HIV in Canada: A primer for service providers

 

Harm Reduction Programs

Key Points

  • The consistent and correct use of certain harm reduction interventions (needle and syringe programs, opioid agonist therapy and safe consumption services) are effective strategies to reduce the risk of HIV and hepatitis C.

One effective harm reduction approach is needle and syringe programs (NSP). These programs provide new injecting equipment to people who use drugs. New needles and injecting equipment need to be used every time a person uses drugs in order to be highly effective. These programs typically offer other services such as information, counselling and referrals. NSPs operate most commonly out of fixed sites; however, needle and syringe distribution also happens through mobile sites, pharmacies, vending machines and during outreach. Evidence reviews have found that the use of NSPs by people who inject drugs is associated with significant reductions in injecting risk behaviours and reduced HIV and hepatitis C transmission rates. NSPs are thought to be more effective when combined with an array of harm reduction approaches, such as educational interventions and opioid agonist therapy (OAT).

OAT is another effective strategy and involves the use of prescription medications to reduce drug cravings and prevent withdrawal symptoms for people who want to reduce or eliminate their use of illicit opiates. The most common medications used for OAT are methadone and buprenorphine. These drugs do not create the same euphoric or high feeling that a person would get from injecting, snorting or swallowing illicit opiates. The drugs used in OAT have consistently been shown to help reduce or eliminate injection drug use, related injection risk behaviours and HIV and hepatitis C infection rates among people who inject drugs. Less commonly, hydromorphone or diamorphine (prescription heroin) can be used as OAT for long-term drug users who have been unsuccessful with methadone or buprenorphine. They have been shown to lower illicit drug use and needle sharing, which likely lowers HIV and hepatitis C risk.

Supervised consumption services (SCS) are another effective harm reduction approach. These programs provide supervised areas where people who use drugs can use pre-obtained drugs in a clean and safe environment. SCSs have been shown to attract people who are at increased risk of HIV infection, and they can be important settings for delivering harm reduction education, distributing injection-related equipment and providing referrals to addiction treatment programs. Several studies have shown that SCSs are associated with reductions in injecting risk behaviours such as needle/syringe sharing, which can lead to reductions in HIV and hepatitis C transmission. When people who use drugs participate in less borrowing and lending of used needles, there is less opportunity for HIV and hepatitis C transmission to occur. Research has found that SCS use is also associated with other safer drug use practices such as less public and outdoor injection, less needle reuse, and safe disposal of used injecting equipment.

Coverage of harm reduction services must be high, including in rural and remote communities. to have an impact on reducing HIV and hepatitis C transmission among people who inject drugs. For example, NSPs that do not distribute enough equipment or do not reach enough people who inject drugs are less likely than other programs with better coverage and reach to have an impact on transmission rates. Little is known about coverage in Canada because of insufficient data. However, we do know that HIV prevalence and incidence vary across the country, suggesting that some programs may have better reach and coverage than others.

Despite the proven effectiveness of multiple harm reduction interventions, many of these have not been effectively scaled-up for people who inject drugs.

Resources

Harm reduction in action: Supervised consumption services and overdose prevention sitesPrevention in Focus

HIV prevention for people who inject drugs: New biomedical approaches and time-honoured strategies - Prevention in Focus

Supervised consumption sites: status of applications ­– Health Canada

 

Sources

  1. Strike C, Watson TM, Gohil H, et al. The Best Practice Recommendations for Canadian Harm Reduction Programs that Provide Service to People Who Use Drugs and are at Risk for HIV, HCV, and Other Harms: Part 2. Toronto, ON: Working Group on Best Practice for Harm Reduction Programs in Canada. 2015. Available from: http://www.catie.ca/en/resources/best-practice-recommendations-canadian-harm-reduction-programs-provide-service-people-wh-0
  2. Gibson D, Flynn N, Perales D. Effectiveness of syringe exchange programs in reducing HIV risk behaviour and HIV seroconversion among injecting drug users. AIDS. 2001;15:1329–1341.
  3. Wodak A, Cooney A. Effectiveness of sterile needle and syringe programming in reducing HIV/AIDS among injecting drug users. Evidence for Action Technical Papers. 2004. Geneva: World Health Organization.
  4. Aspinall EJ, Nambiar D, Goldberg DJ, et al. Are needle and syringe programmes associated with a reduction in HIV transmission among people who inject drugs: A systematic review and meta-analysis. International Journal of Epidemiology. 2014;43(1):235–248.
  5. Tilson H, Aramrattana A, Bozzette SA, et al. Preventing HIV infection among injecting drug users in high-riskcountries: An assessment of the evidence. 2007. Washington: Institute of Medicine.
  6. Coffin PO, Rowe C, Santos GM. Novel interventions to prevent HIV and HCV among persons who inject drugs. Current HIV/AIDS Reports. 2015 Mar;12(1):145–163.
  7. MacArthur GJ, Minozzi S, Martin N, et al. Opiate substitution treatment and HIV transmission in people who inject drugs: systematic review and meta-analysis. BMJ. 2012 Oct 4;345:e5945.
  8. Platt L, Minozzi S, Reed J, et al. Needle syringe programmes and opioid substitution therapy for preventing hepatitis C transmission in people who inject drugs. Cochrane Database of Systematict Reviews. 2017;9:CD012021.
  9. Strang J, Groshkova T, Uchtenhagen A, et al. Heroin on trial: systematic review and meta-analysis of randomised trials of diamorphine-prescribing as treatment for refractory heroin addiction. British Journal of Psychiatry. 2015;207(1):5–14.
  10. Oviedo-Joekes E, Guh D, Brissette S, et al. Hydromorphone compared with diacetylmorphine for long-term opioid dependence: a randomized clinical trial. JAMA Psychiatry. 2016 May 1;73(5):447–455.
  11. Perneger TV, Giner F, del Rio M, Mino A. Randomised trial of heroin maintenance programme for addicts who fail in conventional drug treatments. BMJ. 1998 Jul 4;317(7150):13–8.
  12. March JC, Oviedo-Joekes E, Perea-Milla E, et al. Controlled trial of prescribed heroin in the treatment of opioid addiction. Journal of Substance Abuse Treatment. 2006 Sep 1;31(2):203–211.
  13. Kennedy MC, Karamouzian M, Kerr T. Public health and public order outcomes associated with supervised drug consumption facilities: a systematic review. Current HIV/AIDS Reports. 2017 Oct;14(5):161–183.
  14. Potier C, Laprévote V, Dubois-Arber F, et al. Supervised injection services: What has been demonstrated? A systematic literature review. Drug and Alcohol Dependence. 2014;145:48–-68.
  15. Tyndall MW. Impact of supervised injection facilities on community HIV levels: a public health perspective. Expert Review of Anti-infective Therapy. 2003 Dec;1(4):543–549.
  16. Milloy MJ, Wood E. Emerging role of supervised injecting facilities in human immunodeficiency virus prevention. Addiction. 2009;104:620–621.
  17. Kerr T, Tyndall M, Li K, et al. Safer injection facility use and syringe sharing in injection drug users. Lancet. 2005;366:316–318.
  18. Wood E, Tyndall MW, Stoltz J, et al. Factors associated with syringe sharing among users of a medically supervised safer injecting facility. American Journal of Infectious Diseases. 2005;1(1):50–54.
  19. Bravo MJ, Royuela L, De la Fuente L, et al. Use of supervised injection facilities and injection risk behaviours among young drug injectors. Addiction. 2009 Apr;104(4):614–619.
  20. Kerr T, Kimber J, Debeck K, et al. The role of safer injection facilities in the response to HIV/AIDS among injection drug users. Current HIV/AIDS Reports. 2007;4:158–164.
  21. Hedrich, D. European report on drug consumption rooms. 2004. Lisbon: European Monitoring Centre for Drug and Drug Addiction.
  22. MacArthur GJ, van Velzen E, Palmateer N, et al. Interventions to prevent HIV and Hepatitis C in people who inject drugs: a review of reviews to assess evidence of effectiveness. International Journal of Drug Policy. 2014 Jan;25(1):34–52.
  23. Guise A, Albers ER, Strathdee SA. ‘PrEP is not ready for our community, and our community is not ready for PrEP’: pre-exposure prophylaxis for HIV for people who inject drugs and limits to the HIV prevention response. Addiction. 2017 April ;112(4): 572–578. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5145792/
  24. Larney S, Peacock A, Leung J, et al. Global, regional, and country-level coverage of interventions to prevent and manage HIV and hepatitis C among people who inject drugs: a systematic review. Lancet Global Health. 2017;5(12):e1208–e1220.

Do you work in HIV or hep C?
Complete a short survey to evaluate CATIE and enter a draw to win a $250 gift card.