Report to/Rapport au :

Community and Protective Services Committee

Comité des services communautaires et de protection

and Council/et au Conseil

12 June 2008 / le 12 juin 2008

Submitted by/Soumis par :

Steve Kanellakos, Deputy City Manager/Directeur municipal adjoint,

Community and Protective Services/Services communautaires et de protection

Contact Person/Personne ressource :

Dr. Isra Levy, Acting Médical Officer of Health / médecin chef en santé publique intérimaire

Ottawa Public Heath / Santé publique Ottawa

(613) 580-2424 x 23681, isra.levy@ottawa.ca

City Wide / À l’échelle de la ville

Ref N°: ACS2008-CPS-OPH-0008

SUBJECT:	NEEDLE EXCHAnge program - Update
OBJET :	LE POINT SUR LE PROGRAMME D’ÉCHANGE D’AIGUILLES

REPORT RECOMMENDATIONS

That the Community and Protective Services Committee recommend that Council:

1. Receive the information respecting the City’s Needle Exchange Program that was requested at the 3 April 2008 meeting of the Community and Protective Services Committee;

2. Approve the enhancements to the City’s Needle Pick-up Program including a $100,000 operating budget pressure, and a one-time cost of up to $50,000 to complete a safe syringe study, to be included in the 2009 budget, as detailed in this report; and

3. Direct the Medical Officer of Health to report back in the fall of 2009 with a progress report on the enhanced Needle Pick-up Program.

RECOMMANDATIONS DU RAPPORT

Que le Comité des services communautaires et de protection recommande que le Conseil :

1. reçoive l’information sur le Programme d’échange d’aiguilles de la Ville qui a été demandée au cours de la réunion du 3 avril 2008 du Comité des services communautaires et de protection;

2. approuve les améliorations au Programme d’échange d’aiguilles de la Ville, y compris une demande budgétaire de 100 000 $ et un coût ponctuel d’un montant pouvant atteindre 50 000 $ pour mener une étude sur les seringues sécuritaires, qui devront être prises en compte dans le budget 2009 comme l’indique le présent rapport;

3. demande au médecin chef en santé publique de présenter ses conclusions à l’automne 2009 dans un rapport d’étape sur le Programme d’échange d’aiguilles amélioré.

EXECUTIVE SUMMARY

At its meeting of April 3, 2008, the Community and Protective Services Committee (CPSC) directed the then Medical Officer of Health to respond to the Committee’s six key questions with a comprehensive report that provided details on:

1) The history of the City’s Needle Exchange Program (NEP);

2) Medical evidence that current practices meet Ministry’s objectives;

3) Evidence that the current needs-based exchange policy is more effective than a one-for-one needle exchange;

4) Risks associated with a change to a one-for-one exchange model;

5) Comparisons with other large Canadian municipalities; and

6) A financial analysis of changing to a one-for-one exchange model.

The City of Ottawa’s Needle Exchange Program (NEP) is a mandatory harm reduction program that has been in place since 1991 to prevent the spread of communicable diseases such as HIV, Hepatitis B and Hepatitis C.

Medical studies, outlined in this report, have confirmed that HIV incidence has declined in cities that have NEPs and increased in cities that have restricted programs or none at all. HIV risk was three times greater among those individuals that had limited coverage (access to syringes) because of restrictive NEP than those who had adequate coverage. Based on modeled estimates, the City of Ottawa could expect a 33% increase in new infections (i.e., 9 to 21 additional infections per year) if the City were to revert to a one-for-one exchange policy.

Of the 36 Ontario public health jurisdictions currently delivering NEPs none has restrictive one‑for-one exchange programs. HIV infections in Ottawa increased steadily from 145 infections in 1991 (at the inception of the Site program) to 200 infections in 1994 and declined during the period 1996 to 2002 to 60 infections per year (as The Site Program moved away from a restrictive exchange policy).

Individuals with cocaine addictions can require 20-30 or more injections per day. One-for-one exchange policies would require users to retain and carry needles to return them to the Site Program rather than use the needle drop box program for safe disposal of needles or use them less frequently. This would increase the amount of time individuals carry around used needles and therefore the amount of time the needles would be in the community. Thus, the net effect would be an increased health risk from accidental needle stick injuries for residents and service providers including police, paramedics and fire.

Given the medical evidence respecting the efficacy of a non-restrictive needle exchange program, as well as the adverse health consequences and the cost to city and to the health care system overall ($150,000 to $600,000 for each new HIV case), the Acting Medical Officer of Health does not recommend a change to the City’s current needle exchange policy.

At the same time, Ottawa Public Health (OPH) recognizes and acknowledges legitimate community concerns respecting the increasing number of needles discarded by injection drug users on downtown streets and residential neighborhoods. Although OPH and its partners have worked diligently within existing resources to respond to the increasing number of needles on the street (i.e., the number of needles picked up by the Needle Hunter program has increased nearly three-fold in the last three years) it is clear that additional investments and focus on needle pick‑up is required to respond to the safety and quality of life concerns raised by residents in affected neighbourhoods.

Council, at its meeting of May 14, 2008, acknowledged these community concerns by approving a one-time $100,000 investment in Needle Pick-up program enhancements. This report provides details of the spending plan for the $100,000 and outlines additional structural change that OPH proposes to implement the enhancements to the Needle Pick-up program.

OPH proposes to return to Council in one year with a progress report on of the Needle Pick-up program.

Discarded needles are a safety hazard and have an impact on the quality of life for residents in affected areas of the city. The City of Ottawa must continue to address the issue with an enhanced, comprehensive response.

RÉSUMÉ

Au cours de la réunion du 3 avril, le Comité des services communautaires et de protection a prié le médecin chef en santé publique de répondre aux six questions clés du Comité dans un rapport complet comprenant de l’information détaillée sur :

1) l'historique du Programme d’échange d’aiguilles de la Ville d’Ottawa;

2) les preuves médicales indiquant que les pratiques actuelles sont conformes aux objectifs du Ministère;

3) les preuves qui démontrent que la politique d’échange axée sur les besoins est plus efficace que l’échange d’une aiguille neuve contre une aiguille usagée;

4) les risques associés à l’adoption d’un modèle d’échange « aiguille neuve contre aiguille usagée »;

5) les comparaisons avec d’autres grandes municipalités canadiennes;

6) une analyse financière de l’adoption d’un modèle d’échange « aiguille neuve contre aiguille usagée ».

Le Programme d’échange d’aiguilles de la Ville d’Ottawa est un programme obligatoire de réduction des méfaits mis en œuvre en 1991 pour prévenir la propagation des maladies transmissibles telles que le VIH, l’hépatite B et l’hépatite C.

Des études médicales, décrites dans le présent rapport, ont confirmé que la prévalence du VIH a diminué dans les villes qui disposent d’un programme d’échange d’aiguilles, alors qu’elle a augmenté dans les villes qui ont mis en place un programme restreint ou qui n’en offrent aucun.

Le risque d’infection par le VIH était trois fois plus grand parmi les personnes qui avaient accès à une couverture limitée (accès aux seringues) en raison des programmes d’échange d’aiguilles restrictifs que parmi celles qui avaient accès à une couverture appropriée. Selon les estimations modélisées, la Ville d’Ottawa pourrait s’attendre à une augmentation de 33 % du nombre de nouvelles infections (c.-à-d. de 9 à 21 nouvelles infections par année) si la Ville retournait à la politique d’échange « aiguille neuve contre aiguille usagée 

Sur les 36 autorités de santé publique de l’Ontario offrant actuellement des programmes d’échange d’aiguilles, aucune ne dispose de programmes d’échange « aiguille neuve contre aiguille usagée ». Les cas d’infection au VIH à Ottawa ont augmenté de façon constante, passant de 145 infections en 1991 (année de mise en œuvre du Programme SITE) à 200 infections en 1994, pour ensuite diminuer à 60 infections par année entre 1996 et 2002 (à mesure que le Programme SITE abandonnait la politique de distribution restrictive).

Les personnes ayant une dépendance à la cocaïne peuvent avoir besoin de 20 à 30 injections par jour. Les politiques d’échange « aiguille neuve contre aiguille usagée » forceraient les utilisateurs de drogues par injection à conserver et à transporter leurs aiguilles pour les retourner au Programme SITE au lieu de les mettre au rebut de façon sécuritaire dans le cadre du programme de boîte-dépôt pour aiguilles usagées, ou à utiliser moins fréquemment ce système. Cette politique aurait pour effet d’accroître le temps pendant lequel des personnes transportent des aiguilles souillées et, par conséquent, le temps pendant lequel les aiguilles restent dans la collectivité. Il y aurait donc un risque accru de blessure par piqûre d’aiguille pour les résidents et les fournisseurs de services comme les policiers, les paramédics et les pompiers.

Compte tenu des preuves médicales quant à l’efficacité des programmes d’échange d’aiguilles sans restriction ainsi que du coût global pour la ville et le système de santé (entre 150 000 $ et 600 000 $ pour chaque nouveau cas d’infection au VIH), le médecin chef en santé publique intérimaire ne recommande aucun changement à la politique actuelle d’échange d’aiguilles de la Ville.

Parallèlement, Santé publique Ottawa (SPO) tient compte des préoccupations légitimes soulevées dans la collectivité quant au nombre croissant d’aiguilles jetées dans les rues du centre-ville et les quartiers résidentiels par les utilisateurs de drogues par injection. Bien que SPO et ses partenaires aient travaillé très fort avec les ressources actuelles pour tenter de résoudre le problème du nombre croissant d’aiguilles dans les rues (le nombre d’aiguilles ramassées dans le cadre du Programme de ramassage des aiguilles a presque triplé au cours des trois dernières années), il est clair que, pour répondre aux préoccupations relatives à la santé et à la qualité de vie des résidents dans les quartiers touchés, des investissements supplémentaires sont nécessaires. Il faudra également mettre l’accent sur le ramassage des aiguilles.

Au cours de la réunion du 14 mai, le Conseil a répondu aux préoccupations de la collectivité en approuvant un investissement de 100 000 $ visant à améliorer le Programme de ramassage des aiguilles. Le rapport fournit de l’information détaillée sur le calendrier des dépenses de l’investissement de 100 000 $ ainsi que les autres changements structuraux que SPO propose d’apporter en vue d’améliorer le Programme de ramassage des aiguilles.

SPO propose de présenter ses conclusions dans un rapport d’étape sur le Programme de ramassage des aiguilles.

Les aiguilles jetées présentent un danger pour la sécurité et ont une incidence sur la qualité de vie des résidents des quartiers touchés de la ville. La Ville d’Ottawa doit poursuivre ses efforts pour régler ce problème en proposant une solution améliorée et complète.

BACKGROUND

In February 2008, Council Member Inquiry 02-08 sought legal opinion as to the parameters under which the City of Ottawa, as the Board of Health, operates the NEP, including the degree of flexibility the Board has with respect to implementing this mandatory program. The City Solicitor advised the following:

“The City’s Board of Health’s role is full and complete responsibility for the operation, delivery and all aspects of the needle exchange program, including legal liability. However, before the Board of Health proposes changes or sets in place any requirements of a health program/health service that is provided by the City, it is recommended that the change be supported by evidence indicating that the change will enhance or improve the program or service. Failure to provide an “evidence-based” program may lead to a claim that the Board of Health failed to act in good faith in the execution of its duties, thereby exposing the Board of Health, and possibly its individual members, to claims for damages.”

At its meeting of April 3, 2008, Community and Protective Services Committee (CPSC) directed staff to report back on a number of questions pertaining to the City’s Needle Exchange Program (NEP) (full motion attached as Document 1). Staff was requested to provide:

1. The history of the City’s Needle Exchange Program (NEP);

2. Medical evidence that current practices meet Ministry’s objectives;

3. Evidence that the current needs-based exchange policy is more effective than a one-for-one needle exchange;

4. Risks associated with a change to a one-for-one exchange model;

5. Comparisons with other large Canadian municipalities and

6. A financial analysis of changing to a one-for-one exchange model.

Council also directed staff to ensure statistics concerning the numbers of needles distributed and retrieved annually are made available on the City’s website by the fall of 2008. Council further directed staff to identify the costs expended to date this year on responding to requests on the NEP and preparing the current report.

This report provides information respecting the six information requests contained in the April 3 motion responds to the two additional directions cited above; and proposes enhancements to the City’s Needle Pick-up Program.

DISCUSSION

Recommendation 1 – Requested Information Respecting Needle Exchange Programs

To answer these questions, OPH undertook an extensive literature review of studies appearing in respected scientific databases. One hundred and thirty-seven (137) full studies were reviewed (the full bibliography is attached as Document 2). (See Document X for list of the studies reviewed) OPH staff looked for a range of evidence to get as complete a picture as possible of the benefits and risks of different NEP practices. Harm reduction was considered on two levels: to the individual injection drug user and to the community at large.

1. History of the City’s NEP, Reporting, and Evaluation

Purpose of Program

The City of Ottawa’s needle exchange program is called The Site. This provincially mandated harm reduction program has been in operation in Ottawa since 1991. The availability of the NEP has been deemed a necessary public health measure to prevent the spread of communicable diseases, primarily HIV, Hepatitis B and Hepatitis C, and to minimize the risks associated with substance use in society. The Site Program provides access to sterile needles and other injection equipment for injection drug users, health education to promote safety and minimize risks associated with substance use, and referral to primary health services, addictions treatment services or social service agencies to individuals whom the professional staff assess are in need or have the readiness to access services if available.

Exchange Policy

The program originally utilized a one-for-one needle exchange policy. In 1998, the policy was changed to the current non-restrictive policy in response to high rates of HIV infection in injection drug users in Ottawa. This policy change was in keeping with the trends seen across Ontario, Canada and across the world to less restrictive NEPs.

The current City policy states that clients are not refused needles/syringes on the basis of having none to return. Based on the Ontario Needle Exchange Programs: Best Practices Recommendations, 2006, each client is asked: how many needles do you need to keep you safe?

Reporting

The Site Program provides reports annually on service utilisation statistics (e.g. the number of syringes provided) and key accomplishments of the program to the Ministry of Health and Long- Term Care. Reports have also been prepared and submitted to Committee and Council since the NEP was first proposed in 1989 (A History of Reports is attached as Document 3).

Evaluation

OPH implements operates a cyclical program evaluation and annual planning process, including a review and analysis of epidemiological data; service utilization statistics; quality assurance surveys; and key informant feedback, best practices literature and research. These activities assist in formulating action plans for the following year.

The Site Program is actively engaged in research initiatives for the purposes of program evaluations. OPH benefits from a collaborative research partnership with the Canadian Institute of Health Research, the Public Health Agency of Canada and the University of Ottawa to implement the national I-Track Study, which examines HIV prevalence and behaviours that increase HIV transmission among men and women who inject drugs.

2. Medical Evidence that Demonstrates Current Best Practices Meet the Ministry’s Objectives

Ministry Objectives

In the late 1980’s, the Ontario Ministry of Health, under the Health Protection and Promotion Act[1], mandated that boards of health ensure access to sterile injection equipment due to the growing rate of HIV and Hepatitis B and C infection among injection drug users.

The Ministry’s goal was to prevent the transmission of HIV, Hepatitis B, C and other blood‑borne infections, as well as other associated diseases in communities where drug use was recognized as a problem.

The Ministry’s objective was to require boards of health to provide needle and syringe exchange programs. These programs were to also include counselling, education and referral to primary health services and addiction/treatment services.

Medical Evidence

In order to identify medical evidence, OPH conducted searches in established research databases including CINHAL, Cochrane Database of Systematic Reviews, CORK, EMBASE, Medline, and PsycINFO for articles published from January 2000 – 2008.

Web Sites that were also searched for content related to the this topic included:

• The Canadian Centre on Substance Abuse (CCSA)

· Canadian Society for Addiction Medicine (CSAM)

· Canadian HIV/AIDS Legal Network

· Centres for Disease Control and Prevention (CDC)

· European Monitoring Centre for Drugs and Drug Addiction (AMCDDA)

· Forward Thinking on Drugs

· Health Canada

· Public Health Agency of Canada (PHAC)

· World Health Organization (WHO)

The searches generated numerous abstracts that were subsequently scanned for relevancy as to include in a list of search results. Six hundred and thirty-four (634) articles were found during the database search. Abstracts were then reviewed for the purposes of determining whether they were pertinent to address the questions specific to the report to Council. One hundred and thirty seven (137) studies were reviewed including several that were based on a meta-analysis of existing literature and which specifically related to Council’s questions on effectiveness, one-for-one exchange and community safety.

A 2005 study by A. Wodak and A. Cooney[2] presents one of the most comprehensive reviews of studies on the effectiveness of NEPs. The authors reviewed one hundred and twenty (120) studies from 1989 to 2002, examining HIV seroconversion, HIV seroprevalence, HIV risk behaviours and NEP effectiveness. The study used the Bradford Hill criteria, including strength of association; replication of findings; temporal sequence; biological plausibility; coherence of evidence; and reasoning by analogy; to assess the scientific credibility of studies for inclusion in the review.

For example, the authors referenced an article published in Health Outcomes International (2002)[3] that reported that in 103 cities in 24 different countries HIV prevalence declined by a mean annual 18.6% for 36 cities with NEP, compared to an 8.1% increase in 67 cities without NEP.

Another example cited by the authors is a 1997 study by Hurley et al[4] which found that, of 52 cities without NEP and 29 cities with NEP in Asia, Europe, North America, South America and South Pacific, on average HIV seroprevalence increased by 5.9% per year in the 52 cities without NEP and decreased by 5.8% per year in the 29 cities with NEP.

In another study Wodak and Cooney[5] looked at 7 separate systematic reviews of NEPs conducted by or on behalf of U.S. government agencies from 1991 – 2001. All 7 studies concluded that NEPs prevent HIV transmission.

Among Wodak and Cooney’s conclusions, based on this comprehensive review, were the following:

1. There is compelling evidence that increasing the availability, accessibility, and both the awareness of the imperative to avoid HIV and utilization of sterile injecting equipment by injection drug users reduces HIV infection substantially;

2. There is evidence that sterile injecting equipment reduces other infections such as hepatitis and several bacterial infections (of the heart valves for example);

3. There is no convincing evidence of any major unintended negative consequences; and

4. Needle Exchange Programs are cost-effective.

Two early studies (Montreal[6] and Vancouver[7]) are cited by critics of NEPs as showing that implementation of a needle and syringe exchange program caused an increase in new HIV infections in participants who used them. Vlahov 1998[8] references a case-controlled study in Montreal, which found of 974 HIV-negative subjects, followed for an average of 22 months, 89 subjects seroconverted. Consistent use of a needle exchange program compared with non-use was associated with an odds ratio for HIV seroconversion of 10.5However, this study has been criticized because the NEP selected higher risk injection drug users, and this is argued to be the more likely explanation for the findings.

Moreover, the senior author of the Vancouver study, Dr. Martin T. Schechter of the University of British Columbia, has since pointed out that more recently the incidence of HIV infections has decreased in Vancouver. He has further explained in detail, in public testimony before the Public Safety and Neighbourhood Services Committee of the San Diego City Council in September 2000, that in his view, the data from his studies had been misrepresented.

3. Evidence that the Current Need-Based Model Is More Effective Than A One-For-One Exchange

Decline of Disease

A 2005 study by Des Jarlais et al[9] indicates that adequate “coverage” (level of syringe availability) matters when it comes to the effectiveness of NEPs. The study shows that the period of 1990-2001 included a very large expansion of syringe exchange in New York City, from 250,000 to 3 million syringes exchanged. Over this same period, HIV prevalence declined from 54% to 13%. Hepatitis C virus prevalence declined from 80% to 59% among individuals without HIV, and from 90% to 63% overall.

Bluthenthal et al 2007[10], in a study of 24 needle exchange programs and their injection drug using clients in California, found that NEPs that provide less restrictive dispensation policies have more clients with adequate syringe availability (needed quantities). Bluthenthal 2007[11], based on the findings from the study of 24 NEPs and their injection drug using clients, also found that needed quantities (availability of syringes) is associated with lower odds of HIV risk.

As part of the Ontario I-Track study referenced above, Dr. Robert Remis, a University of Toronto professor who heads up the Ontario HIV Epidemiologic Monitoring Unit, modelled the incidence of HIV among injection drug users locally from 1977-2004. HIV infections in Ottawa increased steadily from 145 infections in 1991 (at the inception of The Site Program) to 200 infections in 1994 and declined during the period 1996 to 2002 to 60 infections per year (as The Site Program moved away from a restrictive exchange policy). Dr. Robert Remis recently noted that in Ottawa the rate of HIV infection is that one of every 1 per 100 person years100 injection drug users becomes infected annually in Ottawa, which, although declining in relative terms, is 4 to 4.5 times higher than anywhere else in the provinces.[12]

Access to Addiction Treatment

An additional positive outcome of NEP has been the increased access to addictions treatment and health services by injection drug users. Wodak and Cooney, based on the comprehensive review referenced above, concluded that there is reasonable evidence that Needle Exchange Programs can increase recruitment into drug user treatment.

Latkin 2006[13] studied 440 drug injectors with disadvantaged backgrounds in Baltimore, Maryland who reported injecting in the prior 6 months but were not currently in treatment. Follow-up interviews were conducted. The study found that entering treatment was associated with previous NEP utilization.

Latkin also cites Strathdee et al 1999[14] who found that utilizing NEP services was also associated with entry into a detoxification program for HIV seropositive and HIV negative drug users in Baltimore. She also cites Shah and colleagues 2000[15] that found that, among HIV negative injection drug users, utilizing the Baltimore NEP was associated with enrolling in a methadone treatment program, compared to injectors who did not use NEPs.

In a 2000 study by Hagan et al[16] among heroin injectors in Seattle, compared to those who had never used a NEP, new NEP users were five times more likely to enter methadone treatment and were 60% more likely to remain in methadone treatment over the 1-year study period.

Ottawa Public Health did not find any studies indicating that NEP users were less likely to enter or remain in treatment programs.

In Ottawa, there are an estimated 3,000 injection drug users. In 2007, The Site served an estimated 800-1000 individuals and undertook specific counseling related to treatment readiness and discussion about service options in Ottawa with 357 individuals. Thirty-five (35) specific referrals were made to treatment programs.

Number of Injection Drug Users

Wodak and Cooney² looked at 7 separate reviews of NEPs conducted by or on behalf of U.S. government agencies from 1991 – 2001. All 7 studies concluded that NEPs are not associated with an increase in the number of injection drug users.

Perception Among Youth

There has been little research done in this area. However, the City of San Diego’s Final Report of the Clean Syringe Exchange Program Task Force 2001[17] cites a survey by John Hopkins University researchers of high school students from four Baltimore City high schools conducted to determine what factors influenced the students’ attitudes about illicit drug use. Among the 1,110 students who responded to the survey, nearly half of the students (46%) viewed seeing drug users at clean syringe exchange sites as a deterrent to drug use and almost as many (43%) viewed seeing drug users at a clean syringe exchange site as having no impact. The Task Force concludes that these data refute the claimargue against the intuitive perception that needle and syringe exchange programs send the wrong message to youth.

Level of Discarded Needles

Fuller 2002[18] evaluated the New York State Expanded Syringe Access Demonstration Program (ESADP) including comparing the number of discarded needle and syringes on the street pre- and post- ESADP. Needle/syringe counts were conducted by trained survey teams of counters and recorders on 27 systematically sampled city blocks in Harlem, New York. The study reports that mean ratios of needles/syringes to background trash have not increased in Harlem since ESADP began and concludes that no evidence of harmful effects (discarded needles/syringes) resulting from ESADP was observed.

Vlahov 1998⁸ states: “Another issue is whether or not needle exchanges will result in more contaminated syringes found on the street. If a needle exchange is designed as one-for-one the answer is no.” He referenced a Baltimore systematic street survey that showed no increase in discarded needles following the opening of the NEP with a one-for-one policy. However, he did not specifically address non-restrictive NEPs. Contacted at John Hopkins University by an OPH researcher, Professor Vlahov stated that he has since broadened his conclusions to include non‑restrictive programs as not increasing the number of needles on the street based on the work of Fuller (referenced above).

Bluthenthal 2007¹⁰, referenced above, in his study of 24 NEPs in California found that safety syringes (e.g. retractable needles) disposal was associated with high syringe “coverage” (level of availability). He concludes that syringe availability is strongly associated with safer injection behaviours without impacting syringe disposal among NEP clients.

4. Evidence of any Adverse Effects and Areas of Risk Associated with a Change to a Strict One-For - One Exchange

Two studies provide evidence that one-for-one programs are less effective than non-restrictive programs in reducing the spread of communicable diseases.

Bluthenthal 2007¹¹, referenced above, found that HIV risk was three times greater among those individuals that had limited coverage (access to syringes) because of restrictive NEP than those who had adequate coverage.

Kral 2004[19] classified 23 NEPs in California in 2001 according to whether the program provided a strict one-for-one exchange program, gave a few extra syringes above one-for-one or provided syringes based on need rather than on the number of syringes turned in by clients. Kral found that among people who accessed need-based NEP, 37% reported re-use of a syringe versus 63% of those who accessed more restrictive programs. Re-using needles is a known risk factor for the spread of communicable diseases.

An individual addicted to cocaine can require 20-30 or more injections per day. One-for-one exchange policies would require users to retain and carry very large numbers of needles to return them to The Site Program rather than use the black boxesneedle drop boxes. As injection drug users would need to save needles for exchange, the City’s black boxesneedle drop boxes would be poorly utilized. This will increase the time that used needles are carried around and the amount of time the needle would be in the community. Thus, the net effect would be increased health risks from accidental needle stick injuries for residents and service providers including police, paramedics and fire.

5. Comparisons of the Harm Reduction Practices of other Large Canadian Municipalities

Thirty-six (36) out of 36 municipalities delivering NEPs in Ontario have need-based exchange policies including the City of Ottawa. No Ontario public health jurisdiction operates a one‑for‑one NEP. Most large Canadian cities operate distributive programs under need-based policies, including Halifax, Winnipeg, Montreal and Vancouver. However, it should be noted that Regina operates a one-for-one program. Non-restrictive needle exchange programs are accepted internationally and nationally as the best practice for NEPs by such organizations as World Health Organization (WHO), Canadian Medical Association, and the Ontario Needle Exchange Network.

6. An Analysis of the Financial Implications of Changing to a One-for-one Exchange Program

Cost for the program

The current budget for The Site Program is $380,000 cost shared 75/25 ($95,000 municipal dollars) with an additional allocation of $156,000 (100% provincial).

In order to implement a one-for-one needle exchange policy, OPH will require additional staff and infrastructure to accommodate service encounters beyond the current 27,000. This would require additional dedicated vans and outreach personnel in Vanier, Lowertown, Centretown and elsewhere in the city. The costs are estimated as follows:

• Up to 3 additional outreach vans, purchase and fit-up costs and along with operational costs- $200,000[i]
• Up to 6 new FTEs (salary and benefits @$70,000)– $540,000
• 1 on-call supervisor/ program manager- $100,000

This could increase the current budget by an additional $840,000; the cost share arrangement for this additional funding with the province would need to be determined.

Cost to the health care system

Cost to health care system has been calculated by focusing on treatment costs for HIV. It has been estimated that one case of HIV costs the system approximately $150,000 to $600,000. Based on Des Jarlais⁹ and Bluthenthal¹⁰ and the Ottawa experience (factoring modelled incidence and case reports of HIV infections to OPH) the city could expect an approximate 33% increase in new infections each year (i.e., ranging from 9 to 21 additional people infected due to a change to a one-for-one policy). This would result in a conservative estimated increased cost ($150,000 per individual) to the health care system of $1.35 to $3.15 million should treatment be sought and received.

Recommendation 2 - Needle Pick-Up Program Enhancements

Discarded needles are a safety hazard and have an impact on the quality of life for residents in affected areas of the city. The City of Ottawa must continue to address the issue with an enhanced, comprehensive response.

Reducing Community Risk

The City’s Needle Exchange Program operates on the principle of recovering all needles that are provided to clients. Needle drop boxes are available at 24 sites in the community for safe disposal of used syringes. A list of the location of needle drop boxes can be found at:

http://ottawa.ca/city_services/recycling_garbage/special_items/needles_en.html#drop, and at:

http://ottawa.ca/city_services/recycling_garbage/special_items/needles_fr.html.

The exchange rate is obtained calculated by direct counts of syringes distributed along with estimates of syringes returned, including randomly weighing black boxneedle drop box containers. Black boxes are made available in the community for safe disposal of used syringes.

Injection drug users obtain needles from a range of sources. In 1998, the City’s Needle Hunter Program was established to supplement the recovery policy and reduce harm to the community at large by picking up discarded needles. In 2001, an integrated approach across City departments was developed to harmonize the response to discarded needles found on public and private property.

The Changing Environment of Drug Use

Ottawa is facing the challenge of a changing environment of drug use. Clearly, there has been a marked increase in the number of needles on the street over the last two years. For example, in 2005, the Needle Hunter Program picked up 714 needles, in 2006, 1,523 needles were picked up, and in 2007, 2,029 needles were picked up.

The increase in needles on the street results in part from:

• The influx of cocaine to the City of Ottawa—cocaine has become the drug of choice among injection drug users locally;
• The introduction of the practice of injecting cocaine intravenously to achieve a greater “high” – this has become the methodology of choice for cocaine users; and
• Cocaine use can require 20-30 or more injections per day and hence, increasing health and safety risks.

The presence of discarded needles on the streets is a legitimate concern for residents in affected areas of the city as it is both a quality of life issue and a safety issue for them. Residents in affected neighbourhoods are not satisfied with the current situation and have voiced concerns have been vocal in bringing this issue to the attention of OPH, City Councillors and the media. City Councillors and staff agree the issue must be addressed and are responding to fill the gap.

Discarded needles

OPH has, since the beginning of the needle exchange in 1991, implemented measures to respond to public concerns of discarded needles and public safety issues, including the installation of needle drop boxes in areas experiencing significant numbers of discarded needles; a by-law prohibiting the disposal of needles as household waste; the initiation of a Needle Hunter Program (Causeway Work Centre) in 1998; creation of a central data collection system to accurately track the number of discarded needles reported; and, the distribution and web access of public education materials on safe disposal procedures.

The above measures now form key parts of the City’s integrated response system to discarded needles, which was introduced in 2001. This system was coordinated through the City’s Call Centre, now 311, to provide residents a central point of access to address their concerns.

The following is a breakdown of the total number of discarded needles reported to the City each year.

Year	2000	2001	2002	2003	2004	2005	2006	2007
Total	813	497	644	562	809	714	1,523	2,029

It would appear that OPH’s objective numbers are mirroring the community’s subjective experience. In addition to the changing environment of drug use, other possible explanations include: the extension of the Needle Hunter contract for an additional month in 2006 due to mild weather and large numbers of needles clustered in a “single find” reported. Increased community awareness and engagement together with the assistance of individual community members in locating and picking-up discarded needles led to increase needle recovery.

The Needle Hunter Program is responsible for 70-90% of the total number of discarded needles collected by the City’s response system. The remainder is collected by Surface Operations, By‑law officers, Public Health Inspectors and Site Program staff. In 2006, the Needle Hunter Program collected 1,381 of the 1,526 discarded needles reported. This represents less than 0.5% of the needles distributed by the needle exchange program. The vast bulk of needles collected are through the needle drop box program and the pharmacy based “Take it Back” program described below.

Of note, one of the best solutions for removing reducing discarded needles from in the community is the increased instalment of needle drop boxes. They are available around the clock 24/7 and if placed in the right locations will allow for safely disposale of used needles with minimum effort. It has been observed that clients are increasingly using the needle drop box program to dispose of their used needles.

A recent study conducted by the Site Program Departmental Consultative Group indicated that 110-150% of syringes distributed by the Needle Exchange program are recovered through the City’s integrated response system. Legitimate purchases from pharmacies and other sources represent a significant portion of the needles “on the street.” Thus, another initiative that has been created is the Take It Back Pharmacies’ program to provide additional means for safely disposing of used needles and syringes. Currently 78 local pharmacies are participating in this initiative across the City and a complete list can be found on the City of Ottawa’s website at

http://app01.ottawa.ca/takeitback/BusinessList.do?prod_id=35&lang=en or at

http://app01.ottawa.ca/takeitback/BusinessList.do?prod_id=35&lang=fr .

OPH is working with community members and Causeway Work Centrethe Needle Hunter program contractor staff to explore strategies to address the number of discarded needles in Ward 12. These include: completing site visits with community members; the doubling of the number of daily sweeps; improving the City’s internal communication and responsiveness; and, community education sessions on safe disposal of needles, delivered in partnership with the AIDS Committee of Ottawa.

The current annualUntil May 14, 2008, the budget available for the Needle Hunter program is was $50,000, which provides 1,470 hours of ‘needle hunter’ work. These funds cover the cost of the crews and the ongoing support services that are provided by the contractor. As requested by Council, a Request For Proposal is currently being sought to find an optimal contractorensure the optimal service provider undertakes the next stage of this work.

Evaluation ToolsMeasuring Progress

In order to allow for the program to be evaluated monitored and provide timely available information to the public, OPH has:

• Created a central data collection system to accurately track the number of discarded needles reported; and
• Ensured the distribution of and web access to public education materials on safe disposal procedures. This became even more critical following the establishment of a by-law prohibiting the disposal of needles as household waste.

2008 Programmatic Response to Getting Discarded Needles off the Streets

OPH’s measures for needle recovery and public safety were not designed to handle the current environment and volume of needles. A new approach will strengthen and enhance the City’s ability to respond to this challenge and eliminate needles from the streets.

OPH is implementing an enhanced and comprehensive programmatic response, that includes five key components:

1) Organizational realignment;

2) Reinvigorating the integrated response;

3) Program enhancements;

4) Partnerships; and

5) Liaising with the community.

To ensure full and appropriate focus on respective mandates OPH is realigning its organizational structure by transferring responsibility for needle pick-up out of the Infectious Diseases program and into the Environmental Hazards program. The Infectious Disease Prevention and Control (IDPC) program’s mandate is the reduction of infectious disease risk in the community; the Environment and Health Protection mandate is to eliminate health hazards in the community.

OPH will take the lead role in reinvigorating a city-wide integrated approach involving Surface Operations, By-law, Police, Parks and Recreation, Public Health, and Corporate Communications. OPH will coordinate regular monthly meetings and quarterly reporting of progress to Senior Staff will be established. The goal of a reinvigorated integrated approach is to ensure a “rapid response” capability and an effective needle tracking system. This will be done through program enhancements, including items suggested in the request to the province for additional funding; community engagement and partnerships; and greater accountability through a report to Council in the fall of 2009.

Initiatives and deliverables identified to enhance the programmatic response include but are not limited to the following:

· Implement monthly meetings with Site Program Departmental Consultative Group (SPDGC) to confer on emerging service delivery issues, program and policy development, and emerging community concerns (Ongoing);

· Review and update the SPDCG priorities and work plan (30 September 2008);

· Provide quarterly operational progress reports to OPH senior management (Ongoing); and

· Review and update counselling strategies and policies with clients (December 2008).

· Establish Safety Syringes Study research advisory committee to design a second feasibility study of the use of safety syringes for the program, involving SPDCG members and other key stakeholders. The study will also include a market search for safety syringes and a proposed timetable is as follows:

· The study design and RFP completed (December 2008);

· Research Ethics Board approval (January 2009);

· Preliminary product evaluation with NEP clients completed (Phase 1: Spring 2009);

· Feasibility study (Phase 2 September 2009); and

· Analysis and Report to SPDCG and OPH management (December 2009).

· Links will be maintained with the University of Ottawa, Canadian Institute for Health Research and the Public Health Agency of Canada for I-Track Study and Social Networks Study (Ongoing); and

· Web-based public information on Harm Reduction updated (30 September 2008).

OPH is implementing a broad range of program enhancements in the immediate, medium and long term, including:

Immediate:

• Hiring and training a student Public Health Inspector (PHI) for the summer 2008 to pick- up needles and map and record where needles are being discarded; ensure the 2 students hired for beach sampling are also trained on needle pick-up to ensure back-up;

• Re-allocating funding within its operational budget to hire a full-time Public Health trainee (1 FTE);
• Creating a hotline for discarded needles;
• Developing specific criteria for the selection of the best possible entity for the contracting of the Needle Hunter Program; and
• Expanding the hours of operation of the Needle Hunter program and expand the collection program from three areas to four to encompass Byward Market/Lowertown, Centretown, Hintonburg plus Vanier.

Medium Term:

By September 2008

• Hiring and training 1 full-time PHI trainee in fall of 2008 within current budget resources of $100,000 and identify as a budget pressure in the 2009 operating budget. Monitor program and identify if additional resources are required and include as a budget pressure in future budgets as required;
• Expanding the black boxNeedle Drop Box program by increasing the number of black boxes for disposal of used needles;
• Enhancing statistics-gathering capabilities in order to know how many needles need to be picked up and more precisely how many are being recovered (e.g. hire Environmental Consulting Company to open black boxneedle drop boxes for actual counts of needles rather than estimating by weight and discounting for estimated non-needles refuse);

• Utilizing geo-mapping to identify hot spots and track movement of hot spots for internal planning purposes; and
• Developing comprehensive web package that will include specific information on needle pick-up and reporting on numbers of needles distributed and received annually.

By December 2008

• Reviewing and updating Site counselling strategies with clients and related policies;

· Reviewing peer-based programs in place in other jurisdictions and explore local feasibility with partners; and

· The design and RFP for a fFeasibility study of single-use, safety syringes completed.

Long-Term:

By June 2009

• Reporting back on feasibility study of safety syringes;

· Exploring methods of reaching potential clients who are not returning needles for exchange e.g. social networking; and

· Formalizing linkages with the University of Ottawa, Canadian Institute for Health Research and the Public Health Agency of Canada for I-Track Study and Social Networks Study.

By the Fall 2009

· Acting MOH to report back to City Council with progress to date.

By December 2009

· Analysis and fFeasibility study of single-use, safety syringes report to SPDCG and OPH management (December 2009).

2008 Program enhancements ($100,000)

By the end of the fiscal year 2008, the $100,000 approved by Council (May 14, 2008) will be allocated to the following program enhancements:

· Student engaged immediately until August 31st, 2008: $6,500;

· Additional black boxesneedle drop boxes (16 x $1.8) to be placed by September 31st, 2008: $28,800;

· Increased routes for needle hunters (2 x $15,000.00) by July 1st: $30,000;

• PHI trainee from August 31st to December 31st, 2008: $30,000 (salary, equipment and mileage); and
• Start-up costs for Feasibility Study on Safety Syringes $4,700.

Total cost until December 31st, 2008: $100,000

Given that the $100,000 approved by Council on May 14 was one-time money, Ottawa Public Health proposes to include a $100,000 pressure in the 2009 budget to sustain these programmatic enhancements going forward.

Further, a budgetary pressure of up to $50,000 will be identified for the 2009 budget to complete the Feasibility Study on Safety Syringes.

Further to the program enhancements to be undertaken by OPH, aAs well, additional work will be done to enter into partnerships and enrich community input. This will be accomplished by:

• Establishing terms of reference for a new front line provider partnership between OPH, the Ottawa Police Service and Community partner agencies (immediate);
• Developing and implementing a Community Engagement Strategy (September 2008);

· Releasing a local action plan for the partnership (December 2008); and

· Establishing a community input mechanism to increase interface with consultative groups, including representatives from Community Associations and BIA’s, on the issue of eliminating needles on the street (December 2008).

Direction to Post Statistics Respecting Needles Distributed and Retrieved

Council directed staff to ensure statistics concerning the numbers of needles distributed and retrieved annually are made available on the City’s website by the fall of 2008. OPH will be proceeding with the required work to complete this request.

Direction to Identify Costs Expended on NEP Inquiries and Reports

Council further directed staff to identify the costs expended to date this year on responding to requests on the NEP and preparing the current report.

In reviewing OPH files since December 1, 2007 to May 30, 2008, OPH has received approximately eighteen (18) inquiries from Councillors and the public related to needle exchange issues. As of December 2007, OPH received five (5) inquiries from Councillor Monetteone councillor.

In 2008, OPH received five (5) inquiries from a concerned resident and seven (7) inquiries were received from either a Councillor, constituent or staff from Surface Operations.

While these statistics include the inquiry for the recent needle stick, the data does not include direct contacts between Councillors or the public and OPH staff, which were not recorded and subsequently not reported to the Office of the Medical Officer of Health.

With respect to staff time, depending on the complexity of the response, anywhere from two (2) to nine (9) staff were involved in the research, drafting or editing of the response. It is estimated that approximately 10 to 15 hours of staff time was spent in preparation of responding to one individual’s requests and in excess of 20 hours of staff time was spent in preparation of the various responses to Councillor Monetteone councillor.

CONCLUSION

Given the medical evidence respecting the efficacy of a non-restrictive needle exchange program, as well as the adverse health consequences and the cost to city and to the health care system overall ($150,000 to $600,000 for each new HIV case), the Acting Medical Officer of Health does not recommend a change to the City’s current needle exchange policy. Given the medical and scientific evidence respecting the efficacy of a non-restrictive needle exchange program, and taking into consideration the legal advice previously received by Council, the Acting Medical Officer of Health does not recommend a change to the City’s current needle exchange policy. Further, the Acting Medical Officer of Health is recommending to Council a variety of enhancements to needle recovery efforts and that a progress report be made by the Fall of 2009.

CONSULTATION

OPH liaised with medical experts cited in this report to obtain additional materials and to seek clarification and additional information.

The Acting Medical Officer of Health sought information from and consulted with:

• Counterparts in regions of Ontario and other provinces and with medical experts in addiction medicine, as well as the Chief Public Health Officer, Public Health Agency of Canada;
• Ottawa Police Chief and senior staff, Community Health Centre representatives and medical experts in Ottawa; and
• Representatives of Safer Ottawa.

The Acting Medical Officer of Health provided a verbal update on the current Needle Exchange Program to the Health and Social Services Advisory Committee at its meeting of May 27, 2008.

FINANCIAL IMPLICATIONS

Subject to Council approval, $100,000 will be identified as part of the new operating needs and $50,000 will be identified as a 1-time operating requirement in the 2009 draft budget that will be tabled to Council November 5th.

SUPPORTING DOCUMENTATION

Document 1 – Needle Exchange Program Motion from April 3 CPSC Meeting

Document 2 – Bibliography of 137 Studies reviewed in Preparation of this Report.

Document 3 – Reports on the NEP submitted to Committee and Council since Inception of the NEP in 1989.

DISPOSITION

Ottawa Public Health Branch of the Community and Protective Services Department will action any direction received as part of consideration of this report.

Document 1

Community and Protective Services Committee

Disposition 24

Thursday, 3 April 2008

WHEREAS thousands of needles are picked-up every year on downtown streets and in residential areas within the City, not only by agencies but by local residents, in an effort to protect the community at large;

AND WHEREAS there was a noted increase in complaints of discarded needles since the introduction of the City’s Needle Exchange Program in 1999 and the incidents of needle-stick injuries appear to be on the rise due to an apparent increase in the amount of unsafely discarded needles;

AND WHEREAS Ottawa has the highest rate of HIV prevalence among injection drug users (IDU) in Ontario and second highest rate in Canada at 20%;

AND WHEREAS in accordance with the City’s Needle Exchange Program (“NEP”), the Public Health Unit distributes needles without requiring a used needle to be provided in exchange;

AND WHEREAS the Shepherd' s of Good Hope has implemented a “one-for-one” needle exchange program as of October 15th of 2007;

AND WHEREAS it is suggested that, in order to have an effective harm reduction strategy in a municipality, each needle exchange program should work in unison along the same parameters;

AND WHEREAS it is suggested that a direct one-for-one needle exchange encourages the safe disposal of used needles;

AND WHEREAS the city has a Needle Exchange Program which implies a direct one for one and not a distribution program.

AND WHEREAS the title of our current program implies a needle exchange not distribution methodology;

AND WHEREAS the recommended date in the 2002 report “Action Plan of the Site Program Review” that Site Program policies, program information annual reports and statistics will be available on the City’s Website has not been met;

AND WHEREAS the reporting measures attributed to the City’s NEP appear to have failed to prove the success of a broader, needle exchange program;

THEREFORE BE IT RESOLVED that the Medical Officer of Health be directed to prepare a comprehensive report on the Needle Exchange Program, to be presented to the Community and Protective Services Committee by July 2008, incorporating the following information:

1. The detailed history of all reports on the City’s NEP, including how the reporting of the NEP was accomplished, where it was published, how the program was evaluated, including by what measures the program was evaluated against;

2. Medical evidence that demonstrates that the current best practices successfully meet the Ministry’s objectives;

3. Evidence that the current needle distribution model is more effective than a direct, one-for-one needle exchange model and evidence of any adverse effects that could be associated with a proposed change in the current needle distribution practice to a direct, one-for-one needle exchange;

4. An outline of all the areas of risk associated with a potential change of policy from the current needle distribution practice to a direct, one-for-one exchange and detail how the risk was assessed;

5. Comparisons of other large Canadian municipalities and their current harm reduction practices;

6. An analysis of the financial implications of changing the current practice to a direct, one-for-one exchange;

BE IT FURTHER RESOLVED THAT the Community and Protective Services Committee recommends that Council, as the Board of Health, directs the Medical Officer of Health to ensure that the statistics concerning the numbers of needles distributed and retrieved annually are made available on the City of Ottawa’s website by the fall of 2008; and,

BE IT FURTHER RESOLVED that the costs expended to date this year on responding to questions and information about the Needle Exchange Program and the costs to prepare the current report, be included in the July report.

CARRIED

Document 2

List of Studies Reviewed

NEP Articles Reviewed – May/June 2008

Listed by Author

1. Anonymous (2005). Needle-Exchange Program Dashed in Massachusetts. AIDS Patient Care & Stds, 19(9):619.

2. Aitken, C., Moore, D., Higgs, P., Kelsall, J. and Kerger, M. (2002). The Impact of a Police Crackdown on a Street Drug Scene: Evidence from the Street. Int J Drug Policy, 13(3):189-198.

3. American Academy of Pediatrics Committee on Pediatric,A.I.D.S. (2006). Reducing the Risk of HIV Infection Associated with Illicit Drug use. Pediatrics, 117(2):566-571.

4. Amundsen, E.J. (2006). Measuring Effectiveness of Needle and Syringe Exchange Programmes for Prevention of HIV among Injecting Drug Users. Addiction, 101(7):911-912.

5. Anderson, R., Clancy, L., Flynn, N., Kral, A.H. and Bluthenthal, R.N. (2003). Delivering Syringe Exchange Services through "Satellite Exchangers": The Sacramento Area Needle Exchange, USA. International Journal of Drug Policy, 14(5/6):461-463.

6. Appel, P.W., Ellison, A.A., Jansky, H.K. and Oldak, R. (2004). Barriers to Enrollment in Drug Abuse Treatment and Suggestions for Reducing them: Opinions of Drug Injecting Street Outreach Clients and Other System Stakeholders. American Journal of Drug & Alcohol Abuse, 30(1):129-153.

7. Appel, P.W. and Oldak, R. (2007). A Preliminary Comparison of Major Kinds of Obstacles to Enrolling in Substance Abuse Treatment (AOD) Reported by Injecting Street Outreach Clients and Other Stakeholders. Am J Drug Alcohol Abuse, 33(5):699-705.

8. Ashton, M. (2004). Needle Exchange: The Vancouver Experience. Addiction Research & Theory, 12(5):445-460.

9. Bailey, S.L., Ouellet, L.J., Mackesy-Amiti, M.E., et al. (2007). Perceived Risk, Peer Influences, and Injection Partner Type Predict Receptive Syringe Sharing among Young Adult Injection Drug Users in Five U.S. Cities. Drug & Alcohol Dependence, 91(Suppl 1):S18-29.

10. Beletsky, L., Davis, C.S., Anderson, E. and Burris, S. (2008). The Law (and Politics) of Safe Injection Facilities in the United States. Am J Public Health, 98(2):231-237.

11. Betteridge, G. (2004). British Columbia: Studies show Positive Public Impacts of Harm-Reduction Measures for Drug Users. HIV/AIDS Policy & Law Review / Canadian HIV/AIDS Legal Network, 9(3):27.

12. Birkhead, G.S., Klein, S.J., Candelas, A.R., et al. (2007). Integrating Multiple Programme and Policy Approaches to Hepatitis C Prevention and Care for Injection Drug Users: A Comprehensive Approach. International Journal of Drug Policy, 18(5):417-425.

13. Bloom, D.E., Mahal, A. and O'Flaherty, B. (2005). Economic Perspectives on Injecting Drug use. Advances in Health Economics & Health Services Research, 16:371-395.

14. Bluthenthal, R.N., Anderson, R., Flynn, N.M. and Kral, A.H. (2007). Higher Syringe Coverage is Associated with Lower Odds of HIV Risk and does Not Increase Unsafe Syringe Disposal among Syringe Exchange Program Clients. Drug & Alcohol Dependence, 89(2-3):214-222.

15. Bluthenthal, R.N., Ridgeway, G., Schell, T., Anderson, R., Flynn, N.M. and Kral, A.H. (2007). Examination of the Association between Syringe Exchange Program (SEP) Dispensation Policy and SEP Client-Level Syringe Coverage among Injection Drug Users. Addiction, 102(4):638-646.

16. Bluthenthal, R.N., Heinzerling, K., Martinez, A. and Kral, A.H. (2005). Police Crackdowns, Societal Cost, and the Need for Alternative Approaches. Int J Drug Policy, 16(3):137-138.

17. Bluthenthal, R.N., Malik, M.R., Grau, L.E., et al. (2004). Sterile Syringe Access Conditions and Variations in HIV Risk among Drug Injectors in Three Cities. Addiction, 99(9):1136-1146.

18. Bluthenthal, R.N., Gogineni, A., Longshore, D. and Stein, M. (2001). Factors Associated with Readiness to Change Drug use among Needle-Exchange Users. Drug & Alcohol Dependence, 62(3):225-230.

19. Bourgois, P. (1998). The Moral Economies of Homeless Heroin Addicts: Confronting Ethnography, HIV Risk, and Everyday Violence in San Francisco Shooting Encampments. Subst Use Misuse, 33(11):2323-2351.

20. Boutwell, A. and Rich, J.D. (2004). Syringe Access for Injection Drug Users in Rhode Island. Medicine & Health, Rhode Island, 87(1):15-16.

21. Braine, N., Des Jarlais, D.C., Ahmad, S., Purchase, D. and Turner, C. (2004). Long-Term Effects of Syringe Exchange on Risk Behavior and HIV Prevention. AIDS Education & Prevention, 16(3):264-275.

22. Bravo, M.J., Royuela, L., Barrio, G., de la Fuente, L., Suarez, M. and Teresa Brugal, M. (2007). More Free Syringes, Fewer Drug Injectors in the Case of Spain. Soc Sci Med, 65(8):1773-1778.

23. Brown, N.L., Luna, V., Ramirez, M.H., Vail, K.A. and Williams, C.A. (2005). Developing an Effective Intervention for IDU Women: A Harm Reduction Approach to Collaboration. AIDS Education & Prevention, 17(4):317-333.

24. Bruneau, J., Brogly, S.B., Tyndall, M.W., Lamothe, F. and Franco, E.L. (2004). Intensity of Drug Injection as a Determinant of Sustained Injection Cessation among Chronic Drug Users: The Interface with Social Factors and Service Utilization. Addiction, 99(6):727-737.

25. Bruneau, J., Lamothe, F., Franco, E., et al. (1997). High Rates of HIV Infection among Injection Drug Users Participating in Needle Exchange Programs in Montreal: Results of a Cohort Study. Am J Epidemiol, 146(12):994-1002.

26. Burris, S., Strathdee, S.A. and Vernick, J.S. (2003). Lethal Injections: The Law, Science, and Politics of Syringe Access for Injection Drug Users. University of San Francisco Law Review, 37(4):813-885.

27. Burrows, D. (2006). Rethinking Coverage of Needle Exchange Programs. Subst Use Misuse, 41(6-7):1045-1048.

28. Burrows, D. (2006). Advocacy and Coverage of Needle Exchange Programs: Results of a Comparative Study of Harm Reduction Programs in Brazil, Bangladesh, Belarus, Ukraine, Russian Federation, and China. Cadernos de Saude Publica, 22(4):871-879.

29. Caiaffa, W.T., Bastos, F.I. and Proietti, F.A. (2003). Practices Surrounding Syringe Acquisition and Disposal: Effects of Syringe Exchange Programmes from Different Brazilian Regions--the AjUDE-Brasil II Project. International Journal of Drug Policy, 14(5/6):365-371.

30. Caiaffa, W.T. and Proietti, F.A. (2003). Ecological Analyses and the Evaluation of Needle and Syringe Programmes. International Journal of Drug Policy, 14(5/6):359-360.

31. Cao, W. and Treloar, C. (2006). Comparison of Needle and Syringe Programme Attendees and Non-Attendees from a High Drug-using Area in Sydney, New South Wales. Drug & Alcohol Review, 25(5):439-444.

32. Carrieri, M. and Spire, B. (2007). 'Forced Treatment Interruptions' and Risk of HIV Resistance in Countries Adopting Law Enforcement Against Marginalized Populations. AIDS, 21(8):1062-1063.

33. Carruthers, S. (2007). The Organization of a Community: Community-Based Prevention of Injecting Drug use-Related Health Problems. Subst Use Misuse, 42(12-13):1971-1977.

34. Centers for Disease Control and Prevention (CDC). (2007). Syringe Exchange Programs--United States, 2005. MMWR - Morbidity & Mortality Weekly Report, 56(44):1164-1167.

35. Chemtob, D., Damelin, B., Bessudo-Manor, N., et al. (2006). "Getting AIDS: Not in My Back Yard." Results from a National Knowledge, Attitudes and Practices Survey. Isr Med Assoc J, 8(9):610-614.

36. Cleland, C.M., Deren, S., Fuller, C.M., et al. (2007). Syringe Disposal among Injection Drug Users in Harlem and the Bronx during the New York State Expanded Syringe Access Demonstration Program. Health Education & Behavior, 34(2):390-403.

37. Coffin, P.O., Latka, M.H., Latkin, C., et al. (2007). Safe Syringe Disposal is Related to Safe Syringe Access among HIV-Positive Injection Drug Users. AIDS & Behavior, 11(5):652-662.

38. Coffin, P.O., Ahern, J., Dorris, S., Stevenson, L., Fuller, C. and Vlahov, D. (2002). More Pharmacists in High-Risk Neighborhoods of New York City Support Selling Syringes to Injection Drug Users. J Am Pharm Assoc (Wash), 42(6 Suppl 2):S62-7.

39. Coffin, P.O. (2000). Syringe Availability as HIV Prevention: A Review of Modalities. Journal of Urban Health, 77(3):306-330.

40. Cohen, J. and Csete, J. (2006). As Strong as the Weakest Pillar: Harm Reduction, Law Enforcement and Human Rights. International Journal of Drug Policy, 17(2):101-103.

41. Cooper, H.L.F., Wypij, D. and Krieger, N. (2005). Police Drug Crackdowns and Hospitalisation Rates for Illicit-Injection-Related Infections in New York City. International Journal of Drug Policy, 16(3):150-160.

42. Cruz, M.F., Patra, J., Fischer, B., Rehm, J. and Kalousek, K. (2007). Public Opinion Towards Supervised Injection Facilities and Heroin-Assisted Treatment in Ontario, Canada. International Journal of Drug Policy, 18(1):54-61.

43. Cusick, L. and Kimber, J. (2007). Public Perceptions of Public Drug use in Four UK Urban Sites. Int J Drug Policy, 18(1):10-17.

44. Davis, C.S., Burris, S., Kraut-Becher, J., Lynch, K.G. and Metzger, D. (2005). Effects of an Intensive Street-Level Police Intervention on Syringe Exchange Program use in Philadelphia, PA. Am J Public Health, 95(2):233-236.

45. Day, C., Conroy, E., Lowe, J., Page, J. and Dolan, K. (2006). Patterns of Drug use and Associated Harms among Rural Injecting Drug Users: Comparisons with Metropolitan Injecting Drug Users. Aust J Rural Health, 14(3):120-125.

46. De, P., Cox, J., Boivin, J.F., Platt, R.W. and Jolly, A.M. (2007). Rethinking Approaches to Risk Reduction for Injection Drug Users: Differences in Drug Type Affect Risk for HIV and Hepatitis C Virus Infection through Drug-Injecting Networks. Journal of Acquired Immune Deficiency Syndromes: JAIDS, 46(3):355-361.

47. Des Jarlais, D. (2007). Reducing Syringe Sharing among Injecting Drug Users in Winnipeg: 81% Success Or 19% Failure?[Comment]. Addiction, 102(10):1636.

48. Des Jarlais, D.C., Braine, N., Yi, H. and Turner, C. (2007). Residual Injection Risk Behavior, HIV Infection, and the Evaluation of Syringe Exchange Programs. AIDS Education & Prevention, 19(2):111-123.

49. Des Jarlais, D.C., Kling, R., Hammett, T.M., et al. (2007). Reducing HIV Infection among New Injecting Drug Users in the China-Vietnam Cross Border Project. AIDS, 21(Suppl 8):S109-14.

50. Des Jarlais, D.C., Perlis, T.E., Stimson, G.V., Poznyak, V. and WHO Phase II Drug Injection Collaborative Study,Group. (2006). Using Standardized Methods for Research on HIV and Injecting Drug use in developing/transitional Countries: Case Study from the WHO Drug Injection Study Phase II. BMC Public Health, 6:54 (2006 Mar 2).

51. Des Jarlais, D.C., Sloboda, Z., Friedman, S.R., Tempalski, B., McKnight, C. and Braine, N. (2006). Diffusion of the D.A.R.E and Syringe Exchange Programs. Am J Public Health, 96(8):1354-1358.

52. Des Jarlais, D.C. (2005). Evaluating National Harm Reduction Programs. Addiction, 100(11):1575-1576.

53. Des Jarlais, D.C., Perlis, T., Arasteh, K., et al. (2005). HIV Incidence among Injection Drug Users in New York City, 1990 to 2002: Use of Serologic Test Algorithm to Assess Expansion of HIV Prevention Services. Am J Public Health, 95(8):1439-1444.

54. Des Jarlais, D.C., Perlis, T., Arasteh, K., et al. (2005). Reductions in Hepatitis C Virus and HIV Infections among Injecting Drug Users in New York City, 1990-2001. AIDS, 19(Suppl 3):S20-5.

55. Des Jarlais, D.C. and Braine, N. (2004). Assessing Syringe Exchange Programs. Addiction, 99(9):1081-1082.

56. Des Jarlais, D.C. (2000). Structural Interventions to Reduce HIV Transmission among Injecting Drug Users. AIDS, 14(Suppl 1):S41-6.

57. Des Jarlais, D.C., Braine, N. and Friedmann, P. (2007). Unstable Housing as a Factor for Increased Injection Risk Behavior at US Syringe Exchange Programs. AIDS and Behavior, 11(Suppl2):S78-S84.

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80. Kidorf, M., Disney, E., King, V., Kolodner, K., Beilenson, P. and Brooner, R.K. (2005). Challenges in Motivating Treatment Enrollment in Community Syringe Exchange Participants. Journal of Urban Health, 82(3):456-467.

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86. Lawrie, T., Matheson, C., Bond, C. and Roberts, K. (2003). Pharmacy Customer's Views and Experiences of using Pharmacies which Provide Needle Exchange Services in Aberdeen and Glasgow, Scotland. International Journal of Drug Policy, 14(5/6):445-447.

87. Leonard, L., Derubeis, E., Pelude, L., Medd, E., Birkett, N. and Seto, J. (2008). "I Inject Less as I have Easier Access to Pipes" Injecting, and Sharing of Crack-Smoking Materials, Decline as Safer Crack-Smoking Resources are Distributed. Int J Drug Policy, 19(3):255-264.

88. Lurie, P., Gorsky, R., Jones, T.S. and Shomphe, L. (1998). An Economic Analysis of Needle Exchange and Pharmacy-Based Programs to Increase Sterile Syringe Availability for Injection Drug Users. J Acquir Immune Defic Syndr Hum Retrovirol, 18(Suppl 1):S126-32.

89. MacDonald, M., Law, M., Kaldor, J., Hales, J. and J. Dore, G. (2003). Effectiveness of Needle and Syring Programmes Fo Rpeventing HIV Transmission. International Journal of Drug Policy, 14(5/6):353-357.

90. Martinez, A.N., Bluthenthal, R.N., Lorvick, J., Anderson, R., Flynn, N. and Kral, A.H. (2007). The Impact of Legalizing Syringe Exchange Programs on Arrests among Injection Drug Users in California. Journal of Urban Health, 84(3):423-435.

91. Mateu-Gelabert, P., Treloar, C., Calatayud, V.A., et al. (2007). How can Hepatitis C be Prevented in the Long Term? International Journal of Drug Policy, 18(5):338-340.

92. McVeigh, J., Beynon, C. and Bellis, M.A. (2003). New Challenges for Agency Based Syringe Exchange Schemes: Analysis of 11 Years of Data (1991-2001) in Merseyside and Chesshire, United Kingdom. International Journal of Drug Policy, 14(5/6):399-405.

93. Morissette, C., Cox, J., De, P., et al. (2007). Minimal Uptake of Sterile Drug Preparation Equipment in a Predominantly Cocaine Injecting Population: Implications for HIV and Hepatitis C Prevention. International Journal of Drug Policy, 18(3):204-212.

94. Morrison, A., Elliott, L. and Gruer, L. (1997). Injecting-Related Harm and Treatment-Seeking Behaviour among Injecting Drug Users. Addiction, 92(10):1349-1352.

95. Neale, J., Tompkins, C. and Sheard, L. (2008). Barriers to Accessing Generic Health and Social Care Services: A Qualitative Study of Injecting Drug Users. Health & Social Care in the Community, 16(2):147-154.

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98. Ouellet, L., Huo, D. and Bailey, S.L. (2004). HIV Risk Practices among Needle Exchange Users and Nonusers in Chicago. Journal of Acquired Immune Deficiency Syndromes: JAIDS, 37(1):1187-1196.

99. Parsons, J., Hickman, M., Turnbull, P.J., et al. (2002). Over a Decade of Syringe Exchange: Results from 1997 UK Survey. Addiction, 97(7):845-850.

100. Pauly, B.B. (2008). Shifting Moral Values to Enhance Access to Health Care: Harm Reduction as a Context for Ethical Nursing Practice. Int J Drug Policy, 19(3):195-204.

101. Pauly, B.B. and Goldstone, I. (2008). Harm Reduction in Nursing Practice: Current Status and Future Directions. Int J Drug Policy, 19(3):179-182.

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103. Pollack, H.A. (2001). Cost-Effectiveness of Harm Reduction in Preventing Hepatitis C among Injection Drug Users. Medical Decision Making, 21(5):357-367.

104. Raboud, J.M., Boily, M.C., Rajeswaran, J., O'Shaughnessy, M.V. and Schechter, M.T. (2003). The Impact of Needle-Exchange Programs on the Spread of HIV among Injection Drug Users: A Simulation Study. J Urban Health, 80(2):302-320.

105. Rich, J.D., Hogan, J.W., Wolf, F., et al. (2007). Lower Syringe Sharing and Re-use After Syringe Legalization in Rhode Island. Drug & Alcohol Dependence, 89(2-3):292-297.

106. Rich, J.D., Wolf, F.A. and Macalino, G. (2002). Strategies to Improve Access to Sterile Syringes for Injection Drug Users. AIDS Read, 12(12):527-535.

107. Schechter, M.T., Strathdee, S.A., Cornelisse, P.G., et al. (1999). Do Needle Exchange Programmes Increase the Spread of HIV among Injection Drug Users?: An Investigation of the Vancouver Outbreak. AIDS, 13(6):F45-51.

108. Shannon, K., Rusch, M., Shoveller, J., et al. (2008). Mapping Violence and Policing as an Environmental-Structural Barrier to Health Service and Syringe Availability among Substance-using Women in Street-Level Sex Work. International Journal of Drug Policy, 19(2):140-147.

109. Shaw, S.Y., Shah, L., Jolly, A.M. and Wylie, J.L. (2007). Determinants of Injection Drug User (IDU) Syringe Sharing: The Relationship between Availability of Syringes and Risk Network Member Characteristics in Winnipeg, Canada. Addiction, 102(10):1626-1635.

110. Shin, S.H., Lundgren, L. and Chassler, D. (2007). Examining Drug Treatment Entry Patterns among Young Injection Drug Users. American Journal of Drug & Alcohol Abuse, 33(2):217-225.

111. Snead, J., Downing, M., Lorvick, J., et al. (2003). Secondary Syringe Exchange among Injection Drug Users. J Urban Health, 80(2):330-348.

112. Spittal, P.M., Small, W., Wood, E., et al. (2004). How Otherwise Dedicated AIDS Prevention Workers Come to Support State-Sponsored Shortage of Clean Syringes in Vancouver, Canada. International Journal of Drug Policy, 15(1):36-45.

113. Strathdee, S.A., Ricketts, E.P., Huettner, S., et al. (2006). Facilitating Entry into Drug Treatment among Injection Drug Users Referred from a Needle Exchange Program: Results from a Community-Based Behavioral Intervention Trial. Drug & Alcohol Dependence, 83(3):225-232.

114. Strathdee, S.A. and Bastos, F.I. (2003). Sterile Syringe Access for Injection Drug Users in the 21st Century: Progress and Prospects. International Journal of Drug Policy, 14(5/6):351-352.

115. Strike, C.J., O'Grady, C., Myers, T. and Millson, M. (2004). Pushing the Boundaries of Outreach Work: The Case of Needle Exchange Outreach Programs in Canada. Soc Sci Med, 59(1):209-219.

116. Strike, C.J., Challacombe, L., Myers, T. and Millson, M. (2002). Needle Exchange Programs. Delivery and Access Issues. Can J Public Health, 93(5):339-343.

117. Strike, C.J., Myers, T. and Millson, M. (2002). Needle Exchange: How the Meanings Ascribed to Needles Impact Exchange Practices and Policies. AIDS Educ Prev, 14(2):126-137.

118. Tempalski, B., Friedman, S.R., DesJarlais, D.C., McKnight, C. and Keem, M. (2003). What Predicts which Metropolitan Areas in the USA have Syringe Exchanges? International Journal of Drug Policy, 14(5/6):417-424.

119. Thein, H., Denoe, M., vanBeek, I. and Dore, G. (2003). Injecting Behaviour of Injecting Drug Users at Needle and Syringe Programmes and Pharmacies in Australia. International Journal of Drug Policy, 14(5/6):425-430.

120. Thompson, S.C., Boughton, C.R. and Dore, G.J. (2003). Blood-Borne Viruses and their Survival in the Environment: Is Public Concern about Community Needlestick Exposures Justified? Australian & New Zealand Journal of Public Health, 27(6):602-607.

121. Tomolillo, C.M., Crothers, L.J. and Aberson, C.L. (2007). The Damage done: A Study of Injection Drug use, Injection Related Abscesses and Needle Exchange Regulation. Subst Use Misuse, 42(10):1603-1611.

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Document 3

History of Reports to Committee and Council

City of Ottawa’s Needle Exchange Program (NEP)

1989

Subject: Description of Special Services, Needle Exchange Program, Anonymous Testing, AIDS in the Workplace.

November 8, 1989 Regional Council approved the above-noted report from the Health Committee, which recommended “that Health Department staff be authorized to seek federal and provincial funding to implement a harm reduction program to prevent Human Immune Deficiency Virus in injection drug users which included an education program, provision of clean needles and referral to rehabilitation.

The report cited the dramatic spread of HIV through needle sharers and emphasized that the proposed program is not ‘just a needle exchange’ but a harm reduction program, an HIV prevention program, an educations program and also a program that offers testing and counselling to people taking drugs.

The proposed Ottawa needle exchange component of the program does state that “Needles will be provided free of charge, one for one, according to procedures developed for the program.”

Expected Outcomes of the program with respect to the needle exchange component were cited as:

· Increase in IDUs seeking help to rehabilitate;

· Decrease in the sharing of unclean needles

· Increase in the cleaning of needles/exchange of needles purchasing of new ones;

· Decrease in HIV infection over time;

1990

Subject: Update on the Needle Exchange Program

September 12, 1990 Regional Council received a brief information report update on the needle exchange program indicating that the Ministry of Health was responding favourably to the City’s proposal and the Health Department hoped to have funding in place for proposed program by the end of the year.

1991

Subject: Communicable Disease Control – Update on the Needle Exchange Program

July 11, 1991 the Medical Officer of Health advised Health Committee that the opening day of the Needle Exchange program (SITE) would be Friday, July 19, 1991.

Health Committee was provided the following information on the program: Program is being funded 100% by the Federal and Provincial governments and is being run in partnership with the Youth Services Bureau; Annual budget is $247,000; Location is 480A Somerset (also the location of the Region’s Birth Control Clinic) with a mobile van also in operation; Services to include the supply of new needles, syringes, bleach kits, confidential testing and assistance plus health information.

Information was forwarded to, and received by, Regional Council at its meeting of August 14, 1991.

1993

Subject: Needle Exchange Program

August 11, 1993 Regional Council approved recommendations from the July 8 meeting of the Health Committee respecting the Needle Exchange program as follows:

1. That Health Department staff contact the manufacturer immediately to request that RMOC needles have an identifying mark placed on them.

2. That the municipalities of Nepean, Gloucester and Vanier also develop procedures for the pick-up of needles in public areas and that the results of this be reported back to the December 1993

3. That a report come to the Health Committee in the fall providing a detailed update on the Needle Exchange Program including: methods of increasing HIV testing; methods of increasing access; and the inappropriateness of continuing with the numbers of needles given out.

The Health Committee had received copies of an Ottawa Citizen newspaper article (dated July 7, 1993), which had reported that approximately 6,000 needles provided through the region’s NEP had not been accounted for. The Health Department clarified that the 6,000 unaccounted for needles simply meant that the 6,000 needles had not come back to the clinic but had been disposed of in other ways.

As part of the discussion, some concern was expressed respecting “bulk” exchanges of needles. The AMOH confirmed that the “policy is one clean needle for every dirty needle and often one person carries all the needles in for their friends, which could result in a large exchange.” The AMOH indicated a maximum of 10 syringes are given to first time visitors to the program.

A motion to limit the needle exchange to a one-for-one exchange with a maximum of two clean needles provided to first time clients was lost.

Subject: Update on the Health Department’s HIV Prevention Programme for Injections Drug Users

The Health Committee received a report in September 1993, subsequently received by Regional Council at its meeting of January 12, 1994 that responded to the motions emanating from the July meeting of Health Committee.

The information report indicated that the marking of RMOC needles with an identifying mark would not be economically feasible. The municipalities of Nepean, Gloucester and Vanier were tasked to develop procedures for the pick-up of needles in public area

The report identified that approximately 21% of clientele requested HIV testing; 9.2% of clients were referred to drug rehabilitation programs (though it was noted that referral was hampered by the limited number of rehabilitation spots which numbered 12 for assessment and 20 for treatment at the time).

As of the fall of 1993 the Regional NEP provided for a one-to-one exchange with the provision of a maximum of 3 needles for first time users without exchange. The exchange rate for the program was 80%.

At the time of the writing of the report no agency provided statistics for needles found on the ground.

1998

Amendment to Needle Exchange Policy

The Regional Health Department revised its Needle Exchange policy from a strictly “one-for-one” exchange to a more flexible policy in 1998. The procedure provided that clients could receive 20 needles on a first visit. Return clients were encouraged to bring used needles back to get new ones however. No client will be refused needles on the basis that they do not have any used ones to exchange.

The needle exchange services operated on the principle of recovering all needles that are provided to clients and clients are advised of other locations can be retuned.

The reason for the change was the alarmingly high rates of HIV infection in IDU in Ottawa and the recognition that the use of cocaine as the drug of choice led to very high numbers of needles used.

1999

Subject: The SITE HIV Prevention Program

At its meeting of January 27, 1999 Regional Council approved a report attaching the above noted procedure as Regional policy.

The report also approved establishment of a Needle Exchange Network to increase community and agency involvement; safe zones around schools, parks and day care centres where needle/syringe may not be distributed; development of an incentive program (e.g., food vouchers or clothing) be to encourage the return of more needles; establishment of a needle clean-up program ($10,000 per year for April to November pick-up), and; enhancement of the education program re., safe needle disposal by the community.

2002

Subject: Action Plan of the SITE Program Review

At its meeting of May 22, 2002 Ottawa City Council approved the SITE program action plan with the following highlights:

· Safety

o Public Health acknowledged concerns with respect to the risk of needle stick injuries and committed to coordinated approach to the pick-up o discarded needles as well as the continuation of other discarded needle programs (e.g., Needle Hunters, Needle Black Boxes, Take it Back pharmacies program).

o Committed to evaluate the feasibility of retractable needle

· Accountability and Communication:

o Recommended appointment of an advisory committee with community, client and partnership agency participation

o Continued proactive communication and education re., safe needle disposal, harm reduction, with the transparent posting of policies, annual reports and statistics on the City’s website.

Subject: Quick Response to Discarded Needles Report

At the same May 22, 2002 meeting Ottawa City Council also received a report respecting the Quick Response to Discarded Needles report (a joint Public Works / Public Health report)

Report provided information on a harmonized response to collecting and discarding needles. The report noted:

· Needle Hunter began in 1990 and continues to provide service April to November between 7 and 9 a.m.

· Success of Black Box and Take it Back programs is described but the establishment of an interdepartmental working groups with representatives of Public Works; Public health, By-law Services, Ottawa Police, etc. to develop a harmonized need response that:

o Ensures City will respond within one-hour during regular business hours ot pick up a needle on public property

o Two hour response during off hours and weekends

o Revisits area twice within seven days for locations where needles had been picked-up

o Assistance with the pick-up of needles on private property

o Collection and management of data to maintain an accurate count and tracking

2003

Subject: Update on HIV and AIDS in the City of Ottawa

At its meeting of April 17 the Health Recreation and Social Services Committee (HRSS) received the above-noted report, which contained highlights as follows:

· Report noted that estimated prevalence of HIV infection among injection drug user Ottawa as much higher than in other parts of Ontario.

· Ottawa statistics were attributed to fact that cocaine is the drug of choice in Ottawa and the short lived effect of the drug means that cocaine requires many injections per day thus increasing the risk of unsafe injection practices such as reuse and sharing.

· This finding argued in favour of ensuring adequate access to sterile needles.

Subject: SITE Program Review Implementation: An Update

At the same April 17 meeting HRSS approved the above noted report which was subsequently approved by Council at its meeting of May 14.

· Report recommended the following actions:

o That the Site program continue to monitor both the Needle Hunters and City pickup data for hotspots and work with community partners to address issues

o That staff continue to actively monitor the market for a difficult to reuse product which is safe and reduces the risk of community needle stick injury

o Implement a Department consultative group for the SITE program

Endnotes

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[i] Start up costsOperating cost for additional vans along with operational costincluding fuel, insurance, etc.) are estimated to be $11,000 per year per van for a total of $33,000 annually.

[i] As the materials collected in Needle Drop Boxes are hazardous waste weighing needles/syringes is considered the safest means safer of estimating numbers

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[1] Health Protection and Promotion Act, R.S.O. 1990, c. H.7, Statutes and Regulations, Province of Ontario.

[2] Wodak, A. and Cooney, A (2005). Effectiveness of Sterile Needle and Syringe Programmes. International Journal of Drug Policy, 16(Supplement 1):31-44.

[3] Health Outcomes International (HOI), N.D., M. (2002). Return on investment in needle and syringe programs in Australia. Canberra: Commonwealth Department of Health and Ageing.

[4] Hurley, S.F., Jolley, D.J. and Kaldor, J.M. (1997). Effectiveness of Needle-Exchange Programmes for Prevention of HIV Infection. Lancet, 349(9068):1797-1800.

[5] 130. Wodak, A. and Cooney, A. (2006). Do Needle Syringe Programs Reduce HIV Infection among Injecting Drug Users: A Comprehensive Review of the International Evidence. Subst Use Misuse, 41(6-7):777-813.

[6] Bruneau, J., Lamothe, F., Franco, E., et al. (1997). High Rates of HIV Infection among Injection Drug Users Participating in Needle Exchange Programs in Montreal: Results of a Cohort Study. Am J Epidemiol, 146(12):994-1002.

[7] Schechter, M.T., Strathdee, S.A., Cornelisse, P.G., et al. (1999). Do Needle Exchange Programmes Increase the Spread of HIV among Injection Drug Users?: An Investigation of the Vancouver Outbreak. AIDS, 13(6):F45-51.

[8] Vlahov, D. and Junge, B. (1998). The Role of Needle Exchange Programs in HIV Prevention. Public Health Rep, 113(Suppl 1):75-80.

[9] Des Jarlais, D.C., Perlis, T., Arasteh, K., et al. (2005). Reductions in Hepatitis C Virus and HIV Infections among Injecting Drug Users in New York City, 1990-2001. AIDS, 19(Suppl 3):S20-5.

[10] Bluthenthal, R.N., Ridgeway, G., Schell, T., Anderson, R., Flynn, N.M. and Kral, A.H. (2007). Examination of the Association between Syringe Exchange Program (SEP) Dispensation Policy and SEP Client-Level Syringe Coverage among Injection Drug Users. Addiction, 102(4):638-646.

[11] Bluthenthal, R.N., Anderson, R., Flynn, N.M. and Kral, A.H. (2007). Higher Syringe Coverage is Associated with Lower Odds of HIV Risk and does Not Increase Unsafe Syringe Disposal among Syringe Exchange Program Clients. Drug & Alcohol Dependence, 89(2-3):214-222.

[12] Robert S. Remis MD MPH FRCPC Ontario HIV Epidemiologic Monitoring Unit, Department of Public Health Science, University of Toronto. May 2008.

[13] Latkin, C.A., Davey, M.A. and Hua, W. (2006). Needle Exchange Program Utilization and Entry into Drug User Treatment: Is there a Long-Term Connection in Baltimore, Maryland? Subst Use Misuse, 41(14):1991-2001.

[14] Strathdee, S.A., Celentano, D.D., Shah, N., et al. (1999). Needle-Exchange Attendance and Health Care Utilization Promote Entry into Detoxification. Journal of Urban Health, 76(4):448-460.

[15] Shah, N.G., Celentanoa, D.D., Vlahov, D., et al. (2000). Correlates of Enrollment in Methadone Maintenance Treatment Programs Differ by HIV-Serostatus. AIDS, 14(13):2035-2043.

[16] Hagan, H., McGough, J.P., Thiede, H., Hopkins, S., Duchin, J. and Alexander, E.R. (2000). Reduced Injection Frequency and Increased Entry and Retention in Drug Treatment Associated with Needle-Exchange Participation in Seattle Drug Injectors. J Subst Abuse Treat, 19(3):247-252.

[17] Mathews, W.C., Franz, M., Harris, B., Herring, B., Jackson, P., Lloyd, L., et al. (2001). Clean Syringe Exchange Program Task Force Final Report. San Diego, CA: Clean Syringe Exchange Program Task Force.

[18] Fuller, C.M., Ahern, J., Vadnai, L., et al. (2002). Impact of Increased Syringe Access: Preliminary Findings on Injection Drug User Syringe Source, Disposal, and Pharmacy Sales in Harlem, New York. J Am Pharm Assoc (Wash), 42(6 Suppl 2):S77-82.

[19] Kral, A.H., Anderson, R., Flynn, N.M. and Bluthenthal, R.N. (2004). Injection Risk Behaviours among Clients of Syringe Exchange Programs with Different Syringe Dispensation Policies. Journal of Acquired Immune Deficiency Syndromes: JAIDS, 37(2):1307-1312.