Needle And Syringe Program Services Research Articles

“No-one just does drugs during business hours!”: evaluation of a 24/7 primary needle and syringe program in St Kilda, Australia

BackgroundPrimary needle and syringe programs (NSPs) have been integral for the prevention of blood-borne virus (BBV) transmission among people who inject drugs. Despite this, many people who inject drugs face barriers accessing these services, particularly after-hours when most services are closed. To our knowledge, the St Kilda NSP, in Melbourne, Victoria, is the only primary NSP providing 24/7 dedicated stand-alone face-to-face services for people who inject drugs in Australia. We conducted an evaluation of the St Kilda NSP to assess its role and effectiveness in meeting client needs.MethodsMixed research methods were used to conduct the evaluation. We analysed four quantitative data sets including the Victorian Needle and Syringe Program Information System data; NSP ‘snapshot’ survey data; and St Kilda NSP records of after-hours contacts and naloxone training events. Qualitative interviews were conducted with 20 purposively selected NSP clients, which were focused on individual needs, expectations and experiences accessing the service. Interviews were audio recorded and transcribed, and data were analysed thematically. A convergent research design was used to merge the five data sets.ResultsSt Kilda NSP had 39,898 service contacts in 2018; 72% of contacts occurred outside business hours. Similarly, of 1,185,000 sterile needles and syringes dispatched, 71% were distributed outside business hours. Participants described valuing the after-hours service because drug use patterns did not always align with standard NSP opening hours and after-hours access afforded anonymity when collecting injecting equipment. Narratives highlighted several additional benefits of the 24/7 service, including: access to safer sex equipment; material support; naloxone training; referrals to specialist services; face-to-face emotional and social support from a non-judging worker; and for women involved in sex work in particular, being able to seek refuge when feeling unsafe on the streets.ConclusionsOur study provides evidence of the social and health benefits (beyond that of preventing BBV transmission) that can be gained through the provision of 24/7 primary NSP services. Findings support the need for the establishment of after-hours primary NSPs in other areas of Australia where active street-based drug markets operate outside business hours and concentrated numbers of people who inject drugs live and spend time.

Barriers to hepatitis C treatment among secondary needle and syringe program clients and opportunities to intervene

At least 160,000 Australians are living with hepatitis C (HCV), many of whom are people who inject drugs and access needle and syringe programs (NSP). Secondary NSPs provide injecting equipment via health services that are not dedicated to the provision of services to people who inject drugs; these sites could be a suitable space to increase engagement of people who inject drugs in HCV treatment. Drawing on data from a pilot study exploring the potential of upscaling linkage to HCV care in secondary NSPs, the aim of this research was to explore barriers and enablers to HCV treatment for clients who use these services.We interviewed 34 people who inject drugs (who self-reported HCV positivity) from six secondary NSPs in urban and regional Victoria, Australia in 2018. Fifty per cent were male, with ages ranging from 33 to 58. Twenty-two (65%) had never received HCV treatment and none had experience with direct-acting antiviral (DAA) treatment. Interviews were transcribed and analysed thematically. Field notes from a program evaluation with feedback from secondary NSP staff was also used as a secondary data source.Five themes encompassing a set of contrasting barriers and enablers to accessing HCV care through secondary NSPs were uncovered. Themes included 'misinformation' vs. 'multiple trusted information sources; 'lack of symptoms and motivation' vs. 'benefits of cure'; 'competing priorities' vs. 'willingness and readiness to be cured'; 'unsupportive relationships with staff' vs. 'supportive relationships with staff'; and 'inaccessibility and stigma in health services' vs. 'enhanced support'. Secondary program evaluation data also highlighted that secondary NSP staff were under-resourced and had limited capacity to implement HCV care linkage and information.We identified contrasting barriers and opportunities for accessing DAAs among a sample of secondary NSP clients and staff. Interventions that consider individual, provider and health system level factors are needed if secondary NSP services are to become a suitable setting to initiate conversations with clients around HCV treatment and provide linkages to care.

Prevalence of high-risk drug use and coverage of opioid substitution treatment and needle and syringe programs in Lithuania in 2015–2016: A multi-method estimation study

Background and objectivesIn Lithuania, injecting heroin and other illicit opioids has dominated high-risk drug use since about 2000. More recently, patients have reported a high-risk use of amphetamines. Newly diagnosed HIV cases among people who inject drugs peaked in 2002 and 2009 and drug-related deaths have been on the increase. Yet research has reported a limited number of available harm-reduction programs. This study aimed to estimate the size of high-risk drug using populations in Lithuania and to apply these estimates in assessing the coverage of opioid substitution treatment (OST) and needle and syringe programs (NSP). MethodsWe used indirect prevalence estimation methods (HIV and Mortality Multiplier, Capture-Recapture, Truncated Poisson and the Multivariate Indicator Method) to obtain annual prevalence estimates of the population of high-risk opioid users (HROU) and of people who inject drugs (PWID) in Lithuania in 2015/2016. We computed the coverage of OST (the annual percentage of HROU in these programs) and NSP (the number of provided syringes per PWID per year), using the prevalence estimates and the data from drug services. ResultsThere were between 4854 and 12,444 HROU and between 8371 and 10,474 PWID in Lithuania in 2015/2016. In addition, we obtained a preliminary estimate of 4742–7000 high-risk amphetamine users. This constitutes around 2.5–6.5 HROU and 4.4–5.3 PWID per 1000 inhabitants aged 15–64. On average, 9.9–25.5% of HROUs were in OST and an average PWID in Lithuania obtained 19–29 syringes via NSPs during the study period. ConclusionsWhile the current prevalence of high-risk drug use in Lithuania is comparable to other European countries and for PWID, it is above the average; and the coverage of OST and NSP services in this population is markedly lower than in most countries of the European Union and warrants further investment.

Accessibility of Needle and Syringe Programs and Injecting and Sharing Risk Behaviors in High Hepatitis C Virus Prevalence Settings

Background: Access to healthcare services is a basic human right. Objective: The main purpose of this study is to assess the association between accessibility of needle and syringe programs (NSP) and injecting and sharing risk behaviors. Methods: A cross-sectional study employed respondent-driving sampling (RDS) to recruit a sample of 634 people who inject drugs (PWID) from three provinces, Golestan, Ardabil, and Sistan and Baluchestan, in Iran between November 2018 and February 2019. Participants completed a questionnaire based on the WHO Drug Injecting Study Phase II survey. Results: Participants reported their accessibility of NSP services as low (6%), middle (19%), and high (75%) in the past 2 months at the time of the survey. PWID who had increased access to NSP services were less likely to report utilization of used cooker (aOR = 1.40; CI 95% 0.99–1.82), cotton (aOR = 1.30; CI 95% 0.79–1.81), and water (aOR = 1.07; CI 95% 0.89–1.26), receptive needle/syringe sharing (aOR= 1.86, 95% CI 1.69–2.03), and distributive needle/syringe sharing (aOR= 1.09, 95% CI 0.81–1.37). Conclusions/Importance: There is evidence of inequality in PWID’s access to health care as they relate to the prevention of HCV transmission. An understanding of both the social determinants and prevention of injecting and sharing risk behaviors seeks to connect HCV risk reduction within the context of human rights and vulnerability.

Prevalence and risk factors for injection site skin infections among people who inject drugs (PWID) in Tehran.

Injection drug use is one of the major public health problems in Iran. Injection drug use is associated with numerous negative health outcomes, such as blood-borne infections (HIV, HCV) and injection site skin infections (abscesses, cellulitis). The aim of this study was to determine prevalence of injection site skin infections and its associated risk factors among people who inject drugs (PWID) in Tehran, Iran. The cross-sectional study was conducted from March to August 2016 in Tehran province. A total of 500 PWID were recruited by convenience and snowball sampling from Drop-in Centers (DIC) in the South of Tehran. Our primary outcomes were self-report of ever having injection sites skin infections and receiving treatment for them. We first examined associations between individual variables and lifetime history of having injection site infections in bivariate analysis using the chi-square or Fisher's exact tests, as appropriate. Variables with P-value <.2 were included in a multiple logistic regression model. Overall, 40% (CI95%: 30.3%, 52.2%) of participants reported ever having an injection site infection. In the multivariable model, those with low socioeconomic status (AOR = 2.4, P = .03), self-reported as HIV positive (AOR =1.6, P = .01), reporting more than 3 injections per day (AOR = 4.1, P = .03) and reuse of their own syringes (AOR = 8.5, P = .03) were more likely to have injection sites skin infections. PWID who used needle and syringe program (NSP) services were less likely to report injection site infections (AOR = 0.5, P = .04). We have identified several risk factors for injection sites infections among PWID, including frequency of injection per day, reuse of their own syringes, not using NSP services, HIV status, socioeconomic status with skin infections in PWID. Prevention strategies to reduce skin infections should focus on high-risk injection behaviors and improving access to NSP services.

Uptake of needle and syringe program services in the Kyrgyz Republic: Key barriers and facilitators

BackgroundIn Kyrgyzstan, injection drug use accounts for the majority of HIV infections. Needle and syringe programs (NSPs) are one of three core HIV interventions for people who inject drugs (PWID). However, in Kyrgyzstan all persons diagnosed with drug dependence are subject to compulsory registration for governmental drug dependence treatment services, which creates barriers for PWID to access any health services, including NSPs. MethodsIn 2015, we conducted an assessment at 19 NSP sites in six cities to identify barriers and facilitators that affect PWID uptake of NSP services in Kyrgyzstan. The study involved the conduct of 10 focus groups with 99 PWID (62 males/37 females) and individual interviews with 24 full-time NSP staff. ResultsWe found that access of PWID to NSPs was limited by stigma and discrimination around drug use, fear of police encounters, inconvenient hours of operation, lack of information and motivation from PWID to use NSP services and a limited menu of available injection supplies. At the same time, availability of outreach services and additional health services were highly valued by PWID. ConclusionsStigma and discrimination, combined with the criminalization of drug use and the requirement for official registration of PWID remain key barriers to effective NSP utilization. Law enforcement and health care providers need to be sensitized about the unique context and needs of PWID.

Coverage of harm reduction services and HIV infection: a multilevel analysis of five Chinese cities

BackgroundSince 2003, a harm reduction program for injecting drug users has been rolled out countrywide in China. It entails services for condom promotion, a needle and syringe program (NSP), and methadone maintenance treatment (MMT). However, it remains unknown if and to what extent the coverage of these services at city level is related to a reduced risk of HIV infection among drug users.MethodsWe wished to quantify the extent to which city-level characteristics (such as NSP and MMT service coverage) and individual-level determinants (e.g., self-reported exposure to NSP and MMT services, knowledge, motivation, and skills) were associated with the risk of HIV infection among drug users. In 2006, we conducted an integrated serological and behavioral survey among drug users in five cities of Yunnan Province, China (N = 685), constructing a multilevel logistic regression model with drug users clustered within these cities.ResultsDrug users who reported having received NSP or MMT services were about 50% less likely to be infected with HIV than those who reported not having received them (OR 0.45, 95% CI, 0.26–0.83 for NSP and 0.48, 95% CI, 0.31–0.73 for MMT). Despite a between-city variation of HIV infection risk (ICC 0.24, 95% CI 0.08–0.54), none of the city-level factors could explain this difference. Individual-level determinants such as perceived risk of infection and use of condoms were not associated with HIV infection.ConclusionsAlthough people who had used NSP or MMT services were less likely to be HIV infected, this study found no relationship between city-level coverage of HIV prevention programs and variations in HIV infection between cities. This may have been due to the low number of cities in the analysis. Future research should include the analysis of data from a larger number of cities, which are collected widely in China through integrated behavioral and serological surveys.

Individual-level needle and syringe coverage in Melbourne, Australia: a longitudinal, descriptive analysis.

BackgroundCoverage is used as one indicator of needle and syringe program (NSP) effectiveness. At the individual level, coverage is typically defined as an estimate of the proportion of a person who injects drugs’ (PWID) injecting episodes that utilise a sterile syringe. In this paper, we explore levels of individual syringe coverage and its changes over time.MethodsData were extracted from 1889 interviews involving 502 participants drawn from the Melbourne drug user cohort study (MIX).We asked questions relating to participants syringe acquisition, distribution and injecting frequency within the two weeks before interview. We created a dichotomous coverage variable that classified participants as sufficiently (≥100 %) covered if all their injecting episodes utilised at least one sterile syringe, and insufficiently (<100 %) covered if not. We categorised participants as “consistently covered” if they were sufficiently covered across interviews; as “consistently uncovered” if they were insufficiently covered across interviews; and “inconsistently covered” if they oscillated between coverage states.Chi-square statistics tested proportions of insufficient coverage across sub-groups using broad demographic, drug use and service utilisation domains. Logistic regression tested predictors of insufficient coverage and inconsistently covered categorisation.ResultsAcross the sample, levels of insufficient coverage were substantial (between 22–36 % at each interview wave). The majority (50 %) were consistently covered across interviews, though many (45 %) were inconsistently covered.We found strong statistical associations between insufficient coverage and current hepatitis C virus (HCV) infection (RNA+). Current prescription of opioid substitution therapy (OST) and using NSPs as the main source of syringe acquisition were protective against insufficient coverage.ConclusionInsufficient coverage across the sample was substantial and mainly driven by those who oscillated between states of coverage, suggesting the presence of temporal factors. We recommend a general expansion of NSP services and OST prescription to encourage increases in syringe coverage.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1668-z) contains supplementary material, which is available to authorized users.

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

We appreciate van Beek and Chronister's concerns regarding the funding of harm reduction interventions in an environment of diminishing resources (van Beek & Chronister, 2015), 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 (van Beek & Chronister, 2015). 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

“Doing the devil’s work”: Emotional labour and stigma in expanding Needle and Syringe Programs

Expansion of Needle and Syringe Programs (NSPs) to non-specialised sites requires an NSP workforce with skills in engaging stakeholders who may have different opinions of NSP. This study examined the strategies used by NSP workers to develop and maintain NSP services and the emotional labour involved in performing this work. Qualitative interviews were undertaken with 12 staff of a NSP network in metropolitan Sydney, Australia. Participants had undertaken a range of activities to expand NSP sites, often in unwelcoming environments in which NSP was viewed as a “cowboy” service. Participants’ strategies included building positive, ongoing inter-group contact, being visible in external services, and maintaining their professionalism to promote NSP as a legitimate service and themselves as legitimate health workers. Some participants employed strategies which were at odds with their personal and professional values. Participants relied on cohesion within the NSP team to support and encourage each other. Dealing with external services to establish and maintain NSPs was a source of significant emotional labour for NSP workers and was grounded in the stigma attached to injecting drug use. NSP policies and procedures should account for this additional work undertaken by NSP staff and leadership is required to address stigmatisation of NSPs.

HIV and Hepatitis C Virus Infection and Risk Behaviors Among Heterosexual, Bisexual, and Lesbian Women Who Inject Drugs in Australia.

Women who inject drugs (WWID) are vulnerable to a range of harms, including exposure to sexually transmitted and blood-borne infections, abusive relationships, physical and sexual violence and mental health issues. Lesbians and bisexual women are at greater risk than heterosexual women for substance use disorders. This study aimed to compare a large sample of heterosexual, bisexual, and lesbian WWID and to identify correlates of sexual orientation. The Australian Needle and Syringe Program (NSP) Survey is an annual cross-sectional survey. People who inject drugs (PWID) who attend NSP services are invited to complete a brief self-administered questionnaire and provide a capillary dried blood spot. Of 22,791 survey respondents between 2004-2013, one third were women (n=7,604). Analyses were restricted to the first participation record for each respondent. Of the 5,378 individual women, 4,073 (76%) identified as heterosexual, 1,007 (19%) identified as bisexual, and 298 (6%) identified as lesbian. HIV prevalence was low (<1.0%). More than half (56%) had been exposed to hepatitis C virus (HCV), with prevalence highest among bisexual women (59%). In adjusted analysis, bisexual women had significantly greater odds of initiating injection at a younger age (AOR 1.44, 95% CI 1.19-1.73), and reporting public injection (AOR 1.44, 95% CI 1.21-1.73) and receptive sharing of drug preparation equipment (AOR 1.20, 95% CI 1.00-1.44). Bisexual women (AOR 1.42, 95% CI 1.07-1.88) and lesbians (AOR 1.63, 95% CI 1.10-2.44) had significantly greater odds of reporting sex work than their heterosexual counterparts. Results contribute to the literature on HIV and HCV transmission risk among WWID. Analysis of the relationship between sexual orientation and risk behavior identified bisexual orientation as independently associated with increased risk. Services that target PWID need to recognise and address a broad range of sexual identities and behaviors. Future research should explore reasons for increased risk in sexual minority women.

Characteristics and attendance patterns of a fixed-site NSP and nearby SVM: The benefits of 24-hour access to sterile injecting equipment

Aims: This article describes the characteristics and attendance patterns of clients of a co-located fixed-site needle and syringe program (NSP) and syringe vending machine (SVM) to assess the utilisation and benefits of providing access to multiple distribution services. Methods: Data were collected through cross-sectional surveys with a convenience sample of NSP (n = 98) and SVM (n = 91) recruited attendees in Sydney, Australia. Surveys collected demographic data, self-reported injecting patterns, self-reported receptive equipment sharing, knowledge of hepatitis C and utilisation of the fixed-site NSP and SVM services. Findings: The demographic profile and characteristics of these NSP and SVM groups were similar; no differences were evident in knowledge about hepatitis C risk practices or type of drug used, frequency of injecting, sharing of injecting equipment and place of injecting. Both fixed-site NSP- and SVM-recruited attendees primarily accessed equipment from the fixed-site NSP in the last month. The SVM was usually accessed outside the opening hours of the fixed-site NSP, between 8 pm and 4 am, or in circumstances where equipment could not be obtained from the NSP. Conclusions: Findings support the argument that SVMs act as a complementary service alongside fixed-site NSP services and indicate that providing 24-h access to syringes through multiple mechanisms has benefits for provision of sterile equipment to people who inject drugs.

What's the Cost of Finding the Right Fit? The Cost of Conducting NSP Business in a Range of Modalities

The aim of this study was to calculate the cost of a range of needle and syringe program (NSP) models to contribute to planning for effective NSP delivery. Existing health service data was used to estimate the cost per needle distributed across four modes of service delivery (Primary NSP, including one model of Primary NSP providing primary health care; Secondary NSP; Vending Machine and Outreach) over three years. Costs were primarily affected by the ratio of the volume of equipment distributed to staff costs. The average cost per unit for Primary, Secondary and Outreach modes was approximately $1.00. The cost for Vending Machine provision (accounting for income from service users) was the cheapest option at $0.30–0.40 per unit. When income from services users are not included in calculations, other considerations may be more important than cost when making decisions about providing access to NSP services to a marginalized client group with diverse needs.

Are people who inject performance and image‐enhancing drugs an increasing population of Needle and Syringe Program attendees?

Australian studies of people who inject performance and image-enhancing drugs (PIED) have identified subgroups including professional sportspeople, occupational users (those in protective services/entertainment industries), body image users and adolescents [1]. Between 2000 and 2010, the proportion of respondents in the National Drug Strategy Household Survey who reported non-medical use of steroids remained low and stable at 0.3% or less [2], and PIEDs injectors comprised just 1–2% of respondents in surveys of Needle and Syringe Program (NSP) attendees [3]. Anecdotal reports from NSP services in New South Wales (NSW) and Queensland suggest substantial recent increases in the number of people who inject PIEDs accessing injecting equipment.This study investigates temporal trends in prevalence and patterns of PIEDs injection among Australian Needle and Syringe Program Survey (ANSPS) respondents.

Prevalence and correlates of HIV, syphilis, and hepatitis B and C infection and harm reduction program use among male injecting drug users in Kabul, Afghanistan: A cross-sectional assessment

BackgroundA nascent HIV epidemic and high prevalence of risky drug practices were detected among injecting drug users (IDUs) in Kabul, Afghanistan from 2005-2006. We assessed prevalence of HIV, hepatitis C virus (HCV), hepatitis B surface antigen (HBsAg), syphilis, and needle and syringe program (NSP) use among this population.MethodsIDUs were recruited between June, 2007 and March, 2009 and completed questionnaires and rapid testing for HIV, HCV, HBsAg, and syphilis; positive samples received confirmatory testing. Logistic regression was used to identify correlates of HIV, HCV, and current NSP use.ResultsOf 483 participants, all were male and median age, age at first injection, and duration of injection were 28, 24, and 2.0 years, respectively. One-fifth (23.0%) had initiated injecting within the last year. Reported risky injecting practices included ever sharing needles/syringes (16.9%) or other injecting equipment (38.4%). Prevalence of HIV, HCV Ab, HBSAg, and syphilis was 2.1% (95% CI: 1.0-3.8), 36.1% (95% CI: 31.8-40.4), 4.6% (95% CI: 2.9-6.9), and 1.2% (95% CI: 0.5-2.7), respectively. HIV and HCV infection were both independently associated with sharing needles/syringes (AOR = 5.96, 95% CI: 1.58 - 22.38 and AOR = 2.33, 95% CI: 1.38 - 3.95, respectively). Approximately half (53.8%) of the participants were using NSP services at time of enrollment and 51.3% reported receiving syringes from NSPs in the last three months. Current NSP use was associated with initiating drug use with injecting (AOR = 2.58, 95% CI: 1.22 - 5.44), sharing injecting equipment in the last three months (AOR = 1.79, 95% CI: 1.16 - 2.77), prior incarceration (AOR = 1.57, 95% CI: 1.06 - 2.32), and greater daily frequency of injecting (AOR = 1.40 injections daily, 95% CI: 1.08 - 1.82).ConclusionsHIV and HCV prevalence appear stable among Kabul IDUs, though the substantial number having recently initiated injecting raises concern that transmission risk may increase over time. Harm reduction programming appears to be reaching high-risk drug user populations; however, monitoring is warranted to determine efficacy of prevention programming in this dynamic environment.

Role of Service Providers of Needle Syringe Program in Preventing HIV/AIDS

To provide a national-scale picture of the needle exchange program in Taiwan, this study examined (a) needle and syringe program (NSP) service providers' AIDS-relevant harm reduction knowledge and attitudes; and (b) NSP services schemes and operation barriers encountered by different service modalities. A self-administrated questionnaire was mailed to all participating NSP service providers in Taiwan. A total of 414 service providers completed the postal survey. This study confirms that NSP service providers play an essential role in providing comprehensive activities to reduce HIV/AIDS infection for drug misusers. Knowledge and attitudes of service providers were found to be independently and important predictors of NSP service provisions. Community-based and clinical-based providers had diverse service schemes and encountered operation problems due to different organization characteristics, professional training, and ethical concern. For the future planning of NSP programs, service-specific education and professional support are essential component of service delivery and quality.

Guidelines for better harm reduction: Evaluating implementation of best practice recommendations for needle and syringe programs (NSPs)

Background The objective of this study was to evaluate needle and syringe program (NSP) policies and procedures before and after the dissemination of a set of best practice recommendations. Methods An on-line survey of 32 core NSP managers (100% response rate) and 62 satellite NSP managers (63% response rate). The survey included items about the distribution of needles/syringes, other injection-related equipment and inhalation equipment, and use of a best practice recommendations document. Results The majority of NSPs reported following needle and syringe best practice recommendations. Most core NSPs (88%, n = 28) and satellite NSPs (84%, n = 52) distributed cookers following the dissemination of the document. All core NSPs (100%, n = 32) and nearly all satellite NSPs (97%, n = 60) distributed sterile water ampoules in 2008, many more than in 2006. Although more NSPs distributed safer inhalation equipment in 2008, the majority did not distribute these items. More satellite NSPs (44%, n = 27) distributed glass stems than the core NSPs (16%, n = 5). Commonly cited implementation barriers included funding, senior management and decision-making. Conclusion Our findings demonstrate that NSPs will implement empirically based best practice recommendations and welcome such guidance. The managers we surveyed not only reported increased implementation of practices that have been empirically shown to help reduce disease transmission among injection drug users (IDUs), they also used the best practices document for additional purposes, such as planning and advocacy, and expressed interest in having sets of recommendations developed for other areas of harm reduction. Ensuring high-quality and consistent NSP services is essential to prevent transmission of HIV among people who inject drugs and others in the community. Best practice recommendations can assist in achieving these goals.

Blood-borne Viruses and Risk Behaviours among Injecting Drug Users Recruited from Needle and Syringe Programs in Victoria's Eastern Metropolitan Region

Little has been reported about the risk behaviour and service accessibility of injecting drug users (IDU) living beyond the inner suburbs of Melbourne. This study describes IDUs in the Department of Human Services' Eastern metropolitan region (EMR), including the prevalence of blood-borne viruses and risk behaviours. Fifty-two IDUs were recruited directly from EMR Needle and Syringe Programs (NSP) and through snowball recruitment. IDUs completed a questionnaire and provided a finger-prick blood specimen that was tested for the presence of HIV and Hepatitis C virus (HCV) antibodies. No participants were HIV antibody positive; 29 (56%) were HCV antibody positive. HCV seropositivity was associated with having a tattoo in univariate analysis. The prevalence of HCV in surveyed EMR IDUs was similar to that of Victorian IDUs surveyed in the National Needle and Syringe Program Survey; however, the EMR sample exhibited significantly greater levels of risk behaviour, including the sharing of needles and other injecting equipment, and unsafe sex. Similarly, EMR IDUs from outer and rural suburbs reported greater levels of risk behaviours and lower levels of HCV infection than those from the inner EMR. This study shows that with high levels of risk behaviour and relatively low access to NSP services, Victoria's EMR IDU population is vulnerable to future blood-borne virus outbreaks.

Needles and syringes to care and counselling: The need for innovative primary health care to meet the needs of street-based injecting drug users

This article addresses the potential role that the Australian Needle and Syringe Program (NSP) could play to assist the delivery of primary health care to ?street-based? injecting drug users (i.e., those who spend the greater part of their lives ?on the street?). Their personal circumstances mean that street-based drug users are particularly vulnerable to health problems. However, they also face obstacles that discourage their use of health care services. Consequently, relatively minor health problems may be allowed to deteriorate until emergency treatment is required. As one of few established services frequented by street-based drug users, NSPs may be in a unique position to intervene at an early stage of need. This article draws upon research undertaken with street-based drug users at the primary St Kilda NSP. Some 150 drug users were surveyed. A further 32 were interviewed at length. Users described the obstacles that discouraged their use of mainstream health care services. This article argues that these obstacles - primarily issues of accessibility and attitudinal barriers - might be addressed by linking primary health care services with existing NSP services. NSP staff could draw upon their relationships and skills to refer clients to linked health services.