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Introduction
To many, the idea of giving injecting drug users (IDUs) needles and syringes with which to take their drugs seems like madness. But it is a proven and effective response to a public health need (the prevention of HIV and hepatitis epidemics) that is firmly based in research.

We have outlined the research here to reassure participating pharmacists that you are part of a vital service that is one of the unsung public health success stories of the last 25 years.

The calendar card information project
The calendar card information project was instigated by the Queensland branch of the Pharmacy Guild of Australia, and part funded by Queensland Health.

The aim of the project is to develop the relationship between injectors and their pharmacists, and to enable your profession to play a major role in further strengthening harm reduction approaches to reducing the health and other problems associated with injecting drug use.

Pharmacists will be supplied with the cards to give out to IDUs.

On the back of each card there is information for injectors on an important aspect of injecting drug use, and on the front, there is an attractive image so that injectors will read them, want to keep them, and hopefully show them to other injectors they know.

This briefing paper is being supplied to participating pharmacists to give you background information and guidance on the interventions you can make, and the discussions you can have with IDUs on these issues.

Needle and syringe provision - the evidence
There are a large number of robust studies testing various aspects and outcomes of needle and syringe provision. These form a solid body of evidence to show that providing needles and syringes to IDUs does not increase injecting or drug problems, but it does have a major positive impact in terms of decreasing the prevalence of HIV among IDUs (Des Jarlais et al, 1996; Hurley, 1997).

There is also good evidence that needle and syringe provision is associated with reductions in hepatitis B and C (hep B and hep C) prevalence (Harris, 1997).

A study carried out in America reported that IDUs who used Needle and Syringe Programs (NSPs) were between 6 and 11 times less likely to contract hep B or hep C compared with IDUs who did not (Hagan, et al, 1995).

Research carried out here in Australia found a concurrent decline of 50% in needle sharing behaviour and a decline from 22% to 13% in hep C prevalence among IDUs over a 3 year period (MacDonald, et al, 2000).

Critics of needle and syringe provision have argued that the schemes may increase the use of illegal drugs and cause more widespread use. However, extensive research has shown that this is not the case and that needle and syringe provision can actually reduce drug use through referrals to drug treatment and counselling (Buning, 1991; Heimer & Lopes, 1994; Watters, et al, 1994).

Studies have also concluded that needle and syringe provision does not increase injection frequency among IDUs, the number of initiates to injecting drug use, or the number of people injecting drugs (Normand et al, 1995).

Moreover, NSPs do not increase the number of syringes discarded in public places. Indeed, some areas where NSPs have been introduced have reported a decrease in the number of discarded syringes (Normand, et al, 1995; Oliver, et al, 1992).

Another argument often cited by critics of NSPs is that by giving IDUs access to needles, they may be discouraged from entering drug treatment programmes. Again, extensive research has shown this claim to be untrue. Many IDUs who use NSPs ask for referrals to treatment (Hagan, et al, 1993; Heimer, et al, 1996; Heimer & Lopes, 1994).

In Australia, researchers found that introducing a NSP next to a methadone clinic did not reduce the number of admissions to treatment or result in an increase in dropouts or positive urine tests at the methadone clinic (Wolk, et al, 1990).

In 1991 the Australian Government spent an estimated $10 million on the Needle and Syringe Program. This investment prevented an estimated 3,000 cases of HIV infection, and saved at least $266 million in health care costs in that year alone! (Commonwealth Department of Health and Ageing, 2002).

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HIV
Human Immunodeficiency Virus (HIV) is the human retrovirus that can cause AIDS (Acquired Immune Deficiency Syndrome).

HIV attacks the body’s immune system by targeting and destroying the cells which normally fight off infection. This suppression of the immune system means that people who are ‘HIV positive’ (i.e. people infected with HIV) are at risk of developing ‘opportunistic illnesses’ and other illnesses that are associated with AIDS.

There is currently no vaccine available to prevent people catching HIV.

HIV is mainly passed through:

• unprotected sex;
   
• sharing of needles and syringes; and
   
• unsterile tattooing, body piercing, and medical procedures.

Australia’s HIV epidemic is now about 19 years old. During this time about 5,700 Australians have died from AIDS, and a further 16,700 are living with chronic HIV infection. This is recognised worldwide as a public health ‘success.’

This is because these numbers, although large and tragic for the individuals and families concerned, are in contrast to the global pandemic in which by 1998 there were 33.4 million people living with HIV/AIDS, and in that single year 2.5 million people died from HIV/AIDS-related illnesses worldwide and there were 5.8 million new HIV infections around the world (or 16,000 new infections per day, 11 per minute).

It is because of the prompt and rational responses to HIV in Australia - including improved blood and tissue screening procedures, safer sex campaigns, and the widespread availability of sterile needles and syringes - that infection and mortality rates have been kept relatively low.

Indeed, there is overwhelming evidence that interventions to minimise the harmful effects associated with injecting drug use have been and continue to be highly effective in containing the spread of HIV among people who inject drugs (Australian National Council on AIDS, Hepatitis C and Related Diseases, 2000a).

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Hepatitis C
Hepatitis C (or hep C) is a blood-borne virus that can cause liver inflammation and liver disease. The virus was first identified in 1988. Before then, it was known as ‘non-A, non-B hepatitis’ or ‘post-transfusion hepatitis.’

Hep C is transmitted when blood from an infected person gets directly into the bloodstream of another person. The commonest route of transmission is sharing of injecting equipment. Other behaviours that pose a risk are body piercing, tattooing, or acupuncture with shared, contaminated equipment, sharing toothbrushes, razors, nail clippers or tweezers (known as ‘household transmission’) and occupational needlestick injury.

Hep C is not commonly transmitted during sex and is not classified as a sexually transmitted infection. The hep C virus is not spread through day to day social contact like kissing, hugging, shaking hands, sharing eating and drinking utensils, or sharing bath, shower or toilet facilities.

There is currently no vaccine to prevent hep C. An estimated 200,000 Australians are already infected with hep C, with a further 11,000 new infections occurring each year. Although hep C is a slow-acting virus which for most people does not result in serious disease or death, it remains the most common reason for liver transplant in Australia.

In 1997 it was estimated that the cost of the hep C epidemic in Australia was $107.5 million, rising by $46.6 million (over 50 years) for every 1,000 new infections. With such a large and expanding number of people infected with he pC in Australia, health policy is being re-oriented to meet future demand for treatment and support programs. However, prevention (in the form of secure blood and tissue supplies, and widespread NSPs) remains a key priority (Australian National Council on AIDS, Hepatitis C and Related Diseases, 2000b).

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Conclusion
Whilst the practice of injecting drug use continues, the provision of sterile injecting equipment through NSPs is an important harm reduction strategy for preventing the spread of blood borne viruses such as HIV and hep C.

Pharmacies are an important and significant component of NSPs in Australia. Many pharmacies offering NSP services are able to provide extended hours of service in a wide range of locations, as well as a degree of anonymity to clients.

Needle and syringe provision in Queensland
Needle and syringe provision in Queensland has been very successful partly because the state has placed an emphasis on the provision of needles and syringes and other drug using paraphernalia such as a disposal container, sterile wipes, and sterile water, rather than ‘exchange.’

The success is also partly due to the fact that since the late 1980s, the majority of Queensland pharmacies have become involved in the provision of sterile injecting equipment to IDUs.

Alongside free needle and syringe provision, pharmacy sales account for 50% of the needles and syringes supplied to IDUs in Queensland.

It is this combination of routes of availability that has prevented a major HIV epidemic in the state, and is helping to control the hep C epidemic amongst injecting drug users.

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Bibliography
Australian National Council on AIDS, Hepatitis C and Related Diseases. (2000a). National Hepatitis C Strategy 1999-2000 to 2003-2004: Changes and Challenges. Canberra: Commonwealth Department of Health and Aged Care.

Australian National Council on AIDS, Hepatitis C and Related Diseases. (2000b). National HIV/AIDS Strategy 1999-2000 to 2003-2004: Changes and Challenges. Canberra: Commonwealth Department of Health and Aged Care.

Buning, E.C. (1991). Effects of Amsterdam needle exchange and syringe exchange. International Journal of the Addictions, 26:1303-1311.

Commonwealth Department of Health and Ageing. (2002). Return on investment in needle and syringe programs in Australia.

Des Jarlais, D.C., et al. (1996). HIV incidence among injecting drug users in New York City syringe-exchange programs. Lancet, 348:987-991.

Hagan, H., et al. (1993). An interview study of participants in the Tacoma, Washington, syringe exchange. Addiction, 88:1694-1695.

Hagan, H., Des Jarlais, D.C., Friedman, S.R., Purchase, D. & Alter, M.J. (1995). Reduced risk of hepatitis B and hepatitis C among injecting drug users in Tacoma syringe exchange program. American Journal of Public Health, 85:1531-1537.

Harris, L.A. (1997). American Bar Association Report Endorsing Needle Exchange. August 1997.

Heimer, R.K. & Lopes, M. (1994). Needle exchange in New Haven reduces HIV risks, promotes entry into drug treatment, and does not create new drug injectors. JAMA, 271:1825-1826.

Heimer, R.K., Khoshnood, K., Jariwala, F.B., Duncan, B., & Harima, Y. (1996). Hepatitis in used syringes: the limits of sensitivity of techniques to detect HBV DNA, HCV RNA, and antibodies to HB core and HCV antigens. Journal of Infectious Diseases, 173:997-1000.

Hurley, S.F., Jolley, D.J., & Kaldor, J.M. (1997). Effectiveness of needle-exchange programs for prevention of HIV infection. Lancet, 349:1797-1800.

MacDonald, M.A., et al. (2000). Hepatitis C virus antibody prevalence among injecting drug users at selected needle and syringe exchange programs in Australia, 1995-1997. Medical Journal of Australia, 172.

Normand, J., Vlahov, D., & Lincoln, E. (eds). (1995). Preventing HIV Transmission: Role of Sterile Needles and Bleach. Washington, DC: National Academy Press.

Oliver, K.J., Friedman, S.R., Maynard, H., Magnuson, L. & Des Jarlais, D.C. (1992). Impact of a needle exchange program on potentially infectious syringes in public places. Journal of Acquired Immune Deficiency Syndromes, 5:380.

Watters, J.K., et al. (1994). Syringe and needle exchanges as HIV/AIDS prevention for injecting drug users. Journal of the American Medical Association, 271:115-120.

Wolk, J., Wodak, A., Guinan, J., Macaskill, P. & Simpson, J.M. (1990). The effect of a needle and syringe exchange on a methadone maintenance unit. British Journal of Addictions, 85:1445-1450.

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