Best practice statement

The full text of the best practice statement published by Exchange Supplies, the National Needle Exchange Forum and the UK Harm Reduction Alliance.

Introduction

Provision of sterile injecting equipment, as part of a broader harm reduction approach that includes other interventions such as substitute prescribing, are a vital element in preventing blood borne virus transmission amongst injecting drug users.

Over 200 studies, conducted around the world, were reviewed by the World Health Organisation, in 2004.[1] The conclusion of the review was that there is “compelling evidence that increasing availability of injecting equipment reduces transmission of human immunodeficiency virus (HIV).” [2, 3]

This review, and other studies, have also found that increasing injecting equipment supply through syringe ‘exchange’ and other means:

• reduces hepatitis B virus, hepatitis C virus and other blood borne pathogens among injecting drug users; [4]
• reduce the number of used needles discarded in the community; [5]
• do not encourage injecting drug use; [6]
• do not increase the duration or frequency of injecting; [6]
• do not decrease motivation to reduce drug use; [6]
• are cost effective, and deliver substantial savings in HIV treatment; [7] and
• are often the only contact injecting drug users have with health and social service providers.

Early introduction of needle exchange in the UK averted an HIV epidemic. [8] However, hepatitis C was already endemic amongst injecting drug users when needle exchange was introduced, and incidence (the number of people who catch the virus) and prevalence (the number of people with) of hepatitis C has remained high. [9]

There is evidence that HIV incidence and prevalence is rising.[10] In order to reduce transmission of these viruses, we must work to increase supply, and reduce sharing of syringes and other items associated with the risk of blood borne virus transmission.

Essential service elements

In order to prevent continuing blood borne viral spread, and in particular the risk of a widespread HIV epidemic amongst injectors, injectors must have access to a full range of injecting equipment and items of paraphernalia that have been shown to:

• reduce risk of blood borne virus transmission;
• reduce risk of bacterial or other viral infection; and/or
• increase frequency of attendance.

A range of injecting equipment, paraphernalia and facilities for the safe disposal of used equipment should be available from a range of centre based specialist services, pharmacy needle exchanges, outreach (including peer delivered and secondary needle exchange)

and other services that are:

• local and easy to access;
• user friendly;
• confidential; and/or
• anonymous.

Specialist needle exchange programmes, with suitably trained staff, should be available in every area to provide:
• oral and written safer injecting information and advice;
• general healthcare assessment;
• access to confidential hepatitis B and C and HIV testing;
• hepatitis B vaccination;
• referral to prescribing and other health services including hepatitis C and HIV treatment; and
• wound care advice and treatment.

And

All needle exchange programmes must:

• allow injectors to take all the injecting equipment they need for themselves and the people they inject with;

• not place limits on the amounts of injecting equipment people can take away; and

• not routinely limit distribution of equipment to those who do not bring back used equipment.

References

1 World Health Organisation. Policy Brief: Provision of sterile injecting equipment to reduce HIV transmission. Geneva: 2004 Accessible via: www.who.int/hiv/pub/advocacy/en/provisionofsterileen.pdf

2 MacDonald M. et al. “Effectiveness of needle and syringe programmes for preventing HIV transmission.”

International Journal of Drug Policy: 2003, 14(5–6), p. 353–357. American Journal of Public Health. Dec; 89(12): 1852–4.

3 Gibson DR, Brand R, Anderson K, Kahn JC, Perales D, Guydish J. Two- to sixfold decreased odds of HIV risk behaviour associated

with use of syringe exchange. Journal of Acquired Immune Deficiency Syndromes, 2002; 31: 237–242.

4 Hagan H, Des Jarlais DC, Friedman SR, Purchase D, Alter MJ. Reduced risk of hepatitis B and hepatitis C among injection drug users

in the Tacoma syringe exchange program. American Journal of Public Health, 1995; 85(11): 1531–1537.

5 Doherty MC, Junge B, Rathouz P, Garfein RS, Riley E, Vlahov D: The effect of a needle exchange program on numbers of discarded

needles: A 2-year follow-up. American Journal of Public Health 2000, 90: 936–939.

6 Stimson G V, Alldritt L J, Dolan K A, et al. (November 1988) Injecting Equipment Exchange Schemes Final Report.

Monitoring Research Group, University of London, Goldsmiths College.

7 Health Outcomes International Pty Ltd in association with the National Centre for HIV Epidemiology and Clinical Research and

Professor Michael Drummond, Centre of Health Economics, York University. Return on investment in needle and syringe programs

in Australia. Australian Commonwealth Department of Health and Ageing, 2002.

8 Robertson J R, Bucknall A B V, Welsby P D et al (1986) An epidemic of AIDS-related virus (HTLV lll/ LAV) infection among intravenous

drug abusers in a Scottish general practice. British Medical Journal, 292: 527–30

9 Ashton M. “Hepatitis C and needle exchange: part 1 – the dimensions of the challenge” Drug and Alcohol Findings: 20

10 Judd A, Hickman M, Jones S et al. (2004) Incidence of hepatitis C virus and HIV among new injecting drug users in London:

prospective cohort study. BMJ, doi:10.1136/bmj.38286.841227.7c (published 12 November 2004)