Section 2 Prevention
2.1 In Scotland, the main route of transmission of Hepatitis C is through injecting drug use, in particular, through the sharing and re-use of contaminated injecting equipment. Over 85% of people currently diagnosed with the virus have acquired it in this way. Small numbers have contracted Hepatitis C through other routes, including those who were infected by blood or blood products prior to 1991 before all blood donations began to be routinely tested for Hepatitis C. Significant developments introduced in the Scottish Blood Transfusion Service over the past decade in relation to blood and donor screening have now virtually eliminated blood donations as a source of Hepatitis C infection in Scotland.
2.2 The proportion of injecting drug users who have Hepatitis C is high. Recent studies undertaken among injectors in Glasgow have found between 44 - 62% infected with the virus. The rate of transmission within this population is also high. Again, some studies have found that nearly a quarter of those who have been injecting for less than two years have already contracted the virus.
2.3 Given this context, efforts to prevent Hepatitis C in Scotland must focus on preventing transmission of the virus among injecting drug users - and these efforts are inextricably linked to on-going activities aimed at preventing injecting and helping injectors to stop. These include:
- Improving the accessibility and effectiveness of drug treatment and rehabilitation services
- Improving the accessibility and effectiveness of needle exchange and other harm reduction services
- Preventing drug use among young people
2.4 Organisations and agencies such as needle exchanges; drug treatment, care and rehabilitation services; community pharmacies; social work services; primary care services; schools; prisons and justice agencies; and voluntary sector agencies working with drug users all have a crucial role to play in this work.
2.5 Some of the work already happening in this area is described below.
Drug treatment and rehabilitation
2.6 One way of preventing the transmission of Hepatitis C is by helping injectors to stop injecting. Significant efforts are being made in Scotland to make drug treatment and rehabilitation services more accessible and effective. For example:
2.7 The Scottish Executive has steadily increased investment for drug and alcohol treatment services in the last five years. A total of £33.6 million has been allocated to NHS boards for drug and alcohol treatment services in 2006-07. Drug treatment funding allocated to drug and alcohol action team ( DAAT) areas in 2005 was linked directly to defined outcomes such as:
- Reducing waiting times for treatment
- Increasing the numbers of drug users entering treatment
- Improving the range of services available to drug users.
2.8 The Scottish Executive is also committed to developing national quality standards for substance misuse services in Scotland. Implementation of these standards will be linked eventually to a framework for monitoring and evaluation.
2.9 The UK national clinical guidelines on the treatment of drug misuse ( Drug Misuse and Dependence - Guidelines on Clinical Management) are about to be revised and updated. Scottish clinicians and policy officials from the Scottish Executive are contributing to this process.
Needle exchange and other harm reduction interventions
2.10 It is accepted however, that harm reduction interventions are necessary for those who continue to inject. And again, a great deal of positive work has been undertaken recently in Scotland to improve the effectiveness and accessibility of needle exchange and other harm reduction services. For example:
2.11 The Scottish Executive published the findings of the first ever National Needle Exchange Survey in July 2006, and is currently considering the recommendations of this study. Meanwhile, the Executive will also carry out a synthesis of existing research on the effectiveness of needle exchange services in reducing the transmission of blood-borne viruses (and Hepatitis C in particular), to highlight any evidence of good practice.
2.12 The Scottish Prison Service ( SPS) has developed a harm reduction awareness session which all prisoners attend on admission. This is repeated pre-release for prisoners who are serving longer sentences. The awareness session provides prisoners with information on overdose risk due to loss of tolerance, blood-borne viruses, and ways of getting treatment in prison. SPS has also been piloting a needle replacement scheme at reception in several prisons over the past year - to support the schemes now existing in many police custody suites in Scotland. This involves offering sterile needles to known injectors when they leave prison. A further pilot is currently underway in HMP Aberdeen, where prisoners can also access injecting paraphernalia and support upon release. It is expected that this initiative at HMP Aberdeen will be expanded further in 2007-08 to incorporate a pilot in-prison needle exchange scheme. These activities will be robustly evaluated over a significant period of time.
Preventing drug use among young people
2.13 In terms of prevention services targeted at young people, the Executive's Sure Start programme will provide £57 million in 2006-07 to local authorities to enable them to work with health services and other organisations to support Scotland's most vulnerable children and families. The Changing Children's Services Fund will provide over £65 million in 2006-07 to support local authorities and their partners to improve the quality and integration of services for children and young people, including those involved in or affected by substance misuse.
2.14 The Executive's Drugs Communication Strategy, Know the Score ( KTS), is based on detailed and comprehensive research across Scotland which suggests that young people want evidence-based information. The campaign is targeted at all age groups including young people. It aims to meet the desire for factual and reliable information about drugs and offers a 24-hour helpline advice service, a suite of information materials which can be ordered free of charge, and a website. The Strategy also includes national media and marketing campaigns, often timed to coincide with the launch of new KTS information materials.
2.15 However, these national initiatives are only part of the story. DAATs, community health (and social care) partnerships and other similar multi-agency partnerships around Scotland, are responsible for the strategic planning of local services aimed at preventing drug use among young people in their areas.
2.16 Furthermore, school-based health education also has an important role to play in providing young people with accurate information about Hepatitis C. More will be said about this in Section 5.
What needs to be done?
2.17 Our understanding of what needs to be done in this area has largely been informed by the findings of several key Scottish Executive-funded research studies. For example, we know that:
- Injectors often have poor understandings of how the "indirect" sharing of needles, syringes and other injecting paraphernalia puts them at risk. They also have a lack of knowledge about Hepatitis C (Taylor et al, 2004).
- Few needle exchange services carry out an initial assessment of their clients' needs as standard practice. In addition, there is enormous variation in paraphernalia distribution and in the nature of educational and harm reduction interventions offered by needle exchange services across Scotland (Griesbach et al, 2006).
- Injectors do not always realise that they are entitled to, nor do they always want, a greater number of needles and syringes than they currently receive - nor do services always inform them of their entitlement and encourage them to make use of it. Many areas of Scotland are distributing an insufficient number of needles and syringes to their local injecting population (Taylor et al, 2005; Griesbach et al, 2006).
- Pharmacy needle exchange providers can have negative and judgemental attitudes towards injectors. These attitudes often can be overcome with good regular on-going support from a specialist harm reduction worker (Taylor et al, 2005; Griesbach et al, 2006).
- Inadequate data collection systems are having an adverse impact in many areas on the planning and commissioning of needle exchange and other harm reduction services. The general lack of robust data on current needle exchange activity makes it difficult to accurately assess the need for such services (Griesbach et al, 2006).
2.18 All of these issues need to be tackled at a local level, and NHS boards may wish to consider allocating some of the additional Hepatitis C-related funding they will receive in 2006/07 and 2008/09 to address some of these matters.
Actions on Prevention
From Sept 2006 - Aug 2008
Local planning and commissioning groups (including NHS boards, community health partnerships, prisons and drug and alcohol action teams) should consider whether they can use the funding allocated to them over the next two years to improve local Hepatitis C prevention services (in particular, needle exchange). They should also consider whether it is necessary to improve data collection systems, for the purpose of better informing local planning activities.
By Dec 2006
The Scottish Executive will ask NHS boards to consider whether they have the full range of interventions in place to reduce re-using and sharing of needles, syringes, and injecting paraphernalia and to promote safer injecting. These interventions should include: more outreach and mobile needle exchange services; distributing a wide range of paraphernalia (in addition to needles and syringes) in needle exchanges; and labelling or colour-coding of injecting equipment to help drug users identify their own.
By Dec 2006
Scottish Ministers will publish national quality standards for substance misuse services.
By Mar 2007
The Scottish Executive will consider the recommendations of the National Needle Exchange Survey published in July 2006.
By Apr 2007
The Scottish Executive Substance Misuse Research Team will publish the findings of research on the outcomes and risks associated with the use of injecting paraphernalia such as filters, cookers and tourniquets.
By Apr 2007
The Scottish Executive will carry out a synthesis of existing research on the effectiveness of needle exchange services in reducing the transmission of blood-borne viruses (and Hepatitis C in particular), to highlight any evidence of good practice.
By Apr 2007
The Scottish Prison Service will pilot in-prison needle exchange in HMP Aberdeen. A report of this pilot will be available in 2009.
By May 2008
The Scottish Prison Service will provide injecting paraphernalia to all prisoners with an identified need, upon their release from prison.