Legislative and policy barriers to nsp for pwid

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

Contents About AIVL

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Introduction

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Brief history of NSP in Australia

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Factors Impacting on NSP Legislation and Policy

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Attitudes to Injecting Drug Use and Drug Users and the Impact of such Attitudes on NSP/Injecting Equipment Related Legislation and Policy

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NSP Related Policy and Legislation Not Always Based on Evidence

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The Many Stakeholders with Responsibility and Influence to Change NSP-Related Policies, Legislation and Service Delivery Models

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Risk Aversion, Governments and NSP

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Legislative Barriers

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• Legislative Barriers to Peer Distribution of Injecting Equipment

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• Associated Legislation and Regulatory Frameworks with an Indirect Impact on Peer Distribution

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• Aiding and Abetting and Possession of Other Injecting Paraphernalia

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• Legislation Relating to the Disposal of Used Needles and Syringes

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• Mandatory & Discretionary Reporting

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• The Impact of Local Council Development Applications on New NSP Outlets

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Policy Barriers

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• Range and Type of Injecting Equipment Available

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• Limits on Equipment and User Pays/Cost Recovery Systems

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• The Effectiveness of Guidelines and Protocols Restricting Police Attendance at NSPs 26 • Collection of ‘Statistics’/Completing Surveys and Questionnaires

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• Access to New Injecting Equipment in Prisons

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Environmental/Structural Barriers to NSP Access

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Conclusion

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Barriers to NSP Access/Addressing Barriers – Table

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References

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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: www.aivl.org.au

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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 treatment1 (AIHW, 2008 ANCD, 2009).

Hepatitis C is one of the most commonly notified diseases in Australia. The National Hepatitis C Strategy 2010 – 2013 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 2010–2013 and the National Aboriginal and Torres Strait Islander Sexual Health & BBV Strategy 2010–2013 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 2004 – 2008 (NCHECR, 2009b). These issues of concern are further 1

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Those who have received at least one episode of treatment but are currently out of treatment.

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.

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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

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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 1989. 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.

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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 1986. 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.

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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 50 – 90 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

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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.

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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

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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 12 – 14 percent of respondents between 2005 and 2008. 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

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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

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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.

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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

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access new injecting equipment. As a result people are often forced into reusing equipment and/or finding themselves at secondary services (such as Hospital Accident and Emergency Departments) where equipment is limited or unavailable and their further engagement with the service not always welcomed or encouraged.

The aversion to taking what are perceived as ‘risks’ in a public policy sense is not exclusive to the area of NSP or access to injecting equipment and can be seen at work as a general approach or culture within contemporary governments. This general culture however has led to a legal and policy environment that is often reluctant to engage in necessary processes of reform. This factor must be taken into consideration in relation to how a review of legislative and policy barriers to access to injecting equipment can be initiated and supported in a way that acknowledges the political realities for governments while also ensuring that critical reform in the interests of public health is allowed to move forward. Once again, the existing partnership structures in relation to BBV & STIs at the national, jurisdictional and community levels will be best placed to navigate and support such a reform process. It needs to be emphasised however, that any process of reform to remove legislative and policy barriers to NSP and access to injecting equipment will necessarily require a reaffirmation of the political bravery and leadership that supported the establishment of NSP more than 20 years ago.

All the issues outlined above are interrelated and together map out some of the critical factors that will form the backdrop to potential reform and to the challenges that such a process of reform will entail. AIVL is not naive to the significance of these challenges. We do however believe that it is possible to undertake the necessary reforms to remove barriers to injecting equipment (within and beyond NSP) in a manner that takes account of the diverse needs of key stakeholders. To contribute to the initiation of a review process, AIVL has attempted to outlined at least some of the key ‘sites’ of legislative and policy reform. Each of these key barriers to access are identified, discussed (in more detail than the broader introduction to many of these issues above) and then followed by recommendations for action and overcoming these barriers. As a guide, the barriers to accessing new injecting equipment are grouped under the headings of ‘Legislative Barriers’, ‘Policy Barriers’ or ‘General Barriers’.

Legislative Barriers Specific Legislative, Policy and General Barriers to NSP & Injecting Equipment Access There is a range of federal and state/territory legislation which directly and indirectly impacts on the provision of NSP and access to injecting equipment in Australia. This is further compounded by Australia’s obligations and commitments at international law. While it is not within the scope of this paper to focus in detail on the implications of Australia’s international legal obligations for access to injecting equipment, it is necessary to briefly note a few specific international conventions and federal acts of direct relevance. The instruments outlined below have relevance in a strategic discussion on the need for legislative reform in this area as collectively they form the backdrop to the specific laws governing access to new injecting equipment in each jurisdiction: • International Convention on Economic, Social and Cultural Rights (ICESCR): to which Australia is a signatory, states in Article 12 an obligation on the governments of signatory countries to “provide access to the highest possible attainable standard of health for all”.

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• Universal Declaration of Human Rights: Australia is also a signatory to this declaration which includes a similar obligation in relation to the right to an adequate standard of health and wellbeing under Article 25.

• Single Convention on Narcotic Drugs 1961: Australia is a signatory to this convention which outlines a comprehensive range of legal sanctions in relation to illicit substances including criminalising the possession, use, supply, trafficking, etc of narcotics. Although the convention has not had a direct impact on preventing the implementation of NSP in Australia, it has been used to prevent heroin prescription programs and was drawn upon by those seeking to prevent the implementation of safe injecting rooms in Australia.

• Convention on Psychotropic Substances and the Convention Against Illicit Traffic in Narcotic Drugs and Psychotropic Substances – together these conventions to which Australia is also signatories seeks to expand and reinforce the legal sanctions expounded in the Single Convention with a specific focus on restrictions to importing and exporting.

While being signatories to the above international treaties brings into effect a range of obligations for Australia at international law, it is the process of enshrining these legal obligations into domestic legislation at the federal level that gives effect to these principles in Australian law. While unfortunately the principles and obligations articulated in the ICESCR and the International Declaration of Human Rights have not yet been enshrined in domestic legislation, the obligations contained within the Single Convention and Conventions on Psychotropic Substances have been imported into federal law. In this regard the two most relevant federal acts in relation to barriers to accessing injecting equipment are: • Narcotic Drugs Act 1967 – which enshrines many of the obligations contained in the Single Convention and seeks to stop all non-medical and non-scientific use of narcotic drugs. The Single Convention actually requires signatory countries to enshrine their obligations under the treaty into domestic law and actively maintains a monitoring and compliance process to ensure this occurs.

• Crimes (Traffic In Narcotic Drugs and Psychotropic Substances) Act 1990 – deals with legal sanctions including criminal offences for dealing in drugs including aiding, abetting, counselling, or procuring. It is important to note that this act also mandates criminal offences for the possession of “equipment or materials” that may be used for “dealing in drugs”.

In addition to Australia’s obligations at international law and relevant federal state and territory legislation , NSP implementation and access to new injecting equipment is impacted on by a broad range of jurisdictional regulations, guidelines and strategies (federal and jurisdictional), police guidelines, operational guidelines, pharmacy schemes, local council planning regulations, building by-laws and local service policies as discussed earlier.

In order to simplify the barriers to NSP and equipment access which have been identified in the course of researching this paper, the barriers addressed below are grouped as ‘legislative’, ‘policy’ and ‘general’. ’Legislative’ barriers are legally binding, in short ‘law’. ‘Policy’ barriers, while still formal can more generally be described as courses of action, guiding principles, or procedure considered expedient, prudent, or advantageous. Finally, those barriers grouped as ‘general’ are those that cannot be identified as fitting within either of the former groups, however, remain barriers to NSP and equipment access and subsequently act as barriers to accessing the means of self-determined health including the prevention of Hepatitis C transmission.

It is also necessary to highlight that any process to identify and subsequently reform the barriers to NSP and injecting equipment access would require a detailed investigation of the specific legislation, policies, guidelines, strategies, etc that impact on this issue for each jurisdiction. As a national organisation AIVL has only attempted to provide a general overview of the types of legislative and policy barriers that are currently creating access problems. This is a national discussion paper aiming to provide initial reflection on the issues and act as impetus

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for further investigation. AIVL believes the first stage of any process of reform in this area would require the development of a document such as this one for each state and territory identifying the specific policy and legislative barriers requiring reform. This document should be used as a broad guide to the main issues and as an evidence base for the need for change.

Legislative Barriers to Peer Distribution of Injecting Equipment AIVL’s member organisation in NSW, the NSW Users & AIDS Association (NUAA) have recently released a discussion paper on this issue and while it is NSW focused, the underlying issues and aim(s) of specific legislation are pertinent to all states and territories, with the themes and issues resonating nationally (NUAA, 2009). Given this important work has been undertaken

by NUAA, AIVL has opted to utilise the NUAA discussion paper as a background for this section and as a basis for understanding the general impact of legislation on the issue of peer distribution of injecting equipment.

People who inject drugs and peer education are a priority within the newly released National Hepatitis C Strategy 2010 – 2013. This is because there can be little debate that a major source of access for people who inject drugs to information and education (safer using, street drug quality, etc), referral (health care and service providers reputations and attitudes to injecting drug users) and support comes from peers – other people who inject drugs. Having said that, the other thing people who inject access from their peers is injecting equipment.

Peer distribution of injecting equipment is an effective, convenient, and cost-effective method of distributing new injecting equipment in the ongoing challenge to reduce Hepatitis C and other BBV transmission rates. Currently peer distribution is specifically legislated against in all states and territories. A brief overview of this legislation includes: New South Wales (NSW) – the Drugs Misuse Act 1985 refers to the possession of injecting equipment being illegal unless that person is of a “class of persons prescribed by the regulations” as someone who is authorised to participate in an approved needle & syringe program.

Victoria (VIC) – the Drugs Poisons and Controlled Substances Act 1981 only provides an exemption from aiding and abetting the commission of an offence for a person who sells or supplies a needle or a syringe providing they are engaged or employed by a pharmacist or is a specified (or class of) persons or organisations prescribed under the regulations.

Queensland (QLD) – under the Drugs Misuse Act 1986 it is an offence for a person other than a medical practitioner, pharmacist or person or class of persons authorised to do so by the relevant Minister to supply a needle and syringe.

South Australia (SA) – the Controlled Substances Act 1984 states that a person must not knowingly have equipment for preparing a drug unless they are a member of a specified number of professions or is someone who is licenced to have equipment in their possession by the Minister. The Act and associated regulations details a specific process for licensing associated with “health risk minimisation programs”.

Northern Territory (NT) – the NT Criminal Code makes the supply of a needle and syringe for administering an illegal drug an offence unless it is supplied by a medical practitioner, pharmacist or class of person authorised by the Minister.

Australian Capital Territory (ACT) – the Public Health Act 1997 specifies a doctor, pharmacist, nurse, midwife or health worker may apply to the Chief Health Officer for approval to supply syringes. The Act defines “health worker” as a person who has completed a course of instruction as approved under the Act. The Act also specifies the process of application and

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conditions of approval, renewal and surrender/cancellation of authorisation. An approved person cannot lend or give their approval to another person for the purpose of assisting them to supply syringes.

Tasmania (TAS) – the HIV/AIDS Preventative Measures Act 1993 states that only persons holding a permit approved by the Secretary of Health can legally distribute needles and syringes – medical practitioners, pharmacists and nurses are also permitted to distribute needles and syringes. Employees or other person working for the permit holder can be authorised to supply needles and syringes but permit holders cannot transfer their permit to another person to assist that person supplying needles and syringes.

Western Australia (WA) – the Poisons Act 1964 provides a defence for persons distributing needles and syringes only if it is done through an approved needle and syringe program – the characteristics of such programs are detailed in Act and regulations pursuant to the Act specify strict operational requirements for NSP with serious fines for failure to comply.

Despite this above legislative situation peer distribution continues to occur and acts as a major source of access to new injecting equipment for PWIDs. For example in the 2009 Annual NSP Survey (yet to be published) 54 percent of respondents reported being involved in the practice, reporting that they passed on around 20 percent of their equipment to other users.

However, as outlined above, peer distribution of injecting equipment is in direct conflict with the exemptions made to allow certain classes of people to distribute needles and syringes and enabled NSPs to operate.

Authorisation to dispense NSP equipment does have it’s limitations, which also directly impact on peer distribution as it stands currently and whether it is recognised as peer distribution or not: equipment cannot be provided outside the hours of NSP operation; and unpaid workers, students and volunteers are not permitted to distribute equipment nor provide information on safer drug use. It is also interesting to note that despite peer distribution being illegal in all states and territories, NSPs in a number of jurisdictions routinely ask about the number of persons the equipment is being dispensed for.

Even if the legislation in a particular jurisdiction does not specifically state that unauthorised distribution is an offence, if an unauthorised person does provide NSP equipment they could possibly be prosecuted under a complex network of associated laws and regulations that operate in relation to the use illicit drugs. This situation is highlighted by Byrant and Hopwood in their research on secondary exchange which states that people can be potentially charged with: “...the supply of needles and syringes, and possession and supply of associated equipment for use in the administration of a prohibited drug...prosecution could also occur for aiding and abetting the administration of a prohibited drug. The implication of this last statement is that a person not exempted is at risk of prosecution not simply for supplying syringes but for aiding a further criminal act: illicit drug injection. Of equal concern is that should a person overdose and die when using a syringe provided by a person who is not exempted or in a position where the exemption does not apply, they (the distributor) may be at risk of being prosecuted for manslaughter.” (Bryant & Hopwood, in NUAA, 2009) There are people who inject drugs, aware of the potential consequences, who continue to distribute injecting equipment regardless of the possibility of prosecution. NUAA believes that this is due to an empathetic understanding of the centrality of the syringe within the act of injecting drug use and a mutual understanding of injecting as a pleasurable mode of administration and that this then leads to the provision of new injecting equipment, often regardless of prior acquaintance. Peers will go so far as to pick up more equipment than needed for their personal use so that they have stock on hand for visitors and friends. It is not uncommon for peer networks to be aware of individuals who have established unsanctioned

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NSPs in their homes. As this interviewee from Adelaide stated: “...I had the equipment in the boot of the car, carried it around, and at night I had the CNP operating from my driveway...I’d stock it up...one of the main reasons I lost my house...they thought I was dealing...” (Candy, Peer, Adelaide) While peer distribution occurs, for some highly marginalised groups it is the most effective strategy in reaching people who inject drugs with sterile equipment. As highlighted in NUAA’s discussion paper on peer distribution: “In the Bryant & Hopwood study on secondary exchange (2009), 25.4% of ‘secondary exchangers’ were of Aboriginal or Torres Strait Islander descent. This relatively high proportion suggests that at least some Aboriginal people find it easier to access equipment through social networks than through conventional services” (NUAA 2009).

Peer distribution is imperative in attempting to reach, and increase access for Aboriginal people who inject drugs. Aboriginal people who inject drugs live in a very close-knit community, and there is a strong tendency toward the use of kin-ship and familial relationships in support networks. “...the research also confirms that Indigenous IDUs may obtain clean injecting equipment from trusted friends or other members of the IDU community, and are comfortable with obtaining equipment in this way. A number of respondents spoke of how they themselves played a role in distributing equipment (obtained in bulk from an NSP) to their peers” (Urbis, 2008).

Peer distribution and peer education go hand-in-hand, however we cannot capitalise on this phenomenon because peer distribution of sterile needles and syringes is illegal and PWIDs can be charged under a variety of legislation and dependent on circumstances. Peer education programs and campaigns, wherein peers had the ability to pass along new injecting equipment together with accurate and up-to-date harm reduction information can only be more effective in regard to harm reduction and BBV prevention and transmission awareness when the information is supported by the tools to make choices.

The most often used argument against the support of peer distribution is that peers will sell the equipment ‘on the side’. Some service providers are concerned that sterile equipment will be on-sold by dealers for profit. AIVL would suggest that regardless of how peer distribution occurs, including through dealers, provided that equipment is distributed to people who inject drugs it is a move toward increased access, which in turn is a step toward reducing the rates of new Hepatitis C transmissions. Indeed AIVL would argue that distribution of new injecting equipment through dealer networks, particularly through user-dealers, is one of the most effective ways to ensure that people have access to new injecting equipment every time they inject.

Whether it is for altruistic reasons, whether deliberately established or not, or whether by sheer chance, peer distribution similarly to peer education, is a naturally occurring phenomena. It currently occurs despite it being illegal and in the face of police harassment, personal searches and confiscation of injecting equipment. This situation is compounded by general confusion in regard to equipment possession, disposal and distribution laws, and self administration legislation which discourage NSP access and are discussed elsewhere in this document.

As mentioned earlier in this document, the advent of NSP and necessary changes in legislation to allow for its implementation meant that authorised individuals needed to become exempt from prosecution (particularly in relation to aiding and abetting the commission of an offence) in order to be in a position to distribute needles and syringes. If peer distribution were to be adequately implemented and supported across all jurisdictions it would require not only exempting categories of people (such as volunteers and unpaid staff), but as pointed out in NUAA’s work on this issue it would also specifically require the deregulation of the provision of equipment, this would mean that:

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• “people who inject will be able to carry and distribute clean equipment with less fear and confusion; • Drug user organisations will be able to work to prevent blood-borne virus transmission with their peers with one less major barrier to effective peer education and community development; • NSPs will be able to broaden their ‘reach’, fulfil directives to double their distribution and have another strategy that they can employ legitimately to reach marginalised target groups and they will be able to record data more accurately and more effectively evaluate their practice.”

Nearly as importantly, the government will signal that it takes the health of all the state’s citizen’s seriously and that it does not privilege law enforcement over health care.” (NUAA, 2009: 28).

Too often the fact that PWIDs are already distributing new injecting equipment among their peers and that there doesn’t appear to be evidence of them being charged and prosecuted for same is used as a reason to ‘leave well enough alone’. AIVL would argue that this is not the central issue of concern. At the very least, current legislation on the supply of needles and syringes and other injecting equipment leaves PWIDs at the mercy of the discretion of the police and courts. As outlined above it also leaves people ‘known to police’ open to harassment, searches and confiscation of bulk injecting equipment when they are legally entitled to be in possession of such equipment. But perhaps most importantly, as long as the current legislative prohibitions against peer distribution of injecting equipment prevail, NSPs and health departments will refrain from utilising and developing a highly effective method of increasing access to equipment, education and improving health outcomes for PWIDs.

Associated Legislation and Regulatory Frameworks with an Indirect Impact on Peer Distribution Legislation and regulations on the possession of needles and syringes, possession of other injecting paraphernalia, passing on needles and syringes, aiding and abetting (including injecting others), disposal of used injecting equipment, and self administration of an illegal substance can, to varying degrees impact indirectly on a person’s ability and willingness to access NSPs. While access to NSPs and new injecting equipment is paramount, many of these legislative and regulatory anomalies run counter to harm reduction and subsequently to access to BBV prevention initiatives, including NSP. While it is legal to possess (new and used) needles and syringes in all states and territories, all jurisdictions other than Queensland also have legislation that states that possession of needles and syringes can be used as evidence of drug use and subsequently self-administration of a prohibited substance (commonly termed ‘self-administration’). Although Queensland does not have a ‘self-administration’ offence per se, it is still illegal to administer a dangerous drug to another person or possess equipment used to self-administer under the Drugs Misuse Act and associated regulations.

While it is difficult to ascertain the direct impact of self-administration legislation on access to NSPs and new injecting equipment, a correlation between the possession of both new and used equipment and fear of police attention can be definitively made. Drug user organisations routinely have discussions with PWIDs indicating that fear of “being done for self-admin or existence of trace elements of illegal drugs” acts as both a barrier to accessing NSP and to calling an ambulance for assistance in the case of overdose. In this regard, AIVL believes it would be possible through a more formal research process to establish a connection between the existence of associated legislation such as self-administration offences and barriers to BBV prevention and other harm reduction activities.

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This belief is supported by the findings of AIVL’s National Injecting Equipment Disposal Study (2002), which clearly demonstrated that people who inject drugs are both largely unaware of their rights to have new and used equipment in their possession, and are reluctant to return used equipment to NSPs for fear of police search and potentially being charged (with possession of illegal drugs or ‘trace elements’ of illegal drugs being found in used equipment).

“The majority reported that it was legal to carry a new fit (79%) and 22% claimed that it was legal to carry used injecting equipment. Almost a quarter (24%) had had new fits confiscated and a third (34%) had had used fits taken by police. These figures are remarkably similar to the experience in Victoria, which suggests that these practices are systemic.”

“One of the dominant themes to emerge in relation to leaving needles/syringes at the (public) place of injection and on the street was the concern respondents expressed about ‘the police’.

Clearly, respondents’ fear of police intervention often explained their extreme reluctance to carry injecting equipment, new or used, and their desire to discard needles/syringes as soon as they had served their purpose” (Kelsall, et al, 2002: 10 ).

While those people who inject drugs interviewed in relation to the development of this document did not specifically state they were concerned by ‘self administration legislation’, they did highlight being concerned with being targeted by police due to their vicinity to NSP and having equipment – new or used in their possession, and subsequently ‘being charged by police’. The issue of relationships between police and NSPs and use of guidelines to manage this relationship are discussed later in the document.

Aiding and Abetting and Possession of Other Injecting Paraphernalia The supply of other injecting paraphernalia including filters, water, tourniquets, etc. are technically illegal in QLD, WA, SA, TAS and NT. It is also considered ‘Aiding and Abetting’ the commission of an offence to assist another individual to inject in all states and territories.

While most states and territories supply additional injecting paraphernalia (for free or at cost) it’s possession remains illegal in most of the country, and this inconsistency is another reminder of how associated legislation can impact on NSP access and in many instances acts in direct contrast to harm reduction.

Aiding and abetting legislation has a direct impact on the education (peer and service-based) of people who inject drugs, and the ability to enact realistic education and health promotion.

For instance, neither NSP staff nor peer educators employed through services can realistically show injectors safer injecting practices, vein care and BBV prevention in case of charges of aiding and abetting the commission of an offence. Harm reduction education such as demonstrating how to inject more safely, where to inject in relation to an individual’s veins, and step-by step processes for reducing the likelihood of BBV transmission during the injecting process for instance can potentially leave NSP workers and peer educators open to aiding and abetting charges.

Legislation Relating to the Disposal of Used Needles and Syringes Another area of associated legislation with an indirect impact on access to NSP and new injecting equipment is the issue of disposal of used injecting equipment. An overview of the current situation across the jurisdictions is that legislation on this issue is thoroughly inconsistent. For example, unsafe disposal is considered ‘aggravated littering’ in NSW, where it is also illegal to dispose of equipment in household waste. It is considered ‘littering’ in Victoria, where household disposal is ‘discouraged’, yet not illegal per se. Queensland has unique

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legislation which makes it illegal to inadequately dispose of equipment, but while it is illegal to litter in WA, household disposal of used needles and syringes is acceptable. It is an offence to fail to dispose in the NT, it is an offence to dispose into the household waste in the ACT, and in Tasmania PWIDs must dispose of any used needles and syringes in their possession at the NSP (AIVL, 2002).

In discussions with individuals for this paper it was clear that PWIDs are confused in regard to their legal status in relation to possessing both new and used equipment and safe disposal; “I don’t want to get picked up, sometimes it’s easier just to dump it in the bin.” (Hillary, peer, NSW). The inconsistencies across the states and territories in relation to what constitutes safe disposal of used injecting equipment is also problematic as PWIDs move between jurisdictions in the same way as other members of the community. The AIVL National Injecting Equipment Disposal Study in 2002 highlighted how seriously PWIDs take the issue of safe disposal but also identified the way that legislation and policy can create barriers to the safe disposal of equipment. In any process of review and reform, it will therefore be necessary to address the inconsistencies in relation to unsafe disposal and ensure that PWIDs are properly informed of such changes.

Mandatory & Discretionary Reporting In the majority of states and territories, staff of all government agencies are duty-bound to report to their state’s appropriate community services department responsible for children and young people – children under 16 (including pre-natal infants) and young people they perceive to be ‘at risk’. While wording varies across jurisdictions, the underlying concept and meaning remains the same and therefore wording from the NSW context has been used by way of example; “The Children and Young Persons (Care and Protection) Act 1998; establishes a process for people who have reasonable grounds to suspect that a child or young person is at risk of harm from abuse or neglect, to report to the Department of Community Services (DoCS). Under (the relevant section) of The Children and Young Persons (Care and Protection) Act 1998, it is mandatory for people working in health or welfare to report suspected risk of harm relating to children if they deliver services wholly or partly to children. It is also mandatory for health or welfare managers whose duties include direct responsibility for or direct supervision of the delivery of services wholly or partly to children, to report risk of harm to a child. It should be noted that reporting is mandatory with respect to children and discretionary in relation to young people and pre-natal reporting. Health workers who fail to comply with mandatory reporting requirements are guilty of an offence.”

(The Policy Directive states: ) “Depending on the age of the child, a clinical decision may be required to determine that it is appropriate to provide injecting equipment. It is essential that advice be provided regarding drug and alcohol and other support services prior to provision of injecting equipment”. Further, under Section 25 of The Children and Young Persons(Care and Protection) Act 1998, “a health worker who has reasonable grounds to suspect, before the birth of a child, that the child may be at risk of harm after her or his birth, may make a report.”

In relation to access to new injecting equipment specifically, the NSW NSP Policy Guidelines provide that: NSP staff have an obligation to make a report to the DoCS Helpline regarding children, where a parent’s or carer’s use of alcohol or other drugs is affecting their ability to care for a child and they believe the child is at risk. Such consideration of risk can only be based on the worker’s observations of, and knowledge of, the child’s situation”. (NSW, 2006)

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While AIVL in no way seeks to minimise the important role of mandatory reporting under specific circumstances, there are some concerns about the open-ended nature of the responsibilities and obligations on NSP workers under relevant legislation (and policy) in particular, the fact that such obligations seem very open to individual interpretation. In this regard one of our specific concerns is the relative power given to individual workers to interpret the circumstances under which they should report – individuals who are no less subject to the influence of prevailing societal norms, attitudes and constructions than others.

Mandatory reporting requirements can restrict access to NSPs for some of the most marginalised PWIDs including young people, women with children and pregnant women. As part of the research for this paper, AIVL spoke to a range of NSP clients in various jurisdictions who made mention of their fears and concerns around accessing some NSPs during pregnancy or while their children were present for fear of being reported to the relevant child services department due to their own drug use and regardless of how well their children presented.

While only a single example, the ‘reality’ behind these fears is highlighted by the following comment from an experienced NSP worker: “I worked with this one woman, didn’t matter what the situation, pregnant, with kids, I’m calling DoCS...(when asked ’why’)...they’re pregnant, of course the kid is going to suffer...”

Jane NSP Worker In relation to young people who inject drugs and wish to access NSP services, the situation is further compounded by the fact that many young injectors are already not accessing health services (including but not limited to NSPs). If they do access NSPs then young people often feel they run the risk of being reported, required to respond to questions regarding the nature of their drug use, blood borne virus risk awareness, followed by the determination of another party as to their ‘eligibility’ for new injecting equipment.

While mandatory reporting of young people at risk when assessed and managed appropriately can be of positive benefit to their longer-term health outcomes of young people, and should never be dismissed out-of-hand within NSPs, the intricacies involved within the NSP setting must be acknowledged. Staff must be given advice and training on risk-benefit analysis in relation to mandatory reporting requirements, BBV prevention and in relation to building and maintaining positive client staff rapport with a highly marginalised clientele. The capacity for mandatory reporting legislative requirements to directly and indirectly impact on access to NSPs should be pro-actively assessed as part of any process seeking to remove barriers to new injecting equipment.

The Impact of Local Council Development Applications on New NSP Outlets Ironically it may not be NSP service providers nor injecting drug users who have ultimate authority over the supply and access to injecting equipment; through fixed site, vending machine or mobile service. It may not even be the Minister of Health, or any State or Territory Health Department. Often, it is local council who can choose to support NSP, determine the duration of development application for new and/or future developments, or decline to support a new or expanded service. In short, if NSPs cannot be housed they cannot operate, they cannot be accessed, and sterile injecting equipment cannot be dispensed.

There have been reports of long and difficult planning processes with development applications being supported by council staff with experience in planning and development only to be rejected by councilors. This situation is further compounded by a general lack of support for and understanding of blood borne virus prevention programs which can often dominate the area of NSP development.

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The “NIMBY” or “Not in my backyard” syndrome has been shown to be a common theme in attempts to implement new programs at the local level in many instances. If not directly overriding the establishment of new program initiatives, planning processes can mean many months of negotiation before approval (in whole or with amendments) is granted. This further limits NSPs ability to be responsive to the needs of people who inject drugs and changing drug trends at the jurisdictional and/or local levels.

In some jurisdictions local councils can also have an impact on mobile and outreach services performed by NSP. It is extremely difficult to be proactive and responsive to the needs of people who inject drugs when services must engage in cumbersome and time consuming approval processes for fear of breaking the law themselves: “The catchment area for outreach services is limited to those approved by Order in Council.

Any equipment distribution that occurs outside of those areas is illegal and staff are at risk of being charged with ‘aiding and abetting’ the commission of an offence under the Drugs, Poisons and Controlled Substances Act” (Victorian Department of Human Services, 2001: 11).

These inconsistencies in legislation in-directly impacting on NSPs are not only confusing for NSP staff (who also have limited access to this legislative information), but perhaps more importantly inconsistencies such as those outlined above can actually impact on, and hinder access to NSPs and new injecting equipment. People who inject drugs garner the majority of their information from other people who inject drugs, and negative experiences and half‑truths can quickly gain currency.

Many individuals interviewed in the course of this paper’s development cited lack of awareness of these types of legislation, or confusion concerning legislation as reasons for not accessing NSPs generally, or for not accessing particular local outlets.

Policy Barriers Range and Type of Injecting Equipment Available Ensuring the full range of injecting equipment and paraphernalia are available in all States and Territories and differences between States and Territories in regard to types and amounts of equipment distributed needs to be addressed as a major policy barrier. Most state and territory NSP policies ensures a minimum of sterile injecting equipment which can be dispensed. This minimum range of equipment generally comprises of 1ml insulin syringes (needle attached) and a disposal container.

A wider range of equipment is provided by some primary NSP services including 3ml, 5ml and up to 20ml and 50ml large-bore syringes, various gauges of detachable needle tips, sterile water vials, alcohol swabs, spoons, cotton wool, wheel filters, tourniquets and winged vein infusion sets or ‘butterflies’. In a growing number of jurisdictions these other items of drug use paraphernalia, where available, have strict limits and/or are dispensed on a cost recovery basis.

It is rare for secondary NSP services, vending machines and foot-based outreach to dispense other than 1ml insulin syringes, disposal container and perhaps alcohol swabs. The following example from the NSW NSP Policy Guidelines demonstrates the way that injecting equipment access can be specified in policy: “All primary NSP outlets, and secondary outlets where capacity permits, will stock a variety of injecting equipment, including a range of syringe brands and sizes, a range of needle gauges and sizes, and a range of personal use and other disposal containers. Services must not offer winged vein infusion sets...or syringes with a volume of 10ml or greater. All injecting equipment must be distributed along with an appropriate disposal container.

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Services may, from time to time and depending on budget limitations, provide other goods, such as water for injection, to promote the health of NSP clients.“(NSW Department of Health, 2006) In Victoria, as in some other states/territories, NSP policy dictates that a comprehensive range of injecting equipment be available for clients including detachable needle tips in various gauges, 1ml syringes, alcohol swabs, condoms and water-based lubricant, discrete bags for portage and sharps disposal containers. Injectors interviewed in the course of this paper’s development expressed concerns with the colour of contaminated waste bins – bright yellow in many areas. These concerns were substantiated by earlier AIVL research wherein respondents expressed very similar concerns – that the yellow bins acted as a beacon for police, literally suggesting that the individual had been, or was going to the NSP and therefore should be targeted (Kelsal et al, 2003).

AIVL’s Policy Position on NSPs states: “The act of injecting substances is misunderstood by many. NSPs have a clear role to provide injecting equipment and harm reduction information. Such provision must take into account the needs of those that access the service and should include for example: The provision of sterile injecting equipment and other required paraphernalia; • Access to meaningful harm reduction information; • Demonstrations of safer injecting processes including techniques such as neck and groin injecting; • Vein searches; and • Wound care. “ (AIVL, 2003) When NSPs were initially implemented in Australia heroin, amphetamines and cocaine were reportedly the most common drugs of choice – hence 1ml syringes were the most appropriate injecting equipment to be dispensed through NSPs. However, in the interim drug trends have changed considerable in some jurisdictions and as suggested earlier in this document, evidence (both anecdotal and findings from the Annual NSP Survey 2009), reflect an increase in the number of people nationally injecting pharmaceutical opioids such as MS Contin and OxyContin – from 8% in 2004 to 15% of respondents in 2008 (NCHECR, 2009a). It should of course be noted that this varies between jurisdictions with the injecting of opioid pills either more popular or available in some states and territories than others.

The injection of pills, steroids, buprenorphinre and methadone require the utilisation of equipment other than 1ml insulin syringes if risks including the potential for BBV transmission and vein damage are to be minimised. The use of these drugs requires (not only) specialised knowledge best provided by peer educators, it also requires the use of larger sized syringes, various needle tips, water and particle and/or bacterial filters. However if this paraphernalia is not accessible, people who inject these substances are forced to purchase equipment (where possible), travel longer distances or to another jurisdiction and/or re-use or share equipment. In this regard, AIVL is aware of many instances where individuals have travelled interstate to collect supplies of equipment not dispensed in their home state/territory. This is yet another example of policy sitting in direct contradiction to the principles of harm reduction.

Limits on Equipment and User Pays/Cost Recovery Systems The majority of vending machines charge for equipment, generally $2 to $4, though NSW also has ‘dispensing’ machines in some jurisdictions which provide pre-packed ‘fitpacks’ at no cost. These are generally located in community health centres and/or hospitals. The majority

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of pharmacies charge for equipment with packs consisting of 3-5 syringes and sometimes other equipment such as swabs and a spoon costing between $3 – $8. Pharmacies providing access to new injecting equipment are not required under legislation or policy to provide safe disposal containers.

As with the majority of issues raised in this document, there is no national consistency in regard to the maximum limit of 1ml syringes and/or other injecting equipment an individual can access each visit to a fixed site primary NSP. In policy, Queensland and the ACT have a limit on the maximum amount of 1ml syringes that an individual can access in one visit – 50 single 1ml syringes each visit. Once the maximum limits have been reached the service user can then purchase further 1ml syringes. In contrast NSP policy in South Australia specifies a minimum amount of three 1ml syringes per visit plus a disposal container, while the minimum in Queensland is two 1ml syringes.

South Australia, Tasmania, Western Australia and recently the ACT have all implemented NSP policies in regard to cost recovery for some injecting paraphernalia other than 1ml syringes.

While some have daily limits which when reached will result in the individual being charged for the item, others have no free paraphernalia and a cost is charged against the item from the outset. These paraphernalia (depending on jurisdiction) include water ampules, bacteria and particle wheel filters, larger sized syringes and winged infusion sets.

The reasoning behind limits and cost recovery is generally given as budgetary constraints, and admittedly much of the paraphernalia mentioned is costly, particularly when dispensed in large quantities. However, there is another school of thought that suggests when limits are placed on equipment dispensed to the individual each day; they are more likely to return to the NSP – where ‘contact’ can be maintained and more health services can theoretically be provided.

Anecdotal evidence suggests that this second argument does not hold up in reality as it does not take into consideration other costs to the individual to reach the NSP; travel costs, time taken, inconvenience, etc. When properly considered, all of these factors can make it more likely that the injecting drug user is more likely to re-use their own injecting equipment or share someone else’s rather than make more trips to the NSP. It is also interesting to note that AIVL is not aware of any case where NSP clients have been adequately consulted about whether limits on equipment will result in more contact with the service or whether they wish an increased degree of contact with that provider.

The ‘Review of Enablers and Barriers of Indigenous Drug Users Accessing NSPs’ briefly discusses NSP outlets attitudes toward the amount of equipment they dispensed. Some staff had concerns that clients took too little equipment to ensure their needs were covered – particularly if the clients were known to be dispensing to peers (wherein they turned a ‘blind eye’) or if they had travelled long distances. Other staff (most often those employed at community health centres) were concerned that if clients were not restricted in their access by limits they might ‘abuse’ the system by selling equipment. There was also a reluctance from some to have known dealers have access. This report also supports anecdotal evidence that some people who inject drugs have accessed sterile injecting equipment from dealers.

Restricting the amount of injecting equipment through both policy-determined limits and user pays/cost recovery can acts as a barrier, to both NSP access and to the individual’s ability to enact harm reduction initiatives including BBV prevention and vein care strategies. AIVL questions the degree to which policy decisions that are having a direct impact on the level of access that PWIDs have to new injecting equipment is being informed by either client-need or available evidence. Any process to review the policy barriers to accessing evidence-informed BBV prevention strategies should as a priority seek to examine the current practice of placing limits on injecting equipment occurring in all jurisdictions.

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AIVL is aware of the prevalent view that if people can afford to buy illicit drugs then they should easily be able to afford the cost of injecting equipment. The cost of sterile injecting equipment may appear trivial in comparison to the cost of illicit drugs however, for some, particularly those users on government benefits and those on low incomes, the cost of new injecting equipment can be a major hurdle: “After buying drugs...you may have not a cent over to buy a syringe” (Urbis, 2008). AIVL believes the chronic and growing level of equipment reuse as documented in the available literature supports the reality of the above statement for many PWIDs.

The Effectiveness of Guidelines and Protocols Restricting Police Attendance at NSPs Police and the policy and operational frameworks they adopt can be very supportive or completely counterproductive for harm reduction and therefore NSPs depend entirely on their approach. Police support for harm reduction approaches is critical in facilitating ‘enabling legislative and policy environments’. All states and territories have guidelines for police which support harm reduction services, including NSPs, opiate treatment services and the Medically Supervised Injecting Centre (MSIC) in the case of Sydney. In fact, this support reaches the highest echelons of police hierarchy: “At the most senior level, all Australian police organisations have formally endorsed a commitment to harm minimisation, including harm reduction. The National Drug Strategic Framework 1998-99 to 2001-02 was prepared by a joint steering committee on the Intergovernmental Committee on Drugs (IGCD) and the Australian National Council on Drugs (ANCD) and endorsed by the Ministerial Council on Drug Strategy (MCDS). Thus, police are signatories to, and key players in, the National Drug Strategy (NDS). The Australasian Police Ministers’ Council has since emphasised the commitment of police to harm minimisation in their last strategic plan. This commitment included the focus on reducing ‘net’ or ‘aggregate’ harm and a focus on strategies other than arrest and incarceration” (Spooner, et al 2004: 7).

This support manifests as guidelines for police which encourages them to use discretion in relation to police activities near harm reduction services. These general guidelines were developed to reduce the fear of prosecution, encourage people who use drugs to use NSPs and dispose of used injecting equipment safely. No NSP can be a ‘no go’ area for police; they will not ignore crimes committed on NSP sites, however discretionary police policies and practices include: • Police not conducting unwarranted patrols and personal checks within the immediate vicinity of NSPs that may act to disrupt or deter people from using services; • Police not arresting peer educators or outreach workers while performing their role, provided no offences are committed by educators or workers while providing their service; • Police not arresting people who inject drugs when they are found with injecting equipment and no other offence is disclosed (Burnet Institute, 2008).

While there is obvious outward support from high ranking police for NSPs and other harm reduction initiatives, the police service is hierarchical, with local jurisdictional commanders having responsibility for local police activities. In addition, individual officers like all members of society, are subject to external influences and the term ‘discretionary policing’ is very open for interpretation.

The reality of the relationship between police ‘on the ground’ and NSPs and the users of those programs can be very different from that suggested by guidelines. AIVL has received numerous anecdotal reports from NSP staff and people who inject drugs – which is further substantiated by research – that unsupportive and disruptive policing activities routinely occur (Urbis 2008).

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These activities include; concentrating police activities by targeting the sites of services to search and detain users, searching and detaining outreach workers and peer educators when working with users, searching users and seizing injecting equipment (both used and new equipment), and being generally unsupportive.

Police actions can be one of the strongest determinants of whether a person will access a NSP or not. Their actions can be counterproductive to harm reduction and increase the BBV risks to individuals and the general community. Police activity targeting NSP sites and people who inject drugs leads to: • • • •

decline in the number of clients using services; risky injecting practices and other associated harms; increased numbers of clients in other sites; drug users being reluctant to engage generally (Denham, 2007).

Collection of ‘Statistics’/Completing Surveys and Questionnaires The collection of statistical information at NSPs was a controversial topic for those people who inject drugs interviewed in the course of developing this document. Individuals were uncertain as to whether data collection was mandatory and/or whether the receipt of equipment hinged on giving information to NSP staff. In addition, those interviewed had a number of concerns in relation to the nature of questions asked and whether information could be ‘used against them’. One interviewee mentioned ‘codes’ that incorporated their initials and date of birth and queried whether this was a system used universally at NSPs or to ‘track’ users.

The majority of state and territory NSP policy documentation mentions the collection of statistical information from clients of NSPs. Most often this is discussed in a manner that requires the collection of information to be balanced against obligations under privacy legislation – however, to date no NSP policy/guidelines have demonstrated how existing obligations under privacy legislation and/or the ‘need for confidentiality’ is practically observed when NSP workers are requesting personal information from clients.

Other NSP policy/guidelines also mention service evaluations and involvement in research surveys conducted by parties external to the service. The Annual NSP Survey for example is coordinated by the National Centre in HIV Epidemiology and Clinical Research (NCHECR).

Beyond mentioning participation in these processes, most NSP policy guidelines however do not go further to discuss; the process for weighing the relative cost/benefit of clients completing particular questionnaires/research, protocols for clients with concerns about breaches of confidentiality, the fact that equipment dispensation is not dependent on answering questions (apart from the ACT who do make the voluntary nature of answering questions clear), how to maintain client privacy/confidentiality, or how data and statistics will be used once collected. All of these issues are considered part of standard ethical practice in other areas of health service delivery and research and AIVL remains extremely concerned about the apparent lack of attention to these issues in relation to NSP. There is also a great degree of variety between jurisdictions in relation to what data is actually collected from clients. While some jurisdictions will only collect equipment dispensed and returned for disposal, others collect ‘personal identification codes’, gender, ethnicity, disposal method and drug/s of choice or ‘what substance the equipment will be used to inject’ – among other ‘statistical’ information. Furthermore, at the levels of senior management and policy administration relating to NSP coordination the purpose/use of data collected also remains unclear:

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“There is a lack of understanding by jurisdictions about the purpose and intent of some performance information. As a result there are varying interpretations of the data required for collection and reporting.

There are concerns regarding the current relevance of some of the performance information required for national reporting. It was noted that although this information was relevant when the supporting measures were approved in 1999, it is less relevant today.” (AIHW, 2007) This suggests that, given the hierarchical nature of NSP bureaucracy, if the NSP coordinators at state and territory level cannot comprehend or understand the nature and reasoning for NSP data collection, how is this information supposed to filter to managers and from there to staff and to clients of NSPs? When clients asked why they are being asked such sensitive information staff suggest that it is for ‘reporting purposes’ or that it ‘helps keep the service open’. In the course of researching this document the only information that could be found to have come from clients of NSPs through data routinely collected at NSP sites was related to the number of needles and syringes dispensed and disposed through NSP outlets and the types of referral and information clients have received.

No information could be found on ethnicity, gender, postcode/area, method of disposal, last drug injected/other drugs injected/drug of choice, age, whether condoms were taken, language spoken at home, whether the clients were new to the service, or sharing behaviour – all questions asked at many NSPs. AIVL is very concerned that in the case of NSP data collection it appears to be a case of data collection for its own sake. A certain breach of AIVL’s ethical guidelines for conducting research with PWIDs and we would suggest also a breach of the fundamental principles that underpin the NHMRC’s guidelines on research involving humans.

This situation is extremely concerning in a number of ways. First, the nature of ethical research and privacy legislation suggests that clients should be given feedback on the results of data collected and they should be fully informed as to the purpose of data collected. Neither of which appear to occur when it comes to the data collected at NSPs. Further, on the nature of data collection at NSPs, the majority of primary and particularly secondary NSPs are located in community health services, hospitals or are stand-alone agencies largely funded under state and territory legislation. Therefore, they are subject to the same limitations, laws and policy and regulatory frameworks under which other medical services are required to comply in relation to the Federal Privacy Act and other relevant state/ territory privacy legislation in Australia. Although other than the ACT which is governed by the federal act, all states and territories have jurisdictional responsibilities to clients in relation to privacy, the underlying themes are consistent at the federal and jurisdictional levels: • Usually, when a health service provider needs to collect, use or disclose your health information, they will need your consent.

• To give consent you need to understand what will happen to your information, so you need clear advice from your provider about what they want to do. You must be able to make your own decisions about whether you agree” (Privacy Act).

NSPs are routinely described as a strictly confidential space, however, the very act of collecting data in NSPs often breaches the individual’s confidentiality by both the questions that are asked and the way the information is gathered. In addition, the way the data collected is used and stored by the majority of services and jurisdictions might well breach both policy and legislative privacy requirements if it was ever seriously investigated and compared to other areas of health service delivery. While NSPs are supposedly ‘confidential’ spaces, the data collected is often taken by staff at counters with other staff and clients present – there is little

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or no physical room for confidentiality in the majority of NSPs. PWIDs interviewed for this document had a number of concerns about data collection, to the extent that for some the very act itself was a barrier; “I’d rather use the vending machine and pay than have to answer questions”. (John, peer NSW)

Access to New Injecting Equipment in Prisons There is clear and uncompromising epidemiological and social evidence that Australian governments must improve their response to drug use and BBVs in prisons. The sharing of used injecting equipment and the rates of BBVs in prisons surely indicate that the issue of access to new injecting equipment in Australian prisons can no longer remain an ‘if it happens’ theoretical-type discussion.

In 2001, the National Drug and Alcohol Research Centre (NDARC) stated that the “rationale for establishing syringe exchange programs in prisons is even stronger than in communities” (Rutter et al, 2001). The Australian National Council on Drugs (ANCD, 2002) has publicly supported a trial of Needle & Syringe Programs in Australian prisons in their policy paper on Needle & Syringe Programs. In their recently released discussion paper on NSPs in prisons the Royal Australasian College of Physicians (RACP) has also supported the available local and international evidence in favour of a trial of NSPs in Australian prisons (RACP, 2009).

Within Australian prisons, Hepatitis C rates are extremely high, with one-third of all male prisoners and two-thirds of all female prisoners having Hepatitis C (MACASHH, 2006:10).

According to the recently released National Hepatitis C Strategy 2010-2013, the rate of Hepatitis C in prisons is 40 times the rate within the general community (DoHA, 2010). With large numbers of people who inject drugs being repeatedly incarcerated for short sentences of less than six months; the prison environment has become an incubator for Hepatitis C infection within the general community. Indeed, research has now shown that having been in prison is an independent predictor for Hepatitis C seropositivity (Maher et al, 2004). In addition, it is also worth noting that national surveillance data shows a continuing increase in HIV prevalence among new prison entrants between 2004 and 2008 (NCHECR, 2009b: 24).

Despite the very high rates of HCV infection and increasing rates of HIV prevalence in correctional settings, NSPs are not available in any Australian prisons. It is argued that the lack of access to new injecting equipment for prisoners is in breach of Australia’s obligations under the International Convention on Economic, Social and Cultural Rights (ICESCR) to provide access to the highest possible attainable standard of health for all (ICESCR, Article 12). This same principle is also articulated in the Universal Declaration of Human Rights, Article 25.

The basic principles of human rights and health access at stake is also outlined in AIVL’s own policy statement on prison-based syringe exchange programs which states that: “The Laws of the Australian Government recognise that a person’s capacity to access health services should not be compromised by reason of imprisonment and that all people should have the basic right to health. This recognition is also evidenced in Australia’s international treaty obligations.”

(AIVL, 2008: 4) It is also in breach of general principles as contained in the World Health Organisation (WHO) Guidelines on HIV infections and AIDS in Prisons which states that: “All prisoners have the right to receive health care, including preventative measures (our emphasis) equivalent to that available in the community without discrimination, in particular with respect to their legal status and nationality” (WHO, 1993).

In AIVL’s Prison-Based Syringe Exchange (PSE) Programs Discussion Paper (2008) it is noted that there are PSE Programs in over 60 prisons in at least 9 countries including Switzerland, Spain, Germany, Belarus, Armenia, Iran, Kyrgyzstan, Moldova and Luxembourg (AIVL, 2008: 6).

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A number of these programs have conducted formal evaluations and while the results of the evaluations can vary some of the common outcomes include 98-100 percent syringe return rates, no increases in illicit drug use, no increases in overdose, no attacks or violence associated with the programs, etc (AIVL, 2008: 7). In addition, this growing body of evidence demonstrating the success of prison-based NSPs has shown that: “NSPs in prison have been associated with a substantial reduction in needle and syringe sharing, and there have been no recorded cases of HIV infection among prisoners participating in an NSP” (Australian Drug Blog.)

There is little doubt that informal and unregulated NSP occurs in Australian prisons. AIVL’s concern is that this unregulated provision of syringes acts as an uncontrolled source of BBV transmission in prisons and from there to the general community. Prisons take people from diverse settings who would not otherwise meet, create the opportunity for the transmission of bold borne viruses and then people return to their communities and social networks where they may continue to inject and practice unsafe injecting techniques acquired while in prison.

Although there is a lack of formal research data on the specific nature of prison injection practices, anecdotal information confirms that new injecting equipment in prisons can be worth more than the illicit drugs themselves with a single syringe rented out to many prisoners and potentially used hundreds of times. In addition, AIVL has significant anecdotal evidence that for many, prison is the site for the first use of injectable illicit drugs; this is particularly true for Aboriginal people taking up drug use in prisons.

Australia’s newest prison – the Alexander Maconochie Centre (AMC) in the ACT – opened in 2009 amid debate (from opposing and conflicting viewpoints) that it would be both ‘Australia’s first drug-free prison’ and be the site for ‘Australia’s first trial of prison NSP’. Pragmatic conjecture in support for the latter viewpoint (allowing for the potential trial of NSP in the AMC) not only came from researchers but also drug user organisations and other supporters of NSPs in prisons. Openness to at least consider such a program from the ACT Government, which is essential in support of the establishment of any NSP let alone within a prison setting, has also been implied particularly in the following statements: “A primary concern in the delivery of health services in the correctional context is to ensure that the prison does not become a crucible of contamination and thereby potentially compromise community health.” Drawn from the Ministerial Statement presented to the Legislative Assembly by the Attorney General Mr Jon Stanhope MLA August 2004.

And this from ACT Health Minister Katy Gallagher on ABC Radio on 3 December 2009: “If in 18 months, we’ve got 18 months worth of data that clearly indicates from a harm point of view, from a health point of view, that there would be benefits from having a needle and syringe exchange program then let’s look at it then with the evidence behind it. That was one of the complications for cabinet – we had no evidence of the Alexander Maconochie population and that’s what we’ll have. Some of the data that’s coming through already, clearly indicates that there would be benefits from a needle and syringe exchange program from a health point of view. But of course this issue is complicated and there are a range of views that need to be taken into account.”

Drug use in prison is a fact. That prisoners are routinely sharing syringes and thereby at very high risk of transmitting and contracting BBVs cannot be denied. There can be no question that overwhelming research evidence in support for implementation of NSPs in Australian prisons exists, or at very least for a trial of such to occur. The recognition that Australian prisons are acting as an incubator for BBVs and therefore the trialling of NSPs in Australian prisons should be prioritised by the jurisdictions has been clearly stated in the recently released National Hepatitis C Strategy 2010-2013:

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“In view of the well documented return on investment and effectiveness of Australian community-based needle and syringe program, combined with the international evidence demonstrating the effectiveness of prison needle and syringe programs it is appropriate throughout the life of this strategy for State and Territory governments to identify opportunities for trialling the intervention in Australian custodial settings” (DoHA, 2010).

With all the evidence and support, it is surprising that prison-based NSPs have not been implemented previously in Australian prisons. There is a historical basis for this nonimplementation of this essential BBV prevention initiative, that also has ties to earlier discussion in this document – particularly in relation to attitudes to injecting drug use and drug users and the impact of such attitudes on NSP/injecting equipment related legislation and policy.

Legislative action implemented following the use of a syringe against a prison officer and his subsequent death in NSW in 1991, together with media and corrective services unions, have acted as barriers to the establishment of NSPs in prisons nationally.

The Prisons Syringe Prohibition Amendment Act 1991 (NSW) forbids the introduction of syringes into NSW prisons with a maximum penalty of two years imprisonment. However there does remain a clause which states that distribution of syringes can take place: “If the Governor of the prison has consented to the persons introducing the syringe into the prison” (AIVL, 2008: 15). In this regard, in all jurisdictions the implementation of NSP and access to new injecting equipment in Australian prisons remains for the most part a matter of policy and most importantly, political will.

AIVL acknowledges the right for all workers to a safe working environment. In this regard we support the available evidence from the evaluations of prison-based syringe exchange programs in other countries which shows that the health and safety of prison staff can only be increased, not diminished by the introduction of such programs. Needles and syringes are already present in Australian prisons. The lack of any formal, sanctioned programs makes it more, not less likely that a prison officer might experience an accidental needle stick injury during prisoner and/or cell searches. Evidence from programs overseas have shown that once seen and experienced in operation, prison staff can become some of the strongest advocates for NSP in prisons. The main reason for this is that they can see for themselves how such programs can enhance health and safety for both staff and prisoners.

The debate concerning implementation of NSPs into Australian prisons needs to take into account and balance the rights of prisoners to harm reduction initiatives, particularly in this case BBV prevention and the need for a safe working environment for prison staff. As outlined above, AIVL believes that when it comes to NSP in prisons, the rights of prisoners and staff can be both accommodated and positively addressed through the same measure. The continued refusal to act on NSP in prisons despite the available evidence, means that the basic health and human rights of prisoner’s are being overlooked or ignored by Australian prisons and governments. Prisoners do not have access to the same level of quality health care as the general community. This is not a judgement; it is a fact that must be addressed as a matter of urgency.

“Prison systems and governments can no longer avoid their responsibilities to provide for the health of prisoners by dismissing prison needle exchange programmes as something new or untested. They are neither” (Lines, in McDonald, 2005).

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Environmental/Structural Barriers to NSP Access Few research resources have been given over to the range of barriers to NSP access which we we have termed ‘environmental’ or ‘structural’ which include the use of cameras to monitor staff and equipment safety at services and vending machines, hours of operation, counters in NSPs, NSP locations, NSP staff attitudes, community attitudes and transport. While the ‘Barriers and Enablers for Indigenous IDU to NSP Access’ research discussed some of the issues raised here – particularly in relation to Aboriginal drug user access, two further studies which have addressed some of these issues (to varying degrees) have been conducted by the Western Australian Government and NCHSR (CDCD, 2008; Treloar, et al, 2010). Some of the key environmental or structural barriers that have been identified by AIVL or in research include: • people who inject drugs require access to sterile syringes and clean injecting equipment outside of regular business hours – injecting drug use is often opportunistic, and drug users require equipment at the time of injecting, however many NSP agencies operate on limited or ‘business hours’; • people who inject drugs who live or work in outlying areas may have to travel significant distance to an NSP outlet – this may require significant time and associated cost, particularly if public transport is required (or available); • carrying injecting equipment on public transport – AIVL has considerable anecdotal evidence of PWID being fined for carrying new injecting equipment on public transport.

While there is specific legislation in relation to this in WA only, it provides a unique disincentive to accessing NSP for those who must utilise public transport. PWIDs in WA have confirmed being fined and having equipment confiscated on public transport sometimes when they are close to home and unable to return to the NSP to replace equipment due to cost and the limited hours of operation for NSP; • fear of being identified as a drug user by members of the community – for some it might be less identifying if pharmacy access was utilised (however pharmacy use may have its own disincentives); • lack of privacy and confidentiality for people who inject drugs particularly in rural areas – injecting drug users may feel the need to access equipment in larger towns where they may not be identified (if this option is available); • attitudes and experiences of discrimination by primary and secondary NSP staff – this may be particularly true for secondary staff (for instance in community health services or Accident and Emergency Departments) where NSP is not their primary role; • surveillance (real or perceived) – cameras in NSP services and focused on vending machines; • parking and traffic – the inability to stop and take the time necessary to utilise the NSP; • Lack of awareness of sites and the inability for NSPs to broadly advertise their location acts as an obvious barrier to access; if people who inject drugs do not know where NSPs are situated they cannot access NSP services.

There can be little argument that the more difficult it is made to access NSP the more likely that PWID are to reuse used injecting equipment and/or to share equipment. People who inject drugs garner the majority of their information from other people who inject drugs, and negative experiences, misunderstandings and half-truths can quickly gain currency. In addition, PWIDs travel, and a negative experience of one NSP can quickly become the stereotype for all.

AIVL believes that all the environmental and physical barriers to NSP access must be addressed and a thorough considered national informational campaign for both the general community and PWIDs be implemented.

Research has shown that when the public is made aware of the public health benefits of NSPs, support for the program increases (ANEX, 2009). AIVL would further suggest that the health and other benefits of NSP for PWIDs themselves should also be further promoted so that drug

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users are further encouraged to access services. This would by necessity include information on NSP locations and removing the environmental and structural barriers identified above.

Conclusion This document in no way means to take from the good work done through Australian NSPs (in all it’s adaptations). Nor does AIVL believe that this is the final answer in regard to breaching barriers to access. AIVL feels that this document can be utilised as a platform to initiate discussion and be developed further to instigate change. AIVL’s intention is to raise some of the many interconnected barriers to NSP and new injecting equipment access.

The issues raised in this document can potentially have serious implications for significant numbers of PWIDs. The provision of new injecting equipment through NSPs is an essential harm reduction strategy to reduce the spread of BBVs such as HIV and Hepatitis C. However, Australia’s NSPs were initially implemented in 1986 – in response to HIV/AIDS – before Hepatitis C was recognised as the virulent virus that it is, and prior to awareness of the foothold it had already established among PWIDs. The legislative, policy and environmental/structural barriers discussed; legislation impeding peer distribution, police protocols, confusing and contradictory policy directives and operational issues, can all be overcome. What is required is the commitment and perseverance of the various jurisdictional health departments, policy makers, drug user organisations, police services, corrections and NSP management to be sufficiently brave enough to overcome these barriers.

The following table briefly outlines the barriers to NSPs and new injecting equipment for PWIDs discussed in this document, outlines some of the key reasons how these barriers act to impede access, and recommends actions for change.

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Barriers to NSP Access/Addressing Barriers Barrier Legislative Barriers: Specific legislation in each state and territory preventing the distribution of injecting equipment by ‘unauthorised’ person(s).

Why it is a barrier

What needs to be done

Authorisation to dispense currently has limitations, including inability to dispense out of hours, restrictions on volunteers, students and unpaid workers distributing equipment.

Under guidance and direction of soon to be formed Ministerial Advisory Committee on Blood Borne Viruses and STIs (MACBBVS) Legal Working Group identify legislative and policy barriers to peer distribution of injecting equipment.

Peer distribution of equipment and effective peer education cannot be capitalised on due to legislative restrictions and dependent on circumstances.

Peers reluctant to distribute new injecting equipment due to fear of police, courts and confusion about the law.

Drug user organisations and NSPs cannot work with peers appropriately – major barrier to establishing formalised distribution schemes within peer networks.

Restricts reach of NSPs and leaves peers at mercy of discretionary policing.

Associated legislation and regulatory frameworks with indirect impact on peer distribution, including: - Aiding and Abetting - Possession of needles and syringes - Possession of injecting paraphernalia - Disposal of used injecting equipment - Self-administration

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Inconsistent and confusing legislation acts in direct contrast to harm reduction, including peer education and NSP service education.

PWIDs fearful of carrying needles and syringes and other injecting paraphernalia due to concerns surrounding police, harassment, questioning, searches and/or subsequent charges/convictions.

PWIDs confused about the carrying of used equipment, concerns about police practices based on previous experiences of new and used equipment being confiscated.

The MACBBVS Legal Working Party Report should be used to inform review of relevant legislation and policy at the jurisdictional level.

All states and territories remove and repeal associated legislation creating barriers to access including legislation making ‘unauthorised’ distribution of injecting equipment an offence.

Provide education for PWIDs, NSP workers and other relevant stakeholders about any legislative change(s) and the reasons for such change(s).

All states and territories to review ‘associated legislation’ for negative consequences in relation to access to and distribution of injecting equipment by PWIDs and repeal and revise legislation as necessary.

Provide education for PWIDs, NSP workers and other relevant stakeholders about any legislative change(s) and the reasons for such change(s).

Jurisdictional health departments should strengthen partnerships with state and territory police services with the view to educating and supporting police to apply harm reduction principles in their policing practice and operations.

Barrier

Why it is a barrier

What needs to be done

Mandatory/discretionary reporting in relation to harm to children, young people, neo-natal, pregnant women and families with children.

Reluctance to access new injecting equipment through NSPs due to fear of involvement from ‘family and community services’ departments and agencies.

All states and territories to review legislation relating to mandatory and discretionary reporting for negative consequences in relation to access to new injecting equipment

by PWIDs and repeal and revise legislation as necessary.

Concern with being identified as a ‘young person’ and potentially subject to questioning in relation to drug use and/or being refused access to injecting equipment.

Jurisdictions should develop consistent training for primary and secondary NSP workers on conducting effective risk-benefit analysis in relation to mandatory/ discretionary reporting. Such training should be required for all NSP staff.

Development of training for departmental and NSP staff on providing services for and working with PWIDs including younger PWIDs. Such training should be developed and delivered by drug user organisations in consultation with relevant youth agencies.

State and Territory health departments and NSP services to develop and/or strengthen partnerships with jurisdictional ‘family and community services’ departments and agencies in order to increase understanding of BBV prevention and harm reduction approaches.

Local council by-laws and development applications pertaining to NSP

Can cause extensive delays and/ or prevent the implementation of NSPs and associated services such as vending machines and outreach programs.

Prohibits development of new initiatives and denies access to new injecting equipment through lack of accessible services particularly in relation to 24 hour access.

State and Territory health departments should develop and/or strengthen partnerships between local councils, police and neighbourhood ‘drug action teams’ with the view to educating on the benefits of BBV prevention and harm reduction.

Jurisdictions to review relevant legislation and policy with the view to improving the process and removing delays to NSP service development.

Jurisdictions to provide instructional guidelines for new initiatives and programs to follow when seeking development approvals for NSP services.

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Barrier Policy Barriers: Lack of availability of a full range of injecting equipment in all jurisdictions.

Why it is a barrier Lack of universal access can result in PWIDs having to travel between services and even jurisdictions to access equipment needed. This can significantly increase likelihood of equipment reuse.

Inadequate access to new injecting equipment and other paraphernalia adversely affects the ability of PWIDs to prevent BBVs and practice harm reduction approaches.

What needs to be done State and territory health departments in consultation with drug user organisations regularly conduct research into the injecting equipment needs of PWIDs in their jurisdiction and use data to inform policy decisions on the injecting equipment made available through NSPs .

State and Territory health departments to ensure adequate funding is made available to provide free access to injecting equipment to the levels and ranges identified in the above research and other relevant assessments.

Drug user organisations should identify and provide information for PWIDs on potential alternative sources of new injecting equipment and other paraphernalia including pharmacies.

Drug user organisations should be resourced by health departments to develop a range of peer education initiatives in relation to safer injecting and drug use practices in order to further prevent BBVs and reduce other potential harms.

Limits on amounts and type of equipment available and implementation of user pays/cost recovery models.

PWIDs unable to access sufficient injecting equipment in the amounts and/or types required.

PWIDs unable to afford to purchase specific or sufficient equipment due to imposition of user pays or cost recovery models.

The above barriers significantly increase the likelihood of re-use and sharing of equipment and therefore the transmission of BBVs and other injecting-related harms.

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State and Territory health departments in consultation with drug user organisations regularly conduct research into the injecting equipment needs of PWIDs in their jurisdiction and use data to inform policy decisions on the injecting equipment made available through NSPs .

State and Territory health departments to ensure adequate funding is made available to provide free access to injecting equipment to the levels and ranges identified in the above research and other relevant assessments.

Barrier

Why it is a barrier

What needs to be done

Lack of implementation and effectiveness of police protocols and guidelines relating to NSP.

PWIDs fearful of police attention leading to potential harassment, questioning, searches, confiscation of injecting equipment and/or arrest.

State and territory departments should review protocols relating to NSP in consultation with the relevant jurisdictional police service.

PWID less likely to access NSPs.

Jurisdictional health departments should support the further development and strengthening of partnerships between NSPs and police to identify issues and improve communication.

Drug user organisations and NSPs should be resourced to provide ongoing education on working with PWIDs, harm reduction principles and the role and benefits of NSP for police officers in training academies and among serving officers.

Routine collection of statistics and implementation of surveys and questionnaires at NSPs.

PWIDs reluctant to access NSPs due to concerns about privacy and confidentiality.

PWIDs unlikely to access NSPs or respond to surveys due to concerns with data collection.

State and Territory health departments in consultation with drug user organisations should review data collection protocols and policy including; data collected, reasons for collection, use of data and privacy.

State and Territory health departments in consultation with drug user organisations should develop policies guiding the collection of data for jurisdictions and for the information of NSP staff and PWIDs. The principles contained in AIVL’s National Ethical Guidelines for Research Involving PWIDs should be used by jurisdictions and NSPs to set standards for the collection of any data and for conducting research with PWIDs.

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Barrier Lack of NSPs in Australian prisons.

Why it is a barrier

What needs to be done

Lack of access to NSP and new injecting equipment in Australian prisons is in contradiction with Australia’s obligations to international law and has been demonstrated in evidence to lead to ongoing increases in HCV transmission risk which also increases risk of infection among the general community.

Under guidance and direction of the soon to be formed Ministerial Advisory Committee on Blood Borne Viruses and STIs (MACBBVS) Legal Working Group identify jurisdictional impediments to NSP in prison.

The MACBBVS Legal Working Party Report should be used to inform the review of relevant legislation and policy at the jurisdictional level.

All States and Territories implement NSP in prison in line with available evidence and as part of a comprehensive approach to BBV prevention and harm reduction among prisoners.

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Barrier Environmental/structural issues: - Lack of parking and accessibility to NSP services - Negative attitudes to PWIDs among NSP staff - Restricted operational hours for most NSPs - Surveillance cameras at NSP services - Lack of privacy and confidentiality - Concerns with travel on public transport and carrying injecting equipment - Inappropriate physical environment including counters in primary services - Lack of awareness of services by PWIDs - Lack of knowledge of the role and benefits of NSPs by general community

Why it is a barrier Increases difficultly in accessing NSPs and new injecting equipment.

Increases likelihood of re-use and sharing.

PWIDs more likely to inject in unsafe circumstances, leading to increased risk of BBV transmission and other potential harms associated with injecting.

What needs to be done NSPs should conduct regular reviews of impediments to access and address where possible.

Ongoing and mandatory training for all primary and secondary NSP staff in attitudes and values towards PWIDs and in providing effective service delivery for PWIDs. State and Territory health departments should develop guidelines for new NSP programs which assess, identify and address potential structural and environmental barriers to NSP and strategies for increasing injecting equipment access.

State and Territory health departments to ensure adequate funding is made available to address potential structural and environmental barriers to NSP and injecting equipment access.

AIVL should be resourced to develop and maintain an online national directory of NSPs including location, contact details, opening hours and equipment dispensed/ services available.

Under guidance of the MACBBVS a national education and awareness raising campaign targeting the general public should be developed on the role and benefits of NSPs as a public health initiative.

State and Territory health departments should develop localised service directories for distribution through existing NSPs and relevant services.

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