Primary fixed outletsIDU feedback received about primary fixed outlets (eg in western Sydney, Darwin, Alice Springs, Canberra and Cairns) was broadly positive, with key advantages of these services being that workers were well-informed and treated clients well. In Cairns, for example, an IDU (contacted through the user group QuIHN) described 'the Dolls House' there as a good NSP because it was in a convenient location, was confidential, offered additional services such as counselling and STI testing, plus a vending machine ('If it's working'). In Alice Springs several IDUs said that NTAHC offered a good service – once clients got over their initial nervousness and uncertainty. A major limitation of primary outlets, of course, is that there are relatively few in number, and in particular that there are relatively few located outside the capital cities. For the most part primary outlets also have limited hours of availability, generally operating during standard business hours.
Enhanced servicesConsultations suggested that enhanced NSP operations which offer ancillary health services and/or 'drop-in' facilities – for example MINE in inner suburban Melbourne – may offer benefits in terms of Indigenous access. On the one hand this is because the additional support available may be valuable for IDUs who are heavily disadvantaged and have very limited resources; enhanced services also tend to create more time to establish worker-client rapport and for workers to understand the client's situation. Further, it may be easier for Indigenous communities and families to accept the value of something that provides a range of health and related services rather than an outlet that 'just hands over fits' (Darwin worker). As previously noted, there was positive client comment about the quality of service provided by the enhanced NSP at South Court Primary Care in western Sydney.
However, enhanced services are of course relatively costly to provide, and within a limited NSP budget there may be a trade-off between offering enhanced services in a particular location and providing more numerous if more basic NSP outlets. Given this tension, one possibility could be for governments to allocate some funding outside the NSP budget to enhance services in areas where there are significant numbers of Indigenous drug users. It also needs to be remembered that some clients may in fact prefer a service which simply gives them easy access to clean equipment. Workers consulted at South Court Primary Care saw 'a fine balance' between meeting IDUs' immediate needs (eg for clean fits) and offering a broader service; being too treatment-focussed could 'put people off'.
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Outreach and mobile servicesMobile or outreach teams with both male and female workers were widely seen as a very good option in terms of Indigenous IDU access. DASSA representatives in Adelaide, for example, emphasised the value of such services for particularly marginalised or hard-to-reach groups, including Indigenous IDUs. A Melbourne stakeholder similarly commented that in his experience outreach services were highly valued by Aboriginal IDUS. A mobile service provided by the WA AIDS Council in Perth reportedly reaches numbers of Indigenous clients at some locations44.
Nunkuwarrin Yunti in Adelaide has for some years operated a well regarded outreach service targeting homeless Aboriginal people in particular. The outreach service operated by REPIDU at The Block in Redfern has a large Aboriginal client group. Other examples include MINE in Melbourne which will deliver equipment requested by phone, 365 days a year, and the WASUA outreach service in Perth.
On top of the 'wish list' for some NSP workers consulted in Darwin was a mobile service which could provide HIV and HCV education, condoms and clean injecting equipment. It was said that a van providing such a service could effectively reach 'hotspots', and could also be used to provide some services in remote areas such as Maningrida.
Emergency DepartmentsHospital Emergency Departments across the country represent a key source of secondary NSP services, being particularly important because of their accessibility after hours. However, some hospitals decline to play this role (for example because of the pressure of other work, or because of reluctance to attract IDUs to the hospital). In any event, some people commented that if a country hospital has a generally negative reputation in the local Indigenous community, it is not likely to be an attractive source of injecting equipment for Indigenous IDUs. One WA observer commented that Aboriginal people 'don't like hospitals in the first place'. 'Clients hate them', said a worker in Perth. Some of the nursing staff consulted at the Emergency Department at Port Augusta Hospital said that they had 'never seen an Aboriginal client' requesting needles and syringes.
Other stakeholders consulted in Perth noted that for Emergency Departments themselves NSPs are 'not core business', and in Carnarvon it was said that they see themselves as having 'far more important things to do'; all hospitals departments are 'understaffed, under the pump'. Not all hospital staff have received training relating to provision of NSP services; needle and syringe distribution policy may not be clear, or may be applied differently by different staff members.
Many of those consulted during the study made the point that staff attitudes at hospital outlets are variable and may in some cases be quite negative. An IDU in one town, for example, described staff responsible for issuing needles and syringes at the local Emergency Department as being 'narky' about this; 'they want to make you feel like a junkie'; staff attitudes at the local NSP, he said, were 'way better'. In another town the Emergency Department was described by IDUs as 'a bit of a turnoff'; staff 'treat you like a junkie'; 'I'd rather not go there'. Hospital attitudes are 'still a major obstacle in terms of prejudices (health worker Carnarvon). An Aboriginal worker in one country town thought that Aboriginal IDUs would go to an Emergency Department only 'if they were half dead', reflecting a perception that they were likely to be badly treated both as 'blacks' and as 'junkies'. Indigenous IDUs in another town reported staff at the local hospital seeking to embarrass them by asking them to repeat their request for needles in a louder and louder voice.
Other secondary outletsAs previously noted, one advantage sometimes attributed to secondary NSP outlets is that you are not 'labelling yourself' by going there. On the other hand, it was observed that levels of staff training and the way IDUs are treated can vary substantially from service to service. Consultation suggested the value of providing NSP services through agencies which have a good general reputation within Indigenous communities, which are in accessible locations (eg by public transport) and where the service can be provided in a discreet fashion.
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PharmaciesIn a number of locations it was noted that pharmacies are playing a smaller role in the supply of clean injecting equipment than they have done in the past when the alternatives were more limited.
Numbers of those consulted during the present study (eg in Canberra, Alice Springs, Carnarvon) were of the view that pharmacies tend to be used mostly by 'middle class', employed and/or recreational drug users ('Mr Average' or Mr Next Door'), while government or community-run NSP outlets are more likely to be used by disadvantaged, marginalised or dependent IDUs. 'Functional' injectors are generally inclined to use pharmacies, said a Melbourne worker, while it tends to be low-income and long-established drug users who are happy to use NSP services – people with 'nothing left to lose'. In Mildura it was said that the NSP sees no 'white collar clients'; these IDUs were assumed to purchase equipment from a pharmacy, or possibly acquire both drugs and injecting equipment from Melbourne or Adelaide.
Most of the community pharmacy representatives who were consulted in various locations indicated that those who purchase injecting equipment from them do tend to be 'middle class' customers, and that Aboriginal people purchasing needles and syringes is not common. A Mildura pharmacy, by contrast, reported significant numbers of Aboriginal people among its customers for injecting equipment. This pharmacy, which sells injecting equipment (3-packs and 5-packs), is also the pharmacy which dispenses most of the prescriptions written at the Aboriginal Co-operative. It reported that something like 30% of its needles and syringe customers were Aboriginal. Most of the sales were made after hours, with the typical age group being late twenties/thirties. In Port Augusta and Mt Isa, also, there are pharmacies with active links with the local AMS, which sell injecting equipment and reported having some Aboriginal customers.
IDUs who were interviewed during this study tended to be generally unenthusiastic about community pharmacies as a source of injecting equipment. For an IDU interviewed in Alice Springs, for example, pharmacies were the last resort: he tried 'not to go there at all'. Service at a pharmacy was described as impersonal, and 'some of the ladies screw their face up at you'. Particularly in small towns, it was said, the pharmacy may offer little privacy to IDUs. Indigenous IDUs may face the additional barrier of being seen by staff as 'undesirables' on the basis of race as well as drug use. Because of embarrassment and lack of privacy, people who go into a pharmacy intending to buy needles may get nervous, 'buy some lollies and walk out' (Carnarvon).
Vending machinesGiven Indigenous IDU concerns with privacy and anonymity, it was widely thought that vending or dispensing machines were one useful way of improving their access to clean injecting equipment. Despite the need to have the correct change available, a number of the IDUs consulted said they would prefer to use a machine rather than go to a hospital Emergency Department; using the machine was discreet, quick, and did not require interaction with unsympathetic people. A vending machine can definitely be 'a good supplement to back up a primary NSP after hours' (Alice Springs).
On the other hand, a machine is obviously useful only if it is well maintained and regularly restocked. (One IDU in Cairns claimed that a local vending machine was 'always empty'.) NSP staff consulted in Canberra commented that ensuring that the local machines were stocked and in working order was 'the bane of our life'. In Mount Isa there was reference to the difficulty of finding the right location for a vending machine – for example one that was safe and convenient for users while not being easily observed by others.
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Aboriginal Medical ServicesCommunity controlled and government run Aboriginal medical services play a crucial role in the delivery of health services for Indigenous Australians across the country. However, their role in the provision of NSP services has been modest to date. Relatively few community controlled services, for example, have been willing to operate as secondary NSP outlets. There is a range of reasons for this, as summarised in section 3.2.3.
Both previous research and the present study also indicate that Indigenous IDUs themselves may have significant reservations about using AMSs as a source of clean injecting equipment. Some of the IDUs interviewed by the study team in various locations were quite dismissive of the possibility of obtaining services at their Aboriginal Medical Service: 'They wouldn't have a clue'; 'They're not interested; 'No one in their right mind would go to [the AMS] to ask for a fit'. It was also clear that the 'shame' of revealing oneself as a drug injector was likely to be much greater if the person you were dealing with was also Indigenous.
As explained in earlier sections of this report, IDU reservations about using Indigenous-specific services reflected concern that they would be embarrassed or compromised by being seen by other community members or relatives, that appropriate standards of confidentiality might not be observed, and that health workers would lack expertise and/or empathy. Some nursing staff or AHWs were said to see NSP services as inappropriate or distasteful; of one country AMS that is authorised as an NSP outlet it was said that 'the staff aren't amenable' to offering the service.
While AMSs were useful for many other purposes, a Western Sydney IDU did not see them as an attractive provider of NSP services: 'I don't want them looking down on me'; 'I'd feel so embarrassed, ashamed'. Another IDU commented that while he attended a men's group at the local AMS, he 'kept quiet' about his drug use. In Taree, although there is an NSP service available at the Biripi AMS, numbers of Aboriginal IDUs evidently prefer to obtain injecting equipment from the mainstream service based at the local Community Health Centre. In another location a male IDU said that although he used the AMS for his general health needs, he tried to ensure that he would not be recognised by staff as an IDU by injecting in places on the body which were not likely to be detected by health workers or doctors.
One result of Indigenous IDUs' reservation about using an Indigenous-specific outlet is that, where an AMS does provide such a service, it may be used largely by non-Indigenous clients. For example Nunkuwarrin Yunti's fixed site serves mostly non-Indigenous clients, as does the NSP outlet at Winnunga Nimmityjah Aboriginal Health Service in Canberra. Coomealla Aboriginal Health at Dareton, near Mildura, offered an NSP service a few years ago, but no longer does so. During its period of operation it reportedly placed great emphasis on attempting to ensure clients' anonymity – for example by making deliveries of injecting equipment so that people did not have to come to the health service.
Within Aboriginal medical services the attitudes and approaches of CEOs evidently vary. At Nunkuwarrin Yunti in Adelaide, for example, it was said that clear and strong leadership had been important in enabling the service to play an active role in harm minimisation for IDUs. At an AMS in another State, by contrast, the CEO was said to be unenthusiastic about providing the NSP service, choosing to 'turn a blind eye' to it.
At one AMS the point was made that the service's capacity to work effectively with any drug users was severely limited by the difficulty of employing a drug and alcohol worker. Two reasons for this were offered: a severe shortage of qualified D&A workers (especially Indigenous workers), and a lack of ongoing funding for such positions. The outcome was that the AMS lacked expertise in drug-related matters and was unlikely to be proactive in addressing them. In Port Augusta and in the Gascoyne region of Western Australia, also, it was emphasised that there was a severe shortage of drug and alcohol workers.
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Peer servicesAmong those consulted by the study team there was frequent reference to the value of peer-based services in reaching Indigenous IDUs. Essentially this meant services provided by current or former IDUs, though in some cases there was an emphasis on the peer also being Indigenous. Among the IDUs interviewed in Alice Springs, for example, there was comment on the value of health services using peer educators ('people like us') to outreach to Aboriginal youth in particular. (It was interesting that some IDUs appeared to expect NSP workers themselves to have a history of injecting; in Canberra, for example, there was a complaint about one service to the effect that 'some of them up there aren't even users'.) It appeared that, at least within an Indigenous context, the 'peer' did not necessarily have to be someone in the same age group; it was said in several locations that older people might be the most effective workers with young Indigenous IDUs45.
Some of the stakeholders consulted emphasised that, across the NSP, there is a place for both peer and non-peer services. Merely being a former user does not make you a good worker, while 'there are some fantastic NSP workers who've never been near drugs themselves' (Melbourne). It was emphasised that peer services need to be well managed and supported (Melbourne).
SAVIVE workers consulted in Adelaide made the point that it could be very difficult to recruit Indigenous peer workers (ie with experience of drug injecting) because they were reluctant to label themselves as drug users: 'You out yourself and you're out of the community'.
ChoiceWhile there is no one type of NSP service which can be described as best or most acceptable for Indigenous IDUs, the point was frequently made that access is facilitated by offering clients some options as to which service they use.
44 For an international review of the value of both mobile vans and dispensing machines in meeting needs among hard-to-reach IDUs, see Islam MM and Conigrave KM, 'Assessing the role of syringe dispensing machines and mobile van outlets in reaching hard-to-reach and high-risk groups of injecting drug users (IDUs): a review', Harm Reduction Journal 4:14, 2007. Among other things this review concludes that 'dispensing machines and mobile vans are preferred modalities for hidden and high-risk IDUs
45 The role of peer-based services is emphasised in some of the earlier Australian studies, for example Australian Federation of AIDS Organisations, Something is Going to Get Us, November 2005.