New Best Practice Guidelines for Harm Reduction Programs Promote Needle Distribution
The World Health Organization1 identified harm reduction programs, such as needle and syringe programs, as a key component of comprehensive HIV prevention programming for people who use drugs. Over the past 20 years, the scientific evidence about how best to deliver these programs has grown in quantity and sophistication. To make sure that Canadian programs keep pace with emerging evidence, a new best practice recommendations document is now available for harm reduction programs that provide services to people who use drugs.
What Is the Best Practice Recommendations Project?
Community service providers identified a pressing need for cross-Canada best practice recommendations that focused on needle exchange programs and smoking/inhalation programs. There was a great desire to integrate recommendations and innovations from the most current evidence into their practice. While earlier recommendations were released by some provinces, Best Practice Recommendations for Canadian Harm Reduction Programs that Provide Service to People who Use Drugs and are at Risk of HIV, HCV and Other Harms: Part 12 was developed for programs nationally (Part 2 is under development -- see below). The aim of this project is to promote consistent, high-quality, harm reduction services to people who use drugs in Canada.
The Working Group on Best Practice for Harm Reduction Programs in Canada who prepared this document is a cross-Canada, multi-stakeholder team with representation from researchers, service providers, policy makers, and people with lived experience/who use drugs. Best Practice Recommendations: Part 1 features up-to-date scientific evidence about risk, behaviours and prevention of HIV, hepatitis C, hepatitis B and other harms.
How Are Needles Used to Inject Drugs?
There are various ways that people can use drugs -- injection is just one. Typically, injection is used by some people who use drugs because of the immediate effect and the intense high created. For someone to inject a drug, it must be mixed with water in a container (such as a "cooker" or spoon, or occasionally directly in the syringe). Sometimes this solution is heated while other times it is not. The solution is then drawn through a filter through the needle and into the syringe. The person's skin is cleaned and a tourniquet used to help find the vein to be injected.
Potential Health Issues With Needle Use
One of the potential problems with injecting is that it can lead to blood-to-blood contact between people if sharing of needles/syringes or other injecting equipment occurs. Blood-to-blood contact increases the risk of acquiring and/or transmitting HIV, hepatitis C and hepatitis B. Another potential problem is that any impurities or contaminants in or on the drugs and equipment can lead to skin and vein problems and other infections.
How Can Needles Transmit HIV, Hepatitis C and Hepatitis B?
Studies have looked at whether or not HIV, hepatitis C and hepatitis B can survive in needles. The viruses must be able to survive in order for transmission to occur. Research has shown us that HIV can survive in blood in needles for up to 30 days or more and that this is affected by factors such as volume of blood, temperature and duration of storage.3-5 Furthermore, needles collected from places where people inject within the community (e.g., "shooting galleries") have shown evidence of HIV6-9 so we know that it is possible for HIV to be present in needles.
Compared to HIV, hepatitis C is 10-times more easily transmitted through a contaminated needle.10,11 Research has shown that hepatitis C can survive for up to 63 days in needles.12 Hepatitis C has also been detected in used needles and injecting equipment collected from community locations.13
Compared to HIV, hepatitis B is 100-times more infectious.14 Hepatitis B is also resilient and easily transmitted via needle sharing. At room temperature, hepatitis B can survive in dried blood for at least a week.15 The Public Health Agency of Canada has reported that hepatitis B can survive in dried blood for weeks and remain stable on surfaces for at least a week.16
In light of these risks, the Working Group recommends that harm reduction programs distribute needles (and also other injection equipment) to facilitate the use of a sterile needle and syringe for each injection.
So How Many People Who Inject Drugs Have HIV, Hepatitis C and Hepatitis B in Canada?
Across Canada, the prevalence of HIV among people who inject drugs, as observed with data from a large study was 13%, ranging from 3% in Regina to 24% in Edmonton.17 The study also found that life-time prevalence (current or past infection) of hepatitis C was 66%, ranging from 62% in Winnipeg to 69% in Sudbury and Victoria.17 Much like HIV, hepatitis C prevalence varies across regions.
According to national 2011 HIV estimates, up to 16% of all new HIV infections in Canada (incidence) may have been due to injection drug use.18 This estimate includes 435 new HIV infections attributed to injection drug use and 80 new HIV infections attributed to either injection drug use or men having sex with men (because the person participated in both behaviours prior to HIV diagnosis). A high proportion of new HIV infections among Aboriginal people and women were likely due to injection drug use. According to national 2011 HIV estimates, 58% of the estimated new HIV infections in Aboriginal people were attributable to injection drug use.18 Among women, 23% of the estimated new HIV infections were attributable to injection drug use.18
According to national 2007 hepatitis C estimates (the most recent year for which we have data), there were 7,945 new hepatitis C infections, of which 83% were attributable to injection drug use.19
There is limited data on hepatitis B among injection drug users in Canada. However, according to the Enhanced Hepatitis Surveillance Strain System, injection drug use accounted for 12% of all new hepatitis B infections between 2005 and 2010.14
Injection Risk Behaviours and Disposal
Following more than 20 years of harm reduction programming and education, needle-sharing practices have generally declined across Canada. However, programs cannot be complacent because sharing continues at varied rates across the provinces and territories.17,20-25
A large Canadian study tells us that people who inject drugs continue to participate in behaviours that can transmit HIV, hepatitis C and hepatitis B. According to this study, 15% of people who inject drugs reported that in the previous six months they had borrowed needles/syringes already used by someone else.17 Rates ranged from 9% to 27% in different parts of Canada. In addition, 31% of people who inject drugs reported borrowing other injection equipment already used by someone else.17 Rates ranged from 24% to 41% in different parts of Canada. Studies also show that people who have trouble accessing a sterile supply of needles are more likely to borrow and share needles.21,26
Given ongoing risk behaviour, and concerns that restricted or lack of access might fuel sharing, the Working Group recommends that sterile needles are distributed to clients in the quantities requested by clients, without requiring the return of used needles, and that programs place no limit on the number of needles provided per client, per visit. These recommendations will help ensure that people who inject drugs will have enough sterile needles and will reduce the need for sharing.
The Working Group also recommends that programs encourage clients to return and/or properly dispose of used needles and syringes. A comprehensive set of recommendations to ensure proper disposal of used needles and syringes is available.
Other Recommendations Regarding Needle Distribution
People who inject drugs have individual preferences for needle gauge, syringe volume and brand, and may not use needle and syringe program services if they cannot obtain their preferred types. Needles with a higher gauge are thinner (have a smaller diameter) than needles with a lower gauge. Many people who inject drugs prefer higher-gauge needles because they are often less painful and less likely to result in vein damage.27 People who are experienced with injecting drugs sometimes prefer lower-gauge needles, which can be less likely to clog than higher-gauge needles and are better able to pierce through thick scar tissue.27 To ensure that programs provide equipment that clients want to use, the Working Group recommends that programs:
- offer a variety of needle and syringe types (i.e., gauge, size and brand), educate clients about proper use;
- provide pre-packaged safer injection kits (needles/syringes, cookers, filters, ascorbic acid when required, sterile water for injection, alcohol swabs, tourniquets, condom and lubricant) and individual safer injection supplies concurrently.
Recommendations Regarding Equipment
Best Practice Recommendations: Part 1 provides recommendations and summary of evidence regarding risk, behaviours and prevention related to other injection equipment including cookers, filters, ascorbic acid, sterile water, alcohol swabs and tourniquets. Each of these pieces of equipment can play a role in the transmission of infections and access to all this equipment is important in helping reduce risk. The Working Group offers recommendations for each piece of equipment in individual chapters.
The Working Group recommends that programs provide pre-packaged injection kits and also individual safer injection supplies concurrently. Making it easier to access a sterile supply of all injection supplies will help to reduce transmission of infections and other health-related problems.
We have highlighted one set of recommendations here, but the full document provides recommendations for many other aspects of harm-reduction programming including other injection-equipment distribution, safer crack cocaine smoking equipment distribution, disposal and handling of used drug use equipment, safer drug use education, and education and naloxone distribution in opioid overdose prevention. In an upcoming Prevention in Focus article_,_ we will focus on the distribution of safer crack cocaine smoking supplies.
We are also developing Part 2 of the Best Practice Recommendations, which will focus on program models, testing and vaccination, first aid, referrals and counselling, and relationships with law enforcement and other organizations. Phase 2 is scheduled to be completed in the latter part of 2014.
The authors would like to thank the Canadian Institutes of Health Research for its funding of the project development activities. We are very grateful to the funding received from the AIDS Bureau, Ontario Ministry of Health and Long Term Care to complete the chapters related to needles and syringes, other injecting equipment, safer crack smoking equipment and disposal and handling.
The Best Practice Recommendations for Canadian Harm Reduction Programs that Provide Service to People who Use Drugs and are at Risk of HIV, HCV and Other Harms: Part 1 is the product of the Working Group on Best Practice for Harm Reduction Programs in Canada that, in addition to Strike and Watson, includes: Hopkins S, Watson TM, Gohil H, Leece P, Young S, Buxton J, Challacombe L, Demel G, Heywood D, Lampkin H, Leonard L, Lebounga Vouma J, Lockie L, Millson P, Morissette C, Nielsen D, Petersen D, Tzemis D, Zurba N.
- World Health Organization. Priority interventions: HIV/AIDS prevention, treatment and care in the health sector; 2009.
- Strike C, Hopkins S, Watson TM, Gohil H, Leece P, Young S, Buxton J, Challacombe L, Demel G, Heywood D, Lampkin H, Leonard L, Lebounga Vouma J, Lockie L, Millson P, Morissette C, Nielsen D, Petersen D, Tzemis D, Zurba N. Best Practice Recommendations for Canadian arm Reduction Programs that Provide Service to People Who Use Drugs and are at Risk for HIV, HCV, and Other Harms: Part 1. Toronto, ON: Working Group on Best Practice for Harm Reduction Programs in Canada. 2013.
- Abdala N, Reyes R, Carney JM, Heimer R. Survival of HIV-1 in syringes: effects of temperature during storage. Substance Use and Misuse, 2000;35:1369-1383.
- Abdala N, Stephens PC, Griffith BP, Heimer R. Survival of HIV-1 in syringes. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology, 1999;20:73-80.
- Heimer R, Abdala N. Viability of HIV-1 in syringes: implications for interventions among injection drug users. AIDS Reader, 2000;10:410-417.
- Chitwood DD, McCoy CB, Inciardi JA, McBride DC, Comerford M, Trapido E, McCoy V, Page B, Griffin J, Fletcher MA, Ashman MA. HIV seropositivity of needles from shooting galleries in south Florida. American Journal of Public Health, 1990;80:150-152.
- Heimer R, Kaplan EH, Khoshnood K, Jariwala B, Cadman EC. Needle exchange decreases the prevalence of HIV-1 proviral DNA in returned syringes in New Haven, Connecticut. American Journal of Medicine, 1993; 95:214-220.
- Shah SM, Shapshak P, Rivers JE, Stewart RV, Weatherby NL, Xin KQ. Detection of HIV-1 DNA in needle/syringes, paraphernalia, and washes from shooting galleries in Miami: a preliminary laboratory report. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology, 1996;11:301-306.
- Shapshak P, Fujimura RK, Page JB, Segal D, Rivers JE, Yang J. HIV-1 RNA load in needles/syringes from shooting galleries in Miami: a preliminary laboratory report. Drug and Alcohol Dependence 2000;58:153-157.
- Kiyosawa K, Sodeyama T, Tanaka E, Nakano Y, Furuta S, Nishioka K, Purcell RH, Alter HJ. Hepatitis C in hospital employees with needlestick injuries. Annals of Internal Medicine, 1991; 115:367-369.
- Mitsui T, Iwano K, Masuko K, Yamazaki C, Okamoto H, Tsuda F, Tanaka T, Mishiro S. Hepatitis C virus infection in medical personnel after needlestick accident. Hepatology, 1992;16:1109-14.
- Paintsil E, He H, Peters C, Lindenbach BD, Heimer R. Survival of hepatitis C virus in syringes: Implication for transmission among injection drug users. The Journal of Infectious Diseases, 2010;202(7):984-990.
- Crofts N, Caruana S, Bowden S, Kerger M. Minimising harm from hepatitis C virus needs better strategies. British Medical Journal, 2000;321:899.
- Public Health Agency of Canada. Brief Report: Hepatitis B Infection in Canada. Surveillance and Epidemiology Division, Disease and Infection Control, Infectious Disease Prevention and Control Branch. 2011.
- Thompson SC, Boughton CR, Dore GJ. Bloodborne viruses and their survival in the environment: is public concern about community needlestick exposures justified? Australian and New Zealand Journal of Public Health 2003;27(6):602-607.
- Public Health Agency of Canada, Pathogen Regulation Directorate. Hepatitis B virus (HBV) Pathogen Safety Data Sheet -- Infectious Substances; 2011.
- Public Health Agency of Canada. I-Track: Enhanced surveillance of risk behaviours among injecting drug users in Canada. Phase 1 report. Ottawa: Surveillance and Risk Assessment Division, Centre for Infectious Disease Prevention and Control, Public Health Agency of Canada; 2006.
- Public Health Agency of Canada. Summary: Estimates of HIV Prevalence and Incidence in Canada, 2011. Surveillance and Epidemiology Division, Professional Guidelines and Public Health Practice Division, Centre for Communicable Diseases and Infection Control, Public Health Agency of Canada, 2012.
- Robert Remis. Modelling the incidence and prevalence of hepatitis C infection and its sequelae in Canada, 2007 final report. Public Health Agency of Canada.
- Fischer B, Rehm J, Brissette S, Brochu S, Bruneau J,El-Guebaly N, et al. Illicit opioid use in Canada: comparing social, health, and drug use characteristics of untreated users in five cities (OPICAN study). Journal of Urban Health, 2005;82(2):250-266.
- Fischer B, Manzoni P, Rehm J. Comparing injecting and non-injecting illicit opioid users in a multisite Canadian sample (OPICAN Cohort). European Addiction Research, 2006;12(4):230-239.
- Ivsins A, Chow C, Macdonald S, Stockwell T, Vallance K, Marsh DC, Michelow W, Duff C. An examination of injection drug use trends in Victoria and Vancouver, BC after the closure of Victoria's only fixed-site needle and syringe programme. International Journal of Drug Policy, 2012 July;23(4):338-340.
- Millson M, Leonard L, Remis RS, Strike C, Challacombe L. Injection drug use, HIV and HCV infection in Ontario: The situation in 2004. University of Toronto: HIV Social, Behavioural and Epidemiological Studies Unit. 2005.
- Roy E, Boudreau JF, Leclerc P, Boivin JF, Godin G. Trends in injection drug use behaviors over 10 years among street youth. Drug and Alcohol Dependence, 2007;89(2-3):170-175.
- Urban Health Research Initiative of the British Columbia Centre for Excellence in HIV/AIDS. Drug situation in Vancouver. 2009.
- Bluthenthal RN, Ridgeway G, Schell T, Anderson R, Flynn NM, Kral AH. Examination of the association between syringe exchange program (SEP) dispensation policy and SEP client-level syringe coverage among injection drug users. Addiction, 2007 Apr;102(4):638-646.
- Zule WA, Desmond DP, Neff JA. Syringe type and drug injector risk for HIV infection: a case study in Texas. Social Science and Medicine, 2002;55(7):1103-1113.
Carol Strike, Ph.D., is an associate professor at the University of Toronto's Dalla Lana School of Public Health, with 15 years of experience in harm reduction, addiction treatment and health services research.
Tara Marie Watson completed her Ph.D. at the Centre for Criminology and Sociolegal Studies, University of Toronto. She has long-standing research interests and experience in drug policy, harm reduction and corrections.