statistically significant differences between coverage levels. More adequately supplied injectors were also more likely to always safely dispose of used syringes by returning them to the exchange, though this fell short of statistical significance once other factors had been taken in to account.
These results were relatively clear cut, possibly because so few injectors made up for shortfalls by purchasing syringes from pharmacies, which at the time could be supplied only on prescription.
Another important finding was that injectors in treatment were twice as likely to be adequately supplied as those who were not. As in other studies,1 5 this probably reflects a synergistic impact, with exchanges facilitating treatment entry and treatment stabilising lives and reducing injection frequency, making it easier for exchanges to meet patients’ remaining needs.
The implications of these findings can already be found in guidelines endorsed by the National Needle Exchange Forum for England and Wales.7 These advise allowing injectors "to take all the injecting equipment they need for themselves and the people they inject with" without capping supplies or routinely tying distribution to returns.
There is some way to go to meet this standard. In 2004/5 a survey found that exchanges in England rarely operated a strict one-for-one policy, but also that amounts returned were commonly taken in to account in deciding how much to supply.8 A minority had fixed quantity caps. More common was a variable cap, often depending partly on returns. Around 30-40% had no upper limit. The result was wide variation in how much each exchange gave to the average client. Overall this was one syringe every two days, meaning that many customers must have been under-supplied. At the same time in Scotland (where there are legal caps on the quantity which can be supplied at a single visit) the picture was similar, though there the average distributed per client was less.9 Policies on how much to distribute per visit are not the sole reason for shortfalls; opening hours and other accessibility issues also play a role.
The featured study concerned itself with only one element of coverage – adequacy of supply of exchange users – not with the extent to which all injectors in the area were adequately supplied.6 In 2000/1 exchanges in Brighton and Liverpool supplied enough equipment for just over 1 in 4 injections in their areas and in London 1 in 5,10 if anything less than a national estimate for England in 1997.11
Thanks for their comments on this entry in draft to Ricky Bluthenthal of the RAND Corporation. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
1 Ashton M. Hepatitis C and needle exchange: part 4 • the active ingredients. Drug and Alcohol Findings: 2004, 11, p. 25–30.
2 FEATURED STUDY Bluthenthal R.N. et al. Examination of the association between syringe exchange program (SEP) dispensation policy and SEP client-level syringe coverage among injection drug users. Addiction: 2007, 102(4), p. 638–646.
3 FEATURED STUDY Bluthenthal R.N. et al. Higher syringe coverage is associated with lower odds of HIV risk and does not increase unsafe syringe disposal among syringe exchange program clients. Drug and Alcohol Dependence: 2007, 89, p. 214–222.
4 As opposed to those they intended to pass on to someone else.
5 Van Den Berg C. et al. Full participation in harm reduction programmes is associated with decreased risk for human immunodeficiency virus and hepatitis C virus: evidence from the Amsterdam Cohort Studies among drug users. Addiction: 2007, 102, p. 1454–1462.
6 Burrows D. Rethinking coverage of needle exchange programs. Substance Use & Misuse: 2006, 41(6–7), p. 1045–1048.
7 UK Harm Reduction Alliance, National Needle Exchange Forum, Exchange Supplies. Reducing Injecting Related Harm: consensus statement on best practice. London: UKHRA, 2006.
8 Abdulrahim D. et al. The NTA’s 2005 survey of needle exchanges in England. National Treatment Agency for Substance Misuse, 2007.
9 Griesbach D. et al. Needle exchange provision in Scotland: a report of the National Needle Exchange Survey. Scottish Executive, 2006.This reports (p.24) that 3,553,911 syringes were distributed to 31,955 (14,229 + 17,726) clients which equates to about 1 every 3 days, but many services were unable to estimate the number of clients, suggesting that this is an over-estimate.
10 Hickman M. et al. Injecting drug use in Brighton, Liverpool, and London: best estimates of prevalence and coverage of public health indicators. Journal of Epidemiology and Community Health: 2004, 58, p. 766–771.
11 Parsons J. et al. Over a decade of syringe exchange: results from 1997 UK survey. Addiction: 2002, 97, p. 845–850.
LINKS Hepatitis C and needle exchange: parts one, two, three and four Nuggets 10.7 5.8 Comment on this entry Back to contents list at top of page
Wednesday, February 13, 2008
How many IDUs?
Did you ever wonder how many IDUs are in your country?
Below, find a published article that attempts to answer this question, for 105 countries.
Estimates of injecting drug users at the national and local level in developing and transitional countries, and gender and age distribution.
http://sti.bmj.com/cgi/content/full/82/suppl_3/iii10
These numbers are estimates. But as Dick Franks says, "Some data is better than no data."
You could use this data to:
Rob
Below, find a published article that attempts to answer this question, for 105 countries.
Estimates of injecting drug users at the national and local level in developing and transitional countries, and gender and age distribution.
http://sti.bmj.com/cgi/content/full/82/suppl_3/iii10
These numbers are estimates. But as Dick Franks says, "Some data is better than no data."
You could use this data to:
- Advocate for a population estimation to be done, if there is no data on your country here
- Estimate the percentage of all IDUs in your country that your PSI intervention is reaching
- Compare the numbers of IDUs reached by all programs in your country against the total number of IDUs, to see the percentage of IDUs not being reached. This could constitute the beginning of a "Gap Analysis" that could help if you're considering a GF Round 8 proposal.
Rob
Tuesday, February 12, 2008
Knowing the evidence base for our IDU work
Do some key stakeholders in your country view your IDU program with suspicion?
If so, it's especially important to know the evidence base for our models and to be aware of what global health bodies support the work.
Go to the link below for the WHO document:
EVIDENCE FOR ACTION: EFFECTIVENESS OF COMMUNITY-BASED OUTREACH IN PREVENTING HIV/AIDS AMONG INJECTING DRUG USERS
http://www.emro.who.int/aiecf/web2.pdf
The document outlines WHO's position on the existing evidence that supports IDU interventions, including outreach and needle distribution.
WHO supports the kind of work we're doing to reduce death and disability among IDUs. We should be using that support to help build enabling environments for our programs.
Rob
If so, it's especially important to know the evidence base for our models and to be aware of what global health bodies support the work.
Go to the link below for the WHO document:
EVIDENCE FOR ACTION: EFFECTIVENESS OF COMMUNITY-BASED OUTREACH IN PREVENTING HIV/AIDS AMONG INJECTING DRUG USERS
http://www.emro.who.int/aiecf/web2.pdf
The document outlines WHO's position on the existing evidence that supports IDU interventions, including outreach and needle distribution.
WHO supports the kind of work we're doing to reduce death and disability among IDUs. We should be using that support to help build enabling environments for our programs.
Rob
Monday, February 11, 2008
Welcome!
Welcome to PSI's IDU Blog.
I hope you'll find this a useful way to keep up-to-date on important new IDU-related issues.
I want to point out - I'm not an expert Blogger. A Blog simply seemed to be the most convenient medium to get information to you all. So this is an experiment. If you have suggestions about how to improve this service, please contact me or Mariah.
I wanted to thank Haneefa Saleem, Mary Warsh, and Mariah Preston who did most of the leg work to get this up and running.
Now, to work...
In this inaugural message, I wanted to inform you of a recent study published showing the efficacy of using Naloxone to reduce deaths from overdose among IDUs.
Go to: http://www.harmreductionjournal.com/content/5/1/2
Overdose is one of the major causes of death among IDUs, and in some parts of the world (including many places in the US, like California) is one of the leading causes of death among youth, overall. Naloxone is a cheap (about $1), harmless antidote that can save someone in overdose from dying.
PSI is not yet running any interventions to prevent OD deaths, but we are actively exploring the possibility of doing so, through Naloxone distribution. If there is a significant OD problem in your country, you might consider this as a potential program option. (Contact me or Mariah for technical assistance.)
FYI, early in his tenure, Karl Hofmann approved PSI Central Asia to launch a Naloxone program, if we could find funding. (We're still searching for that funding.) We already have a draft DALY worked out to measure the health impact for preventing overdose deaths. And let me just say that the country that launches a Naloxone program will likely accrue significant DALYs per dollar spent.
Cheers
Rob
I hope you'll find this a useful way to keep up-to-date on important new IDU-related issues.
I want to point out - I'm not an expert Blogger. A Blog simply seemed to be the most convenient medium to get information to you all. So this is an experiment. If you have suggestions about how to improve this service, please contact me or Mariah.
I wanted to thank Haneefa Saleem, Mary Warsh, and Mariah Preston who did most of the leg work to get this up and running.
Now, to work...
In this inaugural message, I wanted to inform you of a recent study published showing the efficacy of using Naloxone to reduce deaths from overdose among IDUs.
Go to: http://www.harmreductionjournal.com/content/5/1/2
Overdose is one of the major causes of death among IDUs, and in some parts of the world (including many places in the US, like California) is one of the leading causes of death among youth, overall. Naloxone is a cheap (about $1), harmless antidote that can save someone in overdose from dying.
PSI is not yet running any interventions to prevent OD deaths, but we are actively exploring the possibility of doing so, through Naloxone distribution. If there is a significant OD problem in your country, you might consider this as a potential program option. (Contact me or Mariah for technical assistance.)
FYI, early in his tenure, Karl Hofmann approved PSI Central Asia to launch a Naloxone program, if we could find funding. (We're still searching for that funding.) We already have a draft DALY worked out to measure the health impact for preventing overdose deaths. And let me just say that the country that launches a Naloxone program will likely accrue significant DALYs per dollar spent.
Cheers
Rob
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