IntroductionThis report was commissioned by the Department of Health and Ageing (DoHA) in consultation with members of the COAG Multilateral Group on Needle and Syringe Programs. The purpose of the study was to examine factors that either deter or support access to Needle and Syringe Program (NSP) services among Aboriginal and Torres Strait Islander injecting drug users (IDUs). The importance of this issue reflects, among other things, the fact that rates of hepatitis C (which is closely associated with infection as a result of unsafe injecting) are disproportionately high, and apparently continuing to increase, among Indigenous Australians.
The main elements of this qualitative study were a review of the findings of previous research on relevant topics; consultation with Health Department personnel in the States and Territories; consultation with other experts and stakeholders; and fieldwork visits to 14 metropolitan, regional and country locations in seven states and Territories.
FindingsSeveral earlier studies have examined aspects of injecting drug use and blood borne virus (BBV) infection among Indigenous Australians; in general the findings of the present study were consistent with the outcomes of previous research. Key findings include the following:
- There are no comprehensive data on the numbers of Indigenous Australians who inject drugs or on the numbers of Indigenous IDUs who currently access NSP services. However the available evidence suggests that, if anything, injecting drug use may be more common in the Indigenous than in the non-Indigenous population, and that there are substantial numbers of Indigenous IDUs who do have some contact with NSP services.
- There appears to be much in common between Indigenous and non-Indigenous IDUs. Among both groups, for instance, the average age of first injecting is evidently around 18 years; in both groups female injectors represent a significant minority; and the drugs most commonly injected in various locations appear to be similar as between Indigenous and non-Indigenous IDUs.
- It is common for Indigenous IDUs to inject drugs in the company of friends, relatives or a partner. Often these companions may be Indigenous also, but there are nevertheless high levels of interaction between Indigenous and non-Indigenous IDUs.
- NSP outlets mostly see IDUs, both Indigenous and non-Indigenous, aged between about 25 and 45. Younger IDUs - including Indigenous IDUs - may be at significant risk of BBV infection as a result of inexperience, lack of knowledge and reluctance to use NSP services.
- Many of the stakeholders who contributed to this study believed that understanding of the risk of contracting HIV and hepatitis C from sharing a needle was widespread among Indigenous IDUs. Sharing of injecting equipment - with or without an effort at cleaning needles between users – was nevertheless reported as fairly common. Reasons for sharing include lack of sufficient equipment, being part of a group that acquires and uses drugs together, confusion, lack of knowledge, and sometimes a lack of concern with the consequences.Top of page
- It was generally thought that there was at present little drug injecting in remote Indigenous communities – with Cape York possibly an exception. However the situation in remote areas needs to be kept under review because there are likely to be significant dangers if circumstances change.
- Relatively few Indigenous-specific health services currently provide NSP services. The reasons for this include the 'crowded Indigenous health agenda', on which a disease such as hepatitis C does not at this stage rank very high, and the fact that the NSP's harm reduction approach is seen as running counter to the abstention philosophies which are common in Indigenous communities. By the same token, Indigenous IDUs may feel that their privacy is better protected if they do not use Indigenous-specific services.
- At present Indigenous IDUs are therefore largely dependent on mainstream services for the supply of clean needles and syringes, and in various ways they encounter barriers and enablers similar to those experienced by other IDUs. Thus, like others, they stand to benefit from improvements such as longer hours of operation of NSP outlets and increased geographical coverage, and from siting and design of outlets which afford privacy.
- As a doubly marginalised group, however, Indigenous IDUs may be especially hesitant to approach an NSP outlet, and it appears to be common for them to try to get friends or acquaintances to obtain equipment on their behalf. If Indigenous use of NSP services is to increase, IDUs need to know that they will be treated helpfully and courteously and that their circumstances will be understood. Access is thus likely to be improved by NSPs taking steps to ensure that they are, and appear to be, inclusive and 'Indigenous-friendly'.
- Because Indigenous communities, both urban and rural, are often small and close-knit, Indigenous IDUs are likely to be particularly concerned about privacy and anonymity. Indigenous IDUs who live in country areas, however, are generally likely to have limited access to services and little choice as to where they seek injecting equipment.
- There is no one type of NSP outlet which best meets the needs of Indigenous clients. However the study indicates that Indigenous IDUs are sometimes reluctant to use pharmacy and hospital outlets, and that they value mobile and outreach services where these are available. Vending machines (which are few in number except in New South Wales) facilitate access, both in city and country areas, because of their availability at any hour and because they avoid the need for IDUs to interact with a possibly unsympathetic worker.
- Partly because there has in the past been relatively little advocacy from the Indigenous health sector on behalf of IDUs, mainstream outlets may find it difficult to know how well or badly they are meeting the needs of Indigenous clients, and how they could reduce barriers for those whom they are not effectively reaching. Therefore it is to be welcomed that NACCHO and its affiliates have in recent years been more actively engaged in this area.
- This study did not specifically examine issues relating to drug injecting in prison or ways of reducing the harms associated with this. However, particularly given the high rates of incarceration among Indigenous Australians, both male and female, this is an important matter that demands attention.
- The suggestions for improving access which emerged from this study were of several different kinds. Some focussed on fostering effective links or partnerships between NSP planners and providers and the community controlled health sector, so as to ensure that provision of NSP services is more consistently informed by Indigenous perspectives and insights. Some related to NSP improvements or developments of a general kind, while others aimed to address barriers perceived as affecting Indigenous IDUs in particular. Some related to initiatives within Indigenous health services or Indigenous communities.
- In consultation with communities, the Australian, State and Territory Governments should give high priority to identifying effective ways of reducing rates of HCV infection among young Indigenous Australians, and implement policies, projects and practices designed to achieve this.
- The Australian, State and Territory Health Departments should promote and support active cooperation between the Indigenous health sector and those responsible for planning and delivering NSP services, and in particular ongoing involvement by NACCHO and its affiliates in relevant research and policy development
- At this stage improving access to mainstream NSP services represents the most effective way of facilitating access for Indigenous IDUs. This needs to be pursued both through general service improvements (eg continuing improvement in the number and location of NSP outlets, longer hours of operation including evenings and weekends, wider use of vending machines, offering IDUs some choice of services wherever possible, flexibility in amount and types of equipment offered), and also through initiatives designed to address the needs of Indigenous IDUs in particular. Policies and practices specifically addressing Indigenous access should include:
- training in cultural competence and safety for mainstream NSP workers
- consultation by NSP planners and service providers with relevant Indigenous organisations, Indigenous communities and Indigenous IDUs themselves
- employment of Indigenous staff where this is considered appropriate
- expansion and improvement of NSP services in regional and rural areas in particular, including ongoing training for people providing services through secondary outlets and pharmacies
- increased use of mobile and outreach services
- use of posters, sign, brochures and the like which indicate that service providers are Indigenous-aware and Indigenous-friendly
- more secure funding for innovations, projects and pilot programs designed to address Indigenous needs.
- training in cultural competence and safety for mainstream NSP workers
- Where Indigenous organisations are willing to deliver NSP services there should be continuing support and encouragement for them to do so; the possibility of offering some funding assistance for this purpose should be considered. Indigenous health services which do not wish to offer NSP services directly should be encouraged (for example through assistance with staff training) to play an ancillary role through liaison with NSP outlets in their area, providing information to clients and referring people to NSP services where appropriate.
- DoHA and the State and Territory Health Departments should give high priority to research and policy initiatives designed to address the issue of unsafe drug injecting in adult and juvenile prisons.
- DoHA and the State and Territory Health Departments should make use of this report in undertaking consultation and information-sharing with Indigenous communities around the issues of blood-borne viruses, injecting drug use, and ways of reducing hepatitis C infection among Indigenous Australians.