e-Bulletin 16: The Injecting Equipment Edition

Welcome to the latest edition of the Hepatitis Scotland e-Bulletin.  In a change to our previous format we will now be publishing themed e-Bulletins relevant to particular areas in the field of viral hepatitis.

Earlier this week the Scottish Needle Exchange Conference (SNXC12) showed that, as many services and areas in Scotland continue to innovate locally and improve prevention methods, sharing the experiences and evidence with a wider audience is of benefit to many. This month we summarise recent evidence on injecting equipment provision (IEP) and safer injecting - as well as the usual updates on viral hepatitis in a latest news section.

On the 30th of October we will also broadcast a related Webinar discussing injection practice, with presentations by Professor Avril Taylor and Graham Macintosh. 

We hope this new bulletin format will stimulate further discussion around the topics we cover.

Injecting Equipment Provision: the ayes have it

Hepatitis Scotland Comment


Injecting Equipment Provision (IEP) is fundamental to reducing the risk of transmission of blood borne viruses. Recent Scottish research, presented at SNXC12, has given a hint that wider coverage of IEP may have at least a key association in making a significant impact on incidence rates of HCV transmission.

Massive rates of BBV transmission and prevalence amongst people who inject drugs in Greece, where the loss of funding recently closed many exchange services, and Russia, where there are little or no harm reduction services for the largest population of injecting users in the world, gives a human face to scientific evidence. Scotlands world leading IEP distribution and research highlights that expanding the coverage and access of IEP  also expands the evidence base of its effectiveness.


To make it as easy as possible to access sterile injecting equipment, liberal policies that enable the tailoring of services that benefit and therefore engage the drug user are more likely to meet unmet demand for sterile equipment. A local Glasgow based study on the provision of plastic ampoules of water highlights that if equipment is of utility to the injector then they will use that service. Although recent evidence points towards paraphenalia as a key factor in transmission more research is required not only on outcomes from distributing sterile paraphenalia, but in furthering treatment engagement. The NEO system, recently introduced in Glasgow and presented on at SNXC12,  has allowed real time inputting and analysis of data and is potentially of major benefit in analysing local trends.  Although DBS testing is raising awareness of BBV status, this is not necessarily predictive of improved risk behaviour. Higher levels of constructive engagement with service users are needed to improve risky practice.


IEP alone as a prevention strategy is insufficient, it should be part of a wider programme of measures designed to reduce the potential for transmission of BBVs. A recent UK study evidenced the benefit of concurrent IEP and opioid substitution therapy.  There is also the continuing  body of evidence that opiate replacement therapies, such as methadone prescription, are central to combatting the spread of HIV, and by association, HCV. 


Alongside these efforts, peer education also has a very important role to play - as well as active rather than passive needle exchange services - such as mobile 24 needle exchange programmes.  Drug consumption rooms often engage with a socially marginalised and vulnerable population group of long-term injecting drug users who have frequently  had no previous interaction with any form of drug treatment or the wider service system. Heroin prescription may be particularly effective at reducing incidents of unsafe injection. The Swiss needle park experience suggests  that the pragmatic good sense of harm reduction policies can be understood and embraced by persons with a wide range of political views, if the need and evidence is obvious.


In terms of safer injecting, a number of other issues arealso  raised throughout the evidence.  Factors such as deprivation, poor education, unstable housing (including a lack of affordable social housing), mental health problems, policing, public and political pressures which stand in direct opposition to strong scientific evidence, as well as age and gender, are all linked to an increase in risky injection practises.  Evidence suggests that in order to tackle unsafe injecting, not only do we have to tailor services to the needs of drug users and offer more active educational and other interventions, governments and communities must also seek to address many of the above mentioned social problems.


References  Please note an Athens or journal subscription may be needed to access some articles. Please contact david@hepatitisscotland.org.uk if this is an issue.


Needle Exchange Surveillance Initiative (NESI): Prevalence of HCV and injecting risk behaviours among people who inject drugs attending injecting equipment provision services in Scotland, 2008/09 and 2010.

The aim of NESI is to measure and monitor the prevalence of Hepatitis C and injecting risk behavours among people who inject drugs in Scotland.


Signs of success – latest national NESI data?

This presentation, from the Scottish Needle Exchange Conference, also includes very early but  potentially exciting trends from the 2011 survey.


Trends in drug use, Harms and Responses: Latest NEO data analysis

This presentation, from the Scottish Needle Exchange Conference, looks at early data from IEP software package recently introduced across Glasgow IEP services.


Uptake of paraphernalia from injecting equipment provision services and its association with sharing of paraphernalia among injecting drug users in Scotland 

The uptake of paraphenalia appears to be associated with higher levels of safer injecting practice. 


Water for Injection provision pilot (Glasgow)

This local study looks at the provision of plastic ampoules of water to PWIDs at 3 key Glasgow Injecting Equipment Provision services. Alongside the provision of plastic ampoules there appears to have been a significant increase in the supply of other injecting equipment provision during the time of the pilot. This may be a good tool in attracting PWID into services and increasing the opportunities for positive engagement.

The Impact of Needle Exchange and Syringe Provision and Opiate Substitution Therapy on the Incidence of Hepatitis C Virus in Injecting Drug Users: pooling of UK evidence.

 Data pooled from studies across the UK. This study aimed to determine whether opiate substitution therapy and needle and syringe exchange programmes, singly or in combination, can reduce the transmission of hepatitis C among drug injectors. 


Benefits of Concurrent Syringe Exchange and Substance Abuse Treatment Participation.

Evidence from Baltimore in the USA that encouraging syringe exchange participants to enter treatment will reduce their drug use, crime and injecting more than syringe exchange alone - with obvious positive outcomes for BBV transmission.


Attribution of Hepatitis C Virus Seroconversion Risk in Young Injection Drug Users in 5 US Cities

Associations between sharing drug preparation equipment and HCV seroconversion are not attributable to under-estimating of syringe sharing. Avoiding HCV infection will require substantial reductions in exposure to all sources of contaminated blood.


Russia's drug policy fuels BBV epidemic

Russia has the largest population of injecting drug users (IDUs) in the world—an estimated 1·8 million people. More than a third have HIV; in some regions, the proportion is nearer to three-quarters. An estimated 90% of Russian IDUs have Hepatitis C.


Injection behaviors among injection drug users in treatment: The role of hepatitis C awareness

Risky injection behaviors remain prevalent and awareness of HCV infection was associated with increased risky injection behaviors.


A comparison of syringe disposal practices among injection drug users in a city with versus a city without needle and syringe programs.
The researchers found 44 syringes/1000 census blocks in San Francisco, and 371 syringes/1000 census blocks in Miami. Users with access to services reported improperly disposing of syringes 13% of the time versus 95%  by IDUs without access to exchange services.


Continuing HIV Risk in New York City Injection Drug Users: The Association of Syringe Source and Syringe Sharing 

This study found a strong association between consistently accessing sterile syringes and reduced syringe sharing and that IEP services reduce risk through the potential delivery of structured or informal interventions so mas to effect positive behavioral change.

Spatial Access to Syringe Exchange Programs and Pharmacies Selling Over-the-Counter Syringes as Predictors of Drug Injectors' Use of Sterile Syringes

Here findings suggest that greater  access to IEP increases the odds that PWIDs will consistently use sterile syringes.


Prevention and Control of Infectious Diseases among People who Inject Drugs. European CDPC and European Monitoring Centre for Drugs and Drug Addiction. 2011


The provision of non-needle/syringe drug injecting paraphernalia in the primary prevention of HCV among IDU: a systematic review

The evidence to demonstrate that the provision of sterile non-N/S injecting paraphernalia reduces HCV transmission or modifies injecting risk behaviours is currently limited by an insufficient volume and quality of studies. Further research is required to inform practice and policy in this area.


Guidance on how to prevent injection-related disease spread in Europe. Read more here.


HIV Infection During Limited Versus combined HIV Prevention Programs for IDUs in New York City: the Importance of Transmission Behaviours

 A success story of the reversal of a serious epidemic of HIV among injectors, with needle exchange the key  ingredient. 


Injection behaviors among injection drug users in treatment: The role of hepatitis C awareness

This study shows a higher level of risk behaviours in populations where higher proportions of IDUs are aware or think they are HCV-positive, and posits that therefore these IDUs may adopt more of a fatalistic attitude toward risky injection practices. It recommends interventions that could improve services for IDUs including those that explicitly and repeatedly educate IDUs about safer injection practices and the treatability of HCV.


WHO Guidance on Prevention of Viral Hepatitis B and C among People who Inject Drugs.

This guidance includes recommendations on the use of low dead space, or fixed needle and syringes, rather than separate syringe and needle.


Tackling hepatitis C: a tale of two countries

Professor Graham Foster comments that, “the message from Scotland is absolutely clear. If you set clear targets and you nominate individuals with clear tasks, action happens. If you set rather vague, pious wishes, nothing effective will take place.”


Switzerland, HIV and the power of pragmatism: Lessons for drug policy development

The Swiss experience with drug policy change demonstrates that the pragmatic good sense of harm reduction policies can be understood and embraced by persons with a wide range of political views.


Addiction, agency, and the politics of self-control: Doing harm reduction in a heroin users’ group

This case study of a heroin users’ group in the USA demonstrates the importance of destigmatization for successful health promotion.


Findings from the evaluation of Vancouver’s Pilot Medically Supervised Safer Injecting Facility – Insite


Further evaluation of the Medically Supervised Injecting Centre during its extended Trial period
(2007-2011), Sydney


Latest News on Viral Hepatitis


Hepatitis C Virus-Specific Immune Responses in Non Injecting Drug Users -

A small research study (N=57) suggests that sexual behaviour associated with non-injecting drug use might be a risk factor for Hepatitis C transmission. Subjects with HCV seroprevalence were significantly more likely to have bought sex in the past 6 months, to have had more casual partners of the opposite sex in the last 6 months, and those partners were more likely to have ever injected drugs compared to subjects without HCV-specific immunity. HCV seroprevalence was not associated with recent noninjection drug use practices however it was not able to fully separate out sexual behaviours and drug use as they were often concurrent. The study was also based on behaviours in the last 6 months.


If replicated in larger studies this research has implications for advice on key risk factors.  View full publication here.(athens access required).



New drug and vaccine updates


Idenix Hepatitis C Drug trial also halted due to safety concerns. Read article here.


Blood filtering as a new treamtent option for Hepatitis C - view study here.


Challenges for HCV Vaccine Development in HIV–HCV Coinfection. Read article here.


Antibody therapy to prevent Hepatitis C? Read article here.


Hepatitis C vaccine undergoing trials. Read article here.


Hepatitis B Update


Earlier treatment for young patients with chronic hepatitis B more effective in clearing virus. Read article here.


Higher than expected rates of HBV chronic infection among gay men, drug users and babies. Read article here.


General Hepatitis News


Impact of Hepatitis C on Survival in Dialysis Patients. Read article here.


Infections among homeless could fuel wider epidemics. Read article here.


Ex-prisoner, HIV/AIDS advocacy groups ask court for prison needle exchanges. Read article here

Services and Events

Positive Support is a Lanarkshire-based organisation providing an information, advice and support service for people living with, or affected by, Hepatitis C and/or HIV .



Hepatitis Scotland goes Social


You can now follow Hepatitis Scotland on Facebook and Twitter, as well as watching us on Youtube. 


Visit www.hepatitisscotland.org.uk and click on the links


Alternatively find us at http://www.facebook.com/pages/Hepatitis-Scotland/216995888407836 for Facebook


https://twitter.com/hepscotland to follow us on Twitter, and


https://www.youtube.com/user/Hepatitisscotland?feature=mhee to watch us on Youtube. 

We hope that our presence here means that we can increase opportunities for sharing information, promoting activities or events, as well as providing a wide variety of means for people to contact us with questions or requests.


If you have any research, news, ideas or upcoming events that you would like to see featured in our e-Bulletin then please contact David Barbour at david@hepatitisscotland.org.uk.






Hepatitis Scotland
91 Mitchell Street
G1 3LN

Telephone: 0141 225 0419
Fax: 0141 248 6414