ANCD Position Paper: Needle and Syringe Programs
17 October 2013
The Australian National Council on Drugs (ANCD) has today released a position paper on needle and syringe programs (NSPs) and is calling on all Australian governments to significantly increase both their commitment and funding to these vital public health programs.
The position paper is based primarily on recognition of the long standing success of NSPs in preventing and limiting the spread of HIV and other blood borne viruses (BBVs), and the ability of these services to engage people in the health system in a way that no other service is able to do.
NSPs have been operating in Australia since 1986. They have been part of our HIV/AIDS strategy since 1989, part of our drug strategy since 1993, and part of our Hepatitis C Strategy since 1999. As a result, Australia has one of the lowest rates in the world of HIV amongst injecting drug users: around 1%, compared to around 16% in the USA, and even higher figures in neighbouring countries.
NSPs are also an important part of the front-line response to hepatitis C in Australia. The Annual National NSP Survey has shown a significant decline in hepatitis C prevalence among NSP clients which is very important given the scale of the epidemic and the fact that injecting drug users constitute over 90 per cent of all new infections. NSPs also provide other important services, including primary healthcare, education, referrals to other services including treatment and increasing the safe disposal of injecting equipment. They have been, and continue to be one of the most effective components of Australia’s response to HIV and hepatitis C.
The evidence for the effectiveness and cost effectiveness of NSPs is very strong. The 2009 study Return on Investment 2: Evaluating the Cost-Effectiveness of Needle and Syringe Programs in Australia, commissioned by the Department of Health and Ageing and conducted at the National Centre in HIV Epidemiology and Clinical Research (now the Kirby Institute) at the University of New South Wales, showed that between 2000 and 2009, NSPs prevented over 32,000 new HIV infections and almost 100,000 new hepatitis C infections. The programs were also highly cost effective, providing savings of over $1 billion in healthcare costs. Indeed for every $1 invested in NSPs there was a return of $27.
The ANCD has also welcomed the high levels of public support for NSPs, which have increased substantially over time as people become aware of the good outcomes for public health and safety that NSPs provide.
However, new HIV notifications have started to rise over the last decade, with some, albeit small increases in infections among highly marginalised groups of injecting drug users. Whilst it is not cause for panic, it does demonstrate the potential of what can occur if our vigilance is not maintained. We are more vulnerable than we realise, especially given that spending on harm reduction services, which includes NSPs, has recently been reported to have significantly declined over the last seven years from $44.8 million in 2002/03 (or $54.5 million in adjusted 09/10 figures) to only $36.1 million in 09/10.
The ANCD is also becoming very concerned at increasing reports of NSP programs having been closed or having their funding and services reduced. At least five NSPs around the country have recently been reported as being closed including - at least one peer-based NSP. At least two outreach services have also been cut. Ongoing cuts to Australia’s NSPs are likely to result in an increase in HIV and hepatitis C infections, whilst restrictions in the range of sterile equipment being offered to save money or the introduction of charging for equipment for cost-recovery will lead to fewer people accessing this vital and highly effective preventive service.
The difficulty in measuring changes over time to NSP access and service delivery models highlights the need for greater transparency in both the funding provided for NSPs in Australia and the levels and coverage of services provided.
Dr John Herron, Chairman of the ANCD, stated, “In my life and particularly in my role as Chairman of the Australian National Council on Drugs, I have met many people and families that are working through the pain that drug dependence can cause. It serves as a reminder that any family can find themselves in this situation and whilst the needle and syringe program may not stop this from happening it can greatly reduce the likelihood of HIV or hepatitis C whilst people are injecting drugs. This is incredibly important given the implications for the individual, family and community if these blood borne viruses are not prevented. Just as importantly, NSPs can also be the necessary conduit to getting people assistance earlier than might otherwise be the case.”
“We need to understand that drug use occurs for many reasons, but everyone is entitled to have their health protected. Don’t ever think that it could never be your child, brother, sister or friend that will benefit from these programs.”
“I also think that it is essential to acknowledge the support and work of pharmacists, many of whom participate in providing this vital public health service to their local communities. I encourage all pharmacists to become actively involved in providing NSP services and hope that in coming years we see even greater levels of participation.”
Ms Annie Madden, Executive Officer of the Australian Injecting and Illicit Drug Users League (AIVL), and a member of the ANCD, said, "AIVL welcomes the release of this important and very timely updated paper from the ANCD. As the national organization representing the more than 300,000 regular clients of NSPs across Australia, AIVL is very concerned about recent reductions in both NSP funding investment and service provision in a number of states and territories. We believe Australia is on the cusp of undoing almost 25 years of unprecedented public health outcomes due to a dangerous combination of complacency and a lack of appreciation of just how much is at stake if current access to services are further eroded."
"Early action by both governments and drug users themselves when the threat posed by HIV first emerged in Australia in the late 1980's allowed us to avoid a major HIV epidemic among people who inject drugs. But we can never afford to become complacent about this achievement. When it comes to HIV prevention the job is never done, and we know from other countries (similar to our own) that even small changes in access to new injecting equipment can quickly lead to significant increases in HIV transmissions. We also know that once an increase in HIV infection rates commences among people who inject drugs, it can take decades to get it back under control, if it is possible at all!"
“We are currently seeing programs experience 'death by a thousand cuts'. We need all governments to understand that the vast majority of Australians support and understand the importance of these programs in protecting the health of the entire community and they will be very troubled by the long term health care costs and implications that will result from these services being reduced. Whether we are talking about the general community or prisons, one simple fact remains; NSPs save lives and reducing or preventing access to NSPs will cost lives."
"One of the most successful aspects of Australia's national response to the prevention of blood borne viruses such as HIV and hepatitis C among people who inject drugs has been the support for peer-based NSPs run 'by and for' drug users. These services are known for the quality of peer education they provide and their ability to access highly marginalised networks of drug users. Fear of stigma and judgment often keeps drug users away from health services. Peer-based NSP has been shown to be an important way to break down such barriers, reduce drug related harm and ultimately, save lives. Put simply, increased support for peer-based services is vital for a successful response to HIV and hepatitis C."
Mr Gino Vumbaca, Executive Director of the ANCD, added, “The importance of NSPs in maintaining public health and safety cannot be underestimated. It is a wise investment that should not only be secure but also substantively increased to ensure that we do not see the harms of HIV and hepatitis resurfacing in Australia. NSPs are simply an integral part of our health system today and deserve a far greater level of recognition than they receive for their ability to bring some of the most marginalised and disenfranchised people in our communities into the health system. Sometimes these are people that may never have experienced any meaningful contact with the health system.”
“We have been very fortunate in Australia in not having to deal with high rates of HIV infection, however if we are to keep all members of the public protected then we need to support these specialised, evidence based services that target at risk groups within our communities.”
“The reducing level of support for NSPs by governments across Australia has compelled the ANCD to show its support for NSPs and their clients. We must ensure this story of success is being heard and commence a period of renewal, commitment and innovation for NSPs. This is particularly the case for the vast number of drug users that end up in our prison system, none of which as yet provide any access to clean equipment and in some jurisdictions even a lack of proper treatment services. ”
The position paper is available HERE
Position statement recommendations
The Australian National Council on Drugs (ANCD) is the principal advisory body to the Prime Minister and the Federal Government on drug and alcohol policy, and recognises the significant contribution of needle and syringe programs (NSPs) to public health. We call on all Australian governments to continue to commit to the operation and expansion of NSPs, and to recognise NSPs as a core business of Australia’s alcohol and other drugs sector.
The ANCD believes that while it is important to utilise NSPs to provide additional health services, education, and referrals to people who inject drugs, the provision of sterile injecting equipment should remain a primary focus. We believe that it is appropriate for Australia to aim for 100 per cent coverage of injections with sterile equipment, and for its NSPs to operate in ways that facilitate this aim.
It is important that NSPs continue to be funded at appropriate levels, and that there is a much greater level of transparency of the funding provided.
In addition, ongoing data needs and current data gaps, require that a national minimum data set for all Australian needle and syringe programs is developed and implemented.
||A continued commitment by all Australian governments to the operation and expansion of NSPs in Australia.
||Develop systems that enable transparency in NSP funding.
||Develop and implement a national minimum data set for all Australian NSPs.
||Consider further development of the National NSP Strategic Framework, or the extension of the current Framework beyond 2014.
||As part of an aim to attain 100 per cent coverage of injections with sterile injecting equipment, increase the availability and accessibility of sterile equipment for people who inject drugs, by:
||Expanding the number of NSP service locations (including syringe vending machines), and broadening of the types of health-related services involved in delivering NSP services.
||Encouraging primary NSP services to initiate and support a range of secondary outlets within agreed geographical boundaries.
||Increasing the role and participation of non-government organisations, particularly peer-based services, in NSP delivery.
||Removing any restrictions that limit the amount of sterile equipment that may be dispensed.
||Ensuring that equipment is free wherever possible.
||Increasing the range of injecting equipment available at NSPs, including ensuring the provision of ancillary equipment, to meet the existing needs of people who inject drugs and changing patterns of drug use.
||Supporting research into understanding the injecting practices of people using pharmaceutical opioids and performance and image enhancing drugs, as a component of increasing their awareness about and willingness to access NSPs.
||Removing any onerous approval processes necessary for health services and staff to be involved in NSPs.
||Amending all relevant legislation (Federal or jurisdictional) to legally permit the secondary distribution of sterile injecting equipment (e.g. by peers and others) to people who inject drugs.
||Update and further disseminate the Australian Government’s NSP Information kit to the community, and particularly people whose work may bring them into contact with NSP attendees who are not primary NSP staff, including police, pharmacy and hospital workers, to further inform them on the functions and successes of NSPs.
||Increase the provision of ongoing training and opportunities for professional development for all NSP staff; including training on working with people from Aboriginal and Torres Strait Islander, culturally and linguistically diverse (CALD), and younger populations.
||Encourage the employment of Aboriginal and Torres Strait Islander people and people from diverse cultural and linguistic backgrounds at NSPs.
||Ensure that policing guidelines relating to NSP clients and operations are current and support the objectives of NSPs that all police officers are aware of these guidelines, and that police receive information and education on the value of NSPs and of harm reduction more generally.
||Increase hepatitis B vaccination rates among people who inject drugs, by making hepatitis B vaccinations available at all NSPs where this is appropriate, utilising evidence-based strategies for improving vaccination rates
||Improve the capacity of NSPs to inform and educate clients about hepatitis C and provide referrals to testing and treatment where appropriate.
||Immediately introduce a prison-based NSP in every Australian jurisdiction, with rigorous evaluations to inform and develop an Australian evidence base on NSPs in prisons.