Safer Injecting Practices

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Common Drugs and Injecting Practices

Heroin (pure/white heroin/ ‘No. 4’): mainly in the north-eastern states

Heroin (Smack / brown sugar): not readily injectable as it comes in the

form of crude, impure powder

• Before injecting, a user has to prepare or ‘cook’ the drug

• Most users mix the powder with an injectable sedative drug (like Avil), boil it, filter it with a cotton swab and then inject it

Buprenorphine (Tidigesic/Norphine) or

Pentazocine (Fortwin): probably the most popular drugs for injecting

among IDUs in India

•Most users mix them with one or more of the following sedatives for enhancement of the effects: •Diazepam (Calmpose)•Chlorpheniramine (Avil)•Promethazine (Phenargan)

Dextrprpoxyphene (Proxyvon / Spasmo- Proxyvon / SP): available

as capsules and NOT AS INJECTIONS

•Users open the capsules, take the powder out, crush it, mix it with another liquid / drug and then inject it•Seen only in the north-eastern states, very rare in other parts of the country

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Encouraging Safer Injecting

• Educate clients on safe injecting methods:• Risks of sharing N/S, equipment, drugs• Need for cleaning injecting sites• Differentiating between arteries and veins• Rotation of injecting sites• Injecting in safer sites• Sites where NOT to inject

• Outreach staff should distribute alcohol (spirit)/Betadine/ Savlon swabs along with needles/syringes to every injecting client

Arteries and Veins

1. Never inject into an artery

2. If you hit an artery:

There will be excruciating pain

Bleeding may not stop

May need to see a doctor

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Sites to Avoid When Injecting

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These include– Groin– Heart– Neck– Forehead – Part of palm

below the wrist

– Part of foot below the ankle

Educating on Safer InjectingPEs and ORWs need to be trained on

safer injecting practicesEducative sessions on safer injecting

practices should be planned and conducted regularly at the field level

PEs and ORWs should discuss safer injecting practices during one-on-one interactions

Special sessions with audio visual aids/films may also be conducted at the DIC level

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Needle Syringe Exchange Programs

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Goal and ObjectivesGoal :

To ensure that every injecting act is covered with a safe needle/syringe

Objectives:1. To facilitate safe injecting practices by:

Providing new needles and syringes, alcohol swabs, distilled water etc.

Practicing safe disposal Removing contaminated needles/syringes from

circulation

2. To educate and inform IDUs and partners about safe injecting practices

3. To befriend the IDUs and link them with other services and assist in reduction of high risk practices/behaviour8

Basic Components of NSEP

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Distribute Collect Dispose

& INFORM

Who Implements NSEP?

1. PEs and ORWs in areas where IDUs congregate/reside

2. Health workers (nurse/counsellor/ANMs) at DICs/clinics

3. PEs/others designated as Secondary Distributors (SDs) in far flung areas difficult for ORW/PE to reach

4. Sometimes, NSEP may be implemented by a local key informant

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Where?

At hotspots/sites where IDUs can be accessed

Static/Fixed sites – Clinics or DICs

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What Will Be Distributed?

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1. Needles: 24”, 26”2. Syringes: 1ml, 2ml, 5ml,

10ml3. Other equipment: filter,

cooker, tourniquet (where budget permits)

4. Need based IEC5. Alcohol/spirit swabs (to

prevent abscesses)6. Swabs, bandages, etc. (to

manage abscesses)7. Condoms8. Distilled water

NSEP – Operational AspectsNSEP should operate all 7 days of the week

● At times when IDUs need it most

The planning should be based on:● Spot analysis● Contact mapping● Risk and vulnerability analysis

A carefully planned outreach will determine● Locations/contact points for delivering NSEP● Number of N/S required● Timing of operation● Division of IDUs and areas amongst the outreach

team● Individual tracking and monitoring13

Operational Aspects N/S distribution should be accompanied by

IDUs returning used N/S However, the return should not be a prerequisite

for distribution

Collection of used N/S from IDUs reduces number of used N/S available for recirculation and so reduces risk of contamination/sharing

The return rate of N/S depends on: The relationship between IDU and staff Conducive environment for NSEP

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For a Successful NSEP

Ensure:Easy accessibility of N/SConfidentiality of the IDU and partner

Many IDUs are fearful of being identified and seen as IDUs by the public and family/friends while accessing NSEP

Supply (delivery) meeting demand – in quantity and quality

Behaviour and attitude of outreach staff during interaction with IDUs and partners

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Collection and Disposal of Needles and Syringes

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Collection of Scattered N/S

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Collection of Scattered N/S

Often used N/S lie scattered in fields/hotspots

These might prick children or be reused by other IDUs, causing transmission of infections

A 1-day activity should be organized periodically by the TI to gather these N/S

Use the IDUs/PE/ORW for this activity Inform the general community beforehand Explain the importance of the activity The local police station can also be informed

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Precautions for Collecting Used N/S Wear latex plastic gloves (thick gloves, not the ones

used in clinics) Do not recap N/S Do not bend/break N/S manually Always pick up from the barrel end (syringe end) Use tongs, if possible, to pick up Definitely use tongs to pick up if more than one N/S Separate with a stick and pick up each N/S

separately Put N/S into the puncture-proof container ensuring

that needle-end faces downwards to avoid accidental injury

Secure the lid of the container tightly Avoid manual (direct hand) transfer of needles

/sharps waste from one container to another Transfer collected N/S directly into the main sharp

container placed in the DIC

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Materials Needed for Collection of N/SPuncture proof boxes – serially numbered,

marked with biohazard symbolThick colour-coded plastic bags – marked with

biohazard symbolThick rubber glovesTongs/large forcepsPlastic bin with sievePlastic bin without sieveDisinfectant solution – sodium hypochloride,

bleach, large plastic bins (translucent white or blue in colour)

Hub cutter for mutilating disinfected syringes, if syringes are disposed of by burial on site

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Monitoring of NSEPMonitor NSEP on a regular basisThree types of monitoring tools should be

employed: Weekly review meetings with outreach staff regarding

coverage, areas of weakness and next week’s work plan

Record based monitoring to analyse and review coverage, number of IDUs reached regularly, number of N/S distributed and the return rates

Field based monitoring: PM should regularly visit hotspots, interact with clients, observe the outreach staff and also interact with other community members

Observation from the field visits should be tallied with the records entered by the ORW to get a realistic picture of the quality of the services being offered

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Role of the PM in NSEPSupervise NSEP outreach staffBuild staff capacity and skill on NSEP Develop work plans with ORWs and PEsLiaise with other agencies, local NGOs,

CBOs and other groups in the community

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Points to Remember

NSEP is the backbone of IDU TI programs NSEP faces major resistance from the general

community; significant efforts must be dedicated to conducting advocacy

NSEP serves not only to provide a safe method of injecting, but also as an entry point into the IDU community

Collection of the returned N/S and safe disposal is as important as distribution of N/S

“Remember this is a Needle Syringe Exchange Program, not a mere N/S

distribution program”

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Thank you