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Needle and Syringe Programmes (NSPs) for HIV Prevention
Needle and syringe programmes (NSPs) are a type of harm reduction initiative that provide clean needles and syringes to people who inject drugs (PWID). The World Health Organisation (WHO) recommends providing 200 sterile needles and syringes per drug injector per year, in order to effectively tackle HIV transmission via this route. 1
Many programmes supply other equipment to prepare and consume drug such as filters, mixing containers and sterile water. The majority of NSPs are run by drug services or pharmacies and operate from a range of fixed, mobile and outreach sites. 2
NSPs aim primarily to reduce the transmission of HIV and other blood-borne viruses caused by the sharing of injecting equipment. Many also work to reduce other harms associated with injecting drug use by providing:
- advice on safer injecting practices
- advice on minimising the harm done by drugs
- advice on how to avoid and manage an overdose
- information on the safe handling and disposal of injecting equipment
- referrals to HIV testing and treatment services
- help to stop injecting drugs, including access to drug treatment (e.g. opioid substitution therapy (OST) and encouragement to switch to safer drug taking practices
- other health and welfare services (including condom provision) 3
A study by the WHO reported that:
"NSPs substantially and cost effectively reduce the spread of HIV among PWID and do so without evidence of exacerbating injecting drug use at either the individual or societal level". 4
How are needle and syringe programmes delivered?
Fixed NSP sites are typically located where there is an open drug scene, i.e. where drugs are bought and sold openly. They are normally converted shops or offices and have a reception area for clients who drop-in and for giving out new, and receiving used, injecting equipment.
At fixed sites, it is easier to offer additional services such as healthcare and testing and counselling for HIV and other blood-borne viruses. 5
Mobile NSPs operate from a van or bus with needles and syringes distributed through a door or window. Some large mobile NSP sites act like fixed sites with testing and other healthcare services also available.
Other mobile NSPs run in conjunction with fixed sites. In these instances, the fixed site is typically located in an area with high numbers of PWID with the mobile NSP focussing on harder to reach or smaller populations. 6
Mobile NSPs can be more accessible than fixed NSPs and often face less opposition than sites such as the Insite facility in Vancouver, Canada. 7
Outreach programmes take many forms including mobile units (such as a van or bus), backpacking services on the street or even home deliveries. 8
They typically operate where there is a shortage of funding for NSPs. For example, it is the preferred method of delivery in Haryana, India, where peer educators reach out to PWID who do not openly buy or sell drugs. 9
Some outreach NSPs exist to complement fixed or mobile NSPs where PWID are not engaging with established services. Outreach workers are tasked with encouraging PWID to use existing fixed or mobile sites. 10
Syringe vending machines
Countries including the Netherlands, Germany, Italy and Australia use syringe vending machines in addition to other forms of NSPs. Syringe vending machines accept coins and tokens (typically distributed by outreach workers) in return for harm reduction packs. In Australia, these packs include several needles and syringes as well as alcohol swabs, cotton wool, sterile water and spoons. Others contain educational materials. 11
The machines are typically mounted on the outside walls of fixed NSP sites. They are also installed in places where needles and syringes are hard to access. Most provide needles and syringes 24 hours a day, 7 days a week. 12
Pharmacy-based NSPs operate in a number of ways. Some sell needles and syringes directly to PWID, while others exchange harm reduction kits for vouchers. The main advantage of pharmacy NSPs is that in many places, pharmacy networks are already well established and often located near to large groups of PWID. Moreover, their open hours are often more convenient than those at fixed sites. 13
However, pharmacy-based NSPs are very limited in low-income countries. Even where they do exist, some pharmacists are reluctant to sell needles and syringes to PWID or deal with their disposal. 14 Moreover, they rarely offer education and additional healthcare services. 15
Needle and syringe programme coverage worldwide
120 countries worldwide report HIV transmission among PWID - 86 of these countries implement needle and syringe programmes. 16
17 countries and territories in Asia implement NSPs to varying degrees. For example, in Cambodia, Mongolia, the Philippines and Thailand, NSP provision exists on a very small scale. In others, the number of NSP sites has increased, for example, in Bangladesh (from 93 in 2010 to 120 in 2012) and Indonesia (from 120 in 2006 to 194 in 2011). 17 Moreover, the number of needles and syringes distributed per PWID per year varies dramatically from 263 in Bangladesh to less than 10 in Thailand, Indonesia and the Philippines. 18
NSPs in this region are delivered in a number of ways. In some places, fixed NSPs have been integrated with other facilities such as health clinics and pharmacies. In Vietnam, sterile injecting equipment and condoms are made available through 24-hour self-service boxes in public places. At one location on the China/Myanmar border, harm reduction services are provided at a grocery store. 19
However, NSP coverage is still too low to have a significant impact on HIV prevalence among PWID. 20
Russia, Eastern Europe and Central Asia
29 countries and territories in Eastern Europe and Central Asia have implemented NSPs. NSPs in this region are delivered in a range of settings from prisons in Tajikistan to mobile units in Albania. 21
Since 2010, Kyrgyzstan, Tajikistan and Ukraine have increased the number of NSP sites. However, in same period, some countries scaled back provision (including Belarus, Hungary and Kazakhstan). By contrast, Armenia, Croatia and Kosovo have seen an increasing proportion of PWID being reached by NSPs. As a result, coverage rates vary dramatically across the region - from 10 percent in Georgia to 72 percent in Belarus. 22
A report by the Eurasian Harm Reduction Network estimated that only 10 percent of PWID in Eastern Europe and 33 percent of PWID in Central Asia are able to access NSPs. 23 In Russia, there are 2 million injecting opiate users, of whom, 37 percent are estimated to be living with HIV (in some regions HIV prevalence reaches up to 75 percent) yet the government continues not to implement NSPs. 24
Western and Central Europe
Despite high NSP provision levels across most of the region, interventions vary both among countries and within countries themselves. For example, there is only one NSP site in Cyprus compared to over 2000 in Spain. In many countries, there is a significant accessibility gap between urban and rural areas. 26
Service coverage also varies in terms of number of syringes distributed per PWID per year. For example, in Norway and Luxembourg over 200 syringes per person per year are distributed compared to less than 100 in Sweden, Cyprus and Greece. 27
5 countries in this region operate NSP programmes. Brazil has the highest number of NSP sites with up to 54 percent of PWID reportedly having used sterile injecting equipment the last time they injected. Despite having only three NSP sites, this figure is 92 percent in Paraguay. 29 There are no NSPs in Colombia despite reportedly high levels of injecting practices. 30
The Middle East and North Africa
9 countries the Middle East and North Africa (MENA) currently implement NSP programmes. 31 Iran had the highest level of NSP provision in the region with 421 sites as of 2011. Iran also distributes the most needles and syringes per PWID per year (26-35). 32
NSP service coverage throughout MENA is thought to be extremely limited and remains too low to have a positive impact on the transmission of HIV and other blood-borne viruses. 33
NSP provision throughout sub-Saharan Africa is limited to interventions by non-government organisations (NGOs). 34 However, in June 2012, the Kenyan government announced plans to distribute over 8 million needles and syringes to 50,000 PWID nationwide. 35 In Mauritius, the number of NSP sites increased from 39 in 2010, to 52 in 2012. However, as in most countries throughout this region, coverage remains very low. 36
6 Caribbean countries reportedly have PWID but only Puerto Rico has implemented NSPs to date. However, in the Dominican Republic, clean syringes are available in pharmacies. 37 NSP coverage in the Caribbean is very low - an estimated 0.3 syringes are distributed to PWID per year. 38
Barriers to accessing needle and syringe programmes
Legal, social and cultural barriers
In many countries worldwide, criminalisation of PWID is a major barrier to NSP services. Criminalisation of possession of illicit substances and injecting equipment often forces PWID to hide their equipment and engage in unsafe injecting practices, with many threatened, abused, extorted or arrested by the authorities. 40 One study from Northern Morocco reported that 87 percent of PWID had experienced police violence. 41
Legal age restrictions for accessing NSPs in some countries prevent PWID under 18 years old from accessing these services despite evidence that the age people start injecting drugs is decreasing. 42 Mandatory detention of PWID in detoxification centres in countries such as China is also a barrier to accessing NSPs. 43
Even in places where it is legal to purchase needles and syringes, stigma, discrimination or disapproval from the community prevent many PWID from accessing NSP services. 44 Moreover, in many places, PWID experience stigma and discrimination from healthcare workers, or receive services that are not delivered in a culturally sensitive way. 45 46
Political and economic barriers
For example, in December 2011, the United States Congress reinstated a federal ban on funding for both domestic and international NSP interventions marginalising existing programmes away from mainstream policy and funding. 48 In Canada, a lack of federal support means NSPs, and other forms of harm reduction, are typically delivered by NGOs, civil society groups, provinces and territories. 49
Russia doesn't provide state funding for NSPs with officials maintaining that they increase injecting drug use despite evidence to the contrary. 50 However, international donors are funding a number of NSPs in cities across the country. 51
Some countries suffer from the withdrawal of international funding for NSPs. For example, NSPs have proved highly successful in Romania, limiting HIV prevalence to 1 percent among PWID. However, since joining the European Union, the World Bank no longer classifies Romania as a developing country making it ineligible for a number of international grants threatening a funding crisis. 52
Physical and geographical barriers
In other places, access to NSPs is limited by geographical distance, particularly in remote and rural areas. Indeed, a number of studies have shown that PWID who live in close proximity to NSPs are more likely to use them. 53
Even where they are in reach, many sites have restricted opening hours, long waiting times, insufficient resources (including needle and syringe supplies) as well as inadequately trained medical personnel. 54 55 56
- 1. IAVIReport (2006) ' Injection of Hope: Needle and syringe programs can lower HIV infection rates and provide important outreach to injection drug users'
- 2. NICE (2014) ' Needle and syringe programmes'
- 3. NICE (2014) ' Needle and syringe programmes'
- 4. WHO (2004) ' Effectiveness of sterile needle and syringe programming in reducing HIV/AIDS among IDUs'
- 5. WHO (2007) ' Guide to starting and managing needle and syringe programmes'
- 6. WHO (2007) ' Guide to starting and managing needle and syringe programmes'
- 7. Huffington Post (2013, 18 September) ' Is InSite Really All It's Cracked Up To Be?'
- 8. NWPH (2011) ' Substance Misuse Treatment Framework (SMTF) Service Framework for Needle and Syringe Programmes in Wales'
- 9. Jain, B. et al (2014) ' Effect of peer-led outreach activities on injecting risk behavior among male drug users in Haryana, India' Harm Reduction Journal 11(3)
- 10. WHO (2007) ' Guide to starting and managing needle and syringe programmes'
- 11. McDonald, D. (2007) ' The evaluation of a trial of syringe vending machines in Canberra, Australia' The International Journal of Drug Policy 20(4):336-339
- 12. WHO (2007) ' Guide to starting and managing needle and syringe programmes'
- 13. WHO (2007) ' Guide to starting and managing needle and syringe programmes'
- 14. Vorobjov, S. et al (2009) ' Should Pharmacists have a Role in Harm Reduction Services for IDUs? A Qualitative Study in Tallinn, Estonia' Journal of Urban Health 86(6):918-928
- 15. WHO (2007) ' Guide to starting and managing needle and syringe programmes'
- 16. IHRA (2012) ' Global State of Harm Reduction 2012'
- 17. Peterson, Z. et al (2013) ' Availability of HIV prevention and treatment services for people who inject drugs: findings from 21 countries' Harm Reduction Journal 10(13)
- 18. IHRA (2012) ' Global State of Harm Reduction 2012'
- 19. IHRA (2012) ' Global State of Harm Reduction 2012'
- 20. WHO, UNODC & UNAIDS (2012) ' Technical guide for countries to set targets for universal access to HIV prevention, treatment and care for injecting drug users'
- 21. IHRA (2012) ' Global State of Harm Reduction 2012'
- 22. UNAIDS (2012) ' Global AIDS Response Progress Reporting 2012'
- 23. Eurasian Harm Reduction Network (2013) ' Quitting While Not Ahead: The Global Fund’s retrenchment and the looming crisis for harm reduction in Eastern Europe and Central Asia'
- 24. Lunze, K. et al (2014) ' Punitive policing and associated substance use risks among HIV-positive people in Russia who inject drugs' JIAS 17(1):19043
- 25. IHRA (2012) ' Global State of Harm Reduction 2012'
- 26. European Harm Reduction Network (2011) ' Harm Reduction in Europe: mapping coverage and civil society advocacy'
- 27. WHO, UNODC & UNAIDS (2012) ' Technical guide for countries to set targets for universal access to HIV prevention, treatment and care for injecting drug users'
- 28. Mathers, B.M. et al (2010) ' HIV prevention, treatment, and care services for people who inject drugs: a systematic review of global, regional, and national coverage' The Lancet 375(9719):1014-1028
- 29. UNAIDS (2012) ' Global AIDS Response Progress Reporting: Country reports'
- 30. UNAIDS (2012) ' Global AIDS Response Progress Reporting: Country reports'
- 31. Mumtaz, G.R. et al (2014) ' HIV among People Who Inject Drugs in the Middle East and North Africa: Systematic Review and Data Synthesis' PLOS Medicine 11(6)
- 32. Nasirian, M. (2012) ' Modeling of new HIV infections based on exposure groups in Iran' LAP Lambert Academic Publishing: Saarbrücken, Germany
- 33. Nasirian, M. (2012) ' Modeling of new HIV infections based on exposure groups in Iran' LAP Lambert Academic Publishing: Saarbrücken, Germany
- 34. IHRA (2012) ' Global State of Harm Reduction 2012'
- 35. IRIN Africa (2012, 7 June) ' KENYA: Needles to be distributed to injecting drug users'
- 36. IHRA (2012) ' Global State of Harm Reduction 2012'
- 37. IHRA (2012) ' Global State of Harm Reduction 2012'
- 38. UNAIDS (2011) ' How to get to zero: Faster. Smarter.'
- 39. IHRA (2012) ' Global State of Harm Reduction 2012'
- 40. IHRA (2012) ' Global State of Harm Reduction 2012'
- 41. Association de lutte contre le sida (ALCS) and Open Society Institute (26 October 2011) ' For a New Approach Toward Drug Users, Based on Health and Human Rights' National Conference, Morocco
- 42. Zindagi, N. (2009) ' Rapid Situation Assessments of HIV prevalence and risk factors among people injecting drugs in four cities of Punjab'
- 43. Zhang, L. et al (2013) ' Ability to access community-based needle-syringe programs and injecting behaviors among drug users: a cross-sectional study in Hunan Province, China' Harm Reduction Journal 10(8)
- 44. Petersen, Z. et al (2013) ' Availability of HIV prevention and treatment services for people who inject drugs: findings from 21 countries' Harm Reduction Journal 10(13)
- 45. IHRA (2012) ' Global State of Harm Reduction 2012'
- 46. ANCD (2011) ' Injecting drug use and associated harms among Aboriginal Australians'
- 47. Degenhardt, L. et al (2014) ' What has been achieved in HIV prevention, treatment and care for people who inject drugs, 2010-2012? A review of the six highest burden countries' The International Journal on Drug Policy 25(1):53-60
- 48. The White Hours (2012) ' Federal Funding Ban on Needle Exchange Programs'
- 49. IHRA (2012) ' Global State of Harm Reduction 2012'
- 50. openDemocracy (2009, 5 November) ' Russia's drugs problem: blame the West'
- 51. Sarang, A. et al (2008) ' Access to syringes in three Russian cities: implications for syringe distribution and coverage' The International Journal on Drug Policy 19(Supplement 1):25-36
- 52. TIME (2010, 20 September) ' Eve of an HIV Epidemic in Romania'
- 53. NICE (2008) ' Needle and syringe programmes for injecting drug users: Synopsis of the evidence and economic modelling'
- 54. IHRA (2012) ' Global State of Harm Reduction 2012'
- 55. Zindagi, N. (2009) ' Rapid Situation Assessments of HIV prevalence and risk factors among people injecting drugs in four cities of Punjab'
- 56. NICE (2008) ' Needle and syringe programmes for injecting drug users: Synopsis of the evidence and economic modelling'
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