1. Safer Injecting Practices

2. 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

3. 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

4. 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

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

6. 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

7. Needle Syringe Exchange Programs

8. 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

9. Basic Components of NSEP
Distribute
Collect
Dispose
& INFORM

10. 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

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

12. 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

13. 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

14. 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

15. 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

16. Collection and Disposal of Needles and Syringes

17. Collection of Scattered N/S

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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”

24. Thank you