Calls for access to safe injecting supplies as a critical public health measure during the COVID-19 pandemic

Abstract

More than three decades of research has provided compelling evidence regarding the effectiveness, safety, and cost-effectiveness of needle and syringe programs (NSPs) in reducing syringe-sharing and transmission of HIV, HCV, and other bloodborne infections. However, repressive drug policies and drug law enforcement practices around the world continue to undermine their operations and scale-up, as well as access to harm reduction among people who inject drugs (PWID). The COVID-19 pandemic has heightened access barriers to NSPs, raising concerns about unsafe injecting practices due to inadequate access to safe injecting supplies. This commentary discusses the robust public health responses that are needed at this particularly vulnerable and critical juncture to ensure access to safe injecting supplies and minimize the risk for transmission of bloodborne infections among PWID.

Commentary

People who inject drugs (PWID) are disproportionately affected by bloodborne infections, with 1.7 million and 10 million of the 13 million PWID worldwide estimated to be living with HIV and hepatitis C (HCV), respectively.^1,2 The World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS), among other international and national healthcare organizations, have endorsed harm reduction measures such as needle and syringe programs (NSPs) as critically important pursuant public health and human rights-based approaches to drug use.^1,3 More than three decades of research from around the globe has provided compelling evidence regarding the effectiveness, safety, and cost-effectiveness of NSPs in reducing syringe-sharing and transmission of HIV, HCV, and other bloodborne infections.⁴

However, although 87 countries had at least one operational NSP operating in 2019,⁵ repressive drug policies and drug law enforcement practices around the world continue to undermine their scale-up and operations, as well as access to harm reduction among PWID.³ Notably, only 14 of 68 countries reporting program data to UNAIDS distributed the WHO’s recommended number of syringes to PWID annually for preventing HIV transmission.³ Punitive laws, including the criminalization of the possession of drugs and injecting paraphernalia, run counter to established scientific evidence and drive unsafe injecting practices and the transmission of bloodborne infections.^3,6 This raises concerns regarding how these risks posed under drug criminalization might be further heightened by increased surveillance associated with the enforcement of social distancing orders during the COVID-19 pandemic, which are likely to disproportionately impact PWID.

Though access to NSPs is particularly important amidst the COVID-19 pandemic, PWID in many settings are now encountering reduced access as existing NSPs have closed or restricted their hours,⁷ raising concerns about unsafe injecting practices due to inadequate access to harm reduction supplies. Barriers to maintaining regular services have been attributed to the lack of personal protective equipment (PPE) for workers along with directives to close services deemed “non-essential”.⁷ Where NSPs continue to operate, access to services has been reduced due to restrictions placed on travel – particularly for PWID in non-urban centres where NSPs are typically less available.⁸ In light of the pandemic, previous plans to expand NSPs are also now on hold as public health attention is redirected to COVID-19 and efforts to comply with social distancing. For example, the Correctional Service of Canada announced a temporary halt to the expansion of the Prison Needle Exchange Program.⁹ Suspending the operation or expansion of NSPs, however, means PWID will be exposed to the risk of acquiring HIV, HCV, and other bloodborne infections at continued or elevated levels alongside risk for COVID-19. While social distancing is a necessary measure to contain the spread of COVID-19, it also comes with an increased risk of social isolation and erosion of informal networks of support, including through harm reduction programs, and can itself increase the risk of bloodborne infections.¹⁰

In response to overlapping public health crises of bloodborne infections and COVID-19, there is an urgent need to leverage emergency powers, where possible, to prioritize evidence-based harm reduction strategies and ensure the continued operation, optimization, and expansion of NSPs. First, governments must suspend drug law enforcement activities – including issuing arrests, charges, or citations for possession and possession with the intent to distribute, and issuing paraphernalia-related charges for distributing harm reduction supplies. Second, governments must recognize NSPs as “essential services” during “shelter-in-place” orders and secure PPE for workers by adding NSPs to the PPE priority list. Continued operation of NSPs not only provide access to safe injecting supplies but also a venue for COVID-19 testing and, when available, administration of vaccines for PWID who may not access traditional health care services.¹¹ Third, NSP policies must also change to enable low-threshold distribution — that is, the provision of unlimited access to sterile needles and syringes using approaches that maximize accessibility while enabling social distancing (e.g., vending machines, no-contact pick up). Studies from multiple settings have revealed the negative effects of NSP policies that limit access to sufficient numbers of sterile needles and syringes (e.g., one-for-one exchange, limits on number of syringes exchanged per visit).¹² In settings where modifications were made to restrictive NSP policies by implementing low-threshold distribution, significant reductions in syringe borrowing, lending, and HIV transmission have been observed.¹³ Finally, where possible, efforts must be made to maximize reach to individuals who are unable to physically access NSPs, including those who live outside of urban centres, by expanding mobile vans and delivery services, and moving work forward on the expansion of new NSPs as planned, while engaging in social distancing practices (e.g., syringe drop-off, mail-based syringe distribution). These recommendations have been emphasized in various harm reduction guidance documents,^14,15 and represent best practices in NSP delivery during the COVID-19 pandemic.

As the COVID-19 pandemic heightens access barriers to safe injecting supplies and further elevates the risk for bloodborne infections among PWID, robust public health responses are needed to ensure improved and unhindered access to NSPs to avoid an increase in the transmission of bloodborne infections. The responsibility to promote and protect public health and human rights make it imperative that governments adopt necessary harm reduction measures at this particularly vulnerable and critical juncture, while ensuring that these measures outlast the pandemic.