|HIV/AIDS & HCV|
|Written by Wendy Loxley|
Western Australian initiatives to prevent the spread of HIV/AIDS amon injecting drug users
Wendy Loxley, Allison March, National Centre for Research into the Prevention of Drug Abuse, Curtin university of Technology, Perth, Western Australia
Paula Watt, Georgina Westlund & Charles Watson, health Department of Western Australia
Michelle Kosky, Western Australia AIDS Council
In Western australia (WA), concern about the spread of HIV/AIDS among injecting drug users was evident from as early as 1984. An initial strategy was the formation of a palicy group which consisted of representatives from government and non-government agencies including the WA AIDS Council, the Health Department of WA and drug treatment agencies.
A variety of initiatives are described in this paper, including the sale of needles and syringes in pharmacies; needle exchange schemes and outreach services; vending machines to sell needles and syringes; education of drug treatment workers; direct education of injecting drug users; formation of a drug users’ collective; and WA support for the National IVDU and AIDS Campaign.
It is concluded that while there is no way of knowing whether the very low rate of HIV infection among injecting drug users in WA is related to these initiatives, or due to West Australian geographical isolation, there has been a remarkable degree of co-operation and integration between the various agencies involved, which can only assist in the fight against HIV/AIDS.
"The problem of illicit drug use in WA is very different from that in other states in Australia. Whilst it is known that illicit drug use exists (particularly intravenous use) the number of known users is very low and widely distributed demographically. [It is estimated that] there are 2,000 - 4,000 regular users ... [and that] in any one year up to 10,000 West Australians will inject illicit drugs. These 10,000 will not be confined to the metropolitan area. HIV infection rates in IV Drug Users are very low in WA. Less than 1% of tested users are infected". (Westlund, 1989, p.3).
In 1984 the Health Department of WA formed an AIDS Advisory Committee (AAC) to co-ordinate government policy development in response to the AIDS epidemic. This was, perhaps, WA’s earliest bureaucratic recognition that HIV/AIDS was a threat that would not go away, and that formal structures had to be in place to respond to that threat.
Significantly, both government and, later, non-government organisations (in the form of the West Australian AIDS Council (WAAC) which was invited to AAC in 1987) are now represented on that Committee. The WAAC was formed (in May 1985) chiefly as a result of lobbying within the gay community, but it included representation from other groups from its outset. The WAAC received support from the State and Commonwealth Health Departments, as did other AIDS Councils in Australia but it differed from other state-based AIDS Councils in that it recognised from the outset that prevention and education programs would have to be targeted at injecting drug users (IDUs) and other groups as wel1 as gay men. Accordingly, an early appointment to the board of WAAC was a representative of Cyrenian House, which is a local drug rehabilitation Centre.
On the government side, AIDS education and prevention was being undertaken by the Health Promotion Services and the STD Clinic of the Health Department. In late 1985, the WAAC convened the first meeting of a group that was later to become the Intravenous Drug Users Initiatives Group (IVDUIG). This meeting focused on information dissemination and the development of harm reduction strategies and was attended by staff of the Health Promotions Branch, representatives of drug treatment agencies, IDUs themselves, as well as WAAC. At this first meeting it was decided that the priorities for future prevention strategies should be drug workers’ and users’ education through workshops, pamphlets and billboards. This group has continued to meet, with a membership drawn from government and non-government AIDS and drug treatment agencies; advocates for users and researchers working in the HIV/IVDU area. All of the initiatives described in this paper were discussed in this forum at every stage of their development and implementation. This ensures that all involved parties are informed about current strategies, and have an opportunity for input into planning and decision-making.
These early steps demonstrate the co-operation and integration of strategies between government and non-government agencies that have characterised WA’s efforts to prevent the spread of HIV/AIDS among IDUs.
The WA prevention and education strategies directly targeted at IDUs and those that work with them fall generally into two main categories:
1. Increasing the supply of sterile drug injecting equipment; and
2. Education about risks and risk-prevention for IDUs and those who come into contact with them.
Individual strategies will be discussed under these two categories in chronological sequence.
Increasing the supply of sterile injecting drug equipment
Sale of needles and syringes (N&S) by pharmacies: A decision was made by the Health Department in late 1986 to promote the sale of sterile injecting equipment to drug users by pharmacists, because these were seen to be accessible, strategically placed, already selling N&S (e.g. to diabetics) and had a legitimate role in health care. The AIDS Advisory Committee had already been advised by its pharmaceutical services branch that there was not known to be any legal impediment to the sale of N&S to anyone, either under the Poisons Act, nor the Misuse of Drugs Act. It was agreed that while pharmacies were able to sell individual N&S, it would be preferable for these to be packaged in a way that promoted sex and needle hygiene among IDUs, allowed for responsible disposal and could act as a vehicle for referral to treatment agencies. Accordingly, the SS5 Kit was born. This contained, at the outset, a lml N&S (the pharmacist was to supply another four); a rigid disposal container; a condom with information how to use it; pamphlets on needle cleaning, safe drug use, safe sex, AIDS testing and contact telephone numbers; and a disclaimer, stating the pharmacies did not encourage illicit drug use. The whole thing was neatly packaged in a plastic pack, and supplied to pharmacies free of charge. They were then free to sell it at the recommended price of $3.00
After negotiation with the appropriate professional bodies, distribution of the kits to pharmacies commenced in June 1987 By January 1988, 5,371 kits had been distributed and 35% of all the pharmacies in the State were involved in the scheme. Within 12 months of the scheme's commencement, close to 10,000 kits had been distributed; 85% to pharmacies (the remainder went to needle exchange schemes see below)
By August 1988, the need for increased distribution to non-metropolitan areas had been recognised. Although the take-up among metropolitan pharmacies had been generally satisfactory, some country pharmacies had failed to re-order, after initial participation, leaving a concern that IDUs living in the country were being inadequately serviced. One possibility is that ili country areas IDUs cannot be as anonymous as they are in the city and hence are often reluctant to use pharmacies where they might be recognised. This is a concern that still exists and is being addressed.
Currently 65 out of a total of 486 West Australian pharmacies are selling SS5 Kits. A logo has been prepared for participating pharmacists to stick on their windows advertising SS5 Kit availability and the SS5 Kit has been improved, with a slightly different disposal container, more information about pregnancy and safe disposal and updated pamphlets. The Health Department is also supplying pharmacists with small plastic bags displaying information about safe disposal for the sale of individual N&S. More recently, some pharmacists have expressed interest in participating in needle exchange schemes.
Needle Exchange Schemes (NES): Where the sale of N&S has been a Health Department initiative, although enhanced by discussions within the IVDUIG, NES have been a community based initiative by WAAC. In June 1987, the Executive Director of WAAC attended a working party meeting about IDUs and HIV/AIDS in Sydney, and returned with the conviction that WA should have a NES like the other States. In July 1987, the first NES were set up at WAAC for daylight hours and a local gay sauna, to provide service from ¢.00pm to 3.00am. SS5 Kits and N&S were supplied by the Health Department of WA but the organisation and maintenance of the operation was in the hands of WAAC.
The philosophy behind these exchanges was then and remains, that they should be user-friendly, non-judgemental and client directed. They were specifically designed to allow users to obtain sterile equipment and although exchange of old for new was preferred N&S were not withheld if no used ones were returned. Workers were encouraged to build rapport with clients and offer them information about safer drug use, HIV/AIDS generally and referral to treatment and/or testing agencies, but there was to be no pressure applied to clients to enter treatment for their drug r use. To ensure the confidentiality of the service, clients were not required to identify themselves and only a minimum of statistics were kept.
Since 30 June 1988, approximately 5,000 N&S have been distributed through the WAAC Exchange with about 2,000 being returned and approximately 24,000 through the sauna with around 7,200 returned. There is now a new NES at the local detoxification unit of the WA Alcohol and Drug Authority and at the major metropolitan STD Clinic where HIV/AIDS testing is carried out.
Outreach Services: In addition to the NES discussed above, WAAC decided that Outreach services were also required, to reach those drug users who would not come into the city to use the NES and to make contact with casual users - particularly the young - who might not identify themselves as being at risk. A number of models of such services were available from that provided in Amsterdam which takes methadone and N&S to users (Buning, van Brussel and van Santen, 1988) to Outreach Vans operating in Sydney and Canberra, neither of which takes methadone to users. The earliest of the Australian Outreach Vans, operating in the Kings Cross area of Sydney, takes information, needles, condoms and testing into the streets, while the Van in Canberra does not offer testing. It was decided that the supply of sterile equipment and information was the priority in Perth and that the Van would not offer testing, although clients would be referred to testing centres if they requested it. A WAAC proposal sought funding from the Commonwealth Government and capital costs were met from this source. Salaries of workers on the Van are incorporated into the WAAC budget as an on-going commitment.
The Van (known as PSST for "Practise Safe Sex Today") commenced its operation in April 1988. It took some time to become established. Perhaps because it commenced in winter, or because there was an initial concern among users that the police might use the return of used needles as evidence of possession of illegal drugs; an eventuality which has not occurred due, perhaps, to the fact that police liaison was established before commencement. The Van now has regula contact with around 200 IDUs per week. Since July 1988, nearly 9,000 N&S have been distributed, and round one third of these returned. More importantly, anecdotal evidence from the workers on the Van suggests that those who are in regular contact with this service use the opportunity to discuss relevant issues with workers and some considerable behaviour change in the direction of safer drug use has taken place.
The Van moves around on a regular schedule which includes parks in those suburbs where IDUs might be found. Users are advised about this schedule by printed material which is available from a number of sources and is reproduced in a local pop music newspaper.
Vending Machine: For some time there have been discussions within IVDUIG about the need to supply sterile equipment through as many outlets as possible. While it is known that bringing users into contact with people who can support and advise them promotes appropriate behaviour change (Stimson, Donoghoe Alldritt & Dolan 1988), it has also been recognised that because of the illicit nature of their drug use, some users are reluctant to use services which bring them into contact with anyone, even the relatively anonymous service provided by local pharmacies. For those people a non-contact service is needed and a vending machine to supply sterile needles and syringes, together with health advice pamphlets and condoms and other minor health supplies was suggested.
The initiative has been largely in the hands of WAAC who have negotiated with a variety of organisations and institutions for provision of the machine and a site to position it. Two prototypes of a machine have been built, but have not yet been put into operation.
Education about risks and risk-prevention
A variety of strategies fall under this heading, including direct education of IDUs, professionals and the general community; strategies to enhance the safe collection and disposal of used N&S; development of an IDUs Collective; and the trialling of bleach vials for needle cleaning. These initiatives will be discussed in an order roughly approximating the chronology of their introduction, although many of them were and are running simultaneously.
Education of drug treatment workers: At the first IVDUIG meeting called by WAAC, it was agreed that the education ® those who had professional contacts wit} IDUs was an important priority. Accordingly, the first ‘Drug Workers and AIDS seminars were held in mid-1986 an aimed to provide information about AIDR and related issues and skills for people working with IV Drug Users. Although initially only one workshop was planned, the response for a variety of government and non-government agencies to whom invitations were sent was so overwhelming that two seminars became necessary.
The workshop was held under the auspices of 1VAAC, but was planned and facilitated jointly by representatives of WAAC, the Health Promotions Branch of the Health Department, and a non-drug rehabilitation agency.
Feedback from participants was very positive and it was agreed that further workshops would be held when the need arose. Further workshops were held in 1987 and 1988 each time as a co-operative effort between WAAC, the Health Promotion services of the Health Department and the Drug Education Centre of the WA Alcohol and Drug Authority. Education of drug workers about AIDS is now in the hands of this latter organisation.
Education of IDUs: Direct education for IDUs has been through a variety of means Information and health promotion pamphlets have been distributed widely and through a variety of sources, not least the NES and in SS5 Kits as well as doctors street workers, treatment agencies, prisons, WAAC and so on. The updating of information so that it remains relevant and accurate has been a central concern for those most involved in pamphlet and poster production: the Health Department and WAAC. Discussion of the design and content of new or updated printed material has taken place at the IVDUIG meetings, so that a variety of opinions can be taken into consideration.
The West Australian AIDS Council, assisted by the Health Department of WA, has also facilitated a number of public meetings of IDUs which have been advertised through the SS5 kits, community newspapers, treatment agencies, and local radio stations. This endeavour has now given way to the formation of a local IDU Collective known as WAIVE, which is discussed in more detail below.
Other education for IDUs includes those programs offered by treatment, rehabilitation and street work agencies. One NSW initiative which has been proposed is the production of a ‘split kit’ that can be leh on the beds in detoxification and rehabilitation agencies for users when they leave. Such a kit would contain pamphlets about healthy practices, a list of contact names and phone numbers (e.g. for AIDS Council, testing clinics and drug information), and a timetable for the PSST van.
Western Australian Intravenous Equity (WAIVE): In November 1988 IDU representatives from each state met in Canberra and formed the Australian IV League to represent IDUs in the discussion of health strategies relating to the prevention of HIV. The State body formed after that meeting WAIVE, which held its first meeting in February 1989. The group has a commitment to information dissemination to drug users and has produced a magazine, poster, T-shirts, and is working with the Health Department of WA to produce 2 educational videos targeted at users and drug workers. The group also consults with WAAC and participates in IVDUIG meetings.
WA support for National IVDU and AIDS Campaign: Currently the Commonwealth Department of Health and Community Services is planning a national campaign to promote reduction in the transmission of HIV/AIDS among IDUs. Although promoting abstinence from drug use is the government’s long term aim, it has been recognized that this must be accompanied by other strategies, based on harm minimisation principles.
The State Governments are responsible for supporting this campaign, in particularly in Phase 1 which aims to raise community awareness of intravenous drug use and HIV/AIDS. The Health Department of WA has devised a number of low-key strategies supporting and supplementing the National Education Campaign, targeted at children aged ¢-12 years; adults in the general community; and professionals, particularly pharmacists, health surveyors and police. The emphasis is on the maintenance of public safety (needle disposal) and the awareness of the urgency for reducing the spread of HIV in IDUs.
Although the strategies to be described below are initiated by the Health Department of WA, extensive discussion of their efficacy and implementation has taken place in the IVDUIG. The non-government organisations (particularly WAAC and WAIVE) are supporting these strategies by emphasis on safe disposal of N&S in their direct work with IDUs.
(i) Children aged 6-12 years.These initiatives aim to teach children not to pick up or play with discarded needles, and to tell an adult if they find one. ‘Constable Care’ (a popular and familiar cartoon Police Department character) stickers with the message "Never pick up needles! Tell an adult" are being distributed to all children in primary schools in WA, accompanied by educational sessions by the Police Community Education Team where this is requested by the school.
Information on the campaign is being mailed to all primary school Parents’ Associations and an Education Department ‘Policy for Dealing with Needles and Syringes’ is being sent to each school. School Principals will receive additional briefing material, and Health Education Of ficers are available to talk to Parents’ Associations if requested.
(ii) Adults in the general community. This section of the campaign attempts to raise community awareness of the necessity for the availability of NES and to minimise any adverse impact such programme may have. A survey will be conducted in metropolitan and two large county towns to ascertain community attitudes towards and knowledge of injecting drug use and HIV/AIDS, and the related issues of N&S disposal and risks of HIV. Information about methods of safe collection and disposal of discarded needles and needle injury action plans will be placed in community newspapers, and major newspapers will be utilized for publicity of innovative programme developments in the IDU/AIDS area, exposure of the reality of recreational drug use, human interest stories and interviews. There will also be radio talk back interviews focusing on major issues. Staffed telephone information services will be advertised and provided and Health Education Of ficers will be available to give talks to community groups on request.
(iii) Pharmacists. The importance of the role of pharmacists in the supply of N&S was discussed above. This section of the campaign recognises this importance and aims to continue raising pharmacists’ knowledge of harm reduction strategies and to maximise their role on information provision to IDUs and the general community about safe disposal and needle injuries. Pharmacists are to be encouraged to provide disposal containers (SS5 Kits) or information about disposal with the sale of all N&S, and the hope is to increase the proportion of pharmacists participating in the SS5 Kit programme by 50%. Information seminars for pharmacists were planned and are now underway.
(iv) Health Surveyors. Local Authorities via Health Surveyors are to be encouraged to facilitate the safe collection and disposal of discarded N&S in their jurisdiction and to equip Health Surveyors with the necessary information on needle collection and disposal and needle injury.
Surveys of both metropolitan and country local areas are being conducted to determine the extent of the discarded N&S problem and will be repeated during the next 12 months to monitor the situation. Metal community-based disposal bins in which N&S can be placed are being trialled. Extended N&S collection equipment is being trialled with Local Authorities and information seminars for Health Surveyors are being run. encouraged to make collection and disposal information available to members of the public and the Police Department will be requested to equip all Police Vehicles with small disposal containers. Information about these issues will be relayed to Police Officers through their Gazette.
Bleach 2x2x2: This strategy is a part of the total harm minimisation focus of initiatives for IDUs in WA. It is obiously preferable for users to use a sterile needle on every occasion, but the reality is that some users cannot or will not do this. Research suggests that most sharing users clean their needles between usages but that there is considerable reliance on hot water, which is inadequate to kill HIV. The Health Department of WA and WAAC have recently embarked on a trial of Multi Use Vials containing bleach for IDU's who are unable to get clean needles. This is a similar trial to that conducted in Massachusetts where vials have been tested over a one year oeiod. There it was found that the number of users who cleaned their needles using bleach increased from 5% to 85% after 12 months. The vial was a 10cc clear plastic vial, ¾ filled with bleach at ›.5% available chlorine and a pierceable rubber stopper. Vials were distributed to users through an Outreach programme.
In WA the distribution of similar vials to IDUs through the PSSTVan and drug workers is being trialled and the viability of this strategy assessed. If appropriate, vials will be provided to users as required. The bleach 2x2x2 approach (clean twice in fresh water, twice in bleach and twice in fresh water), which meets all the criteria for an effective needle cleaning technique, is being recommended to all users participating in the trial.
The trial commenced in February 1990. Trial packs were distributed through the Van and the bleach technique demonstrated: recipients were asked to return a post-free response card through the mail. Focus groups were held with IDUs who have received trial bleach vials and bleach vials were distributed through selected pharmacies in SS5 Kits with a returnable questionnaire.
While it is too soon to comment on the outcome of this trial, it is to be hoped that the results will be sufficiently favourable to allow for continuation of this important strategy.
It is not the intention of this paper to compare initiatives in WA with those in other States of Australia or, indeed, in other countries. Concern about the transmission of HIV/AIDS is so widespread that similar strategies and techniques are being used in many places. What is notable in WA is the way in which a full range of strategies has been introduced in co-operation with agencies. WA has benefited from the experiences gained in other States and other countries and it is to be hoped that others will profit from the experience in WA.
The co-operation and integration of services between government, non-government and user groups is perhaps the most remarkable characteristic of the WA approach. Through the intravenous Drug Users Initiatives Group meetings as well as numerous less formal conversations and consultations, sharing of ideas, values and understandings has occurred which has allowed for the implementation of strategies to meet a number of objectives and appeal to a wide variety of IDUs and those that come into contact with them.
As noted in the introduction to this paper, there is a very low rate of HIV infection among IDUs in WA. There have been 76 AIDS cases which represents 4.816 of the national total, of which 32 have died. (NH&MRC, 1989). There are 508 known cases of HIV in WA, 3.9% of which are injecting drug users, while a further ¢.5% are both homo or bisexual and injecting drug users. (Health Dept of WA 1990).
While there is no way of knowing whether this is due to the implementation of the comprehensive programme of education and prevention described above, or to the geographical isolation of WA or perhaps to some combination of the two, the current Australian National AIDS and Injecting Drug Use Study in which data are be,ing collected in five Australian cities, including Perth, will monitor behaviour change and seroprevalence in IDUs and should enable us to ascertain whether this programme is effective in the longer term in preventing the further spread of HIV/AIDS into the injecting drug user population of WA.
Buning, Ernst C., van Brussel, Giel H.A. and van Santen, Gerrit. 1988. Amsterdam’s drug policy and its implications for controlling needle sharing. NIDA Research Monographs, 80, 59-74.
National Health and Medical Research Council. Special Unit in AIDS Epidemiology and Clinical Research. 1989 TabulaUon of cases ot AiDS and HIV infection in Australia.
Health Departmentof WA. 1990 Epidemiology and Research Branch.
Stimson, Gerry V., Donoghoe, Martin, Alidritt, Lindsey and Dolan, Kate. 1988 HIV transmission risk behaviour of clients attending syringe-exchange schemes in England and Scotland. British Journal ot Addiction. 83, 1449-1455.
Westiund, Georgina. 1989 Illicit Drug Use and HIV Infection. Unpublished paper. Health Departmentof WA.