Australia is one of the leading countries responding to the global health cost relating to illicit drug use. Australian Governments work collaboratively with organisations and communities to address the social, economic, and health issues faced by illicit drug users and the community. The global issue for health policy makers in Australia is that over 80-85% of people in Australia who have contracted blood borne diseases such as hepatitis C or AIDS has occurred through sharing equipment linked to illegal drug use.
Hepatitis C has not received the global media attention that AIDS received yet it is the ‘most commonly reported infectious disease in Australia today’ (Hep C Resource Manual pg. 1). The issue for Health Care Policy makers and workers in the industry has been that illegal drug use, of course, is illegal, so what do you do with diseases which are spread through illegal drug use whilst reducing risk and trying to stop the spread of infection, disease and deaths in the community?.
Australian’s overall philosophy to this question is through harm minimisation. Harm minimisation is the policy that underpins the National and State Public Health strategies such as National Drug Strategy 2010-2015. Harm minimisation is Australian’s approach to reducing drug-related harm relating to both legal and illegal drugs and involves supply reduction, demand reduction and harm reduction strategies. Supply reduction; demand reduction and harm reduction is a simple concept for a difficult issue facing society.
Supply reduction aims to disrupt production and distribution of illicit drugs, which health care professionals and policy is not part of, this is a role for law enforcement and not for health care workers. Demand reduction is reducing demand for taking or starting to take harmful drugs which is done through education programs, like people attending at schools to give talks or through advertisements on TV, magazines, radio and other media and also through fear of police involvement and finally harm reduction which is reducing the harm of drug users, even though illegal and reducing harm in the community.
Harm reduction focuses on preventing and/or reducing the harm associated with risky activities, not on preventing people from doing activities. The term is a simple one and can relate to all types of drug use without judgement calls to users and it puts the focus more on the health and safety of the person rather than blame or judgement. An example would be for an alcoholic to try to consume a glass of water in-between drinks. This concept has been around for a long time.
Apparently in early century China , many drunken people fell into canals and drowned near the local drinking area, but preventing alcohol use was difficult so they built fenced around the canals to prevent deaths, another example is seatbelts in cars preventing harm through car accidents. Harm minimisation provides people who inject illegal drugs with the capacity and resources to make decisions about their drug use. There are no judgements about drug use instead the philosophe is to accept that some people choose to inject drugs.
Harm reduction encourages a change in the way drugs are used to reduce health risks such as catching hepatitis C and AIDS. It is estimated that 25,000 HIV infections and 21,000 hepatitis C infections between the period 1988 to 2000 have been prevented (Annual Surveillance Report, National Centre in HIV Epidemiology and Clinical Research, 2004). Of all new Hepatitis infections in Australia, 90% result from the sharing or re-use of contaminated drug injecting equipment and only 10% from other sources such as tattooing and body piercing and mother to baby transmission.
(Hepatitis C Manual). Australia has a multifaceted prevention response to Hep C and other blood borne viruses based on the concept of harm reduction and the key component of the national response by providing sterile injecting equipment through the Needle and Syringe Programs. One of the strategies of harm minimisation to reduce risk are Needle and Syringe Programs which operate throughout Australia providing clean needles and offer information about safer drug use.
Their aim is to reduce risk of infection by avoiding sharing or re-using equipment preventing blood borne viruses. ‘Over 33 million units of injecting equipment were supplies by states and territories under the Needle and Exchange programme during 2005-2006’ Hepatitis C Resource Manual (2008 p. 55). ‘It cost $130 million to fund the Needle and Syringe Program from 1991 – 2000 and is estimated that this saved over $7,025 million in HIV treatment costs and $783 million in hepatitis C treatment costs’ (The return on investment in NSP’s in Australia Report, Commonwealth of Australia, 2002).
The hepatitis C virus is highly contagious and people often are not aware they have contracted the virus putting others at risk. Harm reduction also includes programs that reduce harm to the community. Needles or syringes left in public places are a risk, even though low, so putting syringe disposal facilities in appropriate public locations can reduce risk or the perception of risk.
There have been many influences that have occurred resulting in the non-judgemental harm minimisation response to blood borne diseases and these responses and community views have resulted in the current policy of harm minimisation and a view that a drug user is a sufferer of a disease rather than someone committing criminal acts or activities, even though legally they are breaking the law. There has been an evolution in laws and policy relating to the blood borne disease of hepatitis C.
The Australian Red Cross Blood Service began screening for hepatitis C in February 1990 and before this time, people who were infected with hep C when they received blood or blood products contaminated with the virus. Hepatises C is a blood-borne virus that affects the liver and transmission occurs when the blood of someone infected with the virus enters the bloodstream of another person. It is not a sexually transmissible infection but it is transmitted through blood to blood contact so getting the disease through sexual contact is possible but not likely.
There have been many influences which resulted in policy change and new policies dating back to 1971 when the first blood samples were taken at the Fairfield Infectious Diseases Hospital. The changes and influences for health policy of illegal drugs and blood borne diseases stemmed from the emerging response to the HIV epidemic where in 1986 the first Needle and Syringe Program opened in NSW. In 1989 the Australian Intravenous League commenced and operated as an unfunded national network until 1998.
In 2003 the Ministerial Advisory Committee on AIDS, Sexual Health and Hepatitis (MACASHH) was established supported by three expert subcommittees, Hepatitis C Subcommittee; the HIV/AODS and the Indigenous Australians Sexual Health Committee. In 2005 the National Aboriginal and Torres Strait Islander Sexual Health and Blood Borne Virus Strategy was developed with the aim of strengthening the capacity of the Aboriginal Community Controlled Health Services to strengthen their capacity to deliver sexual health programs and build collaborative partnerships with the mainstream health sector.
In October 1994 the Australian Health Ministers’ advisory Council developed the National Hepatitis C Action Plan which recommended activities for surveillance and epidemiology, testing, clinical management, counselling, education, presentation and research. Then in 1995 Australia’s first state-based hepatitis C strategy was produced in Victoria and in December 1996, Hepatitis C was incorporated into the Third National Strategy on HIV/AIDS and the Australian National Council on AIDS became the Australian National Council on AIDS and related Diseases (ANCARD) to incorporate hepatitis C.
IN 1998 the first funding was received for the National Hepatitis C Education & Prevention Program among people who use drugs illegally. In 1999 The Commonwealth Government made funding available over four years for community-focused hepatitis C education and prevention initiatives and in June 2000 Australia launches the National Hepatitis C Strategy 1999-2000 to 2003-2004 a world first in terms of comprehensive public health response to hepatitis C.
In 2002 Commonwealth Department of Health and Ageing Funds first ever national meeting of Needle and Syringe Programs (NSP’s) In November 2003 Pegylated combination therapy is listed on Australia’s PBS S100 subsidised drug scheme and then in May 2004 was the launch of the first National Hepatitis C Awareness week. In June 2004 Senate Committee report inquiry into Hepatitis C and Blood supply in Australia then the following year was the launch of National Aboriginal and Torres Strait Islander Sexual Health and Blood Borne Virus Strategy.
The sharing or re-using of contaminated needles and syringes used during drug injecting is the most common mode of hepatitis C transmission in Australia where it can also occur during drug preparation and the injecting process through the sharing or re-using of other contaminated injecting items such as mixing spoons, swabs, water, needles, syringes, syringe plungers and tourniquets. Hands and surfaces used for mixing can also become contaminated during the process. It is important to remember that even the smallest amount of blood that may not be visible to the naked eye can transmit hepatitis C.
The risk of transmission to workers in a health care setting is low and the risk through a health care needle stick injury ranges from 2% to 8%, there have been cases of disease through blood splashes to the eye and these are rare. Hospital and health care environments have infection control procedures and usually if there has been an infection it has been through a break down in procedures. All health care workers and in fact all members of the community should treat all blood with the assumption that it contains a blood borne disease.
Information reduces risk and the risk increases when people are uninformed or is under the influence of drugs, alcohol or suffering from mental health issues. Through education, illegal drug users who inject drugs may use safer injecting practices that will reduce the risk of hepatitis C and AIDS. Now mainstream activities, such as piercings and tattoos have reduced risks through practitioners using standard infection control procedures, assuming everyone and everything has the potential to contain a blood borne disease without any judgement calls.
Pharmacotherapy is the recognised medical treatment to treat opioid dependence and aligns with the Government’s harm reduction policy. It aims to reduce the health, social and economic harms caused by addiction to illicit drugs. It is used as part of a comprehensive treatment program including counselling as well as physical and mental health monitoring and support. Methadone is the most widely and effectively used drug substitution program for heroin dependence and it has an effect similar to heroin and is taken orally. It is part of harm reduction as it reduces the harms associated with drug use and injecting vulnerabilities.
Other prescribed drugs are Naltrexone, Buprenorphine and Suboxone, which are prescribed by Drs and health care professions. A drug overdose can be fatal and getting help must be quick. The concern is that if someone has an overdose from illegal drugs that the person making the call may be in trouble with the Police however in Australia, by law, if someone is at risk an Ambulance must be called and the Ambulance office and call centre operators do not need to call the police unless they are in danger or if there is a death.
Hepatitis C is a notifiable disease and an issue-tested positive is whether they have to tell anyone and this issue is referred to as disclosure. In Australia it is up to the person with hepatitis C or AIDS, to decide whom to tell, when and how. There is no legal requirement to disclose hepatitis C status to anyone except to the Red Cross Blood Service, if entering Australian Defence force or to health care workers who are undertaking procedures where there could be risk.
Those with hepatitis C and AIDS have a contractual relationship to disclose their health status when considering insurance and donation of semen, it is a legal requirement that laboratories notify health departments of all positive hepatitis C diagnosis. These results are used for epidemiologic purposes and Health Departments are bound by law to keep personal information confidential. Discrimination regarding infection of hepatitis C or AIDS either direct or indirect is unlawful. There are fears of transmission and assumptions and judgements made about injecting drug use and about people who inject drugs.
Health care workers have an active and important role to play in reducing and responding to discrimination. In a health care setting, discrimination can be subtle and best practice guidelines should determine the work practices of how to interact with patients with a positive diagnosis. There is currently no vaccine for blood borne diseases, so prevention is not an option, yet the Australian National Drug Prevention Strategy of harm minimisation is working at reducing spread of disease and saving lives.
The approach can be applied with sensitivity to all age groups and to all members of the community and to any drug user regardless of the level of drug use. This strategy underpins all areas of health work and assists those on the ground level implementing policy. Luckily for Australians, Governments and Health Care Policy makers did not put their head in the sand and assume the problems of illicit drug use would go away or that they used a more legal or criminalisation approach to drug use.
Due to Australia’s approach to illicit drug use, today there are around 271,000 infected with hepatitis C and this figure would definitely have been much higher.
References Burton, K, 2004. Illicit drugs in Australia: Use, Harm and Policy Responses. Parliamentary library, [Online]. 1, 1-13. Available at: http://www. aph. gov. au/library/intguide/sp/illicitdrugs. htm [Accessed 01 October 2011]. D, Collins, 2008. National Drug Strategy 2010-2015. 1st ed. Ministerial Council on Drug Strategy : Commonwealth of Australia . Department of Health and Aged Care 200, Hepatitis C: Informing Australia’s National Response.
DHAC, Canberra Department of health and ageing, 2008. National hepatitis c resource manual. 2nd ed. Australian government: PHD publications G, Dore & J, Sasadeusz Editors 2006, Coinfection: HIV & Viral Hepatitis a guide for clinical management. Australasian Society for HIV Medicine Inc. Available at: http://www. ashm. org. au/uploads/File/cionfection-mono. pdf Richters Juliet Ed. ,2006, HIV/AIDS, hepatitis and sexually transmissible infections in Australia. Annual report of trends in behavior 2006. National Centre in HIV Social Research (NCHSR). UNSW.