Cullen

Hope

Iversen

Jenny Iversen

Jim McVeigh

Kwon

Larance

McVeigh

National Institute for Health and Care Excellence

Ritter

Sagoe

Sievert

van Beek

Vivian D. Hope

WHO & UNODC & UNAIDS

English

Crossref

International Journal of Drug Policy

Access to needle and syringe programs by people who inject image and performance enhancing drugs

Iversen, J

Hope, VD

McVeigh, J

E-space: Manchester Metropolitan University's Research Repository

Iversen, J and Hope, VD and McVeigh, J (2016)Access to needle and syringeprograms by people who inject image and performance enhancing drugs.International Journal of Drug Policy, 31. pp. 199-200. ISSN 1873-4758Downloaded from: http://e-space.mmu.ac.uk/624836/Version: Accepted VersionPublisher: ElsevierDOI: https://doi.org/10.1016/j.drugpo.2016.01.016Please cite the published versionhttps://e-space.mmu.ac.ukAccepted ManuscriptTitle: Access to needle and syringe programs by people whoinject image and performance enhancing drugsAuthor: Jenny Iversen Vivian Hope Jim McVeighPII: S0955-3959(16)00039-6DOI: http://dx.doi.org/doi:10.1016/j.drugpo.2016.01.016Reference: DRUPOL 1713To appear in: International Journal of Drug PolicyReceived date: 4-12-2015Revised date: 12-1-2016Accepted date: 21-1-2016Please cite this article as: Iversen, J., Hope, V., and McVeigh, J.,Accessto needle and syringe programs by people who inject image andperformance enhancing drugs, International Journal of Drug Policy (2016),http://dx.doi.org/10.1016/j.drugpo.2016.01.016This is a PDF file of an unedited manuscript that has been accepted for publication.As a service to our customers we are providing this early version of the manuscript.The manuscript will undergo copyediting, typesetting, and review of the resulting proofbefore it is published in its final form. Please note that during the production processerrors may be discovered which could affect the content, and all legal disclaimers thatapply to the journal pertain.Page 1 of 7Accepted Manuscript1Access to needle and syringe programs by people who inject image and performance enhancing drugsAuthors: Jenny Iversen1, Vivian Hope2,3 and Jim McVeigh41. Viral Hepatitis Epidemiology and Prevention Program, The Kirby Institute, UNSW Australia, Sydney, Australia.2. Public Health England, Colindale Avenue, London, United Kingdom3. Centre for Research on Drugs and Health Behaviour, London School of Hygiene & Tropical Medicine, United Kingdom4. Centre for Public Health, Liverpool John Moores University, Liverpool, United KingdomCorrespondence to:Jenny IversenViral Hepatitis Epidemiology and Prevention Program The Kirby InstituteUNSW AustraliaSYDNEY NSW 2052Phone: +61-2 9385 0900Fax:     +61-2 9385 0920Email: JIversen@kirby.unsw.edu.auWord count: 1067 Page 2 of 7Accepted Manuscript2We appreciate van Beek and Chronister’s concerns regarding the funding of harm reduction interventions in an environment of diminishing resources (1), however we disagree with their conclusion and support the international guidelines for equitable and non-discriminatory NSP provision for all people who inject drugs. van Beek and Chronister outline the response of the Kirketon Road Centre (KRC),  an established primary health care facility in Sydney, New South Wales (NSW), to a potential “public policy dilemma” resulting from an increase in the injection of drugs with the primary purpose of enhancing image and/or performance in Australia (1). Using data from surveys of 102 men injecting image and performance  enhancing drugs (IPEDs) attending the KRC Needle and Syringe Program (NSP), they assessed the risk of blood-borne viral (BBV) infections in this group to be lower than among people who inject  drugs primarily for their psychoactive effects. The KRC subsequently implemented a policy decision to limit the availability of injecting equipment from their NSP to people who inject IPEDs. The authors also encouraged other NSP services to undertake local assessments.“Cost and capacity” were identified as the main rationale for initiating this restrictive policy. IPED injectors comprised a minority of KRC NSP attendees (6%), but were receiving 15% of the injecting equipment distributed. A number of factors likely contribute to this disparity. Firstly, over two-fifths (44%) of the KRC IPEDs population sampled reported collecting equipment for others. Secondly, IPEDs users typically procure injecting equipment at the beginning of cycle of multiple drugs requiring both intramuscular and subcutaneous administration; potentially creating an impression that unreasonably large quantities of injecting equipment are procured. Thirdly, in Australia steroid injecting equipment (detached syringe plus injection and drawing up Page 3 of 7Accepted Manuscript3needle) cost less per unit than the combined 1ml needle and syringe; thus 15% of injecting equipment does not necessarily equate to 15% of expenditure. In Queensland, where a similar increase in people who inject IPEDs was observed over the last 5 years (2) and NSP access is unrestricted, the state-wide expenditure on injecting equipment for IPED injectors attending NSPs in the 2013/14 financial year was approximately AUD$50,000 (R Kemp 2015, pers. comm., 26 October). Assuming similar expenditure on IPED injecting equipment in NSW, this represents <1% of the annual NSW NSP budget (3) and is relatively inexpensive compared to the cost of treating BBV infections (4). Nevertheless, given the 25% reduction in NSP spending nationally between 2002-03 (AUD$36.8M) and 2009-10 (AUD$28.75M) (5), we agree with van Beek and Chronister that Australian NSP budgets are currently stretched and resources provision for NSPs is an issue in other countries.The primary aim of the NSP is to prevent BBV transmission by providing sterile injecting equipment and information on safer injection practices. The results of the KRC study indicate that receptive sharing of needles and syringes is low among IPED injectors sampled, indicating that they have been successful in minimising injection-related risk in this population. This success should be applauded. Of concern is the high proportion of gay and bisexual men in the KRC study (42%), including four who self-reported that they were living with HIV infection. Although none of the KRC respondents self-reported hepatitis C virus (HCV) infection, only one third reporteddiagnostic screening for HCV in the previous year. Previous Australian research identified HCV antibody prevalence of 10% among people who inject steroids (6), significantly higher than observed in the general community (7). Sero-prevalence of BBVs among IPED injectors in Australia is likely to be comparable to that in United Kingdom (UK), with an estimated 1% living with HIV infection, 8% exposed to hepatitis Page 4 of 7Accepted Manuscript4B and 5% to HCV (8), despite relatively short histories of injection. In the UK, the National Institute for Health and Care Excellence (NICE) guidelines specifically recommend NSP provision to people who inject IPEDs (9). In Australia, the Fourth National Hepatitis C Strategy 2014-2017 acknowledges that the drug of choice is changing among people who inject drugs (PWID), and states that the injection of methamphetamines and performance and image-enhancing drugs is creating new groups at risk of hepatitis C, and thus new target groups (10). WHO/UNAIDS/UNODC Technical Guide for national HIV prevention, treatment and care, advocates universal access among PWID and recommend that services (including NSP) should be equitable, non-discriminatory (without exclusion criteria) and that supply should be determined by need and not limited by cost or other considerations (11). This Technical Guide also states that service access should not be restricted by sociodemographic or other criteria, including age, gender, sexual behaviour, employment status or substance use status.As in the UK (12), a high proportion of people who inject IPEDs attending Australian NSPs obtain injecting equipment for others, sometimes for many people. This suggests that, rather than limit NSP service delivery, greater efforts are required to engage with IPEDs injectors who are not currently engaged with harm reduction services and may be at greater risk. Harms associated with injection of PIEDs extend beyond the transmission of BBVs through injection. In a previous Australian study, 41% of men who injected steroids reported an injection-related health problem in the previous month and 6% reported ever experiencing an injection site abscess (13). A recent UK study also identified high prevalence of injection site infections and injuries in this population, with over a third reporting redness, swelling or tenderness in the previous year and 6-8% ever experiencing an abscess or open wound (14). As in the Page 5 of 7Accepted Manuscript5KRC study, Larance and colleagues (2008) also documented low prevalence of receptive needle and syringe sharing (5%), however injection from a shared vial or bladder was much more common (29%). Further, high levels of both current psychoactive drug use (8, 15) and transitions between IPEDs and psychoactive drug have been documented (16). Finally, a screening process to identify ‘need’ of specific groups of people who inject drugs, in which those injecting IPEDs are deemed to be at negligible risk of BBV transmission, may result in increased complacency and have a negative impact on risk behaviour with consequent increases in BBV transmission. Australian NSPs have historically been guided by the principles of equity and non-discrimination in keeping with the universal access advocated in the WHO/UNAIDS/UNODC Technical Guide. The provision of NSP access to people who inject IPEDs in Australia and elsewhere should be not a public policy dilemma, as all forms of injecting drug use have the potential to increase the risk of transmission of BBVs and cause other harms.Page 6 of 7Accepted Manuscript6References1. van Beek I, Chronister KJ. Performance and image enhancing drug injectors' access to needle syringe programs: Responding to a public policy dilemma. Int J Drug Policy. 2015;26(9):868-74.2. Iversen J, Topp L, Wand H, Maher L. Are people who inject performance and image-enhancing drugs an increasing population of Needle and Syringe Program attendees? Drug Alcohol Rev. 2013;32(2):205-7.3. National Centre in HIV Epidemiology and Clinical Research. Return on investment 2: Evaluating the cost-effectiveness of needle and syringe programs in Australia 2009. Sydney: National Centre in HIV Epidemiology and Clinical Research, The University of New South Wales, Sydney, NSW, 2009.4. Kwon JA, Anderson J, Kerr CC, Thein HH, Zhang L, Iversen J, et al. Estimating the cost-effectiveness of needle-syringe programs in Australia. AIDS. 2012;26(17):2201-10.5. Ritter A, McLeod, R., & Shanahan, M. Government drug policy expenditure in Australia, 2009/10.  NDARC DPMP Monograph No. 24. Sydney: National Drug and Alcohol Research Centre. , 2013.6. Day CA, Topp L, Iversen J, Maher L. Blood-borne virus prevalence and risk among steroid injectors: results from the Australian Needle and Syringe Program Survey. Drug Alcohol Rev. 2008;27(5):559-61.7. Sievert W, Altraif I, Razavi HA, Abdo A, Ahmed EA, Alomair A, et al. A systematic review of hepatitis C virus epidemiology in Asia, Australia and Egypt. Liver international : official journal of the International Association for the Study of the Liver. 2011;31 Suppl 2:61-80.8. Hope VD, McVeigh J, Marongiu A, Evans-Brown M, Smith J, Kimergard A, et al. Prevalence of, and risk factors for, HIV, hepatitis B and C infections among men who inject image and performance enhancing drugs: a cross-sectional study. BMJ open. 2013;3(9):e003207.Page 7 of 7Accepted Manuscript79. National Institute for Health  and Care Excellence. Needle and syringe programmes NICE public health guidance. London: National Institute for Health  and Care Excellence., 2014.10. Commonwealth of Australia. Fourth National Hepatitis C Strategy 2014-2017. Canberra. http://www.health.gov.au/internet/main/publishing.nsf/Content/ohp-bbvs-hepc (accessed 27 October 2015). 2014.11. WHO & UNODC & UNAIDS. Technical guide for countries to set targets for universal access to HIV prevention, treatment and care for injecting drug users (revision). Geneva, Switzerland: WHO, UNODC, UNAIDS, 2012.12. Cullen KJ, Hope, V., Parry, J., Ncube, F. Risk and vulnerability among people who inject image and performance enhancing drugs in England and Wales 2012-2013: Where should we focus harm reduction? . Paper presented at the 24th International Harm Reduction Conference , Kuala Lumpur, Malaysia. 2015.13. Larance B, Degenhardt L, Copeland J, Dillon P. Injecting risk behaviour and related harm among men who use performance- nd image-enhancing drugs. Drug Alcohol Rev. 2008;27(6):679-86.14. Hope VD, McVeigh J, Marongiu A, Evans-Brown M, Smith J, Kimergard A, et al. Injection site infections and injuries in men who inject image- and performance-enhancing drugs: prevalence, risks factors, and healthcare seeking. Epidemiol Infect. 2015;143(1):132-40.15. McVeigh J, Evans-Brown M, Bellis MA. Human enhancement drugs and the pursuit of perfection. Adicciones. 2012;24(3):185-90.16. Sagoe D, McVeigh J, Bjornebekk A, Essilfie MS, Andreassen CS, Pallesen S. Polypharmacy among anabolic-androgenic steroid users: a descriptive metasynthesis. Subst Abuse Treat Prev Policy. 2015;10:12.

Iversen, Jenny

Hope, Vivian D

McVeigh, Jim

LSHTM Research Online

Access to needle and syringe programs by people who inject image and performance enhancing drugs.

Iversen, J 

UNSWorks

https://e-space.mmu.ac.uk/624836/1/ijdp2016.pdf

Access to needle and syringe programs by people who inject image and performance enhancing drugs

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