Legislative and Policy Barriers to Needle & Syringe Programs and Injecting Equipment Access for People Who Inject Drugs

Transcription

1 Legislative and Policy Barriers to Needle & Syringe Programs and Injecting Equipment Access for People Who Inject Drugs Australian Injecting and Illicit Drug Users League (AIVL) 2010

2 Contents About AIVL 1 Introduction 2 Brief history of NSP in Australia 5 Factors Impacting on NSP Legislation and Policy 8 Attitudes to Injecting Drug Use and Drug Users and the Impact of such Attitudes on NSP/Injecting Equipment Related Legislation and Policy 9 NSP Related Policy and Legislation Not Always Based on Evidence 10 The Many Stakeholders with Responsibility and Influence to Change NSP-Related Policies, Legislation and Service Delivery Models 12 Risk Aversion, Governments and NSP 13 Legislative Barriers 14 Legislative Barriers to Peer Distribution of Injecting Equipment 16 Associated Legislation and Regulatory Frameworks with an Indirect Impact on Peer Distribution 19 Aiding and Abetting and Possession of Other Injecting Paraphernalia 20 Legislation Relating to the Disposal of Used Needles and Syringes 21 Mandatory & Discretionary Reporting 21 The Impact of Local Council Development Applications on New NSP Outlets 22 Policy Barriers 23 Range and Type of Injecting Equipment Available 23 Limits on Equipment and User Pays/Cost Recovery Systems 25 The Effectiveness of Guidelines and Protocols Restricting Police Attendance at NSPs 26 Collection of Statistics /Completing Surveys and Questionnaires 27 Access to New Injecting Equipment in Prisons 29 Environmental/Structural Barriers to NSP Access 32 Conclusion 33 Barriers to NSP Access/Addressing Barriers Table 34 References 40

3 About AIVL This national policy discussion paper has been developed and published by the Australian Injecting and Illicit Drug Users League (AIVL). AIVL is the national peak organisation for the state and territory drug user organisations and represents issues of national significance for people who use illicit drugs and people on opioid pharmacotherapy. The organisational philosophy of AIVL is user-centred and peer-based with the dual aims of reducing drug-related harm and promoting and protecting the health and human rights of people who use/have used illicit drugs. AIVL operates within a health promotion framework as articulated in the Ottawa Charter for Health Promotion (1986). With this overall framework in mind, AIVL undertakes a broad range of health promotion and disease prevention activities and programs. One of the primary aims of the organisation is to prevent and reduce the transmission of blood-borne viruses such as hepatitis B and C and HIV among people who inject illicit drugs, and to ameliorate the negative impact of such conditions among those already infected. In addition to disease prevention activities, AIVL also works to promote the provision of highquality, accessible and relevant services to people who use/have used illicit drugs throughout Australia, including drug treatment services. Although AIVL represents and addresses issues affecting all illicit drug users and people on opioid pharmacotherapy, AIVL and its member organisations maintain a priority focus on injecting drug users and injecting drug user issues due to the higher levels of harm and marginalisation routinely experienced by people who inject drugs. AIVL believes that people who use illicit drugs and those on opioid pharmacotherapy have the right to be treated with dignity and respect and to be able to live their lives free from discrimination, stigma and health and human rights violations. Further information about the aims, objectives and work of AIVL can be found at: 1

4 Introduction The Australian Injecting & Illicit Drug Users League (AIVL) has developed this position paper with a view to providing a national overview of the legislative and policy barriers which currently restrict access to Needle & Syringe Programs (NSPs) and new injecting equipment for PWIDs. As a national organisation, one of AIVL s key roles is to encourage and support critical discussion on issues of national significance for the health and wellbeing of PWIDs. In this context, it is beyond the scope of this discussion paper to provide a detailed examination of the specific laws, policies and other regulatory frameworks that affect access to new injecting equipment in each jurisdiction. Instead, as a national discussion paper this document aims to inform further discussion and examination of the legislative and policy reform that may be necessary to address barriers to access. In this regard the paper identifies the broad types of legislation, policy and other regulatory frameworks that directly or indirectly impact on access to injecting equipment at the jurisdictional level. Our hope is that this paper will act as a catalyst for further discussion, but any actual process of reform would require a more detailed analysis of the relevant legislation and policies for each state/territory. The provision of new injecting equipment through NSPs is an important harm reduction strategy to reduce the spread of blood borne viruses (BBVs) such as Human Immune-deficiency Virus (HIV), Hepatitis C (HCV) and hepatitis B (HBV). While it is impossible to ascertain exact figures in relation to the number of PWIDs in Australia at any one time, according to the National 2004 Drug Strategy Household Survey (AIHW 2005), about 313,500 people reported having injected illicit drugs at some time in their lives and 73,800 reported having done so in the preceding 12 months. In addition, there are approximately 40,000 individuals on pharmacotherapy programs nationally with an additional 40,000 people estimated to be between treatment 1 (AIHW, 2008 ANCD, 2009). Hepatitis C is one of the most commonly notified diseases in Australia. The National Hepatitis C Strategy estimates some 284,000 people had been exposed to hepatitis C in Australia at the end of 2008 with an estimated 212,000 people with chronic Hepatitis C, and up to 10,000 new infections occurring annually (DoHA, 2010). While the number of new infections has declined since 2001, it is estimated that up to 90 percent of new infections and 80 percent of existing infections were transmitted through the sharing of injecting equipment (Razali, et al, 2007). In addition to the overall situation in relation to Hepatitis C prevalence among PWIDs, Indigenous people who inject drugs have been identified by AIVL and the relevant national strategies as needing specific and priority focus to address the disproportionate affect BBVs are having on this group within our community. The Building the Evidence Report highlights the increasing disproportionate effect of Hepatitis C (and HIV) on Indigenous people who inject drugs. Rates of Hepatitis C infection are between 2 and 11 times higher among Indigenous PWIDs than non-indigenous PWIDs. The National Hepatitis C Strategy and the National Aboriginal and Torres Strait Islander Sexual Health & BBV Strategy also identify Aboriginal and Torres Strait Islander people who inject drugs and/or in custodial settings as key target groups within both strategies Recent surveillance data reflects that among both Aboriginal people who inject drugs and prisoners the incidence of HIV is increasing: with 22 per cent of new HIV infections among Aboriginal people being due to unsafe injecting drug use (compared to 3 percent for non Indigenous cases); in relation to HIV and prisoners, prevalence has been steadily increasing from (NCHECR, 2009b). These issues of concern are further 1 Those who have received at least one episode of treatment but are currently out of treatment. 2

5 complicated when coupled with increases in the availability, purity and use of heroin and pharmaceutical opioids as detailed in recent data and media reports (IDRS, 2007 & 2008; NCHECR, 2009a; The Australian, 18/03/09; ABC Radio National, 17/03/09). In addition to the above concerns, strategies for effectively addressing the continued transmission of BBVs among PWIDs also need to be considered in the light of recent evidence on the rates of unsafe injecting practices. The Annual NSP Survey has shown the rate of people reusing someone else s needle & syringe has shifted little in the past 5 years indicating the need to undertake more focused efforts to remove remaining barriers to NSP access and to expand peer education activities among people who inject drugs (NCHECR, 2009a). Data from the 2008 Annual NSP Survey show that rates of reusing injecting equipment may be increasing with almost half (48%) of all respondents reporting reuse of injecting equipment. While further work needs to be done to better understand the reasons why people reuse injecting equipment, AIVL believes some of the key drivers of equipment reuse is due to: the placement of arbitrary limits on the amount and type of equipment people can access; lack of after hours and 24 hour access to NSP; the increasing cost of injecting equipment through user-pays systems; lack of access to new injecting equipment in prisons; and little or no information on how to adequately clean used equipment should drug users find themselves with no other option. This unsatisfactory situation is contrasted with recent modelling work conducted by the NCHECR which suggests that there may be a direct correlation between the numbers of needles & syringes distributed and reductions in Hepatitis C infections. As a result this research has concluded that a doubling of the number of needles & syringes currently being distributed would achieve a halving the number of new Hepatitis C infections. It further notes however, that if a reduction of availability of new injecting equipment was to occur in the order of onethird, then a 3-fold increase in incidence of Hepatitis C could be expected (Jisoo A Kwon, et al 2009). This is also further supported by the Building the Evidence Report which has highlighted the need for significant new investment in Hepatitis C IDU peer education and NSP if Hepatitis C is to be adequately addressed (Griew, R. et al. 2008). It is well accepted that NSPs are the frontline of BBV prevention among people who inject drugs. The evidence demonstrating both the effectiveness and cost-effectiveness of NSPs is extremely strong in relation to HIV and HCV (Health Outcomes International, 2001, NCHECR 2009c). While the evidence to support the effectiveness/cost-effectiveness of NSPs is arguably stronger in relation to HIV than HCV, there are a range of inter-related factors that, if properly considered do show a considerable and growing impact of NSP on HCV infection rates. Decreases in HCV prevalence rates particularly among young and new injectors accessing NSPs could be one important indicator of the growing impact of NSP on HCV (NCHECR, 2009b). Unfortunately, despite the evidence of the effectiveness of NSP as a HIV and Hepatitis C prevention strategy, there is also a growing evidence base showing major problems with the levels of access to new injecting equipment (Griew et al, 2008). The continuing high levels of hepatitis B transmission among people who inject drugs further underlines this problem. There is virtually no 24 hour or after-hours access to injecting equipment in Australia with the majority of primary outlets operating at best within business hours. There are vending machines in some major cities but these have been very slow to roll-out across Australia, PWIDs are usually required to have money to use these machines and vending machines only carry very basic injecting equipment. 3

6 Some pharmacies in major cities and regional centres provide NSP but drug users must be returning used equipment to access free new equipment otherwise they need to pay for the equipment. In many areas there continues to be major problems with the attitudes of pharmacists and particularly pharmacy staff to providing NSP and to people who inject drugs. Many pharmacies do not provide NSP at all, or similar to vending machines, very basic equipment. NSP access is provided on a 24 hour basis through the Accident and Emergency (A&E) Departments of some hospitals. However PWIDs experience very high levels of discrimination when attempting to access these programs as they are viewed as wasting the time of A&E staff on junkies when there are deserving patients needing emergency care. Not surprisingly therefore PWIDs anecdotally report that they are very reluctant to access NSP through A&E departments at hospitals unless there is no other option. In the majority of states and territories of Australia it is illegal for a person not authorised to distribute injecting equipment to provide such equipment to another person. These laws effectively make it illegal for one PWID to give another a new syringe. Despite these laws, peer distribution of injecting equipment is one of the main ways that PWIDs get access to new injecting equipment. Preliminary data from the 2009 Australian NSP Survey indicates that, despite being unlawful in most jurisdictions, onward supply of needles and syringes (peer distribution) is common in all states and territories. In 2009, onward supply of needles and syringes (in the month prior to survey completion) was reported by 37 percent of NSP Survey participants nationally, with prevalence of 30 percent or more occurring in all states and territories (NCHECR, yet to be published). There are also major problems with access to the amount and types of injecting equipment required to implement the safer injecting and BBV prevention messages that drug users are meant to employ. Many NSPs have strict limits on the amount of equipment that an individual user can access each visit and/or per week. In short we disseminate best practice BBV prevention messages and then refuse to provide access to the amounts and types of equipment that will allow people to put these public health messages into practice. Limitations on amount of equipment are largely dictated by budgetary constraints. Investment in Australian NSPs has remained relatively stable for many years despite ongoing concerns about a significant gap between the numbers of needles & syringes distributed against the estimated numbers of injecting episodes. The recently released Return on Investment in NSP 2 Report highlighted that up to 50 percent of all injections are likely to be taking place without new injecting equipment an estimate that AIVL believes represents a best case scenario (NCHECR, 2009c). Information about legislation and policy frameworks that underpin the Needle & Syringe Programs at a state and territory level is also largely unavailable and where information does exist, it is often confusing and contradictory. Many people move around the country for personal and professional reasons and for holidays but it is very difficult to access information about the laws and policies relating to injecting equipment, safe disposal, illicit drugs, privacy, etc, in each jurisdiction. This situation often results in drug users inadvertently breaching or just being confused about local NSP related laws and policies such as possession of needles and other paraphernalia, disposing of used equipment into household garbage, confusion about rights relating to police questioning, etc. There is now a clear and strong evidence base to support the role that NSPs together with peers and peer education, play in relation to preventing and responding to BBV transmission among people who inject drugs. It is with the need to strengthen the effectiveness of NSP in relation to BBV prevention in mind that AIVL has developed this position paper on Legislative and Policy Barriers to New Injecting Equipment and NSP Access. The paper aims 4

7 to identify the policy and legislative barriers to current new injecting equipment and NSP access, and to make recommendations in relation to those barriers with the view to reducing BBV transmission rates in the future. The specific issues covered in the discussion paper include: removing barriers to peer distribution of injecting equipment; ensuring the full range of injecting equipment and paraphernalia are legally available in all states and territories; removing policy and legislative inconsistencies in relation to safe disposal of used injecting equipment; assessing the impact of self-administration legislation on BBV prevention; reviewing the impact of local council development applications on new NSP outlets; and reviewing the effectiveness of policy protocols restricting police attendance at NSPs. In developing this paper, AIVL sourced available literature, expertise and evidence. This process included a review of relevant policy documents, research, legislation and reviews and in-depth interviews with current and former NSP staff from across the country and those employed in NSP policy environments. Further, recorded discussions with people who inject drugs (both users of NSP services and those with a preference for peer distribution, vending machines and/or pharmacy) were used to substantiate the issues raised through the literature review and personal correspondence with relevant experts utilised to elucidate any issues requiring clarification. Names of personal interviewees have been changed to maintain confidentiality and anonymity. In all, AIVL believe the issues raised in this discussion paper represent the broad spectrum of legislative, policy and general barriers to injecting equipment and NSP access for people who inject drugs. Brief history of NSP in Australia Needle and syringe programs (NSPs) are internationally recognised as the primary harm reduction tool in the prevention of blood borne viruses (BBVs) such as HIV and Hepatitis C and other health related problems that can be associated with injecting drug use. In Australia general recognition of the valuable contribution NSPs play in reducing the risk of BBV transmission led to the inclusion of NSPs in the first National HIV/AIDS Strategy (the White Paper) in This was followed by subsequent implementation of a national system of NSPs across the country and has positioned the Australian approach to NSP as an internationally acclaimed model. This early and swift implementation of NSPs has resulted in low numbers of HIV infection among people who inject drugs, very unlike other countries that were, and in some cases remain slow to implement NSPs resulting in HIV infection rates among people who inject drugs many times higher than in Australia. Unfortunately, in relation to Hepatitis C, the same cannot be said due to the very high HCV prevalence rates among PWIDs before NSPs were introduced, the more virulent nature of HCV and a general lack of additional resourcing to allow NSP to effectively respond to the challenge of Hepatitis C. The nett result of this very different context for Hepatitis C is that responding to HCV particularly among people who inject drugs, remains a significant challenge for Australia. While the manner in which NSP was implemented in Australia was fortuitous in regard to HIV transmission rates among people who inject drugs, it has also had a historical impact on the legislative and policy framework which underpins NSPs in Australia to the current day. Australia s first NSP was an illegal program established at the Alcohol and Drug Service, St. Vincent s Hospital in Darlinghurst, Sydney in November 1986 as an act of civil disobedience. 5

8 The impetus to initiate this first NSP came about through the frustration of many failed attempts to obtain government approval for a legal needle syringe pilot program throughout the year Those involved in the trial argued that HIV was already rapidly spreading through injecting drug users in the community. They proved this claim by testing the syringes returned to the pilot and showing that there was an increase in HIV prevalence over time. (ANCD, 2006) While health sector staff involved in the establishment of this first illegal NSP were not subsequently prosecuted, the NSW Government did review the results of the trial service. Growing concern about the potential for HIV to quickly spread beyond people who inject drugs into the wider general community led the authorities in NSW to agree to the establishment of a state-wide NSP system based in pharmacies and the community. Although it took a number of years to make the necessary policy and legislative reforms to allow NSPs to be established, other states and territories followed the NSW lead, by 1988/89 a national system of NSPs and the associated legal and policy reform had begun to be implemented. Since this time the positive benefits of the rapid implementation of a national system of NSPs has been well documented in the available literature. Between 1990 and 2000 it was estimated that NSPs had prevented at least 25,000 HIV and 21,000 Hepatitis C infections with between $2.4 and $7.7 billion saved in prevented health and social costs (Health Outcomes International, 2001). Building on these results, a more recent study in 2009 found that for an investment of $243 million (AUD) between 2000 and 2009 the Government had saved $1.28 billion (AUD) in short-term health savings. A cost benefit of $4 saved for every $1 invested (NCHECR, 2009c). Over the past 20 years, NSP has developed across Australia under a national policy framework which is largely federally funded but locally administered by state and territory health departments through area and regional health services and NGOs. While it is difficult to source exact numbers of NSPs across Australia in 2010, currently available data suggest there are approximately 3000 NSP outlets in Australia located in a range of settings including government health services, non-government organisations, pharmacies, hospitals, community health centres, etc. Available data shows that from an initial annual distribution rate of 6.3 million in 1991, the number of 1ml needles & syringes distributed through NSPs annually has steadily increased to 15 million in 1995, 19 million in 1997, and 27 million in 2003 to the current estimate of 31 million in 2007 (NCHECR, 2009c). It is important to note however that these figures do not account for the large amount of larger syringes, detachable needles, winged infusion sets and other injecting equipment that is distributed through outlets or for the fact that demand for new equipment greatly outstrips supply. Despite the availability of enhanced federal funding for NSP since 1999/2000 under the COAG National Illicit Drug Diversion Initiative Supporting Measures for NSP there has never been the development of a system of nationally consistent protocols to guide the implementation of NSP in Australia. This lack of an agreed national NSP framework has led to the development of a mixed system of service models which can vary from jurisdiction to jurisdiction and even between local government areas and health regions. While in some jurisdictions primary responsibility for models of service delivery rest with the state health department, in other jurisdictions the responsibility for the details of service delivery are left with the particular area health service or individual community based organisation. Some jurisdictions and services offer a mixture of NSP service models, others may offer only one. Funding models differ, as do budgets, equipment dispensed, policy and legislation, protocols and operation. Despite the above differences in operational models and service delivery approaches, the major models of NSP service delivery implemented nationally in 2010 include: Primary NSPs those services wherein NSP is the primary function of the service: equipment dispensation, disposal programs, referral, support, education. 6

9 Peer-based NSPs similar to primary NSPs, however managed and staffed by injecting drug using peers. These services often primarily operate from drug user organisations (DUO), but may be co-located within other services such as peer-based NSPs within community health centres. Secondary NSPs services wherein NSP is secondary to core-business or is offered as one of a number of health and social services and include hospital Accident and Emergency Departments, Community Health Centres, and Youth Health Centres. Vending Machines injecting equipment provided through dispensing machines. Vending machines were first introduced in Europe in 1987 and subsequently to Australia and New Zealand. Internationally they may also exchange new for used equipment. In Australia they provide limited equipment for a coin or free of charge. Mobile & Outreach Introduced in the Netherlands initially in 1986, the first mobile NSP bus was actually a methadone service which also offered needle and syringe exchange (ANCD, 2006). In Australia, the first mobile NSP was colloquially named the AIDS Bus, it began initial operation in response to HIV and also offered safe sex equipment and information. These services visit regular scheduled sites at designated times, sometimes the same site is visited a number of times in a shift. Some jurisdictions provide a mobile service in the form of a foot patrol workers with supplies of equipment visit designated hot spots of injecting. In some cases home delivery or the delivery of injecting equipment to pre-arranged rendezvous points is also offered. Community pharmacy-based NSP scheme provided by pharmacies on a commercial retail basis (some also receive some government assistance) not all pharmacies participate in the scheme. It is estimated that pharmacy-based distribution of NSP equipment accounts for percent of all injecting equipment dispensed depending on the jurisdiction. It is further estimated that there is approximately 750 pharmacies currently participating within a government supported NSP scheme. Estimates on the numbers of pharmacies that do not participate within a government scheme, but do sell new injecting equipment are not available (ANEX, 2008). In recent years a number of research studies have begun to focus more on the different types of NSP service models available and the reasons why people might access or have a preference for certain service types over others rather than focusing on the profile of the clients accessing major primary outlets alone. For example, some of the reasons why individuals choose pharmacy access over going to a primary/secondary service, and may be prepared to pay for equipment have included lack of awareness of other service options available, relative convenience of the pharmacy location, problems with transport, the limited operating hours of local primary or secondary programs compared to the pharmacies, policing practices and fear of police harassment at recognised NSP programs, the anonymity of accessing a pharmacy scheme and the associated ability to avoid the stigma associated with being identified as an IDU (Treloar and Cao, 2005). Not surprisingly the clients of primary/secondary NSP services do overlap to an extent with those who choose pharmacy-based NSP but some studies have highlighted that there can also be significant differences between these two groups. For example one recent study found that those who primarily choose to access injecting equipment through pharmacies were less likely to have severe drug-related issues, more likely to report lower prevalence of HIV and hepatitis C, more likely to report a higher rate of needle and syringe reuse and had lower rates of use of health services (such as BBV testing). In contrast, users of primary NSP services were found to have been exposed to higher levels of injecting risk (such as imprisonment), injecting more frequently in more risky circumstances (such as public injecting) and were more likely to 7

10 report reuse of more than one other person s syringe in the month prior to the study (Treloar and Cao, 2005). There is little doubt that the policy and legislative reforms that were necessary to allow for the implementation of NSPs in Australia were both bold and heroic at the time they were undertaken. In 2010 however, the question becomes whether those early and necessary reforms are sufficient to maintain and further develop a national NSP system that is vastly more complex and diverse than when it commenced. The legislative reforms made at the commencement of NSP, while significant in impact were in reality quite modest. They were aimed at creating a basic level of legality and policy to allow NSP to exist at all. Where there had been nothing or barriers to NSP provision there now needed to exist a workable legal framework. There was a good deal of work involved in reviewing, and then either repealing existing laws and policies and/or crafting new or replacement provisions. The fact remains however, that then as now we all knew that this brave new world that allowed for NSP was for the most part sufficient but did not represent best practice. For instance; while it was no longer an offence to be in possession of a needle or syringe, possession of other essential drug use paraphernalia such as filters, water vials, spoons, etc remained illegal. Although some protection was provided to authorised NSP staff, individual drug users were provided with no protection from aiding and abetting laws in regard to the possession of drug use paraphernalia other than needles and syringes. Authorised personnel were originally only covered against being charged with aiding and abetting in relation to the distribution of needles and syringes (not other paraphernalia), nor were they originally permitted to disclose the location of other NSPs legal protection has since been extended. In NSW, pharmacists were exempt from being charged with aiding and abetting as long as they provided needles and syringes within an approved scheme. Unfortunately however the definition of an approved scheme was not provided at the time a matter that has subsequently been amended and all pharmacists are now exempt as long as the provision of needles and syringes are part of their usual business. Regulations now also provide cover for pharmacy assistants where they originally did not. Although only one example, the above situation in relation to possession of drug use paraphernalia and aiding and abetting provides some insight into the complex web of legislation and policy reform that was necessary to allow access to injecting equipment when NSP first commenced and how we have come to the less than ideal framework that is operational today. Factors Impacting on NSP Legislation and Policy Historically the factors impacting on the establishment, ongoing management and subsequent access (and barriers to access) to NSPs and injecting equipment more broadly, are complex and interrelated. Not surprisingly, these factors are also the necessary back-drop to which all latter policy and legislative barriers to NSP and injecting equipment need to be discussed including: attitudes to injecting drug use and drug users and the impact of such attitudes on NSP/injecting equipment related legislation and policy; the extent to which such policy and legislation is based on evidence and good practice; understanding the many actors with responsibility for and power to influence and change such legislation and policies; and the impact of the growing culture of risk aversion within government at both state/territory and federal levels. All of these critical factors are discussed in more detail below. 8

11 1. Attitudes to Injecting Drug Use and Drug Users and the Impact of such Attitudes on NSP/Injecting Equipment Related Legislation and Policy Generally, people who inject drugs are viewed as a collective criminal class: in short certain substances are illegal, the use of those certain substances is illegal, and therefore people who use those substances are engaging in criminal behaviour and are by definition criminals. Further to this, AIVL s recently commissioned market research into people who inject drugs and discrimination highlighted the extent to which members of the general public have invested in extremely negative stereotypes about people who inject drugs. Indeed the level of investment in negative attitudes towards drug users was so strong that any challenges to those stereotypes were met with disbelief and/or outright hostility. Participants were not only quite comfortable in admitting to routinely discriminating against people who inject drugs but stated that they believed that displaying such attitudes and behaviour was making a positive contribution to society in that it would discourage people from participating in injecting drug use. In addition to these views, participants in focus groups stated that people who inject drugs are feared, and association with them implies contamination or being tarred with the same brush (GFK Bluemoon, 2010). Many of the above attitudes and views were clearly driven by a general prohibitionist reaction in relation to people who inject drugs which is both perpetuated and encouraged by the constant war on drugs rhetoric within the media and government policy. It is interesting to note however that it is not just individual drug users who carry the negative perceptions of the community in relation to illicit drugs but also the services that are utilised by drug users are also seen in an associated negative light. A strong view held by many of the participants in focus groups was that NSPs send the wrong message, encourage drug users to keep using, have a honey-pot effect and encourage public disposal of used injecting equipment. As discussed further later in this document, it is very important to note the association between how the negative attitudes and views of members of the general public, often fuelled by sensationalist media stories, can have a major impact on how those who have responsibility in relation to legislative and policy development and program implementation operate. Some of the negative views of harm reduction services and NSP in particular generally include: Harm reduction being in conflict with the goals of law enforcement; NSPs attracting users and dealers who take advantage of policing guidelines; NSPs lead to an increase in discarded drug paraphernalia; NSPs compromise the prevention of drug use and treatment; Harm reduction and NSP in particular increases uptake and levels of drug use; Services for people who inject drugs result in innocent people not being able to access medical treatment; and Harm reduction services are too liberal. 2. NSP Related Policy and Legislation Not Always Based on Evidence While some of the legislative and policy decisions that have been taken in relation to NSPs and access to new injecting equipment are evidence informed, there are many examples in both the legislative and policy areas that are not based on evidence or informed by good practice. Indeed too often critical decision making relating to improving access to new injecting 9

12 equipment is instead increasingly informed by factors such as community attitudes, media bias, political sensitivities and economic realities. Examples of this process at work include; in the case of NSW the removal of larger bore syringes and winged infusion sets from NSP dispensing in the late 1990 s; the continued legislative and policy barriers to peer distribution of new injecting equipment including self-administration laws; the increasing limits on the amounts and types of injecting equipment mandated in some state/territory NSP policies; and the continued refusal to provide access to new injecting equipment in Australian prisons. a) Removal of large-bore syringes and winged infusion sets in NSW: In the late 1990 s, NSPs funded through NSW Health were instructed to cease the dispensing of larger-bore syringes (10ml and above) and winged infusion sets (butterflies). At the time NSW Health and the minister responsible were clear that this policy shift was implemented to make difficult (or impossible) the injection of oral methadone. At the time the NSW Users & AIDS Association (NUAA) developed a questionnaire targeting methadone injectors and a subsequent report of the findings made (NUAA, 1998, unpublished). This report contained over 400 responses from people who injected methadone, with greater than 95 percent stating that the removal of this equipment would not stop them from injecting methadone. The Annual NSP Survey states that in NSW, methadone was the last drug injected for between percent of respondents between 2005 and Larger-bore syringes and winged infusion sets continue to be available in every other state and territory and despite this, the figures for methadone as last drug injected comparatively ranged from 8 10 percent for the same years. (NCHECR, 2009a). Not only has this policy decision been made in contradiction to available evidence and expressed intentions of service users, it has also resulted in greater harm to people who inject methadone in NSW. Without access to the necessary injecting equipment reports from drug users indicate that people are forced in to multiple injections with smaller syringes and detachable needles and are therefore less likely to dilute the solution to a less viscous liquid both of which led to significantly greater levels of harm and vein damage. In addition, the cost of large-bore syringes and winged infusion sets through pharmacies (average $1.00 $3.00/ unit through a limited number of pharmacies) also results in people reusing equipment due to the expense and risk associated with acquiring such equipment. In making this policy move, media statements by the NSW Government at the time underlined an awareness of the implications of the policy change for the health of people who inject drugs by allowing a staged withdrawal of the injecting equipment concerned. This approach was identified as necessary to allow education of NSP clients in disease prevention. Despite the perceived potential risks associated with the removal of the equipment the policy approach was taken to ensure that all NSW drug programs continued to meet community expectations (NSW Government Media Release, 1998). b) Barriers to peer distribution of injecting equipment: While addressed in more detail later in this document, peer distribution of new injecting equipment is actively prevented through legislation and then reinforced through NSP policy and practice. While the precise wording of the laws concerned varies, in all states and territories in Australia it is currently illegal for an individual to provide others with access to injecting equipment unless that person is authorised to dispense new injecting equipment through NSP. This legislative context is not created by a single law but rather by the complex 10

13 interaction of a series of laws including but not limited to self-administration, aiding and abetting an offence, placing others at risk of danger and either laws or policies relating to the authorised dispensing of injecting equipment. This network of laws and policy has been both implemented and maintained despite a growing and strong evidence base demonstrating the value of peer distribution of injecting equipment as a BBV prevention strategy. The extent to which peers are already engaging in this practice despite the existing laws and modelling work demonstrates an urgent need to increase the availability of injecting equipment to halt further HCV and HIV infections. The fact that peers are engaging in distribution of injecting equipment despite illegality and that police are not seeking to charge people for engaging in such behaviour is sometimes raised as a rationale for needing no legislative or policy change on this issue. The fact remains however that retaining such unnecessary and potentially harmful laws leaves PWIDs at the mercy of police discretion. Indeed, anecdotal reports from drug users confirm the use of such laws to harass and hold, remove equipment and threaten even if it does not result in actual charges or convictions. With an urgent need to improve access to injecting equipment in the interests of BBV prevention, the continued existence of such non-evidence based laws and policies will only serve to stand in the way of NSPs making use of a valuable resource and cost-effective public health measure in relation to peer distribution. c) Limits on the amounts and types of injecting equipment: Closely related to the issue of peer distribution is the issue of placing limits on amounts and types of injecting equipment that PWIDs can access through NSPs. Rather than a legislative barrier, limits on equipment are activated at a policy level within jurisdictions and vary in both approach and impact across the country. By way of example, in NSP policy in both the ACT and QLD an individual can access a maximum 50 syringes/day. As already outlined above, NSW does not provide access to specific types of equipment and other jurisdictions including WA and SA have introduced user-pays models into their NSP systems which can be a factor in decisions to reuse equipment for some drug users. As outlined above in relation to peer distribution, these policy approaches have been implemented and maintained despite a wealth of evidence from Australia and internationally highlighting the highly cost-effective nature of the government investment in NSP and the significant public health implications if adequate access to injecting equipment is not provided, is removed or is limited. This is further supported by evidence of a chronic and increasing level of reuse of injecting equipment in Australia and an unacceptably high number of new HCV infections each year and increasing HIV infections among our most marginalised drug users. Although AIVL acknowledges the pressures on NSPs in relation to budgetary constraints, we still find it necessary to ask what further evidence and impetus is needed to reverse this harmful policy practice of placing limits on access to both amounts and types of injecting equipment? d) Lack of access to new injecting equipment in Australian prisons: As with placing limits on the amount and type of injecting equipment available, the continued refusal to address the lack of access to new injecting equipment in Australian prisons is not a legislative barrier but a policy one. This issue along with some of the others outlined above is addressed in more detail later in the document but it is such a blatant example of poor public health policy and practice that it needed to be included in this list of examples of nonevidence based policy approaches. While Australia has no evidence base upon which to draw in relation to prison-based NSP, such programs do operate in numerous other countries and 11

14 a number of these programs have now been evaluated. This evidence highlights that NSPs in prisons do not result in needles and syringes being used as weapons, do not lead to increases in drug use and can act to increase rather than decrease the overall health and safety of the environment. 3. The Many Stakeholders with Responsibility and Influence to Change NSP-Related Policies, Legislation and Service Delivery Models International obligations, federal, state and territory legislation, state/territory health department policies, area or regional health policies and procedures, service level policies and procedures, federal, state and territory policing guidelines and local government by-laws are just some of the main legal and policy mechanisms that have an impact on the planning, development and implementation of NSPs and in providing access to injecting equipment. In Australia NSP is largely funded by the Australian Government and subsequently administered and legally governed by the states and territories. Generally health department polices specific to NSP operations are developed at the state/territory level, with more generalist policies (OH&S for instance) developed at the service and/or area/regional health service tiers. Police guidelines in relation to NSP are developed at the jurisdictional level, however interpretation of those guidelines occurs on local area level along with policing priorities and operational activity. While NSP management are encouraged to consult with local government and police, there are some incidences wherein development approval must be sought installation of vending machines and development applications for new NSP services are but two examples. In relation to NSPs in Aboriginal Communities, local Aboriginal Medical Services (AMSs) are also consulted. It is hardly surprising that with so many stakeholders involved in NSP legislation, policy, regulations, guidelines, implementation and establishment from such a varied political and social spectrum, that NSP policy and legislation is sometimes cumbersome and inconsistent. Further, this network of relationships and obligations also mean that the establishment and further development of services can be time consuming and politically and socially complex. In looking to identify and address legislative and policy barriers to NSP and access to new injecting equipment it will be necessary to give appropriate consideration to the above network of key stakeholders and relevant processes. While these existing relationships and obligations may present challenges for this process of reform, it will be important to remain focused on the public health benefits of removing barriers to accessing injecting equipment. In this regard, utilising existing national advisory structures (including the Ministerial Advisory Council on BBV & STIs (MACBBVS), the BBVS Sub-Committee, the Ministerial Council on Drug Strategy (MCDS) and the Inter-Governmental Committee on Drugs (IGCD) or their equivalent structures) will be critical to successfully navigating and negotiating the web of relationships and existing legal and policy obligations that will require review and as appropriate, repeal and redevelopment. 12

15 4. Risk Aversion, Governments and NSP In many ways it could be considered that the amount of attention given to needle and syringe programs is in direct contrast to the level of financial investment in the program. NSPs are actively discouraged from advertising their services, location(s) or nature of the program for fear of negative media and/or community attention. Unfortunately this fear of negative attention has been driven by the reality of relentless attacks on NSP in the mainstream media and the actions of a small minority of individuals within the community aimed at discrediting the vital work of NSPs. The actions of the media and these individuals have led to the development, over time, of a strong culture of risk aversion at the federal and jurisdictional level. External pressures and perceived threats can lead to NSP service providers keeping their heads down and being reluctant to extend or promote NSP services: We re the most vulnerable program around, and we have to be very cautious...nsp services tend to see themselves as occupying a marginal or insecure position within the health system...(the) wider health system doesn t recognise the value of NSPs. (Urbis, 2008) Not surprisingly, over time these sentiments have become formalised in the policies and procedures that govern NSP at the jurisdictional level. The NSP Program Policies of a number of jurisdictions contain Program Promotion policies suggesting that program promotion (including location of services) should be targeted specifically at clients/people who inject drugs rather than more widely. The policies state that this approach is being taken at least in part for the protection of client confidentiality, but it is also quite specifically aimed at ensuring the program does not generate attention at a community or political level. Examples of these policies include the following: Program promotion activities and materials should be targeted specifically at IDUs and non-targeted promotion should be kept to an absolute minimum. There must be a balance between ensuring that IDUs are aware of the program and the potential for over-exposure that may lead to a high level of general community attention. To protect the anonymity of clients there should be limited public advertising of the program. Word of mouth promotion through clients is generally an effective means of service promotion. Advertising for a specific outlet or dispensing machine should not be conducted through the media or other publications circulated to the general public. While it is possible to understand why and how such policy positions have developed over time, it is equally important not to lose sight of why NSPs were established in the first place, the level of the bipartisan political support that allow this to occur and the fact that there is actually a significant level of ongoing support within the general community for NSPs. NSPs and those who fund, administer and operate them must always remain focused on their primary goal of BBV prevention. Policy makers would do well to remember that there has been no action at the federal or state/territory levels to indicate a waning of the bipartisan political support for NSP and access to injecting equipment. Indeed the recent historic sign-off on the new national strategies in relation to BBV & STI by the health ministers of governments at all levels would indicate that such support is as strong as it has ever been. In addition to negative media coverage there has also been supportive coverage and whenever they are asked, the general public overwhelmingly understands and supports the need to provide access to injecting equipment (Matthew-Simmons, 2008). Like all policy responses, there can be unintended negative consequences associated with their implementation. This is particularly the case when the policy involves a sensitive public health initiative such as access to injecting equipment. Unfortunately, although maintaining a low-profile for NSPs has invariably been driven by a genuine commitment to protecting the program, it has simultaneously resulted in people who inject drugs particularly those travelling or new to an area, often finding it unnecessarily difficult to gain information on where to 13