Section 4: Integrating injecting equipment provision with other services
IEP services have traditionally been seen as 'low-threshold' services. However, the intention has always been that IEP services should provide a route into treatment for injecting drug users. More recently specialist and enhanced IEP services in Scotland have begun to provide their clients with far more than just a route into drug treatment. These services give their clients access to a wide range of primary care and social care interventions, by providing regularly-scheduled "clinics" or consultations on the premises of the IEP service.
There is also a growing trend by specialist and enhanced services to offer a range of BBV interventions on-site. For example, at the time of the National Needle Exchange Survey in 2005, 40% of specialist IEP services in Scotland provided HCV testing facilities on-site. 19
There is also evidence from qualitative research carried out among injectors in the UK which indicates that injectors can face a range of barriers when trying to access help from generic health and social care services. 73 These barriers include the burden of appointments, travel to services, stigma and negative staff attitudes, personal ill-health, lack of material resources and anxieties about accessing support.
Therefore, any move towards providing these more generic services within the premises of an IEP service is to be encouraged and strongly supported. Such a development is very much in line with the principles of integrated care as set out in the Effective Interventions Unit publication, Integrated care for drug users - principles and practice:
Integrated care for drug users is an approach that seeks to combine and co-ordinate all the services required to meet the assessed needs of the individual. It requires:
- Treatment, care and support to be person-centred, inclusive and holistic to address the wide ranging needs of drug users
- The service response to be needs-led and not limited by organisational or administrative practices
- Collaborative working between agencies and service providers at each stage in the progress of the individual. 74
IEP services are well-placed to play a major role in bringing about better, more integrated care for injecting drug users, and the recommendations in this section focus on improving integration between IEP services and other types of services. This includes services which aim to identify those who are infected with HCV, and which link them into clinical care and social support.
Recommendation 14: BBV testing and vaccination for IEP clients
IEP services should encourage clients to be tested annually for HCV. In addition, wherever possible, all IEP services should make available vaccination (for HAV, HBV and tetanus) and testing (for HCV, HBV and HIV) on-site in a suitable private space.
Testing - including pre- and post-test discussion, sample collection, result-giving and onward referral - should always be delivered by appropriately trained staff. Where IEP services do not offer testing and vaccination facilities on-site, they should develop referral pathways that are user-friendly and accessible to injecting drug users.
The 2007 Needle Exchange Surveillance Initiative ( NESI) found that a large proportion of injecting drug users attending IEP services in Scotland are not only infected with HCV, but are unaware that they are infected. 13 If this situation remains unchanged, it is expected that the number of injectors who go on to develop HCV-related decompensated cirrhosis in Scotland will double between 2000 and 2020. 75 Guidance issued by the Royal College of General Practitioners points out that unless testing and early treatment is made more widely available, HCV is likely to cost the NHS across the UK up to £8 billion over the next 30 years as increasing numbers of people will require treatment for cirrhosis, liver failure and liver cancers. 76
Given the high prevalence, and incidence, of HCV among injecting drug users, frequent testing must be recommended. However, the aim is not only to reduce the number of undiagnosed infections among injecting drug users, but also to promote better integration between IEP services and specialist hepatitis services - so that those who are infected can receive the treatment they need.
Research undertaken during Phase I of the Hepatitis C Action Plan for Scotland (September 2006 - March 2008), found that there was a lack of integration among primary care, specialist hepatitis services, addiction, prison and social care services. This resulted in many HCV-infected persons not obtaining the anti-retroviral treatment and care they needed. 77 This same study found that there were also often lengthy delays between having blood taken, and receiving a test result. Injecting drug users, in particular, often fail to return to their GP to learn of their HCV status following a test.
Action 10 of the Hepatitis C Action Plan, Phase II requires that NHS Boards work together with Community Health Partnerships ( CHPs) to develop and implement innovative approaches to improve HCV testing and referral activities by GPs and practitioners in other community settings. 1 The recommendation made here - that testing facilities be made available through IEP services - may be considered to be one such innovative approach, and would result in making testing more accessible to injecting drug users.
When offering testing to injecting drug users, it is important to keep in mind that many injectors do not perceive HCV with the same level of concern as they do HIV, nor do they necessarily understand the significance of a positive HCV test result. 18,17, 72 Injectors must be made aware of the implications of both a positive and a negative result so that they are able to give informed consent to be tested. Explaining this may take time, and should be done by suitably trained staff in a way which respects the individual's privacy and confidentiality. There is SIGN guidance available, as well as the guidance issued by the RCGP (mentioned above), which should provide the basis for pre- and post-test discussions carried out with clients in IEP services. 78
In relation to Hepatitis A, Hepatitis B and tetanus, these guidelines recommend vaccination of injecting drug users on the basis of current Department of Health guidelines, Immunisation against Infectious Diseases 2006 (The Green Book). 79 (See Chapter 17, page 150; Chapter 18, pages 168-169; and Chapter 30, page 372.)
Recommendation 15: Improving integration between IEP services and other services
All IEP services should be able to signpost, and where possible, formally refer clients to treatment for drug misuse.
In addition, IEP services should be able to signpost, and where possible, formally refer clients to other broader health and social support services, including:
Wherever possible, IEP services should make any one or more of these broader support services (excepting emergency department care) available on-site. Where this is not possible, user-friendly and accessible referral pathways should be developed.
An international review of qualitative research carried out for NICE found evidence to suggest that a range of harm reduction interventions (including referrals to drug treatment and other services; BBV testing; and medical care), in addition to IEP services, were accessed and valued by injecting drug users. 32 These findings are supported by a study from Scotland which sought to identify and rank client preferences in relation to the development of IEP services. This study found that access to dressings for wounds and sores and antibiotic prescribing were considered to be particularly important, since injectors can be reluctant to visit their GPs for these problems. 58
Just as there may be some benefits to providing a range of other services within the premises of an IEP service, so there may also be benefits from providing injecting equipment on the premises of other services. For example, a review carried out for NICE found evidence to show that hospital-based IEP services may increase the accessibility to outpatient services among injectors attending these services. 6 This same review also found that the provision of injecting equipment through health care services may decrease emergency department use by injectors.
IEP services should not prevent injectors from being referred for treatment for HCV (or other BBV) infection on the basis that they are still injecting. SIGN Guideline 92 on the Management of hepatitis C, states that:
Current injecting drug users infected with HCV should not be excluded from consideration for HCV clinical management, including antiviral therapy, on the basis of their injecting status.78
IEP service providers should also be aware that it is not uncommon for drug users to continue to inject even after entering a programme of substitute prescribing treatment. For example, an observational study carried out in Scotland found that half of the 30 injectors who took part in the study were receiving methadone treatment, but were still injecting. 17 Similarly, the 2007 Needle Exchange Surveillance Initiative ( NESI) found that between 70-77% of IEP service clients in Glasgow, Edinburgh and Lanarkshire reported receiving methadone treatment in the last six months. 13
NICE reviewers found evidence to suggest that the combination of methadone maintenance therapy and full participation in an IEP programme reduces the incidence of HIV and HCV among drug users. 6 Therefore, IEP services should not discourage injectors from accessing sterile needles and other injecting equipment on the basis of receiving treatment for drug misuse.