The vanguard of harm reduction: the future of New Zealand's needle exchange
In 1987 New Zealand established its Needle Exchange Programme (NEP), perhaps the first country to do so on such a comprehensive scale. Now, 20 years on, there are 212 outlets operating nationally and 17 dedicated exchange outlets utilising a peer service model. There are 182 pharmacies and health related organisations providing new, sterile injecting equipment and collection of used items. In our Guest Editorial, Needle Exchange Programme National Manager Charles Henderson writes about the programme’s current status and what should happen to ensure its future.
It needs to be understood right from the outset. Drug use has always been part of the human condition, and will be for the foreseeable future. Even in our distant past, we used drugs ranging from alcohol to opiates and hallucinogens to induce altered states of mind or assist in spiritual quests.
The grim reality of harmful drug use is apparent to NEP workers on a daily basis. Regardless of our opinions or world view, illicit drug users continue to risk ill-health, addiction, disease and prosecution. Those who have become dependant have a career of narrowing choices. With the knowledge and understanding we now have about drugs and what they do to people, it is an oxymoron to say that those dependant on drugs lack willpower or could stop if they wanted to.
Ongoing prohibition has had many implications in our society. Fear of prosecution means that illicit drug users are forced to act covertly; often resorting to unsafe methods in their attempts to remain hidden. Even though we have been authorised to supply clean injecting equipment since 1987, NEP clients still must run a legal gauntlet because possessing the very equipment we supply is against the law. This has huge implications on the personal and public health objectives of the NEP as we attempt to minimise the spread of blood borne viruses (BBVs) within the IV drug using population, and from there to the wider community.
This is why New Zealand’s Needle Exchange Programme has always taken the pragmatic approach of reducing the harm that can result from drug use. Providing clean needles and decirculating contaminated ones is not condoning drugs. It’s a way of reducing suffering and loss of life, and it often provides the only point of contact through which drug users can be educated, informed, and assisted with access to treatment options. Individuals often turn to drug use as a way of coping at a particular point in their lives. They should not then be condemned to a life of despair and worthlessness. The majority get through it with the right assistance and continue on the path as productive and participating members of society.
One of NEP’s greatest strengths is its emphasis on peer service. Dedicated exchange outlets are run and staffed largely by people who have themselves been injecting users. They understand the lifestyle and how best to impart information by showing genuine empathy and understanding, and by taking a non-judgemental approach. More than 75 percent of the national distribution of sterile injecting equipment is through the 17 outlets using the peer service model.
We have to recognise illicit drug use as a health issue if we’re serious about minimising its related harm - from a Government and policy level through to doctors, pharmacists and public attitude. Treatment must acknowledge that drug addiction is a chronic relapsing condition which may require several interventions over a lifetime, but that there are many ways of reducing its harm. Longer prison sentences and harsher penalties only further prevent these individuals from receiving a health based solution.
So where is NEP now?
Over the last 20 years we’ve had some very real and measurable success. In 2004 I personally headed a study into the prevalence of HIV, Hepatitis B and Hepatitis C amongst injectors attending the programme. We examined trends in their injecting practices, sexual behaviours and other risk factors associated with BBVs. The study consisted of an anonymous questionnaire completed by 412 people and a finger-prick blood test. We were able to compare results with two more limited studies done in the late 90's. Many of the results were robust, indicating that drug users are changing their behaviours.
|Re-use of someone else's needle||19%||21%||15%|
|Use of new neelde each time||40%||48%||50%|
The table above compares risk behaviour survey results for 1997, 1998 and 2004.
Needle exchange was instigated early in New Zealand, mainly as a response to the potnetial HIV/AIDS epidemic. As a result we have the lowest rate of HIV transmission amongst injectors attending the NEP in the world. HIV prevalence of 0.3 percent is an outstanding result!
No blood tests were positive for Hepatitis B, but Hepatitis C results were more concerning. It is a difficult virus to control and is easily transmitted via shared injecting equipment. Seventy percent returned positive, and the longer a user had been injecting, the more likely they were to carry Hepatitis C. Of note was that the prevalence amongst injecting drug users under 25 was less than 30 percent, indicating that early education and intervention may reduce the overall pool of Hepatitis C infection amongst them over time.
There is no doubt in my mind that we have saved the country millions of dollars in disease prevention and downstream health costs. This is endorsed by the 2002 NZ NEP Review which stated that New Zealand’s NEP is both effective and efficient, particularly with respect to prevention of HIV infections among injecting drug users and every dollar spent on the programme between 1988 and 2001 avoided $20 in lifetime treatment costs.
However, it also seems clear that the programme must be maximised so that it reaches a greater proportion of injecting drug users if we are to effectively reduce Hepatitis C transmission and prevalence in the future.
So what is the future for NEP?
While needle exchange must remain is core activity, NEP must also continue to develop to incorporate ancillary services via the dedicated outlets. These should include Hepatitis C clinics, vaccination programmes, provision of food, and more education on sexual behaviour, injecting techniques and wound management. NEP needs increased national awareness to encourage participation, particularly amongst young people and those in more remote areas.
We’ve made a definite start with all of the above, but the future will largely be determined by two things: funding and targeted interventions based on best evidence.
In terms of funding, we simply cannot allow NEP to be seen as a poor cousin to other approaches in our national drug policy. The recent National Drug Policy 2006-2011 consultation document has relegated our approach of harm reduction to “problem limitation” thereby lessening its importance in respect to the internationally accepted three-pillar approach of supply, demand and harm reduction. Internationally, in places that do not accept harm reduction programmes such as the NEP, HIV/ AIDS rates of over 50 percent have been reported.
Household Drug Surveys indicate two percent of New Zealanders inject or have injected drugs in the last 12 months. This means 85,000 people are potentially susceptible to bloodborne viruses from drug use, and these people will have contact with other New Zealanders. We cannot ignore these issues and hope they will go away.
Increased funding is needed to improve the outreach capabilities of the programme. Outreach is fundamental to the successful future of NEP, yet it is relatively ignored as attention and resourcing is concentrated on law enforcement and border interdiction.
Outreach takes the concept of harm minimisation to the most isolated and vulnerable users around the country, often providing a lifeline for those who would otherwise find it near impossible to learn about the help available.
A trial mobile needle exchange has recently begun operating on the West Coast. This service makes contact with those in the injecting community who are well-placed to publicise its availability to their peers. It’s another example of the sorts of effectiveness only possible through the groundlevel, evidence-based approach the peer-based dedicated exchanges can provide. The service is currently being evaluated and it is hoped it can be rolled out to other areas as part of a broad range of interventions to maximise NEP’s effectiveness now and into the future.
While many New Zealanders, including many politicians, remain blissfully unaware or perhaps a little fearful of NEP, its importance as an effective means of minimising harm to all New Zealanders cannot be underestimated. The 2004 survey indicates that on the whole we are getting it right, and we are making an incredible difference.
The introduction of a free one-for one (new for old) distribution scheme in 2004 is an example of the continued investment and support NEP does receive from Government. Removing the economic barrier (previously distribution of injecting equipment was on a user-pays basis) is crucial if we are to reduce the sharing and re-using of injecting equipment. Such behaviours are devastatingly efficient ways of transmitting BBVs, and other ways may arise in the future.
The future of the Needle Exchange Programme must be centred on consolidating its ground-level approach, providing solid scientific evidence, and through this expanding the service’s reach and effectiveness. This will take increased funding, continued strategic management and planning and robust evaluation of any targeted intervention that is implemented. Money well spent in my view.
- Matters of Substance, guest editorial, February 2007