Distribution of Harm Reduction Kits in a Specialty HIV Hospital

Abstract

Casey House, a small Toronto, Ontario, hospital for people living with HIV, implemented a harm-reduction kit distribution program in October 2014 to decrease harms from reuse of injection and smoking equipment among its clients—inpatients and outpatients. Program statistics (November 2014–June 2017) show an increase in the number of kits—injection and smoking—distributed each year. The program is perceived by staff to communicate openness and increased willingness of clinicians and clients to discuss drug-related harms.

Hospitals are often unwelcoming places for people who use drugs.¹ In this article, we describe a harm-reduction program in a small hospital in Toronto, Ontario.

INTERVENTION

The harm-reduction injection and smoking kit distribution and disposal program (hereafter kit-distribution program) implemented by Casey House provides current hospital inpatients and people receiving outpatient care from Casey House community nurses (hereafter clients) with 24-hour access to kits. The safer-injection kits include a new needle and syringe, alcohol swab, filter, tourniquet, cooker, and a sterile water ampoule as recommended.² The safer smoking kits include a glass stem, brass screens, push stick, and mouth piece as recommended.² Both kits include contact information for a local, full-service needle-and-syringe program that also distributes naloxone kits and offers low-threshold drug treatment.

PLACE AND TIME

Casey House, Canada’s first and only stand-alone hospital for people living with HIV/AIDS, is a government-funded hospital providing inpatient (i.e., 13 beds in 2014) and outpatient care and community programming. In 2014, it implemented the kit-distribution program.

PERSON

The program was designed primarily for Casey House clients who use drugs and also their visitors.

PURPOSE

In 2012, the Harm Reduction Advisory Group, comprising Casey House staff, recommended implementation of a kit-distribution program to increase client knowledge of drug-related harms and access to new equipment, reduce drug-related harms (e.g., cellulitis; transmission of HIV, hepatitis B and C, and other bloodborne pathogens), promote the safe disposal of used harm-reduction equipment, and to encourage clients to speak with staff members about drug-related harms.

IMPLEMENTATION

The Works, a large harm-reduction program operated by Toronto Public Health, provided training for Casey House staff and all of the supplies for the kits at no cost to Casey House. The training for all full-time nurses and social workers consisted of a one-day job shadowing of needle-and-syringe program counselors at The Works and a half-day workshop where they learned about trends in drug use, the purpose of and how to use each piece of equipment in the kits, and how to educate clients about the kits.

Kits and biohazard disposal bins are available 24 hours per day from the nursing station, first-floor lobby, second-floor lounge, and the foyer of the hospital. There are no limits on the number of kits that can be taken. In all locations except the nursing station, clients can access kits whenever they wish without having to interact with staff. Casey House staff anticipated that the program might also attract people who use drugs in the immediate vicinity and located supplies in the foyer, which is accessible to anyone. However, the kit-distribution program was not advertised outside of Casey House nor on the “map” of programs in Toronto. The Casey House kit-distribution program is the only location in the area offering 24-hour access in Toronto. The nearest harm-reduction program is a 10-minute walk away.

EVALUATION

Using a constructive process evaluation model,³ we reviewed program statistics and a trained interviewer completed semistructured interviews using a preset guide about the operation of the program with four staff members representing each discipline. Following established qualitative research methods for social settings,⁴ we took detailed notes about answers to the questions during the interviews, and we used conventional content methods⁵ to analyze these notes. To create a low-barrier program, the only information collected is the number of kits distributed and no information about who obtains the kits.

In light of this program design, we asked staff to describe who they had observed using this program. Receptionists who monitor the foyer through security cameras and are sometimes engaged in conversations by people picking up the kits estimated that most of the kits from this location were obtained by individuals who were not Casey House clients, were male, and were older than 35 years, and most kits were picked up between 5 pm and midnight and on weekends. When asked about interactions with those obtaining the kits, receptionists noted that they were often asked for and provided information about drug treatment, housing, social assistance, services for abused women, and naloxone kits. If a person accessing kits indicated that they were in crisis, the receptionist sought help from Casey House social workers or nurses.

From November 14, 2014, to June 30, 2017, the program distributed 15 948 injection kits and 4907 smoking kits (Table 1). Each year, the number of kits distributed has increased. The total number of injection and smoking kits distributed at the foyer progressively rose, but distribution in the second floor lounge and nursing station did not. Staff believed that the program grew over time because it was anonymous and available 24 hours per day. Furthermore, receptionists reported that they had been told by clients that the hospital foyer was a safer place to pick up equipment than at other harm-reduction programs where there is drug dealing and sex work.

TABLE 1—

Injection and Smoking Kit Distribution by Location and Year: Toronto, Ontario, November 2014–June 2017

	Foyer, No.	First-Floor Lobby, No.	Second-Floor Lounge, No.	Nursing Station, No.	Total, No.	Mean No. per Month
Injection kits
Nov 14–Dec 31, 2014	74	55	32	0	161	107
Jan 1–Dec 31, 2015	2 077	515	90	14	2 696	225
Jan 1–Dec 31, 2016	8 265	923	25	0	9 213	768
Jan 1–Jun 30, 2017	3 776	102	0	0	3 878	646
Total	14 192	1 595	147	14	15 948
Smoking kits
Nov 14–Dec 31, 2014	17	23	17	0	57	38
Jan 1–Dec 31, 2015	533	177	16	5	731	61
Jan 1–Dec 31, 2016	2 186	261	0	0	2 447	204
Jan 1–Jun 30, 2017	1 617	55	0	0	1 672	279
Total	4 953	479	33	5	4 907

Staff members noted that the training they received helped to increase their confidence to initiate discussions with the clients about their drug use. Staff also noted that providing clients with information about the kit distribution program increased mutual trust and comfort to discuss drug use. Furthermore, staff believed that the visibility of the kit distribution sites for people entering the hospital for consultations communicated a message of openness and tolerance within Casey House. For the minority of staff who did not support the kit program, Casey House provided additional education about harm reduction and a peer staff member and a client modeled how to assess and talk about drug use with clients.

ADVERSE EFFECTS

Kits were made four times per month by Casey House staff, but demand regularly exceeded the supply, and kits were sometimes not available for two- to three-day intervals for nonclients living around Casey House but were always available for inpatients and outpatients. Although there were no reports of finding used needles or glass stems, neighbors complained about finding other contents of the kits discarded on their properties. In response, Casey House asked those accessing kits to dispose of unwanted items in the biohazard containers located adjacent to the kits.

SUSTAINABILITY

Although the program was implemented for Casey House clients to reduce drug-related harms, it has also attracted an unexpected number of people who use drugs from the community area around the hospital. Location, safety, anonymity, and 24-hour open access to supplies are thought to be key program design features that attracted this group. Although providing kits to non–Casey House clients contributes to public health goals, Casey House was strained to ensure uninterrupted access. In response, Casey House enlisted clients to help make the kits, and staff from MAC Cosmetics, a corporate sponsor, to help with kit-making to meet demand. In the spring of 2017, Casey House moved to a new building across the street from its original location. In this new facility, there is more space to distribute kits as well as individual pieces of equipment (e.g., needles, cookers, stems, alcohol swabs). It is hoped that this new approach to distribution of equipment will reduce littering in the vicinity and better correspond with best-practice recomendations.²

PUBLIC HEALTH SIGNIFICANCE

Evaluation of the program points to the promise of hospital-based kit distribution programs as a structural intervention to reduce drug-related harms among inpatients and among other people who use drugs in the vicinity. This small evaluation contributes to the call for evaluation of implementation of needle-and-syringe programs in hospital settings.⁶ Furthermore, more formal evaluation of this and similar programs is needed to fully understand if and how different models of kit distribution influence access (e.g., distributed by clinical staff vs unsupervised distribution), reach, equipment sharing, and public order issues.