Safer Injecting Practices

Common Drugs and Injecting Practices Heroin (pure/white heroin/ ‘No. 4’): mainly in the north-eastern states Heroin (Smack / brown sugar): not readily injectable as it comes in the form of crude, impure powder Before injecting, a user has to prepare or ‘cook’ the drug Most users mix the powder with an injectable sedative drug (like Avil), boil it, filter it with a cotton swab and then inject it Buprenorphine (Tidigesic/Norphine) or Pentazocine (Fortwin): probably the most popular drugs for injecting among IDUs in India Most users mix them with one or more of the following sedatives for enhancement of the effects: Diazepam (Calmpose) Chlorpheniramine (Avil) Promethazine (Phenargan) Dextrprpoxyphene (Proxyvon / Spasmo- Proxyvon / SP): available as capsules and NOT AS INJECTIONS Users open the capsules, take the powder out, crush it, mix it with another liquid / drug and then inject it Seen only in the north-eastern states, very rare in other parts of the country

Encouraging Safer Injecting Educate clients on safe injecting methods: Risks of sharing N/S, equipment, drugs Need for cleaning injecting sites Differentiating between arteries and veins Rotation of injecting sites Injecting in safer sites Sites where NOT to inject Outreach staff should distribute alcohol (spirit)/Betadine/ Savlon swabs along with needles/syringes to every injecting client

Arteries and Veins Never inject into an artery If you hit an artery: There will be excruciating pain Bleeding may not stop May need to see a doctor

Sites to Avoid When Injecting These include Groin Heart Neck Forehead Part of palm below the wrist Part of foot below the ankle

Educating on Safer Injecting PEs and ORWs need to be trained on safer injecting practices Educative sessions on safer injecting practices should be planned and conducted regularly at the field level PEs and ORWs should discuss safer injecting practices during one-on-one interactions Special sessions with audio visual aids/films may also be conducted at the DIC level

Needle Syringe Exchange Programs

Goal and Objectives Goal : Objectives: To ensure that every injecting act is covered with a safe needle/syringe Objectives: To facilitate safe injecting practices by: Providing new needles and syringes, alcohol swabs, distilled water etc. Practicing safe disposal Removing contaminated needles/syringes from circulation To educate and inform IDUs and partners about safe injecting practices To befriend the IDUs and link them with other services and assist in reduction of high risk practices/behaviour

Basic Components of NSEP Distribute Collect Dispose & INFORM

Who Implements NSEP? PEs and ORWs in areas where IDUs congregate/reside Health workers (nurse/counsellor/ANMs) at DICs/clinics PEs/others designated as Secondary Distributors (SDs) in far flung areas difficult for ORW/PE to reach Sometimes, NSEP may be implemented by a local key informant

Where? At hotspots/sites where IDUs can be accessed Static/Fixed sites – Clinics or DICs

What Will Be Distributed? Needles: 24”, 26” Syringes: 1ml, 2ml, 5ml, 10ml Other equipment: filter, cooker, tourniquet (where budget permits) Need based IEC Alcohol/spirit swabs (to prevent abscesses) Swabs, bandages, etc. (to manage abscesses) Condoms Distilled water

NSEP – Operational Aspects NSEP should operate all 7 days of the week At times when IDUs need it most The planning should be based on: Spot analysis Contact mapping Risk and vulnerability analysis A carefully planned outreach will determine Locations/contact points for delivering NSEP Number of N/S required Timing of operation Division of IDUs and areas amongst the outreach team Individual tracking and monitoring

Operational Aspects N/S distribution should be accompanied by IDUs returning used N/S However, the return should not be a prerequisite for distribution Collection of used N/S from IDUs reduces number of used N/S available for recirculation and so reduces risk of contamination/sharing The return rate of N/S depends on: The relationship between IDU and staff Conducive environment for NSEP

For a Successful NSEP Ensure: Easy accessibility of N/S Confidentiality of the IDU and partner Many IDUs are fearful of being identified and seen as IDUs by the public and family/friends while accessing NSEP Supply (delivery) meeting demand – in quantity and quality Behaviour and attitude of outreach staff during interaction with IDUs and partners

Collection and Disposal of Needles and Syringes

Collection of Scattered N/S

Collection of Scattered N/S Often used N/S lie scattered in fields/hotspots These might prick children or be reused by other IDUs, causing transmission of infections A 1-day activity should be organized periodically by the TI to gather these N/S Use the IDUs/PE/ORW for this activity Inform the general community beforehand Explain the importance of the activity The local police station can also be informed

Precautions for Collecting Used N/S Wear latex plastic gloves (thick gloves, not the ones used in clinics) Do not recap N/S Do not bend/break N/S manually Always pick up from the barrel end (syringe end) Use tongs, if possible, to pick up Definitely use tongs to pick up if more than one N/S Separate with a stick and pick up each N/S separately Put N/S into the puncture-proof container ensuring that needle-end faces downwards to avoid accidental injury Secure the lid of the container tightly Avoid manual (direct hand) transfer of needles /sharps waste from one container to another Transfer collected N/S directly into the main sharp container placed in the DIC

Materials Needed for Collection of N/S Puncture proof boxes – serially numbered, marked with biohazard symbol Thick colour-coded plastic bags – marked with biohazard symbol Thick rubber gloves Tongs/large forceps Plastic bin with sieve Plastic bin without sieve Disinfectant solution – sodium hypochloride, bleach, large plastic bins (translucent white or blue in colour) Hub cutter for mutilating disinfected syringes, if syringes are disposed of by burial on site

Monitoring of NSEP Monitor NSEP on a regular basis Three types of monitoring tools should be employed: Weekly review meetings with outreach staff regarding coverage, areas of weakness and next week’s work plan Record based monitoring to analyse and review coverage, number of IDUs reached regularly, number of N/S distributed and the return rates Field based monitoring: PM should regularly visit hotspots, interact with clients, observe the outreach staff and also interact with other community members Observation from the field visits should be tallied with the records entered by the ORW to get a realistic picture of the quality of the services being offered

Role of the PM in NSEP Supervise NSEP outreach staff Build staff capacity and skill on NSEP Develop work plans with ORWs and PEs Liaise with other agencies, local NGOs, CBOs and other groups in the community

Points to Remember NSEP is the backbone of IDU TI programs NSEP faces major resistance from the general community; significant efforts must be dedicated to conducting advocacy NSEP serves not only to provide a safe method of injecting, but also as an entry point into the IDU community Collection of the returned N/S and safe disposal is as important as distribution of N/S “Remember this is a Needle Syringe Exchange Program, not a mere N/S distribution program”

Thank you