Q&A: Safe injection sites reduce HIV infection

Dec 1, 02:16 AM

In 2003, Canada’s first safe injection site opened in Vancouver’s downtown east-side, an area known for its rampant drug use, homelessness, and high rates of HIV infection.

Insite,which drew about 5,000 users in its first year of operation, is a place where habitual drug users can safely go to inject illegal drugs under close supervision by nurses.

While studies have shown the clinic to be successful at reducing harm and illness to habitual drug users, Prime Minister Stephen Harper announced in late 2006 that the “waiver of law,” which allows the site to operate, will only be in effect until June 2008. That waiver allows the site to operate without fear that users or staff will face criminal charges.

Despite the uncertain future of the Vancouver clinic, researchers and advocates in Toronto are calling for a similar facility to be established to serve its much smaller drug using population.

Dr. Peggy Millson is an HIV/AIDS researcher at the University of Toronto’s Faculty of Medicine, focussing primarily on harm reduction. She says safe injection sites for habitual drug users are a proven effective method of reducing the spread of HIV through needle sharing.

Millson is also part of an ongoing research group created as part of the Toronto Drug Strategy announced in 2005.

She thinks Toronto needs to look at the success of the clinic in Vancouver as an example to follow. RyersOnline’s Michael Lehan spoke to her about safe injection sites.

They provide an opportunity to use sterile equipment which is provided by the site. That’s immediately a huge benefit for preventing blood borne diseases such as HIV and Hepatitis C. They also provide a clean environment, which reduces abscesses and damage to the vein which drug users are prone to, and it provides supervision in the event that someone overdoses.

By reducing the amount of needle sharing and other equipment such as cookers, it’s made a huge difference. The evidence is very clear that reducing the amount of sharing has a major impact on infection rates. It works better than simple needle exchange, because it eliminates the need for drug users to have or store their own equipment, particularly important if they’re homeless.

That’s a function of their use and their pattern of use. How frequently they inject and where they inject. If they have access to clean and sterile equipment their only risk is through sexual contact, which is shared by the whole population.

The risk depends on who they’re sharing with. In Vancouver where HIV spread rapidly in the 1990s there is roughly a one in five chance a person they’re sharing needles with might be HIV positive. In Toronto it might be one in twelve. So it depends on the city, as well as your network of associates.

Another is issue is that the likelihood of a drug user having Hepatitis C, which is a very serious blood borne virus that can cause liver failure or cancer. In most cities in Canada it’s one in two. That’s another opportunity for safe injection sites to cut down on risk.

There definitely is evidence in Vancouver that more people are going into detox. For people who have been chronic, long-term heroin users, the opportunity for them to completely withdraw from any opiate related drug and stay off is very difficult.

They have modifications in their central nervous system that means for the rest of their lives potentially they will have cravings for this type of drug and they have a need thats difficult to control, especially if they’re expected to live in an environment where frequent drug use is occurring. That’s where methadone treatment comes in. People can take it by mouth that replaces the need for an injectable opiate. It lasts for 24 hours so they can take it once a day, it doesn’t get them high, it just reduces their craving so they can carry on a normal life.

Getting people who have been using opiates into a better, healthier, more productive life might not involve stopping all drugs. It may involve giving them access to well provided methadone service which means they no longer require injecting, which significantly reduces their chances of exposure to blood borne viruses like HIV.

There’s two strains of evidence here. One is the harms of injecting in public locations and unsafe places, there’s a lot of evidence about that. We’ve done some research in Toronto showing that people who were homeless or marginally housed were much more likely to engage in risky injection behaviour than people who had stable housing because they have no safe place to inject or store equipment.

There’s also evidence from Europe and quite strong evidence from Vancouver evaluating the actual impact of the operating sites that show a reduction in overdose and unsafe injection practices. In the European case they have been able to improve people’s housing situations. In Frankfurt for example, they provide a full service site where people have access to other social services or immediate referral.

Vancouver has done something like that with referral to detoxification programs and treatment programs, and there’s been an increased uptake in program use.

There’s actually quite strong evidence. The arguments against safe injection sites are not based on any kind of rationale or scientific evidence, they’re ideologically based.

There’s two issues in terms of attitudes. One is the attitude of a local community to the site and across the world there’s been different ways of addressing that.

In Geneva, some sites have a community advisory group so they can get input from people in the community, and any issues or concerns that arise can be brought to the sites attention and addressed. That’s been one strategy to deal with community-level reactions because people are not necessarily comfortable with having such a site in their neighbourhood. However if you’re in a neighbourhood like Vancouver’s downtown east side, where the alternative is very unsafe street conditions, people realize this is a better option.

The other thing is the more ideologically driven arguments that this supports or accepts drug use in a way some people are not comfortable with and I think the best response to that is to look closely at the evidence. It makes people’s behaviour safer and it also brings more people in for treatment. So if people want to put their money where their mouth is and say drug users should have access to treatment then this is one way to create that.

They may not go to treatment the first time they use the service, but over time it builds confidence in the service providers that they can be trusted to discuss treatment options in a fair and reasonable way. It creates a bridge for people who are interested in treatment, and for people who aren’t, it keeps them alive and healthy until such time they may be able to consider treatment.

It’s clear this is a strategy that does not increase or encourage drug use but on the contrary gives them the opportunity to modify or eliminate their drug use.

There needs to be a careful assessment done, which involves getting information from the community about where would a likely place where a safe injection site would be effective. There would need to be community consultation, and development of an understanding with the communities chosen and an explanation of what’s involved in a site. It would need negotiation with police, it’s very important that police accept this is a health site and they not interfere with the proper functioning of the service.

I’m part of a group that was created as an outcome of part of the Toronto Drug Strategy. One of their recommendations was to assess the need for a safe injection site in Toronto. We’re interviewing key informants that are familiar with the drug issue in Toronto, we’re looking at the data that’s available, and we’re also looking at other models in the worlds to see what kinds of approaches might work for Toronto.

posted by: Michael Lehan

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