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EXECUTIVE SUMMARY
1. Increasing scientific evidence suggests that sharing injecting paraphernalia by injecting drug users ( IDUs) could transmit hepatitis C infection (Mathei et al, 2006). Since its legalisation in the UK in 2003 with subsequent additions in 2005, the supply of paraphernalia to IDUs from needle exchanges has been given increasing attention by commissioners and service providers. Approximately 80% of needle exchange agencies in Scotland (Griesbach et al, 2006) and England (Abdulrahim, 2006) recently reported supplying citric acid sachets. Other items were supplied to relatively lesser extents, with some geographical coverage noted as patchy. There is an increasing range of paraphernalia being marketed for needle exchange supply. Additionally, some services are known to supply makeshift items (e.g. hand rolling cigarette filters and packed down citric acid in non sterile bags). Paraphernalia items are not classed as 'medical devices' therefore not subject to devices testing requirements. So although there are several types of item for needle exchange providers to choose from, there is little information to inform their choice.
2. Paraphernalia is supplied for three reasons: (1) to discourage sharing and hence prevent blood borne virus transmission, (2) to prevent skin and soft tissue infections by facilitating the use of sterile equipment, and (3) to attract injecting drug users ( IDUs) into needle exchange services. The latter has been demonstrated by Garden et al (2003), who showed citric acid sachet supply increased the numbers of injectors accessing services. Griesbach et al (2006) also note citric acid sachet supply influenced needle exchange visits at the Glasgow Drug Crisis Centre. The first two factors have not been previously studied.
3. This study had two aims, which required two distinct pieces of work:
a) To test paraphernalia items and injection preparation methods in the laboratory to quantify the theoretical benefits and/or risks that they present to health, thereby identifying from those tested the items of paraphernalia and preparation methods that present the least theoretical risk to individual health.
b) To conduct an investigation into the impact that paraphernalia supply is making on sharing and health in the practice setting and compare this with non-supply.
4. The first aim was set in order to subject paraphernalia to some controlled testing similar to medical devices testing. Work was based in the laboratory. A controllable experimental method was developed that replicated the injection preparation practices of IDUs. Stages in the injection preparation process studied were hand washing, use of cookers, use of acids and use of filters. The results were also informed by the qualitative field work conducted for stage two. Results suggested, in addition to needles and syringes, the least theoretical health risks would result from the following:
- Encouraging hand cleansing before injecting
- Promoting the use of single use cookers but this must be accompanied with equipment and advice to avoid or reduce the risks from batch preparation (e.g. adequate needles and syringes, small volumes of sterile water, sterile acid).
- Sterile citric or ascorbic acid sachets accompanied by a strong message to add small amounts stepwise
- Filters that remove particles, do not shed fibres or retain drug. In this work the Sterifilt performed best out of the filters tested.
5. The second aim was studied by undertaking a comparison study, examining the health and sharing practices of IDUs in Dundee, where paraphernalia (except water) was supplied with Aberdeen, where only swabs were supplied. Levels of ever sharing of paraphernalia items were statistically higher in Aberdeen, except for cookers which were similarly high in both areas due to batch preparation. Sharing of paraphernalia in the past month was reported to a lesser extent in both areas compared to 'ever' and there were no statistical differences between the two locations, although sharing in the past month was lower in Dundee. Sharing of needles and syringes was relatively low in both locations, but saving own needles and syringes for reuse was very common.
6. Qualitative interviews showed this was because insufficient quantities of needles and syringes were available when needed. Some injectors reported using multiple sets to facilitate a single intravenous access. They also distributed them to peers when they were in need of clean equipment. This suggests that strategies to increase convenient access need to be developed. There was no statistical difference between the number of participants with non infected complications or skin and soft tissue infections in each location, although numbers were lower in Dundee and the infections seen in Aberdeen may have been more severe. The level of skin and soft tissue infection seen in Aberdeen was lower than that predicted at study design based on the literature.
7. Data collection had to be modified following the pilot stage due to low recruitment rates at both sites. The restriction on information obtained was with hindsight too limited. Lack of collection of data on paraphernalia use for every injecting episode or frequency of use of needle exchanges makes it impossible to conclude whether paraphernalia impacts on sharing and injecting site complications or not. Several suggestions for improved future quantitative work have been made in chapter 5.
8. Qualitative interviews with participants found that the term 'paraphernalia' was not always understood. Risks of Hepatitis C Virus ( HCV) transmission through paraphernalia sharing were not often explicitly mentioned without prompt. The Dundee participants were more aware of the need to avoid paraphernalia sharing. Most said they attempted to do so, although they did not always do this in practice. Reasons for continued sharing and use of makeshift paraphernalia in Dundee centred on lack of convenient access at the time of need. Lack of planning for future injecting, peer distribution and the priority of obtaining drugs over equipment all influenced paraphernalia use. Convenience, including distance from the exchange, has previously been identified as a factor in needle and syringe sharing in Glasgow (Hutchinson et al, 2000) and was also found here.
9. Support for water supply was expressed by some in Dundee. In Aberdeen access to makeshift paraphernalia, particularly citric acid causes difficulties. Limited outlets, refusal of sales, over-inflated prices for suspected IDUs and concerns about quality were described. Some participants perceived there to be a culture of sharing of paraphernalia, promoted by lack of availability and desperation to obtain items, especially citric acid when 'strung out'. Interviewees expressed fear, distress and anger from lack of access to paraphernalia and voiced strong support for it. Sharing was seen by some in Aberdeen as inevitable. Participants in both locations suggested HCV was not as 'important' as HIV as it had not been subject to mass media public health campaigns. Participants raised several ideas on ways to promote awareness of HCV, which mainly focused on mass media campaigns, more information from exchanges and many suggestions on how to attract new and younger IDUs into services. These are detailed in chapter 5.
10. In summary, the lab based information offers performance data for certain commercially available paraphernalia items. The quantitative field work data was insufficiently sensitive to give support to the supply or non supply of paraphernalia but the qualitative data gave strong support. Several suggestions for future research and twelve recommendations for practice have been made. These are summarised in chapter 5.
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