The history of needle sharing and the development of needle and syringe programmes

In the 19th century, there was only a slow realisation of the possibility for spread of infection by injecting - one of the earliest recorded cases of infection following injection was a report in the Lancet in 1876 (nearly 10 years since the concept of anti-sepsis had been introduced by Lister in 1867) of tetanus resulting from hypodermic injection of morphia.

The first published realisation that needle sharing could lead to the spread of blood borne viruses came as early as 1891, and is chilling in its prescience:

"Undoubtedly the greatest circumspection is necessary in the use of the needle - for diseased blood or specific virus may be transmitted from one person to another" (Bartholomew 1891)

Unfortunately, it took at least 2 more decades for such warnings to even begin to be adequately heeded.

The first recorded example of infection spread via needles used for non medical injecting is that of malaria in 1929 (Biggam 1929).

Crane (1991) summarises the recognition of various infections transmitted via injecting in the USA in the 1930’s. At this time injectors of street drugs would probably have used a medicine dropper attached to a hypodermic needle with the aid of a cigarette paper to make a tight seal.

The role of needle sharing in the transmission of hepatitis A and B among injecting drug users was probably first well described in a paper by Howard and Borges published in 1971.

Many of the infective complications of injecting drug use were recognised during the 19th and 20th centuries. In the early 1980’s, the discovery of the HIV virus and its routes of transmission, leant far greater urgency to the studies of injecting practice and infection spread. Almost a decade later, hepatitis C was also identified as a significant risk for injectors.

The 'Edinburgh experience'
In 1986 it became apparent that Edinburgh had a high prevalence of HIV amongst injecting drug users.

An influential paper published in 1986 in the British Medical journal by Robertson et al reported the testing for HIV of blood samples that had been systematically stored since 1982. These samples had been taken following the discovery of increasing numbers of hepatitis B positive heroin users. It later emerged that the cause of this increase was an acute shortage of injecting equipment following the closure of the main supplier and a voluntary sales ban by local community pharmacists at the request of the police.

On testing the stored blood of this group of 164 injecting drug users, it was found that 51% of the samples were positive for HIV. It was possible to pinpoint the time of seroconversion for 33 people to a period between the end of 1983 and the beginning of 1984.

Extrapolating from these figures, Robertson et al suggested that the true prevalence rate of HIV positive injectors in Edinburgh in 1986 could have been as high as 85%. From interviews with 40 of the group, it was possible to establish that as sterile injecting equipment became harder to obtain, the group formed an intimate equipment-sharing community, with reports of gatherings of 10-20 injectors using one syringe and needle. Comparisons were made with the similar ‘shooting galleries’ reported from the USA.

The development of UK service provision
Sterile injecting injecting equipment for illicit drug users was first provided in the late 1960’s to those few injectors who were given prescriptions of injectable heroin or methadone.

Injecting equipment had been available for sale to injecting drug users since the late 1960’s. Between 1982 and 1986 the Royal Pharmaceutical Society recommended that needles and syringes should only be sold to bona fide patients for therapeutic purposes. Although this policy was not adopted by all community pharmacists, it certainly reduced the overall availability of needles and syringes. The recommendation was withdrawn in 1986 because of concerns about the spread of HIV.

Needle and syringe exchange services began officially in the UK in 1987, when the Department for Health and Social Security (DHSS) commissioned a pilot study to evaluate their effectiveness.

At the time that needle exchanges (now more accurately termed Needle and Syringe Programmes) came into being in the UK, there was huge anxiety amongst the general population about the perceived threat of AIDS, fuelled by the media and by government sponsored advertising campaigns. Injecting drug use was identified early on as being one of the major potential risk behaviours for HIV infection.

Injecting drug users could hardly fail to know that they were at high risk of contracting a potentially fatal condition. The prevailing view of injecting drug users in the mid-1980’s was that they were deviant, self-indulgent and often out of control. The idea that injecting drug users might alter their behaviour on a widespread basis to reduce their risks was novel. Injecting drug users made the necessary behaviour changes to limit the transmission of HIV – needle exchanges provided the means for them to able to make those changes.

The first dedicated needle exchange to begin operating in the UK was opened in Peterborough in 1986. The first pharmacy scheme began operation by Boots in Sheffield in the same year.

The Kaleidoscope needle exchange in South London began operating in September 1986 as part of a wider church-based project which was also involved in substitute prescribing and other non drug-related social problems. The project was established in purpose built accommodation and was unusual for UK schemes in that it was open seven days a week from 7am to 11pm and remained open right through the night on Fridays.

The Maryland Street Needle Exchange in Liverpool began operating in October 1986 from a modified toilet within the Mersey Drug Training and Information Centre (which subsequently became HIT), sited next door to the drug dependency unit. The opening hours were 9.30-5.30 Monday to Friday.

In 1987 the DHSS set the following criteria for the pilot schemes; they should:

• Provide injecting equipment on an exchange basis to drug users already injecting and unwilling or unable to stop

• Provide assessment of and counselling for clients’ drug problems

• Provide advice on safer sex and offer counselling on HIV testing

• Collect information on clients and collaborate with a monitoring and evaluation project.

At this time projects were often staffed by nurses who had received little or no specific training on the subject of safer injecting.

The DHSS simultaneously commissioned an evaluation of syringe exchange schemes nationally. Reporting on these, Stimson et al concluded that needle exchanges reached considerable numbers of injectors, many of whom were not in contact with any other services.

The exchanges tended to attract:

• Opiate users

• Older, long-term injectors

• Fewer females than males.

Some problems were identified by the first evaluation report, including high client turnover and a marked lack of impact on sexual risk behaviour. The link between the presence of the schemes and HIV prevention was tenuous. However, there was general consensus that provisding needle exchange was an effective means of HIV prevention.

As needle exchange was seen to be effective, did not outrage public opinion or cause other anticipated potential problems, the network of needle exchanges expanded rapidly across the country, alongside a national expansion in the substitute prescribing of methadone.

A ‘user friendly’ approach
The term ‘user friendly’ to describe the philosophy of needle exchange was employed to make a clear distinction between needle exchange and other abstinence orientated services that were available for drug users in the mid-1980s.

This term, borrowed from the computer industry encapsulated some of the fundamental principals underpinning successful needle exchange that still apply today:

• No waiting lists

• A minimum amount of information from clients

• No entry criteria apart from injecting drug use (although age restrictions were applied)

• Easy access

• No requirement to stop using drugs.

There was also a commitment to provide accurate information about the risks of injecting drug use alongside encouragement to adopt safer injecting practices.

The balance between remaining user friendly whilst providing the essential information that injectors need to reduce the risks that they are exposed to is one that many services have struggled with. Difficult though this balance can be, being user friendly is not a good enough reason to fail to challenge risky behaviours.

The public health response
In the mid-1980s UK drug treatment services had become largely focussed on the achievement of abstinence. Whilst this approach may have been appropriate for those drug users who wished to stop taking drugs, the evident public health threat from HIV meant that new approaches had to be found.

The objectives of a public health based approach were to:

• Make contact with the whole population at risk

• Maintain contact

• Encourage behaviour change.

The Advisory Council on the Misuse of Drugs presented the following hierarchy of goals in 1988:

• Reduce sharing of injecting equipment

• Reduce the incidence of injecting

• Reduce the use of street drugs

• Reduce the use of prescribed drugs

• Increase abstinence.

The public health response has almost certainly been an important factor in keeping HIV infection amongst UK injectors low, although the response has not been adequate to prevent widespread infection with Hepatitis C in many areas.

The first decade of the 21st Century has seen the development of the recovery movement, which places a renewed emphasis on the achievement of abstinence, but the desirability of a continued public health approach alongside this was acknowledged in the UK government drug stategy document published in 2010.

References
Robertson J R, Bucknall A B V, Welsby P D et al (1986) An epidemic of AIDS-related virus (HTLV lll/ LAV) infection among intravenous drug abusers in a Scottish general practice. British Medical Journal, 292: 527-30

Stimson, G. V., Alldritt, L., Dolan, K., Donoghoe, M. and Lart, R. A. (1988) Injecting Equipment Exchange Schemes: Final Report, London, Goldsmiths' College

Advisory Council (1988) AIDS and Drug Misuse (Part 1). HMSO, London

Drug Strategy 2010 Reducing demand, restricting supply, building recovery:
Supporting people to live a drug free life. HM Government.