Hepatitis C Action PlanPrevention Working Group

Findings and recommendations

Norah PalmateerHealth Protection Scotland

Greater Glasgow & Clyde MCN

June 11th, 2008

Scope, Objectives, and Approach of the Working Group

Scope:– Injecting drug users (IDUs)– Provision of injection equipment

Objectives: – To examine

• The effectiveness of injection equipment provision• The current provision of injection equipment in

Scotland• Existing policy on injection equipment provision

Approach:– Systematic reviews of the scientific literature– Reviews of existing reports

Format of this presentation

Evidence

Issue

Recommendations

Actions

Distribution of needles/syringes by Drug Action Team• Numbers of N/S per IDU per year per DAT area ranges

from 57 to 479

DAT

Estimated number of current injectors

2003

Total no. of syringes distributed

2004-05

No. of syringes per injector per

year Fife 1124 538337 479

East Lothian 83 27850 336 Aberdeen City 2050 605374 295

Dumfries & Galloway 663 190609 287 Lanarkshire 1146 326351 285

West Lothian 251 69133 275 Kinross 297 67496 227

Dundee City 475 104946 221 Glasgow 4908 1049770 214

Ayrshire & Arran 1715 335543 196 Moray 111 18199 164

Midlothian 91 14739 162 Angus 322 50374 156

Forth Valley 901 110000 122 Aberdeenshire 681 79000 116

Highland 373 32579 87 Borders 87 5388 62

Argyll & Clyde 2199 125924 57

(Source: National Needle Exchange Survey)

EVIDENCE

Distribution of other injection equipment by NHS Board• Major variations in any access to injection equipment

other than needle/syringes exist across Scotland

Health Board Citric acid

Stericups/ cookers Filters

Sterile water

Argyll & Clyde (n=4) √√√√ √√√ √√√√ √ Ayrshire & Arran (n=3) √√√ √

Borders (n=1) √ Dumfries & Galloway (n=3) √√√ √√ √

Fife (n=3) √√√ Forth Valley (n=2) √ √

Glasgow (n=2) √√ Grampian (n=6) Highland (n=2)

Lanarkshire (n=5) √√√√√ √ √ √ Lothian (n=8) √√√√√√√√ √ √

Shetland (n=1) Tayside (n=5) √√√√√ √√√√√ √√√√√ √

(Source: National Needle Exchange Survey)

EVIDENCE

Other evidence

• Most injection equipment facilities do not provide evening or weekend service; only one is open 24/7

• Adherence to guidelines on numbers of needles/syringes to be distributed is inconsistent(Source: National Needle Exchange Survey)

• There is a direct relationship between injection equipment sharing and poorer access (distance) to needle exchange(Source: Hutchinson et al., 2000)

EVIDENCE

Issue 1

• Widespread variations in the provision and uptake of injection equipment exist throughout Scotland

• Many NHS Boards do not have formal networks to facilitate the prevention of Hepatitis C

• Comprehensive National Guidelines for services providing injection equipment do not exist

ISSUE

Action 13: Each NHS Board will have, or be affiliated to, a Network covering the Prevention of Hepatitis C and comprising representatives of all stakeholder sectors. Guidance regarding Network membership and Terms of Reference will be established. Each NHS board will identify a Hepatitis C Prevention Lead.

Action 14: National Guidelines for services providing injection equipment to IDUs will be developed. A Guideline Development Group will be established.

RECOMMENDATIONS

ACTIONS

Improved access to needle exchange Prevention networks should be established Standards/guidelines on HCV Prevention Services

should be developed

Review of the international literature

• No definitive evidence of needle exchange having an impact on HCV transmission among IDUs– But absence of evidence ≠ absence of effect– Few robust studies have been undertaken

• Evidence that needle exchange reduces needle/syringe sharing

(Source: Palmateer et al., 2008)

EVIDENCE

Evidence from Scotland• Studies provide evidence that harm reduction measures led to

considerable reduction in HCV transmission among IDUs• An estimated 4500 HCV infections were potentially prevented in

Glasgow during 1988-2000 as a result of harm reduction

EVIDENCE

0

20

40

60

80

100

1990 1992 1994 1996 1998 2000 2002

Year tested

Pre

vale

nce

(%

)

Glasgow

Lothian

Tayside

Grampian

(Source: Hutchinson et al., 2002)

But…• Injecting risk behaviour persists

– Around 30% of IDUs in Scotland report having injected with a used needle/syringe during the previous month

– Around 40% of IDUs in Scotland report having injected with other used injection equipment in the last month

(Source: Scottish Drugs Misuse Database)

• Storage of needles/syringes by IDUs for re-use is common, which could result in the inadvertent sharing of such equipmentSource (Taylor et al., 2004)

• Glasgow IDUs: 20-30 infections per 100 person years of injecting(Source: Roy et al., 2007)

• An estimated 1000-1500 IDUs in Scotland are infected annually(Source: Hutchinson et al., 2006)

EVIDENCE

Issue 2

• The re-use/sharing of injection equipment among IDUs is still highly prevalent and Hepatitis C transmission among IDUs throughout Scotland is still very common

ISSUE

Increase access/uptake/coverage of injection equipment Access to needle identifiers

• Action 15: Services providing injection equipment (needles/syringes and other injection paraphernalia) will be improved in accordance with the Guidelines referred to in Action 14. Improvements will be made in terms of: i. Quantity (increasing access and uptake of equipment

through innovative, including outreach, approaches)ii. Quality (e.g. the colour coding of equipment to avoid

sharing) and,iii. Nature (e.g. the provision of equipment other than

needles/syringes)

RECOMMENDATIONS

ACTIONS

HCV in prison

• It is estimated that between 200 and 300 inmates inject drugs in prison at least once per month(Source: 2007 Prisoner Survey)

• Inmates who inject drugs in prison usually do so with unsterile injecting equipment(Source: Taylor et al., 1996)

• Evidence of HCV transmission in prison:– Shotts prison study: 12 cases per 100 person-years of

incarceration among IDUs(Source: Champion et al., 2004)

• Needle exchanges in prisons have been implemented in some European countries– Evaluations have demonstrated acceptability among

inmates/staff and showed a reduction in needle/syringe sharing

(Source: Palmateer et al., 2008)

EVIDENCE

Issue 3

• IDUs who continue to inject drugs in prison do not have access to injection equipment in that setting

ISSUE

• Action 17: An in-prison needle/syringe exchange initiative will be piloted as one of a range of harm reduction measures to reduce the transmission of Hepatitis C in prison.

ACTIONS

Summary of actions

• Affiliation with a network covering the prevention of Hepatitis C

• Development of National Guidelines for services providing injection equipment

• Improvement of services providing injection equipment in terms of quantity, quality, and nature

• Pilot of in-prison needle exchange

Acknowledgements

• Members of the Prevention Working Group