Pharmacy Needle and Syringe Survey, Western Australia 2009

Transcription

1 MONOGRAPH 5/2009 Pharmacy Needle and Syringe Survey, Western Australia 2009 Joanne Bryant Hannah Wilson Carla Treloar

2 MONOGRAPH 5/2009 Pharmacy Needle and Syringe Survey, Western Australia 2009 Joanne Bryant Hannah Wilson Carla Treloar Faculty of Arts and Social Sciences The University of New South Wales

3 Copies of this monograph or any other publications from this project may be obtained by contacting: Level 2, Robert Webster Building University of New South Wales Sydney NSW 2052 Australia Telephone: Fax: nchsr@unsw.edu.au Website: ISBN Monograph 5/2009 Edited by Sarah Fitzherbert Layout by Judi Rainbow The (NCHSR) is part of the Faculty of Arts and Social Sciences at the University of New South Wales. NCHSR research projects are partly or fully funded by the Australian Government Department of Health and Ageing. Suggested citation: Bryant, J., Wilson, H., & Treloar, C. (2009). Pharmacy Needle and Syringe Survey, Western Australia 2009 (Monograph 5/2009). Sydney:, The University of New South Wales.

4 Contents Acknowledgments List of tables List of figures ii iii v Key findings 1 Recommendations 2 Introduction 3 Method 5 Data collection 5 Data analysis 5 Response rates 5 Findings 7 Demographic profile 7 Patterns of acquisition of sterile needles and syringes 7 Drug use 10 Engagement in risk practices for the transmission of blood-borne viruses 13 Testing for hepatitis C and HIV, and self-reported prevalence 16 Sexual practice 17 Knowledge about hepatitis C, and perceptions of risk 18 Limitations 21 Conclusion 22 References 23 Appendix: Questionnaire 25 Pharmacy Needle and Syringe Survey, Western Australia 2009 i

5 Acknowledgments The authors acknowledge the valuable contribution of the project s reference group: Lisa Bastian, Sexual Health and Blood-Borne Virus Program, Department of Health, Western Australia Jude Bevan, Senior Policy Officer, Sexual Health and Blood-Borne Virus Program, Department of Health, Western Australia Frank Farmer, Manager, Hepatitis Western Australia Trish Langdon, Executive Director, Western Australia AIDS Council Georgiana Lilley, Sexual Health and Blood-Borne Virus Program, Department of Health, Western Australia Mark Lowery, Executive Officer, Western Australia Substance Users Association Lyn Metcalf, Branch Director, Pharmacy Guild of Australia, Western Australia Branch Lenette Mullen, President, Pharmacy Council of Western Australia Nancy Quach, Pharmacist, Yirrigan Drive-in Chemist Leona Stephens, Blood-Borne Virus and Sexual Health Project Officer, Great Southern Aboriginal Health Service This study was funded by the Sexual Health and Blood-Borne Virus Program, Department of Health, Western Australia. The authors are grateful to the staff at participating pharmacies for their time and care in facilitating the data collection and surveying respondents. The authors also thank Peter Hull at the National Centre in HIV Social Research (NCHSR) for his advice throughout the project. ii Bryant, Wilson and Treloar

6 List of tables Table 1: Demographic characteristics 7 Table 2: Where needles and syringes had been obtained in the previous month 8 Table 3: How often respondents had been to pharmacies and NSEPs to obtain injecting equipment in the previous month 8 Table 4: What respondents had usually bought at pharmacies in the previous month 8 Table 5: Knowledge about where, other than at pharmacies, injecting equipment could be obtained 9 Table 6: Main reason for using a pharmacy, among those who knew of other places to obtain sterile needles 9 Table 7: Secondary exchange in the previous month numbers of distributors and recipients, and relationship between them 10 Table 8: Proportion who had passed on various types of information to others, among those who had and had not engaged in secondary exchange in the previous month 10 Table 9: Characteristics of injecting drug use, among West Australian pharmacy clients 11 Table 10: Treatment for drug use 11 Table 11: Attachment to drug-using networks, among clients of West Australian pharmacies 12 Table 12: Attachment to drug-using networks, by various demographic, drug-use and risk-practice variables 12 Table 13: Engagement in risk practices for the transmission of blood-borne viruses reuse of another s needle and syringe, reuse of ancillary injecting equipment, and reuse of any equipment in the previous month 13 Table 14: Number of people after whom a needle and syringe was used in the previous month, and the respondent s relationship to them 14 Table 15: Engagement in practices that increase the risk of transmitting bloodborne viruses, by age, gender and place of residence 14 Table 16: Whether or not needles had been cleaned in the previous month 15 Table 17: Among those who had cleaned a needle and syringe in the previous month, after whom they had used it, and cleaning methods and substances 15 Table 18: Self-reported testing for hepatitis C, and hepatitis C status 16 Table 19: Treatment for hepatitis C 16 Table 20: Self-reported testing for HIV, and HIV status 17 Table 21: Location of most recent HIV and/or hepatitis C test, among those who had ever been tested 17 Table 22: Sexual risk practice in the previous month 18 Table 23: Knowledge about hepatitis C 18 Pharmacy Needle and Syringe Survey, Western Australia 2009 iii

7 Table 24: Perceptions of the benefits of using sterile injecting equipment and of risk for the transmission of hepatitis C 18 Table 25: Perceptions of the benefits of using sterile injecting equipment and of risk for the transmission of hepatitis C mean scores 19 Table 26: Perceptions of the benefits of using sterile injecting equipment and of risk for the transmission of hepatitis C mean scores, by various demographic, drug-use and risk-practice variables 19 iv Bryant, Wilson and Treloar

8 List of figures Figure 1: Drug most recently injected by West Australian pharmacy clients 11 Figure 2: Proportion ever tested for hepatitis C, and their hepatitis C status 16 Pharmacy Needle and Syringe Survey, Western Australia 2009 v

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10 Key findings The demographic and drug-using profiles of survey respondents who purchased sterile injecting equipment from pharmacies in Western Australia differ in important ways from existing data about injecting drug users in Western Australia that were collected from needle and syringe exchange programs (NSEPs). Clients of pharmacies appear to be younger (mean 32.4 years), with shorter injecting histories (mean 12 years) and report injecting less frequently (38.4% reported having injected daily or more frequently) and most commonly inject meth/amphetamine (58.5%). Almost three-quarters (70.1%) of respondents reported having obtained injecting equipment exclusively from pharmacies in the previous month, showing the extent to which pharmacybased injecting drug users in Western Australia are a distinct population of users. Because these users generally do not visit NSEPs, they are likely to be excluded from current surveys of those at risk for the acquisition of blood-borne viruses. Fewer than one in five pharmacy clients (16.5%) could correctly identify a place other than a pharmacy where they could obtain sterile needles. This means that most pharmacy clients did not know about other NSEPs available in Perth, despite most of them having reported that they lived in the Perth metropolitan area. More than a quarter of pharmacy clients (28.3%) reported that in the previous month they had reused a needle and syringe after somebody else had already used it, and nearly half (46.9%) reported having reused or shared at least one type of ancillary injecting equipment such as spoons, filters, tourniquets, water and/or drug solution. About half the pharmacy clients (49.4%) reported having had a recent test (in the previous 12 months) for hepatitis C. Among those who had been tested, the prevalence of hepatitis C was very low (12.2%); however, this data was selfreported so it may not be accurate. Pharmacy clients appear to be disconnected from important services that provide treatment for drug users and those with blood-borne viruses. Over half (56.1%) reported that they had never had treatment for their drug use and a quarter (25.6%) had either never been tested or were unsure if they d been tested for hepatitis C. Pharmacy clients had a high level of knowledge of how hepatitis C was transmitted, with about 80% correctly identifying that it was contracted by sharing needles and/or other injecting equipment. While pharmacy clients were generally aware of the benefits of using sterile injecting equipment, they were less confident in their ability to put that awareness into practice. They did not see themselves as highly susceptible to hepatitis C, nor did they believe it was a severe condition. Pharmacy Needle and Syringe Survey, Western Australia

11 Recommendations Given the findings of this study, we recommend the following: Consider conducting periodic surveillance of pharmacy clients by collecting data about practices that put them at risk for the acquisition of blood-borne viruses, as well as data about testing rates and hepatitis C and HIV status. Develop strategies to increase awareness among pharmacy clients of the existence and location of needle and syringe exchange programs (NSEPs) and the services they offer, including providing confidential testing for bloodborne viruses and referrals for drug treatment. Strategies to raise awareness might include disseminating information through pharmacies, perhaps by distributing printed resources, and expanding the current outreach work of NSEPs. Develop strategies to increase the uptake of treatment for drug use among pharmacy clients who need or want treatment, possibly by providing printed resources for pharmacy staff to distribute to their clients and/or by training pharmacy staff to pass on knowledge about available treatments and the process of referral. Develop strategies to increase the use of sterile ancillary injecting equipment among pharmacy clients. This may include training for pharmacy staff to promote the use of sterile ancillary equipment to their clients. Develop strategies to increase rates of testing for blood-borne viruses among pharmacy clients, possibly by providing printed resources for pharmacy staff to distribute to their clients, and/or by training pharmacy staff to provide information about where and how clients can access testing services 2 Bryant, Wilson and Treloar

12 Introduction Most of what is known about drug use and risk practices for the acquisition of bloodborne viruses (BBV) of people who inject drugs derives from those who visit needle and syringe programs to obtain injecting equipment. Australia has high-quality ongoing information about those who visit these programs from the Australian Needle and Syringe Program (NSP) Survey (NCHECR, 2009). However, we do not know, first, to what extent those who visit pharmacies are a group of users distinct from those who visit needle and syringe programs or, second, whether they have different levels of knowledge about bloodborne viruses or risk practices for the acquisition of these viruses while injecting. Western Australia (WA) has wellestablished and extensive needle and syringe distribution programs, which in 2007 dispensed more than four million sterile needles and syringes (Department of Health WA, 2009). Approximately 55% of the equipment was distributed through two fixed-site needle and syringe exchange programs (NSEPs) in the inner-city Perth area and two mobile services, one in metropolitan Perth and one in the southwest of the state (Department of Health WA, 2009). These outlets operate on the basis of one-for-one exchange whereby clients can purchase sterile needles and syringes and then return them used in exchange for new sterile equipment. NSEPs provide clients with injecting equipment, advice about safer injecting, BBV-testing services and referrals to other services, and undertake activities such as community liaison, advocacy and education. Western Australia also has secondary outlets located in non-metropolitan health service emergency departments and public health centres. Under a Department of Health directive, all rural and regional health services with an emergency department are required to provide sterile needles and syringes to clients after hours. Five of these sites distribute equipment using vending machines. About 36% of the distribution of needles and syringes in Western Australia takes place through community pharmacies (Department of Health WA, 2009). Pharmacies do not exchange equipment; rather, clients must purchase the items. A variety of pre-packaged products are available, all of which contain a number of 1 ml needles and syringes and some of which include items of ancillary injecting equipment such as sterile water ampoules, spoons, filters and swabs. The cost of these products is determined by pharmacists and generally ranges in price from six to eight dollars (Department of Health WA, 2008). Although many needles and syringes are distributed through pharmacies in Western Australia, no research has been carried out via pharmacies since 1995 when Lenton and Tan-Quigley (1997) conducted the Fitpack Study. This study recruited a sample that was young (mean 26.2 years) and reported comparatively high-risk practices, with 27.7% reporting that they had used a needle after someone else in the previous month, and 58.5% that they had shared other injecting equipment (Lenton & Tan-Quigley, 1997). However, the selfreported rates of testing for hepatitis C were high, with 64.9% saying that they had ever been tested and a quarter of those (25.2%) reporting that they were hepatitis C positive. This data was collected 14 years ago, so it is likely that important characteristics of the pharmacy-based injecting population have changed. The Australian NSP Survey indicates that the demographic and drug-using profiles of Australians who inject drugs and attend needle and syringe programs have changed in the previous ten years, with respondents getting older and having had longer injecting careers (NCHECR, 2009). The availability of drugs has also changed since the late 1990s, with the use of heroin having declined from 2000 (Topp et al., 2003). Also, the number and range of harm reduction services have increased, which is of particular relevance to Western Australia. At the time that the Fitpack Study was conducted, the majority of sterile needles and syringes in Pharmacy Needle and Syringe Survey, Western Australia

13 Introduction Western Australia were distributed through pharmacies and only one mobile NSEP was in operation, located in metropolitan Perth. This suggests that people who inject drugs in Western Australia now have improved access both to services aimed at reducing drug-related harms and information about blood-borne viruses and their transmission routes. The lack of recent information about pharmacy clients and the large distribution of needles and syringes through pharmacies means that little is known about a potentially sizeable population of injecting drug users in Western Australia. The aims of the current study were to collect data from people who obtained needles and syringes from pharmacies about their: demographic profile patterns of acquisition of needles and syringes recent drug use risk practices for the acquisition of hepatitis C and HIV rates of testing for hepatitis C and HIV and whether or not they were positive sexual risk practices knowledge about hepatitis C perceptions of the benefits of using sterile injecting equipment and of risk for the transmission of hepatitis C. 4 Bryant, Wilson and Treloar

14 Method Data collection The sampling for this project was conducted in two stages: 1) pharmacies were selected and recruited, and 2) injecting drug users were recruited. We selected pharmacies from a list of those that sold sterile needles and syringes that was provided by the Sexual Health and Blood-Borne Virus Program of the Department of Health, Western Australia. Sampling was stratified to recruit pharmacies in both metropolitan and non-metropolitan areas. Pharmacies in non-metropolitan areas were oversampled to allow us to recruit a sample size that was large enough to enable comparison with the sample recruited through pharmacies in metropolitan areas. All pharmacies were ranked based on the volume of needles and syringes distributed in Pharmacies in or above the 90th percentile were selected from metropolitan regions, and those in or above the 85th percentile from non-metropolitan regions. As compensation for their participation, pharmacists were offered a nominal fee of $50 plus $2.50 for each survey they distributed. During a single week in May 2009, pharmacy staff were asked to distribute a self-complete survey to every person buying sterile needles and syringes in their pharmacy. This method of distribution was based on a census approach whereby every person within a given time period was given an opportunity to complete the survey. Surveys could be returned to the pharmacy within the study period and exchanged for $10. The survey instrument (see Appendix) was developed in consultation with the project reference group and the staff of the Sexual Health and Blood-Borne Virus Program at the Department of Health, Western Australia. The survey collected information about: demographic profile risk behaviours for the transmission of blood-borne viruses patterns of acquisition of needles and syringes self-reported testing for hepatitis C and HIV and whether or not the respondent was positive to either sexual risk behaviours extent and method of cleaning of injecting equipment knowledge about hepatitis C perceptions of the benefits of using sterile injecting equipment and of risk for the transmission of hepatitis C. Where possible the survey used standard items such as behavioural surveillance questions from the Australian NSP Survey (NCHECR, 2009). Other validated items from the research literature were also employed, such as perceptions of BBVrelated risk (Racz et al., 2007). Data analysis Univariate analyses were conducted on some aspects of the data. Group differences were tested using the χ 2 test for categorical data and the t-test for continuous data. Response rates Fifty-two pharmacies were invited to participate, 36 in metropolitan Perth and 16 in non-metropolitan regions. In total 30 pharmacies agreed to take part, 22 from Perth and eight from other areas, resulting in a 58% overall response rate. The 30 participating pharmacies accounted for 31.8% of the total distribution of needles and syringes via pharmacies in Western Australia. Three pharmacies declined to offer the $10 incentive and instead offered a free packet of needles and syringes. The 30 participating pharmacies distributed a total of 441 surveys during a one-week data collection period and 136 surveys were returned, giving a 30.8% response rate. Due to the relatively poor response during this initial data collection period, we asked five of the highest distributing pharmacies to extend their collection for another seven Pharmacy Needle and Syringe Survey, Western Australia

15 Method days. During this period, stickers were added to the front of each survey package emphasising the $10 incentive. An additional 129 surveys were distributed and 44 returned, a response rate of 34.1%. Overall, the response rate for the entire data collection period was 31.6%. Pharmacies that offered free packets of needles and syringes achieved a response of 14.3% and those offering $10 a response rate of 34.9%. Data were cleaned and 16 cases were removed because of either too much missing data, illogical responses or their having been identified as duplicates, which left a total of 164 valid surveys. The smaller-than-expected sample size meant that we were unable to compare data on some key characteristics. In particular, despite oversampling in nonmetropolitan regions, we were unable to compare groups based on place of residence (i.e. metropolitan or major city versus regional or remote). 6 Bryant, Wilson and Treloar

16 Findings Demographic profile The average age of respondents was 32.4 years (see Table 1), which is a younger average age than that reported by West Australian respondents to the Australian NSP Survey (median age 35 years [NCHECR, 2009]). About two-thirds of the sample were male (64%, n = 105), a similar proportion to that reported in the Australian NSP Survey. Most respondents were heterosexual (82.3%, n = 135), employed either part or full time (39%, n = 64) and lived in a family environment either with a partner (34.8%, n = 57) or parents or other relatives (12.2%, n = 20). Very few of the respondents (6.1%, n = 10) reported living outside of metropolitan Perth (see Table 1). Patterns of acquisition of sterile needles and syringes Acquisition from a pharmacy While all respondents had to have visited a pharmacy to receive the survey, most (90.2%, n = 148) reported having visited a pharmacy at another time during the previous month (see Table 2, page 8). The frequency of visits to a pharmacy was not high, with over half the respondents (54.9%, n = 90) saying that they had visited a pharmacy for sterile needles less often than weekly (see Table 3). The most common products purchased from pharmacies were packages of five needles and syringes (65.9%, n = 108), followed by packages that included three needles and syringes and a selection of ancillary items (15.9%, n = 26) (see Table 4). Other products were not commonly purchased, nor were items such as single needles, single water ampoules, spoons and so forth (see Table 4). Acquisition from a needle and syringe exchange program Only a small proportion of respondents (12.2%, n = 20) reported having visited an NSEP in the previous month (see Table 1: Demographic characteristics Number of sites 30 Response rate 31.6% Number surveyed 164 Age mean 32.4 range not reported Gender male female transgender not reported Sexual identity heterosexual gay/lesbian/bisexual other not reported Aboriginality Aboriginal or Torres Strait Islander other not reported Place of residence* major city not major city not reported Place of birth Australia other not reported Main language spoken English other not reported Employment status employed full or part time unemployed student pensioner/dole recipient other not reported Housing: currently living alone with partner (including kids) with kids with parents/relatives with friends/flatmates not reported *Calculated using Australian Bureau of Statistics standard geographical classification codes: major city includes metropolitan Perth; not major city includes inner regional, outer regional, remote and very remote regions. Pharmacy Needle and Syringe Survey, Western Australia

17 Findings Table 2). Indeed 70.1% (n = 115) of respondents reported having exclusively attended pharmacies (see Table 3). This shows the extent to which injecting drug users who obtain sterile needles from pharmacies in Western Australia are distinct from those who obtain them primarily from NSEPs. It also shows to what degree they are likely to be excluded from current surveillance mechanisms that recruit samples from NSEPs, such as the Australian NSP Survey (NCHECR, 2009) or the Illicit Drug Reporting System (Black et al., 2007). The exclusion of pharmacy clients from established surveillance systems means that little or nothing is known about them and their risk practices for the transmission of blood-borne viruses, their rates of testing or hepatitis C or HIV status. International experience shows that, without adequate monitoring and appropriate intervention, the incidence of blood-borne virus infections can increase rapidly among such populations. While this more often happens in resource-poor environments (Rhodes et al., 2002; Taha et al., 1998; Weniger et al., 1991), it can also occur in well-resourced areas. A notable example was the experience among injecting drug users in Vancouver, Canada, where the prevalence of HIV infection jumped from about 2% in the late 1980s (Strathdee et al., 1997) to about 30% by the late 1990s (O Connell et al., 2005; Hogg et al., 2005). This rapid increase occurred despite the early introduction of an NSEP (Strathdee et al., 1997) and demonstrates the value of adequate monitoring and appropriate intervention even in well-resourced settings. Recommendation: Consider conducting periodic surveillance of pharmacy clients by collecting data about practices that put them at risk for the acquisition of bloodborne viruses, as well as data about testing rates and hepatitis C and HIV status. Table 2: Where needles and syringes had been obtained in the previous month Number surveyed 164 Pharmacy Friends/Partner Dealer Needle and syringe exchange program Public health unit/community health centre Vending machine Hospital *Respondents could choose more than one option. Table 3: How often respondents had been to pharmacies and NSEPs to obtain injecting equipment in the previous month Number surveyed 164 Obtained equipment from a pharmacy not in the previous month once in the previous month less often than weekly a couple of times each week daily or almost daily not reported Exclusive use of pharmacy Median number of visits to a pharmacy (IQR*) Obtained equipment from an NSEP not in the previous month once in the previous month less often than weekly a couple of times each week daily or almost daily not reported Exclusive use of an NSEP Median visits to an NSEP (IQR) *IQR = interquartile range Table 4: What respondents had usually bought at pharmacies in the previous month Number surveyed 164 Product five needles and syringes three needles and syringes plus a selection of ancillary items single needle and syringe single water ampoule, spoon, alcohol swab, cotton balls five needles and syringes plus a selection of ancillary items three needles and syringes plus the complete range of ancillary items no usual pattern not reported Bryant, Wilson and Treloar

18 Findings Knowledge about other sources of injecting equipment, and reasons for using pharmacies A third of respondents (32.3%, n = 53) said that they knew of places other than pharmacies where they could obtain sterile needles and syringes. However, when asked to specifically name these places, only half (16.5%; n = 27) of those who reported knowing of other places could actually do so (see Table 5). This suggests that most pharmacy clients (83.5%) did not know about needle and syringe distribution services such as permanent or mobile NSEPs. Considering that most respondents lived in metropolitan Perth (see Table 1), it is possible that some would use these services if they knew about them. Table 5: Knowledge about where, other than at pharmacies, injecting equipment could be obtained Number surveyed 164 Respondents who knew of places other than pharmacies to obtain sterile needles Respondents who correctly identified that sterile needles could be obtained at a: fixed-site NSEP NSEP van hospital Total Raising awareness of the existence of NSEPs is important and would be most successfully achieved using a mix of strategies. These might include a) disseminating information about NSEPs through pharmacies, or b) increasing the outreach work of NSEPs. Disseminating brief printed resources such as leaflets or flyers at pharmacies is an immediate and straightforward way of raising awareness among pharmacy clients. However, any strategy implemented through pharmacies requires a lowimpact approach that preserves the quick transaction that attracts pharmacy clients to pharmacies. Data from this study show that respondents chose pharmacies over other providers of equipment primarily because they were easy to get to (45.3%, n = 24) but also because they were convenient (11.3%, n = 6) and discrete (11.3%, n = 6) (see Table 6). This is supported by other research (Treloar et al., in press). Increasing the outreach work of NSEPs could include having a larger number of mobile services and/or services that engaged peers and utilised existing networks, such as that described in the following section. Outreach programs have the added benefit that trained staff are available to conduct interventions with clients, something that pharmacy staff may not be trained to do. Whichever approach is used, increased contact with NSEPs might also lead more pharmacy clients who are currently disengaged from important treatment services to be referred for testing for blood-borne viruses and to take up treatment for drug use and/or hepatitis C. Recommendation: Develop strategies to increase awareness among pharmacy clients of the existence and location of needle and syringe exchange programs (NSEPs) and the services they offer, including providing confidential testing for blood-borne viruses and referrals for drug treatment. Strategies to raise awareness might include disseminating information through pharmacies, perhaps by distributing printed resources, and expanding the current outreach work of NSEPs. Table 6: Main reason for using a pharmacy, among those who knew of other places to obtain sterile needles Number surveyed who knew of places other than pharmacies to obtain sterile needles 53 Main reason easy to get to discrete convenient opening hours anonymous good service other not reported Secondary exchange A large proportion of respondents reported having received sterile needles from friends, partners (29.3%, n = 48) or dealers (20.7%, n = 34) in the previous month (see Table 2). Likewise, almost half (42.7%, n = 70) reported having passed on sterile needles to others, most of whom (85.7%, n = 60) were friends (see Table 7). This is known as secondary exchange. The 70 respondents who said they had passed on sterile needles to others reported that they had supplied a total of 450 other people (see Table 7), or about six people each. Similar data collected from pharmacy clients in New South Wales indicates that respondents who passed on sterile needles to others gave needles to an average of four people each (unpublished NCHSR data). This suggests that, as among pharmacy clients in New South Wales, pharmacy clients in Western Australia do not distribute equipment to large networks of other people who inject drugs. Pharmacy Needle and Syringe Survey, Western Australia

19 Findings Table 7: Secondary exchange in the previous month numbers of distributors and recipients, and relationship between them Number surveyed 164 Respondents who distributed sterile needles and syringes Total number of recipients 450 Relationship to recipient* friend partner dealer/customer other not reported *Respondents could choose more than one option. Secondary exchange has been identified as a useful mechanism through which to reach injecting drug users who have little or no contact with formal harm reduction services (Irwin et al., 2006; Sears et al., 2001). Since almost half the respondents in this study passed on sterile equipment, this practice could be capitalised on to reach hidden injecting drug users. A secondary exchange program in California uses a group of peer distributors to dispense the bulk of its needles and syringes, an estimated 435,000 per year. The distributors are coordinated and trained by three paid staff (Anderson et al., 2003). These sorts of programs are low cost and have extensive geographic reach, but there are barriers to their adoption from the policy and legal points of view. For example, while approved distributors such as pharmacists and staff of NSEPs have legislative protection to distribute needles and syringes for the purposes of injecting illegal drugs, this does not extend to peers (Lenton et al., 2006). Service providers must also consider how a secondary exchange program might be viewed by the public, and how public disapproval could potentially undermine the vulnerable community support for harm reduction services such as NSEPs (Lenton et al., 2006). A critical aspect of effective secondary exchange is that drug users who pass on equipment to their peers also pass on information. However, the pharmacy clients in our study who engaged in secondary exchange were no more or less likely than those who did not to pass on information about safe injecting, hepatitis C and the availability of health services (see Table 8). Drug use Pharmacy clients reported that they had been injecting for an average of 12 years (see Table 9), with their average age at first injection 20.3 years. Most commonly respondents reported that their first injection had taken place in a private setting such as a friend s home (43.3%, n = 71), their own home (29.3%, n = 48) or a dealer s home (8.5%, n = 14) and only small proportions reported having injected for the first time in a public space such as a street, park or beach (4.9%, n = 8) or car (1.8%, n = 3). The drug most commonly recently injected was meth/ amphetamine (by 58.5%, n = 96) followed by heroin (30.5%, n = 50) (see Table 9 and Figure 1). Pharmacy clients reported injecting relatively infrequently, with a little over a third (38.4%, n = 63) saying they injected daily or more frequently (see Table 9). Almost half the respondents (47.6%, n = 78) reported having injected in public in the previous month (see Table 9), the most common public places being a car (38.4%, n = 63) and/ or a street, park or beach (29.3%, n = 48). However, Table 8: Proportion who had passed on various types of information to others, among those who had and had not engaged in secondary exchange in the previous month Distributed needles and syringes Did not distribute needles and syringes Number surveyed Respondents who have told others: where to get injecting equipment how to inject safely how to prevent overdoses where to see a doctor who is friendly to drug users where to get tested for hepatitis C how to get treatment for drug use how to get treatment for hepatitis C where to get information about hepatitis C and injecting Note: Comparisons between distributors and non-distributors were made using the 2 test. No comparisons were significant. 10 Bryant, Wilson and Treloar

20 Findings respondents more commonly reported having injected in private settings in the previous month, including in their own home (72%, n = 118), a friend s home (53%, n = 87) or a dealer s home (32.2%, n = 53). This is a profile of drug use that differs in important ways from that of West Australian respondents to the Australian NSP Survey. In 2008 respondents who attended NSPs in Western Australia reported an average injecting history of 15 years and were most commonly heroin users (32%), with meth/amphetamine having been recently injected by 28% (NCHECR, 2009). Moreover, 63% of these respondents reported having injected daily or more frequently (NCHECR, 2009). Overall, this suggests that pharmacy clients inject less frequently, more commonly inject meth/ amphetamine and have shorter injecting histories. Meth/ amphetamine 58.9% Cocaine 4.3% Other 1.2% Heroin 30.7% Morphine 3.7% Methadone 1.2% Table 9: Characteristics of injecting drug use, among West Australian pharmacy clients Number surveyed 164 Duration of injecting (years) mean 12 range 0 38 not reported Most recent drug injected meth/amphetamine heroin cocaine morphine methadone anabolic steroids buprenorphine/subutex Other not reported Frequency of injecting more than 3 times most days to 3 times most days once a day more often than weekly but not daily less often than weekly not in the previous month not reported Those who injected daily or more frequently Any public injecting yes no not reported Figure 1: Drug most recently injected by West Australian pharmacy clients Treatment for drug use Over half the respondents (56.1%, n = 92) reported that they had never had treatment for their drug use (see Table 10), a higher proportion than the 28% of West Australian respondents to the NSP Survey who had never received drug treatment (NCHECR, 2009). Part of this difference may be that pharmacy clients had shorter injecting histories, injected less frequently (see Table 9) and were younger (see Table 1). It may also be that some pharmacy clients did not need or want treatment. However, the findings of this study suggest that those who do need or want treatment may not be well connected to services, thereby making access to treatment more difficult. While it is an important feature of NSEPs to provide and encourage referral to treatment, pharmacists and their staff do not have formal mechanisms for doing this and may not know how to advise clients if asked. Table 10: Treatment for drug use Number surveyed 164 Treatment for drug use yes, currently yes, in the past no, never not reported Type of treatment received (n = 64)* methadone detoxification, rehabilitation, counselling, Narcotics Anonymous naltrexone, buprenorphine, LAAM** * Respondents could choose more than one option. ** LAAM = levo-alpha acetyl methadol Pharmacy Needle and Syringe Survey, Western Australia

21 Findings Improving rates of treatment for drug use among pharmacy clients who need or want it may be achieved by improving awareness of NSEPs, as previously recommended. If pharmacy clients increasingly attended such programs they would have greater access to information about drug therapy and how to avail themselves of it. An equally important approach might be to provide pharmacy staff with accurate information to pass on to their clients about how and where to access drug treatment. Printed resources could be provided for pharmacy staff to distribute to clients, but it would also be valuable to train pharmacy staff, using existing workforce development programs, to increase their knowledge about treatments available to drug users. An added benefit of such training might be that more pharmacists would be willing to administer drug treatment themselves through pharmacybased dosing with pharmacotherapy. Recommendation: Develop strategies to increase the uptake of treatment for drug use among pharmacy clients who need or want treatment, possibly by providing printed resources for pharmacy staff to distribute to their clients and/or by training pharmacy staff to pass on knowledge about available treatments and the process of referral. Attachment to drug-using networks Two questions were included in the survey to measure respondents degree of attachment to networks of other users. Respondents were asked how many of their friends injected drugs and how much of their time was spent with people who injected. Most respondents (47%, n = 68) reported that none or a few of their friends injected, with fewer reporting that some injected (14.6%, n = 24) or most or all injected (28.7%, n = 47). Similarly most respondents (45.1%, n = 74) reported that none or a little of their free time was spent with people who injected, with fewer reporting that they spent some of their time (25%, n = 41) or most or all of their time (25%, n = 41) with other injecting drug users. Participants responses were used to calculate a scale ranging from zero to 16. Respondents with low attachment scored between zero and five, those with medium attachment scored from six to 10, and those with high attachment 11 to 16. Most respondents (66.5%, n = 109) reported having low attachment and only a very small proportion (4.9%, n = 8) high attachment to drugusing networks (see Table 11). This corresponds with other data collected in this survey which indicate that those who distribute sterile equipment to other drug users have small networks of about six people. Comparing those with low attachment to those with medium attachment suggests that respondents with low attachment may be more commonly female, engage in less frequent injecting and be less likely to reuse needles already used by someone else (see Table 12). Table 11: Attachment to drug-using networks, among clients of West Australian pharmacies Number surveyed 164 Low attachment Medium attachment High attachment Table 12: Attachment to drug-using networks, by various demographic, drug-use and risk-practice variables Low attachment Medium attachment High attachment Number surveyed Age (mean, SD) Female Heterosexual Engaged in daily or more frequent injecting Reused someone else's needle and syringe Reused ancillary equipment Reused any equipment Note: The sample sizes in some categories are small and percentages should be interpreted cautiously. For this reason p-values are not calculated. 12 Bryant, Wilson and Treloar

22 Findings Engagement in risk practices for the transmission of blood-borne viruses Of respondents who had injected in the previous month (n = 145), over a quarter (28.3%, n = 41) said that they had reused a needle after somebody else had already used it (see Table 13) and almost half (46.9%, n = 68) reported having reused or shared at least one type of ancillary injecting equipment, such as spoons, filters, tourniquets, water and/or drug solution (see Table 13). Nearly a quarter of all respondents (24.4%, n = 40) reported that someone had injected them in the previous month after injecting themselves or others. This is a risk profile that differs in important ways from that of respondents to the Australian NSP Survey. In 2008, 19% of West Australian NSP Survey respondents reported having reused a needle and syringe after somebody else and 39% reported having reused or shared ancillary equipment (NCHECR, 2009). This suggests that a greater proportion of pharmacy clients than NSP clients engaged in injecting practices that put them at risk for the transmission of blood-borne viruses. Almost half the respondents (46.9%, n = 68) reported having reused or shared at least one type of ancillary injecting equipment in the previous month (see Table 13). Evidence from the United States supports that sharing ancillary equipment poses a risk for hepatitis C transmission and suggests that sharing of some types of ancillary equipment can pose a higher risk than sharing needles (Hagan et al., 2006; Thorpe et al., 2002). A three-year prospective cohort study in Chicago found that sharing cookers (containers used to mix and heat drugs) and water were predictive of hepatitis C seroconversion even when sharing needles and syringes was accounted for (Thorpe et al., 2002). While we do not know whether this evidence can be extrapolated to Australia where drug preparation practices are different, any attempt to Table 13: Engagement in risk practices for the transmission of blood-borne viruses reuse of another s needle and syringe, reuse of ancillary injecting equipment, and reuse of any equipment in the previous month Number surveyed who had injected in the previous month 145 Had respondent used another's needle and syringe? yes no not reported How often had respondent used another's needle and syringe? more than 5 times to 5 times twice once never not reported Had respondent reused another s ancillary equipment? yes no not reported Which ancillary equipment had been reused? water spoon filter drug solution/mix tourniquet not reported Had respondent reused any equipment (needle and syringe and/or ancillary equipment)? yes no not reported Pharmacy Needle and Syringe Survey, Western Australia

23 Findings moderate the incidence of hepatitis C transmission should consider the role of ancillary injecting equipment. Increasing the use of sterile ancillary equipment by pharmacy clients is challenging, especially because, as other data from this survey show, most respondents know that sharing ancillary injecting equipment is a risk for hepatitis C transmission (see Table 23, page 18). However, respondents did not buy (see Table 4) or use (see Table 13) sterile ancillary equipment to the extent necessary to reduce risk. It is important to consider how to increase the sales and use of sterile ancillary injecting equipment. While staff of NSEPs would be aware of the importance of its use, staff of pharmacies may be less so. Training pharmacy staff through existing workforce development programs could raise this awareness and provide them with strategies to encourage clients to buy and use sterile ancillary injecting products. Recommendation: Develop strategies to increase the use of sterile ancillary injecting equipment among pharmacy clients. This may include training for pharmacy staff to promote the use of sterile ancillary equipment to their clients. Of respondents who had reused another s needle and syringe, most had done so after only one other person (41.5%, n = 17), usually a friend (29.3%, n = 12) or Table 14: Number of people after whom a needle and syringe was used in the previous month, and the respondent s relationship to them Number surveyed who reused another s needle and syringe in the previous month 41 Number of people after whom the needle and syringe was used more than 5 people to 5 people people one person don't know how many not reported Relationship to people after whom needle and syringe was used* regular sex partner casual sex partner close friend acquaintance other *Respondents could choose more than one option. Table 15: Engagement in practices that increase the risk of transmitting blood-borne viruses, by age, gender and place of residence < 30 n (%) Age Gender Place of residence 1 30 n (%) Male n (%) Female n (%) Major city n (%) Not major city 2 n (%) Number surveyed who had injected in the previous month Had respondent reused another's needle and syringe? Yes 22 (32.8) 18 (24.0) 29 (30.9) 10 (20.4) 39 (30.0) 0 (0.0) No 44 (65.7) 57 (76.0) 64 (68.1) 39 (79.6) 90 (69.2) 8 (100.0) not reported 1 (1.5) 0 (0.0) 1 (1.1) 0 (0.0) 1 (0.8) 0 (0.0) Had respondent reused ancillary equipment? Yes 38 (56.7)* 29 (38.7)* 47 (50.0) 19 (38.8) 59 (45.4) 3 (37.5) No 28 (41.8) 46 (61.3) 46 (48.9) 30 (61.2) 70 (52.8) 5 (62.5) not reported 1 (1.5) 0 (0.0) 1 (1.1) 0 (0.0) 1 (0.8) 0 (0.0) Had respondent reused any equipment? Yes 36 (53.7)* 26 (34.7)* 44 (46.8) 17 (34.7) 56 (43.1) 1 (12.5) No 30 (44.8) 49 (65.3) 46 (52.1) 32 (65.3) 73 (56.2) 7 (87.5) not reported 1 (1.5) 0 (0.0) 1 (1.1) 0 (0.0) 1 (0.8) 0 (0.0) 1 Calculated using Australian Bureau of Statistics standard geographical classification codes: major city includes metropolitan Perth; not major city includes inner regional, outer regional, remote and very remote regions. 2 Sample size in this category is small and percentages should be interpreted cautiously. For this reason p-values are not calculated. *p < Bryant, Wilson and Treloar

24 Findings regular sex partner (29.3%, n = 12) (see Table 14). This supports the notion that people who inject drugs usually share needles with a small number of people close to them. Previous research suggests that injecting drug users choose to share with people they know well because they believe this will reduce their risk of acquiring a bloodborne virus (Loxley & Ovenden, 1995; Loxley & Davidson, 1998; Rhodes et al., 1998). However, judgments about how safe it is to share needles with another person are usually based on how clean they look (Loxley & Ovenden, 1995) or how much the other person is trusted and loved (Rhodes et al., 1998; Dear, 1995) rather than on any forthright discussion of serostatus. Data from this survey show that about half the pharmacy clients either had not recently been tested or had not been tested at all (see next section), meaning that many did not know their current serostatus in relation to blood-borne viruses; this makes a discussion of serostatus impossible. Thus, even though needle sharing among pharmacy clients usually takes place with a small number of well-known others, it likely carries a high risk for the transmission of a blood-borne virus. The receptive sharing of needles and syringes was not significantly different whether or not it occurred between younger (< 30 years) or older ( 30 years) respondents (see Table 15). However, younger respondents were significantly more likely than older respondents to report that they had reused or shared ancillary injecting equipment (56.7% versus 38.7%, p <.05) (see Table 15). This finding underscores the importance of increasing the distribution of sterile ancillary injecting equipment, particularly to more vulnerable populations such as young people who may have less experience and knowledge of safer injecting practices. Cleaning needles and syringes Over half the pharmacy clients who had injected in the previous month (52.4%, n = 76) reported that they had cleaned a needle and syringe in the previous month (see Table 16). Similarly 47% of West Australian respondents to the Australian NSP Survey reported having cleaned needles (NCHECR, 2009). Among those pharmacy clients who had cleaned needles, water was the most common substance used, usually cold water (40.8%, n = 31) but also hot water (31.6%, n = 24) or boiling water (26.3%, n = 20) (see Table 17). Bleach was also used by some respondents (18.4%, n = 14). Most respondents reported having cleaned their needles by rinsing and/or flushing multiple times (73.7%, n = 56). Cleaned needles were most commonly used two to five times before being discarded (50%, n = 38) (see Table 17). Table 16: Whether or not needles had been cleaned in the previous month Number who had injected in the previous month 145 Had the respondent cleaned a needle and syringe? yes no not reported Table 17: Among those who had cleaned a needle and syringe in the previous month, after whom they had used it, and cleaning methods and substances Number who had cleaned a needle and syringe in the previous month 76 Person who had previously used needle and syringe me only me and someone else someone else not reported What had it been cleaned with? cold water hot water boiling water bleach swabs soap/detergent other not reported How had it been cleaned? rinsed/flushed more than once wiped rinsed/flushed once soaked other not reported Usual number of times needle and syringe had been cleaned and reused before it was replaced none once to 5 times to 10 times more than 10 times not reported Pharmacy Needle and Syringe Survey, Western Australia