CURRENT DEVELOPMENTS IN THE FIELD OF AIDS AND DRUGS
AUTODESTRUCT SYRINGES AND NEEDLES DISTRIBUTION SYSTEMS FOR SYRINGES AND NEEDLES
COMMUNITY BASED PREVENTION AND CARE INITIATIVES
TABLE OF CONTENTS
2. Report of the expert-meeting
3. Syringe distribution in the E.C.
R.Braam, D.De Bruin & Drs.E.Fromberg *
4. Users opinions on services
Dr.J.P.Grund, S.Stern & Drs.J.Chatab *
5. Single use syringes
Drs E.Fromberg & P.McDermott *
6. Annexes *
The origin of this report is a mixed one. On one hand the AIDS and Drugs department of NIAD was preparing a proposal for a expert meeting on community based AIDS prevention and care initiatives, on the other hand the European Commission felt the need to explore users opinions on single use syringes. A happy coincidence led to the coalescence of these two objectives, finally resulting in this report.
The root common to the studies to be combined was the observed need to be informed about user’s perceptions of the services that are provided in the framework of HIV prevention.
Although harm reduction policies have been adopted in a few places before the AIDS-epidemic started, it was the realisation that HIV could and would spread from intravenous drug- users to the general population, that started a rethinking of the policy towards them.
In the 1960’s and 1970’s existing drugservices were generally abstinence-oriented and attracted only a small percentage of the users. AIDS however necessitated a change into a health-oriented policy that had to attract a large percentage of the using population. Although the interest of the general population and the interest of the users now ran parallel, this did not change the attitudes of the general population. Even if user groups, junkiebonden etc. became involved in a few countries, this affected the policy only on the surface, because the moral attitude among the general population and their governments prevailed. So the health-oriented policies were top-down implemented and were often not user oriented. This was especially the case where the services are delivered by the drug aid institutions, that experienced big difficulties to change the attitudes of their staff from a treatment orientation into a service orientation, guided by the users’ needs, which is necessary to be effective.
This irrational, moral preoccupation on the different levels can be exemplified by some examples:
- Steroid-injecting is rarely an object of government policy, although this practice is as much a risk regarding AIDS as the injection of psychotropic drugs.
- The "no bleach/only exchange"-attitude aiming at a consistent policy, which however implies a consistent risk.
- The obsessive identification of drugusers as marginals blocking the perception that recreational/nondependent drugusers are probably a more important means of spread than the really marginalised.
- The neglect of noninjectors likelihood to engage in unsafe sex influenced by drugs, especially alcohol, although it has been shown that gay men’s unsafe behaviour increases when using alcohol, crack, poppers etc. The Dutch "safe house" campaign: "Have a safe rave!", is a rare example that adresses this matter.
Thus there is a clearly perceived need to involve users and users’ perceptions in the implementation of health oriented policies as the provision with clean needles and syringes. Experiments with peer education, are another example of this development.
This study basically involves three parts:
- a literature review, updated by short visits, covering the whole of the European Community describing the availability of injecting equipment services.
- a study of intravenous drugusers opinions on and experiences with these injecting equipment services. As only three countries have significantly implemented injecting equipment service’s, although at a different level, we decided to interview intravenous drugusers in those three countries: the U.K., Germany and the Netherlands.
- a study of intravenous drugusers opinions on single use syringes.
The actual research was preceded by an expert meeting where along with community based AIDS prevention and care different aspects of the studies were discussed among representatives of the three countries involved. This was an extension of the initial idea to have this meeting with representatives of only two countries. The report of this meeting is given in chapter II.
The literature review was started by requesting the governments of all member states of the E.C. to inform us about injecting equipment services in their countries. Added to the information thus obtained was information from streetcornerworkers and other persons involved on the streetlevel in the different countries. The results are presented country by country in chapter III.
The main objective of the study was to record the opinions of users about the services provided. Although AIDS-prevention is clearly in the users interest, the main impetus for the providing of clean syringes and needles has not been the concern for the spread of HIV-infection among drugusers, but the fear that by way of drugusers HIV would spread among the general population. This has generally lead to an top-down approach, in which the services provided were defined by non-users that were generally not to well informed about the norms and values of users. Moreover we should record these perceptions as unbiased as possible. Users being dependent in various ways on the drug institutions, including the injecting equipment service’s, may be tempted to answer questions in such a way as to please those that they are dependent upon. So our overriding interest has been to avoid subjects being questioned by drug service personnel, also because of their probably different attitudes.
To fulfill this requirement we used as much as possible interviewers that were either (injecting) drug users themselves, or "credible" non-users related to the selfhelpgroups (Mainliners-London, Mainline and MDHG Amsterdam, DV8 Rotterdam, users related to the Merseyside Drug Training and Information Centre-Liverpool, JES Berlin, Deutsche AIDS-Hilfe Frankfurt and instructed them to this aim.
We left the selection of interviewees to the interviewers, however stressing the necessity to obtain them at the street level and not within drug services, to avoid other biases.
We recognised the fact that this procedure would cause most of the interviewers to be rather inexperienced, but felt this to be less important than the risks attached to systematically biased interviewers interviewing a systematically biased sample of respondents.
A second consideration was that injecting equipment service’s are highly different and have highly different regulations in the different countries, and even in different cities within one country. To avoid on one hand the eventual conclusions to be influenced to much by the local situation and on the other hand to minimize the interviewers selection bias, we decided to perform our research in two cities in each country. We selected cities with considerable IVDU-populations: Berlin, Frankfurt, Amsterdam, Rotterdam, London and Liverpool, were we had the relevant connections to execute the research. So the final sample of 92 respondents consists of six subsets (5 of 15 respondents and one of 17) each interviewed by a different interviewer.
We realised that the data that would be obtained in this way had to have a rather limited validity, unless we would be able to interview large numbers of users. This however was impossible within the funding available, so we chose to perform limited, targeted preliminary research, establishing a network for future more extensive research. Therefore the study has been as well a pilot, to research the possibilities of this approach, which we consider now a sucses.
The NIAD department of Research has been invited to produce a questionnaire for the study on users opinions on the services provided. This questionnaire, although scientifically valid, was rejected by those responsible for the actual interviewing being present at the expert meeting. A simplified questionnaire was subsequently developed wich, by the way, turned out afterward to have it’s disadvantages as well but at least was acceptable for the interviewers within their relation to the "scene". This exemplifies again the pilot quality of this study: it should be as user oriented as possible, even at the cost of decreased scientific validity. All involved agree that the phenomena studied are difficult to approach and that within the framework of this study testing the possibilities of our approach is an important basis for future research.
A final remark is that we underestimated research and organisational costs and over-estimated travel costs. The network we employed and, doing so, reinforced was such that much information was obtained during meetings within other frameworks and also time spent on the phone etc. was considerable.
SYRINGE DISTRIBUTION IN THE E.C.
R.Braam, D.De Bruin & Drs.E.Fromberg
The Servicio de Drogodependencias de la Mancomunidad de Ayuntamientos de las Comarcas de Catalunya de Penedès-Garraf has taken the initiative to organise a syringe exchange program in april 1990. This resulted in an actual start of this program, effectuated by 22 pharmacies in this region on 15 januari 1992. They distributed 9.155 kits, containing a disposable syringe, a condom and an information sheet on proper injection techniques. The return percentage was 51,44 %.
This results of this program have been used to facilitate the initiation of similar programs in other parts of Catalonia. On 10 february a resolution to this aim has been passed by the Catalonian Parliament.
USERS OPINIONS ON SERVICES
Dr.J.P.Grund, S.Stern & Drs.J.Chatab
USERS PERCEPTIONS ABOUT AUTODESTRUCT SYRINGES
- Drs.E.Fromberg & P.McDermott
The driving force behind the development of autodestruct syringe has at first not come from the field of drugs. The main impetus came from the United Nations Childerns Fund (UNICEF), supported by the World Health Organisation (WHO), that ceased to supply disposable syringes to the developing countries from april 1987, except to those that have developed a system of effective disposal of these after one use. Within this framework autodestruct syringe in immunization programs serve to prevent people to remain unvaccinated because of fear for attracting AIDS or other blood-transmissible diseases. Since 1987 the WHO has tested 273 different models, and rejected more than three quarters of them (1), although the technical requirements for such syringes, to be used only for vacinations, are considerably less complicated than those for intravenous drugusers. By example: intravenous drugusers require syringes that permit to aspirate for blood also once the injection stroke has begun.
The basic intention behind proposals for autodestruct syringe for intravenous drugusers is however a technological fix to force "irresponsible" drug-users into a "responsible" behaviour and although the general idea is popular among AIDS-prevention workers, most of these do not realise the complications of such devices in terms of their acceptance by intravenous drugusers.
One of the first to research these aspects was De Loor in Amsterdam (2). In this important study he first sets out to describe the general procedure followed by intravenous drugusers to take a shot and concludes that the plunger has to have the capability be pushed down and pulled back several times. The possible risk that anything goes wrong during this procedure disabling the syringe would make such a autodestruct syringe completely unacceptable for intravenous drugusers and would make them return to far more dangerous practices.
Another important observation of De Loor is that in most versions of autodestruct syringe the user has to add one more action to this ritualised behavioural repertoire to disable the syringe. He feels that this disabling action, that is contrary to the users interest, will generally not be taken. To the contrary, intravenous drugusers live in a "preservation culture", aimed partly to preserve injecting equipment for future use in case of need, but, even more important, because they consider a syringe not to be a throw-away item, as a used condom, but as an object with an added value, like a special cigarette-holder for tobacco smokers. "The syringe is a symbol, an extension of the libido, a guide between the inner life (the wall of the blood vesel) and the outer life (reality)", writes De Loor, also referring to Lou Reed: "It’s my wife. It’s my life".
Finally De Loor draws attention to the different ways in which syringes and/or needles can be shared and concludes that not only autodestruct syringe but also single use needles should be developed, unless the needle is fixed to the syringe.
Based on the models he had available he concluded that none of them met the requirements of intravenous drugusers. Although he did not exclude the possibility that "somewhere in the world there might be a genius able to solve the problems at hand" he was sceptic on this possibility and stressed that an eventual search for a autodestruct syringe should not stand in the way to optimize the present syringe distribution systems.
At the expert meeting it was concluded that to generate detailed discussions with intravenous drugusers on autodestruct syringe, actual models have to be available to elicit specific observations and reactions as a basis for more generalized discussions. This being the case we had to find actual prototypes. By courtesy of Mr.G.van der Kort of Omnilabo International BV at Breda, The Netherlands, we obtained a sufficient number of one type. This ingenious model made repeated pull and push possible. Only when completely emptied, the syringe with fixed needle was disabled by pulling the plunger back by means of cutting the syringe open with to minute knives through two grooves along the barrel.
Schematic representations of two other models as given by De Loor (2) were used to support our research were available as well. The first is a model developed by MedTech Imnc., the other is a model developed by Tom Rossmark, a general physician in Amsterdam. These schemes are added as annex *.
As a consequence the technological objections of intravenous drugusers reported here are limited to the actual prototype available. This procedure has however succeeded in initiating in depth discussions about the principles behind the idea and the technology applied to generalize conclusions to other models.
After providing our interviewers with a number of the sample autodestruct syringe around fifty people, all active intravenous drugusers, were shown the single use syringes and asked their utility and the value of the concept. Some people were shown the syringe in small groups, while others were interviewed one to one. It was sought to avoid leading the conversation in any direction, so the points below reflect the views of those interviewed.
Although the number of people involved is very small, the uniformity of the recorded answers is extremely high indicating a high generalisability.
The structure of both individual interviews and group discussion was the following:
1.showing the model and playing with them
2.noting remarks about this model
3.showing the schematic representation of the two other models 4.noting remarks about these models
5.general perception of the idea of a selfdestruct syringe
in principle good, if only ....
in principle bad, because....
This approach was the result of an earlier experiment with autodestruct syringe in London where in 1989 three actual models were tried by active users. In all three cases "with not a little thought and some perseverance the users involved succeeded to figure out how to use them repeatedly" (3).
As the numbers of interviewed people are small a statistical analysis suggests makes no sense. We just give the points that were forwarded.
Technical observations on the sample model
The following are the technical comments on the sample model being made by the interviewees:
1. The non-removable needle is unanimously rejected. Users will never accept a syringe with a fixed needle, for different reasons:
- Sharing the prepared shot is very common and ritually significant: fixed needles increase risk.
- Some of those interviewed in Liverpool receive injectable methadone. This means that Liverpool’s injectors have diverse equipment needs. Both 5 ml and 10 ml syringes are used, and some people require two different sizes of needle to prepare an injection. A long needle with a wide gauge is used to draw up the methadone, which is then replaced with a shorter, finer needle for injection.
- Water has to be dripped on the spoon, this is done with the syringe without needle.
- A fixed needle increases risk as you cannot remove it for safe disposal, by hiding it in the barrel of the syringe.
2. The plunger disappears when pressing completely into the syringe and by retracting disables the syringe. This is a disadvantage: most users refill with a little blood after completely emptying the syringe to suck the leftover dope in the needle and needle holder back in the syringe to inject this as well.
3. The volume is to small, especially for two shots, only 0.4 ml blood can be aspirated.
4. The fingerholder is too large, and prevents the syringe to be flat on your arm.
5. The connection between the two parts of the plunger is weak. The two parts easily disconnect.
6. The plunger runs to heavy. One needs more force than in a conventional disposable syringe, which increases the risk on perforation of the vein, abcesses etc.
7. The syringe can be made reusable by closing the sides with some glue. Another way to make it reusable is to remove the plunger completely out of the syringe, to cut the knives away and reinsert the plunger. Or by turning the plunger a little bit, making the cut is alongside the groove and does not pierce the barrel.
8. After playing around for a little while, filling the syringes with water, some people noticed that the disabling mechanism allowed the drug to leak out of the syringe. This was felt to be a terminal fault.
The schematic representation of the other two models evoked no relevant remarks, but basically underlined the above criticisms on both the technological and the general level. The addition of this representations in the inquiry underlined the need for actual models in this type of research as already was suggested at the expert meeting.
It can thus be concluded that the technology of the sample syringes was unanimously disliked. None of the interviewees would willingly use this syringe, except one in Amsterdam who would like to try it just once for curiosity, but clearly not more than once.
The general perception of a autodestruct syringe
Only very few interviewees did not reject the principle of a autodestruct syringe. One of them stated "I have always syringes, emergencies do not occur with me" indicating that he was able to use the normal disposables as intended, as a autodestruct syringe, but this turns out to be rather exceptional. All these however thought the technical obstacles virtually insuperable.
That so very few people thought the concept of a autodestruct syringe desirable is not necessarily because most intravenous drugusers wish to re-use syringes, but for other more pragmatic reasons. Some of the points made were critical of the general technology, others oppose the whole concept. Most agreed upon the search for a autodestruct syringe being a waste of time and money. The points made were:
1. Why re-invent the wheel? Most people interviewed felt that current syringe technology works extremely well. Some people made the point that safer injecting practices and HIV awareness must be a matter of individual responsibility. Technological solutions may lull people into a false sense of security, possibly causing them to ignore the need to be HIV aware, leading to the sharing of water, spoons, and the need for safe sex.
2. Two people objected to the principle on political/ethical grounds. They felt that autodestruct syringe were being introduced so that somebody could make money from a patented design. Perhaps in response to a comment from the interviewer about the re-use of syringes in Africa and Eastern Europe, they made the point thnat if the HIV problem in the underdeveloped world was due to the re-use of disposable syringes, how helpful would a more expensive patented technology be in adressing that problem?
3. Several interviewees pointed out that preparing illegal drugs for injection is not the same as using pharmaceuticals. If making a speedball (heroin and cocain mixture) or injecting tablets, the plunger may well be pushed up and down several times. During this process, the sample syringe had a tendency to seize up.
4. Similarly, it was pointed out that if somebody has poor veins and has trouble getting a hit, the plunger may be pulled backwards and forwards several times. Sometimes the syringe becomes filled with blood and may need to be emptied into a spoon to be injected in two halves. It was felt that this would not be possible with a autodestruct syringe.
5. If travelling, or at work, some individuals re-use the same syringe, some replacing the needle each time, others re-using the same needle. These people are reluctant to carry several syringes, because of the bulk. This problem was felt to be particularly acute for cocaine users who may inject several times in a relatively short period.
6. There was concern about the possibility that somebody would wish to replace a technology that serves their needs so well, with one that seems so unreliable.
7. As among normal syringes already a relatively large number show construction mistakes, even more will be made when the mechanism is more complicated. This will increase the number of situations where the available autodestruct syringe will malfunction an so increase the number of situations where a risk for HIV transmission has to be taken. The risk to lose your dope wil make users to avoid using autodestruct syringe as much as possible.
8. The use of autodestruct syringe will lead to more crises. For safe use you need time and quietness. This complicated system "will fuck you up" with all the risks of that.
9. There would also be a number of ways autodestruct syringe could be re-used, causing more problems. The experience mentioned in London (3) as well as the present study has shown that the inventiveness of the inventor will probably always be surpassed by the intravenous drugusers one. So for those that really want to keep their autodestruct syringe for re-use in emergencies (and this will be the vast majority of intravenous drugusers) the costly technology will not work.
10. "If I was sick and had only a autodestruct syringe I might inadvertently overdose as I might use two normal hits worth or more, as I would know I could not have another hit later", was a feeling expressed by 3 interviewees, indicating that the restriction imposed on the users can actually increase the risks of intravenous drug use.
There was then, an overwhelming consensus against the autodestruct syringe by the interviewees. Perhaps surprisingly, this consensus was not based on knee-jerk fear of change, but on a wide range of political, ethical, cultural practical and technological arguments, that interviewees generally agreed upon as could be noticed in the group discussions. All respondents agreed that autodestruct syringe would not be of any practical use in the prevention of the spread of HIV, mainly because those that are responsible already behave as responsable as possible within the possibilities offered by the syringe distribution systems available, and if confronted with an emergency will certainly find ways to re-use the autodestruct syringe. If enough normal disposable clean syringes and needles are available, the forced replacement of them by autodestruct syringe for intravenous drugusers will in all probability increase the risks taken. Most risks actually being taken could be significantly reduced by making normal disposable syringes more easy available.
Those that did not reject autodestruct syringe in general were those that had themselves under the present condition well provided with clean syringes as to enable them to use the syringes only once. For them the autodestruct makes no actual difference, as long as their technical requirements are met.
As the idea behind autodestruct syringe is to force into single use those that are not able to operate safe under the present conditions and as such re-use the present syringes at least more or less regularly. It is however these people that object against the autodestruct syringe just because they perceive, probably correctly, that the autodestruct syringe will increase te number of times that they inject unsafely.
Production costs of autodestruct syringe will be significantly higher than normal disposables, so the cost of providing intravenous drugusers with autodestruct syringe will increase. The money involved would probably be used more effectively if spent on extension and optimalisation of the present syringe distribution systems and on increasing the users awareness of HIV.
Given the near unanimous rejection of the concept of autodestruct syringe, we must bear in mind that if the current syringes are phased out, it is possible that a large proportion of injectors may resort to other solutions such as eyedroppers or glass syringes. The implications that such a change might have for the transmission of HIV is presently unknown and it may be well that this factor will need to be tested before restricting the availability of existing syringes in favor of autodestruct syringe. However, we feel that all presently available research data strongly tend to reject the notions underlying the eventual decision to introduce autodestruct syringe as replacement for the presently used injection equipment which serves so well. Moreover, the decision to provide IVDUs only with autodestruct syringe would be felt as a hostile act, just because of the enforced technological fix designating IVDUs again as irresponsible and the waste of money that could be spent much better in the fight against HIV.
- 1. P.Evans, Expanded Program of Immunization, WHO, Geneva.
2. A.de Loor: De eenmalige spuit, goed idee of idee fixe, Adviesburo Drugs, Amsterdam, 1991.
3. J.Mordaunt, Mainliners, London.
- Questionnnaire Opinions on injecting equipment services in England
- schematic representations of autodestruct syringes used in inquiry
*hier drie lege pagina’s invoeren i.v.m. pagina nummering, die door binder moeten worden vervangen door bijgeleverde schema’s (dit uitdrukkelijk aan Adriaan doorgeven!!!).