Josie Smith Research Scientist, NPHS Advancing the Health Protection agenda: Needle Exchange in Wales – raising the profile and identifying new initiatives Josie Smith Research Scientist, NPHS

Aims Evidence Recent research within Wales Development of the All Wales Needle Exchange Forum Key aims Working groups Website Raising the profile in Wales and beyond…

Comprehensive review of international evidence Alex Wodak and Annie Cooney 2006 ‘ There is compelling evidence that increasing the availability and utilisation of sterile injecting equipment by IDUs reduces HIV infection substantially’ ‘There is no convincing evidence of any major, unintended negative consequences’ Using the Bradford Hill criteria

HIV prevention ‘NSE are cost effective’ ‘NSE have additional worth while benefits apart from reducing HIV infection….’ ‘….not enough on own to control HIV infection among IDUs’

HCV prevention Lack of control studies & not going to happen But – in countries with poor NSE – high HCV prevalence HCV is transmitted by injecting risk behaviour – there is evidence the NSE reduces injecting risk behaviour therefore NSE has to be a pillar in HCV prevention

Reducing sharing: challenges in the provision of NSE Structural: the environment that creates situations where sharing is the default option (homeless/public injecting, prison injecting, poor NSE availability) Marginalisation: low self esteem, poor knowledge, vulnerability all disempowering the individual The social role of sharing: Sharing between partners & close friends not perceived as high risk, unequal power within relationships The drugs used: Heroin withdrawal and crack or amphetamine binges can create situations where sharing becomes the easiest option or accidental option

Hepatitis C prevalence and incidence amongst IDUs South Wales, London and Glasgow

HCV incidence Highest amongst the homeless Correlated with reports of paraphernalia sharing Correlated with reports of high rates of NS sharing Infection early in injecting careers

HCV incidence study NSE use amongst the follow up sero-negative cohort Drug agency / mobile 65% Pharmacy 22% Other people 12%

How is NSE perceived by IDUs in Wales? Needs Assessment Majority 88% of IDUs used NSE in area regularly, positive experiences were reported Approximately one fifth relied on someone else to get NS (distance, travel time, opening times, confidentiality & privacy) Swabs, citric acid water not available in many areas Pharmacy exchange - perception that exchange was often not confidential and concerns around staff attitude

Barriers to NSE use Qualitative study (49 in depth interviews) Availability Generally good in larger towns/cities Sometimes stock shortages in pharmacy NSE especially weekends Type At times range of equipment limited Quality sometimes substandard Quantity Number needed may vary – distance from exchange / work / injecting practices / other responsibilities Consistency across NSE important

Barriers to NSE use Qualitative study Geographic access Access can be a problem in some areas, particularly smaller towns and rural areas relaying on a single outlet Opening times Perceived to be slightly restrictive Fear of public exposure Key theme – particularly if close to family home - reluctance to disclose identity Homeless IDUs Absence of secure storage space

Barriers to NSE use Qualitative study Attitudes of staff IDUs Perceptions of negative stereotyping and discriminatory treatment by pharmacy NSE staff indicated as a barrier to accessing services Awareness among recent IDUs A priority

Important to acknowledge: Strong network of needle exchange services in Wales Range of outlets - pharmacy, voluntary, statutory, mobile and outreach Many highly motivated, experienced and dedicated needle exchange staff So how can services best move forward to address the challenges and barriers identified? What is the role of Health Protection in facilitating change?

Development of the Forum KEY AIMS To raise profile: - Challenge uninformed views with evidence and ongoing discussion Challenge practice of ‘anyone who is available’ Ensure presence in policy making and strategy development at regional and national level To highlight the extent and importance of the role of needle exchange services in Wales: In the wider context of harm reduction In the reduction in transmission of chronic disease especially hepatitis C and HIV Frontline in engaging injecting drug users

Development of the Forum To ensure high quality, accredited training and education available and received by all relevant staff: Recognition of ‘relationship’, confidentiality etc, interaction not transaction Interagency training To address issues of supply: Centralised purchasing – economies of scale Maximise consistency of supply including injecting paraphernalia

Development of the Forum To ensure equity of service To establish a standardised data collection system and build an evidence base for planning and developing services

Progress to date Established a Forum planning group Representation from all regions: Statutory and voluntary sector drug services community pharmacy CSP CPA Public Health Service Users

Progress to date WEBSITE: www.wnef.org.uk Central to open discussion and communication What you will find: Location mapping Resource library What’s new Forum About us – minutes, terms of reference etc Working groups

Progress to date Working groups: Special interest Initiated and developed by forum members Task led Research Development of best practice guidance and monitoring/evaluation tools Opportunity to work with individuals within and beyond Wales

Future developments Secure funding e.g. for maintaining website, developing working groups etc Develop working groups programme Continue to raise profile and influence policy and guidance e.g. WAG substance misuse strategy and forthcoming NICE guidance Tie in developments of Forum with those of the blood borne viral hepatitis action plan for Wales