Syringe+Vending+Machines+-+can+they+stop+the+spread+of+HIV+and+HCV?

Student number: 8794375 Student name: Grace Tanner Tutor name: Steve Badman

**__The artefact__**

View the full artefact using the following link: http://www.southsydneyherald.com.au/automatic-dispensing-machine-now-operational/#.UmhLPRbWHzJ

The article ‘Automatic Dispensing Machine now operational’ was published on the South Sydney Herald website on Friday April 12, 2013. The article was written by Kate Reakes, manager of the Harm Minimization Program run by the Sydney Local Health District. In the article, Reakes provides an update on the installation of an Automatic Syringe Dispensing Machine in Redfern, an inner-city suburb of Sydney, New South Whales. As explained by Reakes in the article, the installation came in response to unacceptably high levels of Human Immunodeficiency Virus (HIV) and Hepatitis C (HCV) infections among injecting drug users in the suburb of Redfern (Reakes, 2013).



**__Central Public Health Issue__** The central public health issue this article represents is the harm associated with injecting drug use in Australia. The spread of blood-borne viruses among injecting drug users from sharing contaminated injecting equipment is the most significant and common harm associated with injecting drug use (Islam, Wodak, & Conigrave, 2008). More specifically, the article addresses preventing the spread of the blood-borne viruses HIVand HCV among injecting drug users through the use of Syringe Vending Machines. Therefore, this wiki will focus on the prevention of blood-borne viruses HIV and HCV among injecting drug users in Australia.

**__Literature Review__** As reported by the National Drug Strategy, since 1998 fewer Australians are using illicit drugs. Despite this encouraging trend, the harms from injecting drug use persist, particularly in relation to the spread of the blood-borne viruses HIV and HCV (National Drug Strategy, n.d.). Sharing contaminated injecting equipment has become the single most common mode of HIV and HCV transmission among injecting drug users (Islam & Conigrave, 2007). Statistics published in 2010 by the Australian Institute of Health and Wellbeing established that one in ten injecting drug users in Australia reported sharing needles and almost four in ten had shared other injecting equipment (Australian Institute of Health and Welfare, 2011). These unsafe injecting practices place injecting drug users at an increased risk of contracting and transmitting HIV and HCV. Not only does this risky behavior potentially result in the transmission of these blood-borne viruses between injecting drug users, the transmission has a flow on effect to non-injecting segments of the community, for example through sexual relations (Islam & Conigrave, 2007).The prevalence of HIV in Australia is considered lower than in most other comparable high-income countries (Australian Government Department of Health and Ageing, 2010). At the end of 2008, an estimated 17 444 people in Australia were living with HIV infection (Australian Government Department of Health and Ageing, 2010). Of all HIV diagnoses made between 2007 and 2012, only 2% were attributed to injecting drug use (The Kirby Institute, 2013). Thus, the prevention of HIV among injecting drug users has been highly successful in Australia. However, the statistics are not so encouraging for HCV. HCV is a significant public health issue and one of the most commonly reported notified diseases in Australia. At the end of 2008, there were an estimated 212 000 people in Australia with chronic HCV and an estimated 10 000 new infections occurring annually (Australian Government Department of Health and Ageing, 2010). The sharing of injecting equipment among injecting drug users accounted for approximately 90% of new HCV infections and 80% of existing HCV infections in Australia (Australian Government Department of Health and Ageing, 2010). Therefore, the prevention of HIV and HCV among injecting drug users remains an important public heath issue in Australia.

There has been considerable research over the past decade on the spread of HIV and HCV among injecting drug users and the effectiveness of Australia’s response to addressing this issue. Since 1985 harm minimization has formed the basis of Australia’s National Drug Strategy and continues to do so today (Australian Government, n.d.). Harm minimization recognizes that while illicit drug use can never be completely eradicated, measures can be taken to reduce its negative consequences (Guanaratna, 2005). As part of Australia’s harm minimization approach to illicit drug use, Australia employs harm reduction strategies such as Needle Syringe Programs and Pharmacotherapy Substitution Programs. For the past decade, harm reduction approaches to HIV and HCV prevention among injecting drug users have been accepted as mainstream global drug policy (Wodak & Maher, 2010). Almost all agencies of the United Nations with a responsibility for drug policy support harm reduction (Wodak & Maher, 2010). Thus, over the last decade research on preventing the spread of blood-borne viruses among injecting drug users has largely focused on harm reduction strategies. Specifically, there is abundant research on the success of Needle Syringe Programs. These programs have operated in Australia since the 1980s and are considered the hallmark of Australia’s harm reduction strategies. Needle Syringe Programs provide sterile needles and syringes and other injecting equipment to users (The National Center for Education and Training on Addiction, n.d.). A 2009 report evaluating the effectiveness of Needle Syringe Programs in Australia found that approximately 32 000 new HIV infections and 97 000 new HCV infections were prevented over 2000-2009 as a direct result of the programs. In addition, the report established that Needle Syringe Programs resulted in health care cost savings of over four dollars for every one dollar spent (Australian Government Department of Health and Ageing, 2009). The results of this report were based on a mathematical epidemic model which simulated HIV and HCV transmission among injecting drug users in Australia. There are however limitations to this method. The model approach is a simplification of reality and does not incorporate much of the large heterogeneity that exists between people. For example, in the economic analysis the researchers assumed that all individuals had the same healthcare and medication use (Australian Government Department of Health and Ageing, 2009). The results of this report however are supported by numerous other studies. For example, a 2004 review commissioned by the World Health Organization on the effectiveness of Needle Syringe Programs found there was compelling evidence for the effectiveness, safety, and cost-effectiveness of the programs (Wodak & Maher, 2010). Additionally, in 2006 eight reviews of the evidence for Needle Syringe Programs concluded they were effective in reducing blood-borne viruses and were unaccompanied by serious unintended negative consequences such as inadvertently increasing illicit drug use (Wodak & McLeod, 2008).



Over the past decade there has also been substantial research into the effectiveness of Syringe Vending Machines, which form part of the Needle Syringe Program. Syringe Vending Machines are units that dispense sterile injecting equipment in order to provide anonymous 24-hour access to sterile injecting equipment (Australian Government Department of Health and Ageing, 2009). A 2008 review of 14 studies examining whether Syringe Vending Machines assist in reducing the spread of blood-borne viruses amongst injecting drug users found they were effective in increasing access to sterile injecting equipment (Islam, Wodak, & Conigrave, 2008). Thus, Syringe Vending Machines were found to increase access to the means of prevention of blood-borne virus transmission.This review however also has limitations in its methodology. For example, only English language studies were reviewed despite the majority of Syringe Vending Machine initiatives operating in non-Anglophone countries and the studies were mostly from developed countries (Islam, Wodak, & Conigrave, 2008). Therefore while the findings are generalizable to Australia, the findings may not be generalizable to non-Anglophone or developing countries where many injecting drug users are situated. Despite this, the findings of the review are supported by other studies. For example, a 2007 study found that Syringe Vending Machines made sterile injecting equipment more accessible as they extended the hours of access to sterile equipment to reach a broader range of injecting drug users and also provided an anonymous, confidential delivery mode (Islam & Conigrave, 2007). Thus, research over the past decade demonstrates that Australia’s National Drug Strategy has been successful in reducing the spread of HIV and HCV among injecting drug users through its use of harm reduction strategies. This is evidence by numerous studies into the effectiveness of Needle Syringe Programs, such as Syringe Vending Machines. **__Cultural and Social Analysis__** Despite the achievements of the National Drug Strategy, there is a growing movement towards reforming Australia’s drug policy away from its current prohibition basis. In 2011 and 2012, Australia21 convened roundtable discussions with former senior Australian politicians and high-level experts on drug policy. From the discussions, it was concluded that the prohibition of drugs is ineffective and has failed (Australia21, 2012). One of the arguments from the discussion was that the prohibition and criminalization of illicit drug use has stigmatized illicit drug use. Moral panic is an intense feeling held by members of a society that wrongdoers pose a threat to the society and therefore something needs to be done about their behavior (Goode & Ben-Yehuda, 2009). The prohibition of illicit drug use is an example of a moral panic, which has resulted in the condemnation of illicit drug use and a strong social reaction against the use of illicit drugs in Australia. The most recent National Drugs Strategy Household Survey conducted in Australia indicates that the use of illicit drugs by adults is not accepted by the vast majority of people (Australian Institute of Health and Welfare, 2011). Thus injecting drug use, because of its illicit nature, is not accepted by the larger part of Australian society making it a highly stigmatized practice. The stigma and discrimination associated with being identified as an injecting drug user has been recognized as a primary barrier to injecting drug users accessing prevention education, care, support and treatment (Islam & Conigrave, 2007). For example, injecting drug users may not access Needle Syringe Programs as they do not want to be identified as an injecting drug user, which deprives them of safe injecting equipment and increases their risk of HIV and HCV contraction and transmission. Therefore it is crucial to consider societies opposition to illicit drugs when addressing injecting drug use as the views of society have a serious impact on the behavior of injecting drug users and their resulting health outcomes.

As a consequence of the Austalia21 roundtable discussions, debate has commenced in Australia on shifting drug policy away from prohibition to decriminalizing illicit drugs, in part to reduce the stigma and discrimination attached to illicit drug use. Not only do stigma and discrimination deter injecting drug users from accessing resources such as Needle Syringe Programs, there are other factors that act as barriers. As a result, there are certain groups among injecting drug users that have been identified as being at a greater risk of contracting and transmitting blood-borne viruses (Australian Institute of Health and Welfare, 2011). These include Aboriginal and Torres Strait Islanders and those in rural locations due to a lack of access to clean equipment and community attitudes. People who are new to injecting and young people are also at a higher risk due to their risk taking behaviors and lack of understanding about the routes of transmission and possible consequences of their actions. Additionally, people in custodial settings are at a greater risk due to a high rate of imprisonment for drug-related crime and the associated unsafe injecting practices (Australian Institute of Health and Welfare, 2011). Thus, while the spread of HIV and HCV is an issue among all injecting drug users, there are users who are affected more than others and this should be taken into consideration by public health experts. The spread of HIV and HCV remains an important public health issue in Australia and it is important to note the negative effect that stigma resulting from the prohibition of illicit drugs has on injecting drug users accessing services provided for them. While debate has opened in Australia on reforming national drug policy to tackle such issues, change in policy is a slow and complicated process. Therefore, health experts should continue to focus on delivering harm reduction strategies such as Needle Syringe Programs with a particular focus on delivering these services to the groups of injecting drug users who are at a greater risk of contracting and transmitting HIV and HCV.

**__Analysis and Reflection__** The article chosen for this wiki represents the use of harm reduction strategies, specifically Syringe Vending Machines, in reducing the spread of HIV and HCV among injecting drug users in Australia. As outlined in the article, the Syringe Vending Machine was installed in response to unacceptably high levels of HIV and HCV in the Sydney suburb of Redfern (Reakes, 2013). This shows that while Needle Syringe Programs have been successful in preventing thousands of new infections of HIV and HCV in Australia, the threat of these blood-borne viruses spreading among injecting drug users remains a significant public health issue which Australia needs to continue to work hard at preventing. Additionally, the article is a good example of strategies used to overcome the issues that result from the stigmatization of illicit drug use. As discussed previously, injecting drug users are often deterred from accessing Needle Syringe Programs, as they do not want to be identified as an injecting drug user due to the stigma attached to this label. However, Syringe Vending Machines offer a discrete and confidential mode of delivering sterile equipment to injecting drug users. Thus Syringe Vending Machines are a way to overcome some of the barriers injecting drug users face in accessing services.



This topic is of personal interest to me as I am directly involved in harm reduction strategies as the pharmacy I work at participates in the Needle Syringe Program and also the Pharmacotherapy Substitution Program. Therefore, this wiki has been incredibly interesting, particularly when researching the stigma attached to injecting drug use and the effect this has on users accessing services and help. I witness first hand the effect stigma has on injecting drug users. For example, one of the patients undergoing pharmacotherapy substitution for a heroin addiction feels so embarrassed and ashamed that he tells other people his treatment is instead for pain management. From this wiki, I have also learnt that policy regarding public health issues such as illicit drug use is complex and can be influenced by a multitude of factors. It is therefore imperative that policy is based on evidence rather than on intuition or prejudice. Thus, this wiki has reinforced the importance of using evidence-based practice in my future learning.

**__Reflection tasks__** http://healthcultureandsociety2013.wikispaces.com/Harm+minimisation+-+an+oxymoron%3F

http://healthcultureandsociety2013.wikispaces.com/%27The+Junkie%27+Moral+panic%2C+stigma+and+the+road+to+recovery

**__Reference list__** Australia21. (2012). //Alternatives to prohibition: Illicit drugs: How we can stop killing and criminalizing young Australians.// Retrieved from Australia21 website []

Australian Government Department of Health and Ageing. (2009). //Return on investment 2:////Evaluating the cost-effectiveness of needle and syringe programs in Australia////2009.// Retrieved from Australian Government Department of Health website []

Australian Government Department of Health and Ageing. (2010). //Sixth National HIV Strategy 2010-2013.// Retrieved from Australian Government Department of Health website []

Australian Government Department of Health and Ageing. (2010). //Third National Hepatitis C Strategy 2010-2013.// Retrieved from Australian Government Department of Health website []

Australian Government. (n.d.). The National Drug Strategy 2010-2015. Retrieved from []

Australian Institute of Health and Welfare. (2011). //Drugs in Australia 2010.// Retrieved from Australian Institute of Health and Welfare Australia website []

Gunaratnam, P. (2005). //Drug policy in Australia – the supervised injecting facilities debate//. Retrieved from []

Goode, E., & Ben-Yehuda, N. (2009). //Moral panics: The social construction of deviance//. Chichester, U.K: Wiley-Blackwell.

Islam, M. M., & Conigrave, K. M. (2007). Syringe vending machines as a form of needle syringe programme: Advantages and disadvantages. //Journal of Substance use, 12//(3), 203-203. doi:10.1080/14659890701249640

Islam, M., Wodak, A., & Conigrave, K. M. (2008). The effectiveness and safety of syringe vending machines as a component of needle syringe programmes in community settings. //The International Journal on Drug Policy, 19//(6), 436-441. doi:10.1016/j.drugpo.2007.07.006

National Drug Strategy. (n.d.). The National Drug Strategy 2010-2015. Retrieved from []

Reakes, K. (2013, April 12). Automatic Dispensing Machine now operational. //South Sydney Herald.// Retrieved from [|http://www.southsydneyherald.com.au/automatic-dispensing-machine-now-operational/#.Um2maxbWHzK]

The Kirby Institute. (2013). //2013 Annual Surveillance Report of HIV, viral hepatitis, STIs.// Retrieved from University of New South Whales website []

The National Center for Education and Training on Addiction. (n.d.). Harm Minimisation. Retrieved October 20, 2013, from []

Wodak, A., & Maher, L. (2010). The effectiveness of harm reduction in preventing HIV among injecting drug users. //New South Wales Public Health Bulletin, 21//(3-4), 69. doi:10.1071/NB10007

Wodak, A., & McLeod, L. (2008). The role of harm reduction in controlling HIV among injecting drug users. //AIDS (London, England), 22 Suppl 2//(Suppl 2), S81-S92. doi:10.1097/01.aids.0000327439.20914.33