Hepatitis C Action Plan Prevention Working Group Findings and recommendations

1. Hepatitis C Action PlanPrevention Working GroupFindings and recommendations Norah PalmateerHealth Protection Scotland Greater Glasgow & Clyde MCN June 11th, 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. EVIDENCE 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)

5. EVIDENCE 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)

6. EVIDENCE 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)

7. ISSUE 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

8. RECOMMENDATIONS • Improved access to needle exchange • Prevention networks should be established • Standards/guidelines on HCV Prevention Services should be developed • 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. ACTIONS

9. EVIDENCE 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)

10. EVIDENCE 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 (Source: Hutchinson et al., 2002)

11. EVIDENCE 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)

12. ISSUE 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

13. RECOMMENDATIONS • Increase access/uptake/coverage of injection equipment • Access to needle identifiers ACTIONS • 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: • Quantity (increasing access and uptake of equipment through innovative, including outreach, approaches) • Quality (e.g. the colour coding of equipment to avoid sharing) and, • Nature (e.g. the provision of equipment other than needles/syringes)

14. EVIDENCE 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)

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

16. ACTIONS • 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.

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