1. Hepatitis C Action Plan Prevention Working Group Findings and recommendations Norah Palmateer Health Protection Scotland Greater Glasgow & Clyde MCN June 11 th, 2008

2. Scope, Objectives, and Approach of the Working Group Scope: –Injecting drug users (IDUs) –Provision of injection equipment Objectives: –To examine The effectiveness of injection equipment provision The current provision of injection equipment in Scotland Existing policy on injection equipment provision Approach: –Systematic reviews of the scientific literature –Reviews of existing reports

3. Format of this presentation Evidence Issue Recommendations Actions

4. Distribution of needles/syringes by Drug Action Team Numbers of N/S per IDU per year per DAT area ranges from 57 to 479 (Source: National Needle Exchange Survey) EVIDENCE

5. Distribution of other injection equipment by NHS Board Major variations in any access to injection equipment other than needle/syringes exist across Scotland (Source: National Needle Exchange Survey) EVIDENCE

6. Other evidence Most injection equipment facilities do not provide evening or weekend service; only one is open 24/7 Adherence to guidelines on numbers of needles/syringes to be distributed is inconsistent (Source: National Needle Exchange Survey) There is a direct relationship between injection equipment sharing and poorer access (distance) to needle exchange (Source: Hutchinson et al., 2000) EVIDENCE

7. Issue 1 Widespread variations in the provision and uptake of injection equipment exist throughout Scotland Many NHS Boards do not have formal networks to facilitate the prevention of Hepatitis C Comprehensive National Guidelines for services providing injection equipment do not exist ISSUE

8.  Action 13: Each NHS Board will have, or be affiliated to, a Network covering the Prevention of Hepatitis C and comprising representatives of all stakeholder sectors. Guidance regarding Network membership and Terms of Reference will be established. Each NHS board will identify a Hepatitis C Prevention Lead.  Action 14: National Guidelines for services providing injection equipment to IDUs will be developed. A Guideline Development Group will be established. RECOMMENDATIONS ACTIONS  Improved access to needle exchange  Prevention networks should be established  Standards/guidelines on HCV Prevention Services should be developed

9. Review of the international literature No definitive evidence of needle exchange having an impact on HCV transmission among IDUs –But absence of evidence ≠ absence of effect –Few robust studies have been undertaken Evidence that needle exchange reduces needle/syringe sharing (Source: Palmateer et al., 2008) EVIDENCE

10. Evidence from Scotland Studies provide evidence that harm reduction measures led to considerable reduction in HCV transmission among IDUs An estimated 4500 HCV infections were potentially prevented in Glasgow during 1988-2000 as a result of harm reduction EVIDENCE (Source: Hutchinson et al., 2002)

11. But… Injecting risk behaviour persists –Around 30% of IDUs in Scotland report having injected with a used needle/syringe during the previous month –Around 40% of IDUs in Scotland report having injected with other used injection equipment in the last month (Source: Scottish Drugs Misuse Database) Storage of needles/syringes by IDUs for re-use is common, which could result in the inadvertent sharing of such equipment Source (Taylor et al., 2004) Glasgow IDUs: 20-30 infections per 100 person years of injecting (Source: Roy et al., 2007) An estimated 1000-1500 IDUs in Scotland are infected annually (Source: Hutchinson et al., 2006) EVIDENCE

12. Issue 2 The re-use/sharing of injection equipment among IDUs is still highly prevalent and Hepatitis C transmission among IDUs throughout Scotland is still very common ISSUE

13.  Increase access/uptake/coverage of injection equipment  Access to needle identifiers Action 15: Services providing injection equipment (needles/syringes and other injection paraphernalia) will be improved in accordance with the Guidelines referred to in Action 14. Improvements will be made in terms of: i.Quantity (increasing access and uptake of equipment through innovative, including outreach, approaches) ii.Quality (e.g. the colour coding of equipment to avoid sharing) and, iii.Nature (e.g. the provision of equipment other than needles/syringes) RECOMMENDATIONS ACTIONS

14. HCV in prison It is estimated that between 200 and 300 inmates inject drugs in prison at least once per month (Source: 2007 Prisoner Survey) Inmates who inject drugs in prison usually do so with unsterile injecting equipment (Source: Taylor et al., 1996) Evidence of HCV transmission in prison: –Shotts prison study: 12 cases per 100 person-years of incarceration among IDUs (Source: Champion et al., 2004) Needle exchanges in prisons have been implemented in some European countries –Evaluations have demonstrated acceptability among inmates/staff and showed a reduction in needle/syringe sharing (Source: Palmateer et al., 2008) EVIDENCE

15. Issue 3 IDUs who continue to inject drugs in prison do not have access to injection equipment in that setting ISSUE

16. Action 17: An in-prison needle/syringe exchange initiative will be piloted as one of a range of harm reduction measures to reduce the transmission of Hepatitis C in prison. ACTIONS

17. Summary of actions Affiliation with a network covering the prevention of Hepatitis C Development of National Guidelines for services providing injection equipment Improvement of services providing injection equipment in terms of quantity, quality, and nature Pilot of in-prison needle exchange

18. Acknowledgements Members of the Prevention Working Group