The Centre for Harm Reduction carried out a review of New Zealand’s Needle Exchange Programme (NEP) between April and September 2002. The Review’s aim was to assess whether the NEP is working in the most effective and efficient way possible within available resources.
Methods Information was collected through a review of relevant literature, consultations with the NEP stakeholders (the New Zealand Ministry of Health, the Pharmacy Guild of New Zealand, the Pharmaceutical Society of New Zealand, and Needle Exchange National & Regional) and other key agencies (including representatives of New Zealand’s law enforcement agencies), a survey of NEX users, and a call for public submissions. A major feature of the Review was the adaptation of methods and data used in Return On Investment In Needle & Syringe Programs In Australia (Health Outcomes International et al, 2002) to enable projections of the numbers of people living with HIV and HCV infections and produce cost/benefit estimates for New Zealand’s NEP.
Results
Effectiveness
Most of the scientific evidence clearly demonstrates that needle and syringe programmes worldwide are effective in reducing prevalence and/or incidence of HIV infection in injecting drug users. New Zealand enjoys one of the lowest prevalences of HIV infection in IDUs (0.3%) among more developed nations, lower even than countries such as Australia and The Netherlands which have (arguably) employed more comprehensive and intensive needle exchange strategies. It is estimated - by adapting the work of Health Outcomes International et al (2002) to suit New Zealand - that had the NEP not been introduced, by the end of 2001 New Zealand would have had an extra 1,454 people living with hepatitis C, another 1,031 people living with HIV/AIDS, and an extra 20 people would have died following an HIV infection.
A gradual decline has occurred in the prevalence of needle-sharing among New Zealand IDUs since the mid-80s, and the most recent survey data show a substantial reduction in prevalence of sharing (in the month prior to survey), from 50 in 1994 to six per cent in 2002. While proving a direct link between NEP activities and behaviour is difficult, the implication is that the NEP has contributed to a reduction in needle-sharing among IDU.
The NEP appears to be effective in reaching New Zealand’s IDUs, with less than 5% of survey respondents reporting frequent difficulty in obtaining injecting equipment. Over 90% of respondents perceived little or no difficulty with access due to distance from an outlet. Nevertheless, the Review identified several regions which were under-serviced by NEs, including Auckland, Southland and the West Coast of the South Island. There are also some concerns about the NEP’s reach in terms of Maori and smaller ethnic groups.
Efficiency
A cost/benefit analysis was conducted based on the estimated numbers of HIV and HCV infections prevented by NEP introduction, annual treatment costs for people living with HIV or HCV disease, and annual investment in the NEP. Treating the estimated 1,031 extra people living with HIV/AIDS and the estimated 673 diagnosed with chronic HCV by the end of 2001 (had the NEP not been introduced) would have added $35,678,516 to New Zealand’s total healthcare outlay between 1988 and 2001, while total expenditure on the NEP over that period was estimated at $10,644,588. Thus the net benefit due to the NEP – based on HIV and HCV treatment costs avoided between 1988 and 2001 – is $25,033,928. Every $1 spent on New Zealand’s NEP saved an estimated $3.35 in healthcare costs which would otherwise have accrued over the period of investment. Extending the projections forward until all the extra New Zealanders infected with HIV or HCV between 1988 and 2001 due to non-establishment of the NEP were estimated to have died produces a cumulative net benefit of $202,274,686; using this approach, every $1 spent on the NEP between 1988 and 2001 yields $20.00 in lifetime treatment costs avoided.
Each needle and syringe distributed by New Zealand’s NEP costs approximately $0.90, making the programme about as efficient in terms of unit cost as the Australian state of Victoria, but less efficient than the average of all Australian state programmes (NZ$0.74). Economies of scale and population density are probable explanations.
Service delivery
The NE users’ survey revealed that NE users were very happy with the service they received at NEXs (96.5% selecting “good” or “very good”). The most popular options for improving service were one-for-one (new for old) syringe exchange and out-of-hours electronic syringe dispensers.
NE users were less satisfied with pharmacy exchange services, with 21.2% rating it as good or very good. Better staff attitudes (towards IDUs) and lower prices of injecting equipment were the options favoured for improved service.
Other issues
In the consultations, nearly universal support was expressed for removing the anomaly of possession of injection equipment being an offence under the Misuse of Drugs Act [section 13(1)(aa)] while a defence exists under the Health (Needles and Syringes) Regulations 1998.
One for one (new for old) needle and syringe exchange is the mode of service favoured by all NE staff. Experience to date with one-for-one has been very positive in terms of increasing distribution of new and return of used equipment, and (anecdotally) reducing syringe re-use. The Review’s survey of NE users found that IDUs attending NEXs offering one-for-one exchange reported significantly lower prevalences of needle and syringe sharing and re-use than IDUs attending other NEs.
Electronic dispensers (vending machines) currently used by NEXs in Auckland and Christchurch to provide after-hours service are working well, and were frequently nominated as a potential method of improving the reach of the NEP.
The concept of providing syringe disposal bins in public places was supported by many of those consulted as a way of enabling safer disposal and reducing the visible aspects of illicit drug use.
Training for pharmacy staff and NE workers and volunteers was widely approved as a means of increasing the effectiveness and efficiency of the programme.
Conclusion
New Zealand’s NEP is both effective and efficient, particularly with respect to prevention of HIV infections among injecting drug users.
Recommendations
1. That the effectiveness and efficiency of New Zealand’s NEP be acknowledged.
2. That New Zealand’s government and community recognise the vital role of the NEP in preventing HIV infections.
3. That consideration be given to opening a second peer-based NEX in Auckland, to bring per-capita service coverage closer to the level which exists elsewhere in New Zealand.
4. That consideration be given to improving NEP coverage on the South Island’s West Coast and Southland by opening branch NEXs and/or upgrading and expanding existing pharmacy outlets.
5. That consideration be given to increasing the reach of the NEP by enabling and/or encouraging the provision of needle exchange services through existing health service infrastructure, such as Community Health Centres and Sexual Health Clinics.
6. That consideration be given to expanding the use of electronic dispensers at NEXs to provide after-hours exchange services.
7. That the costs and benefits that would result from the introduction of free one-for-one (new for old) needle and syringe exchange in New Zealand be formally investigated.
8. That the crucial role of NE volunteers in New Zealand’s NEP be affirmed, and that any resolution of the “reimbursement problem” must not jeopardise volunteers’ input to the programme.
9. That New Zealand’s parliament approve the proposed amendment to the Misuse of Drugs Act which would remove the offence of possession of needles and syringes legally obtained through the NEP.
10. That the (perceived) problems of pharmacy staff attitudes towards needle exchange clients be addressed in a systematic way by the Ministry of Health, NENZ and the Pharmacy Guild; research into pharmacy exchange users’ perceptions of service would be a useful first step.
11. That the Pharmaceutical Society provide NEST with details of pharmacy closures, openings, and changes of ownership on a monthly basis.
12. While return of used needles and syringes to NEs or pharmacies for destruction should remain first priority, NEs should address the issue of disposal of needles and syringes, by means other than return to NEs or pharmacies, in their IDU education activities in order to reduce visibility of needles and syringes in public places and risk of needlestick injury.
13. That training modules for pharmacy staff be developed by NENZ/ NEST in consultation with the Pharmacy Guild and Pharmaceutical Society, promoted by them, and delivered by NEST staff.
14. That GP training in New Zealand include a component on aspects of illicit drug use, including the NEP (its rationale and operation) and methadone maintenance programmes.
15. That the Ministry of Health liaise with the NZMA about encouraging GPs to work with their local NEXs to provide improved access to testing, counselling and primary healthcare services.
16. That basic training for NZ police include a short session on New Zealand’s harm minimisation policy and the NEP. NENZ should liaise with police to achieve this goal.
