evaluation of needle exchange: research report dec 18

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[REACHING OUT FINAL REPORT] December 1, 2008

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RESEARCH REPORT

ReachingOut:EvaluatingOutreachandNeedleExchangeServicesonVancouverIsland

PreparedbyJoanMacNeil,PhD,RN

BernadettePauly,PhD,RN

SchoolofNursingUniversityofVictoria

FINALReportDecember1,2008


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Table of Contents

Executive Summary ..3

Acknowledgements..34

Background 4

Research Objectives.. . 5

Literature Review. 6

Methodology. 8Sample .8Data collection.9Data analysis 10

Findings..10Client profile...10History of drug use....12Health concerns.15Access to AVI services .18Island geographic and vulnerable group coverage.. 22Changes in access to AVI services at the Victoria site. ..23

Discussion. 29

Conclusions across the island.31

Overall recommendations.32

Recommendations for the Victoria site...34


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Executive Summary

Background: AIDS Vancouver Island (AVI) initiated a needle exchange indowntown Victoria in 1987. Over the years, the services were expanded to coversites throughout the island, reaching several thousand clients. Vancouver Island

fixed site needle exchanges and outreach had never been evaluated.

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Purpose: The purpose of this research was to evaluate the island wide needleexchange and outreach services of AVI to determine how services could bedelivered more effectively for those most at risk.

Methodology: The methodology was based on principles of community basedresearch and consisted of quantitative file reviews and in-depth qualitativeinterviews with clients who used the needle exchange services at four sitesthroughout the island, focus group discussions with peer outreach workers andstreet outreach staff, and individual interviews with community partners as well

as observations of clients/staff interactions.

Findings: Results attest to the benefits of having a fixed needle exchange whereneedle exchange services not only prevent HIV and other infections such ashepatitis C through provision of clean supplies and information, but open the doorto other services such as housing and income. The trust and acceptance byoutreach staff of clients who use injecting drugs supported clients to feel safe inwhat for many was an unsafe world. Results from the Victoria site revealed thatthe closure of the fixed site decreased access to not only the needle exchangeservices but also decreased access to other services, thus exposing alreadyvulnerable clients to increased health risks.

1 It should be noted that after the research was initiated, the Victoria fixed needle exchange closed, creating

special issues for this site.


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RESEARCH REPORT

Reaching Out: Evaluating Outreach and Needle Exchange Services onVancouver Island

Background

On Vancouver Island, despite efforts to reach more clients with comprehensiveHIV and hepatitis C (HCV) prevention services, there are some disquietingtrends. The prevalence of HIV and HCV remains unacceptably high among thosewho use injecting drugs in Victoria, at 15.4% for HIV and 68.5% for HCV. 2 Inaddition, drug consumption patterns could be contributing to the increased risk ofexposure. While heroin may be injected 1-2 times a day, addiction to cocaine

requires more frequent injections. Results from the I-Track study confirm thatover 70% of people who use injection drugs in the Victoria sample, injectedcocaine as their most common drug over the past 6 months, with over 50%reporting injecting more than 6 times per day.3 At the same time, 18.9% of theVictoria sample reported borrowing needles/syringes for injection in the pastmonth. In addition to needle sharing, participants reported engaging in riskysexual behavior such as having multiple sexual partners and not using acondom.

While the number of people who use injection drugs across the island is notknown, there are an estimated 1,500 to 2,000 people who use injection drugs inVictoria. Illicit substance use, including injection drug use, often collides withhomelessness, increasing the vulnerability of individuals to not only HIV andHCV, but also to poor health as a result of inadequate shelter, poor nutrition,violence and poverty. As part of the Victoria Homeless Needs Survey, it wasestimated that about 1,242 people in the capital region were homeless orunstably housed.4 Almost half (47%) of the participants in the Victoria HomelessNeeds Survey 2007 reported alcohol or drug use and 41% of participantsindicated that alcohol and drug use was one of three major factors contributing toinadequate housing. Although only 2.8% of the Victoria Census MetropolitanAreas population are Aboriginal, 1 in 4 (25%) of those surveyed identifiedthemselves as Aboriginal.

In British Columbia, approximately 4% of the population is Aboriginal, yet 19% ofnew HIV infections and 14% of the AIDS diagnosis between 1996 and 2000 were

2Public Health Agency of Canada. (2006).I-Track: Enhanced surveillance of risk behaviours among

injecting drug users in Canada.Phase I report. Ottawa, ON: Public Health Agency of Canada.3 Ibid.4 Victoria Cool Aid Society. (2007). Housing first: Plus supports. Summary of the results of the homeless

needs survey. Victoria, BC: Vicotira Cool Aid Society.


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attributable to these populations.5 Vancouver Island is home to approximately33,000 First Nations people, of whom 57% are under 24 years of age. TheVancouver Island Health Authority has reported that Aboriginal people on theisland have mortality rates 4-7 times higher, a life expectancy of up to 13 yearsless than the rest of the population, and cases of HIV, tuberculosis and hepatitis

C are increasing. Reaching Aboriginal clients is often difficult for a variety ofreasons, including institutional and cultural barriers.

AIDS Vancouver Island (AVI) initiated a needle exchange in downtown Victoria in1987. Over the years, the services have expanded to include street outreach,health referrals, sexual and drug education and health promotion. AIDSVancouver Island currently conducts fixed site needle exchanges and outreachin Courtney/Comox, Campbell River and Port Hardy/Port McNeil and providesoutreach to other communities. The populations using the service are diverse.For example, in Port Hardy, First Nations clients use the service most frequently.In downtown Victoria, many of the users of AVIs needle exchange are street

involved, experiencing both homelessness and drug use.

In 2005/2006, the street outreach program reached over 8,000 clients across theisland, with well over 400 newly registered clients, and over one million syringesdistributed with a return rate of 99.8%. New programs such as hepatitis Cprevention, HIV positive support groups, and prison outreach have been added.On May 31, 2008, Victorias only fixed site needle exchange was closed andreplaced with mobile needle exchange services only.

In consultation with AVI staff, it was decided that the purpose of this researchwas to evaluate needle exchange and outreach services for those who useinjection drugs, including needle exchange services throughout the island with aparticular emphasis on improving access for the most vulnerable andgeographically isolated. Although some of the needle exchange services havebeen in existence for over 20 years, the needle exchange programs had notpreviously been evaluated.

Research Objectives

The objectives of the evaluation research were: To gain an understanding of gender differences in accessing services;

To explore the social and contextual factors such as unstable housing,limited access to drug treatment and other health services affectinginjection drug use and potential HCV and HIV transmission; and

To assess how services can be delivered more effectively with greatercoverage to more isolated communities and those most at risk.

5 BC CDC. HIV/AIDS Update Annual. 2001. Vancouver: BC Centre for Disease Control.


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etics and

This research was approved by the Human Research Ethics Board, Office ofResearch Services, at the University of Victoria.

Literature Review

A growing body of international scientific evidence indicates that needleexchange programs, through reductions in needle sharing, (NEPs) can reducerates of HIV infection among injecting drug users6,7,8,9,10 . In Canada,evaluations of early needle exchange programs looked at the number of peoplreached, rates of needle and syringe exchange, demographic characterisbehavioral factors, including drug injection practices and sexual activity.

More recently, Gold, Gafni, Nelligan et al11used conservative estimates of thenumber of cases of HIV infection expected to be prevented with and without theprogram, to predict that if 275 people used the Hamilton needle exchange, itwould prevent 24 new cases of HIV infection over 5 years, thereby providing cost

savings of $1.3 million after program costs were taken into account andconcluding that needle exchanges are an efficient use of financial resources. Theauthors also point out that people who use drugs are not a homogeneous group,therefore needle exchange programs should be evaluated in order to gain insightinto their client population and tailor their outreach.

In Vancouver, Strathdee, Patrick, Currie et al12 conducted a prospective study ofmore than 1000 injecting drug users (IDUs) to describe the prevalence andincidence of HIV-1, hepatitis C and risk behaviors. While the study was notintended to evaluate the effectiveness of the needle exchange, it did concludethat HIV incidence might have been much higher among the cohort if there hadbeen no needle exchange, and emphasized the importance of providing acomprehensive program that includes counseling, support and education. Theauthors also pointed out the importance of considering social andcontextual factors that may directly or indirectly relate to HIV transmission. In theVancouver study, unstable housing was independently associated with HIV-positive status.

6 Wodak, A., & Cooney, A. (2006). Do needle syringe programs reduce HIV infection amoung injecting

drug users: A comprehensive review of the international evidence. Substance Use and Misuse, 41:777-813.7 Institute of Medicine. (2007). Preventing HIV infection among injecting drug users in high risk countries:

An assessment of the evidence. Prepublication Copy. Washington, DC: The National Academies Press.8 Bastos, F. & Strathdee, S. (2000). Evaluating effectiveness of syringe exchange programmes: Current

issues and future prospects. Social Science & Medicine (51): 1771-1782.9

Desjarlais, D. Marmor, M. et al. (1996). HIV incidence among injecting drug users in New York City

syringe-exchange programmes.Lancet(348):987-991.10 World Health Organization International Collaborative Group (1994).Multi-city study on drug injecting

and risk of HIV infection. (WHO/PSA/94.4). Geneva: World Health Organization.11

Gold, M., Gafni, A., Nelligan, P. & Millson, P. (August 1, 1997). Needle exchange programs: An

economic evaluation of a local experience. Can Med Asso J. 157(3): 255-262.12 Strathdee, S., Patrick, D., Currie, S. Cornelisse, P., Rekart, M., Montaner, J., Schechter, M., &

OShaughnessy, M. (1997). Needle exchange is not enough: Lessons from the Vancouver injecting drug

use study. AIDS, 11(8): F59-F65.


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While there is significant evidence of the effectiveness of needle exchangeprograms worldwide, little is known about the processes and mechanisms thatare most effective in reaching high risk and vulnerable populations. Data from astudy by Blumenthal, Ridgeway, Schell et al.13 support dispensation programs

that provide injecting drug users with sufficient syringes and sterile equipment.Others have documented the role that unstable housing plays in increasinginjection risk behavior (DeJarlais, Braine & Friedman14, Elifson, Sterk & Theall15).DesJarlais, Braine, Yi and Turner16 examined residual injection risk behavior, i.e.sharing, and HIV infection to evaluate six large syringe exchange programs in theUnited States. Interestingly, they found little HIV transmission associated withresidual injection risk behaviors among the participants in the programs.However, they caution that this may not hold for transmission of hepatitis B andhepatitis C, both of which are more readily transmitted than HIV through thesharing of needles and syringes and through the sharing of drug preparationequipment (cookers, cottons, rinse water). Another study17 for the U.S found that

when the maximum number of needles distributed per person was capped, thefewer needles exchanged led to a greater number of bacterial abscesses.

Models for the delivery of needle exchange services have been describedincluding peer outreach, mobile services, fixed sites and secondary distribution.1819 However, the evaluation of different models of the delivery of needle exchangeservices has received limited attention in research except for peer basedoutreach models. Strike et al., in an ethnographic study of Ontarios needleexchanges, described the use of four models for delivery of needle exchangeservices including fixed sites, mobile services, home visits and satellite sites.They found that fixed and mobile sites reach different groups of people and bothare needed. Fixed sites have the advantage of providing more confidentialspaces for counseling and increased referrals. Mobile services tend to reachhigher risk users who may not other wise access services but provide lessconfidential spaces.

13Bluthenthal, R., Ridgeway, R., Schell, T., Anderson, R., Flynn, N. & Kral, A. (2006). Examination of the

association between syringe exchange program (SEP) dispensation policy and SEP client-level syringe

coverage among injection drug users. Addiction, 102, 638-646.14 DesJarlais, D., Braine, N. & Friedmann, P. (2007). Unstable housing as a factor for increased injection

risk behavior at US syringe exchange programs.AIDS Behavior, 11, S78-S84.15 Elifson, R., Sterk, C., Theall, K. (2007) Safe living: The impact of unstable housing conditions on HIV

risk reduction among female drug users.AIDS Behavior,11, S45-S55.16

DesJarlais, D., Braine, N., Yi, H., & Turner, C. (2007). Residual injection risk behavior, HIV infection,

and the evaluation of syringe exchange programs.AIDS Education and Prevention, 19(2), 111=123.17 Tomolillo, C.M. et al. (2007). The damage done: A study of injection drug use, injection related

abscesses and needle exchange regulation. Substance Use & Misuse, 42(10), 1603-1611.18

Strike, C., Challacome, Myers, T. & Millson, M. (2002) Needle exchange programs: Delivery and access

issues. Canadian Journal of Public Health, 93(2), 339-343.19 Strike, C., Leanard, L., Millson, M., Anstice, S., Berkeley, N., & Medd, E. (2006) . Ontario needle

exchange programs: Best Practice recommendations. Toronto, ON: Ontario Needle Exchange

Coordinating Committee.


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There is an urgent need to evaluate the AIDS Vancouver Islands street outreachneedle exchange program which has been in existence for 20 years. Inparticular, the diversity of populations who use the services and the limitedunderstanding of the barriers faced by women, and geographically isolatedcommunities provided additional impetus to move forward with this research.

METHODOLOGY

The overarching methodology used was community based research was used anoverarching philosophy for this study. The principles of community basedresearch20 include:

The research involves and recognizes existing communities builds on strength and resources within the community facilitates partnerships in all phases of the research

integrates knowledge and action for the mutual benefit of the partners promotes co-learning and empowerment to address social inequalities involves a cyclical and iterative process addresses health and is predicated on a model of emphasizing physical,

mental and social well being and accounts for a broad range ofdeterminants of health.

shares findings and knowledge among all partners .

While community based research provided the overarching philosophical andmethodological approach, in this evaluation we drew on file reviews to generatequantitative data and conducted qualitative interviews and focus group methodsto gain in-depth insights. The sample and methods used in this study are outlinedbelow.

Sample

The study population consisted of a convenience sample of 33 people who usedinjection drugs and were using the needle exchange services of AIDS VancouverIsland. Participants were recruited at the sites of the needle exchange, thepurpose of the study explained, and if they agreed to participate, they were takento a private room or ambulance, where they read or had read to them theconsent form. After verbally agreeing to be interviewed, the interviews began andwere audiotape recorded.

At the Victoria site, focus groups were held with street outreach staff as well aswith peer outreach workers. Those participating in the focus groups were readthe consent and verbally agreed to participate. These focus groups were alsoaudiotape recorded.

20 Israel, B., Schulz, A., Parker, E. & Becker, A. (1998) Review of community-based research: Assessisng

partnership approaches to imporve public health.Annual Review of Public Health, 19, 173-202.


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Data Collection

Data collection occurred in the spring and summer of 2008 at Port Hardy,Campbell River, Courtney/Comox and Victoria. Prior to data collection several

preparatory meetings were conducted with the staff of AVI in Victoria. In addition,the researchers traveled to each site up island to discuss the proposed researchwith AVI staff and obtain their input into the data collection plan.

The study was conducted at these four sites on Vancouver Island. All four siteshad fixed needle exchanges when the study was initiated. The Victoria fixed siteneedle exchange closed on May 31, 2008 after the study had begun. Theconfiguration and services at each of the fixed sites varied with some having aprivate entrance for the needle exchange only. Three of the four sites hadconnection to outreach nursing services from community or public health, withservices being provided daily to weekly. Each site ran a positive wellness

program and volunteer programs were integral to service delivery in all four sites.Hours of operation varied with up island sites being open during weekday hoursonly. The Victoria site, through the mobile services, provided outreach in theevening until 10 pm.

Both qualitative and quantitative data were collected. Data collection consistedof in-depth qualitative interviews with users of needle exchange services at the 4sites throughout the island. Interviews and focus groups were conducted by theprimary researchers and a set of guiding questions were developed for theinterviews and focus groups to ensure consistency. The in-depth interviews andfocus groups were tape recorded and transcribed verbatim. The transcripts werechecked for accuracy. Field notes of researcher observations were made before,during and after interviews.

Using methods of file review, quantitative data related to needle distribution andcollection were also reviewed for each site.

When data collection had already begun up island, AVI was forced to close thefixed site in Victoria on May 31, 2008 rendering the situation in Victoria differentfrom the other sites. Because of the closure of the fixed site needle exchange inVictoria, data collection at the Victoria site consisted of going out with the bikepatrols and the mobile van in the evenings and informally talking to clients,conducting formal interviews in the back of the ambulance, conducting a focusgroup with the street outreach staff, interviewing outreach nurses and police,observing education sessions at the AVI site, and conducting 3 focus groupinterviews with peers before and after the closure of the fixed site. Tenqualitative in-depth interviews were conducted with clients who were usingneedle exchange services. Data collection began in May and ended inSeptember.


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Data Analysis

Following transcription, the qualitative data was coded inductively to identify keyreoccurring themes. The purpose was to provide qualitative description from theperspectives of those who receive needle exchange services as well as those

who provide these services or work in partnership with service providers.Qualitative description can be differentiated from other forms of qualitativeanalysis (e.g. ethnography, grounded theory or phenomenology) in that itprovides a close up and descriptive account from the perspectives of thoseinterviewed as opposed to the aim of interpreting data. This can be a particularlyuseful approach if the aim is to inform the development of interventions orimproving programs such as the delivery of needle exchange services.

FINDINGS

Client Profile

Formal in-depth confidential qualitative interviews were conducted with 33 clientsover a two month period in the four sites. In the three sites with fixed locations,the majority of clients approached indicated a willingness to be interviewed.Clients at the mobile van in Victoria were less likely to consent to an interview asthey indicated they needed to move on. This was consistent with the observedbrief interactions clients had at the van where they quickly received or exchangedneedles and equipment before moving on. A similar situation was observed onbike outreach.

Twenty-three men (23) and ten women (10) were interviewed. The average ageof the entire sample was 40.3 years. The average age of the men was 43 yearsand the average age of the women was 34 years (See Table 1). The men tendedto be, on average, 10 years older than the women. Participants in the Victoriasample tended to be much younger with an average age of 34.6 years. Themales ranged in age from 19 to 60 years and the females younger, from 20 to 46years. Of the 33 participants, 8 people self-identified as Aboriginal, comprisingalmost 25% of the sample.


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Table 1: Demographic Characteristics of Sample

Male (23) Female (10)Average age 43.17 33.7

(range 19-60) (range 20-46)

Average age of whole sample = 40.30

Average age Victoria sample = 34.6

Ethniciity:Aboriginal 8Canadian 25

Education level:Grade 5-8 6Some high school 14High school graduate 13University/college degree 3

Housing:Rooming house 1Living with parents 2Shelter 1Transition house 4Rent apartment 5Trailer 8Tent 1Boat 4On the street/outside 7

Source of income:Job (part-time) 2Income assistance (welfare) 11Income assistance (disability) 13Inheritance 1Sex trade work 3Selling drugs 2

Lived in the area:6 months to 1 year 45-10 years 1Greater than 10 years 28

Although the clients interviewed represented a convenience sample from acrossthe island, their profile reveals that they are among the most disadvantaged inour society. Over half lived in unstable housing or on the streets, exposing themto increased health risks. Only 2 people had regular part-time work. Twenty-fourpeople out of the 33 were on income assistance, and 13 of these were ondisability assistance. Twenty (20) of the sample had not finished high school.Thus, all were likely living in poverty and economically vulnerable.


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The majority of the participants had been local residents for five years or more.Twenty-nine of the 33 participants had lived in that particular geographic area for5 years or more, demonstrating that they are not a mobile, but rather a stablepopulation despite their addiction.

History of drug use:

Those participants interviewed were asked about their experience using injectingdrugs, including how and when they started, as well as the types of drugs theyinjected.

Length of drug use: 6 months to over 20 years

Type of drug injected: Heroin and cocaine most common

Morphine, speed, MDA, dilautid, talwin, and oxycontin., among others mentionned

The Myth of Mono Drug Use

When asked about which drugs they were injecting, most of the sample reportedmultiple drug use which seemed to change over time and was partiallydependent on what was available on the street. Only one client recently reportedthat she had just switched to only smoking crack. Others who reported smokingcrack, also reported injecting cocaine muscling cocaine or doing speed balls.Although limited in availability, heroin was described by several as their drug ofchoice. A few clients indicated that they had switched to injecting heroin

because it provided a better high:

Then Id try whacking it once in awhile with a syringe, just to get high.One hundred times better and I havent been able to take drugs any otherway since.

I smoked it (heroin), snorted it, every single day. Then about 2 years afterthat I found out how to shoot it and I, thats the best thing I ever felt in mylifeand it just got worse and worse. It takes over.

Since I was 16. I overdosed the first time I did it (heroin) and I liked it.Sounds kind of sick, sorry. I dont know. I just tried heroin and liked thefeeling, the security I got from it.

I had a phobia for needles all my life. And when I got into heroin which ismy drug of choice, because you know that feeling when you shoot up frombeing sick physically to, being well in a couple of seconds, its such anawesome feeling.


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As illustrated by the latter three quotes, while heroin can be an antidote for painand drug withdrawal, it can also take over your life.

About one third of the sample reported being in the methadone program for their

heroin addiction, yet at the same time many were still injecting other drugs e.g.cocaine or morphine. Those who were on methadone described methadonetreatment as helpful in managing their addiction and their life.

Reusing Your Own

Several participants had been accessing the needle exchange services forseveral years, and had been users for a long time. They noted that because ofthe increased availability of clean needles and equipment, there was, in theiropinion, less sharing. Those interviewed at the sites outside of Victoria allreported that they never reused a needle, their own or someone elses. In

contrast, client responses to the question The last time you injected, did you usea clean needle? at the Victoria site reported self reuse such as:

I never use anyone elses. I may reuse my own. But most people, I dontreally know anyone who will use someone elses needle. People are prettysmart about that.

This was also reported by the outreach nurses, People are reusing their ownsyringes. I have clients tell me that they reuse their needles five to six times.Other participants in Victoria noted that they had seen people picking up dirtyneedles and using them.

It is important to note that the issue of reuse of needles was unique to theVictoria participants. . All the clients interviewed outside of Victoria said they canalways access clean needles when they need them and were all adamant thatthey never reused their needles.

Patterns of Drug Use

Clients were asked to respond to the question Can you tell me a bit about howyou started using drugs? The majority of participants identified that drug use hadbegun during their teens. At least 5 participants reported that they starting usinginjecting drugs after a severe workplace injury such as a crushed leg with chronicpain or a broken pelvis. One noted he started injecting after going through adivorce and losing his business and another after having her children taken awayinto care. Another talked about growing up on a reserve where there were lots ofdealers. He described his mother as someone who encouraged him to injectdrugs, but to do so in his room at home.


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Familial introduction and patterns of drug use were reported by someparticipants, particularly those in upisland locations. One person related that theyhad access to heroin in spite of limited supplies on the street because anotherfamily member was a heroin dealer. Another person reported that:

Everyone in my family uses. I have a brother who is a heroin addict whowont see Christmas. My son (19 years) injects so I get clean needles forhim. Its bad because I am surrounded by addicts so [I] try to keep themsafe.

As part of explaining patterns of drug use, individuals described avoidingsituations that could retrigger their use. One interviewee stated he feltcomfortable coming to AVI as long as he did not run into people he did not wantto run into and that that was why he had moved far away outside of town. He wason methadone but still occasionally used heroin and reported:

I dont want a whole bunch (of needles) at a time because that is just atemptation. Just having them there, having syringes stashed away is just areservation to use.Thats saying Im going to use. Its just a matter oftime.

I dont socialize with other people. I dont hang out with dopies. They arenot the best of friends. They are not the most trustworthy people either.

It seemed that for many, living in an entrenched drug family, or entrenched drugculture, where that is all you know and all you do, made it extremely, if not almostimpossible, to stop injecting. More than a third of the sample had long termhistories of drug use whose lives were a cycle of injecting, followed by attemptsat detox then out on the street again, perhaps rehabilitated, perhaps not. Living insuch circumstances made it difficult to break the cycle of drug use.

Trying to Numb the Pain

When asked How would you say drugs have affected your life? 29 of the clientsreported a negative effect or as one client observed:

Its something you do because you are not whole. Youre damaged.Youre doing it to make you feel.Thats numbing it..

Another participant from another part of the island voiced similar insights:

We try to be numb but it is not working.Try to be numb, but I think what itis, is that I have so much drugs in my system now that I dont, Imnormal

Another participant painfully noted


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I dont consider that I am living my life right now. I am doing drugs for areason. It just stopped everything. And when I start feeling stuff I dontwant to feel, I just do more drugs. And I dont like this because I amgetting older.

Another participant commeted:

Its, aah, ruined my life. People around me. Its hurt a lot of people.

Some of the participants described the numbing effect or feeling of safety that isprovided by drugs that can block out the physical and emotional pain. At thesame time, participants acknowledge that the use of drugs had a devastatingeffect on their lives. As one participant above indicated, she considered that herlife had stopped.

Failed detox/rehabilitation

Ten of the sample reported that they had tried detoxification in hospital and or aclinic. Four followed this with rehabilitation. No one reported any success withdetox or rehabilitation which is consistent with other research in which high ratesof failure are reported. One participant had been in rehabilitation 25 times andonce managed to stay drug free for a whole year. One participant was about totry again and another was currently in rehabilitation but still reported injectingdrugs occasionally.

Health Concerns:

Physical Health Concerns:HIV positive 6Hepatitis C positive 16 (includes 2 who received treatment)Liver problems 2Terminal cancer 3Severe injury 5ADHD 3

Six out of 33(18%) reported that they were HIV positive and 16 (49%) reportedhaving had hepatitis C. The percentage HIV positive was slightly higher than forthe I-track study and the percentage hepatitis C positive was considerably lower.It is difficult to draw conclusions from this because of the small sample size andthe fact that the I-track study took place in Victoria only. In addition to the poorhealth effects caused by HIV and hepatitis C, five had disabilities due to a severeinjury while working and each described a long and painful recovery. Oneparticipant, disabled from a work injury was in constant pain which affected hisability to sleep, stated:


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..Ive got 2 pinched nerves in my, between the discs squashed in mypack. This things (crushed leg) starting to get arthritic now andwith allthe other stuff, the pain. I havent slept more than an hour at a time in thelast 4 years

Three self-reported attention deficit hyperactivity disorder21 and commented thatit had interfered with their schooling and their current ability to concentrate.

Participants interviewed up island reported having access to a physician andbeing treated with respect. In Victoria, most either had a regular doctor or went tothe Cool Aid clinic when they needed to see someone. Regardless of location,clients accessing hospital care reported being discriminated against and notlistened to by health care providers because they were labeled as injection drugusers.

Living with Pain

The pain of the clients lives was communicated in the interviews conductedacross the island. Several made reference to traumatic events that hadhappened when they were small children but could not actually talk in specifics.Over half of the sample reported traumatic events in their adult lives that theywere trying to hide or deal with e.g. rape, loss of children and death. Forexample, when asked about a health concern over HIV or other things, one clientstated:

Yeah, thats the only thing (HIV) that they say I have. Right? Everythingelse about me is fine. Emotional and mental torment from things thathappened to me as a child. So that would be another issue. Trauma oversomething that happened to me as a child. I cantI cant deal with this.Its too much. The person that was involved, I just want to kill himbut itslike, you knowthe guys in jail so what do you do.

Another participant who was both HIV and hepatitis C positive for over ten yearsrevealed despair when asked about health concerns:

And the nerve damage is coming into my legs. And sometimes I cantwalk even half a block. Its starting to spread and pretty soon it is going togo into my other leg. So I am going to start really considering takingmedication. I am so tired. Im really bad. I am always falling and hurtingmyself.

Another participant was grieving for loss of work and his girlfriend and said heused drugs to cope with the pain:

21 Mate, G. (2008).In the realm of hungry ghosts (pp.415-418). Toronto, ON: Alfred A. Knopf Canada.


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I had a job, severed a tendon, then my girlfriend died. I worked all thetime. But that was the first time in my life when I have been through amourning grieving process, when I didnt have a regimen or routine in mylife.

Another participant who had had her children taken away from her showedinsight into her need for healing by stating:

Well, actually I have to come to terms with it (losing the children) myself.Theres a lot of feelingcreatingwhich doesnt make any sense to manypeople but actually coming to the streets and cracking out has been,really, really kind of what I really needed.There are a lot of other thingsin my subconscious mind that needed to come out. I have done a lot ofhealing.

Another showed the despair felt after losing her children by stating:

And now I am terminally ill. I have a kidney disease which may or may notbe able to be cured. Its kind of slowed down my IV drug use because I getattacks. They sometimes last for 8 hours. And its just the most agonizingpain. The only thing that helps is percosets but smashing coke..I reallydont. I have given up. Ive lost the kids.

This pain, experienced as physical, emotional and psychological, and asdescribed above alleviated by drug use, affected all aspects of their lives.

Overdosing

When asked about their health concerns, no one mentioned the dangers or fearsof overdosing, yet when talking about their drug use, the majority mentionedoverdosing as a concern for themselves and others. Several of the participantshad experienced over doses and described almost dying. One participantstated he was on disability because of damage to his brain from an overdose.While several recognized the dangers of overdosing, one reported the following:

I overdosed the first time I did it (heroin) and I liked it. Sounds kind of sick.Like I have been on the streets off and on throughout my whole life.

It may well be that the experience of coming close to an overdose helped toovercome other pain or trauma associated with life on the street. One participantdescribed how someone had just overdosed at her place and had had seizures.When the researcher asked how he felt afterward, she reported:

Thats the worst part of it. When you do down, you dont remember it. Andthats why people continue. If you could see what happened to you, youmight quit. You might. But you dont remember it. And when you come to,


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Ive been down 3 times, like everyone is in your face and you arelikeYou have no idea what happened to you and you have no fearbecause you have no idea what happened.

Such explanations help to explain why overdoses were not readily reported as a

health concern. Another participant acknowledged how serious he thought hisoverdose had been, but stated:

Horrible. I thought I was going to die. Almost did die. The mentality didntchange one bit. I was hoping to get out of the hospital so I could use thatdrug again, right away as soon as I could.

Overdoes are clearly profound potentially life threatening experiences which maybring individuals into contact with the health care system. Seven participants hadbeen through detox and rehabilitation only to relapse. Eight were also onmethadone for their heroin addiction but admitted they still injected, but less

frequently and usually with cocaine. One participant noted:

I go to detox and that, I just overdosed on my last relapse. Thats been 49times that I overdosed. Ive been dead for 5 of them. I had one seriousheart attack where they say I chemically boosted the heart with a speedbolt of coke, speeding it then the heroin slowing it down.

This profile of the participants interviewed points to their vulnerability to poorhealth and increased risk for HIV and/or hepatitis C infection. If this conveniencesample profile is comparable to the majority of the clients who access the needleexchange services throughout the island, it would be important to bear in mindthat their addiction is just one part of their vulnerability.

Access to AVI Services

Thirty of the 33 participants interviewed accessed AVI services by foot or by bike.Only two participants drove to the site of the needle exchange and one often hadhis neighbor pick up needles for him as he lived far away and was unable toaccess the site due to a disability. The frequency of the visits to the needleexchanges varied from daily to once a month.

Preventing disease

Virtually all clients talked about using the needle exchanges throughout theisland as a key resource to obtain access to clean supplies for injecting. For mostclients, the needle exchange was identified as an important resource forpreventing the spread of disease. Participants outside of Victoria all stated thatthey could always access clean needles when they needed them. It should benoted that one site had negotiated with a nearby pharmacy to distribute needleswhen AVI was closed.


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Several participants had used drugs for a long time and had been accessingneedle exchange services for several years. They noted that because of theincreased availability of clean needles and equipment through AVI, theyobserved that there was less sharing and fewer people dying.

I think over the years things have changed, especially with this place(AVI) being here. You can get new ones. (Before).a lot of friends died.

One participant commented that he had a friend who reported that he was usinga dull needle (reused) but he noted that he would not share with anyone becauseof all the diseases around. The importance of HIV prevention was apparent inthe lack of sharing reported by most of the participants or as one intervieweenoted:

Oh, I think it is awesome. And you go down a back alley in Vancouver,you are guaranteed to find 10 to 20 users in the back alley using mudwater, mud puddle water to fix. And they wonder why so many people aredying there from so many drug diseases. So its nice to have this.

In their comments, participants also indicated the importance of needle exchangeservices in providing access to those who typically face barriers in accessinghealth care services because of their drug use and the impact it can have on thecommunity.

For a small town it is running well. Services are confidential and there istrust.

..because if I did have a closed mind to harm reduction before, thatopinion has changed and has grown over the years. Not having access tosyringes, pipes and clean water. That situation is asking for more diseaseto be spread.

In addition, almost all participants identified that they accessed these servicesfor other reasons and resources. These are described below.

Finding a Safe Place

In addition to accessing the sites for clean injecting supplies, the majorityof participants expressed very strong positive responses to questions about theirexperiences in accessing needle exchange services. They described coming tothe exchanges as supportive, comfortable, and safe. At all four of the sites,participants indicated that the needle exchange was a safe place. One person


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described AVI as a normal place in a weird world. Its a safe place. You canrelax. For some safety was in the form of food, a warm place to sit, or a hotdrink. For others, it was described as a safe place where they felt they would notbe judged.

Comfortable. Doesnt make me feel weird. Friendly helpful,nonstigmatizing. I feel ok.

X doesnt make me feel uncomfortable. X doesnt make me feel weirdasking for crack pipes, lighters. So I am accepted for who I am

I dont find any of these people here judge people so its comfortablecoming in and getting what you need.

They dont belittle you. Make you feel.its much like a normal place.

Started coming to AVI for syringes, of course and then I started to talk topeopleSquares, straight johns. Everyone I know is a drug addict. Youknow I have been a drug addict for of, 40 something years. Coming herefor someone straight to talk to. Yeah, something different. Come out of myworld and into yours. Im not comfortable around people cause I havebeen in jail for 22 years.

For those in Victoria, the researchers asked about their experiences with thefixed site before the service closed. Clients noted that they felt safe and trustedthe staff as revealed by the following quotes:

felt more comfortable and safer at the fixed site as it was indoors

It was awesome, because the staff were really nice to us. They talked touse, Encouraged us. Just made me feel like I was not floating someplace,like someone actually does give a shit somewhere. I could come here andget what I needed.

In particular, the statements above reflect the importance of having access to asafe, nonjudgmental space that provided a reprieve from life on the street. InVictoria, many of the participants reflected on the closure of the needle exchangeand the loss of a safe place where they could use the phone or wash their hands.For the Victoria site, the exchange was also a place to share information aboutlife on the street, as noted by the following client:

Nobody has the news on the street whether, Ok, just for example, Ill tellyou this right now. I was calling up xxx. People thinking that she got herface. Like mutilated and stuff. She was found in the park but we dontknow because there are too many rumors, whereas if we came herebefore, we would get the news right away.


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News could also include learning about bad drugs on the street. Connecting withfriends and finding out news were important functions of the needle exchangeidentified by Victoria participants.

Rumors of the closure had filtered up island and during interviews, several clientsat other sites asked questions and were interested in learning more about theclosure of the Victoria site and the implications of that for other sites.

Education, Counselling and Support

As described previously, a range of education, counseling and support servicesare provided at all sites. Participants described AVI as providing supportivecounseling and access to HIV, hepatitis C and STI testing and information.

Ive accessed AVI also to help complete my income taxand for

supportive counseling.

Any problem I have, theyll look into it. You know if I cant, need to findout stuff, they help in that situation.

They know their stuff. They explained stuff to me that I didnt think I had ahope in hell of getting. They went through the steps the ministry is lookingfor.

People there are great. My spouse is HIV positive and has hepatitis C sohave a lot of questions. Had a lot of questions which I have had answered.Theyve given me multiple times to come back and talk to them.

A few previous clients indicated that they were a volunteer at that site and thatwas a source of support. One person said, Theres a good feeling from helpingpeople.

AVI was a source of information related to health problems as well as counselingand support.

Point of Access to Other Services and Resources

Access to the AVI needle exchange provides a point of entry into other neededservices such as nursing care, assistance with welfare and disability applications,assistance with income tax, and housing. Such connections assisted clients todealing with the many uncertainties in their lives. For example, one participantstated:


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They helped me get on disability. Theyve helped me get into rehab,detoxes.

Thus, needle exchange services for many who use drugs act as an accessibleentry point into other health and social service systems. In some respects,

needle exchange services function as primary health care services consistentwith the WHO features of primary health care such as being appropriate andaccessible to the community being served..

Client Suggestions for Improving Access to Services

Clients were asked for suggestions and most indicated that the current serviceswere meeting their needs, except in Victoria. A few participants in the northernpart of the island suggested that being open an evening in the week-end wouldincrease access.

Island Geographic and Vulnerable Group Coverage:

At all the AVI sites, staff make tremendous efforts to provide comprehensiveservice with existing resources, e.g. having a welfare worker come in to the officeand be available one day per week or having the public health nurse hold a clinicone half day per week. One of the most important assets of the needleexchange services is the positive and confidential attitude of the staff. They hadknowledge and understood their communities, including where the mostvulnerable clients might be found.

Efforts are being made to reach out to the broader communities e.g. schools,First Nations. For example, discussions with the outreach staff in the northernpart of the island revealed that they are making efforts to reach out to isolatedAboriginal communities but that this takes resources e.g. travel by float plane andstaff time. Given the geography and size of the island, some of the communitiesare physically hard to travel to. In these instances, staff have enlisted volunteerswho are traveling to the more remote areas e.g. logging camps, fishing boats,and willingly conduct outreach. This demonstrates using systems of secondarydistribution to enhance services.

This research found that both men and women access the services with equalcomfort levels and trust. While fewer women were interviewed, this may reflectthat fewer female clients use injecting drugs, or more likely, the invisibility ofwomen on the streets. More research is needed to explore the reasons why orwhy not women use needle exchange services.


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Changes in Access to Services at the Victoria Site

Prior to May 31, 2008, the fixed site in Victoria was open seven days a weekfrom 3 to 11 pm Mondays through Saturdays, and 5 to 9 pm Sundays. Servicesincluding needle exchange were provided by the outreach staff and the street

nurses were on site at the exchange from 3 to 11pm, Monday through Friday.

In addition to the needle exchange and nursing services, the fixed site offered thefollowing services: health referrals, addictions referrals, shelter requests, clothingrequests, hospital referrals (rides), transportation referrals, phone outreach,counseling, hygiene supplies, comprehensive prevention education, other harmreduction services, and sometimes food.

At the beginning of June, 2008, service delivery in Victoria shifted from a fixedsite to a mobile van parked on a side street away from the downtown core areaand mobile outreach on bicycles and on foot. The van operates a mobile

outreach from 6:30 pm-10:30 pm Monday through Saturday and Sundays, 5:00-9:00 pm. The foot/bike outreach operates downtown from 3:30-9:30 pm. In Juneand July the street nurses were at AVI only on Tuesday afternoons, from 3:30 6:00 pm and for the positive wellness program. In August, the street nursesbegan doing outreach with the mobile van from 8-10 pm, five days a week. Afterthe closure of the fixed site, the street nurses increased their strolls and drivesaround the downtown core. Following the closure of the fixed site, efforts weremade by other service providers including the street nurses to increasesecondary distribution of clean supplies for injecting.

The clients who had accessed the services at the fixed site before the closure,and were now users of the mobile services, all stated the bike outreach wasgood and something that should be kept but that it did not replace a fixed site.

They need to have a needle exchange, a permanent oneYou know, justlike the old one. Where we could go for coffee and talk, you know. At leastneedles werent spread all over the place.

I know a lot of people who were clean and sober, not using, they wentthere and sat in the back part of the place to get away from everythingelseit was like a socially positive environment for them to stay off drugsby going there. Which doesnt soundits weird but that is what was goingon

Needles Distributed and Recovered

The number of clients accessing the AVI needle exchange dropped dramaticallyafter the closure of the fixed site, from 373 in May to 273 in June and 277 in July.The majority of the clients reached in June and July were reached by the


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outreach on foot and/or the bikes as opposed to the mobile van. In addition, afterthe closure of the fixed site, the numbers of needles distributed and collected byAVI dramatically decreased (see Table 2 below). AVI needle distribution in Junewas down 46% and intake decreased by 69% compared to May. AVI distributionand collection in July increased over June, but was still significantly below the

April and May numbers. Needle distribution and collection by others increased inJune and July, however, the overall total distributed in July was still over 4,000less than in May, and the total collected was over 17, 000 less than in May. Thenumbers for August reveal an increase in the numbers of needles distributed(27,000) but only 10,000 collected which is disturbing. The decrease in numbersof clients and in needles distributed and collected directly relates to the closure ofthe fixed site.

Table 2: Needles Distributed and Recovered by AVI in Victoria in 2008

2008 Distributed RecoveredMonthly average (Jan-April) 34,9000 24,400

June 16,700 7.500July 25,000 19,000August 27,000 10,700September 24,473 21,647*October 22,095 7,966

*One client brought in10,000 needles.

Table 3: Needles distributed and recovered by all service providers (includes AVI, VARCS,SOLID, City of Victoria drop boxes and other service providers)

2008 Distributed RecoveredMonthly average (Jan-April) 45,400 36,900June 24,700 13,400July 33,400 24,000August 36,500 19,700September 34,213 27, 383*October 29,805 12,617

*Includes the AVI client who returned 10,000 needles.

The numbers of needles distributed and recovered for September 2008 arehigher for AVI but if you take out the 10,000 recovered from one client, thenumbers of needles recovered are still very low (see Table 3). The numbers forsyringes recovered by AVI and all services providers are disturbingly low forOctober. Outreach workers have indicated they are not seeing more needles onthe streets.

After the closure of the fixed site in Victoria at the end of May, 2008, the servicesoffered by the AVI outreach have been reduced, the number of clients reachedhave been reduced demonstrated by the drop in client numbers, and the natureof interactions with clients has changed with contacts becoming of shorter


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duration. One of the nurses who does street outreach, made the followingobservation,

On outreach, people are actively using. They are with their peers. It is astreet culture where there is no confidentiality. The dynamics of

interactions on the street are different and were not able to talk aboutissues. The clinic is a private space, people disclose more, there is directaccess to referralsBeing inside away from the craziness of the streetcreates an opportunity.

Staff noted that at the fixed site they were better able to develop relationshipswith clients as the site provided a place to meet, talk and develop trust. Althoughstreet outreach services included needle exchange, the Victoria fixed site wasused by many individuals in need of a place off the street or out of the rainbecause they had nowhere else to go during the evening hours. Some of theseindividuals did not use drugs or the services of the needle exchange but the site

provided a place to find food, shelter and friendship

The site also served as a communication hub where people could find out whathad happened to friends, use the phone to call family, receives calls from clientsin treatment or in jail, and importantly, to find out about any bad drugs and whatto avoid. Clients also had access to comprehensive education regarding HIV andhepatitis C prevention, and ways to stay healthy. At the fixed site, the streetnurses were there daily from 3 -11 pm and provided consistent and regularaccess to health services and referrals. Information obtained from clients andstaff confirmed that the fixed site offered a consistent and readily accessibleplace and service for people with little consistency in their lives.

One provider summarized succinctly, the findings of this research when theystated:

Now we have decreased access to health care, decreased access tosupport services, , health education counseling or referrals.

Interviews with others service providers, including the police, affirmed the needfor a fixed site but stressed that it not serve as a drop in program. Staff indicatedthat the fixed site had simultaneously been meeting a need for those withoutshelter for a safe place to go during the evening hours. Several of thoseinterviewed recommended that Victoria needs multiple fixed sites to encourageneedle exchange but reduce overload at any one site. The loss of the fixed sitemeant a loss in access to services for already vulnerable clients.

No Safe Place: Displacement of Clients

In the month after the Victoria closure, clients expressed fear and anxiety in partrelated to the loss of the fixed site and the increased police presence. At the


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time of the closure, there was a concerted effort by police to crack down on drugdealing and to consistently break up groups of people and move them along.People on the street indicated that they were trying to keep out of the public eyeand not wanting to or able to linger in any one spot. In many interviews anddiscussions, clients, workers and others indicated that there are many people

whom they have not seen since the closure. This was confirmed by the bikeoutreach workers, who noted that people were harder to find. The street nursesalso reported that even though they increased their strolls and driving around thedowntown core, they were seeing fewer clients and receiving fewer phone callson their 1- 800 number.

As noted above, several clients reported that the closure of the needle exchangemeant a loss of a safe place to go. Several also indicated that while there wereproblems at the fixed site in Victoria, they described this as something that theystayed away from, did not participate in, or did not understand.

I kind of like to make sure that everyone else was treated with respect toobecause they helped us. I didnt understand, begin aggressive towardsthem. I felt protective towards them. Even garbage outside or somethinglike that.

great, efficient, a place to be warm. Never made it a hang out. Kept it arespectable place. A lot of people did respect it with their drug use. ..

This client, like others who used the site, indicated that activity outside the sitewas not reflective of the many clients who used the site or what was going oninside. The loss of the fixed site had implications for all who used the site.

It is important to note that none of the other needle exchange sites up islandhave experienced the high volume of use associated with the Victoria site andnone have experienced people using or creating disturbances on the streetoutside the exchange.

Harder toAccess Services:

Numerous clients reported increased difficulties and less access to needleexchange services as a result of the closure of the fixed site.

Oh, I sure liked it a lot better when it was in a fixed site. Yeah, of courseits great that we can get new needlesbut it is really hard cause my HIVhas affected my nerves and it is hard for me to walk.

Its not that far.And not only that. I dont know where they are half of thetime. Not like at the needle exchange.

only accessed them a couple times because usually I cannot find them


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A sense of fear prevailed in the initial reaction to the outreach workers on bikesand the needle exchange in the van. Some clients reported that they thought theoutreach workers were police on bikes initially and that the parked van was apolice van with a camera. By August, it appeared that some of this had

decreased as clients became more familiar with the van and the outreachworkers on their bikes, but contacts are still sporadic and very short. In addition,continued pressure from police to break up groups and move people on wasreported by clients as constantly being under pressure. This pressure,combined with the increasing presence of gates throughout the city, left manyclients feeling vulnerable and at risk as well as, in some cases, potentiallypushing drug use out into the open. The following quotes from clients illustratethe effect of these pressures and displacement of people making it difficult tolocate clients.

people have been going out of their way to try to get out of the publics

eye so that we can be out of the way

People are under pressure-no safe place to go. People are moved on andharassed. A guy was picking up pop cans at the XXXX and was chargedwith public loitering.

everybodys lost, everyones scattered all over the place, theres not oneset spot. People are scattering all over the place.

..today the staff that were on bikes came to see us because they werewondering where to find people because of the cops kicking us out ofother places. We cannot have one specific place so it is hard for them tofind us. If they cant find us, they cant give us clean things to use.

The inability to locate clients and the feeling of being constantly moved onis akin to pushing drug use underground with the potential for increasedrisk behaviors and lack of access to clean injection supplies as shown bythe last quote above.

Most of the clients interviewed were accessing the outreach services for needles,water, condoms and sometimes for food. In response to the question When youneed new clean needles can you get them? a couple of the clients said yes,always but the others said no, not always. One client said because it is too hardfor me to figure out where they are going. But now I know about this mobile van.But all those times I had no idea where to get them. Its just more complicatednow. Another said he accessed the mobile services as follows only a couple oftimes a month because I usually cannot find them. Yeah, but Ive got lots offriends who usually get boxes of syringes that I can just go and see them.


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Others commented that the van was too far away from where they stayeddowntown, and others made reference to buying needles on the street asdemonstrated in this response Yes, usually someone has them. If not, if there isno one here, it might cost you. Another client responded Do you thinksomeone is going to walk all the way across town to find out they are not even

here for a needle.theyre going to find the easiest way. Another client noted thechange as follows:Used to be able to. And so most people are willing to sharethe rigs that they have. Most people are turning a dollar for a clean rig. Well, notgoing around selling, but if you ask them for one, they ask you for a buck.Acouple of clients commented that services were not available in the daytime.

It was clear during the street outreach, that AVI staff have very positiverelationships with the clients they serve and that they have and continue tomake extraordinary efforts to reach clients in often challenging conditionssuch as cold and rainy weather.

Displacement of Drug Use

The police call data for 4 weeks prior to the closure of the fixed site and for 8weeks after the closure was reviewed and compared to the calls received for thesame 12 week period for the year before, 2007. In reviewing the calls receivedby neighborhoods, there were three neighborhoods that received the most policecalls; downtown, Rock Bay/Gorge, followed by the neighborhood in which theneedle exchange was located. From 2007 to 2008, calls increased in all three ofthese neighborhoods but the specific type of call which increased the most wasfor unwanted person. This type of call can be anything from a panhandler, tosomeone who is intoxicated and is bothering people, to sleeping in a doorway,sitting in a private entry way (inside or outside) or loitering in an undergroundparking lot. It means their presence is generally suspicious or causing adisturbance of some kind.

In looking more closely at smaller geographic areas, the calls were analyzed forthe data where Comorant Streetis located. For the 12 week period pre and postclosure, the total calls received in 2008 decreased almost four timesfrom thosein 2007 (80 to 22). In 2007, most of these calls received were for assistpolice/fire/ambulance, check well being, drugs, and unwanted persons. After theclosure of the fixed site exchange, there were no calls received for drugs for thisstreet, and only one received for an unwanted person.

The police call data for streets or areas where focus groups and outreachworkers had noted an increase in clients after the closure of the fixed site, werereviewed. Police calls in all the neighboring streets increased dramatically from2007 to 2008 confirming that closing the needle exchange just moved peoplearound and further out. For example, calls for the streets within a 3 to 4 blockradius of the former fixed site almost tripled from 2007. There was also anincrease in calls received for Centennial Square, specifically for drugs and


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unwanted persons. The calls for the street where Streetlink is located, remainedthe same. This police call data supports data from the focus groups andinterviews that people and drug use have moved further afield. Drug use has notappeared to decrease, it has just spread out from the downtown area and insome areas, become less visible.

Peers, familiar with drug use, identified at least 17 hotspots prior to the closure ofthe fixed site. Several hotspots were located within a ten block radius of the fixedsite, with the other spots located outside of this core area. After the closure, theyreported that the number of hotspots increased (e.g. there is drug useeverywhere and in spots we havent seen before). The hotspots post closurewere spread throughout the downtown area with drug use extending out ofdowntown into adjacent areas. This movement of hotspots for drug use wasconfirmed through the data related to police calls. The key implication is thatclosure of the needle exchange led to increased drug use in adjacent areas.

Discussion

The Ottawa Charter for Health Promotion22 outlines the prerequisites for healthas peace, shelter, education, food, income, a stable eco-system, sustainableresources, social justice and equity. These social determinants of healthrepresent the economic and social conditions that influence the health ofindividuals, communities and jurisdictions.

Research in both Canada and the United States operationally defined unstablehousing/homelessness as living on the street or living in a shelter or a singleroom occupancy hotel23, 24. This research has found that unstably housedexchange participants were more likely to engage in increased injection riskbehavior such as needle sharing than those who were stably housed. Beingunstably housed has often been associated with higher rates of HIV risk behavioramong people who use injecting drugs 25 and can drive epidemics of HIV amongthis group of people. The concentration of unstably housed people who usedinjecting drugs in the inexpensive hotels in the Downtown Eastside section ofVancouver facilitated widespread sharing within this group, and fueled the rapid

22World Health Organization. (1986). Ottawa Charter for Health Promotion, p.5. Retrieved November 17,

2008 from http://www.who.int/healthpromotion/conferences/previous/ottawa/en.23 DesJarlais, D., Braine, N., & Friedmann, P. (2007). Unstable housing as a factor for increased injection

risk behavior at US syringe exchange programs.AIDS Behavior,11,S78-S84.24

Elifson, R., Sterk, C., Theall, K. (2007). Safe living. The impact of unstable housing conditions on HIV

risk reduction among female drug users.AIDS Behavior, 11, S45-S55.25 Corneil, T., Kuyper, L., Shoveller, J., Hogg, R., Li, K., Spittal, P., Schechter, M. & Wood, E. (2006).

Unstable housing associated risk behavior, and increased risk for HIV infection among injection drug users.

Health Place, 12(1), 79-85.


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outbreak of HIV in that city even though many of the people who used injectingdrugs were participating in the local syringe exchange program26 .

The client profile and unstable housing experienced by the participantsinterviewed for this research throughout the island places them at heightened risk

for both HIV and hepatitis C, as well as other health risks. Their profile alsoconfirms their vulnerability to the consequences of drug use.

In 2007, the feasibility study on supervised consumption options in Victoria27identified critical service gaps for drug users, specifically with regard todetoxification, treatment, housing/shelter, basic social and health care, as well asspecialized services for special groups. These gaps were also identified sevenyears earlier in another research study.28 The 2000 study on injection drug usein Victoria, recommended mobile sties for needle exchange but not at the loss ofa fixed site. The client profiles in this present evaluation research and theirreported histories reveal that not much has changed, and in fact, the clients may

be at greater risk in Victoria due to the closure of the fixed site. Additionalevidence for the greater risk among those who use injection drugs in Victoriawas provided by the frequent reports of needle reuse, the substantial decrease inthe number of syringes recovered, and the displacement of clients and drug usethroughout downtown and surrounding areas.

The history of drug use by the participants revealed the injection of multiple drugsover time. This is an important finding in that it exposes the clients to more risk inrelation to which drugs are available on the street. This finding of multiple druguse is similar to the pattern of drug use reported in the 2006 I Track study29 forthe Victoria site. This finding also refutes the myth that those who use injectiondrugs are switching to only smoking crack. All of those who used injection drugsin this research who reported smoking crack, also reported simultaneousinjecting drug use.

This research was limited by the large geographic area that AVI covers, as wellas the numbers of people interviewed, and the researchers resources. However,in checking with seasoned outreach staff, the findings were confirmed as fittingwith their realities and experiences. At the same time, it is recognized that theclosure of the fixed site in Victoria, created unforeseen challenges for outreachstaff and the delivery of needle exchange and other services.

26

Strathdee, S., Patrick, D., Currie, S., Cornelisse, P., Rekart, M., Montaner, J., Schechter, M. &OShaughnessy, M. (1997). Needle exchange is not enough: Lessons from the Vancouver injecting drug

use study.AIDS,11(8): F59-F65.27 Fischer, B. & Allard, C. (2007). Feasability study on supervised consumption options in the city of

Victoria. University of Victoria: Centre for Addictions Research of BC.28

Stajduhar, K. Poffenroth, L. & Wong, E. (2000).Missed opportunities: Putting a face on injection drug

use and HIV/AIDS in the capital health region. Vancouver, BC: British Columbia Centre for Disease

Control.29 Public Health Agency of Canada. (2006).I-Track: Enhanced surveillance of risk behaviors among

injecting drug users in Canada. Phase I report. Ottawa: ON: Public Health Agency of Canada.


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Besides previous research demonstrating the efficacy of needle exchangeservices in preventing HIV and hepatitis C, additional research has also shownthat needle exchange services which offer easily accessible adequate cleansupplies not only prevent viral infections but also abscesses30 .Of particular

concern for the Victoria site, is the self-reported reuse of needles which in part issubstantiated by the dramatically low numbers of needles recovered. In 2006,AVI island wide had a needle return rate of 99.8 %. The numbers in Tables 2 and3 of this report attest to the dramatic effect that the closure of the fixed site inVictoria had on needle recovery rates which is alarming. The effect of this reuseon clients health remains to be determined.

Conclusions Across the Island

The findings from across the island attest to the benefits of having a fixed siteneedle exchange where the needle exchange services not only prevent

infections such as HIV and hepatitis C, but open the door to other services.Trust and acceptance by the outreach staff of people who use injecting drugsfacilitated the clients to seek other services and to feel safe in what for many wasan unsafe world. Fixed sites provided confidential spaces that were valued bystaff and clients.

It should be noted that while AVI has island wide services, there is large diversityin terms of population density and concentration of risk behavior. Providing harmreduction services in downtown Victoria is different from offering these servicesin the northern part of the island where your population is less dense and widelyscattered over a large geographic area. Throughout the island, AVI staff havemade outstanding efforts to deal with these different challenges and it is clearthat if their services did not exist, there would be reduced access to services anda potential for increased HIV and hepatitis C rates.

At every site, observing the staff interacting with diverse community groups in thedifferent settings revealed the strong links with community partners and supportthat AVI has built and continues to build. It also should be noted that theresearchers recognize that this did not happen over night, but that it has beenpart of, in some cases, years of effort and advocacy and education in theircommunities.

Conducting this research gave the researchers an opportunity to begin tounderstand how great the needs are for outreach in both urban and ruralcommunities, and to appreciate the effective use of limited resources in providingservices to often marginalized populations. Staff dedication, commitment andenergy in providing services are to be commended.

30 Tomolillo, C. et al. (2007). The damage done: A study of injection drug use, injection related abscesses

and needle exchange regulation. Substance Use & Misuse, 42(10): 1603-1611.


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Across the island, the majority of people who use the exchange who wereinterviewed for this study, were homeless or unstably housed with limited accessto food, transportation and social support. Vulnerability due to a lack of the basicdeterminants of health such as housing, income and food among AVI clientscontributes to poor health. Unstable housing clearly puts many clients at

heightened risk of HIV and hepatitis C, as well as other health concerns. Healthconcerns may go unmet because of barriers in accessing health care services.These issues belong to the community at large and cannot be solely addressedby AVI. Harm reduction services are a vital component of the overall response tohomelessness and drugs, but are just one link to a myriad of supports andcomprehensive services that AVIs clients need to break the cycle of addictionand homelessness. AVI has been providing access to these other supports butcannot continue to fill these service gaps.

Of particular concern in Victoria is the impact of the closure of the fixed site onthe number of needles distributed and collected, displacement of clients and drug

use, and the overall reductions in service. It was encouraging that at the time ofthe closure other service providers increased efforts to distribute clean supplies.However, the numbers of needles returned is far below pre-closure rates and riskbehaviors related to self reuse of needles was identified as a concern in Victoriaonly.

In Victoria, AVI staff and outreach nurses have found the brief encounters on thestreet and at the van difficult in terms of not having privacy and a place to have ameaningful conversation with clients. While needle exchange on the bike and atthe van reaches some clients, interactions are often limited and of brief duration.Furthermore, the closure of the fixed site resulted in contact being lost with asignificant number of registered clients. These clients include those who wouldstop by after work or were diabetics using the fixed exchange.

The closure of the fixed site is not only surprising but inconsistent given that akey recommendation of the 2007 Mayors Task Force on Breaking the Cycle ofMental Illness, Addiction and Homelessness recommendations includedStrengthen harm reduction services to help mitigate public health and publicorder issues; in particular, investigate the use of substitution therapies and indoorsupervised consumption sites and services.(p. 14). The current researchverifies that Victoria has experienced a loss in harm reduction services andreinforces the need for enhanced harm reduction services consistent with theMayors Task Force recommendations.

Overall Recommendations

1. Continue to strike the balance to meet the needs of visible and invisiblediverse clients who use injecting drugs throughout the island. Fixed siteservices need to be to be a feature of programs island wide. Additionalmobile outreach services should be considered for up island locations but


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require appropriate resourcing and supports.. Secondary distribution bypeers and outreach workers could be enhanced to increase access toclean supplies, especially for those who are geographically or sociallyisolated.

2. Continue to build connections with the populations served and bridges tothe larger communities in which AVI operates across the island. Inparticular, relationships with Aboriginal communities, women and thosewho are geographically isolated are important areas for development.

3. Continue to advocate for resources for people who use injecting drugs.Those whose addiction and sometimes mental health issues requireaccess to a wide range of treatment options. Increase connections andintegration with other health and social service providers. For example,acess to income and housing support workers and nursing services couldbe expanded at all sites.

4. Continue to offer and create peer opportunities to develop the capacity ofpeer leaders in the street community as a means of developing effectiveprogramming through advising and gaining insight into the currentsituation such as the closure of the Victoria fixed site. Such opportunitiescan also provide a means of a acknowledging expertise, skill developmentand training.

5. Stay the course despite controversythe community needs harmreduction services. Continue to build external relationship with citycouncils, policy and health authorities, and other health and social serviceproviders to garner support and collaborative action on the needleexchange. This has the potential to address issues related to nimbyism(not in my backyard) in the location of a needle exchange. Take proactivesteps to educate the community and build relationships with neighboringbusinesses, etc.

6. Needle exchange is only one part of harm reduction .Continue to use theneedle exchange as a safe way to engage clients in the othercomponents. Needle exchange is a point of access to other health andsocial services. Integration of needle exchange into health and socialservices should be considered.

7. Advocate with the broader community for improved access to stablehousing for the many clients who are unstably housed and need addictionservices. Increase access to housing support workers in the community. InVictoria, connections to the Victoria Integrated community outreach teamand other outreach teams would enhance access to housing and otherservices.


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Recommendations for Victoria Site

1. Continue to collect the monthly data on needle distribution and collection

services.

2. Continue monthly monitoring of registered clients accessing the needleexchange services.

3. Urgent need for accessible fixed multi-site needle exchanges with accessto comprehensive services as well as bike outreach.

4. Explore options for improving access to comprehensive services. Asdescribed above, enhance connections to housing, income and healthcare services.

5. Urgent need for an evening drop-in place for people on the streets. Thereis a gap in lack of availability of drop-in evening services with the closureof the fixed site. This needs to be addressed collaboratively as it is notonly an issue of providing needle exchange services.

6. Address issues related to open public injecting through review andimplementation of recommendations for supervised consumption sitespreviously developed by the City of Victoria.

7. That multiple locations and extended hours of service be promoted toenhance access to clean needles for a diverse range of clients who useinjection drugs.

8. That adequate physical space and staffing be ensured at a fixed site toprovide the conditions necessary for safe and effective operation.

9. Continue to educate clients regarding the risks of reusing needles.

AcknowledgementsThe researchers would like to acknowledge the support they received from thestaff of AIDS Vancouver Island, the sharing provided by clients who usedinjecting drugs and their peers, the time and information provided by communitypartners, including the outreach nurses and the police. This collaboration,allowed us to enter into your world for a short while. We hope that we havecaptured your insights appropriately.


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