During the mid-1990s, Vancouver experienced a well characterized HIV outbreak among injection drug users (IDU) and many questioned how this could occur in the presence of a high volume needle exchange program (NEP). Specific concerns were fuelled by early research demonstrating that frequent needle exchange program attendees were more likely to be HIV positive than those who attended the NEP less frequently. Since then, some have misinterpreted this finding as evidence that NEPs are ineffective or potentially harmful. In light of continuing questions about the Vancouver HIV epidemic, we review 15 years of peer-reviewed research on Vancouver’s NEP to describe what has been learned through this work. Our review demonstrates that: 1) NEP attendance is not causally associated with HIV infection, 2) frequent attendees of Vancouver’s NEP have higher risk profiles which explain their increased risk of HIV seroconversion, and 3) a number of policy concerns, as well as the high prevalence of cocaine injecting contributed to the failure of the NEP to prevent the outbreak. Additionally, we highlight several improvements to Vancouver’s NEP that contributed to declines in syringe sharing and HIV incidence. Vancouver’s experience provides a number of important lessons regarding NEP. Keys to success include refocusing the NEP away from an emphasis on public order objectives by separating distribution and collection functions, removing syringe distribution limits and decentralizing and diversifying NEP services. Additionally, our review highlights the importance of context when implementing NEPs, as well as ongoing evaluation to identify factors that constrain or improve access to sterile syringes.
Aims To assess heroin injectors’ perceptions of and responses to a warning issued by public health officials regarding high-potency heroin and increases in fatal overdoses. Design Semi-structured qualitative interviews Setting Vancouver, Canada. Participants Eighteen active heroin injectors Measurements Semi-structured interview guide focussing on heroin injectors’ perceptions of and responses to the overdose warning, including reasons for failing to adhere to risk reduction recommendations. Findings Although nearly all participants were aware of the warning, their recollections of the message and the timing of its release were obscured by on-going social interactions within the drug scene focussed on heroin quality. Many injection drug users reported seeking the high potency heroin and nearly all reported no change in overdose risk behaviours. Responses to the warning were shaped by various social, economic and structural forces that interacted with individual behaviour and undermined efforts to promote behavioural change, including sales tactics employed by dealers, poverty, the high cost and shifting quality of available heroin, and risks associated with income-generating activities. Individual-level factors, including emotional suffering, withdrawal, entrenched injecting routines, perceived invincibility and the desire for intense intoxication also undermined risk reduction messages. Conclusions Among heroin injectors in British Columbia, a 2011 overdose warning campaign appeared to be of limited effectiveness and also produced unintended negative consequences that exacerbated overdose risk.
BackgroundIn Canada, funding, administration, and delivery of health services—including those targeting people who use drugs—are primarily the responsibility of the provinces and territories. Access to harm reduction services varies across jurisdictions, possibly reflecting differences in provincial and territorial policy commitments. We examined the quality of current provincial and territorial harm reduction policies in Canada, relative to how well official documents reflect internationally recognized principles and attributes of a harm reduction approach.MethodsWe employed an iterative search and screening process to generate a corpus of 54 provincial and territorial harm reduction policy documents that were current to the end of 2015. Documents were content-analyzed using a deductive coding framework comprised of 17 indicators that assessed the quality of policies relative to how well they described key population and program aspects of a harm reduction approach.ResultsOnly two jurisdictions had current provincial-level, stand-alone harm reduction policies; all other documents were focused on either substance use, addiction and/or mental health, or sexually transmitted and/or blood-borne infections. Policies rarely named specific harm reduction interventions and more frequently referred to generic harm reduction programs or services. Only one document met all 17 indicators. Very few documents acknowledged that stigma and discrimination are issues faced by people who use drugs, that not all substance use is problematic, or that people who use drugs are legitimate participants in policymaking. A minority of documents recognized that abstaining from substance use is not required to receive services. Just over a quarter addressed the risk of drug overdose, and even fewer acknowledged the need to apply harm reduction approaches to an array of drugs and modes of use.ConclusionsCurrent provincial and territorial policies offer few robust characterizations of harm reduction or go beyond rhetorical or generic support for the approach. By endorsing harm reduction in name, but not in substance, provincial and territorial policies may communicate to diverse stakeholders a general lack of support for key aspects of the approach, potentially challenging efforts to expand harm reduction services.Electronic supplementary materialThe online version of this article (doi:10.1186/s12954-017-0177-7) contains supplementary material, which is available to authorized users.
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