Chapter 9: Needle and syringe programs: aims, benefits and how to set up a program

• Needle and syringe programs (NSPs) provide a range of services and have many health and cost benefits for individuals, communities and health services. For instance, they:
  • provide information and equipment to encourage safe injecting
  • reduce harm associated with injections for people who inject drugs (PWID), and their families
  • reduce the transmission of human immunodeficiency virus (HIV), hepatitis B and C
  • provide referral to other treatment and support services.
• NSPs should aim to provide a friendly, safe environment and one that is culturally appropriate, free of judgement and discrimination, accessible and acceptable to PWID.
• NSPs are provided through a variety of services using different models of service delivery.
• The process of setting up an NSP involves strong engagement with communities and various organisations which in itself provides opportunities to give information, address misinformation and assumptions, promote the benefits of NSPs, and develop partnerships.
• Information and support regarding what steps are involved in setting up NSPs is provided through the Department of Health's website and the Sexual Health and Blood-borne Virus Program (SHBBVP).

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NSPs are supported and recommended by the national drug, HIV and hepatitis C strategies as well as the national and WA Aboriginal blood-borne virus and sexually transmissible infections strategies as a key public health measure to prevent transmission of blood-borne viruses (BBVs) among PWID.

The National Drug Strategy 2017–2026 (the National Drug Strategy) advocates a balanced approach to the three principles of harm minimisation that are central to the strategy. The three principles are:

• demand reduction: preventing the uptake of, or delaying the onset of, use of alcohol, tobacco and other drugs; reducing the misuse of alcohol, tobacco and other drugs in the community; and supporting people to recover from dependence through evidence-informed treatment
• supply reduction: preventing, stopping, disrupting or otherwise reducing the production and supply of illegal drugs; and controlling, managing or regulating the availability of legal drugs
• harm reduction: reducing the adverse health, social and economic consequences of the use of drugs, for the user, their families and the wider community.

The National Drug Strategy also emphasises the importance of the following factors underpinning those strategic principles:

• partnerships
• coordination and collaboration
• national direction, jurisdictional implementation
• evidence-informed responses.

While the National Drug Strategy does not condone drug use, it acknowledges the occurrence of injecting drug use and recognises the importance of preventing and minimising the associated health, social, cultural and economic harm among individuals, families and communities in order to build safe, healthy and resilient communities.

The key aims of NSPs are to:

• reduce the transmission of HIV, hepatitis B and C
• minimise related harm for individuals and communities
• encourage safer injecting by providing education and access to clean needles, clean injecting equipment and safe disposal containers.

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NSPs not only reduce harm for PWID but have many health and cost benefits for individuals, communities and health services, such as those associated with reducing the transmission of HIV and hepatitis C. In Australia, between 2000 and 2009 it was estimated that 32,050 HIV and 96,667 hepatitis C infections were avoided due to the availability of NSPs, saving $1.28 billion in national healthcare costs. For every dollar spent on NSPs, an estimated $4 is saved.

NSPs aim to provide a non-judgemental and friendly environment and have many benefits for individuals and communities. These programs:

• provide clean needles, syringes and other equipment to encourage and enable safer injecting and disposal of used needles and syringes
• reduce the incidence of sharing and reusing injecting equipment
• prevent the ongoing transmission of BBVs, such as HIV, hepatitis B and hepatitis C
• provide information to PWID on safer injecting
• reduce health harms, such as infections associated with injecting, and other drug-related harms
• provide friendly, safe spaces for PWID which also enable social connectedness
• provide a point of contact with health services for people who may be vulnerable or marginalised
• promote health-seeking behaviour
• enable access to testing and treatment of sexually transmitted infections (STIs) and BBVs, such as HIV and hepatitis C
• enable brief intervention and referral to support services, such as counselling, mental health, drug and alcohol, legal and social services
• enable partnerships between communities, drug treatment, education and other services to reduce drug-related harms
• improve the community’s understanding and knowledge to reduce stigma 

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PWID cover the spectrum of society and include occasional through to dependent users. Nevertheless, there are higher rates of injecting drug use among people who have a history of trauma, mental health issues or incarceration. These factors can make people more vulnerable to injecting drug use or may occur as a consequence of their drug use. Already marginalised groups, such as Aboriginal people, may face additional stigma if they inject drugs, particularly if they live in small communities where their choice of services may be limited or where maintaining their privacy may be more difficult.

Reducing barriers and enabling access to services as outlined in Chapter 1 are particularly important for NSPs and their clients. Services should ensure a friendly, safe environment and one that is culturally appropriate, free of judgement and discrimination, and accessible and acceptable to the client group.

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NSPs can be delivered in different ways. The SHBBVP coordinates NSPs statewide, guides health service providers, and specifies requirements for setting up and delivering the programs. Links to relevant policy documents are provided in this chapter. The different types of NSPs dictate different service delivery methods. For instance, NSPs based in the health service provide sterile injecting equipment in the form of packaged kits, including a safe disposal receptacle, but services are not dependent on the return of used equipment. On the other hand, needle and syringe exchange programs (NSEP) exchange free equipment on a one-to-one basis upon return of used equipment, or in some instances, at a cost if no used equipment is returned.

NSPs operate through different services and locations throughout WA and use different models. A shared practice however is to distribute needles and syringes along with disposal receptacles and information on safe disposal. The four main models of NSP provision are:

• NSEPs
• NSPs
• pharmacy-based NSPs
• needle and syringe vending and dispensing machines.

Access to NSPs in regional and remote areas is limited, highlighting the importance of ensuring access through pharmacies and hospitals. Community pharmacies are not mandated to sell needles and syringes, but most do. All regional and rural hospitals that provide emergency after hours services are required to ensure access to sterile needles and syringes to PWID after hours, and provide 24-hour access if there is no local pharmacy.

Access is generally provided through emergency departments. Additionally, health service staff should provide information to PWID as required, especially the availability of treatment services for drug and alcohol dependency and hepatitis C. A range of products are available through the NSPs. More information is available within the NSP online orientation and training package at: https://aodelearning.mhc.wa.gov.au/

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Obtaining approval for an NSP is not a difficult process, and the SHBBVP can assist with the steps required and completing the application form. The SHBBVP can guide and assist the NSP coordinator with an information pack, and ongoing support and training as needed. More information can be found on the websites below or by contacting the SHBBVP.

Setting up an NSP involves:

• effective engagement with PWID agencies that work in the sector, relevant health services, organisations and the community
• applying for approval through the SHBBVP
• completing the following steps:
  • nominate an NSP coordinator (see the link below for who can be an NSP coordinator and the duties of the position)
  • fill out an application form
  • develop guidelines to establish and operate an NSP (contact the SHBBVP for assistance)
  • submit these documents to the SHBBVP.

https://ww2.health.wa.gov.au/Articles/F_I/How-to-obtain-a-needle-and-syringe-program-NSP-approval

http://ww2.health.wa.gov.au/Articles/F_I/Information-for-needle-and-syringe-program-NSP-providers

For more details, contact the SHBBVP, Department of Health, Western Australia. Phone: 9222 2355. Email: NSP@health.wa.gov.au

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Setting up an NSP requires effective engagement with PWID as well as local health and community services, the SHBBVP and community members. While community engagement can take some time, the SHBBVP can provide assistance and support with this process. Client satisfaction surveys conducted by NSPs provide information that may be useful as a starting point. Depending on the location and available services in the area, representatives of the following programs and organisations may be helpful:

• client advocacy groups, such as Peer Based Harm Reduction WA
• boards of Aboriginal Community Controlled Health Services (ACCHS)
• regional public health units (PHUs)
• STI and BBV health services
• drug and alcohol services
• mental health services
• regional hospitals
• community leaders and forums.

The process of engagement itself offers opportunities for giving information, addressing misinformation, promoting the benefits of NSPs and developing ongoing partnerships with other organisations. It is important to discuss concerns and barriers to setting up an NSP as well as to acknowledge the real challenges that services may face in meeting the needs of both PWID and the broader community. Some of the issues and concerns that may need to be addressed include:

• attitudes of services and communities towards PWID
• difficulties with acknowledging that drug use is happening in their communities
• perceptions that NSPs may facilitate drug use or harbour illegal activity
• barriers to NSPs promoting their services in some communities
• assumptions made about what services PWID may want to access, or do access
• stigma, discrimination, privacy and confidentiality
• understanding that PWID (and their families) may need to be supported for many years before deciding to seek treatment for drug and alcohol use
• respecting the rights of PWID to choose not to engage in diversionary programs but still be able to access health care
• safety for clients and staff
• lack of awareness among the community and health service staff about the availability and access to newer and highly effective treatments for hepatitis C
• lack of availability of dedicated services or practitioners in some regions to provide treatment for hepatitis C, drug and alcohol, mental health and support.

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