Two groups - the Prevention Group and Education, Training and Awareness-raising Group - undertook activities to gather robust data to inform the development and expansion of Hepatitis C Prevention Services during 2008 and beyond. The scope of the work was confined to the prevention of Hepatitis C among IDUs through, in the main, the provision of injection equipment because i) the great majority of Hepatitis C infections occur as a consequence of drug injecting practices and, ii) this intervention type, unlike, for example, methadone maintenance, was and is designed principally to prevent the transmission of BBVs among IDUs. Considerable consideration, however, was given to measures aimed at preventing the initiation, and promoting the discontinuation, of drug injecting.
The key objectives were to examine i) the effectiveness of injection equipment provision in preventing the transmission of Hepatitis C among IDUs, ii) the current provision of injection equipment to IDUs in Scotland, and iii) existing policy on injection equipment provision to identify gaps in, and issues relating to, existing services.
The approaches adopted to examine evidence involved undertaking systematic reviews of the scientific literature and reviews of existing reports, such as that for Scotland's National Needle Exchange Survey, and telephone interviews in the context of reviewing current teaching on Hepatitis C in Scotland's educational establishments.
The following is presented: background information, a summary of the key findings and, for each key issue, evidence supporting the proposed action(s) to be taken and desired outcomes.
- The estimated number of current IDUs in Scotland in 2003 was within the range 17,700-20,300. 27
- It is estimated that 90% of Scotland's Hepatitis C infected population has injected drugs. 4
- In Glasgow, the incidence of Hepatitis C is steady at 20-30 infections per 100 person years of injecting. 4
- Approximately 30% and 40% of IDUs in Scotland, in contact with drug treatment or harm reduction services, report having recently injected with a needle/syringe and other injecting paraphernalia used previously by someone else, respectively. 28
- As at mid-2005, 188 needle/syringe exchange outlets, of which 136 were pharmacy based, were operating. Of 43 specialist, non-pharmacy facilities, 22 offered mobile/outreach services. 23
- At least 3.5 million needles/syringes were distributed to IDUs during April 2004-March 2005. 23
- The incidence of Hepatitis C infection among persons who do not inject drugs is low and the scope for preventing Hepatitis C infection among non-injectors is very limited; for example, it is estimated that around 10 babies, born to infected mothers in Scotland, are infected annually 31 but, currently, no interventions, such as antiviral therapy during pregnancy and caesarean section, have been shown to be both safe and effective. 30
- Measures to prevent people contracting Hepatitis C through blood or blood product transfusion are highly protective. Other interventions designed to protect the public from Hepatitis C include the exclusion of known infected healthcare workers from operating on patients 29 and the recent licensing of tattoo parlours in Scotland; 32, 33 in these two contexts, transmissions in Scotland have not been identified but it should be appreciated that instances of transmission are difficult to identify because Hepatitis C rarely presents as an acute illness.
Summary of Key Findings
- Since the late 1980s, services providing needles/syringes to IDUs have been developed; these, likely, have made a major contribution to the prevention of HIV transmission among IDUs in Scotland. In the context of the more infectious and more longstanding (in terms of prevalence) Hepatitis C virus, however, there are many issues which need to be addressed.
- Widespread variations in the provision of injection equipment and educational initiatives for IDUs to prevent Hepatitis C transmission due to gaps in co-ordination and guidance, exist; there remains, however, uncertainty about the relationship between such variations and the incidence/prevalence of Hepatitis C among IDUs.
- A high frequency of injection equipment sharing and incidence of Hepatitis C among IDUs is observed.
- Opportunities to evaluate novel approaches to injection equipment provision in community and prison settings, exist.
- A dearth of Hepatitis C information provision for young people in educational settings is evident.
Widespread variations in the provision and uptake of injection equipment and educational initiatives to prevent Hepatitis C transmission exist throughout Scotland. Many NHS Boards do not have formal networks to facilitate the prevention of Hepatitis C. Other than guidelines on the number of sets of needles/syringes that can be given to IDUs, comprehensive National Guidelines for services providing injection equipment do not exist.
- The estimated numbers of needles/syringes distributed to each IDU during 2005 ranged from 57-479 among Scotland's Drug Action Team areas. 23
- The shortfall in sets of needles/syringes that need to be distributed to IDUs, if the number of such sets is to correspond with the number of injecting events, is estimated to be several million/year. 23,27
- Major variations in any access to injection paraphernalia other than needles/syringes (filters, stericups/cookers and sterile water) exist across Scotland. 23, 34
- Based on work undertaken in Glasgow, there is evidence of a direct relationship between injection equipment sharing and poorer access (distance) to a needle/syringe exchange facility. 35
- Most injection equipment facilities do not provide evening or weekend access and only one service in Scotland is open 24/7. 23
- Experts are of the opinion that some, particularly recent-onset, IDUs do not frequent existing injection equipment provision services because they feel uncomfortable about disclosing their behaviour to individuals who they perceive to be disapproving of them.
- Adherence to official guidelines on the numbers of needles/syringes to be distributed to IDUs is inconsistent among services providing injection equipment. 23
- Most injection equipment provision services do not provide an evening or weekend service. Only one service is open 24/7. 23
- Each NHS Board will have, or be affiliated to, a Network covering the Prevention of Hepatitis C and comprising representatives of all stakeholder sectors. Guidance regarding Network membership and Terms of Reference for the Hepatitis C component will be established. Each NHS Board will identify a Hepatitis C Prevention Lead ( Action 13).
- National Guidelines for services providing injection equipment to IDUs will be developed. A Guideline Development Group will be established ( Action 14).
These actions will ensure that approaches to the provision of injection equipment to IDUs throughout Scotland are highly effective and, where appropriate, consistent.
The re-use/sharing of injection equipment among IDUs is still highly prevalent and Hepatitis C transmission among IDUs throughout Scotland is very common.
- It is estimated that well over 90% of new Hepatitis C infections in Scotland occur in people who have injected drugs; 4 small numbers of infections may occur in persons who have never injected drugs but usually they are indirectly associated with injecting drug use: for example, babies born to infected mothers who have injected drugs 29 and sexual partners of infected injectors. 36
- Around 30% and 40% of IDUs in Scotland, in contact with drug treatment or
harm reduction services, report having injected with a needle/syringe and other injecting paraphernalia, used before by someone else, during the previous month,
- Although there is some evidence of a decline in the frequency of injection equipment sharing during the last ten years, its extent is minimal. 28
- The incidence of Hepatitis C infection among IDUs in Glasgow remains extremely high at 20-30 per 100 person years of injecting. 4
- It is estimated that between 1,000 and 1,500 IDUs in Scotland are infected annually. 2
- A systematic review of the literature did not identify definitive evidence of harm reduction interventions, including needle/syringe exchange, educational initiatives and Hepatitis C testing, having had an impact on Hepatitis C transmission among IDUs but the absence of such evidence does not necessarily mean absence of effect as hardly any robustly designed studies have been undertaken anywhere. Nevertheless, studies have demonstrated that the provision of injection equipment is associated with reductions in numbers of needle/syringe sharing episodes. 37
- Scottish investigations, the findings of which have been published in reputable scientific journals, provide evidence that harm reduction measures - principally needle/syringe exchange and methadone maintenance therapy - may have led to considerable reductions in Hepatitis C transmission among IDUs. 38-40 It is estimated that, in Glasgow during 1988-2000, such interventions may have prevented 4,500 infections. 41
- Further, the prevalence of Hepatitis C among young IDUs (aged less than 25) in Scotland's major cities declined from 60-90% in the late 1980s/early 1990s to 15-40% in the late 1990s/early 2000s - a trend which coincides with the expansion of harm reduction services. 40
- An ethnographic study found that the storage of needles/syringes by IDUs for re-use was common - a practice which could result in the inadvertent sharing of such equipment. 42
- Services providing injection equipment (needles/syringes and other injection paraphernalia) will be improved in accordance with the Guidelines referred to in action 14 above. Improvements will be made in terms of the i) quantity (increasing access and uptake of equipment through innovative, including outreach, approaches) ii) quality ( e.g. the colour coding of equipment to avoid sharing) and, iii) nature ( e.g. the provision of equipment other than needles/syringes), of provision ( Action 15).
- Educational interventions aimed at vulnerable individuals, IDUs and those at risk of starting to inject will be designed and implemented to highlight how Hepatitis C transmission can be prevented. Particular attention should be given to initiatives aimed at identifying existing and newly diagnosed IDUs with Hepatitis C to prevent the onward transmission of infection ( Action 16).
These actions, hopefully, will lead to reductions in injection equipment sharing and Hepatitis C transmission among IDUs; if such reductions are achieved it may be difficult to attribute them, with certainty, to the specific interventions as described above.
IDUs who continue to inject drugs in prison do not have access to injection equipment in that setting.
- Although methadone therapy for prison inmates in Scotland has become increasingly available in recent years, it is estimated that between 200 and 300 inmates inject drugs in prison at least once/month. 43
- Inmates who inject drugs in prison do so, usually, with unsterile, often "home-made", injection equipment. 44
- A study, undertaken in Shotts Prison in 1999/2000, demonstrated an incidence of 12 infections per 100 person years of incarceration among inmates who had ever injected drugs during their lives. 45
- Needle/syringe exchange schemes have been implemented in selected prisons in some European countries, particularly Spain, Germany and Switzerland, but not the UK; evaluations, undertaken in some instances, demonstrated acceptability of the intervention to inmates/staff and an association between in-prison provision of needles/syringes and a reduction in needle/syringe sharing frequency. None of the evaluations had the power or the appropriate design to demonstrate effectiveness, apropos reducing Hepatitis C transmission. 37
- An in-prison needle/syringe exchange initiative will be piloted as one of a range of harm reduction measures to reduce the transmission of Hepatitis C ( Action 17).
This action will demonstrate the acceptability, to users and prison officers, and use of an in-prison service providing injection equipment.
Persons in school and further education settings receive little, if any, education about Hepatitis C.
- The majority of secondary schools deliver little or no teaching on Hepatitis C within either their Drug or Sex Education Programmes. Only half of secondary schools provide education on injecting drugs. 46
- In the primary school setting, references to Hepatitis C are not made. 46
- In the further education college setting, there is little evidence of initiatives relating to the provision of information on Hepatitis C. 46
- Experts are of the opinion that education on Hepatitis C, in the context of other BBVs such as HIV, should be provided to young people under the age of 25 in the above settings but also in other community settings for vulnerable young people ( e.g. juvenile offender settings) who may miss out on such education if it was provided in educational establishments only. 46
- Hepatitis C guidance and educational support materials (within the context of BBVs/drugs misuse) will be developed, disseminated and evaluated to raise awareness among young people in school, further education and community settings, and other settings which support vulnerable young people. Staff/peer group training initiatives will facilitate the implementation of this action ( Action 18).
This action will increase awareness and knowledge of Hepatitis C among young people in Scotland.