Report Template (Short) s1

ST on Syringe Availability (ST10) – Assessment Report

7 May 2007

Dagmar HEDRICH

REITOX Heads of National Focal Points

1. Presentation of the instrument

A table for reporting about syringe availability was introduced into national reporting guidelines in 2003 - the Standard Table 10. It replaced a previously used questionnaire with open questions, which covered the wider thematic area of infectious disease prevention measures for drug injectors (1).

The ST 10 aims to capture information about the types of needle and syringe programmes (NSPs) available in the countries; the number of outlets for syringe exchange; the volume of syringes exchanged, distributed and sold to drug users at these programmes; as well as via vending machines and sales at community pharmacies; and finally the number of clients using such facilities.

Within the 2007-2009 WP of the EMCDDA, a revision of data collection instruments is to be conducted with the overall aim to ensure to take better account of the changing patterns of drug use and responses and to improve cost/effectiveness of data collection. This process begins with the revision and rationalisation of tools introduced in the context of the new Reitox reporting structure and includes the Standard Table 10.

The present assessment report is part of the revision exercise and aims at providing an overview of the data collected and of their use and usefulness with regard to reporting on syringe availability in Europe.

Structure of the tool The instrument includes a reporting table and open questions. In tabular format, information about the availability of the different types of NSPs (fixed, mobile, street-outreach, pharmacy-based, vending machine, inside prison, and ‘other’) and the number of outlets or points where syringes are made available

1 other areas of the ‘old’ ST 10 were integrated into the structured questionnaire 23.

to drug users (2 ) are requested per NSP-type. The number of syringes provided is also asked in breakdown by types of NSP, as well as indications about the relative proportion of syringe exchange, distribution and sale. The number of community-based pharmacies as well as the number of syringes sold to drug users are requested.

Furthermore, the tool asks for the number of contacts clients made at the different types of syringe provision points and for the number of individual clients seen at these outlets. In addition and especially wherever such quantitative information was not available, references to studies about needle exchange clients, the number of IDUs reached by syringe programmes, the estimated geographical coverage of syringe provision and the estimated percentage of the overall IDU population covered by syringe provision could be given in response to open questions that followed the reporting table.

Other questions allowed NSPs to specify any ‘other’ types of syringe provision in the country and give the references and information sources for the data. The Standard Table 10 - Syringe availability can be downloaded from the EMCDDA website at http://www.emcdda.eu.int/?nNodeID=5777.

2. Potential and use of data

2.1 Implementation

In 2004, the ST 10 was implemented for the first time. Information was provided by 25 EU countries, Norway and Bulgaria. No update was formally required in 2005, but Belgium and Malta submitted the table also during this year. In 2006, when the ST10 was again part of the formal reporting requirements, it was implemented by NFPs of all 27 EU countries as well as by the Norwegian Focal Point.

2.2 Use of the data

Annual Report and Statistical Bulletin

Data collected with the ST 10 have been reported in Annual Reports and in the Statistical Bulletin since 2005. Six data tables on syringe availability in the years 2002 and 2003 were originally published in SB 2005(3). They covered the types, number of points and number of syringes exchanged, distributed or sold; and the full list of tables can be seen below. References and notes on methods and definitions complement the information provided in the Statistical Bulletin.

Tables on syringe availability published in the Statistical Bulletin:

2 NSP-points were defined as individual locations or physically distinct outlets where syringes are available for free or against payment. 3 http://stats05.emcdda.eu.int/en/page032-en.html

 Number of syringe provision points and number of syringes exchanged, distributed or sold

 Year of introduction of needle and syringe programmes. Types of programmes available (4)

 Number of non-pharmacy-NSP points and number of syringes exchanged, distributed or sold

 Total number of pharmacy-based NSPs and number of syringes exchanged or distributed

 Number of syringe vending machines and number of syringes distributed or sold

 Number of syringes sold to IDUs at community pharmacies

Integrating data for the years 2004 and 2005 that became available in the second round of reporting (in 2006), the first five tables were updated for the Statistical Bulletin 2007 (5). The results presented in the tables reflect that data on the number of syringes provided are not available to the same extent from all types of syringe provision points in the Member States.

Information on types of NSPs was available from all countries. Data on the number of specialised fixed and mobile NSP points was reported by 23 EU countries and Norway. The number of syringes provided at specialised non-pharmacy based NSP points was available from 21 countries.

Most countries were able to provide data on non pharmacy-based NSPs in 2004 and 2006. However, no data from Germany and from Italy were available in both years, and Ireland and the Netherlands could not provide the number of syringes from any type of outlet. Information on the number of syringes provided at least one type of NSP was missing in further countries and national totals of syringes could sometimes not be calculated.

While pharmacy-based needle and syringe programmes exist in eight countries and six of the countries report the number of such outlets, data on the number of syringes given out to drug users through pharmacy-NSPs were in 2004 only provided by Spain, France and Portugal, as well as by the French Community in Belgium and by Northern Ireland. In 2006, new information on pharmacy-NSPs became available from Scotland, but France did not provide a new estimate.

Syringe vending machines exist in ten countries, but in most of those just a few machines operate. National level data on syringes sold or distributed through such vending machines were only available from four countries.

Data are particularly poor with regard to the number of syringes sold to drug users at community pharmacies, where only Finland, the Czech Republic and France provided estimations, based on studies

4 Table 2 also contained information about the year when needle and syringe programmes were introduced in each country, collected with another data-collection tool. 5 In the SB 2007, the previously used table reference ‘NSP’ was changed ‘HSR’ (health and social responses).

(the latter country only for 2003). This led to the removal of the table on pharmacy syringe sales in the 2007 Statistical Bulletin.

Information about the proportion of exchanged, distributed and sold syringes at specialised fixed and mobile NSPs was available from 17 countries.

Data on client contacts and on the number of individual NSP clients were available for at least one type of NSP from eight of the new Member States Czech Republic, Hungary, Slovenia, Slovakia, Latvia (only number of individual clients), Lithuania, Poland and Romania, as well as from Finland, Sweden, Greece and Spain (only number of client contacts), England and Scotland.

2.4 Relevance of the data

The data collected with ST10 have allowed the EMCDDA to characterise needle and syringe programmes in the countries according to their typology and to identify commonalities. A general picture of the national network of non pharmacy-based NSP points (they are usually based at drugs agencies) could be drawn. The lack of involvement of pharmacies in programmes for syringe provision has become visible in most European countries.

The data confirm that nearly all countries run needle and syringe programmes based at drugs agencies and reach out to specific risk populations with mobile syringe provision. Comparatively few countries make use of pharmacies as outlets for needle and syringe programmes and the number of pharmacies participating in the schemes is often very limited. However, a few countries have obtained a wide geographical coverage through pharmacy-based networks for needle and syringe exchange, exceeding by far that through those located at drugs agencies and other specialised health or social services. Three countries (CZ, DK,NL) reported a number of between 100 and 165 outlets, Spain and the UK around 400 and in all other countries where data were available, the number of such NSPs is below 50. The data also allow to document that syringe turnover is higher at NSP points located at drugs agencies than at the average pharmacy-based NSP outlet. Data from ST 10 confirm furthermore that prison-based NSPs are rare.

For ten countries which have national data on syringes provided from specialised NSPs as well as a recent IDU estimate, a crude estimation of the yearly number of syringes that an injector can on average obtain through such programmes was made and reported in AR 2006. Results of this exercise showed not only a large variation between countries but documented that a high level of syringe coverage can be achieved through public health programmes. On the other hand, this analysis highlighted an urgent need to stimulate more in-depth studies about drug users’ syringe sources, obstacles or easiness of syringe purchase, and other determinants of syringe availability from countries where neither the number of specialised syringe distribution points nor the reported numbers of syringes provided to drug users match the potential need as based on epidemiological data on the prevalence of drug injecting. 3. Conclusions

The table should be reviewed in the light of the following findings:

 All countries able to provide data on types of needle and syringe programmes  Most countries can provide information on the number of outlets/syringe provision points and the number of syringes

Reliability and consistency of the data on NSP types and units have increased. A majority of countries have a good overview of the number of NSP units and of the volume of syringes provided at national level.

 The continuation of data collection about NSP types and points and on the volume of syringes provided by specialist programmes will contribute to expanding the analytical capacity of the EMCDDA.

Future rounds of implementation of the revised ST 10 should allow to consolidate the existing data basis and, in a medium-term perspective, allow the analyses of trends.

 In most countries, the majority of syringes used for drug injecting are likely to be purchased from pharmacies. Estimates for syringe sales are barely available, despite the importance of such data for determining syringe coverage.

Questions regarding syringe sales through pharmacies can be discarded as the data are currently not available through sources that are accessible to most NFPs. New sources for estimating such numbers should be explored: can Focal Points and the EMCDDA stimulate research about the sources where drug injectors usually obtain syringes (like for example implemented by the NFP of Luxembourg); can sales statistics be accessed from commercial companies producing or marketing syringes; is there a possibility to collect this information through pharmacy-surveys.

 The lack of data on clients of NSPs concerns mainly ‘old’ EU Member States

No information on the number of contacts or individual clients was available for most of the older Member States (Belgium, Denmark, Germany, France, Ireland, Italy, Luxembourg, the Netherlands, Austria and Portugal) but also for Bulgaria, Estonia, Malta and Norway. As the information is limited to geographic regions where drug injecting is more recent and less prevalent, no European analysis was possible.

Possible reasons for the lack of client data at harm reduction agencies have been explored in the context of the work of the EMCDDA on data collection at low-threshold agencies. Firstly, in the countries concerned, client-based monitoring systems (e.g. TDI) might be uncommon for documenting ‘front-office’ service provision like syringe exchange, provision of food/drinks or condoms, or the brief and informal contacts taking place between staff an drug users in ‘drop-in’ areas. In addition, the turnover of clients can be very high in large agencies and make such data-collection methods impractical. Secondly, NSPs are typically

based at a specialist drugs agencies which function at the lowest entry-threshold, which can mean that full anonymity of the service user is preserved to promote high levels of accessibility. Funding of the agencies is more often not based on the individual client in care (like this is the case in agencies providing structured treatment), which determines monitoring and reporting.

The use of other approaches should be explored to collect the necessary and relevant information about the population of drug users that makes use of NSPs. Client surveys could be a valuable data source, as they might cover further relevant information, especially on clients’ risk behaviour.

 The development of a European protocol for client-surveys at NSPs could be an important step to improve comparability and relevance of client information, incl. on risk behaviour.

Despite the sometimes patchy datasets, the data collection exercise with ST 10 has gained coherence and quality and contributed to provide a better insight into the national situation with regard to syringe availability through specialised needle and syringe programmes. The data offer – at least for some part of the European region – further valuable background information on client contacts and number of individual drug users reached by syringe programmes.

Data on syringe exchange are likely to exist at local level in many larger European cities. Where such datasets are readily available and accessible, and of sufficient quality, they could be used as additional and cost-effective data source for drawing up a coherent national picture and improving the understanding of syringe exchange as a public health measure at European level.