This is a report on a national study commissioned by the Department of Health and Ageing (DoHA) in co-operation with the Health Departments of the States and Territories.
Australia has been a world leader in minimising the spread of HIV, hepatitis C and other blood-borne infections through the provision of Needle and Syringe Program (NSP) services that are designed to reduce unsafe injecting practice among drug users. Among other things the Australian approach has involved many successful partnerships between government and non-government bodies – the latter including drug user support and advocacy groups. However there is concern about increasing rates of hepatitis C infection among Indigenous Australians, which suggest that Indigenous injecting drug users (IDUs) may not be benefiting as much as they could from NSP policies and services.
In 2005 DoHA commissioned a National Needs Assessment designed to facilitate 'a more strategic approach to the expenditure of national funds' supporting Needle and Syringe Programs. One of the priority initiatives identified by that Needs Assessment was a study to examine enablers and barriers relating to Indigenous access to NSPs. The objectives of the present study were as follows:
- to consider current strategies across jurisdictions for supporting or increasing access to NSP services by Indigenous people who inject drugs
- to identify relevant enablers and barriers in diverse geographical areas (metropolitan, regional, rural/remote)
- to identify any particular types of NSP outlet or service that Indigenous IDUs are more likely to use
- to identify effective practices that could be more widely adopted as best practice models for increasing Indigenous access
- to describe characteristics of the 'drug culture' of Indigenous IDUs.
The Reference Group
State and territory representatives
Scope and limitations of the study
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Research undertakenA number of previous Australian studies have examined various aspects of drug use, BBV infection and use of services among Indigenous IDUs; the main research method relied on has been survey interviews with small samples of Indigenous IDUs. Such studies have generated valuable information, although there are major difficulties in obtaining appropriate samples of respondents and in assessing the extent to which these are representative of the Indigenous IDU population.
Given the policy-related objectives of the present research, a more wide-ranging approach was desirable. Key elements of this study included the following:
- Fieldwork visits to a range of cities and towns across Australia, involving consultation with substantial numbers of relevant individuals and organisations such as Aboriginal community controlled health services, drug and alcohol workers, sexual health workers and NSP service providers, as well as small numbers of Indigenous IDUs. The locations visited by the study team are listed in section 1.3.
These research visits were conducted by two-person teams which included an Indigenous and a non-Indigenous researcher.
- Consultation with relevant Health Department personnel in the States and Territories.
- Consultation with a range of other organisations or individuals identified as key stakeholders, including the Australian Injecting and Illicit Drug Users League (AIVL), the National Aboriginal Community Controlled Health Organisation (NACCHO) and its State/Territory affiliates.
- A review of relevant literature.
The Reference GroupDoHA invited a range of key organisations and agencies to nominate representatives to form a Reference Group which could provide advice and guidance on conduct of the study. Members of the Reference Group are listed at the front of this report.
Urbis initially provided information about the study to the Reference Group, and sought their comments and suggestions, in a teleconference organised by DoHA in May 2007. Subsequently individual members of the Reference Group provided Urbis and DoHA with further advice or information on particular issues. A second teleconference with the Reference Group took place in November 2007, providing an opportunity for Reference Group members to comment on progress reports prepared by Urbis. Members of the Reference Group also offered comments on the draft version of the final report.
State and territory representativesUrbis also received substantial expert assistance from State and Territory Health Department representatives on the COAG Multilateral Group on Needle and Syringe Programs – also listed at the beginning of this report.
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Scope and limitations of the studyThis was a qualitative research study focussing on practical policy questions around improving Indigenous client access to NSP services, and this was clearly reflected in the research methods adopted. The project was not designed to generate statistical information on Indigenous IDUs, on their use of drugs or on levels of BBV infection in this population – though the report contains references to data of this kind derived from other sources.
There is a range of different strategies that can be considered relevant to reducing the levels and impacts of BBV infection among Indigenous Australians – including, for example, more systematic screening and testing, community education initiatives, improved treatment and follow-up services, and suitable prison and post-release programs. (The National Aboriginal and Torres Strait Islander Sexual Health and Blood Borne Virus Strategy 2005-2008 accordingly reflects a range of different approaches and initiatives.) While this report makes some reference to broader issues of this kind, its focus is specifically on the harm minimisation strategy of improving access to NSP services.
Several important limitations of the study need to be noted. For example, this project involved consultation only with relatively small numbers of Indigenous drug users; further, these are not generally likely to have included people in the most marginalised or 'hidden' groups of IDUs. Since no research was undertaken in the Torres Strait, specific issues that may arise for Torres Strait Islander communities and individuals are not considered in this report1. Nor was research undertaken in Tasmania2. Although the particular towns and cities visited by the study team were chosen to reflect a broad range of geographical and social characteristics, the coverage was by definition selective. For instance, no specific information on Brisbane is included in the body of the report.
Another important limitation is that the study did not involve a specific examination of matters associated with drug injecting in prison – acknowledged by many as a significant issue in relation to the spread of hepatitis C (prison has sometimes been described as an 'incubator' of hepatitis C). More detailed and specific research is required on prison-related issues and on the ways in which these might be addressed.
It should also be noted that the study did not involve any broad program of consultation with Indigenous leaders or communities. The study team suggests that DoHA and the State and Territory Health Departments should consider ways of using the findings of this project as a basis for broader community consultations.
Needle and Syringe Programs were originally introduced in Australia to limited the spread of HIV, and this of course remains a key objective. Given the origins of this report, however, it focuses more consistently on issues relating to hepatitis C.
1 A Queensland Health worker consulted in Cairns believed that there was in fact very little drug injecting in the Torres Strait – reflecting, among other things, the small size and remoteness of these communities.
2 The original brief called for research in six jurisdictions – New South Wales, Queensland, Northern Territory, Western Australia, South Australia and Victoria. Fieldwork in the ACT was added at the suggestion of members of the Reference Group, specifically because useful links with local IDUs could be accessed through The Connection in Canberra.