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& Safety Journal

AUTUMN 2018 IN THIS ISSUE . . . HIV/AIDS and Injection Drug Use   

Introduction The Urgency - What we Know Why is this Issue so Important?

Action Plan

Trade Practices Act 1974 NOTICE TO ADVERTISERS & ADVERTISING AGENTS. The Consumer Protection provisions of the Trade Practices Act 1974, notably Sections 52 and 53, forbid both a corporation and an individual 1. from engaging in misleading or deceptive conduct in trade or commerce (Section 52); 2. from making false representations in connection with the promotion by any means of the supply or use of goods or services (Section 53). An advertisement which contains false representations in contravention of Section 53 may render the individual or the corporation making those representations liable to a fine of up to $10,000 (or 6 months imprisonment) in the case of an individual or up to $50,000 in the case of a corporation and a damages action by a party who has suffered loss as a result. Engaging in misleading or deceptive conduct may render the individual or corporation liable to a damages action by an injured party. It is obvious that whilst advertisements must not contain misleading, deceptive or false information, it is impossible for us to ensure that all advertisements submitted for publication conform with the Act. Our position is recognised by the Act itself in Section 85 (3) which provides a defence for a publisher who has received an advertisement in the ordinary course43 of business and did not know or had no reason to suspect that its publication would amount to a contravention of the provisions of the Act. We, therefore, ask all advertisers and advertising agents to satisfy themselves that each and every advertisement submitted for publication complies strictly with the Act. In case of doubt, advertisers and advertising agents should seek legal advice. CRIME PREVENTION & SAFETY JOURNAL IS PRODUCED BY HILTON PUBLISHING BRIGHTON VIC ABN 75 820 269 595 CRIME & SAFETY JOURNAL - PAGE 1


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HIV/AIDS and Injection Drug Use Canada is in the midst of a public health crisis concerning HIV and AIDS, and injection drug use, as the infection continues to spread in vulnerable populations, showing little respect for geographical boundaries. Those becoming infected are younger and younger, with the median age of new infection having dropped from 32 years to 23 years. Incarceration constitutes a risk for HIV, with limited innovations being implemented to improve the situation. Aboriginal peoples are over-represented in groups at high-risk for HIV infection. Women represent an increasing percentage of new HIV cases. The number of new HIV infections among injection drug users is increasing dramatically, with Vancouver now having the highest reported rate in North America. The proportions of this public health crisis are not well understood by the public. Immediate action is required at all levels of governmental and communityleadership. ·

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Policy and legislative issues must be addressed: enhance governmental and community leadership, change the Criminal Code by adopting laws that favour a medical approach over a criminal one and are applied with consistency, improve conditions in correctional settings, and base all decisions on available and emerging evidence (see page 12 for specific strategies). Prevention and intervention efforts must be enhanced: deal with discriminatory attitudes, improve needle exchange and disposal services, and change the nature of, and improve access to, methadone programming (see page 15 for specific strategies). Treatment options for substance use and HIV must be improved: expand the continuum of alternatives available, improve the quality of professional training, and research the interactions of treatments for drug use with treatments for HIV and other illnesses (see page 16 for specific strategies). Issues specific to Aboriginal populations must

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receive special and urgent attention: improve data describing the problems, develop culturally appropriate strategies, and ensure better coordination of those involved in the provision of services (see page 19 for specific strategies). Issues unique to women must be addressed: direct educational efforts at health care professions and women (through peer support), and conduct appropriate research (see page 21 for specific strategies).

The dollar costs of inaction are soaring, requiring an estimated $100,000 per HIV infection in direct costs alone. Immediate action is required. It is clear that with much work to be done and, given limited human and financial resources, we cannot do everything. The Task Force on HIV/AIDS and Injection Drug Use has identified the priority issues and the first steps to help stop the spread of HIV among injection drug users. The Task Force calls upon individuals, communities, non-governmental groups and governments to take responsibility for transforming this Plan from words into action. In particular, the Task Force strongly reconfirms the responsibility of the federal Minister of Health to show leadership on this issue, in partnership with key ministries (Justice, Solicitor General, Corrections) through initiating action, monitoring implementation, and evaluating outcomes. Introduction In many ways, Canada is in a good position to address the issue of HIV, AIDS and injection drug use (IDU). Our researchers and programmers have been prominent contributors to an increasing knowledge base in this area. We have an extensive network of needle exchange programmes. There is

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a widely dispersed base of community organizations which either already are, or could be, enlisted to respond. There is clear evidence of a desire on the part of the enforcement sector to be involved. We have a social safety net, universal health care and a broad public health system. The existence of problems within our correctional system has been recognized, resulting in a major study which provided concrete recommendations for improvement (“HIV/AIDS in Prisons: Final Report of the Expert Committee on AIDS and Prisons”, Correctional Service Canada, 1994) and a follow-up report two years later (“HIV/ AIDS in Prisons: Final Report”, by the Canadian HIV/ AIDS Legal Network and the Canadian AIDS Society, 1996). In short, there is much to be applauded in the progress already achieved in addressing this crisis. However, we must be prepared to move forward and build on these accomplishments. Canada is still in the midst of a public health crisis concerning HIV/AIDS and injection drug use. Despite clear indications of an escalating problem since the mid-1980s and the use of a variety of approaches to address it, the spread of HIV among drug users is increasing, as is the incidence of hepatitis and tuberculosis. Epidemics continue to emerge among new populations. Intersecting issues–HIV and AIDS, substance use, mental health –create multiple problems in an individual for which there is no prescribed course of intervention or treatment. It must also be noted that IDU is not the only connection between HIV, AIDS and substance use–alcohol and other drug use can alter judgment and adversely affect the adoption of safer sex practices, leading to an increased risk of contracting HIV. Continuing marginalization and stigmatization of drug users, especially those who inject, and those who are HIV positive or have AIDS, remain barriers to progress. Leadership is in question, from key community levels up to the federal government. With the above needs and urgency in mind, and acting on a key recommendation from the “Second National Workshop on HIV, Alcohol and Other Drug Use” held in Edmonton in 1994, a Task Force was created to develop a “National Action Plan on HIV/AIDS and Injection Drug Use”. Funded by Health Canada and coordinated by the Canadian Centre on Substance Abuse (CCSA) and the Canadian Public Health Association (CPHA), this group has built on the discussions from the Edmonton Workshop, identified

the most pressing issues of the day and recommended strategies and stakeholders for their implementation. While not claiming to be a comprehensive solution, it is a roadmap for a journey which must be initiated without delay if further spread of this epidemic is to be curtailed. The Urgency– What We Know(1) (1) Unless otherwise indicated, the information included in this section was obtained from “Epi Updates”, Laboratory Centre for Disease Control, Health Canada, December, 1996. HIV rates in Canada are still increasing, with the infection spreading in vulnerable populations and showing little respect for geographical boundaries. Canada is estimated to have had between 19,000 and 20,000 AIDS cases at the end of 1996 (adjusted for reporting delays and underreporting), with 72% of cases reported as having already died. Another 10,000-12,000 cases are expected by the year 2000. In terms of HIV, by the end of 1994 Canada is estimated to have had between 42,500 and 45,000 cumulative cases. Each year adds an additional 2,500 to 3,000 new cases. Those becoming infected with HIV are younger. The median age of new HIV infection has dropped from age 32 years in those infected before 1983, to 23 in the period 1985-1990. It is clear that HIV is increasingly a problem of Canada’s youth. HIV among injection drug users is increasing dramatically, with Vancouver now having the highest rate in North America. Although only 8.2% of cumulative AIDS cases reported to date are among injection drug users, the proportion of cases has increased over time, particularly for women - while 6% of cases before 1989 could be attributed to IDU, this figure rose to 15% between 1989 and 1992, and to 24% between 1993 and 1996. For men, the figures rose from 1%, to 2.6% to 5%, for the same time periods. HIV data are of even greater concern. In Ontario, prior to 1995, 2.8% of new positive tests were

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IDUs. This has more than doubled to 6.1% in 1995. In British Columbia, the same figures jumped from 9% prior to 1995, to 38% in 1995. In terms of HIV prevalence among IDUs, which gives us a snapshot of the proportion currently infected, Montreal has a rate of 20% and Vancouver is at 25%. New infections are occurring at a rapid rate. Currently in Montreal, it is 8.2 per 100 person-years (Hankins, et al., 1997), and a Vancouver study has documented a rate of 18.6 per 100 person-years. This means that among 100 uninfected individuals on January 1, 1997, who continue injecting, 19 of them will have become infected with HIV by the end of this year. This is the highest reported rate in North America (Strathdee et al, in press, 1997). Although most available data focus on major urban settings, the importance of this issue to other cities and rural areas must not be overlooked, or neglected. In particular, as HIV spreads through the general population, facilitated by injecting drug practices, it is of increasing concern to all Canadians, regardless of geography. Incarceration is a risk factor for acquiring HIV, with few innovations being implemented which would improve the situation. The legal aspects of drug use, and their intersection with HIV/AIDS, have created an emergency situation in our prisons. Many injection drug users spend time in prison settings, either directly, because of drug convictions, or due to other criminal convictions related to that use. Between April, 1994, and August, 1995, the number of known cases of HIV/AIDS in federal correctional institutions rose by 40%. Rates of Hepatitis C range from 28 to 40%. It is a fact of life that inmates will continue to engage in high-risk behaviours. Unfortunately, administrative responses within federal and provincial correctional services aimed at preventing the spread of HIV have thus far been limited (Jürgens, 1996). With the majority of prisoners moving back to the community once their jail terms have been completed, the seriousness of this issue for all Canadians cannot be ignored. Despite limited epidemiological information, existing data clearly indicate Aboriginal peoples are over-represented in groups most vulnerable to HIV infection, and the epidemic shows no sign of slowing.

groups most vulnerable to HIV risk –inner-city populations, sex-trade workers, incarcerated individuals. In a 1995 study, 30% of IDUs who used needle exchange programmes in Vancouver were Aboriginal (Patrick et al, in press, 1997). Within our prison settings, 14% to 40% of inmates are Aboriginal (depending on the province), placing them at increased risk within this confined environment, in which the incidence rate is high (Jürgens, 1996). As well, many Aboriginal people move back and forth between urban settings and reserves, further increasing the potential for spread of HIV. It should also be noted that some Aboriginal populations have higher rates of sexually transmitted diseases, which increases the risk of HIV transmission. Women represent an increasing percentage of new HIV cases, many contracting the infection through injection drug use. The proportion of AIDS cases among adult women, as compared to all adult cases, has increased significantly, from about 5.5% during 1981-1989 to 7.2% during 1993-1996. Injection drug use accounts for 17% of all cases, second only to heterosexual transmission. As of September, 1996, 116 AIDS cases have been attributed to perinatal transmission. An increasing percentage of women being tested for HIV are being found to be positive. Prior to 1995, about 8.5% of women tested in Ontario were HIV positive, compared to about 16.4% in 1995. In B.C., this rate changed from 9% to 22.8% for the same time periods. Key risk-factors are injection drug use, and having sexual partners who are at increased risk for HIV. The cost of inaction will outweigh the cost of response, in dollars, and in human suffering. A recent study attempted to assess the direct and indirect costs associated with the treatment of AIDS and HIV, finding that direct medical costs of treating HIV were $100,000 per individual (Hanvelt and Meagher, 1996). It is expected that treatment costs will increase as new drugs become

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available, and are used for longer periods of time. By any analysis, the costs of this crisis are enormous, and most are yet to come. This is in addition to the pain and suffering of persons living with HIV and AIDS, and the loss and grief experienced by loved ones.

dren. Although epidemiologists agree that this epidemic is unlikely to ignite within the broader community to the same extent it has among injection drug users, it will nonetheless touch many lives, infecting and affecting many people who have never used drugs.

New drug-using trends can affect HIV rates significantly.

While recognizing the seriousness of our circumstances, it must be acknowledged that there is hope. There are effective strategies that have been documented and can be implemented, and there are new paths to explore. Drug users can and do learn to use safer methods of injecting which can protect them, their partners, and their children from HIV. Some stop using drugs altogether. The right interventions, offered at the right time, do work. It is time to move beyond debating ideological differences and take full advantage of the knowledge and experience already available. It is time to act.

Attention has typically been focused on the heroinusing population, but new trends indicate an increasing shift toward cocaine use in many cities across the country. In Vancouver, 80% of needle exchange clients inject cocaine (Strathdee et al, in Press, 1997). In Montreal, the figure is 70% (Hankins, 1997) and in Halifax 52% (Grandy, 1995). This raises the spectre of a broader range of networks for HIV transmission, given that there is not perfect overlap between heroin and cocaine-using populations. Combined with the higher injection rate (up to 20 times per day), health and safety concerns are significantly increased. Why Is This Issue So Important? It has been estimated that between 42,500 and 45,000 people have been infected with HIV in Canada. It is impossible to know exactly how many have become infected through the use of injection drugs, but the information provided above clearly indicates not only are the absolute numbers of concern, but most importantly, they are on the rise. In the U.S., for instance, a recent study estimated that nearly 50% of new HIV infections each year now occur among IDUs (Holmberg, 1996). While the direct and indirect costs associated with these HIV infections are still being calculated, early indications suggest they will no doubt justify a dramatic increase in investment to keep this epidemic under control. It is not only the absolute numbers one must take into account, but the alarming and consistent rates of increase, as well as the toll in dollars and human suffering. People who inject drugs do not usually continue to do so all their lives. When they successfully stop injecting, society wants them to have years of productive life ahead of them. For this to happen, we must keep them healthy, HIV free, and alive. Injection drug users do not live in a vacuum. They are members of our community and, both during and after the periods of their lives which involve the injection of drugs, they form intimate partnerships and have chil-

The Action Plan Scope The Action Plan: 路

identifies the most pressing issues, offers strategies with which to address these concerns, and suggests who are in the best positions to implement the recommendations. It recognizes that different issues are of greater or lesser importance to different individuals and organizations, and presents the current recommendations as first steps in addressing priority concerns. strongly supports the use of a harm reduction approach, in conjunction with other, complementary approaches recognizes the urgent need to make strong recommendations, but not to be prescriptive. Each level of government, each community, each individual must apply the recommendations as is appropriate, developing unique, but complementary responses to a common problem, takes a simple, straight-forward approach to increase the likelihood of action, but does not avoid complex issues, in particular, those dealing with drug policy and enforce

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ment issues, · recognizes that marginalization and stigmatization of drug users in general, and those infected with HIV in particular, are key barriers to progress against the epidemic, and focuses its efforts on reducing these barriers. Placing these individuals at the margins of society reduces access to health-enhancing services, ultimately placing the community-at-large at greater risk from the spread of HIV, · does not address in detail the long-term prevention measures for young people who may be at risk from using drugs at some point in their lives. The Action Plan focuses on the immediate priority of reducing harm to those who are at risk of initiating injection drug use, or are already doing so. Philosophy There are many underlying philosophies on which to base an approach to HIV, AIDS and IDU. The Task Force supports each individual and community in its right to select the most appropriate modality for its needs. Treatment of drug use has been primarily based on an abstinence model, which has a goal of total cessation of use. While recognizing the merits of this approach, the Task Force, in assessing the issues around HIV, AIDS and IDU, recognizes that abstinence is not always a realistic or feasible goal for the individual using currently illegal drugs and that, in the interest of public health, alternative methods must be considered. While neither condoning nor condemning drug use, this harm reduction model accepts that drug use continues to occur, and that many initiatives can be undertaken to minimize the harm to all involved. This approach does not exclude abstinence as an eventual goal, should the individual decide to pursue it. However, the focus is on minimizing the harmful outcomes that can be associated with drug use. Examples of harm reduction initiatives include provision of needle exchange, condoms, information on safe-injecting practices, and safe-injecting rooms or shelters. Evidence-based support for these approaches continues to mount, both in Canada (e.g. Hankins, 1997) and elsewhere (Lurie & Drucker, 1997). Methodology

The Task Force was composed of a spectrum of voices from the Canadian HIV, AIDS and substance use fields, including public health, the legal system, enforcement, community-based organizations, medicine, research; Aboriginal peoples, consumers, men and women (individual members are identified in Appendix C). Following a 2-day meeting of the Task Force, a draft document was prepared and sent for additional comment to 80 key stakeholders in Canada and internationally. It was also distributed, as an interim document for information only, to key policy and decision makers across the country, including federal and provincial Ministers, Medical Officers of Health and professional Colleges. After considering all input, a revised Action Plan was adopted by the Task Force and presented to Health Canada. Dissemination will be as broad as possible, including on the internet, to target key decision-makers, community leaders and mobilizers, and the media. Guiding Principles · · ·

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Effective leadership is required at all levels. Community involvement is key to the success of the Action Plan. All recommendations are aimed at decreasing the marginalization and stigmatization of injection drug users, and particularly those living with HIV or AIDS. Suggested strategies attempt at all times to recognize the diversity among injection drug users and to be aware of the variety of needs when designing programmes and policy. Collaboration with a wide base of partners is essential to the successful development and implementation of policies and programmes, drawing from the HIV, AIDS, substance use and mental health fields as well as ensuring all sectors are involved (health, enforcement, legal, and others). New partners should continually be sought. Those using the services must be involved in the processes which affect them–policy and programme development. Ongoing assessment and evaluation of the

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efforts and interventions undertaken are the cornerstones of all initiatives. Priority Issues The Task Force considered a broad range of urgent needs concerning HIV and AIDS and injection drug use. The recommended actions and implementation strategies have been captured in the following sections under five key headings: Policy and Legislation, Prevention and Intervention, Treatment, Aboriginal Peoples and Women.

education, health, justice, welfare, governmental and non-governmental groups). Clear and appropriate leadership roles must be indicated. Our policies must be ethical and involve consumers in their development. Politicians and community leaders are encouraged to be bold, passionate and risk-taking in their responses to this issue, using existing and emerging research findings. Recommendations

Policy and Legislation

1. Leadership and commitment to action must be enhanced.

Overview

How?

There are a number of limitations to existing drug policy in Canada which affect our ability to address HIV and AIDS in the injection drug using population, and, in fact, may contribute to the situation or make it worse: o given the currently illegal status of many drugs, those who inject often opt for the most efficient and fast means of introducing the substance into their bodies–injection drug use–in an attempt to maximize a speedy effect and, at the same time, minimize the likelihood of detection and arrest. o The illegal status of drugs makes the user afraid to go to health or social services, increasing marginalization o service providers themselves may shy away from providing essential education on safer use of drugs for fear of being seen to condone use o the illegal status of drugs fosters emotion-laden anti-drug attitudes toward the user, again adding to marginalization of this population, and directs action toward punishment of the “offender”, rather than fostering understanding and assistance. Canada requires policies which encourage injection drug users to access services, which ensure these services are relevant to client needs, and which allow our society to move toward destigmatization in response to this issue. Policies must encourage multisectoral participation and community partnerships (multi-sectoral refers to a variety of sectors such as

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In view of the seriousness of the problem and the multi-sectoral nature of the solutions required, the federal Minister of Health should take the lead in ensuring a coordinated and integrated response to all recommendations in this National Action Plan. Continue or renew national strategies to address HIV/AIDS and substance use with appropriate levels of funding, directed primarily at community-based initiatives. Foster formal linkages and permanent mechanisms for consultation and communication among all relevant players, including the criminal justice and health systems, as well as social services. Ensure funding exists for alternative programmes in prevention, drug treatment and diversional sentencing to community programmes, including those implemented under Bill C-41(2) (Alternative Measures). Existing funds should be allocated to these programs and, in addition, funding should be increased through innovative options such as the following:

1) 50% of the revenues produced through Anti-Drug Profiteering/Proceeds of Crime cases, 2) A 25% surcharge placed on all fines to drug traffickers. (2) Bill C-41, proclaimed in September, 1996, gives courts of law flexibility in responding to a

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variety of crimes, including drug-related offences, and encourages diversion of the perpetrator away from the criminal justice system to more appropriate consequences. In the case of currently illegal drugs, this could include counselling, treatment, community service, and so on. Use of these funds should be overseen by a partnership of key involved Ministries, federally and provincially. ·

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Ensure all provinces become signatories to Bill C-41, and develop nationally coordinated implementation strategies. Ask that the Health and Enforcement in Partnership (HEP) Steering Committee consider all recommended policy issues and facilitate implementation within their respective departments.

2. The Criminal Code must be changed. How? ·

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Provide specific exemptions under the legislation to ensure that physicians may prescribe narcotics (e.g. heroin, cocaine) to drug users in an effort to medicalize drug use and reduce harm associated with obtaining drugs on the street (e.g. English Model). Research to assess the feasibility of this approach should be undertaken on a pilot basis. Decriminalize the possession of small amounts of currently illegal drugs for personal use. Institute heavy penalties for the commercial trafficking of any drug to minors. Initiate discussions among judges, prosecutors and police officers to address the lack of national consistency in the application of laws. For a variety of reasons, these sectors exercise such a high degree of discretion that national legislation no longer has national applicability. This discussion is made necessary by the increasing use of diversion in the justice system and new initiatives by the health service aimed at drug users. The principal goal of these discussions must be to protect the rights of the drug user, within an accepted legal framework.

1996, for a full examination of correctional issues and accompanying recommendations. How? ·

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Allow prisoners who have been in a methadone maintenance programme prior to incarceration to continue to receive such treatment in prison. Ensure methadone treatment is available to opiate-dependent prisoners who were not receiving it prior to incarceration. Institute programmes to evaluate the need for methadone maintenance therapy prior to prison release, and ensure priority transfer to community programming on the outside at release. Conduct pilot programmes of needle exchange in federal and provincial correctional settings.

4. Since sound policy decisions rely on solid research data and directions, research activities must be recognized, utilized and enhanced. How? · ·

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Involve IDUs in all aspects of research. Continue to monitor HIV rates and use this information fully in developing new policies and programmes. Investigate local transmission patterns of HIV in IDUs. Fund additional research to determine the extent of diversion of prescription opiates to the black market. Include quantitative, qualitative and ethnographic methodologies in research designs in order to increase the usefulness of data to policy and programme development. Use the “Guidelines on Ethical and Legal Considerations in Research on AIDS and Drug Use at the Community Level”(4) when conducting community-level research.

(4) Using conservative figures, if 40% of the currently estimated 50-80,000 IDUs in Canada requested methadone services, at least 20,000 spots would be required.

3. Conditions in correctional settings must be improved.(3) (3) The reader is directed to the document “HIV/ AIDS in Prisons: Final Report” by Ralf Jürgens,

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Key Partners · ·

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drug users federal, provincial and territorial Ministers of Justice and Corrections provincial Attorneys General police organizations Bureau of Drug Surveillance, Health Canada Laboratory Centre for Disease Control, Health Canada policy makers Colleges of Physicians and Pharmacists legislators lawyers’ associations the judiciary Health and Enforcement in Partnership Steering Committee researchers (universities, Statistics Canada, Medical Research Council, Ministries of Health, Social Services, Justice, etc.) Provincial and Territorial Departments of Public Health HIV/AIDS and substance use service providers

Prevention and Intervention Overview For long-term impact, and to truly address the issues of marginalization and stigmatization, it is essential that key agencies show leadership in prevention activities. Those providing services in the areas of HIV, AIDS and substance use are, and must continue to be, instrumental in creating an environment which is open to a change of norms. They must work together to achieve these goals. This will be a first step in achieving public awareness and acceptance of the realities in their midst. It is critical that more effective prevention and early intervention strategies be developed both for drug use and HIV infection. To protect young people in Canada and future generations, it is essential to have good health promotion programmes suited to communities and cultures across the country. This should include

programmes to support strong mental health and selfesteem of individuals, and provide sound education about drugs, healthy sexuality and healthy relationships. It should also include research to help us understand what makes young drug users decide to start injecting and what the appropriate response should be. It does not serve realistic health goals to try to scare children away from the natural developmental tasks of exploring sexuality, taking risks, setting one’s own boundaries and establishing an identity. Only truthful information and respectful discussion will serve long term health goals. While these long-term public health issues must not be neglected, they are not the focus of this Action Plan. The prevention issues and strategies identified here are aimed at helping Canadians at immediate risk. We need to help those people who are using injection drugs today. At the most basic level, attitudes towards injection drug users living with HIV or AIDS must be addressed as a first step in the destigmatization and normalization process. A starting point is the education of the public and professionals, which will lead to increased awareness of the issue. Needle exchange, while a demonstrably effective and essential complement of HIV prevention (Hankins, 1997; Lurie & Drucker, 1997), can work better through decentralization and integration with community-based health services. The overriding goal must be to minimize risk to the individual, the community and society as a whole, through providing care and support to our most vulnerable citizens. Recommendations 1. Discriminatory attitudes toward drug users living with HIV or AIDS must be addressed, with a view to elimination, both in the general public and within professional groups. How? ·

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Actively involve drug users in policy development, programme planning and implementation for prevention, care and support, as well as in evaluation. Create community-based peer-support and

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advocacy groups for drug users, and integrate drug of health services (including health promotion, users into existing organizations. nutrition, self-esteem training, safe injecting · Develop programmatic inter-agency and interpractices) rather than marginalize this one disciplinary links (mental health, addiction, service. Expansion of alternative sites such as acute care, community hospitals, HIV treathospital Emergency Rooms, Public Health ment). clinics, community-based clinics and pharma· Promote awareness, recognition and accepcies must be considered in order to achieve tance in the justice system and in law enforcedecentralization. ment that addiction is better dealt with as a · Encourage every pharmacy in the country to health and social issue, than a criminal one. sell needles, advertise needle exchange ser· Improve diagnostic and treatment capabilities vices in the community, and offer disposal of physicians, nurses, pharmacists, etc. through services in conjunction with local health aufocused, cross-disciplinary education at the thorities. undergraduate level and through continuing · Consider giving community awards to pharmaeducation. cists for their support in order to encourage · Provide training and information to the juditheir continuing involvement, as well as that of ciary and others in the criminal justice system their peers. on the link between HIV and AIDS, and IDU, · Purchase needles for community programming as a health issue. in bulk for an entire city, as in Montreal, or for · Promote harm reduction as a necessary coma whole province, as in B.C. This is a costponent of a range of strategies when developcutting measure which would allow more ing programmes and policies. needles to be made available. · Enhance intersectoral responsibility at all levels · Offer needles on their own and as part of a of government, recognizing that HIV/IDU package including alcohol swabs, condoms, encompasses health, social and corrections lubricant, pamphlets, pharmacy addresses, etc. considerations. 3. Access to methadone treatment must be im· Examine, and change where necessary, poliproved. cies and procedures of professional bodies (e.g. physicians, pharmacists) to make sure How? they facilitate harm reduction and encourage · Revoke the need for physicians to have authothe involvement of members in caring for rization from the federal Minister of Health to injection drug users. prescribe methadone. Revoking the need for · Involve all partners and especially community authorization will allow physicians to prescribe organizations in promoting needle exchange methadone like any other drug, making methaand disposal as health and safety issues (e.g., done more accessible. availability of needle exchange programmes · Make appropriate training available to physiand appropriate, accessible disposal facilities cians to encourage their involvement in providreduces the likelihood of injury to children, ing methadone treatment to injection drug janitorial staff, and others, that can result when users. needles are improperly discarded in play· Dramatically increase the availability of methagrounds and other locations). done treatment, at a minimum increasing the · Develop other partnerships to enhance this total number receiving treatment from the process (e.g., persons with diabetes and their current 3,600 to 7,200 within 18 months.(5) organizations). · Reduce and eliminate other barriers. 2. Services involving the exchange of needles must be improved. How? ·

Provide access to needle exchange in the community, and integrate with a broad range

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