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Needle exchange program delivery models
Best practice recommendations — in detail
To reduce the transmission of HIV, HBV, HCV, other bloodborne pathogens and to prevent other drug-related harm:
u Provide NEP services using a delivery model(s) that maximizes accessibility for IDUs
u Tailor NEP services to meet the needs of sub-populations of IDUs (e.g., youth, women and ethno-cultural groups)
u Involve IDUs in the design and delivery of services
u Conduct outreach in the community and at other agencies serving IDUs
u Collaborate with local agencies that serve IDUs to provide additional locations for IDUs to receive NEP services
u Collaborate with local pharmacies to ensure that IDUs can purchase sterile needles
i N t r o d u c t i o N
To reduce transmission of bloodborne pathogens, NEPs increase access to sterile needles among IDUs, remove used needles from circulation, educate clients about safer injection practices and provide education, referrals and other services. In Ontario, NEPs are mandatory public health programs in communities where drug use is recognized as a problem (Ontario Ministry of Health and Long Term Care, 1997).
As described in the NeP effectiveness section, the effectiveness of NEPs to prevent HIV transmission among IDUs is influenced by the number of needles distributed. However, NEP effectiveness is also influenced by the ability of NEPs to attract and retain clients, and to encourage/facilitate behavioural change. Service providers and researchers have noted the importance of the mode of service delivery, location and hours of operation as factors that directly impact on accessibility and effectiveness of NEPs. NEPs that are designed to maximize accessibility in terms of location and time are more likely to prevent the transmission of HIV, HCV, HBV and other bloodborne pathogens from non-sterile needles and syringes. Studies show wide diversity among IDUs in terms of gender, age, years of injecting and type of drug injected, culture, language, race, mental health status and other factors. As a result, IDUs have varied service needs, and studies show that different models attract different types of IDUs. Personal preferences and chaotic daily lives also influence program attendance. As a result, NEPs need to tailor service delivery to accommodate the diverse needs of the IDU population.
Over the past two decades, varied service models for NEPs have been developed and implemented to increase accessibility for clients. To maximize the advantages and offset disadvantages of different types of model, many programs in Canada, and elsewhere, offer services using more than one model. As Henman et al. (1998) note, when different service models are combined, NEPs are likely to achieve maximum effectiveness.
While a mixed model approach is likely to maximize effectiveness, not all jurisdictions have the resources or expertise to offer services using different models. Historically, many NEPs in Ontario started with one
or two models of service delivery and added additional models in relation to their funding, increased knowledge of the IDU community, requests from clients, partnerships with other agencies and an increase in staff expertise. As well, many NEPs in Ontario and elsewhere experimented with and refined their models of service delivery in response to client need.
In this section of the Best Practices, we review evidence about the most commonly used models of service delivery: fixed site, four types of outreach (mobile service, satellite sites, peer/secondary exchangers, home delivery), pharmacy, mixed model and multi-service. These models have received the most attention and evaluation.
Unfortunately, many studies do not report the service model of the NEP under study. As a result, the evidence about the effectiveness of particular NEP models is less well developed. The evidence available to evaluate the relative effectiveness of one type of model versus another is often lacking. Most studies compare the types of clients attracted to a particular model versus another type of model. There have been no randomized controlled trials evaluating relative effectiveness. However, the literature reviewed here does show that different models attract different types of IDUs, which suggests that there is no ONE best model of service delivery.
For easy comparison of the strengths and limitations of each model of service delivery, please see table 7.
table 7: Comparison of the strengths and limitations of different NEP models
model type Strengths Limitations
fixed site NEP u Services are free for IDUs
u User friendly
u Education and other services available on-site
u Disposal of used equipment
u Limited hours of operation
u Location – limited and/or identifying
u Crowded when program is busy
u Clients reluctant to use sites perceived to be too governmental, clinical, gay- oriented or HIV related
mobile NEP1 u Services are free for IDUs
u User friendly
u Increases accessibility (i.e., go where the clients are)
u May be insufficient space for counselling sessions, arranging referrals, HIV and other disease testing, helping clients fill out forms and
model type Strengths Limitations
Satellite Outreach sites3
u Services are free for IDUs
u May attract different groups of IDUs
u Increase accessibility in terms of location, time, culture and age group
u May offset operational and human resource costs from the parent NEP to the satellite site
u Increases service complement at satellite agency without incurring NEP equipment/disposal expenses
u Difficult to enforce parent NEP policies on satellite sites
u Staff turnover at satellite site may require frequent training of staff by parent NEP
Pharmacy u Extended hours of operation
u Multiple locations
u Less stigmatizing/more anonymous
u Costs for IDUs to purchase needles
u No disposal of used equipment
u No harm reduction services offered
u Reluctance to sell to IDUs
u Reluctance to sell small quantities of needles
u Limited hours/days of operation Peer-based
outreach
u Peer knowledge of drugs, drug use and the drug scene
u Peer knowledge and empathy about living conditions and context
u Increases reach of the NEP to IDUs who will not/cannot use the NEP
u May provide employment skills, and income for peer exchangers
u Improve self esteem and self worth
u No cost to the NEP if peers are unpaid
u More convenient/accessible for clients
u Peers have credibility and can be important role models for risk reduction
u Training/supervision of peers can be costly
u Conflicting identities as peer worker and IDU community member
u Peer worker identity may be used to continue/further street economy activities
u May violate worker/client boundaries
Vending machines
uLocation and 24 hour availability
u Convenience
u Ease of use
u Limited staffing required
u No face to face harm reduction services offered
u Difficult to maintain anonymity when in a public space
1 Excluding home visits 2 Home visits by mobile NEPs
3 Also known as community coalitions or partner agencies, satellite NEP sites are agencies that serve IDUs for other purposes and through a
f I x E D S I t E S
NEPs based at fixed sites range from single offices to office suites that provide space for exchange services, counselling, phone referrals, supply storage, etc. In Ontario, fixed site NEPs are located within public health units, AIDS service organizations, other health or social service agencies and/or stand-alone rented spaces. Workers have found that fixed sites with the following features best meet program and client needs: a c c e s s i b i l i t y
u Barrier free entrance where clients can come and go freely u Friendly and welcoming atmosphere when clients enter u Equipment and information that are easily located S i z e
u Sufficient space for multiple clients to enter, leave and interact with staff and other clients u Sufficient space for enclosed offices and space to store supplies
C o m f o r t
u Space for clients and staff to sit, relax and speak with each other P r i v a c y
u Have enclosed offices and space for counselling, medical testing and other private matters
u Have enclosed offices for clients to speak with workers about personal concerns and/or receive results from HIV, HCV or other medical tests
u Have enclosed offices for staff and clients to make telephone calls for referrals, appointments or other private matters
Determining optimal locations for fixed sites is crucial for NEP effectiveness. As indicated above, where fixed sites are located determines, to a large extent, the likelihood that IDUs will use the services. Several studies in the United States have shown that NEPs located within walking distance are more likely to be used than NEPs located further away. As well, these studies show the importance of multiple NEP locations to ensure that IDUs located throughout a community have access to program services (WHO, 2004). Once operational, many programs modify and/or increase their locations over time in relation to a greater understanding of client need, changes in the IDU community, new opportunities to partner with other agencies, opposition from the surrounding community, increased funding and other factors. Issues regarding site selection are also reviewed in the NEP start-up tasks section.
drawing clients into a fixed site when drug use is geographically dispersed and/or the catchment area for the NEP is large. On the other hand, fixed sites that are well attended can become overcrowded and uncomfortable for clients and staff.
As well as spatial and time constraints, acceptance of an NEP by staff of a larger agency (e.g., public health unit) can create challenges for both NEP staff and clients. In particular, fear about NEP clients and reluctance to collaborate with the NEP may lead to a hostile environment and negatively impact program attendance. Fixed sites can also be focal points for opposition by community residents. Some NEPs have moved to reduce opposition and to ensure access for clients.
Clients may be reluctant to use fixed sites if they fear police surveillance of the location. While infrequently reported in Ontario, fixed NEP sites have been used by law enforcement agencies for surveillance purposes. In the past, NEPs experiencing surveillance by the police have negotiated (or re-negotiated) a non- surveillance agreement (see the relationships with law enforcement section).