Response to Marsden et al (2020): Mitigation for the impacts on needle and syringe programmes is needed.

Abstract

In their recent editorial, Marsden et al. [1] highlight many of the challenges that the current novel coronavirus (COVID-19) pandemic presents for vulnerable populations and those who use substances world-wide. One of these challenges is maintaining the provision of sterile needles and syringes to people who inject drugs. Needle and syringe programmes (NSP) are key to preventing and controlling many of the harms associated with injecting drug use, such as HIV, hepatitis C virus (HCV) and skin and soft tissue infections [2]. Evidence indicates that these, when delivered with sufficient coverage and in parallel with other interventions, have a core role to play in the elimination of HCV [3, 4]. Delivering NSP with sufficient coverage is challenging under normal circumstances [5, 6]. Social distancing has now made their delivery even more so. Cheshire and Merseyside, in the North West of England, has an established system for monitoring NSP provision [7]. In response to COVID-19 this was enhanced to gather data on changes in service provision (opening hours, access restrictions, etc.) and to report weekly activity data. While most NSP services have remained open with social distancing, 45% have reduced hours or have additional access restriction in place. Although a few additional services have started to offer NSP, client visits to NSP dropped substantially in mid-March 2020, and have been reduced by approximately two-fifths since the week commencing (w/c) 23 March; comparing the w/c 5 May to w/c 2 March, the number of visits were reduced by 42% and clients by 46% (where data are available). Although the impact of social distancing and other COVID-19 restrictions on drug use and routes of administration remain unclear, these marked changes in NSP use are of concern. They indicate a probable rise in the re-use of equipment, therefore an increased risk of sharing and harm. As a consequence, the potential for outbreaks of HIV and HCV is now greatly elevated, and these would not be detected as HIV/HCV testing has all but ceased in the United Kingdom due to social distancing and the focus on testing for COVID-19. As social distancing measures are likely to remain in place for some time, urgent action is needed to ensure that those who need sterile needles and syringes can easily access these. Improved awareness of the continuation of existing NSP provision and improvements to access to this are needed. However, other approaches, such as home delivery, provision by post, peer-supported distribution and vending machines, should urgently be considered. The latter may be challenging because of their sourcing and installation, but the others could all be established relatively quickly. Home delivery and peer distributions schemes already exist in some areas [8], but require careful planning to ensure social distancing is maintained. There are already direct postal sales of injecting equipment to some people who inject image and performance enhancing drugs [9]. By utilizing existing postal and courier services, establishing free postal NSP provision to all people who inject drugs could be achieved relatively quickly while maintaining social distancing. None.