HIV Australia | Vol. 8 No. 1 | April 2010

LUKE WILLIAMS explains why Australian needle and syringe programs are more then just a‘good return on investment’.

Needle and Syringe Programs (NSPs) are credited with keeping Australia’s co-infection rates relatively low. However, the challenges in containing hepatitis amongst drug users remain. Luke Williams visited a 24 hour needle exchange in St Kilda, Melbourne to find the challenges and barriers to reducing rates of co-infection in injecting drug users.

‘The day has been pretty busy so far,’ says Needle and Syringe (NSP) program worker Sally Finn. At least every five minutes, someone comes in to collect a safe use pack.

‘I wish everyone could come and spend a day here, it would really open people‘s eyes about this problem,’ she says. ‘We have people in suits come here all the time, people who turn up in Rolls Royces every few months wanting hundreds of syringes, right down to people in their early teenage years – 13 and 14 year olds who have very difficult lives’.

Needle Exchange programs have had a relatively short and, reportedly, successful life span in Australia. They were first trialled (illegally) in Sydney in November 1986, and there are now more than 3,000 needle and syringe programs operating around Australia, making over a million contacts with injecting drug users each year.1 The number of syringes distributed each year amounts to around 165 per user, one of the highest rates in the world. ² As a result, Australia is considered to be a world leader in NSPs.³ 

While originally controversial, there have been several major reports in recent years which appear to have vindicated the use of NSPs in Australia. In particular, theReturn on Investment in Needle and Syringe Programs in Australia in 2002 found that the programs prevented 25,000 new HIV infections and 21,000 hepatitis C infections in ten years.⁴

Last October, the Chair of the federal government’s Australian National Council of Drugs, John Herron released a statement at launch of the second Return on Investment study saying it ‘provides further validation and clearly shows the outstanding contribution to public health that NSPs have made by preventing over 100,000 HIV and hepatitis C infections in the past 10 years’.⁵

Certainly, for people like Maree, a long-term co-infected drug user who I met at the St Kilda exchange, the advent of NSPs changed the way she used drugs.

‘Back in those days (when she began injecting drugs in the mid 1980s), it was really hard to get clean needles. The only place you could get them were pharmacies, it cost money and they weren’t always open. So we would run out of needles – we would re-use dirty ones and sharpen them with nail files … we would share needles all the time, we didn’t think twice about it. We didn’t even know about things like hepatitis’.

Maree says she hasn’t shared needles in the last ten years and now gets all her syringes from the exchange in St Kilda.

However, ongoing issues remain. Between 2004 and 2008, less than 1.5% of people tested at NSPs had HIV, though among gay men who inject the figure was 37%. Out of all those tested, over 60% had hepatitis C.⁶

Part of the issue is that injecting drug users, for a variety of reasons, still share needles and equipment. Research undertaken in Australia between 2004 and 2008 indicates around 15% of injecting drug users share needles.⁷ Some users I met at the exchange tell me they think the culture of sharing needles is very much alive in some circles and also, clean needles aren’t always available if they are using away from the city. Take David for example – he tells me he got hepatitis C from sharing needles with his mates.

‘People still share all the time, mates who know each other. You might get some for just you and a few others and then you’ll come home and some others will want to join in. There won’t be enough needles to go around, but the others (who don’t have needles) will chuck money so you will end washing yours out and letting them use it’.

Rachel says she was introduced to injecting drug use by a cousin when she was nine.

‘On occasion I would re-use my own dirty fits and I know I didn’t always wash them out properly. A few times I have let my partner use my dirty fit as well … In the last 12 months I have seen people share needles at least a dozen times. Needle sharing is looked down upon amongst drug users, it’s just that people don’t get organised to get their own clean fits’.

Dr Campbell Aitken, from the Burnet Institute, is one of Australia’s foremost researchers in the area and says there are many systemic problems which lead to unsafe injecting practices.

‘Although coverage in Australia is good, there are still many people who want to inject at times when NSPs aren’t open and no other option is available. Vending machines are used in NSW and New Zealand and work very well; supplying needle and syringes from petrol stations and convenience stores has been talked about for years and would certainly help, but there’s little prospect of that occurring’.

Sally Finn believes the situation is further complicated by the way injecting drug users often bond by sharing needles. ‘I think people share in emotive situations, they share in intense relationships, they share their trust in each other, their boundaries shift and they create a kind of distorted intimacy by sharing a needle,’ she says.

The real success of NSPs appears to be in the containment of HIV. The federal government looked at 778 years of data from 103 cities around the world in its 2002Return on Investment report. It found that in cities that had ever had NSPs, there had been an average annual decrease in HIV prevalence of 18.6%, compared with an average annual increase of 8.1% in cities without such programs.⁸

Low HIV prevalence is considered to be the main reason why Australia has low rates of HIV/hepatitis co-infection. Nonetheless, 90% of people with HIV and hepatitis co-infection in Australia are injecting drug users⁹ – a figure largely precipitated by the very high rates of hepatitis C amongst this group.

This potentially confusing set of statistics sometimes leads to questions about why Australia’s HIV levels are so low, but hepatitis levels so high.

‘We think it’s because our NSPs started so early in the HIV epidemic and have achieved very good coverage, especially compared with, for example, the US, where needle and syringe coverage is much lower and HIV rates among injecting drug users are 40–50% in some cities. Whereas hepatitis was already established among injecting drug users before NSPs, and also is much more infectious,’ says Dr Aitkin.

Caroline Perry, who is assistant program manager of the St Kilda NSP, says co-infected patients are rare – but they tend to show a distinct pattern of coming from backgrounds with multiple forms of disadvantage. The last two people the clinic tested and found to be co-infected were both Indigenous, homeless and injecting drug users.One was also gay, an alcoholic and suffered from schizophrenia.

‘We see certain groups of people as particularly vulnerable to getting HIV and particularly hepatitis … there a few reasons for this; poor education around sharing, less access to clean needles. Often Indigenous people, for example are not close to city resources for infection screening. Also, people in these groups are often not getting treated, they can live quite chaotic lives so they don’t turn up to appointments, which means many of them are in really terrible health,’ she says.

HIV, hepatitis and co-infections have been increasing amongst Australia’s Indigenous population over the past few decades. Transmissions attributed to injecting are reported to have increased from 5 to 18% of HIV diagnoses within Australia’s Indigenous communities over the last two decades.¹⁰

Despite the many challenges facing workers in the sector, Sally Finn says she can’t help but feel encouraged by the resilience of the clients she has got to know at the exchange.

‘I think if we are going to get serious about this problem we need injecting rooms (in more places other than Sydney). An injecting room is safe and sterile and people aren’t going tooverdose. People can be shown how to inject safely. I think injecting rooms are really a very effective way to break down all these dangerous myths and misconceptions about safe drug use within the drug user community.’

References

1 Australian National Council on Drugs. (2009). Australia Commemorates20 Years of Needle and Syringe Programs, Available at: http://www.ancd.org.au/news-and-announcements-2006/australia-commemorates-20-years-of-needle-syringe-programs.html (accessed 15 March, 2010).

2 Commonwealth Department of Health and Ageing. (2002).Return on investment in needle and syringe programs in Australia, available at: http://www.health.gov.au/pubhlth/publicat/hac.htm (accessed 15 March, 2010).

3 Commonwealth Department of Health and Ageing. (2009).National Hepatitis C Strategy 2005–2008, available at: http://www.health.vic.gov.au/hivaids/hepatitisc.pdf, p9, (accessed 15 March, 2010).

4 Commonwealth Department of Health and Ageing, Canberra, op. cit.

5 Herron, J. (2009). Speech at Release of Needle and Syringe Study, available at: http://www.ancd.org.au/media-releases/release-of-needle-a-syringe-study-22-oct-2009.html (accessed 15 March, 2010).

6 National Centre in HIV Epidemiology and Clinical Research. (2009). Prevalence of HIV, HCV and injecting and sexual behaviour among IDUs at needle and syringe programs,Australian NSP Survey National Data Report.

7 National Centre in HIV Epidemiology and Clinical Research, op. cit.

8 Commonwealth Department of Health and Ageing, Canberra, op. cit.

9 Dore, G., Sasadeusz, J. (Eds.) (2006).Coinfection: HIV and viral hepatitis – a guide for clinical management, Australasian Society for HIV Medicine, Sydney.

10 National Centre in HIV Epidemiology and Clinical Research. (2009).HIV/AIDS, Viral Hepatitis and Sexually Transmissible Infections in Australia Annual Surveillance Report 2009.

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