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AVAILABILITY OF STERILE INJECTING EQUIPMENT IN PHARMACIES
Dr. Loreta Stoniene
Doc.dr. Romualdas Gurevicius
30 01 2009
Introduction
� Pharmacists can play a key role in preventing the major blood-borne infections caused by human immunodeficiency virus (HIV), hepatitis C virus, and hepatitis B virus.
� Pharmacists are able to contribute to community-level disease prevention initiatives by providing patient counseling (including information on safe needle disposal) and by selling condoms, sterile syringes, etc.
� Pharmacists, by increasing access to sterile syringes, can also help reduce the risk for transmission of blood-borne infections among IDUs.
� Pharmacies can have an important role in HIV prevention among IDUs because:� Pharmacies are a reliable, trustfull source for obtaining sterile injecting
equipment and condoms; � They are conveniantely located; � Some of them work 24 hours per day; � The staff has medical education and they can offer information about
prevention of infections and refer clients to medical and social services.� They can sell sterile injecting equipment without extra documentation.
The evaluation of scientific literature show that:
Study purpose and objective:
� To assess availability of sterile injecting equipment and possibilities to carry out HIV prevention through pharmacies and to develop recommendations for involvement of pharmacies in HIV prevention for IDU’s
� To analyze possibilities, demands and strays to obtain sterile injecting equipments (needles, syringes, distiller water, alcohol sponges, condoms, etc.) and consultations in pharmacies for IDU.
� To analyze pharmacists experience in selling sterile injecting equipment and other goods to IDUs.
� To evaluate pharmacists knowledge's and attitude to HIV prevention and identify possibly problems.
� To compare results between cities.
� To identify possibilities for strengthening participation pharmacists in HIV/AIDS prevention between IDUs.
Methodology� A 50 % simple random sample study was conducted in Vilnius, a
simple random sample study in Alytus and Visaginas. From 1 to 3 pharmacists were interviewed in each pharmacy. The sample consist from 323 pharmacists: 251 in Vilnius, 56 – in Alytus and 16 – in Visaginas.
� According to 2007-01-01 data of National Centre of Mental health, drug addiction prevalence rate in Visaginas was 591,7 cases/100 thousand inhabitants, in Alytus – 146,6, in Vilnius – 474,5. With 10 % standart error (95 % confidence interval) it was planned to interview 93 IDUs in Vilnius, 59 in Alytus, 62 in Visaginas. 236 fully filled questionnaires were received: 111 from Vilnius, 86 from Visaginasand 56 from Alytus.
Demographic characteristics of pharmacists
Previous experience histogramAge histogram
The presence of drug users in pharmacies
Yes No
City
Vilnius
Alytus
Visaginas
0,00 0,25 0,50 0,75 1,00
Sell SN during all carier
Yes No
City
Vilnius
Alytus
Visaginas
0,00 0,25 0,50 0,75 1,00
Sell SN during last month
χ2=1.1, df=2, p=0.566 χ2=2.2, df=2, p=0.329
SN – needles and syringes
Identification of drug using client (1)
χ2=14.2, df=2, p=0.001 χ2=5.96, df=2, p=0.051
Do you personally know IDUs?
Do you have difficulties with IDUsidentification?
67,8 % IDUs from all cities feel safe in
a pharmacy
Identification of drug using client (2)
IDUs age (1)
Mean age 29,36 IDUs research Mean age - 27,46
Identification of drug using client (3)
IDUs age (2) IDUs gender
64,3
70,8
35,7
29,2
0% 20% 40% 60% 80% 100%
Men
Women
Yes No
IDUs research: mean age 36,12
IDUs research: did you visit pharmacy last week?
83,272,5
1,3
27,515,5
0
20
40
60
80
100
Pharmacists' research IDUs research
Per
cent
Mostly men Mostly women Both genders
Bought syringes
size
Mean size of bought syringesVilnius 2,69 ml (SD=0,8), Visaginas 2,20 ml (SD=0,85), Alytus – 3,0 ml (SD=0,68).
11,824,6
7,5
16,4
33,8
62,7
38,5
77,5
9,1 3,115
0%
20%
40%
60%
80%
100%
Vilnius Visaginas Alytus
City, p<0,01
0,5 ml 1 ml 2 ml 5 ml
IDUs research
Identification of drug using client (4)
0
10
20
30
40
50
60
70
Perc
en
t
0,5 ml 1 ml 2 ml 5 ml 10 ml 20 ml 1 ir 2 ml 2 ir 5 ml
0,5 ml 4,4 6,3
1 ml 8,4 62,6
2 ml 52 55,8
5 ml 0,4
10 ml 4,4
20 ml 1,3 1,9
1 ir 2 ml 26 31,3 1,9
2 ir 5 ml 3,1 40,4
Vilnius Visaginas Alytus
Pharmacists research
Identification ofdrug using client (5)
The sizes of sold syringes (pharmacists research)
Did you buy syringes during last visit to pharmacy?IDUs research
Do IDU visits create problems?
χ2=10.64, df=2, p=0.007 χ2=15.64, df=6, p=0.016
Howmany IDUs visited thepharmacy last month?
χ2=8.6, df=2, p=0.014
χ2=21.3, df=2, p=0.001
Do you communicate aboutthe problems with you family ?
Do you communicate about the problems with you colleagues?
χ2=1.85, df=2, p=0.39
No statistically meaningful differences between those for those to whom IDUs create problems and don’t create problems.
Do you communicate about the problems with you manager ?
8,7 5 2,8
91,3 95 97,2
0
20
40
60
80
100
120
To live in society To live in neighbourhood To live infront of you
Per
cen
t
Yes No
25.722.3 20.4
73.476.8 78.6
0.9 0.9 0.9
0
10
20
30
40
50
60
70
80
90
To live in society To live in
neighbourhood
To live infront of you
Perc
en
t
Yes No Don’t know
Tolerance to IDUs
HIV+
No statistically meaningful differences between cities
Q: Would you agree IDU:
Possibilities to participate in HIV/AIDS
prevention programmes (1) p>0.05
39,3
70,9
85,1
13,9
18,3
46,7
38,1
3,7
61,3
31,9
18
11,1
33,1
47,7
27,2
32,2
20,1
26
28,8
11
3,7
52,9
34,1
26
29,7
76,2
12,7
0% 20% 40% 60% 80% 100%
Feel antipathy
Feel discomfort
Feel unsafe
Unethical to sell needles/syringes
To help IDU is professional duty
Pharm. can consult
I can consult IDUs
Ph. is favourable place
My business will suffer
Agree Uncertain Disagree
Possibilities to participate in HIV/AIDS prevention programmes (2) p>0.05
Support from pharmacist requirements(IDUs research)
93,7
87,9
18,6
88,389,4
25,4
84,787,9
15,3
91
90,9
20,3
88,389,4
16,9
82
87,9
15,3
83,8
89,4
16,9
0
10
20
30
40
50
60
70
80
90
100
Vilnius Visaginas Alytus
Per
cen
t
To change N and S** Supply information**
Supply condoms** Supply alcohol sponges**
Supply water for inj.** Consult for safer behaviour**
Provide referrals to drug treatment**
Participation in trainings
31,3
5,3 5
15,2
68,7
94,7 95
84,8
0
10
20
30
40
50
60
70
80
90
100
About drug
prevention
About NSP About harm
reduction
programmes
About HIV
prevention and
treatment
Per
cent
Yes No
No statistically meaningful differences between cities, pharmacy companies,position or previous experience.
Pharmacists misconceptions (1)Participation in programme will
Increased drug use in the country
χ2=6.23, df=4, p=0.182
Increased drug use in the neighborhood
χ2=14.7, df=4, p=0.005
Pharmacists misconceptions (2)Participation in programme will
Decrease HIV transmission
χ2=1.55, df=4, p=0.817
Be important part of comprehensive approach to HIV/AIDS prevention χ2=13.67, df=4, p=0.008
Agree Uncertain Disagree
City
Vilnius
Alytus
Visaginas
0,00 0,25 0,50 0,75 1,00
Decreace HIV transmition
If the pharmacy participates in prevention
programme we will need special trainings
χ2=3.59, df=4, p=0.464
Last place where sterile injecting equipment (SIE) was obtained
Most popular place to obtainsterile injecting equipment (SIE)
Results: Most popular pharmacies amongVisaginas and Vilnius IDUs: about one third of them last time SIE obtained in the pharmacy. For Vilnius respondents the pharmacies are more usual place for obtaining SIE.The main good in pharmacy is syringes (reported 91% IDUs) and needles.
5,41
93,22
40,5451,5242,34 48,48
6,781,89,91
0
20
40
60
80
100
Vilnius Visaginas Alytus
Perc
ent
City, p<0,01
Low th. C. Mobile service Pharmacy Friend Salespeople
Vilnius VisaginasAlytusL
ast P
lace
Low th.c.
Mobile services
Other
Pharmacy
0,00 0,25 0,50 0,75 1,00
City
Mosaic Plot
Low th. C – low threshold centre
Most comfortable place to obtain sterile injecting equipment
Result : pharmacy as comfortable place to obtain condoms was mentioned by one third of Vilnius and Visaginas IDUs.
6,4
48,6
60,6
100
5,41,52,7
36,9 37,9
0
10
20
30
40
50
60
70
80
90
100
Vilnius Visaginas Alytus
Per
cent
City, p<0,01
Low th.c. Mobile service Friend Salespeople Pharmacy
Low th. C – low threshold centre
Need of syringe at night time
Result : Syringes at night are often needed by Visaginas IDUs(about 50 %) and less often (only one third) of Vilnius and Alytus IDUs.
Some results (1)
� The most comfortable place to obtain sterile injecting equipment (SEI) for IDUs is low threshold centre, because the service is friendly/non- discriminated and free of charge.
� The pharmacy is one of places to obtain SIE (mainly syringes and needles), because of longer working hours and better location. On weekends and holidays IDUs visits to pharmacies increase.
� The tolerance to IDUs is very low, in comparison to PHLWA, they are twice more tolerant to PHLWA.
� Knowledge's about prevention programmes are very minimal, more then 90% of them had never participated in any trainings related to such problems.
Some results (2)
� The attitude to harm reduction programmes are very skeptical, and may be conditioned due to the lack of information.
� More then half of respondents are ready to supply leaflets, but not condoms, spirit sponges, cotton-wool.
� About half of pharmacists agree to provide referrals to drug treatment services. Majority don’t agree to provide free sharp containers or think that pharmacy is not a favorable place for needles/syringes exchange. More than 60 % think that pharmacy shouldn't participate in prevention programmes and are uncertain if providing support to IDUs is their professional duty.
Some results (3)
� Majority pharmacists think, that participating in programme will reduce the number of clients, reduce staff security, the community will not trust the pharmacy, and they are uncertain that participation in programme can be important part of HIV/AIDS prevention at national level. They are not sure that syringe exchange can have positive impact to IDUs health.
Recommendations (1)
� 1. To increase pharmacists' knowledge in harm reduction programmes, drug users psychological characteristics:
� 1.1. to prepare postgraduate training programme on harm reduction strategies and their effectiveness, psychological peculiarities of IDUs, communication skills with “difficult” clients, and to give accreditation. This programme could be included into Kaunas University of Medicine postgraduate training centre curriculum.
� 1.2. to integrate information about harm reduction strategies and related aspects into pharmacy students curriculum (for ex. into pharmacy social aspects).
� 1.3. to prepare information package (bulletin, e-bulletin or e-leaflet) about harm reduction strategies and to disseminate by e-mail and post.
Recommendations (2)
� 2. To provide possibilities for pharmacists to participate in HIV prevention according to Good Pharmacy Practice:
� 2.1. to prepare information package about services for IDUs and through pharmacy companies to disseminate them to IDUs.
� 2.2. to develop non-discriminating attitude towards IDUs.� 3. To expand effective (changing risky behavior), available
(mobile mini bus, outreach, or low threshold centre), free and friendly (ensure security sense) – low threshold services, according to IDUs needs.
� 4. To develop social abilities of IDUs to obtain sterile injecting equipment in pharmacies in a civilized way.