Targeted primary healthcare for

injecting drug users: client

characteristics, service utilisation
and incremental cost

Md. Mofizul Islam, MSc, MPhil

A thesis submitted in accordance with the

requirements for admission to the degree of
Doctor of Philosophy

School of Public Health and Community Medicine,

University of New South Wales, Sydney, Australia

August 2012

DECLARATION OF ORIGINALITY
I hereby declare that this submission is my own work and to the best of my
knowledge it contains no materials previously published or written by
another person, or substantial proportions of material which have been
accepted for the award of any other degree or diploma at UNSW or any
other educational institution, except where due acknowledgement is made
in the thesis. Any contribution made to the research by others, with whom I
have worked at UNSW or elsewhere, is explicitly acknowledged in the
thesis. I also declare that the intellectual content of this thesis is the product
of my own work, except to the extent that assistance from others in the
project's design and conception or in style, presentation and linguistic
expression is acknowledged.

Signed

Md Mofizul Islam

30 August 2012

ii

ABSTRACT
Injecting drug users (IDUs) experience a range of health problems. Access to primary
healthcare (PHC) is nevertheless often limited for this marginalised group. Many seek
care at emergency departments and some require hospital admission due to late
presentation. Consequently in some settings IDU-targeted PHC services were
introduced to offer low-threshold services. However, few such services have undergone
evaluation, and thus limited data are available to inform health service planning.
This thesis overviews IDUs barriers to healthcare access (Chapter 2), reviews
operational models of IDU-targeted PHC services (Chapter 3) and, using a case study
approach, evaluates the Redfern Harm Minimisation Clinic (RHMC), a needle and
syringe program (NSP)-based PHC in inner-city Sydney, to determine whether this
service attracts its intended clientele and documents clients reasons for presentation
and service utilisation (Chapter 4).
The prevention and management of the hepatitis C virus (HCV), is a key goal of the
RHMC. Chapter 5 examines the patterns of referral uptake and subsequent antiviral
therapy initiation among IDUs referred from RHMC.
It is expected that IDUs disclose their drug use and associated risk when they access
targeted services to ensure the services delivered are not compromised. Chapter 6
examines the reliability of sensitive information provided by IDUs in targeted PHC
services.
Cost is a fundamental issue in evaluation. Chapter 7 estimates the cost of implementing
RHMC, concluding that greater cost efficiencies could be achieved were RHMC to
offer a wider range of services.
The results suggest that by providing non-judgemental and cost-free services under a
harm reduction framework, targeted PHC services mitigate IDUs perceived barriers to
iii

PHC, and highlight the potential of these services to facilitate reductions in liver disease
burden among IDUs. Adoption of a universal precautionary approach to complement
tailored assessment of health risk behaviours is recommended to reduce social stigma
among this group. It is crucial that services are offered with adequate quality and
quantity with minimum cost and a high throughput is necessary to achieve the latter.
This research has limitations and findings should be interpreted cautiously, particularly
in the context of developing countries. Nevertheless, findings suggest ongoing need for
these services until conventional healthcare facilities evolve to offer acceptable and
accessible environments.

iv

ACKNOWLEDGEMENTS
I thank University of New South Wales for providing me with a University International
Postgraduate Award (UIPA), without which I would not have been able to carry out this
research. I would like to express special debt of gratitude to my supervisors Associate
Professor Carolyn Day, Dr Libby Topp and Professor Kate Conigrave for their valuable
guidance on the research throughout my candidature. It has been a great privilege to learn
from a team of supervisors with versatile qualities, to receive outstanding motivation,
intellectual input and essential guidance throughout the course of my research.
Implementation of a PhD research project, which is unfunded and about contentious public
health intervention, is an extremely difficult task. There were many unforseen barriers
including access to required information and quality and quantity of available data. On a
number of occasions I thought this project was never going to be completed. The
uncertainty prompted me to keep Dr Day busy right from the day one. I am indebted to Dr
Day for her patience and dynamic leadership which kept me moving forward. A substantial
part of the credit goes to Dr Day, who may remember me as one of the most demanding
students.
I was extremely fortunate to have Dr Topp in the supervisory team. Her love and affection
together with her great analytical and writing skills were important to help navigate me
through this difficult journey. I will remember Dr Topp as an excellent researcher, and will
cherish the many great qualities she possesses.
My research career in public health started with the incredible guidance of Professor
Conigrave in 2006 during my MSc at Sydney University, when the foundation of my PhD
research was laid down. Although during the last three years she has played a smaller role
than during my MSc, it has been crucial for timely completion of this thesis. She remains as
my constant source of inspiration.
I am indebted to the clinical nurse consultant of Redfern Harm Minimisation Clinic
(RHMC), my friend Ann White, a person I found to be very honest and supportive

throughout. I will be delighted if her belief about the potentials of my research in bringing
fortunes for her clinic comes true.
I am grateful to the Drug Health Service of Sydney Local Health District for allowing me to
carry out this research into RHMC, and giving me ancillary support. Very special thanks to
Prof Paul Haber for being supportive throughout my candidature. I thank all the staff
especially Stephen Hayes and Sara Grummett of RHMC, Ms Sarah Hutchinson and Lucia
Evangelista of Drug Health Service at the Royal Prince Alfred Hospital for their support. I
also gratefully acknowledge all the co-authors of papers arising from or supporting this
thesis, especially Dr Angela Dawson and Dr Ingrid van Beek.
I thank Dr Topp, A/Professor Day and Professor Lisa Maher for giving me opportunities of
working with the people who inject drugs, and of getting close to those whose healthcare is
the centre point of this thesis. In addition to all the academic stimulation, the material
support I received particularly from Dr Topp, Dr Day and Prof Haber was crucial for me
and my family here in Australia.
During the last three and a half years I learnt many things and experienced many
circumstances which I was unfamiliar with. Undoubtedly these experiences helped me
embrace reality. Doctoral research for a highly motivated overseas student with inherent
strong beliefs but limited luck is a voyage with many untold sufferings, happiness, pains
and achievements. My homage is to all who were with me in this journey. I apologise if
anybody misunderstood me or was hurt for any of my activities whatever I did was in
good faith and with honest intention.
I dedicate this thesis to my parents who sacrificed everything of their lives to ensure true
education for their children.
I gratefully acknowledge the sacrifices of my wife SAMINA, and of our little FEEHA who
still believes I love my laptop more than I love her. Soon she will realise I love her more
than I love anything else in the universe.

vi

TABLE OF CONTENTS
DECLARATION OF ORIGINALITY ......................................................................... II
ABSTRACT ................................................................................................................... III
ACKNOWLEDGEMENTS ............................................................................................ V
TABLE OF CONTENTS ............................................................................................. VII
LIST OF TABLES ....................................................................................................... XIIi
LIST OF FIGURES .....................................................................................................XIV
ABBREVIATIONS ....................................................................................................... XV
CHAPTER 1: INTRODUCTION ................................................................................... 1

CHAPTER 2: . INJECTING DRUG USERS COMMON HEALTH PROBLEMS,

BARRIERS TO HEALTHCARE ACCESS AND THE CONTEXT
OF TARGETED HEALTHCARE ......................................................... 8
2.1

INJECTING DRUG USE AND ASSOCIATED HEALTH PROBLEMS................ 9

2.1.1

PREVALENCE OF INJECTING DRUG USE ........................................................ 9

2.1.2

INJURIES AND INFECTIONS DIRECTLY RELATED TO INJECTING ................. 10

2.1.3

OTHER INFECTIOUS DISEASES .................................................................... 21

2.1.4

NON-INFECTIOUS DISORDERS .................................................................... 25

2.1.5

OTHER COMMON HEALTH PROBLEMS ........................................................ 31

2.2

BARRIERS TO ACCESS TO HEALTHCARE ................................................. 35

2.2.1

STRUCTURAL OR SYSTEM BARRIERS ......................................................... 37

2.2.2

INTERPERSONAL BARRIERS........................................................................ 38

2.2.3

MATERIAL AND SOCIAL BARRIERS ............................................................ 42

2.3

CONTEXT OF TARGETED PRIMARY HEALTHCARE FOR IDUS ............... 43

2.4

CONCLUSION ............................................................................................. 44

vii

CHAPTER 3: PRIMARY HEALTHCARE SERVICES THAT TARGET

INJECTING DRUG USERS: A NARRATIVE SYNTHESIS OF
LITERATURE ........................................................................................ 46
3.1

METHODS .................................................................................................. 47

3.2

RESULTS .................................................................................................. 52

3.2.1

OPERATIONAL MODELS ............................................................................. 52

3.2.2

ACCESSIBILITY AND ACCEPTABILITY OF IDU-TARGETED PHC ............... 58

3.2.3

IMPACTS ON HEALTH OUTCOMES .............................................................. 64

3.2.4

COST IMPLICATIONS .................................................................................. 66

3.2.5

OPERATIONAL CHALLENGES ..................................................................... 67

3.3

DISCUSSION ............................................................................................... 68

3.3.1

LIMITATIONS .............................................................................................. 72

3.4

CONCLUSION ............................................................................................. 74

CHAPTER 4: CLIENT CHARACTERISTICS AND SERVICE

UTILISATION OF A LOW-THRESHOLD PRIMARY
HEALTHCARE CENTRE BASED AT AN INNER-CITY
NEEDLE SYRINGE PROGRAM ...................................................... 76
4.1

METHOD .................................................................................................... 81

4.1.1

REDFERN H ARM MINIMISATION CLINIC AND ITS SERVICE PROVISION .... 81

4.1.2

PROCEDURES .............................................................................................. 82

4.1.3

REFERRALS AND FOLLOW- UP .................................................................... 83

4.1.4

DATA COLLECTION AND ANALYSIS ........................................................... 84

4.2

RESULTS .................................................................................................... 85

4.2.1

SAMPLE CHARACTERISTICS ....................................................................... 85

4.2.2

PATTERNS OF DRUG USE ............................................................................ 85

4.2.3

BLOOD -BORNE VIRUS SEROLOGICAL STATUS, VACCINATION UPTAKE AND

INJECTING RISK BEHAVIOURS .................................................................... 87

4.2.4

CURRENT ACCESS TO GP SERVICES........................................................... 87

viii

4.2.5

COMPARISON BETWEEN IDUS ACCESSING RHMC AND BROADER

SAMPLES OF IDUS...................................................................................... 89

4.2.6

MAIN REASONS FOR PRESENTATION .......................................................... 89

4.2.7

SERVICE UPTAKE AND REFERRAL .............................................................. 89

4.2.8

THE ROLE OF RHMC IN PROVIDING OPPORTUNISTIC HEALTHCARE ........ 93

4.3

DISCUSSION ............................................................................................... 98

4.3.1

PATTERNS OF DRUG USE .......................................................................... 100

4.3.2

COMPARISON BETWEEN IDUS ACCESSING RHMC AND ANSPS

PARTICIPANTS .......................................................................................... 100

4.3.3

REFERRAL UPTAKE .................................................................................. 102

4.3.4

LIMITATIONS ............................................................................................ 104

4.4

CONCLUSION ........................................................................................... 105

CHAPTER 5: ROLE OF RHMC IN HEPATITIS C TREATMENT

ASSESSMENT AND ANTIVIRAL TREATMENT
COMMENCEMENT .......................................................................... 107
5.1

METHOD .................................................................................................. 108

5.1.1

CHARACTERISTICS OF THE COHORT ........................................................ 108

5.1.2

THE RHMC MODEL OF HCV CARE ......................................................... 109

5.1.3

DATA COLLECTION AND ANALYSIS ......................................................... 111

5.2

RESULTS .................................................................................................. 112

5.2.1

CLIENT PROFILE ....................................................................................... 112

5.2.2.

FACTORS ASSOCIATED WITH REFERRAL AND REFERRAL UPTAKE .......... 117

5.2.3

CHARACTERISTICS OF CLIENTS WHO COMMENCED AVT ....................... 117

5.3

DISCUSSION ............................................................................................. 120

5.3.1

CHARACTERISTICS OF REFERRALS, NON -REFERRALS AND NON -ATTENDEES

.................................................................................................................. 120
ix

5.3.2

CHARACTERISTICS OF TREATMENT INITIATORS ...................................... 122

5.3.3

LIMITATIONS ............................................................................................ 124

5.4

CONCLUSION ........................................................................................... 125

CHAPTER 6: THE RELIABILITY OF SENSITIVE INFORMATION

PROVIDED BY INJECTING DRUG USERS IN A CLINICAL
SETTING OF TARGETED HEALTHCARE: WHAT
STRATEGIES TO BE FOLLOWED? ............................................. 127
6.1

METHOD .................................................................................................. 130

6.1.1

ELIGIBILITY CRITERIA.............................................................................. 130

6.1.2

PROCEDURE ............................................................................................. 131

6.1.3

CONSENT AND ETHICS ............................................................................. 133

6.1.4

DATA ANALYSIS ....................................................................................... 133

6.2

RESULTS .................................................................................................. 134

6.3

DISCUSSION ............................................................................................. 140

6.3.1

LIMITATIONS ............................................................................................ 143

6.4

CONCLUSION ........................................................................................... 144

CHAPTER 7: THE COST OF PROVIDING PRIMARY HEALTHCARE

SERVICES FROM A NEEDLE AND SYRINGE PROGRAM: A
CASE STUDY ...................................................................................... 147
7.2

METHOD .................................................................................................. 148

7.2.1

RHMC MODEL OF CARE .......................................................................... 149

7.2.2

COST DATA............................................................................................... 150

7.3

RESULTS .................................................................................................. 153

7.4

DISCUSSION ............................................................................................. 159

7.4.1

LIMITATIONS ............................................................................................ 163

7.5

CONCLUSION ........................................................................................... 163

CHAPTER 8: GENERAL DISCUSSION ................................................................. 164

8.1

OVERVIEW OF MAIN FINDINGS .............................................................. 164

8.2

ACCESSIBILITY AND ACCEPTABILITY OF TARGETED SERVICES ......... 166

8.3

THE ROLE OF RHMC IN PREVENTION AND REDUCTION OF LIVER

DISEASE ................................................................................................... 170

8.4

UNIVERSAL H EALTH INSURANCE IS IMPORTANT BUT NOT SUFFICIENT

................................................................................................................. 170

8.5

SERVICE UTILISATION IN DIFFERENT SETTINGS .................................. 172

8.6

IMPLICATIONS OF THE FINDINGS AND FUTURE RESEARCH ................. 175

8.7

GENERALISABILITY OF THE RESEARCH ............................................... 178

8.8

LIMITATIONS .......................................................................................... 182

8.9

CONCLUSION ........................................................................................... 183

REFERENCES .............................................................................................................. 185

APPENDIX I: PRISMA C HECKLIST ............................................................................ 236

APPENDIX II: RESEARCH PROJECTS UNDERTAKEN AS PART OF THE CANDIDATURE240
APPENDIX III: LIST OF PUBLICATIONS ARISING FROM AND SUPPORTING THIS THESIS
................................................................................................................. 242

PEER REVIEWED PUBLICATION ARISING FROM THESIS............................ 242

OTHER PEER REVIEWED PUBLICATIONS SUPPORTING THIS THESIS
UNDERTAKEN DURING THE CANDIDATURE .............................................. 244

CONFERENCE PRESENTATIONS ................................................................ 245

APPENDIX IV: PUBLICATIONS ARISING FROM AND SUPPORTING THIS THESIS.........247
APPENDIX V: PATIENT ASSESSMENT FORM OF RHMC.........................................................247
APPENDIX VI: FILEMAKER PRO DATABASE USED IN RHMC..............................................247

xi

LIST OF TABLES
TABLE 2.1

COMMON HEALTH PROBLEMS ASSOCIATED WITH INJECTING DRUG USE .. 11

TABLE 2.2

COMMON BARRIERS TO ACCESS TO HEALTHCARE BY IDUS ..................... 36

TABLE 3.1

TABLE STATING THE CRITERIA OF LITERATURE SUITABLE FOR

A NARRATIVE SYNTHESIS .......................................................................... 50

TABLE 3.2

SERVICES PROVIDED , STAFFING AND REPORTED ACCESSIBILITY AND

ACCEPTABILITY OF PRIMARY HEALTHCARE FACILITIES FOR IDUS .......... 55

TABLE 3.3

KEY THEMES ASSOCIATED WITH ACCESSIBILITY , ACCEPTABILITY AND

OPERATIONAL PROBLEMS OF IDU-TARGETED PHC FACILITIES ............... 61

TABLE 4.1

PATTERNS OF SUBSTANCE USE BY CLIENTS OF RHMC IN THE

PRECEDING 12 MONTHS (N=363) ............................................................... 86

TABLE 4.2

CORRELATES OF ACCESS TO GP SERVICES AMONG 359 RHMC CLIENTS 88

TABLE 4.3

COMPARISON BETWEEN RHMC ATTENDEES AND NSW ANSPS

PARTICIPANTS 2006-2009 ......................................................................... 91

TABLE 4.4

REFERRALS AND REFERRAL UPTAKE FOR HEALTH AND WELFARE SERVICES

.................................................................................................................... 92

TABLE 5.1

CHARACTERISTICS OF HCV RNA POSITIVE CLIENTS AND COMPARISON

BY HEPATITIS C TREATMENT REFERRAL AND ATTENDANCE

TABLE 5.2

.................. 113

COMPARISON BETWEEN THOSE WHO DID AND DID NOT COMMENCE HCV
TREATMENT ( AMONG 68 LIVER CLINIC ATTENDEES) .............................. 119

TABLE 6.1

FIVE SENSITIVE QUESTIONS THAT WERE COMMON BOTH IN FFI

AND

ACASI ............................................................................................. 132

xii

TABLE 6.2

DEMOGRAPHIC CHARACTERISTICS OF 173 PARTICIPANTS AND

RELATIONSHIP TO DISCORDANCE IN RESPONSES TO SENSITIVE
QUESTIONS ............................................................................................... 135

TABLE 6.3

COMPARISON OF RESPONSES PROVIDED IN ACASI AND FFI

TO BINARY ITEMS ..................................................................................... 138

TABLE 6.4

COMPARISON OF RESPONSES PROVIDED IN ACASI AND FFI

TO NON-BINARY ITEMS ............................................................................ 139

TABLE 7.1

ESTIMATED INCREMENTAL COST OF ADDING A PHC SERVICE TO AN

EXISTING NSP, 2009-10, AU$ (2009) .................................................... 154

TABLE 7.2

CURRENT AND PROJECTED AVERAGE COST PER OCCASION OF SERVICE

PROVIDED BY THE RHMC CLINIC (AU$) ................................................ 156

TABLE 7.3

ESTIMATED COST FOR 2009-10 WITH VARIATION OF RELEVANT

PARAMETERS ............................................................................................ 158

xiii

LIST OF FIGURES
FIGURE 3.1

PREFERRED REPORTING D IAGRAM FOR SYSTEMATIC REVIEWS AND

META-ANALYSES (PRISMA) SHOWING SELECTION
PUBLICATIONS FOR REVIEW

FIGURE 5.1

...................................................................... 48

FLOWCHART OF THE REFERRAL PATHWAYS FOR HCV POSITIVE

CLIENTS AT THE RHMC

FIGURE 5.2

OF

.......................................................................... 110

FLOWCHART OF DIAGNOSIS, REFERRAL AND TREATMENT PATHWAYS

FOR ALL CLIENTS...................................................................................... 116

FIGURE 7.1

TREND OF AVERAGE COST PER OCCASION OF SERVICE AS ATTENDANCE

INCREASES UP TO FULL UTILISATION LEVEL ........................................... 158

xiv

ABBREVIATIONS
ACASI

Audio Computer-assisted Self-Interviewing

AIDS

Acquired Immune Deficiency Syndrome

ALT

Alanine Transaminase

ANSPS

Australian Needle and Syringe Program Survey

AOR

Adjusted Odds Ratios

AU$

Australian Dollar

AVT

Antiviral Treatment

BBVIs

Blood borne Viral Infections

CDC

Centres for Disease Control

CI

Confidence Intervals

CNC

Clinical Nurse Consultant

DSM

Diagnostic and Statistical Manual of Mental Disorders

ED

Emergency Department

EMCDDA

European Monitoring Centre for Drugs and Drug Addiction

FFI

Face-to-face Interview

FTE

Full-time Equivalent

GP

General Practitioner

HAART

Highly Active Antiretroviral Therapy

HAVIT

Hepatitis B Acceptability and Vaccination Incentive Trial

HBV

Hepatitis B Virus

HBcAb

Hepatitis B core antibody

HCV

Hepatitis C Virus

HIV

Human Immunodeficiency Virus

ICD

International Classifications of Diseases

IDU

Injecting Drug User

KRC

Kirketon Road Centre, Sydney

xv

MMT

Methadone Maintenance Therapy

MO

Medical Officer

MSIC

Medically Supervised Injecting Centres

NIDU

Non-injecting Drug User

NSP

Needle Syringe Program

NSW

New South Wales

OST

Opioid Substitution Therapy

PCR

Polymerase Chain Reaction

PHC

Primary Health Care

RHMC

Redfern Harm Minimisation Clinic

RN

Registered Nurse

RPAH

Royal Prince Alfred Hospital

SD

Standard Deviation

STI

Sexually Transmitted Infections

SVR

Sustained Virological Response

TB

Tuberculosis

USA

United States of America

WHO

World Health Organization

xvi

Chapter 1

CHAPTER 1:
Introduction
Injecting drug users (IDUs) experience a wide range of health problems (Darke &
Ross, 1997; Stein, 1999; Haber, et al., 2009; Latt, et al., 2009). Although most of
these health problems are preventable and/or treatable in primary healthcare settings,
access to primary healthcare (PHC) is often limited for this marginalised group.
Many seek care at emergency departments (EDs) and some require hospital
admission due to late presentation. Barriers to healthcare, subsequent poor health
outcomes and the considerable costs of emergency treatments have led authorities in
some settings to establish IDU-targeted PHC services, using a number of models.
These are low-threshold services and facilitate PHC provision by removing many
of the barriers faced by IDUs when accessing conventional health services. For
instance, unlike conventional settings, low-threshold facilities do not impose
abstinence from drug use as a condition of service access; and clients do not need to
set an appointment or produce identification. Services can be provided on a drop-in,
anonymous basis and are usually free-of-charge. Health insurance and government
benefits are not required to access services (Fernandez, McNeill, Haskew, & Orr,
2006; Islam, Day, & Conigrave, 2010; Islam, Topp, Day, Dawson, & Conigrave,
2012a).

However, insufficient evidence exists on the effectiveness of these services to inform

health service planning. Allocation of limited resources for healthcare targeting
IDUs creates budgetary pressure, which may be unacceptable in settings where
substantial opposition to harm reduction policies exists. Evidence about the

Chapter 1
effectiveness of these services, however, may minimise concerns, and favourable
outcomes may help secure necessary funding for maintaining and/or extending these
services.

To understand the context in which targeted services have been implemented, it is

necessary to assess IDUs common health problems and barriers to their access to
healthcare and the consequences of late presentation to healthcare. Chapter 2
therefore describes the health problems commonly experienced by IDUs that are
directly and indirectly related to injecting drug use; barriers to accessing
conventional healthcare services experienced by IDUs; and the rationale for the
introduction of targeted primary healthcare.

The specific model of targeted PHC services chosen in a given setting will be
influenced by factors ranging from the socio-demographic characteristics of the
target group to the class, form and availability of their preferred drug(s). Such
variations have resulted in the establishment of setting-specific and often
idiosyncratic services, making broad evaluations and reviews difficult and limiting
the generalisability of findings. However, identifying commonalities across the range
of services, irrespective of geographical setting, is important. It is necessary to
document whether these services are accessible to the target group in terms of
reducing barriers to access to care; and whether they are acceptable in terms of
clients return rate, perceived staff attitudes, and uptake of referrals to other services.
Accordingly, Chapter 3 reviews the existing operational models of IDU-targeted
PHC services and assesses the accessibility and acceptability of these services to the
target population. The findings from evaluations of these PHCs are synthesised with

Chapter 1
respect to their impact on health outcomes, cost implications and operational
challenges.
A useful complement to the synthesis of the review would be studying a specific
targeted service. Such an empirical study is likely to provide detailed information on
client characteristics and service utilisation. However, to rigorously evaluate the
effectiveness of such a service using the hierarchy of evidence commonly applied to
health and medical interventions is methodologically challenging (van Beek, 2012).
For instance, a randomised controlled trial (RCT) the gold standard in evaluation
is often not possible due to ethical and pragmatic concerns (Sanson-Fisher,
Bonevski, Green, & D'Este, 2007). Other evaluation designs such as cluster RCTs or
multiple baseline design require numerous services operating with identical or very
similar models of care and thus substantial funding for their establishment. No such
trials have been conducted to date. Key questions can, however, be answered using a
case-study approach. Firstly, are such services accessed by the target group they are
designed for? Attracting the target group is a fundamental step, and therefore a
necessary measure in any evaluation of these services. Other pertinent questions
include whether the services can provide continuity of care as measured by client
return rate. Client return rate is also likely to reflect service accessibility and/or need.

To attract IDUs most targeted healthcare services aim to ensure situational

availability (Islam & Conigrave, 2007b) by offering services from locations already
frequented by IDUs. For instance, under some models of targeted healthcare
provision, clients presence in an NSP or opioid substitution therapy (OST) service is
utilised opportunistically by healthcare workers to offer much needed healthcare.

Chapter 1
Standalone targeted PHC services in red-light districts attract clients by their
convenient locations and/or offering light refreshments. Thus it is appropriate to
examine whether such a service ensures situational availability and opportunistic
healthcare.

Although the assessments outlined above do not provide a firm foundation for a
rigorous outcome evaluation, they are necessary first steps in amassing a preliminary
evidence base which can be used in the absence of hard evidence, and indeed may
facilitate the development of hard evidence. Consequently a retrospective study of a
targeted PHC, the Redfern Harm Minimisation Clinic (RHMC), an NSP-based PHC
in inner-city Sydney, is presented in Chapter 4. This study examines whether this
targeted service attracts and retains the clients for which it was designed, and
documents clients reasons for presentation. The Chapter also documents the
preventative and other healthcare services provided and investigates uptake of
referrals made to other health and social services.

The high prevalence of hepatitis C virus (HCV)-related liver disease among IDUs is
a serious global health concern. In Australia, approximately 197 000 people are
living with chronic HCV infection and an estimated 10 000 new HCV infections
occur each year (Ministerial Advisory Committee on AIDS Sexual Helath and
Hepatitis, 2006; Razali et al., 2007). Projections suggest that the number of people
undertaking HCV treatment need to treble in the near future for the associated
disease burden to be contained (Ministerial Advisory Committee on AIDS Sexual
Helath and Hepatitis, 2006). Although the effectiveness of HCV treatment continues
to improve, there remain substantial barriers to commencement of antiviral therapy

Chapter 1
(AVT) among IDUs (Grebely et al., 2008). Targeted healthcare services are a
strategically important point of contact for HCV prevention and management. Indeed
in settings such as Australia HCV prevention is a key goal of the NSP services where
targeted PHC services are co-located. Although there are notable exceptions (van
Beek, 2007), the specialised nature of HCV treatment often precludes the provision
of HCV treatment directly through such services. Targeted PHC services
nevertheless play an important role in engaging IDUs and referring them to HCV
treatment facilities. Thus it is important to examine the efforts and achievements of
these services with respect to that goal. Chapter 5 examines the patterns and
correlates of uptake of referrals made for RHMC clients to a tertiary liver clinic and
subsequent AVT initiation.

Injecting drug use is a highly stigmatised activity (Simmonds & Coomber, 2009).
The chaotic lifestyles often associated with illicit drug use, burden of HCV and other
infectious diseases and related discrimination result in a heightened level of social
stigma for IDUs. This stigma creates potential barriers to IDUs access to
appropriate healthcare in several ways (Day, Ross, & Dolan, 2003; Link & Phelan,
2006). Non-disclosure of stigmatised behaviours, known as social desirability
response bias, is one such barrier. The literature suggests that many IDUs who claim
to have access to healthcare do not disclose their drug use and associated risk and/or
its extent to their provider (Islam et al., in press; Western Australian Network of
Alcohol and Other Drug Agencies, 2009), when this occurs the quality of healthcare
services delivered may be compromised. Targeted PHCs are tailored to the needs of
the target group, and are necessarily low-threshold; therefore social desirability
response bias may be reduced. In research settings, there are a number of techniques

Chapter 1
for reducing this bias, including detection, measurement and adjustment for social
desirability effects, randomised response techniques, self-interviewing methods and
indirect questioning (Nederhof, 1985). However, the degree of social desirability
bias has not been measured in the clinical environment of a targeted PHC setting.
Chapter 6 examines the extent of socially desirable responses reported by IDUs
accessing services from two targeted PHC services by comparing their self-reported
information about drug and sexual risk taking elicited via clinical face-to-face
interview and by audio computer assisted self-interviewing (ACASI) methods.

Cost is a fundamental consideration in any evaluation and crucial to any agency

wishing to introduce new services. Indeed, the long-term sustainability of any
healthcare service is dependent upon the resources required. Although a cost
effectiveness analysis would be the most appropriate tool to evaluate the economic
implications of targeted healthcare services, there are substantial methodological
challenges as different services attract different subgroups of clients. There is
currently no information available on the costs of an augmented-PHC service that
primarily targets IDUs. A useful assessment of performance can be made with cost
data that are related to program performance, such as coverage by a specific service
(Creese & Parker, 1994). Chapter 7 presents an economic analysis which assesses
the additional cost (incremental cost) of offering PHC from an existing NSP setting,
estimates the costs of PHC activities per occasion of service, and identifies key
factors influencing improved service utilisation by the target population.

Chapter 1
Finally, the findings of this research and their public health implications are
discussed in Chapter 8. The limitations of the research, its generalisability to other
settings and further research directions are also outlined.

In summary, this thesis reviews operational models of IDU-targeted PHC services

and, using a case study approach, evaluates the RHMC, an IDU-targeted PHC
service located in inner-city Sydney, in terms of accessibility and acceptability of
these services to the target population, cost implications and operational challenges.
Results have important public health implications for PHC delivery and service
improvement for IDUs, and these implications are discussed for various settings.

Chapter 2

CHAPTER 2
Injecting drug users common health problems,
barriers to healthcare access and the context of
targeted healthcare
IDUs are at risk of a wide range of health problems arising from non-sterile injecting
practices, complications of the drug itself or of the lifestyle associated with illicit
drug use and dependence (Darke & Ross, 1997; Haber, Demirkol, Lange, &
Murnion, 2009; Latt, Conigrave, Saunders, Marshall, & Nutt, 2009; Stein, 1999). In
addition to complications of drug injection, unrelated health problems, such as
diabetes, may be neglected due to preoccupation with the drug of dependence.
However, despite this high need, for a variety of reasons IDUs are reluctant to access
conventional health and social services (Day, Ross, et al., 2003; French, McGeary,
Chitwood, & McCoy, 2000; Morrison, Elliott, & Gruer, 1997). Many IDUs,
particularly younger people, dislike being identified as drug users (Islam, Stern,
Conigrave, & Wodak, 2008). Therefore, even when healthcare is accessed,
disclosure of injecting is unlikely, and consequently health needs related to their
injecting may be ignored. Moreover, healthcare needs may be complicated by
homelessness and exacerbated by poor nutrition, mental health problems, abuse or
violence, difficulty maintaining hygiene, and chaotic drug use (Anex, 2005; Rowe,
2004; Wright & Tompkins, 2006). Consequently, a significant proportion of IDUs
fail to seek healthcare at an appropriate time, resulting in deterioration of overall
health (Morrison et al., 1997) until emergency treatment is required. This reliance on

Chapter 2
emergency departments (ED) and hospitals consequently creates additional pressure
on limited healthcare budgets (French et al., 2000).

To better understand this phenomenon this chapter describes: i) the health problems
IDUs may experience that are directly and indirectly related to injecting drug use; ii)
the barriers to accessing conventional healthcare services experienced by IDUs; and
iii) the rationale for the introduction of targeted PHC services.

2.1 Injecting drug use and associated health

problems
2.1.1 Prevalence of injecting drug use
Injecting drug use is well established throughout the world and appears to be
emerging in many countries where it has previously been unreported (UNAIDS,
2009). By 2008, injecting drug use had been reported in 148 countries and territories
(Mathers et al., 2008), 19 countries more than in 1998 (Ball, Rana, & Dehne, 1998).
These 148 countries account for 95 percent of the worlds total population. The
prevalence of injecting drug use varies considerably around the world, both between
and within countries. It is estimated that in 2008, 16 million (range 1121 million)
people worldwide injected drugs worldwide (Mathers et al., 2008). Many developing
countries already have substantial problems associated with drug use, but among
other competing health priorities, injecting drug use often fails to receive enough
attention from policymakers (World Health Organization, 2000).

Chapter 2

2.1.2 Injuries and infections directly related to injecting

Injecting-related injuries
IDUs suffer high levels of morbidity and mortality arising from injecting practices
(both sterile and non-sterile); complications of the drug itself or of the lifestyle
associated with illicit drug use and dependence (Table 2.1); and/or unrelated health
problems that may be neglected due to a preoccupation with drug use (Latt et al.,
2009). Injecting is the most harmful route of illicit drug administration. Indeed, poor
injecting practices can lead to a number of injuries. Repeated injecting at the same
site, injecting with a barbed or blunt needle, injecting without having venous access
or inadvertent arterial injection are practices which potentially cause injury (Dwyer
et al., 2009; Salmon et al., 2009; Topp, Iversen, Conroy, Salmon, & Maher, 2008).
However, most of the studies investigating this issue are of cross-sectional design,
and rely on self-reported information from the IDUs (Hope, 2010). Repeated
injecting into the same site may cause local ischemia or necrosis and the tissue may
become susceptible to infection, with an array of bacteria (Cherubin & Sapira, 1993;
Scheidegger & Zimmerli, 1989). Bruising, scarring, swelling at the injecting site,
venous and arterial trauma, and ulcers are injuries that are directly related to poor
injecting practices.

10

Chapter 2

Table 2.1 Common health problems associated with injecting drug use
Injuries and infections directly related to injecting
Injecting-related injuries

Bruising
Scarring
Swelling and inflammation including urticaria
Venous injury
Arterial injury
Ulcers

Injecting-related infections and

complications

Cellulitis and abscess

Thrombophlebitis
Bacteraemia and septicaemia
Musculoskeletal infections
Endovascular complications

Blood-borne virus

Viral hepatitis (hepatitis B and C)

HIV/AIDS

Other infectious diseases

Sexually transmitted infections

Sexually transmitted infections

Respiratory infections

Respiratory tract infections

Tuberculosis (TB)

Non-infectious disorders
Drug dependence and drug use related
disorders
Psychiatric disorders
Other common health problems
Pain
Overdose
Poor dental condition/hygiene
Constipation

11

Chapter 2

Injecting-related infections and complications

There are numerous injecting-related infections, but few clinically validated studies
of such infections (Binswanger, Kral, Bluthenthal, Rybold, & Edlin, 2000; LloydSmith et al., 2008). Cellulitis and skin abscesses are common injecting-related
infections and often co-occur (Stein, 1999; World Health Organization, 2009).
Microbiological studies of soft tissue infections (Orangio et al., 1983) have
demonstrated that infections in IDUs are acquired mainly either from their
commensal flora or from organisms contaminating the drugs, drug adulterants, or
paraphernalia. In a study of a small sample of IDUs opportunistically recruited from
EDs in a New York hospital, Orangio et al (1984) found that 29 of the 38 IDUs
tested were infected with various organisms. Beta haemolytic streptococci and
staphylococcus aureus represented almost half of the pathogens isolated. Individuals
who inject for several years are at risk of developing chronic and recurrent abscesses
that may be related to colonisation with an abscess-inducing subspecies of a common
skin bacterium (Staphylococcus aureus) (World Health Organization, 2009). If
injecting-related soft tissue infections are not treated appropriately, this may result in
serious complications including osteomyelitis, septicaemia, and amputation
(Giudice, 2004; Lloyd-Smith et al., 2005).

Bacteraemia and septicaemia indicate the presence of bacteria in the bloodstream

(Stein, 1999). Either can lead to complications such as endocarditis, septic embolism
and tetanus of the wound. Poverty, poor nutrition, poor dental hygiene and/or
condition and leg ulcers may also contribute to bacteraemia (World Health
Organization, 2009). Among IDUs, musculoskeletal infections, including septic
arthritis and osteomyelitis, generally result from hematogenous seeding or, less
12

Chapter 2
commonly, local extension of a skin or soft-tissue infection. These infections may be
indolent, and the only symptom may be pain without fever (Chandrasekar & Narula,
1986; Sapico & Montgomerie, 1980). Musculoskeletal infections may be
polymicrobial or anaerobic, especially if the injecting site, equipment, and/or drugs
are contaminated with saliva (Gordon & Lowy, 2005). This may occur when a drug
designed for oral administration such as methadone or sublingual administration
such as buprenorphine, is secreted in the mouth and subsequently injected.

Endovascular infections, including infective endocarditis, septic thrombophlebitis,

mycotic aneurysms, and sepsis, are among the most serious complications of
injecting drug use (Gordon & Lowy, 2005; World Health Organization, 2009).
Some injecting-related problems are associated with the use of certain drug types and
preparation. Injection of pharmaceutical preparations such as methadone syrup and
temazepam gel capsules is associated with abscess, fistulas, venous thrombosis and
high rates of digital and limb amputation (Aitken & Higgs, 2002; Jensen &
Gregersen, 1991). Rare but serious complications of injection of crushed tablets
include talc granulomatosis or pulmonary fibrosis (Griffith, Raval, & Nichols, 2012;
Roberts, 2002). The anaesthetic properties of cocaine can limit an individuals ability
to determine whether they have venous access (as opposed to injecting in the
surrounding tissue or skin). This frequently results in trauma through repetitive
attempts to access the vein (MSIC Evaluation Committee, 2003; Rhodes, Briggs,
Kimber, Jones, & Holloway, 2007). Unsuccessful venous access increases
vulnerability to infections since injecting into the surrounding tissue creates a niche
environment in which bacteria can thrive (Lloyd-Smith et al., 2008). Injection of
heroin and cocaine combinations (also known as speedballs) increases the risk of

13

Chapter 2
abscesses and cellulitis, which a case-control study conducted in San Francisco
found to be three times higher for those who used this combination than those who
did not (Murphy et al., 2001).

Drug adulterants can also potentially cause complications. The association between
black-tar heroin and clostridial infections is an example of infections related to
adulterants. Black-tar heroin becomes contaminated with spores when mixed with
adulterants (e.g., methamphetamine or strychnine) or diluted (cut) with substances
such as dextrose or dyed paper. Although black-tar heroin is typically heated in
water before use, clostridial spores survive boiling and may even begin to germinate
(Passaro, Werner, McGee, Mac Kenzie, & Vugia, 1998; Werner, Passaro, McGee,
Schechter, & Vugia, 2000). Intravenous use of black-tar heroin causes venous
sclerosis and promotes the practice of skin popping (subcutaneous or
intramuscular injection) with the loss of usable veins (Gordon & Lowy, 2005).

Injecting crushed tablets, even if filtered, can lead to the introduction of undissolved
(particulate) matter, especially through larger-bore needles (Degenhardt et al., 2006).
The number of particles can be greatly reduced by filtration (McLean, Bruno,
Brandon, & de Graaff, 2009) but insoluble particulates include talc, cornstarch,
cellulose, magnesium stearate and waxes, the injection of which can cause
complications such as embolism, ischemic disease and necrosis (McLean et al.,
2009). Injection of insoluble matter into an artery can result in tissue loss and
possible amputation (Del Giudice, 2004). When a tablet of slow-release morphine
(MS Contin) is crushed and mixed with water, the resulting mixture contains
millions of particles, of sizes from less than 5 m to greater than 400 m (McLean et

14

Chapter 2
al., 2009). These particles will cause great harm if injected into the bloodstream.
Injecting the contents of filters can cause irritation of lining and/or blockage of veins
through the introduction of particulate matter. Adding too little water to the solution
to be injected can create a thick sludge that damages the vein by entering under
high pressure. Although finer bore needles are recommended to reduce vein damage,
they can cause damage by increasing the pressure under which fluid and particulate
matter enter the vein.

The form of heroin traditionally available in Australia was the soluble white form
originating from the Golden Triangle region of South East Asia (Maher, Swift, &
Dawson, 2001). Since 2001 heroin has been less pure with increasing reports of
brown heroin (Stafford & Burns, 2010), which is understood to be heroin in its
alkaline form (Australian Crime Commission, 2012; Day, Topp, et al., 2003). In
many settings outside Australia, street heroin tends to be mostly brown and is sold in
poorly soluble alkaline form (King, 1997). An acid is often added to alkaline heroin
to make it soluble (Scott, Winfield, Kennedy, & Bond, 2000). Acids that can be used
to facilitate solubility in this way include citric, ascorbic, acetic and lactic acids.
Lemon juice is commonly used and both its packaged and fresh forms can carry
fungal infections, which, when injected, can infect the heart (endocarditis) or eyes
(candidal endopthalmitis;a fungal infection of the eyes that can lead to blindness)
(Albini, Sun, Holz, Khurana, & Rao, 2007). This complication has also been
reported following injecting of buprenorphine tablets diverted from the individuals
or someone elses mouth, as candida and many other fungi and bacteria are found in
the mouth (Queensland Injectors Health Network, 2012). However, these are

15

Chapter 2
fortunately relatively rare complications and published literature is mostly based on
case studies.

Blood-borne viral infections

Sharing of contaminated injecting equipment is a major risk factor for the acquisition
of blood-borne viral infections (BBVIs), notably the HCV, the hepatitis B virus
(HBV) and the human immunodeficiency virus (HIV). Among IDUs, sharing of
contaminated equipment is the primary mode of BBVIs (Crofts & Aitken, 1997;
Stimson, Jarlais, & Ball, 1998), although HIV (Degenhardt et al., 2010) and HBV
(Alter, 2003) can also be acquired through unprotected sexual contact. Chronic
infection with these viruses is associated with substantial morbidity and premature
death; the development of Acquired Immune Deficiency Syndrome (AIDS) among
HIV-infected persons (Marmor, Des Jarlais, Friedman, Lyden, & el-Sadr, 1984); and
serious liver disease including cirrhosis and hepatocellular carcinoma among HCV
and HBV-infected persons (Walshe & Wolff, 1952). Although no licensed vaccines
against HIV and HCV are currently available, a safe, affordable and effective
vaccine is available against HBV. However, a number of Sydney studies have
documented low vaccination coverage among clinic, NSP and street-recruited
samples of IDUs (Day et al., 2010; Macdonald, Dore, Amin, & van Beek, 2007;
Ramasamy et al., 2010). In addition, a cross-sectional study of more than 400 heroin
users recruited from a variety of settings across Sydney found HBV knowledge was
generally low among this group (Day, White, Ross, & Dolan, 2003).

HIV prevalence and incidence vary greatly among IDUs throughout the world, but
worldwide an estimated three million people who inject drugs are infected with HIV,

16

Chapter 2
with a range of between 0.8 and 6.6 million (UNAIDS, 2009). HIV infection among
IDUs has been reported in 120 countries. In a further 20 countries where injecting is
known to occur, no reports of HIV among IDUs are available; and in eight countries
HIV has not been detected or is less than 0.01 percent. Given that IDUs in many
developing countries are highly marginalised with limited access to healthcare, these
figures are likely to be underestimates.

The prevalence of HIV among IDUs varies dramatically between and also within
countries. In Australia, annual cross-sectional sero-prevalence studies among
attendees of sentinel NSP sites performed between 1995-2009 indicate an aggregated
prevalence of HIV antibody of little more than one percent (Topp, Day, Iversen,
Wand, & Maher, 2011). Although rates of new HIV infections among IDUs have
been falling overall globally, HIV prevalence is increasing in such low-prevalence
countries as Bangladesh, Pakistan (where injecting drug use is the predominant mode
of HIV transmission), and the Philippines (UNAIDS, 2010), although this estimation
is limited by the fact that the data were collected mainly from urban areas. The
overall reduction in HIV among IDUs has been attributed to harm reduction
programs such as NSPs and OST (UNAIDS, 2010). Harm reduction refers to
policies, programs and practices that aim primarily to reduce the adverse health,
social and economic consequences of the use of legal and illegal psychoactive drugs
without necessarily reducing drug consumption (International Harm Reduction
Association, 2010).

The efficacy of highly active antiretroviral therapy (HAART), which controls viral
reproduction and slows the progression of HIV-related disease, has been improving,

17

Chapter 2
but it remains a disease management tool rather than a cure. Although a number of
candidate vaccines for HIV are at different stages in clinical trials (Spearman, 2006),
a safe and effective vaccine is unlikely to be available in the near future due to
genetic diversity and mutability of HIV-1, the structural features of the viral
envelope glycoprotein, and the presence of carbohydrate moieties that shield
potential epitopes from antibodies (Kwong, Mascola, & Nabel, 2012).

IDUs are one of the main subpopulations affected by HIV/AIDS, but are less likely
to receive HAART than other groups (Aceijas et al., 2006; Wolfe, 2007), even in
those countries with relatively good treatment access for the general population
(Celentano et al., 2001; van Asten et al., 2003). Those IDUs who do receive HAART
usually commence it at more advanced stages of infection (Kohli et al., 2005).
Canadian and US studies have shown that in the late 1990s, when HAART was
widely available free of charge in those countries, only 27 and 14 percent of eligible
IDUs respectively received this treatment (Celentano et al., 1998; Strathdee et al.,
1998).

In developed countries HCV primarily affects IDUs (MacDonald, Crofts, & Kaldor,
1996; Wasley & Alter, 2000). Factors influencing HCV transmission in this group
include high viral infectivity, efficient parenteral transmission, size of the susceptible
population, probability of contact with the infectious individuals, and frequency and
relative magnitude of risk behaviours (Alter, 2002; MacDonald et al., 1996; Topp,
Maher, & Kaldor, 2009). Transmission of HCV among IDUs is primarily through
exposure to contaminated blood during injection through sharing of injecting
equipment such as needles, syringes, spoons, water, cookers or cotton (Alter, 2007).

18

Chapter 2
An international systematic review estimated 67 percent (range 60-80 %) of IDUs
are infected with HCV (Nelson et al., 2011). Like many other developed countries,
injecting drug use is the primary route of HCV infections in Australia. In 2010, the
Australian NSP survey (ANSPS) found 53 percent of participants were HCV
antibody positive (Iversen, Topp, & Maher, 2011). Incidence has been more varied,
with a range from 5.3 to 44.1 per 100 person years, because of differences in study
methodologies, baseline prevalence of HCV infection and socio-demographic
characteristics and risk-behaviour profiles of participants. Most recently Maher and
colleagues (2007) reported an incidence of 45.8 (95% CI 35.6, 58.8) per 100 person
years.

About 80 percent of individuals exposed to HCV develop chronic infection (Te &
Jensen, 2010), and 3 to 11 percent of people with chronic HCV infection will
develop liver cirrhosis within 20 years (Dore, Freeman, Law, & Kaldor, 2002), with
associated risks of liver failure and hepatocellular carcinoma (Limberg, 2004). In
Australia, it was estimated that 5300 (range: 4000 to 6400) people were living with
HCV-related cirrhosis in 2005 (Razali et al., 2007). However, despite increasing
safety and efficacy of HCV treatment, assessment and uptake among IDUs in both
Australia (Grebely et al., 2006; Grebely et al., 2008) and other settings (Mehta et al.,
2008) remain low.

HBV is another highly contagious blood-borne virus and is transmitted through

parenteral, sexual, and vertical routes. Few systematic reviews of HBV prevalence
among IDUs have been published (Levine, Vlahov, & Nelson, 1994). A recent study
estimated that, 1.2 million (range 0.32.7) IDUs globally were hepatitis B surface

19

Chapter 2
antigen (HBsAg) positive in 2010, with an IDU population-weighted global
prevalence of 8.4 percent (Nelson et al., 2011). The largest populations of bloodborne virus infected IDUs by region are East Asia and Southeast Asia (0.3 million,
range 0.10.7) and Eastern Europe (0.3 million, range 0.10.5 million) (Nelson et al.,
2011). Selective vaccination programs against HBV among this group are
characterised by low uptake and difficulty reaching the most at-risk individuals (Day
et al., 2010). Nonetheless, in Australia, rates of newly acquired HBV notification
declined from 2.3 per 100 000 of the population in 2001 to 1.5 per 100 000 in 2006
(NCHECR, 2007). Notwithstanding this decrease, IDUs remain among those at
highest risk of contracting HBV infection (Francois, Hallauer, & Van Damme,
2002). Although vaccination against HBV was added to the infant immunisation
schedule in Australia in 2000, this is not expected to reduce population prevalence
until 2030 (Tawk et al., 2006) and targeted vaccination for IDUs will continue to be
required for the present generation.

Approximately 95 percent of adults with acute HBV infection clear the virus, but
clearance rates may be lower for IDUs than for the general population (Nelson et al.,
2011). This is not well understood, but is thought to be due to repeated HBV
exposure and/or lower immunity due to poorer health and other viral infections
(Matthews & Dore, 2006). For those who fail to clear the HBV virus naturally,
treatment is difficult and not always effective (Shamliyan et al., 2009). Moreover,
co-infection with HCV increases the likelihood of progressive liver disease, cirrhosis
and hepatocellular carcinoma (Amin, Law, Bartlett, Kaldor, & Dore, 2006). An
Australian study demonstrated that the mortality rate in people co-infected with
HBV and HCV viruses are 1.8 times higher than in those with HCV mono-infection

20

Chapter 2
and 4.0 times higher than among those with HBV mono-infection (Amin et al.,
2006).

2.1.3 Other infectious diseases

Sexually transmitted infections
An increasing body of empirical research suggests that individuals who use alcohol
and other illicit drugs are more likely to have multiple sex partners, more
unprotected sex, and a higher prevalence of HIV and sexually transmitted infections
(STIs) than non-drug users (Booth, Watters, & Chitwood, 1993; Chitwood &
Comerford, 1990; Leigh, 1990; Leigh & Stall, 1993; Logan, Cole, & Leukefeld,
2003; Maranda, Han, & Rainone, 2004; Poulin et al., 2001; Ross, Gold, Wodak, &
Miller, 1991; Ross, Hwang, Zack, Bull, & Williams, 2002; Taylor, Fulop, & Green,
1999). The mechanisms underlying facilitation of risky sexual behaviours during
intoxication with illicit, and in particular stimulant, drugs are not fully understood,
but they are likely to include impairment in self-control (dis-inhibition) and/or
increases in sexual desire (Volkow et al., 2007). There is considerable overlap
between sex work and injecting drug use with a substantial proportion of male IDUs
buying sex, male and female IDUs selling sex, and sex workers injecting drugs
(Monitoring the AIDS Pandemic Network, 2005). Many IDUs frequently trade sex
for drugs and therefore have a higher risk of acquiring STIs including HIV (Nguyen
et al., 2004). Both IDUs and non-injecting drug users (NIDUs) who report being
high when having sex are less likely to use condoms (Falck, Wang, Carlson, &
Siegal, 1997). STIs are independent risk factors for the sexual transmission of HIV
(Cohen et al., 1997; Wasserheit, 1992).

21

Chapter 2

IDUs taking amphetamines may indulge in frequent high-risk (unprotected) sexual

activity and therefore their chances for acquiring STIs, including HIV, are greater
(Topp, 2012). Some have speculated that associations may be due to unmeasured
behavioural factors including prolonged sexual activity and/or increased trauma
during sex while under the influence of amphetamine-type stimulants (Semple,
Zians, Strathdee, & Patterson, 2009); poor recollection of self-reported events;
sexual network factors; or potential direct effects of amphetamine-type stimulant on
immune function (Leigh & Stall, 1993). In-vitro studies suggest that certain
neurological and physiological factors linked to methamphetamine use can affect
susceptibility to HIV infection and the development of AIDS-related pathology
(Liang et al., 2008). However, clinical implications of these findings remain unestablished (Kopnisky, Bao, & Lin, 2007).

Cocaine is also known to have an effect of increased sexual desire while users are
intoxicated (Volkow et al., 2007), which may increase users sexual risk behaviours,
which in turn may partly explain the association between cocaine use and greater
risk of STIs. Compared to alcohol and other drugs, the use of cocaine has been
particularly associated with the spread of HIV and other STIs (Bux, Lamb, & Iguchi,
1995; Joe & Simpson, 1995; Kral, Bluthenthal, Booth, & Watters, 1998; Wingood &
DiClemente, 1998). A cross sectional study of 314 IDUs recruited from street
outreach services in the central business district of Melbourne, Australia, found that
the prevalence of STIs was moderate (8%), and the prevalence of asymptomatic
chlamydia (6%) was sufficiently high to justify screening. Despite available highly
active antibiotic treatment for some of the common bacterial STIs such as

22

Chapter 2
chlamydia, gonorrhoea and syphilis, screening and access to appropriate treatment
often are limited for IDUs (Bradshaw, Pierce, Tabrizi, Fairley, & Garland, 2005; van
den Hoek, 1997).

Respiratory tract infections and tuberculosis

Respiratory tract infections are among the most frequent sequelae of drug use. IDUs
have significantly greater risk of community-acquired pneumonia (Hind, 1990).
Tobacco smoking is common and hence respiratory clearance mechanisms may be
impaired (Stein, 1990). IDUs are at increased risk of aspiration, particularly during
opioid overdose. An immune-compromised state resulting from HIV infection or
poor nutrition may also contribute to the increased risk of respiratory tract infection
(Boschini et al., 1996; Louria, Hensle, & Rose, 1967; Tumbarello et al., 1998). For
example, a retrospective analysis of hospitalisations due to infection in 175 IDUs in

Switzerland found that respiratory infection was the second major cause of
hospitalisation (Bassetti, Hoffmann, Bucher, Fluckiger, & Battegay, 2002) after skin
infection.

A recent review found that drug users are at high risk of tuberculosis (TB) infection,
and injecting drug use has been an important contributor in HIV-associated TB
epidemics worldwide (Deiss, Rodwell, & Garfein, 2009). However, in Australia,
overall the incidence of TB cases is low at between 5-6 cases per 100,000
population, with Aboriginal descent bearing the highest burden (20.7 per 100,000),
followed by people born outside Australia (6.6 per 100,000) (Roche et al., 2008).
Data collected through national notifiable diseases surveillance systems show that
unlike other settings, the incidence of TB among IDUs in Australia is no different
23

Chapter 2
than that in the general population (Roche et al., 2008). Conversely, studies from
Europe and north-America report relatively high prevalence of TB among IDUs. The
prevalence of positive tuberculin skin test results among IDUs in the United States of
America (USA) has ranged from 10.3 to 45.8 percent (MacGregor, Dunbar, &
Graziani, 1994; Reyes et al., 1995). In 1997, a cohort study with IDUs recruited via
street outreach in Vancouver reported that 25 percent of IDUs had a positive
tuberculin skin test result (Strathdee et al., 1997). However, there remain a number
of limitations of this test including subjective interpretation, false positivity, cross
reactivity with non-tuberculous mycobacteria, errors in administration and the
requirement

for

two

client-visits

(Khawcharoenporn,

Apisarnthanarak,

Sungkanuparph, Woeltje, & Fraser, 2011).

The physiological effects of drug use, along with the environment, risk behaviours
and life-style, may all contribute to the high prevalence of TB among IDUs
internationally (Deiss et al., 2009). In-vitro studies have demonstrated harmful
effects of drug use on the immune system (Friedman, Newton, & Klein, 2003), with
biologic evidence supporting direct impairment by opioids and other illicit drugs on
the cell-mediated immune response (Wei, Moss, & Yuan, 2003). HIV-induced
immunosuppression is the most important reason for the high TB incidence among
IDUs worldwide (Selwyn et al., 1989). Injecting drug use is frequently associated
with a number of other factors that confer additional risk of TB, including tobacco
use (Altet-Gomez, Alcaide, Godoy, Romero, & Hernandez del Rey, 2005),
homelessness (Barclay, Richardson, & Fredman, 1995; Topp, Iversen, Baldry, &
Maher, Epub ahead of print), alcohol use disorders (de la Haye et al., 2012), and
incarceration (Drobniewski et al., 2005). Overall, worldwide the increased burden of

24

Chapter 2
TB among IDUs has been attributed to both an increased prevalence of
mycobacterium tuberculosis infection and an increased likelihood of progression to
active TB (Perlman et al., 1999).

2.1.4 Non-infectious disorders

Drug dependence and drug use related disorders
Drug dependence typically is a chronic and relapsing medical condition, which is
defined in the DSM-IV (American Psychiatric Association, 1994) and ICD-10
(World Health Organization, 1993) as a pathologic condition manifested by three or
more of seven criteria. These criteria include the development of tolerance to drug
effects, withdrawal symptoms, unsuccessful attempts to cut down or control use, and
continued use in the face of problems that the user knows or perceives to be caused
by use such as legal difficulties, relationship and health problems.

Injecting is an extremely efficient route of drug administration, causing very rapid

onset and maximum subjective effects and hence is strongly associated with drug
dependence (Barrio et al., 2001; Gossop, Griffiths, Powis, & Strang, 1992; Hall &
Hando, 1994). Some drugs are more addictive than others. For instance, injecting of
crack cocaine is associated with rapid transition to dependence after onset of use
(O'Brien & Anthony, 2005). Methamphetamine injectors have an even shorter period
of time from first injecting to regular injecting compared to cocaine injectors
(Gonzalez Castro, Barrington, Walton, & Rawson, 2000). However, although risk of
drug dependence varies across drug types, within drug types injecting is associated

25

Chapter 2
with a faster progression to dependence than other routes of use (Barrio et al., 2001;
Gossop et al., 1992; Hall & Hando, 1994; O'Brien & Anthony, 2005).

Psychiatric disorders and pain

There is strong correlation between illicit drug dependence and psychiatric morbidity
(Kandel, Huang, & Davies, 2001). Dual diagnosis (according to DSM IV or ICD 10)
of mental illness and drug use disorder in IDUs is a common problem (Gu et al.,
2010; Zahari et al., 2010). The impact of injecting as a mode of drug use on
psychiatric disorders is difficult to assess. Data from a national survey of drug use
and health in the USA compared routes of administration of those who reported
heroin, methamphetamine, and cocaine use in the past year, and found that 60
percent (n=396) of IDUs met the DSM-IV criteria for drug dependence and cooccurring mental disorders compared with slightly less than one-third of NIDUs
(p<0.05) (Novak & Kral, 2011). However, the study relied on the self-report rather
than clinical assessment, thus limiting the validity of the findings. In an effort to
compare harms associated with injecting versus smoking methamphetamine,
(McKetin et al., 2008) studied 400 methamphetamine treatment entrants in Sydney
and Brisbane and found that NIDUs reported similarly high levels of physical and
psychological distress and psychotic symptoms to IDUs, but had lower levels of
dependence. Together these findings suggest that it is difficult to estimate the
specific effect of injecting on psychiatric disorder.

Much of the literature is concerned with drug users per se rather than IDUs
specifically. Depression is the most common psychiatric co-morbidity associated
with drug use and the prevalence ranges from 18 to 72 percent (Liao et al., 2011;
26

Chapter 2
Zahari et al., 2010). In a survey involving 41 specialised drug and alcohol treatment
agencies in Brisbane and Sydney, McKetin and colleagues (2011) found that 40
percent of methamphetamine treatment entrants met DSM-IV criteria for a major
depressive episode in the previous year, and a further 44 percent had drug-induced
depressive symptoms that were similarly severe and disabling, 83 percent of
participants injected methamphetamine. However, the study was unable to
effectively distinguish between major depression and drug-induced symptoms of
depression.

Anxiety, another major psychiatric disorder, is also commonly associated with

injecting drug use, particularly during withdrawal from opiates and intoxication with
amphetamines and other stimulants. It can also occur as an independent condition
(World Health Organization, 2009). It is estimated that around half of females and
one-quarter of males diagnosed with drug-related disorders also have an anxiety or
affective disorder, specifically panic, generalised anxiety disorder, post-traumatic
stress disorder, depression and bi-polar disorder (Hall, Teesson, Lynskey, &
Degenhardt, 1999). The prevalence of suicide ideation and suicide attempts ranges
from 50 to 93 percent and 35 to 87 percent, respectively (Erfan, Hashim, Shaheen, &
Sabry, 2010; Sarin, Samson, Sweat, & Beyrer, 2011). Darke & Kaye (2004) found
that suicide attempts represent a major clinical issue among primary injecting
cocaine users and, to a lesser extent, among non-injectors of the drug. Poor sleep
quality is experienced by 66 to 96 percent of IDUs (Gu et al., 2010). Other frequent
psychiatric co-morbidities are current pathological gambling (21%) (Peles,
Schreiber, Linzy, & Adelson, 2010), psychotic disorders (12%), and adjustment
disorders (9%) (Zahari et al., 2010).

27

Chapter 2

The use of different instruments and samples of IDUs influences the prevalence of
psychiatric co-morbidity obtained. In comparing psychiatric syndromes experienced
by users of cigarettes, alcohol and illicit drugs, Kandel and colleagues (2001) found
the highest rate of psychiatric morbidity was among individuals dependent on an
illicit drug. Mental illness may be the cause or effect of substance use. A strong
association exists between drug-induced psychosis and amphetamine intoxication,
particularly in chronic amphetamine users (Darke, Kaye, McKetin, & Duflou, 2008;
Dore & Sweeting, 2006). Drug use (particularly stimulants) can precipitate psychotic
illness but on the other hand people with primary schizophrenia are more at risk of
becoming drug dependent.

Cannabis and psychosis

Cannabis is the world's most commonly used illicit drug (UNODC, 2008).
According to the 2004 National Drug Household Survey, around one-third (33.6%)
of Australians aged 14 years and over reported that they had used cannabis at some
point in their lives (Commonwealth of Australia, 2007). Although it is difficult to
quantify the extent of health-related consequences of its consumption, association
between cannabis and a number of health problems is well established
(Commonwealth of Australia, 2007). Psychosis is possibly the most discussed
among them (Arseneault, Cannon, Witton, & Murray, 2004; McLaren, Silins,
Hutchinson, Mattick, & Hall, 2010; Moore et al., 2007). Psychosis describes a
mental state characterised by delusions, which involve beliefs that are not true;
hallucinations, which involve sensing things that are not there such as hearing
voices; and gross disorganisation of speech and/or behaviour such that the sufferer's

28

Chapter 2
speech and actions do not make sense (American Psychiatric Association, 2000).
The syndrome of psychosis occurs in a range of mental health conditions including
schizophrenia and drug-induced psychosis (Ferran, Barron, & Chen, 2002).

Although risk of psychosis is approximately one in 50 among regular cannabis users

compared with approximately one in 100 among non-users (Hall & Degenhardt,
2010), even this increase in risk is of huge public health importance, because of the
high prevalence of cannabis consumption. Prompt referral to a psychiatrist is
important, because early psychiatric intervention is associated with better response to
treatment (McNally, Bryant, & Ehlers, 2003). If an immediate referral is not
required, then patients must be actively monitored for changes in their mental status.
Primary healthcare centres may not be appropriate venues for psychosis treatment,
but these are potential gateways of preventive interventions and appropriate referrals
to further treatment.

A need for increased treatment provision is likely to be largely driven by an ageing

cohort of cannabis users, with daily smoking of cannabis now most commonly
reported among 30-39 year olds. This group is likely to be experiencing significant
physical and psychological harms as a result of their long-term, regular use. The
increasing prevalence of cannabis use in Aboriginal and Torres Strait Islander
communities are also cause for concern (Commonwealth of Australia, 2007).

In Australia over 40 percent of IDUs use cannabis on a daily basis (Roxburgh &
Burns, 2008). While it is relatively easy to show that polydrug use can lead to
multiple adverse health consequences, studying it remains a challenge, both at the
29

Chapter 2
conceptual and at the practical levels. One simple rationale for this is that all
pharmaceutical drug use follows the general rule that combinations of drugs tend to
increase the risks of adverse health effects. Such effects can occur (generally as acute
toxicity) shortly after the consumption of several substances, or within a short time
afterwards (EMCDDA, 2009e). They can also occur following a long period of use,
due to various mechanisms affecting body systems, including the liver and the
central nervous, cardiovascular or respiratory systems (Macleod et al., 2004;
McCabe, Cranford, Morales, & Young, 2006). Intensive cannabis use is often a
major, but overlooked, component of polydrug use. Cannabis also adversely affects
cognitive functioning which for polydrug users, particularly for IDUs, can impair
initiative in seeking attention for health or social needs (Solowij, Stephens, Roffman,
& Babor, 2002; Solowij, Stephens, Roffman, Babor, et al., 2002) and can enhance
the chance of risk taking behaviours.

Pain
Chronic pain is a common co-occurring condition among individuals injecting
opioids (Heimer et al., 2012) and this pain may go undertreated (Australian and New
Zealand College of Anaesthetists and Faculty of Pain Medicine, 2007). Seeking and
attaining appropriate pain medication can be difficult for many IDUs, especially
when seeking care in the community setting from general practitioners (GPs).
Indeed, the proportion of IDUs at NSPs around Australia who reported injecting
morphine or other pharmaceutical opioids increased from seven percent in 2002 to
16 percent in 2010, making it the third most common drug injected after heroin and
amphetamines (Iversen et al., 2011). GPs may be reluctant to prescribe such

30

Chapter 2
medications if they are concerned the patient is seeking psychoactive medication for
nonmedical purposes (Monheit, 2010).

Some IDUs attend health services primarily to seek opioid based pain killers such as
Oxycontin (Monheit, 2010) or psychoactive medications such as benzodiazepines
(Darke, Ross, Teesson, & Lynskey, 2003). Current efforts to introduce a live
electronic database for prescription drug monitoring (Perrone & Nelson, 2012) will
potentially reduce this reason for healthcare visits. Although true health issues may
not be the primary goal of these doctor shoppers, their visits to and consultation
with the healthcare providers may open an avenue to address some of their essential
health needs.

2.1.5 Other common health problems

Overdose and toxicity
Fatal overdose is a leading cause of death among IDUs (Darke & Hall, 2003). The
risk of fatal opioid overdose may be as high as two percent per year (World Health
Organization, 2009). Studies report that between 50 and 70 percent of IDUs have
experienced a non-fatal overdose at some time in their lives, with between 20 and 30
percent overdosing in the preceding 12 months (Darke, Ross, & Hall, 1996;
MacGregor et al., 1994). Concomitant use of alcohol and other central nervous
system depressants may play a major role in fatality (Darke & Hall, 2003). There is
evidence that systemic disease may be more prevalent in users at the greatest risk of
overdose (Warner-Smith, Darke, Lynskey, & Hall, 2001). Fatal overdose related to
psycho-stimulant drugs such as cocaine and methamphetamine have been of

31

Chapter 2
particular concern in North America (Coffin et al., 2003; Lora-Tamayo, Tena, &
Rodriguez, 1994). In Australia, however, few drug-related deaths have psychostimulant use as the underlying cause (Darke & Kaye, 2003; Degenhardt & Barker,
2003). This continental difference in fatal overdose rate is likely to be due to the
difference in prevalence and type of psycho-stimulant use. Consumption of cocaine,
which is the main psycho-stimulant responsible for fatal cases, is more prevalent in
the Americas, with less use in Australia. This is because the global supply of cocaine
originates almost exclusively from the South American countries of Peru, Bolivia
and Columbia (Darke, Kaye, McKetin, & Duflou, 2007).

Poor dental health/hygiene

Dental problems are very common among IDUs, yet have attracted little attention
(Laslett, Dietze, & Dwyer, 2008; Reece, 2008; Reece, 2009; Robbins, Wenger,
Lorvick, Shiboski, & Kral, 2010). Opioid and amphetamine use, poor housing, poor
hygiene, poor nutrition, and opioid substitution treatment including methadone
maintenance treatment (MMT) are important risk factors for dental health problems
(Robinson, Acquah, & Gibson, 2005). Despite being common, few IDUs receive
dental care and treatment for their often complex dental problems (Robinson et al.,
2005). A cross-sectional study in Melbourne, Australia found that 68 percent of 285
street-recruited IDUs reported dental problems that were typically severe and
causing dental pain. Despite these problems, almost half the sample had not visited
the dentist in the 12 months prior to the survey (Laslett et al., 2008). Another crosssectional study carried out in New South Wales (NSW), Australia with 508 patients
receiving methadone and buprenorphine maintenance treatment at community
pharmacies found that the most common health problems for which participants
32

Chapter 2
sought help were dental (30%) followed by constipation (25%) and headache (24%)
(Winstock, Lea, & Sheridan, 2008).

Poor dental health is related to reduced saliva secretion (xerostomia), teeth grinding
(particularly associated with amphetamine use), poor dental hygiene (e.g. not
brushing), and trauma (World Health Organization, 2009). Poor dental health can
increase the risk of bacteraemia and infective endocarditis. Xerostomia, which is
associated with regular opioid use and so is also a side-effect of methadone
maintenance, can contribute to caries. Another very important issue associated with
poor dental health is pain, which can be severe and may impact on treatment
retention or stability if not appropriately managed, self-esteem may also be effected,
potentially impacting on treatment (Huff, Kinion, Kendra, & Klecan, 2006). There
are few programs available for this group. Given that life-style factors, including
history of homelessness and erratic eating patterns are related to dental problems,
any such programs should be developed and implemented in a manner amenable to
the varying social circumstances of this marginalized group in the community
(Laslett et al., 2008; World Health Organization, 2009). In Australia, private dental
treatment is often unaffordable to the unemployed, and public treatment has limited
availability.

Constipation
The use of opioids can lead to constipation due to their effect on intestinal smooth
muscle and their interference with the bowel's normal elimination function. Those
who are on OST often suffer from constipation. Winstock et al (2008) found that
constipation was the second most common reason for seeking healthcare among
33

Chapter 2
OST clients at community pharmacies in NSW, Australia. It has been estimated that
eventually more than half of OST patients experience some degree of constipation
(Langrod, Lowinson, & Ruiz, 1981; Yuan, Foss, O'Connor, Moss, & Roizen, 1998).
Patients receiving opioids may require pharmacological agents (osmotic laxatives
e.g. lactulose, sorbitol, milk of magnesia) for constipation as primary prevention
strategies alone may be insufficient (World Health Organization, 2009).

Health effects associated with poverty and violence

Illicit drug use is both a cause and effect of poverty and violence, which in turn may
seriously affect health. Illicit drug use and poverty go hand-in-hand (Kaestner,
1999). Perhaps the greatest impact of poverty on the life of a drug user is its effect on
affordability of food intake and medical care. For those living in poverty, a substance
use problem can perpetuate financial difficulties by making it more challenging to
obtain employment. Conversely, the complex relationships between substance abuse
and violence have posed challenges to the public health. A study in USA examined
intimate partner aggression in a sample of 489 participants enrolled in substance use
disorder treatment found a high rate of aggression including injuring partners (33%)
(Chermack et al., 2008). Another study of ED patients in United Kingdom found that
the major reason for drug-related presence was injuries (often assault) (Binks,
Hoskins, Salmon, & Benger, 2005).

34

Chapter 2

2.2 Barriers to access to healthcare

Because of this wide range of physical and mental complications and co-morbidities,
IDUs are among those who have a disproportionate need for healthcare services
(French et al., 2000; McBride, VanBuren, Terry, & Goldstein, 2000; McCoy,
Metsch, Chitwood, & Miles, 2001; Rowe, 2004, 2005). However, despite this
increased need, the literature documents a trend of lower healthcare utilisation
among IDUs (Mor, Fleishman, Dresser, & Piette, 1992; Morrison et al., 1997;
Selwyn, Budner, Wasserman, & Arno, 1993) compared to socio-demographically
similar groups who do not use drugs (Chitwood, McBride, French, & Comerford,
1999; Chitwood, McBride, Metsch, Comerford, & McCoy, 1998; McCoy et al.,
2000; McGeary & French, 2000). When they are admitted to hospital, IDUs are also
more likely than other patients to leave against medical advice (Bradley & Zarkin,
1996). This lower rate of healthcare access and adherence by IDUs is likely the
result of a number of direct and indirect barriers. Broadly those barriers can be
categorised into three groups: (i) structural or system barriers, (ii) interpersonal
barriers, and (iii) material and social barriers.

35

Chapter 2

Table 2.2 Common barriers to access to healthcare by IDUs

Structural or system

Insufficient service provision

barriers

Access to information about service availability

Inability to comply with paperwork
Lack of comprehensive services
Structured appointment system, challenge in chaotic lives
Distance from the healthcare provider and lack of suitable
transportation
Lack of valid documents (e.g. identification cards)
Legal barriers
Conditional services (e.g. abstinence-based treatment)

Interpersonal barriers
-

Provider barriers

Social stigma, negative attitudes toward IDUs

Moral conflicts
Provider beliefs about abstinence-focused care
Concern about the effect of IDUs presence on other
clients
Frustrations over patients frequent relapse to drug use
Concerns about the effectiveness of intervention
Lack of skill and expertise in dealing with drug
dependence

User barriers

Lower priority of accessing healthcare compared to drug

use
Transitional nature of life (e.g. homelessness)
Past experience of discrimination and fear of rejection
Stigma and fear of disclosure
Legal issues
Withdrawal and intense craving

Material and social barriers

Cost of treatment, medication, transport
Lack of support and assistance from family, friends

36

Chapter 2

2.2.1 Structural or system barriers

Although barriers vary across settings, the main structural barrier to healthcare
seeking is insufficient service provision the absolute lack of services accessible to
IDUs (Freund & Hawkins, 2004; Metsch & McCoy, 1999) or an insufficient number
of services to deal with their demand (Deck & Carlson, 2004; Metsch & McCoy,
1999; Sterk, Elifson, & Theall, 2000). In addition, there is also poor information
available to IDUs about healthcare availability (Table 2.2), that is, many IDUs are
unaware of the full range of services available to them (Carroll & Rounsaville, 1992;
Swift & Copeland, 1996). IDUs are often unable to access the desired assistance
because they are ineligible for the service, they lack support, and they are refused.
There may be no clear help or assistance, or they may be unable to complete the
necessary paperwork (Neale, Tompkins, & Sheard, 2008). There is typically a lack
of holistic or comprehensive services, which forces IDUs to access and work with
many different services and providers to meet their complex physical and mental
health needs, often in a variety of locations (Holt et al., 2007). Consequently, the
burden of appointments, including having too many appointments, often across a
range of different agencies; forgetting appointments; excessive waiting periods in
services; and feeling too tired or unwell to attend appointments (Neale et al., 2008),
impedes access. Indeed, the structured system of appointments and restrictive hours
of medical services can be incompatible with the chaotic lives of many IDUs (Rowe,
2004). Transport challenges such as distance and the lack of suitable transport are
other structural barriers. Further structural barriers which potentially prevent access
to health services include bureaucratic obstacles such as healthcare policies requiring
patients to hold valid documents (e.g. Medicare card, valid identification card)

37

Chapter 2
(Drumm et al., 2003; McCoy et al., 2001; Porter, 1999; Porter, Coyte, Barnsley, &
Croxford, 1999).

Criminal sanctions against illicit drug use pose further barriers (Bluthenthal, Kral,
Lorvick, & Watters, 1997) particularly where the legal status of treatment is
ambiguous (e.g. in Malaysia, where MMT was endorsed without legal validation),
negative attitudes persist, or law enforcement agencies are ill-informed about the
medical approach to treating drug dependence (Burris & Davis, 2008). Even when
IDUs try to access mainstream healthcare services, they may be anxious and
concerned about presenting for treatment. For example, mothers who desire
treatment may fear being notified to child protection services (Anex, 2005; Neale et
al., 2008), or employed drug users may fear negative effects on employment (Ahern,
Stuber, & Galea, 2007; Link & Phelan, 2006; Stafford & Petway, 1977). Abstinencebased health services, limited staff skill and confidentiality risks are also important
barriers to access to healthcare (Regen, Murphy, & Murphy, 2002; Rowe, 2004).

2.2.2 Interpersonal barriers

IDUs decisions about seeking healthcare are also influenced by interpersonal
barriers. Interpersonal barriers can be categorised into two groups barriers
implemented by providers and barriers perpetuated by IDUs.

Provider barriers
The available literature suggests that a proportion of healthcare providers hold
negative attitude toward IDUs, although its extent varies across settings (Abouyanni

38

Chapter 2
et al., 2000; Drumm et al., 2003; Neale et al., 2008; Salvalaggio, 2008). Greater
contact with a stigmatised population such as IDUs may reduce prejudice and a large
body of research in social psychology has supported this conclusion (Pettigrew &
Tropp, 2006). Hence, in settings where a harm reduction policy is supported, IDUs
are likely to have greater contact with healthcare providers with a lesser degree of
prejudice than IDUs in other settings. However, social stigma about injecting drug
use is just one of many barriers. McLaughlin and colleagues (2000) demonstrated
that healthcare workers commonly describe IDUs as among the most unpopular
patients and expect them to be more dangerous, more manipulative, less grateful,
less co-operative, less pleasant, more aggressive, less truthful, and more demanding
than most other patients (Link & Phelan, 2006). Moral conflicts, suspected
deceptions (Gourlay, Heit, & Almahrezi, 2005), power differentials in the patientprovider relationship (Salvalaggio, 2008), provider beliefs about abstinence-focused
care (Rowe, 2004), and concerns about possible disruption to their usual practices
(Abouyanni et al., 2000) are prominent provider deterrents to offering care to IDUs.
When IDUs present to hospitals or EDs, they often have negative experiences, and
this is most apparent for women and those living in the rural areas (Neale et al.,
2008). IDUs are sometimes made to feel that they were unworthy of hospital care
and that they were wasting valuable resources. As expressed in Neale and
colleagues (2008) qualitative work:

The doctor actually said to me, You have inflicted it on yourself and you
shouldnt really be here, because you are wasting not only our time, but [the
time of] whatever family you have got. (29-year-old woman), (page 150).

39

Chapter 2
Although GPs are often the first point of contact for patients who are dependent on
drugs and alcohol (Miller & Gold, 1998), many GPs lack the skill or confidence to
deal with drug users; have concerns about the effectiveness, compliance and safety
of opioid maintenance; and fear that IDUs or OST clients will be difficult, aggressive
or demanding (Abouyanni et al., 2000; Roche, Furay, & Saunders, 1991). Some GPs
have expressed concern about turning their practices into drug and alcohol clinics if
they cater for the needs of IDUs (Table 2.2). For example, a Sydney-based study of
GPs found that most of the 416 GPs interviewed raised this as a concern (Abouyanni
et al., 2000). Other perceived barriers include lack of time or remuneration for
managing these complex problems, concerns about possible disruption to their
practices, and the adequacy of support provided to them by public drug and alcohol
services (Abouyanni et al., 2000).

There is also concern about the capacity of IDU populations to demonstrate

adherence to therapeutic regimens which is translated into reluctance to provide
appropriate healthcare (Bogart, Catz, Kelly, & Benotsch, 2001; Dore, 2007).
Frustrations over patients frequent relapse to drug use (Greenwood, 1992), the low
success rates of drug dependence treatment, low patient motivation, costs and the
lack of specialist support (Roche, 1996), insufficient skills and/or confidence to deal
with drug dependence (Abouyanni et al., 2000; Salvalaggio, 2008). In keeping with
this, a perceived lack of provider skill may diminish the value of seeking treatment
and IDUs willingness to access care from certain professionals (Rowe, 2004). Such
negative attitudes have also been identified amongst psychiatrists (Tantam, Donmall,
Webster, & Strang, 1993), pharmacists (Sheridan & Barber, 1996; Winstock et al.,
2008), and general nursing and maternity ward staff (Carroll, 1993). Specific

40

Chapter 2
attention to these issues in medical education appears to have had only a modest
impact on medical students attitude (Silins, Conigrave, Rakvin, Dobbins, & Curry,
2007).

IDU barriers
Drug dependence and withdrawal exerts an inescapable influence on an IDUs
lifestyle. Healthcare needs may take a lower priority than more immediate concerns
related to obtaining food, clothing and shelter and raising enough money to support
drug use (Bruce, 2012; Carr et al., 1996). Apart from this, some IDUs do not
perceive their drug use as problematic and so do not want to seek help (Carroll &
Rounsaville, 1992; Kennedy, Neale, Barr, & Dean, 2001). The transitional nature of
the lives of homeless IDUs makes it even harder to establish and maintain effective
relationships with healthcare providers (Anex, 2005; Rowe, 2004).

Past history of discrimination and fear of rejection has a serious effect on IDUs
willingness to access healthcare (Day, Ross, et al., 2003; Drumm et al., 2003;
Hopwood, Treloar, & Bryant, 2006; Treloar & Hopwood, 2004). Even if IDUs with
a history of having experienced discrimination access care, they may interact with
providers in particular ways because they anticipate that they will be discriminated
against (Brener, von Hippel, von Hippel, Resnick, & Treloar, 2010; Strenta & Kleck,
1984). Indeed IDUs are already sensitised to discrimination and may expect to be
treated negatively by treatment staff. As a result, fear of rejection and discrimination
can create strained and uncomfortable interaction with the treatment staff (Link,
Struening, Neese-Todd, Asmussen, & Phelan, 2001; Strenta & Kleck, 1985). It can

41

Chapter 2
also encourage lying to hide the fact of injecting drug use, and so a negative cycle
can be established.

Stigma associated with injecting drug use and discrimination is an important barrier
to help-seeking for many with drug-related conditions (Day, Ross, et al., 2003; Kelly
& Westerhoff, 2010; Paterson, Backmund, Hirsh, & Yim, 2007). A cross-cultural
study conducted by the World Health Organization in 14 countries examined 18 of
the most stigmatised conditions (included being a criminal, HIV positive, or
homeless) and found that alcohol dependence was ranked as the fourth most
stigmatised condition, while other drug dependence was ranked as the most
stigmatised condition (Room, Rehm, Trotter, Paglia, & stn, 2001). Many
individuals who are affected by drug-related problems experience feelings of shame
and guilt and often fear that personal disclosure or public knowledge of their
condition would lead to broader social disapproval (Ahern et al., 2007; Link &
Phelan, 2006; Stafford & Petway, 1977). Co-morbidity with health problems that are
also stigmatised create additional barriers to access to healthcare. For instance, the
stigma associated with both drug use and mental health problems may result in IDUs
denying symptoms or feeling unwilling and/or unable to seek treatment (Holt et al.,
2007).

2.2.3 Material and social barriers

Material and social barriers to healthcare include treatment and medication cost,
insurance, money to maintain accommodation, transport and access to a telephone
(Drumm et al., 2003; Neale, Sheard, & Tompkins, 2007; Neale et al., 2008). Given

42

Chapter 2
that the majority of IDUs have substandard education and have only minimal
income, these material barriers profoundly limit IDUs access to healthcare (Islam,
Topp, Day, et al., 2012a; Topp et al., Epub ahead of print).

The lack of support and assistance during times of crisis is another key barrier to
healthcare access (Neale et al., 2007). The involvement of family members and
friends in the treatment processes of drug dependence and related health problems
helps to promote positive treatment outcomes (Orford, 1994). Drug use does not
affect individuals in isolation from their social networks. However, IDUs often have
poor family relationships and limited social networks (Neale et al., 2007). When
family members and friends offer tangible and/or emotional support, IDUs are more
likely to access healthcare (Drumm et al., 2003). While support from family, friends
and networks are important enablers, unproductive peer influences (e.g. from fellow
IDUs) may deter IDUs from accessing healthcare (Drumm et al., 2003).

2.3 Context of targeted primary healthcare for IDUs

Given the high health needs and the barriers and limited access to healthcare
described above, it is perhaps not surprising that IDUs are more likely than NIDUs
and the general population to delay seeking healthcare until conditions become
severe (Drumm, McBride, Metsch, Neufeld, & Sawatsky, 2005; McCoy et al., 2001).
This results in reliance on EDs and inpatient care (French et al., 2000; Haber et al.,
2009), resulting in additional pressure on the system with significant cost
implications (Palepu et al., 2001) and often poorer outcomes (Binswanger et al.,
2008). Although most of the health problems are treatable and/or preventable, the
complex barriers described above limit IDUs access to conventional health services.
43

Chapter 2

These barriers to healthcare, consequent poor health outcomes, and excessive use of
ED services by IDUs for health problems which may be prevented and/or treated in a
PHC setting have led authorities in some settings to establish low-threshold and
IDU-targeted PHC facilities (Islam, Day, et al., 2010; Islam, Topp, Day, et al.,
2012a). The key harm minimisation interventions offered to IDUs are NSPs and/or
OST, coverage of which varies considerably across the world (Mathers et al., 2010).
PHC centres may be co-located with such services in order to facilitate their
utilisation among the target population (Islam, Reid, et al., 2012). Thus these
targeted healthcare centres could be enhanced NSPs (Day et al., 2011), OSTs
(Federman & Arnsten, 2007; Umbricht-Schneiter, Ginn, Pabst, & Bigelow, 1994) or
medically supervised injecting centres (MSICs) (Small, Van Borek, Fairbairn,
Wood, & Kerr, 2009; Small, Wood, Lloyd-Smith, Tyndall, & Kerr, 2008) or may be
stand-alone services in areas frequented by the target population (Norman, Mugavin,
& Swan, 2006). As mentioned earlier, these offer low-threshold healthcare that
eliminates or reduces the major barriers IDUs experience in accessing care from
conventional services (Fernandez et al., 2006; Islam, Day, et al., 2010; Islam, Topp,
Day, et al., 2012a).

2.4 Conclusion
This chapter has reviewed IDUs common health problems and barriers to access to
healthcare. The context for the establishment of low-threshold PHCs specifically
targeting IDUs was described. Clearly, despite substantial mortality and morbidity,
IDUs have limited access to healthcare. Although the barriers to access to healthcare
vary across settings, factors such as social stigma, unemployment and drug
44

Chapter 2
dependence are universal and have the potential to affect access to care. Although
such IDU-targeted PHC centres are increasingly being established across a range of
settings and utilising a variety of models, evidence for their effectiveness is scant and
it has been the focus of few studies. In the next chapter, a literature review examines
the accessibility, acceptability, and health impact and cost implications of PHC
services that target IDUs.

45

Chapter 3

CHAPTER 3
Primary healthcare services that target injecting
drug users: A narrative synthesis of literature1
The preceding chapter showed that IDUs experience a wide range of health problems
despite most of these problems being treatable and/or preventable in a PHC setting,
and the context of and rationale for introduction of IDU-targeted PHCs which offer
various degrees of preventative and therapeutic healthcare services for IDUs.
Although IDU-targeted PHC facilities are increasingly being established across a
range of settings and utilising a variety of models, a systematic review on this topic
has not been conducted. A scoping exercise undertaken as part of this study revealed
that a systematic review was not possible as the relevant literature is widely
dispersed across a number of disciplines and includes both qualitative and
quantitative study designs, and many of the available reports are simply describing
process evaluations. This review synthesizes available documentation in order to
facilitate the evidence-base for rational decision making.
The aims of this chapter are to:
a)

outline operational models of IDU-targeted PHC and assess the accessibility

and acceptability of these services to the target population; and

This review was published as: Islam, M. M., Topp, L., Day, C. A., Dawson, A., & Conigrave, K. M.
(2012). The accessibility, acceptability, health impact and cost implications of primary healthcare
outlets that target injecting drug users: A narrative synthesis of literature. International Journal of
Drug Policy, 23, 94-102.
See Appendix II for a list of publications arising from this thesis.

46

Chapter 3
b)

synthesize the findings from evaluations of these PHCs with respect to their
impact on health outcomes, cost implications and operational challenges.

3.1 Methods
A comprehensive search was undertaken of the electronic databases Medline,
Medscape, Current Contents, HealthSTAR, Addiction Abstracts and CINAHL from
1966 to the end of 2010. Search terms entered were primary healthcare for
intravenous drug users, targeted primary healthcare for drug users, primary
healthcare for marginalised population, healthcare for IDUs, primary health
clinic for drug users, healthcare from needle syringe program outlet, syringe
exchange program based healthcare, opportunistic healthcare for drug users,
drug users targeted healthcare, harm reduction based healthcare, primary health
services for drug users, enhanced healthcare, locally enhanced healthcare,
nationally enhanced healthcare, and directed enhanced healthcare. Hand
searching of reference lists was also undertaken. As targeted PHC for drug users is a
relatively recent innovation and there are likely to be service-related documents not
yet located in the peer reviewed literature, the grey literature was also searched,
primarily via the Google search engine using identical search terms. Relevant
websites (for example, the European Monitoring Centre for Drugs and Drug
Addiction [EMCDDA]) were also searched.

47

IDENTIFICATION

Chapter 3

Records identified through

database searching
(n = 71)

Records identified through

personal communication
(n = 5)

INCLUDED

ELIGIBILITY

SCREENING

Records after duplicates removed

(n = 1)

Titles and abstracts

screened
(n =75)

Full-text articles
assessed for eligibility
(n = 46)

Exclusion / inclusion
criteria applied
(n = 29)

Full-text articles
excluded
(n = 11)

Studies included in final

review
(n = 35)

Figure 3.1. Preferred Reporting Diagram for Systematic Reviews and Metaanalyses (PRISMA) showing selection of publications for review 2

PRISMA checklist is presented in the Appendix I

48

Chapter 3

Inclusion-exclusion criteria were developed, based upon a checklist of research

questions, methodology used and study outcomes derived from this reviews aims
and the quality of methods, findings and interpretation (Eakin & Mykhalovskiy,
2003), to assess the literature identified through the search strategy. Articles/reports
that described implementation or evaluation or outcomes of interventions and
epidemiological studies were included in this review, as these are likely to report
factors shaping implementation, acceptability and accessibility. Thirty-five papers
concerning targeted PHC for drug users were identified. Eighteen peer-reviewed
articles identified through electronic database searching directly or indirectly
described PHC that targets IDUs. An additional three articles and two reports located
through hand-searching the reference lists of papers were also included.

Narrative synthesis was employed to analyse the selected material as per current
guidelines (Arai et al., 2007; Popay et al., 2006). This methodology is well suited to
this study as one-third of the retrieved literature described implementation studies or
process evaluations characterised by considerable diversity in their methodology,
design and/or data collection technique (Lucas, Baird, Arai, Law, & Roberts, 2007).
Moreover, narrative synthesis is appropriate in this context to identify the factors
shaping the implementation of IDU-targeted PHC, (i) their accessibility, (ii)
acceptability and (iii) operational challenges, which are vital to policymakers.
Documentation was examined and data coded under these three themes. In addition,
the material was interrogated to establish impacts upon health outcomes and cost
implications.

49

Chapter 3
Table 3.1 Table stating the criteria of literature suitable for a narrative
synthesis
When to consider a narrative synthesis?

The studies included in the review are too diverse, and a systematic review
or meta analysis is not possible

Literature are mostly implementation studies, consider how or why

interventions have particular impacts, including what went wrong when
interventions did not have the anticipated impact. These studies focus on
how factors/processes, operating at the level of systems (which might
include international, national, regional or local level systems, depending on
the intervention)

Studies commonly involve multiple methods and may involve routine data
on the reach of the intervention, new surveys or other methods generating
quantitative data and any of a range of qualitative methods including indepth interviews producing narrative data

Source: Adapted from Arai et al., 2007; Lucas et al., 2007; Popay et al., 2006.

The review focuses on the most common models for IDU-targeted PHC which are
those co-located with NSPs and/or OSTs or other similar services targeting IDUs.
PHC in office-based practitioner settings such as those provided by individual GPs
are not considered, as these do not usually target IDUs specifically, and are difficult
to delineate as they operate under a plethora of models. The small number of
supervised injecting facilities which provide onsite PHC are also considered outside
the scope of this review as they differ markedly from the more common models of
50

Chapter 3
IDU-targeted PHC facilities. Moreover, the literature around services provided by
supervised injecting facilities has to date focussed on elements related to their core
mandate, namely the provision of a supervised place to inject. Limited information,
and no outcome evaluations, are available on the PHC provided by these services;
thus inclusion of this information would add little to this review.

Primary healthcare is defined as socially appropriate, universally accessible,

scientifically sound first level care supported by integrated referral systems in a way
that addresses health inequalities; maximises community and individual selfreliance, participation and control; and involves collaboration and partnership with
other sectors to promote public health. It includes health promotion, illness
prevention, treatment and care of the sick, community development, and advocacy
and rehabilitation (Australian Primary Health Care Research Institute, 2005). More
specifically, as defined by the WHO (World Health Organization, 2009), primary
healthcare for IDUs refers to a comprehensive harm-reduction package including
outreach; peer-led interventions; information, education and communication;
condoms; sterile injecting equipment; and effective drug treatment including OST;
early identification and treatment of STIs and BBVIs and other drug use-related
illnesses; and care, treatment and support for HIV infected drug users.

Definitions of the terms accessibility and acceptability abound in the medical

literature (Ansari, 2007). This review confines accessibility to two indicators: (i) is
the service located in a suitable place, for example, a place where drug users
congregate, or a neighbourhood with a high concentration of drug use?; and (ii) has
the service attempted to reduce barriers known to impede IDUs access to

51

Chapter 3
healthcare? Service acceptability was indicated by measures such as clients return
rate; perceived friendliness of and/or ease of communication with staff; and uptake
of referrals to other services (Rowe, 2004).

Operational models were categorised by three major variables: main services

provided, workforce profile and flexibility of service delivery, for example, outreach
and/or drop-in capacity.

3.2 Results
3.2.1 Operational Models
Twenty of 35 papers described implementation of IDU-targeted PHC, with
information concerning workforce profile, range of services and/or service modality
(Table 3.1). The underlying approaches vary. They may be distributive, providing
basic harm reduction services and simple healthcare with facilitated referrals to
specialist services (Stein & Samet, 1993), such as the IDU-targeted low-threshold
centres in Finland (Arponen, Brummer-Korvenkontio, Liitsola, & Salminen, 2008).
Others are one-stop-shops where a range of services, including specialist services,
are provided onsite (Stein, O'Sullivan, Ellis, Perrin, & Wartenberg, 1993), for
example the Kirketon Road Centre in Sydneys Kings Cross, Australia (van Beek,
2007).

The services offered vary across settings. Services provided at the majority of IDUtargeted PHC facilities include the provision of sterile injecting equipment,
wound/vein care, doctor/nurse consultations, testing for BBVIs and STIs, urinalysis
52

Chapter 3
and pregnancy testing, hepatitis B and hepatitis A vaccinations and counselling.
Some facilities offer OST and hepatitis and HIV treatment (van Beek, 2007) and
dental care (EMCDDA, 2009a). Some facilities provide on-site mental health
services (Kwan, Ho, Preston, & Le, 2008; Norman et al., 2006; Ross, Lo, McKim, &
Allan, 2008). The majority of facilities also offer social and/or welfare services,
including meals, telephone and sometimes internet facilities, rest-rooms, coffee and
snacks, legal services (Arponen et al., 2008; EMCDDA, 2009b; IKHLAS, 2009;
Kwan et al., 2008; Norman et al., 2006); haircuts (IKHLAS, 2009); and/or showers
and washing facilities (Arponen et al., 2008).

An important subset of IDU-targeted PHC is NSP-based PHC. NSPs in many

settings have been augmented to incorporate PHC services for IDUs. For instance,
one-third of NSP-based primary healthcare facilities in USA provide onsite medical
care (Des Jarlais, McKnight, Goldblatt, & Purchase, 2009). In 2008, most NSPs in
the USA offered clinical services, including counselling and/or testing for HIV
(87%), HCV (65%), STIs (55%), and tuberculosis (31%). Eighty-nine percent
provided referrals to drug dependence treatment (Centers for Disease Control and
Prevention, 2010).

In some settings in the UK the local GP service is commissioned to offer basic

medical care, plus enhanced care to substance users in accordance with locally
agreed shared care guidelines (Williams, 2005). This arrangement was introduced in
April 2004. As part of the new contract, GP practices can opt to provide services
over and above those normally provided to patients. The extra services they can
provide are called Enhanced Services, and are delivered to a higher specified

53

Chapter 3
standard. By providing these services GPs help reduce the burden on secondary care
and expand the range of services to meet local need and improve convenience and
choice for patients (British Medical Association NHS Confederation, 2003). There
are three types of enhanced service: (i) Directed Enhanced Services (DES) must be
provided or commissioned by the primary care trust for its population; (ii) Local
Enhanced Services (LES) locally developed services designed to meet local health
needs; and (iii) National Enhanced Services (NES) services to meet local needs,
commissioned to national specifications and benchmark pricing. However, the core
principle of all three types is to provide improved care to specific target groups.
A practitioner providing enhanced services relating to substance misuse should have
the skills to:
(i)

Identify and treat the common complications of drug misuse;

(ii)

carry out an assessment of a patients drug use;

(iii)

provide harm reduction advice to a current drug user or his or her family;

(iv)

test (or refer for testing) for other viruses, including HIV, and immunisation
for hepatitis B to at-risk individuals;

(v)

provide drug information to carers and users as to the effects, harms and
treatment options for various common drugs of use;

(vi)

assess and refer appropriately for drug misuse substitution treatment;

(vii)

utilise the range of commonly used treatment options available including

pharmacological interventions;

(viii)

be aware of local policy; and

(ix)

work in an appropriate multidisciplinary manner (NHS Employers, 2005).

54

Chapter 3

Table 3.2 Services provided, staffing and reported accessibility and acceptability of primary healthcare facilities for IDUs
The centre (reference)

Placement of primary healthcare

NSP

OST

HCV/ HIV treatment

Hepatitis B vaccination

Social & welfare services

Other basic medical services

Medical

Nursing

Counselling

Outreach

Drop-in

Reported accessibility

Reported acceptability

CHCV, New Haven, USA (Pollack, Khoshnood,

Blankenship, & Altice, 2002)

High concentration of injecting drug

use

CityWide harm reduction, New York, USA (Mund et al.,

2008)

Neighbourhood with high HIV and

drug-related mortality rates

+/

NM

Direct aid and support unit of Okana, Athens, Greece

(EMCDDA, 2009a)

Large numbers of street-based IDUs

NM

NM

Drop-in centre, Glasgow, UK (Carr et al., 1996)

Red-light area

NM

Drop-in centre, IKHLAS, Chow Kit, Malaysia (UNAIDS,

1999)
(i) Foster Street, (ii) Health Works (ii) Access Health,
Melbourne, Australia (Norman et al., 2006)

Red-light district

Large numbers of street-based

IDUs/Drug hot spot

HAHRC, Alberta, Canada (Ross et al., 2008)

Under-serviced part of the city with

pockets of drug use
Peripheries of deprived housing estates

NM

NM

NM

Health clinics for problem drug users, London, UK

(Gerada, Orgel, & Strang, 1992)

Major services provided

Staffing

Facility

55

Chapter 3

Table 3.2 Services provided, staffing and reported accessibility and acceptability of primary healthcare facilities for IDUs
The centre (reference)

Placement of primary healthcare

Major services provided

NSP

OST

HCV/ HIV treatment

Hepatitis B vaccination

Social & welfare services

Other basic medical services

Medical

Nursing

Counselling

Outreach

Drop-in

Reported accessibility

Reported acceptability

Staffing

Facility

ISIS Clinic, San Francisco, USA (Harris & Young, 2002)

San Francisco general hospital

NM

NM

NM

Kirketon Road Centre (KRC), Sydney, Australia (van

Beek, 2007)

Red-light area

+/+

Living Room, Melbourne, Australia (Norman et al., 2006)

Drug hot spot

Low-threshold health service centres for IDUs, Finland

(Arponen et al., 2008)

Mainly in cities with high prevalence

of drug use

+*

+*

Low-threshold service, Ganslwirt, Vienna, Austria

(EMCDDA, 2009b; Weigl et al., 2009)

Large numbers of street-based IDUs

NM

Maryland Centre, Liverpool, UK (Morrison & Ruben,

1995)

High rates of drug use

NM

Merchant's Quay, Dublin, Ireland (EMCDDA, 2009c)

High rates of drug use

Next Door, Melbourne, Australia (Norman et al., 2006)

Drug hot spot

+/

Puentes Clinic, San Jose, USA (Kwan et al., 2008)

Co-located with outpatient OST clinic

+/

56

Chapter 3

Table 3.2 Services provided, staffing and reported accessibility and acceptability of primary healthcare facilities for IDUs
The centre (reference)

Placement of primary healthcare

NSP

OST

HCV/ HIV treatment

Hepatitis B vaccination

Social & welfare services

Other basic medical services

Medical

Nursing

Counselling

Outreach

Drop-in

Reported accessibility

Reported acceptability

Major services provided

Staffing

Facility

Redfern Harm Minimisation Clinic, Sydney, Australia

(Day et al., 2011)

Large number of Aboriginal IDUs

and high rates of drug use

SEP for HIV prevention, Malmo, Sweden (EMCDDA,

2009f)

In an outpatient clinic, drug affected

area

NM

NM

NM

The Lifesaving and Life-giving Society (LALS),

Kathmandu, Nepal (Singh, 1997, 1998)

Areas frequented by drug users

NM

The Triangular Clinic in Kermanshah, Iran (World Health

Organization, 2004)

High levels of drug use and HIV

+/+

Wound and abscess clinic, Oakland, USA (Lauretta, Grau,

Arevalo, Catchpool, & Heimer, 2002)

High rates of drug use

Services have been presented in alphabetical order. Abbreviations: HAHRC = Health and Harm Reduction Clinic. CHCV = Community Health Care Van. ISIS = Integrated Soft
Tissue Infection Services. SEP = Syringe Exchange Program. = As all information required for this table were not available, managers of respective facilities were contacted for
required information. # = Close links with NSP. NM = Not mentioned. OMP = Opioid maintenance program. = Close collaboration with detoxification and substitution units. =
Currently not available but referral is available almost from all the centres. = Paramedic staff. *= About half of the centres have this facility

57

Chapter 3

3.2.2 Accessibility and acceptability of IDU-targeted PHC

Accessibility
The majority of IDU-targeted PHC facilities described in the literature are located
(or co-located) in neighbourhoods with high concentrations of drug use, red-light
districts and/or places where drug users congregate to buy drugs or access services
(e.g. OSTs or NSPs). About half of the papers emphasised the appropriate location
of their service(s) as facilitating accessibility (Table 3.1). All except four PHC
facilities also provided on-site NSP; of those four, three were co-located with an
NSP and the fourth did not mention NSP services. A recurrent theme is that
NSPs/OSTs attract clients, and providers utilise this opportunity to engage clients in
healthcare (Carr et al., 1996; Morrison & Ruben, 1995).

Enhancement of NSPs to include PHC is feasible (Day et al., 2011; Pollack et al.,
2002) because IDUs trust NSPs (Lauretta et al., 2002). Altice and colleagues (2005)
found that completion of the vaccination against HBV schedule among IDUs
attending an NSP was substantially higher than among groups referred to other
services, suggesting that NSPs may effectively provide preventive healthcare.

No IDU-targeted PHC reviewed used structured appointment systems. Most patients

were seen on an informal, walk-in, first-come first-served basis. Anonymity was a
salient theme highlighted in almost all the articles/documents reviewed. Anonymous
access removes barriers for undocumented immigrants and individuals engaged in
other illegal or covert behaviours (Harris & Young, 2002). Some facilities followed a
needs-based opening hours system; for example, the drop-in centre in Glasgow
58

Chapter 3
offered healthcare from 7.30 p.m. to midnight to accommodate work practices of
female sex workers, most of whom were drug users (Carr et al., 1996). Similarly, the
mobile outreach clinics of Kirketon Road Centre offered PHC seven evenings a
week to meet the needs of street-based IDUs and sex-workers (van Beek, 2007).
Suitable service hours are pivotal to increased access and continuity of care for
marginalized groups (Carr et al., 1996).

The majority of IDU-targeted PHC facilities offered outreach services and some had
mobile arrangements to facilitate coverage of a wide geographical area and offer
services to hidden populations. Almost all facilities provided services free-ofcharge to remove financial barriers to healthcare. Health insurance or government
healthcare benefits were not required to access services. Outreach services and
mobile arrangements increased accessibility by covering wider geographical areas,
taking services to those who might not present until at a late stage. For example, the
Community Health Care Van, a mobile facility in New Haven, USA, targeted out-oftreatment IDUs with medical and social services at four locations. The timing and
location of the van reflected the schedule of New Haven NSP (Pollack et al., 2002).
Similarly, operating seven evenings a week, the outreach bus of Kirketon Road
Centre was fitted out as a mobile clinic and visited street locations where sex work
and injecting drug use occur (van Beek, 2007).

There is very little literature available on the effect of enhanced service arrangements
on the level of service utilisation and drug health outcomes for IDUs. Only one study
examined the impact of enhanced services on virologic outcomes in a directly
administered antiretroviral therapy trial for HIV-infected drug users of HIV. The
59

Chapter 3
authors concluded that the results offered compelling support for the provision of
enhanced services for active drug usersnotably, case management and medical
services (Smith-Rohrberg, Mezger, Walton, Bruce, & Altice, 2006).

60

Chapter 3

Table 3.3 Key themes associated with accessibility, acceptability and operational problems of IDU-targeted PHC facilities
Associated with accessibility
Suitable location (e.g. NSP/OSTs etc.)

Associated with operational

problems
Harm reduction based service provision Financial sustainability

Flexibility in appointment and drop-in arrangements

Arrangement of social and welfare

Confidentiality/anonymity (no fear of notification to

authorities)
Cost-free services
Opening hours based on need

Associated with acceptability

Unknown service quality

services
Tailored to the lifestyle of client group
Reluctance to attend conventional
healthcare facilities

61

Chapter 3

Acceptability
One evaluation examined both clients and managers feedback on service
acceptability (Norman et al., 2006) and another study examined clients satisfaction
(Harris & Young, 2002). A further 13 reports discussed acceptability based on
authors own perceptions (Table 3.1). Features reported to enhance acceptability
include client anonymity, confidentiality, non-judgemental and friendly staff
attitudes, a harm reduction service provision framework, drop-in arrangements and
no-cost services (Table 3.2). Providing a welcoming environment, ensuring a place
where clients can have time out (Kwan et al., 2008), responsivity to client needs,
the employment of peer workers and women-only (or specific group) times are also
important (Norman et al., 2006). Most reports describe a user-friendly approach to
service delivery and do not pressure clients, thus avoiding alienation and increasing
the likelihood of continuing engagement. Some IDU-targeted PHC facilities combine
workers duties in both outreach and fixed-site settings, as some clients engaged by
the outreach service prefer to consult a familiar worker in the fixed location
(McDonald, 2002).

In a snapshot survey conducted for the evaluation of seven IDU-targeted PHC

facilities in Victoria, Australia, 97 percent of clients reported that they liked staff; 92
percent found services non-judgemental; 89 percent felt they could discuss their
health problems openly; and 95 percent reported they felt safe (Norman et al., 2006).
Similarly, 86 percent of patients expressed positive views about an IDU-targeted
clinic in San Francisco; and 92 percent reported that they were definitely or very
likely to recommend the clinic to others (Harris & Young, 2002). Indeed, all reports

62

Chapter 3
described a substantial improvement in attracting new clients. However, none of the
studies employed rigorous, independent measures most measures were subjective
and relied on client and staff self-reports.

An important aspect of acceptability are difficulties experienced in accessing other

available healthcare services, which to some extent determines the degree of
acceptability of these targeted PHC facilities. For instance, in a study on two of the
oldest IDU-targeted PHC services in London, Gerada and colleagues (1992) found
that only 38 percent of clients were registered with a GP. Even those registered
expressed reluctance to attend GPs. Although not an extensive study by design, the
authors commented that most patients were grateful for access to medical care and
used the facilities appropriately. However, methods used to measure acceptability
were not described.

The tendency of a growing number of IDU-targeted PHC facilities to provide a wide

range of healthcare, social and/or welfare services increases their acceptability to
clients (Morrison et al., 1997). Sometimes references prepared for housing
departments, welfare agencies, police or courts and the provision of meals (Carr et
al., 1996; EMCDDA, 2009d; IKHLAS, 2009) may take precedence for clients, but
can facilitate the adjunct offer of healthcare (Morrison & Ruben, 1995).
Consequently, homeless drug users are an important client group for most IDUtargeted PHC facilities (Harris & Young, 2002; Kwan et al., 2008; Norman et al.,
2006; Rowe, 2005).

63

Chapter 3
Four articles reported clients return rate and/or frequency of service utilisation as an
indicator of acceptability. An internal file-audit of 200 clients of inner-city Sydneys
Redfern Harm Minimisation Clinic (an NSP-based PHC) revealed that 90 percent
made at least one return visit (Day et al., 2011). The authors argued that this high
return rate was largely attributable to systematic follow-up and co-location with an
NSP. Twenty-eight percent (n=370) of all first-time-contacts that attended Dublins
Merchants Quay health promotion unit during an 18-month period re-visited during
the three-month follow-up. At follow-up, 18 percent of attendees who reported at
baseline no history of HIV testing at first visit, had undertaken testing; and 10
percent who reported at baseline not being vaccinated against HBV had undertaken
vaccination at follow-up (EMCDDA, 2009c). More than half of initial clients of
Puentes clinic, San Jose regularly used its services five years after opening, implying
that the clinic functions as a medical home for this population (Kwan et al., 2008).
The Maryland Centre in Liverpool (United Kingdom) provided 5,308 medical
consultations, an average of more than seven per client (Morrison & Ruben, 1995).

3.2.3 Impacts on health outcomes

Receipt of PHC by drug users is associated with reduced severity of drug
dependence. Two randomised controlled trials showed that patients with drug-related
medical conditions were significantly more likely to achieve abstinence or report
reduced opiate use and improved medical outcomes in the onsite care group (PHC
included within the drug treatment program) than the independent care group (PHC
and drug treatment provided separately) (McLellan, Arndt, Metzger, Woody, &
O'Brien, 1993; Weisner, Mertens, Parthasarathy, Moore, & Lu, 2001). In a

64

Chapter 3
retrospective cohort study, patients who received onsite PHC demonstrated
significantly reduced severity of dependence compared to patients who received
offsite PHC, but not necessarily improvement in other health outcomes (Friedmann,
Zhang, Hendrickson, Stein, & Gerstein, 2003). A more recent study found that
receipt of PHC in a distributive model by drug-dependent adults was associated with
reduced problems and severity of dependence over a 24-month period (Saitz, Horton,
Larson, Winter, & Samet, 2005). However, the centre did not target solely IDUs. An
evaluation of Finnish IDU-targeted low-threshold PHC concluded that PHC and
harm reduction services are effective in engaging hard-to-reach IDUs and preventing
BBVI transmission (Arponen et al., 2008).

Referrals are made from IDU-targeted PHC facilities to a range of services including
GPs, hospital EDs, tertiary outpatient clinics, infectious disease, general medicine,
surgery, orthopaedic, gynaecology/obstetrics, psychiatry and welfare services, but
limited information is available on referral uptake. A recent study of RHMC clients
showed that 65 percent of clients who were positive for HCV polymerase chain
reaction (PCR) attended at least one referral to a tertiary liver clinic (Islam, Hayes, et
al., 2010). An Australian evaluation which assessed 12 PHC facilities and ancillary
programs accessed mainly by IDUs, found that clients reported these targeted PHC
facilities as their base and a means to access other services, with the majority also
reporting contact with a GP in the preceding six months. Rates of GP contact were
much higher than those found in a needs analysis conducted in 1999 with a similar
population. However, the survey intended only to provide a snapshot and was
conducted with a convenience sample of just ten clients per fixed site. In addition,

65

Chapter 3
the self-report data were limited by potential social desirability bias (Norman et al.,
2006).

Around half of the IDU-targeted PHC facilities offer assessment and testing for STIs
and one-third offer onsite treatment. A recent case-report from an NSP-based PHC
demonstrated that the provision of PHC from an NSP can facilitate the early
diagnosis of HIV and help prevent the spread of BBVIs and STIs (Islam et al., 2011;
also see Chapter 4). The Triangular Clinic in Kermanshah, Iran that has been
conceptualised to address three critical issues in drug misuse intervention: harm
reduction, STI treatment and HIV care, found that the majority of HIV-positive
clients substantially changed their risk behaviours (World Health Organization,
2004).

3.2.4 Cost implications

Although there are no data on the cost-effectiveness of IDU-targeted PHC, a wound
and abscess clinic conducted in an NSP in Oakland, USA was reported to have
provided economical treatment and aftercare for injection-associated soft tissue
infections. The visit cost was estimated at US$5 per patient, much less than the
estimated costs at hospital outpatient settings (Lauretta et al., 2002). The Integrated
Soft Tissue Infection Service Clinic in San Francisco dramatically reduced ED visits
(33.9%), surgical service admissions (47.3%), inpatient acute care bed days
(33.7%), and operating room procedures (71%), saving approximately US$8.7
million in the first year of operation (Harris & Young, 2002). A full-scale
implementation of Community Health Care Van, New Haven was associated with

66

Chapter 3
more than 20 percent reduction in ED visits, suggesting potentially huge cost savings
(Pollack et al., 2002).

3.2.5 Operational challenges

Reported operational challenges include lack of funding/resources, difficulties in
retaining clients, limited range of services, police harassment and staff shortages. For
example, an evaluation of the Ganslwirt Centres OST program in Vienna indicated
that treatment often ends prematurely and suddenly due to staff fluctuations in the
outpatient clinic (Weigl et al., 2009). Prejudice and suspicion towards their ethos and
clients have forced some IDU-targeted PHC facilities to relocate, sometimes to
locations where client accessibility has been considerably reduced (Arponen et al.,
2008).

The quality of healthcare services from IDU-targeted PHC centre is not clearly
documented in the existing literature. Some services offer comprehensive and quality
healthcare, whereas others have capacity to provide limited services, potentially of
inadequate quality. Satisfaction was the most commonly recorded quality
measure, albeit in less than a quarter of the services reviewed. Other quality
measures such as scope, completeness, effectiveness, efficiency and safety of
interventions (Donoghoe, Verster, Mathers, & Secretariat of the Reference Group to
the United Nations on HIV and injecting drug use, 2009) were rarely recorded.

67

Chapter 3

3.3 Discussion
This review illustrates the barriers to IDUs access to mainstream healthcare services
and suggests that IDU-targeted PHC facilities, by providing non-judgemental and
cost-free services under a harm reduction framework, are likely to increase the
accessibility and acceptability of PHC to this population. Providing anonymous
services from a suitable location, preferably where IDUs dwell or congregate, and
with appropriate opening hours, drop-in provision, and peripheral services may
potentially increase IDUs engagement and satisfaction with these services. Targeted
PHC services have the potential to mitigate IDUs perceived barriers to access to
healthcare delivered in conventional settings. The provision of accessible and
acceptable services which are responsive to the needs of this population is valuable,
facilitating a reduced reliance on inappropriate and cost-ineffective ED care.

The majority of IDU-targeted PHC facilities provide a limited set of medical services
which tend to relate directly or indirectly to drug use. Although the constraints of the
literature precluded systematic comparisons of accessibility and acceptability to that
of GPs or other conventional PHC services, results concerning accessibility and
acceptability are nevertheless important because IDU-targeted PHC facilities are
tailored to, and seek to make contact with, people who may not be committed to
lifestyle change. Consequently, the relationship between NSP staff and their regular
clients facilitates healthcare provision. Thus, equipping NSPs, drug treatment
facilities or other drug-related services with PHC support may facilitate IDUs
access to healthcare. Integrated services are found to be better accessible to IDUs, a
notion supported by the literature (Campbell et al., 2007; Umbricht-Schneiter et al.,
1994), and thus often recommended (Bruce, 2012; Nasiri, 2012). Referral-only
68

Chapter 3
linkage systems to conventional PHC facilities may be insufficient for IDUs,
whereas on-site services may lead to better outcomes (Campbell et al., 2007). Some
experts argue that for many IDUs, offering referral only is akin to denying services
(Nasiri, 2012). Augmenting NSPs and similar services to include PHC may save
resources by building on existing infrastructure and increasing early access to
treatment.

Not all IDU-targeted PHC models suit all settings; the type of facility that is most
appropriate will be influenced by, among other characteristics, the availability,
affordability and assistance of other services; the geographical area; and patterns of
drug use among target populations; existing drug policy; and level of tolerance; and
social stigma associated with illicit drug use. However, for any health service to be
accessible and credible to IDUs, a non-judgmental and client-centred philosophy is
essential. Thus, the benefits of targeted PHC are mostly enjoyed in settings where
harm reduction is accepted either explicitly in national policy documents and/or
through the implementation or tolerance of harm reduction interventions. Even
where harm reduction is considered to oppose the existing drug policy and is only
grudgingly tolerated, offering PHC in conjunction with NSPs has the potential to
enable the facility to function as a medical centre for IDUs.

Providing health and social services beyond syringe distribution can improve the
attractiveness of NSP services. Hence, IDU-targeted PHC facilities are in this
context a valuable and essential healthcare platform. It is, however, important to
ensure that the provision of ancillary services does not inadvertently restrict NSP
coverage by consuming available funds. Harm reduction is still woefully under-

69

Chapter 3
funded (Bergenstrom et al., 2010). It might, therefore, be reasonable to consider the
gradual mainstreaming of these services into conventional healthcare delivery
(Islam, Day, et al., 2010; Appendix IV). However, achieving mainstreaming is
challenging and it is unlikely that there will be a single best answer for all settings
due to substantial geographical, cultural, policy and practice variation.

Although there is very little literature on enhanced models of GP care targeting

IDUs, theoretically these enhanced services have the potential to plug a gap in
essential services or deliver higher than specified care standards, with the aim of
reducing demand on secondary care. These enhanced services expand the range of
options to meet local need and improve convenience. Referring to the UKs GP
based PHC services, Ford (2012) notes that it is difficult to measure the effectiveness
of existing healthcare services, such as general practices, in caring for the needs of
IDUs. Although office-based PHC services were excluded from the review, direct
support for GPs in caring for IDUs would seem to be a valuable option and there is
much to learn from the experience of such initiatives. Clinicians, however, are likely
to vary considerably in their level of preparedness and ability to deal with IDUs,
regardless of available support (McKeown, Matheson, & Bond, 2003), and in
Australia, for example, there has been great difficulty in recruiting GPs to become
OST

prescribers (Longman, Lintzeris, Temple-Smith,

& Gilchrist, 2011;

Scarborough, Eliott, & Braunack-Mayer, 2011).

The political and cultural environment in which PHC services for IDUs are
established varies greatly and certainly the final shape of any facility aiming to
service IDUs will be influenced by local variables (Rowe, 2012). Nonetheless, there

70

Chapter 3
remain a number of common elements, including a harm reduction focus, convenient
location and drop-in arrangements. These approaches are crucial whether IDUtargeted health services are in Sydney, Nepal or Iran. Service utilisation by IDUs is
often determined by convenience, immediate satisfaction and respect, unless the
perceived need for services is very high (Bruce, 2012; Nasiri, 2012).

An important concern yet to be addressed in the literature is the quality of healthcare

offered by IDU-targeted PHC facilities. Given that these facilities vary across
settings in terms of services provided, the workforce employed and service
modalities, it is inevitable that service quality will also vary. Moreover, services are
offered free-of-charge, and with many IDU-targeted PHCs offering other essential
services like NSPs or OSTs within limited budgets, financial sustainability of the
facilities may be tenuous, which may impact on service breadth and quality. For
example, HIV and HBV testing were temporarily suspended at a service in Nepal
due to funding constraints (Singh, 1997). Further research is needed on this issue.

There are huge difficulties in offering PHCs to IDUs in low and middle income
countries where needle and syringe programs (NSPs) and opioid substitution
treatment services are either absent or coverage is poor (Myers, 2012). Existing
services for similarly high-risk populations, such as sex-workers and men who have
sex with men, may be well suited to providing PHC for IDUs; that indeed, given the
considerable overlap in these populations, such services may be expanded to provide
a NSP. This makes good sense for countries where services for these high-risk
groups exist, however many developing countries lack even minimal services for
these groups (Islam & Conigrave, 2008). In such settings, continued attempts to
71

Chapter 3
gradually mainstream harm reduction services (Islam, Day, et al., 2010) may be the
only viable option. Myers (2012) supports this suggestion and also recommends
consideration of peer-led services, an approach well worth exploration in resourcepoor settings.

IDUs endure a plethora of health problems and experience a range of barriers to

accessing healthcare. Developing targeted PHC has substantial potential to reduce
harm and improve healthcare for marginalised IDUs. As NSPs and drug treatment
services are regularly accessed by IDUs, these facilities could be enhanced to include
PHC services. Such PHCs may improve IDUs health and reduce health expenditure
by reducing tertiary service utilisation. Further evaluation using robust research
designs is necessary to clearly establish the effectiveness and cost-effectiveness of
these PHC services.

3.3.1 Limitations
This review suffers a range of limitations. There are no doubt other services that
have not been discussed in the published literature; only literature published in
English was reviewed. Furthermore, there is a dearth of published material that
outlines obstacles encountered in establishing and implementing services. Most
reports are case-studies or process evaluations; some are published only in grey
literature; and rigorous effectiveness and cost-effectiveness evaluations are lacking,
which impacts on the rigor of the study and quality of results. Having not undergone
peer review, information found in grey material may not be generalisable to other
contexts. It is nevertheless important to include grey literature in a review as

72

Chapter 3
excluding material that is not widely available may introduce a methodological bias
and hence the study cannot be considered exhaustive. Findings from PHC targeting
IDUs in abstinence-oriented policy settings would enrich this review; however, all
documents retrieved were from settings where harm reduction is either accepted or
tolerated. Discussion of other setting characteristics that may impact upon
accessibility, acceptability and health outcomes is considered beyond the scope of
this review.

Due to limited literature from developing countries, acceptability was examined on

the same terms for all settings including those with and without universal healthcare
provisions. The narrative synthesis approach relies on a high level of trust in
assumptions made by the authors. Implementation is rarely the focus of published
reports of interventions, particularly those published in peer-reviewed journals where
brevity is an editorial requirement. Although some implementation data may be
found interspersed throughout the text and predominantly in the discussion section,
where authors provide an explanation for the effectiveness, in many cases these
explanations are not empirically supported. Clearly more data are needed on the
types of services IDUs present for, the characteristics of the population using the
service, and the referral uptake and outcomes. It is also important to examine if
clients accessing these targeted services are comfortable in disclosing risk
behaviours which is crucial for providing appropriate healthcare. Whilst cost
effectiveness studies are lacking, there are no published reports of even simple
costing studies, a crucial first point in evaluation.

73

Chapter 3
Undoubtedly more discussion and access to published evaluations, even those
employing below gold standard methodology, will increase discourse about
appropriate methods of evaluation. This in turn may lead to the development of
evaluation-guidelines which can foster quality assessments suitable for publication in
academic journals, thereby increasing the accessibility of relevant literature to
policymakers and service providers. Evaluations would necessarily, as Rowe (2012)
points out, include client feedback. However, client feedback is limited by selection
bias, because only clients who are reasonably satisfied with a service (or desperate)
tend to continue to use that service (van Beek, 2012). Feedback may also be subject
to social desirability bias. Clearly there are huge difficulties in collecting robust
evidence on the effectiveness of any IDU-targeted PHC services. This, of course, is
one reason why the scientific literature on this subject is so sparse (van Beek, 2012).

3.4 Conclusion
In conclusion, the findings of this review indicate that IDU-targeted PHC facilities
provide non-judgemental and cost-free services under a harm reduction framework
and can increase the accessibility and acceptability of primary healthcare for IDUs.
However, there is a dearth of rigorous evaluations of these targeted PHC facilities,
with the public health impact of such services yet to be systematically documented.
Until such services are supported to undertake rigorous outcome evaluations that
clearly document their public health impact, challenges will remain in attracting the
funding necessary to implement these targeted PHC and, where appropriate, expand
and scale-up the services they deliver.

74

Chapter 3
As noted in Chapter 1, rigorous evaluations would be methodologically challenging
and costly. However, examining the level of utilisation, especially the continuity of
care in terms of clients return rate, and whether these services attract the target
group they are designed for may not be that challenging and can provide valuable
information. These issues are basic and crucial to measure the success of these
targeted healthcare services. In particular, it would be important to determine
whether a targeted service is reaching the target group in a setting such as Australia
where clients enjoy universal healthcare provision. The study findings in such a
setting would help minimise the bias of some variables such as the cost of accessing
healthcare in settings where universal healthcare provision does not exist.

The next chapter details the findings of a study carried out in an NSP augmented
PHC service in inner-city Sydney, Australia that examined the client characteristics
and other indicators of uptake and client engagement in preventative and other
healthcare. Specifically, this study examined characteristics, drug use, risk behaviour
and GP access of clients presenting to this low-threshold targeted PHC. The PHC
client characteristics were then compared with those of a broader sample of NSP
attendees in NSW, to see if PHC users are representative of the broader NSP
population.

75

Chapter 4

CHAPTER 4
Client characteristics and service utilisation of a
low-threshold primary healthcare centre based at
an inner-city needle syringe program 3
The previous chapter presented findings of a literature review on IDU-target PHC
services. Although, the findings highlighted the range of PHC models, which have
found acceptable and accessible to IDUs, there remains a dearth of rigorous outcome
evaluations. Methodological challenges are perhaps the most important reasons for
this lack of evaluations. Numerous challenges impede rigorous evaluations of IDUtargeted PHC services. The primary difficulty arises from defining measureable
health outcomes that could underlie evaluation of the impact of the services offered.
The further difficulty relates to identifying methodological designs that are both
appropriate and feasible. It is difficult to design a study which could evaluate
targeted PHC services using the hierarchy of evidence commonly applied to health
and medical interventions (Hawkins, Sanson-Fisher, Shakeshaft, D'Este, & Green,
2007). For instance, a randomised controlled trial (RCT) the gold standard in
evaluation is often not possible due to methodological and pragmatic concerns.
These include, but are not limited to: ethical constraints, contamination, time for
follow-up, cost and external validity (Sanson-Fisher et al., 2007). It would be
ethically challenging to deny a control group with serious health issues access to
3

Study reported in: Islam, M. M., Topp, L., Conigrave, K. M., White, A., Haber, P. S., & Day, C. A.
(in press). Are primary health care centres that target injecting drug users attracting and serving the
clients they are designed for? A case study from Sydney, Australia. [Epub ahead of print]
International Journal of Drug Policy

Please see Appendix II for a list of publications arising from this thesis.

76

Chapter 4
tailored healthcare. Contamination would also pose a particular challenge as
universal healthcare means participants could seek PHC outside the study. As noted
above, determining measurable health outcomes is challenging, and would require
long periods of follow-up, especially for conditions that progress slowly such as
HCV infection, and such studies are likely to be resource-intensive. Furthermore, the
external validity of the study findings, which clearly can only be conducted among
IDUs willing to participate in a clinical trial, may be limited.

Due to the challenges of conducting an RCT, outlined above, it is not possible to

achieve level 1 evidence (Guyatt et al., 2011) for targeted PHC interventions.
Similarly, many public health interventions including NSPs will never be able to
meet such evidence (Day & Topp, 2011; Hawkins et al., 2007). However, this lack
of quality evidence does not equate to evidence for lack of effectiveness for these
interventions, nor should this be a sufficient reason to discard these kinds of
interventions. In fact, there are many public health interventions deemed successful
but lacking high quality evidence due to similar challenges (Rychetnik, Frommer,
Hawe, & Shiell, 2002).

A longitudinal prospective observational study of suitably-recruited cohorts of IDUs

from a targeted facility or a case-control study design would provide useful, albeit
less rigorous data. Such designs are still inherently limited because of the potential
for systematic difference between the groups who access targeted PHC facility and
those who do not (van Beek, 2012). To design an evaluation of RHMC of this
nature, cases could be identified through existing RHMC client records, whereas
control IDU participants could be recruited using a range of approaches, such as

77

Chapter 4
IDUs who access the co-located NSP but not RHMC itself, or IDUs recruited from a
geographical area where targeted PHC facilities are unavailable. Control participants
could be matched on relevant variables such as age, gender and drug. To measure
health outcomes, data linkage could be undertaken to match participant data with a
range of administrative health datasets, including hospital separations, ED use and
attendance at drug treatment services. As indicated above, depending on the
outcomes measured, many of which are insensitive and occur infrequently,
substantial time may be required to yield meaningful results. Furthermore, such
studies are resource-intensive and require significant funding. Unfortunately, the
research reported in this thesis was unfunded and therefore a case-control study,
although recognised as an appropriate design to answer the research questions
addressed herein, was not possible.

The dearth of evaluations of targeted PHCs, temporal pressures and unfunded nature
of the research undertaken in this thesis also limited the use of an alternative design
such as the pre- and post-intervention (Linn & Slinde, 1977). However, it is a
relatively less sophisticated method, as often confounded by variables that cannot
easily be controlled for. Unfortunately, many potentially relevant changes may occur
between before and after periods of measurement, for instance, changes in drug
using patterns across time and the transience of many high risk IDUs. Similar
factors may affect the level of exposure to the intervention and ability to follow-up
service users, many of whom may prefer to remain anonymous and/or uncontactable
for obvious reasons. Further, some IDUs may have access to other services including
conventional healthcare. Moreover, study measures also need to be instituted prior to

78

Chapter 4
interventions being implemented, or preferably for a period prior to this to enable
collection of relevant baseline data.

Given the difficulties in evaluating population-based health interventions, several

alternative methods have been recommended, for instance, (i) the non-RCT, (ii) the
controlled before-and-after study, and (iii) the interrupted time series design
(Cochrane Effective Practice and Organisation of Care Group, 2003). The first two
designs require a control group, which for IDU-targeted services are extremely
difficult to ensure. Although the third design allows the same group to be compared
over time by repeatedly measuring and analysing data (National Health and Medical
Research Council, 2000) and as few as one population group (a baseline measure is
used for control comparison) (Grimshaw, Campbell, Eccles, & Steen, 2000), this
design is, nonetheless, limited by its inability to assess the impact of concurrent
events on the outcomes of interest (Biglan, Ary, & Wagenaar, 2000; Cochrane
Effective Practice and Organisation of Care Group, 2003). A strategy which would
increase confidence that the intervention was responsible for a change in outcome is
to conduct multiple time-series in multiple population units, each of which
deliberately receives the intervention at a different point in time (Biglan et al., 2000;
McGuigan, 1993). This staggered design is known as the multiple baseline design
and has been recommended for a variety of population based interventions (Hawkins
et al., 2007). However, this design needs to be implemented as part of the
establishment phase of multiple PHC facilities, and thus would be expensive and
impracticable given the economic considerations discuss above in sections 8.6.

79

Chapter 4
IDU-targeted services are relatively new and are limited in numbers, which is a key
reason for the lack of evaluations. The aforementioned limitations and a lack of
research funding for evaluation of these services result in process and/or internal
service evaluation only and often using case-study approach that ends up being
confined to extant models already in operation. Process evaluation mostly includes
analyses of utilisation data and client satisfaction surveys, which is limited by
selection and social desirability bias, because only clients who are reasonably
satisfied with a service (or desperate) tend to continue to use that service (van Beek,
2012). Although such evaluations do not constitute scientifically rigorous evidence,
they are good indicators of service processes and are useful tools for policy makers
who rely on a range of input to build policy including more abstract drivers such as
politics, values and opinion (Ritter, 2009).

It is nonetheless important to know whether these targeted healthcare services are

attracting and retaining the target client group. Specifically, it is important to know
the characteristics, drug use, risk behaviour and access to other healthcare providers
by the clients presenting to this low-threshold targeted PHC. This chapter aims to
investigate these issues in a NSP augmented PHC setting the RHMC in innercity Sydney. This chapter aims to investigate whether the RHMC is attracting and
retaining its target client group, and to examine indicators of its effectiveness in
providing preventative and other healthcare.

Specifically, this study (i) examines characteristics, drug use, risk behaviour and GP
access of clients presenting to this low-threshold targeted PHC; (ii) compares these

80

Chapter 4
characteristics with those of broader sample of IDUs in NSW, Australias most
populous state and that in which the RHMC is located; (iii) documents clients
reasons for presentation; (iv) investigates uptake of referrals made to other health
and social services; and (v) presents two case studies as an example of opportunistic
healthcare from an NSP based PHC facility.

4.1 Method
Data were extracted using a retrospective clinical file audit and then analysed. These
data were then compared with data on the characteristics of clients attending NSPs in
NSW (Iversen et al., 2011). Data collection and analysis were approved by the Ethics
Committee of Sydney South West Area Health Service, Royal Prince Alfred
Hospital (RPAH) Zone.

4.1.1 Redfern Harm Minimisation Clinic and its service

provision
In July 2006 the Redfern NSP in inner-city Sydney, Australia was augmented with a
PHC service targeting IDUs. The RHMC is a nurse-led drop-in service with a
sessional (4 hours per week) visiting medical officer providing clinical supervision
for nurses and patient consultations on referral from the nurse. RHMC was set up to
provide a limited range of primary healthcare services with a specific focus on
blood-borne virus prevention and treatment. The service range was determined based
on a needs analysis survey of the target population (unpublished data) and the WHO
definition of PHC for IDUs (World Health Organization, 2009). Services are
provided both by appointment and on a drop-in basis (Day et al., 2011), and

81

Chapter 4
clients presence in the NSP shopfront is often utilised opportunistically to provide
care (Islam, Reid, et al., 2012). Clients may continue attending the RHMC and/or the
NSP according to their own wishes and clinical advice. Clients are generally referred
from the NSP shopfront or nearby outpatient drug treatment or residential drug
treatment services. The nurse-led nature of the service precludes clients from
obtaining benzodiazepines and other prescribed psychoactive medications, an issue
that has been found to complicate health service utilisation by heroin users (Darke et
al., 2003).

4.1.2 Procedures
During initial client assessments, nurses record details about clients demographic
characteristics, access to GP services, interpersonal relationships including
dependents, and five domains: (i) drug and alcohol use; (ii) blood-borne virus risks
and status; (iii) mental health; (iv) sexual and reproductive health; and (v) general
health. This full assessment is updated every 12 months among returning clients.
Referrals are based on the assessment and client preferences. To enhance referral
uptake, clients are provided with assistance to make appointments and telephone or
SMS reminders are sent the day preceding appointments.

Based on the assessment, a range of laboratory examinations may be offered,

including screening for BBVIs and STIs, general pathology tests including urea,
electrolytes, creatinine, liver function tests, coagulation factors and full blood count.
Other

services

commonly

offered

include

care

and

management

for

wounds/veins/abscesses; vaccination against HBV; STI treatment; general health

82

Chapter 4
consultations; drug and mental health issues; welfare services (e.g., advocacy with
respect to public housing); counselling; referrals to other health and related services;
support throughout HCV assessment and treatment; and provision of HCV antiviral
therapy to a small number of clients (see Chapter 5). Although RHMC does not
provide opioid substitution therapy from its premises, it is closely linked to a nearby
opioid substitution therapy clinic, and facilitates referrals of and transport for its
clients to that clinic.

4.1.3 Referrals and follow-up

The nurses of this PHC centre maintain close links with a number of local services
including a tertiary liver clinic and drug treatment services (including an OST clinic,
as described above, and nearby residential drug treatment service) and an Aboriginal
(Indigenous Australian) community controlled medical service. These relationships
allow staff to facilitate referrals to and from each service and arrange further
appointments as necessary. Referrals to other services can be either formal (written
referral, or appointments booked on clients behalf) or informal (clients make their
own arrangements to access recommended services). Nurses in the service support
clients to attend referrals through a range of means including by telephone and/or
text message reminders (see Chapter 5 and Islam, Topp, White, et al., 2012). Uptake
of formal referrals is confirmed through direct communication with the services to
which clients are referred. Client self-reports serve as the record of uptake of
informal referrals.

83

Chapter 4

4.1.4 Data collection and analysis

An audit of files was performed for all clients who accessed this targeted PHC
between July 2006 and December 2009 (n=384 client files). Key variables were
extracted manually from clients intake assessments, progress notes and serological
testing results by the candidate, entered into a Filemaker Pro software database and
analysed using STATA (version 11). Significance of differences between groups was
analysed using chi-square and Fishers exact test for categorical variables, and
independent sample t-tests for continuous variables. Statistical significance was set
at p<0.05. Multivariable logistic regression, using backward elimination, derived
adjusted odds ratio (AOR) and associated 95 percent confident intervals (CI)
controlling for variables associated (at p<0.15) with access to GP services on
univariate analysis.

The Australian Needle and Syringe Program Survey (ANSPS) sample recruited in
NSW between 2006 and 2009 was used as a comparative baseline to determine
differences between RHMC clients and broader populations of IDUs. The ANSPS is
an annual cross-sectional survey of Australian NSP attendees, and previous research
has demonstrated that ANSPS participants are representative of the broader
population of NSP clients (Topp, Iversen, Wand, et al., 2008). Weighted percentage
of relevant variables from ANSPS was calculated using the formula PiXi/Xi,
where Pi is the percentage of variable for year i, and Xi is the total sample size for
that year.

84

Chapter 4

4.2 Results
4.2.1 Sample characteristics
Clients mean age was 35.5 years [SD 9.4 years] and the majority (76%) were
male. Most (77%) clients were born in Australia; 11 percent identified as Aboriginal
and/or Torres Strait Islander (Indigenous Australian); 82 percent reported receiving
government welfare; and 12 percent were employed. Eighty-five percent of clients
reported a history of injecting drug use; almost 15 percent were NIDUs; while just
two clients reported having never used illicit drugs. More than half (53%) the clients
reported being referred from nearby residential drug treatment services; 20 percent
from the co-located NSP; and the remainder from other healthcare services (7%),
family members or friends (2%) or self-referrals (18%). Other than residential
treatment clients, almost all other PHC clients were existing NSP clients, regardless
of from where they indicated they were referred.

4.2.2 Patterns of drug use

Information on drug use was available for 363 clients (Table 4.1). Alcohol was the
substance used by the largest proportion of clients in the preceding 12 months
(68%), followed by methamphetamine and heroin (58% each). However, heroin was
the drug used most frequently (33%, 120/363) during this period, followed by
alcohol (32%, 116/363) and cannabis (32%, 116/363). Heroin (57%) was the drug
reportedly injected most often (daily or more) among IDUs. Among NIDUs, the
most prevalent drug used in the preceding 12 months was alcohol. Almost a third
(31%) of all IDUs reported injecting medications intended for oral use
(benzodiazepines, methadone, buprenorphine and/or other prescribed opioids).

85

Chapter 4

Table 4.1 Patterns of substance use by clients of RHMC in the preceding 12 months (n=363)
Prevalence
n (%)

Route *

Frequency of use *

Injecting
(%)

Non injecting
(%)

Daily or more
(%)

Weekly or more
(less than daily)
(%)

Less than
weekly (%)

Alcohol

247 (68)

247 (100)

116 (47)

66 (27)

65 (26)

Methamphetamine

210 (58)

161 (77)

49 (23)

59 (28)

66 (31)

85 (40)

Heroin

209 (58)

199 (95)

10 (5)

120 (57)

33 (16)

56 (27)

Cannabis

183 (50)

183(100)

116 (63)

26 (14)

41 (22)

Benzodiazepines

130 (36)

9 (7)

121 (93)

44 (34)

36 (28)

50 (38)

Cocaine

117 (32)

95 (81)

22 (19)

33 (28)

27 (23)

57 (49)

Methadone

99 (27)

43 (43)

56 (57)

66 (67)

20 (20)

13 (13)

Ecstasy/LSD

60 (17)

60 (100)

3 (5)

13 (22)

44 (73)

MS-Contin and/or Oxycontin

70 (19)

60 (86)

10 (14)

16 (23)

18 (26)

36 (51)

Buprenorphine

26 (7)

11 (42)

15 (58)

14 (54)

6 (23)

6 (23)

Codeine

13 (4)

13 (100)

5 (38)

3 (23)

5 (38)

* Among those who reported using.

86

Chapter 4

4.2.3 Blood-borne virus serological status, vaccination uptake

and injecting risk behaviours
At baseline, 18 percent of 384 clients tested positive to hepatitis B core antibody
(HBcAb) indicating past exposure to HBV, 96 percent of whom were IDUs. Forty
percent reported past vaccination against HBV, although only half of these reported
completing the multi-dose series. Of those who underwent HCV antibody screening,
62 percent (201/325) tested positive. Qualitative RNA was performed for 170 of the
HCV antibody positive clients, of whom 67 percent tested positive.

Reports of receptive sharing of injecting equipment were common: 79 percent of

IDUs reported a lifetime history of sharing, and 56 percent acknowledged having
shared in the preceding 12 months.

4.2.4 Current access to GP services

Sixty-two percent of clients reported having access to a regular GP. Access to a GP
was more common among women (AOR 2.84, 95% CI 1.49, 5.44) and older clients
(AOR 1.05, 95% CI 1.02, 1.08) after controlling for variables mentioned in Table
4.2. Clients who reported use of buprenorphine (AOR 3.99, 95% CI 1.12, 14.24)
and/or benzodiazepines (AOR 1.83, 95% CI 1.08, 3.11) in the preceding 12 months,
and those currently prescribed mental health medications, mostly antidepressants
and/or antipsychotics (AOR 2.81, 95% CI 1.70, 4.64), were significantly more likely
than other clients to report regular GP access.

87

Chapter 4

Table 4.2 Correlates of access to GP services among 359 RHMC clients

Current GP access
n
Age (years)

359

Gender (%)
Female
Male

358
88
270

Used buprenorphine in
preceding 12 months
Yes
No

350

Used benzodiazepines in
preceding 12 months
Yes
No

350

History of taking mental

health medications
Yes
No

343

24
326

129
221

170
173

(%)

(25)
(75)

(7)
(93)

(37)
(63)

(50)
(50)

Yes
n=239

No
n=120

36 (SD0.6)

33 (SD0.8)

239
71
168

119
17
102

231

119

21
210

3
116

231

119

98
133

31
88

225

118

133
92

37
81

Univariate Relationship
OR (95% CI)

Multivariate Relationship #

p-value

AOR (95% CI)

p-value

1.04 (1.01, 1.06)

<0.01

1.05 (1.02, 1.08)

<0.01

2.54 (1.41, 4.54)

0.01

2.84 (1.49, 5.44)

<0.01

3.87 (1.13, 13.24)

0.03

3.99 (1.12, 14.24)

0.03

2.09 (1.29, 3.40)

<0.01

1.83 (1.08, 3.11)

0.02

3.16 (1.98, 5.07)

<0.01

2.81 (1.70, 4.64)

<0.01

Information regarding GP access was not available for 25 clients; # Complete information for this multivariate model was available for 340 clients.
AOR= adjusted odds ratio. Other variables that were significant only in univariate model history of diagnosis of mental health problem, alcohol drinking
in the past 12 months.

88

Chapter 4

4.2.5 Comparison between IDUs accessing RHMC and broader

samples of IDUs
IDUs accessing RHMC differed in a number of ways from NSP clients who
participated in the ANSPS in NSW during 2006-2009 (Table 4.3). RHMC clients were
more likely to be male; aged25 years; and born in countries other than Australia (all
p<0.01); and less likely to report receptive syringe sharing in the preceding month (6%
vs 16%). When looking only at RHMC clients who were referred from the NSP, this
group was more likely to be male (p=0.03) and less likely to be born in Australia
(p<0.01) than ANSPS participants, but there was no difference in age between the two
groups (p=0.68).

4.2.6 Main reasons for presentation

The most common reasons for initial presentation to RHMC were blood-borne virus
testing and/or vaccination (57%), sexual health assessment or STI check-up (18%),
drug-related health issues (18%) and social services/counselling (5%). Just two percent
of presentations were for welfare services and other assistance. One-quarter of clients
presented seeking more than one service.

4.2.7 Service uptake and referral

Most clients (82%) accessed RHMC more than once, with a mean of 3.5 (SD3.2)
presentations per client. All clinically eligible clients (n=145) were offered vaccination
against HBV, of whom 50 percent completed the three-dose series, while 19 percent
received two doses. Among those who received vaccination, 40 percent were referred to

89

Chapter 4
RHMC from the NSP shopfront. A total of 269 referrals to other health and welfare
services were made for 224 clients, 85 percent of which were formal. Referrals were
made most frequently to the tertiary liver clinic (29%) and GP services (26%). Where
indicated, clients were referred to sexual health services for hepatitis A vaccination. The
majority of informal referrals were made to GP services.

More than half (55%) of the 269 referrals were attended, while 23 percent were not
taken up, and the outcomes of 22 percent could not be ascertained. Referral uptake was
highest for the liver clinic (69%) and drug treatment services (55%). Clients who were
referred to and attended the liver clinic were significantly older than those who did not
attend (38.7 versus 34.6 years; t=2.01, p=0.047). Referrals to GPs were the least likely
to be attended with 36 percent of those referred not attending (Table 4.3).

90

Chapter 4

Table 4.3 Comparison between RHMC attendees and NSW ANSPS participants 2006-2009
Variable

RHMC

ANSPS (NSW)

Mean age

35.5

37

<0.01

Age <25 years (%)

14

<0.01

Male (%)

76

63

<0.01

Aboriginal/Torres Strait Islander (%)

11

14

0.09

Born in Australia (%)

80

85

<0.01

p-value

Receptive syringe sharing last month (%) 6

16

Any treatment/therapy for drug use (%)

89

78

0.09

HCV antibody positive (%)

62

67

0.06

Most prevalent illicit drug (%)

Heroin (58%)

Heroin (37%)

Methamphetamine (58%)

Methamphetamine (25%)

weighted figures for the period: 2006-2009;

<0.01

weighted mean of the medians; * These two variables are not directly

comparable as RHMC assesses drugs used in the last 12 months, whereas ANSPS assesses the last drug injected.

91

Chapter 4

Table 4.4 Referrals and referral uptake for health and welfare services
Attended
n (%)

Did not attend

n (%)

Tertiary liver clinic (n=78)

54 (69)

24 (31)

0 (0)

General practitioner (n=69)

30 (43)

25 (36)

14 (20)

Drug treatment services (n=38)

21 (55)

4 (11)

13 (34)

Sexual health clinic (n=31)

14 (45)

7 (23)

10 (32)

Community mental health/counselling (n=24)

10 (42)

0 (0)

14 (58)

Welfare/Aboriginal medical service/Other (n=29)

18 (62)

1 (3)

10 (34)

Total

147 (55)

43 (23)

75 (23)

Referrals (n=269)

Unknown
n (%)

92

Chapter 4

4.2.8 The role of RHMC in providing opportunistic healthcare

Although only 20 percent of clients accessed services from RHMC were referred
from NSP shopfront, and less than half were identified as accessing the service via
the NSP shopfront, the service has nonetheless played a crucial role in providing
opportunistic healthcare to its target group. The following two case studies illustrate
the important role of NSP-based PHC in achieving outcomes that may not have been
possible in other healthcare settings. The cases occurred during the study period and
were reported as part of the service evaluation. One is the early detection of an
incident HIV positive case and the reports on the commencement and successful
antiviral treatment for HCV infection by a vision impaired client.

Case study 1: Early detection of an incident HIV patient

Transmission of HIV among IDUs with the potential for outbreaks in these
marginalised high-risk populations has been repeatedly documented (Hamers &
Downs, 2003) and remains a serious risk to a population with low HIV prevalence.
Delayed diagnosis may allow continuing high-risk behaviour and further HIV
transmission. The following case study describes an incident HIV case detected in
the RHMC and discusses its implications for HIV prevention in this population.

Study reported in: Islam, M. M., Grummett, S., White, A., Reid, S. E., Day, C. A., & Haber, P. S.
(2011). A primary healthcare clinic in a needle syringe program may contribute to HIV prevention
by early detection of incident HIV in an injecting drug user. Australian and New Zealand Journal of
Public Health, 35, 294-295.

Please see Appendix II for a list of publications arising from this thesis.

93

Chapter 4
A 28 year old man who was an intermittent IDU (mainly methamphetamines) and
was recently HIV negative presented to the NSP service. He had a background of
mild developmental delay, learning disorder and depression. A brief risk assessment
revealed he had unprotected anal insertive and receptive sexual intercourse with a
man 16 hours beforehand. The client was in a hurry and would not wait for
phlebotomy. The client was referred to the PEP (Post Exposure Prophylaxis) Hotline
for advice but would not stay long enough to allow the RN to assist him with the
call. The RN provided him with education, the relevant contact numbers and advised
him to return to the clinic at the earliest opportunity. The client attended the clinic
four days later and following pre-test counselling was screened for HIV. Upon
receiving a positive Western blot HIV result, the client was contacted and attended
the clinic the following day for post-test counselling, support and referral for
specialist care. RHMC established an accelerated referral protocol for HIV services
at its commencement and the client was escorted to the sexual health centre by the
clinic RN and continues in their care. RHMC provides ongoing support via regular
follow-up of the client, assistance with appointments and ancillary services. The
client has obtained advice and resources for safer sex practices to minimise the risk
of further HIV transmission, including condoms and lubricant and advice to disclose
his HIV status to current and future sex-partners.

Staff of the RHMC have a specific interest and skills in the management of people
with drug dependence in whom a chaotic lifestyle may lead to neglect of healthcare
needs in the face of more immediate concerns related to obtaining food, shelter and
money to support drug use (Carr et al., 1996). In contrast to conventional medical
services, the RHMC welcomes active IDUs and offers drop-in arrangements. Most

94

Chapter 4
clients are seen on a walk-in, first-come first-served basis, with an emphasis on
informality (Day et al., 2011). The anonymous and confidential access to healthcare
removes barriers for individuals engaged in illegal, covert and/or stigmatised
activities (Harris & Young, 2002).

Identification of this HIV case underscores how clinics of this type can extend
healthcare support to the IDU subgroup whose lifestyles put them at high risk. Colocation with NSP is a key advantage for this type of service by providing
opportunistic and continuous healthcare to IDUs who face barriers to accessing care
elsewhere. The brief and opportunistic healthcare advice initially provided to the
client reduced the risk that some of his future and current sex partners might acquire
HIV infection.

Successful treatment, management and prevention of HIV requires establishment of

a therapeutic relationship with a range of healthcare providers. This is particularly
challenging to achieve in active IDUs. Transmission of HIV amongst IDUs is now
one of the leading modes of incident HIV infection worldwide. Provision of primary
health and other services, beyond syringe distribution, is a strategy that can facilitate
early diagnosis of HIV and increase the uptake of effective prevention strategies,
improving the capacity of NSP services to achieve their central goal of preventing
the spread of blood-borne virus infection.

95

Chapter 4

Case study 2: Opportunistic and continuing healthcare to a physically

disable client to his successful HCV treatment

This case study describes how the RHMC provided support to an IDU with a
longstanding physical disability enabled commencement of HCV treatment resulting
viral clearance.

A 42 year old man was an IDU with a long history of polydrug use. He had known
HCV infection for several years, longstanding visual impairment and challenges with
mobility, social isolation and difficult interpersonal interactions. He presented to the
NSP requesting sterile injecting equipment as he was intermittently injecting drugs
despite being on opioid maintenance treatment for four years using buprenorphine.
His frequency of injecting drug use had reduced in recent years and he had
considered HCV treatment before but the barriers to accessing appointments in a
tertiary centre were considered too great. Furthermore, his HCV infection, which
was of the treatment resistant genotype 1, also contributed to his considering
treatment as neither worthwhile nor feasible. Over a period of several NSP service
visits, the registered nurse (RN) at RHMC engaged him in discussions about HCV
treatment and ways to circumvent perceived barriers. Ultimately, through liaison
with the nearby tertiary liver clinic, an individualised care plan was developed for
HCV treatment. To support treatment adherence, RHMC staff drove the patient to
the tertiary liver clinic monthly to pick up medication and attend specialist
5

Study reported in: Islam, M. M., Reid, S. E., White, A., Grummett, S., Conigrave, K. M., & Haber,
P. S. (2012). Opportunistic and continuing health care for injecting drug users from a nurse-run needle
syringe program-based primary health-care clinic. Drug and Alcohol Review, 31, 114-115; author
reply 116-117
Please see Appendix II for a list of publications arising from this thesis.

96

Chapter 4
appointments, supervised self-administration of weekly Interferon injections, filled a
dosette box with oral antiviral (ribavirin) medication every two weeks, performed
periodic blood tests as per HCV protocol, assessed and managed side-effects of
treatment including mood disturbance, provided ongoing emotional and other
support, liaised with the methadone clinic where necessary to maintain opioid
maintenance treatment and reminded him (via SMS and phone) about upcoming or
missed appointments. The patient successfully completed all 48 weeks of treatment
and achieved a sustained virological response (SVR). The patient attributed his
success to the ongoing support and care he received from the RHMC.

This is just one example of the type of the specialist care that can be provided by an
NSP-based primary healthcare clinic. Clearly, co-location with an NSP is an added
advantage for this type of service and has the potential of providing both
opportunistic and continuing healthcare. This patient is still in regular contact with
the RHMC. Successful treatment, management and prevention of HCV requires a
trusting relationship with healthcare providers who can provide practical but expert
help for patients with complex needs to implement a challenging healthcare plan.
The role of RHMC in treatment of HCV has been detailed more fully in Chapter 5
(also see Islam, Topp, White, et al., 2012). Providing health and other services,
beyond syringe distribution, is a strategy that is reported to improve the perceived
worth of NSP services (MacNeil & Pauly, 2011).

97

Chapter 4

4.3 Discussion
The results of this audit of three-and-a-half years of operation of a low-threshold
PHC associated with an NSP highlight the fundamental role such a service can play
in offering essential healthcare to high-risk poly-drug users. The results do, however,
suggest that the service has been underutilised. This underutilisation appears to have
been largely due to the RHMCs limited capacity to attract clients from the NSP
shopfront, the main group the service was designed to serve. However, despite these
limitations, the results substantiated by two case studies also highlight the
fundamental role such a service can play in offering essential healthcare to high-risk
poly-drug users. The case studies add support to the assertion that the NSP-based
PHC such as RHMC is a valuable component of the overall HIV prevention strategy
and has capacity to treat complex cases that may be difficult to treat in other settings.

Although 62 percent of participants reported regular access to a GP, 50 percent of

these participants remained unvaccinated against HBV. This is consistent with low
immunisation coverage among IDUs more broadly (Day et al., 2010), despite
government recommendations and vaccination subsidies (Australian Government
Department of Health and Ageing, 2008). Indeed, that IDUs who report regular GP
access would nevertheless attend the RHMC may indicate opportunistic convenience
in accessing RHMC, or it may be that they are accessing GP services primarily for
benzodiazepines or opioids (doctor shopping) rather than for care of their general
health (Islam et al., in press). The latter assertion is supported by the fact that clients
who had recently used prescribed benzodiazepines were more likely to report regular
access to GPs, even after controlling for other known correlates (Galdas, Cheater, &

98

Chapter 4
Marshall, 2005). It could also be that IDUs have greater faith in specialist services
ability to understand healthcare concerns that relate to their injecting drug use
(McLaughlin et al., 2000).

This tendency of some IDUs to attend health services primarily to seek psychoactive
medications (Darke et al., 2003; Islam et al., in press) is circumvented by a nurse-led
service, because in Australia nurses cannot generally prescribe medication. Indeed,
in some settings NSP-based PHCs are the major or even only source of preventive
services (e.g., BBV testing and vaccinations) for their clients (Heinzerling et al.,
2006).

Around half of the clients were referred from a local residential drug treatment
service. Although clients from the residential drug treatment service are encouraged
to use RHMC, it is not mandatory and it is not used by all such clients. Relapse to
injecting following discharge from residential drug treatment or detoxification is
common (Darke et al., 2005). The period immediately following residential drug
treatment is particularly dangerous in terms of both overdose (Strang et al., 2003)
and injecting risk behaviours (Havard, Teesson, Darke, & Ross, 2006). Engagement
with a service that provides both NSP and PHC and that is independent of the
residential treatment program, may increase clients willingness to later access the
service during this high-risk post-discharge period. Although these data were not
systematically collated in this study, anecdotal reports suggest that a substantial
proportion of residential drug treatment clients continued to access RHMC after
discharge from rehabilitation.

99

Chapter 4

4.3.1 Patterns of drug use

Both IDUs and NIDUs in the present sample reported relatively high prevalences of
alcohol use. Although information about the level of unsafe drinking is unavailable,
21 percent of IDUs reported their drug of concern was alcohol. Concurrent alcohol
use is potentially problematic for IDUs, given the high prevalence of HCV infection
and alcohols potential to exacerbate liver disease (Cromie, Jenkins, Bowden, &
Dudley, 1996) and diminish HCV treatment outcomes (Anand et al., 2006). Alcohol
also increases the risk of overdose when consumed with opioids (Warner-Smith et
al., 2001) and unsafe injecting and sexual behaviours (Rees, Saitz, Horton, & Samet,
2001; Stein et al., 2000). However, there may have lack of self-perception of the
risks associated with alcohol consumption (Islam, Day, Conigrave, & Topp, Epub
ahead of print). IDUs with alcohol problems are a potential target group for brief
alcohol interventions, which have been successfully delivered in similar contexts
such as opioid treatment (Watson et al., 2007). Further exploration of the role and
outcomes of brief intervention in the IDU-targeted PHC setting may be warranted.

4.3.2 Comparison between IDUs accessing RHMC and ANSPS

participants
Compared to ANSPS participants, IDUs accessing RHMC reported lower rates of
receptive sharing of syringes in the preceding month (16% vs 6%). Notably, the
majority of clients were initially referred to RHMC from abstinence-based
residential drug treatment centre, where they had resided for more than one month.
However, even RHMC clients referred from NSP reported lower rates of receptive

100

Chapter 4
sharing (6%) in the preceding month than ANSPS participants. The differences in
reported risk may be exaggerated by the method of survey administration the
ANSPS is designed for self-completion whereas RHMC nurses assess risk via faceto-face interviews, which may be subject to greater social desirability bias (White,
Day, & Maher, 2007). Alternatively, clients of this targeted PHC service may have
greater concerns for health than other IDUs, which may manifest as reductions in
risk behaviours.

The RHMC engaged a higher proportion of non-Australian born clients than who
participated in the ANSPS across NSW during the years 2006-2009. This may be
attributable to a small local population of illegal migrant IDUs known to use the
service and who are unable to access Australias universal healthcare system
(Medicare) 6. RHMC or similar clinics are therefore the only available healthcare
providers for such groups. The preponderance of male and younger clients relative to
ANSPS samples (Table 4.3) can be explained by the fact that 53 percent of the
sample was referred from nearby drug treatment facilities which, from June 2007,
referred only male clients. These clients were also younger than the clients referred
from the NSP shopfront.

Medicare is Australias publicly funded universal health care system. Medicare gives access to
health care to all Australian citizens by providing:
free or subsidised treatment by health professionals such as doctors, specialists, optometrists,
dentists and other allied health practitioners (in special circumstances only)
free treatment and accommodation as a public (Medicare) patient in a public hospital
75 per cent of the Medicare Schedule fee for services and procedures if you are a private patient in
a public or private hospital (does not include hospital accommodation and items such as theatre
fees and medicines (Australian Government Department of Human Services, 2012)

101

Chapter 4
The proportion of Aboriginal/Torres Strait Islanders in this sample is much higher
than among the general population (11% versus 2%) (Australian Bureau of Statistics,
2006), but similar to the proportion of Indigenous people in ANSPS samples (Topp
et al., 2011). This is consistent with the overrepresentation of Indigenous Australians
among disadvantaged groups, and their corresponding heightened risk of drug
misuse (Kratzmann et al., 2011). As of today there are few specific programs which
aim to reduce injecting among this disadvantage group. Indeed inadequate funding
for drug and alcohol programs for Aboriginal people has made ongoing programs
unstable (Sweet, 2012).

4.3.3 Referral uptake

Although scant research has documented referral uptake among IDUs, the relatively
high uptake (55%) of referrals to other health and welfare services is notable in
comparison to past literature demonstrating limited referral uptake among IDUs
(Kimber et al., 2008). This high uptake is likely to be attributable to the established
referral linkage system which operates between RHMC and other relevant
organisations and the comprehensive support and SMS/phone reminder system
implemented by RHMC nurses to facilitate referral uptake.

Although many of the clients were covered by Medicare (Australias publicly funded
universal health insurance, see previous page), there are number of non-financial
barriers such as discrimination, social stigma, lack of transportation, lack of priority
to personal health can also impede access to healthcare among IDUs (Friedman,
1994; Islam, Topp, Day, et al., 2012a). Although 62 percent of clients reported

102

Chapter 4
current access to GP services, as noted above, many drug users who claim to have
GP access do not disclose their drug use and/or its extent to their GP (Islam et al., in
press; Western Australian Network of Alcohol and Other Drug Agencies, 2009).
Indeed the study highlights a clear reluctance to utilise GP services. Among all
referrals provided by RHMC, GP referrals were the least likely to be utilised (36%).
This apparent barrier to access to GP services by this marginalised population with
substantial health needs requires attention at both the policy and practice level.

Currently, the RHMCs part-time medical officer attends the clinic for four hours a
week, primarily to review pathology results and discuss cases with the nurses.
Extending this role to include more client consultations and prescription of nonpsychoactive medication might overcome some of the barriers these clients
experience in relation to obtaining comprehensive healthcare from GPs. However,
care needs to be taken that this arrangement, in no way, deters RHMCs ongoing
efforts of linking clients to GP services. Long-term dependence on services such as
RHMC is not desirable as this may deter mainstreaming healthcare for drug users in
conventional healthcare settings.

The RHMC was not funded to provide hepatitis A vaccination. Accordingly 14

percent clients were referred to a sexual health clinic primarily for this purpose.
However, for over half of this group, attendance either did not occur (23%) or could
not be ascertained (32%). This is of concern given the high prevalence (50-60%) of
HCV among Australian IDUs (NCHECR, 2010), and the increased risk of morbidity

103

Chapter 4
if co-infected with hepatitis A (Vento et al., 1998). Hepatitis A vaccination would be
an important intervention for PHCs associated with NSPs to offer.

4.3.4 Limitations
As with any clinical file audit, there were instances of incomplete data. For example,
the files of some early clients (around 10% of RHMC clients) did not have
information on GP access. As those data were missing at random and were mostly
about access to GP services, missing values were omitted from the analyses (Little et
al., 2012).

During three and a half years this PHC-service was utilised by 384 clients, equating
to an average of two new clients per week, fewer than might be considered ideal,
although findings incorporated the period of clinic commencement when clinic
capacity and client numbers were still growing. The anonymity requirements of the
existing NSP service prevent the extraction of the proportion of NSP clients
accessing PHC from this targeted service. More proactive engagement of clients at
the NSP shopfront and an increase in the range of services offered may attract more
clients.

Finally, while overall clients of this PHC service differ from the broader population
of NSW NSP clients on a number of characteristics (Iversen et al., 2011), this
observed difference is mainly due to the attendance of clients referred or recently
discharged from the nearby residential drug treatment centre. This difference,
however, highlights the capacity of RHMC to cater for the needs of various client

104

Chapter 4
groups, including NIDU, for many of whom this targeted PHC remains the only
source of healthcare.

The cost-effectiveness of this and similar services is yet to be determined. The cost
of such services must be balanced against cost savings of reduced hospitalisation and
reduced incidences of chronic disease. Universal access to healthcare under the
Australian healthcare system, the limited range of services RHMC offer and
insufficient engagement of IDUs from the NSP shopfront provide some explanation
for the apparent under-utilisation of the clinic.

Undoubtedly, rigorous evaluation is still required to guide policymakers and

clinicians in further improving service provision. However, it is imperative that
IDUs are offered acceptable and accessible healthcare even while policymakers
await quality evidence to guide best practice.

4.4 Conclusion
A low-threshold PHC service targeting IDUs, such as RHMC, can attract a range of
clients including NIDUs who have considerable healthcare needs. Many of these
clients were not regularly accessing other healthcare, and among those who were,
psychoactive medication seeking may have been an important motivation. Clients
return rate to this targeted PHC centre and successful referral uptake demonstrate
that the service is well accepted by the client group. Most importantly, as case
studies show, its collocation with an NSP shopfront is strategically appropriate for
offering opportunistic healthcare to the target group. However, RHMC appears to be
underutilised and its role as a comprehensive low-threshold healthcare service
105

Chapter 4
remains limited. A more proactive engagement of clients at the NSP shopfront and
an increase in the range of services offered by the RHMC may help attract more
clients.

As noted in Chapter 1, targeted healthcare services are strategically a very important

point of contact and have typically been developed in response to BBVI. To this end
such services have the potential of screening for and managing HCV infection, the
most prevalent and persistent BBVI among Australian IDUs. Although, offering
specialised HCV treatment may not be a specific service of many of such services,
their role in engaging IDUs and referring them to HCV treatment facilities is an
important goal. Table 4.4 indicates that among all the referrals made from RHMC to
other health and welfare services, uptake was highest (69%) for clients referred to
the tertiary liver clinic. Such success warranted further investigation; especially
given the low levels of HCV treatment uptake that have previously been reported
among Australian IDUs (Doab, Treloar, & Dore, 2005). This is therefore explored
further in the next chapter which investigates HCV screening and management
practices for RHMC clients.

106

Chapter 5

CHAPTER 5
Role of RHMC in hepatitis C treatment assessment
and antiviral treatment commencement 7
The preceding chapter showed that a targeted PHC such as RHMC is successful in
attracting clients for BBV testing and the client return rate and referral uptake are
high among those who use the service. Such targeted PHC services may, therefore,
be well placed to support more complicated medical care such as HCV treatment. As
highlighted earlier, in Australia and many other parts of the world injecting drug use
is by far the most common mode of HCV transmission. The high prevalence of
HCV-related liver disease among IDUs is a serious global health concern (Shepard,
Finelli, & Alter, 2005). In Australia, it was estimated that at the end of 2005
approximately 264,000 people had been exposed to HCV, and 5300 were living with
HCV-related cirrhosis (Razali et al., 2007). Eighty-two percent of those testing
positive to HCV antibody were estimated to have been exposed through injecting
drug use (Razali et al., 2007). In the absence of effective therapeutic intervention, the
number of people living with HCV-related cirrhosis is estimated to increase to
25,000 by 2020 (Dore, Law, MacDonald, & Kaldor, 2003). Despite the increasing
safety and efficacy of HCV treatment, assessment and uptake of treatment among
IDUs remain low for multiple reasons, including the chaotic lifestyles and competing
priorities often engendered by drug dependence (Mehta et al., 2008). Other issues
7

Study reported in: Islam, M. M., Topp, L., White, A., Conigrave, K. M., Reid, S., Grummett, S.,
Haber, P. S., & Day, C. (2012). Linkage into specialist hepatitis C treatment services of injecting drug
users attending a needle syringe program-based primary healthcare centre. Journal of Substance
Abuse Treatment, 43, 440-445
See Appendix II for a list of publications arising from this thesis.

107

Chapter 5
such as a lack of treatment support and difficulties navigating the complex tertiary
healthcare system are also important (Stoove, Gifford, & Dore, 2005), leading to
calls for improved integration between relevant services.

NSP-based PHC has the potential to effectively reach IDUs and provide them
preventive and other healthcare services (Islam, Topp, Day, et al., 2012a). Screening
for and management of HCV infection is an aim of such services, however, little is
known about their impact on the uptake and outcomes of referral of clients AVT
assessment for HCV. This study examines (i) the patterns and correlates of uptake of
referrals to a tertiary liver clinic; and (ii) subsequent AVT initiation, among IDUs
referred from RHMC, an NSP-based IDU-targeted PHC service located in inner-city
Sydney.

5.1 Method
5.1.1 Characteristics of the cohort
During the first four years of operation (July 2006-December 2010), 479 clients
accessed RHMC. Clients mean age was 35 years [SD 9.0 years] and the majority
(77%) were male. Most clients (78%) were born in Australia and 13 percent
identified as being of Aboriginal and/or Torres Strait Islander (Indigenous) descent.
Eighty-six percent reported a history of injecting drug use. Reasons for initial
presentation included BBVIs testing and/or vaccination (75%), sexual health
assessment/STI screening (25%), drug-related health issues (20%) and psychosocial
services/counselling (5%). Heroin was the most common drug of concern in the

108

Chapter 5
preceding 12 months, nominated by 42% of clients, followed by methamphetamine
(27%) and alcohol (25%).

5.1.2 The RHMC model of HCV care

An HCV treatment-assessment model of care was developed for IDUs attending
RHMC (Figure 5.1). All clients diagnosed HCV positive by qualitative or
quantitative polymerase chain reaction (PCR) (Roche COBAS Amplicator, Roche
Diagnostics, Sydney, Australia) are encouraged to attend the liver clinic for AVT
assessment. RHMC staff make appointments on behalf of clients and inform them of
the time and location. A reminder is sent to clients via SMS or voicemail the day
before the appointment. Immediately following the referral visit, the liver clinics
senior nurse informs RHMC of the referral outcome. Clients who fail to attend are
immediately contacted by RHMC to facilitate a second appointment. If a client does
attend an appointment, RHMC staff offer support around future appointments and
clinical services. Support and monitoring continues for as long as required.
Depending on client needs, liver clinic staff may consult with the client at RHMC.
The service is able to support complex clients throughout the assessment and
treatment and post treatment period if requested by clients. For example, as
described in Chapter 4, a client living with a major physical disability (visual
impairment) was successfully treated and ultimately achieved a sustained virological
response (SVR), the accepted indicator of successful treatment (Islam, Reid, et al.,
2012; also see Appendix IV).

109

Chapter 5

HCV Ab +ve

RNA positive

HCV test

If consent to
referral obtained,
referral to tertiary
liver clinic and
directions
provided

Phone client
with
appointment
details,
reiterate
location

HCV Ab ve

Check if
client
attended
appointment

Could not attend

RNA negative
Ongoing
support and
reassessment
of risk

SMS
reminder 1
day prior to
appointment

If consent to referral
not obtained, periodic
monitoring and offer
of referral

Attended

Check any
further needs
(GP referral,
further
pathology,
next
appointment)

Follow-up with client,

determine need for
another appointment

Figure 5.1 Flowchart of the referral pathways for HCV positive clients at the RHMC

110

Chapter 5

5.1.3 Data collection and analysis

Key variables were extracted manually from the intake assessment, progress notes
and laboratory results, entered into a Filemaker Pro database and analysed using
STATA (version 11). AVT information was collected directly from client selfreports at clinical settings by RHMC nurses, and corroborated through checking
against the liver clinic database. Data collection and analysis was approved by the
Sydney South West Area Health Ethics Review Committee (RPAH zone).

Data analysis was conducted using chi-square and Fishers exact test for categorical
variables, and independent sample t-tests for continuous variables. One way analysis
of variance (ANOVA) and its non-parametric equivalent (Kruskal-Wallis test) were
conducted where there were three categories of outcome (referred and attended;
referred but did not attend; not referred). Statistical significance was set at p<0.05.
Multivariate logistic regression analysis derived AORs and CIs to assess associations
between attendance at the liver clinic (binary outcome: referred and attended and
referred but did not attend) and socio-demographic, drug use and other potential
covariates. Backward elimination procedures were followed, with univariate
predictors that were significant at p<0.25 considered for the multivariate regression
model.

111

Chapter 5

5.2 Results
5.2.1 Client profile
Seventy-four percent (n=353) of 479 clients who accessed RHMC during the audit
period underwent HCV antibody screening, and 60 percent (212/353) of them tested
HCV positive. Qualitative HCV-RNA testing was performed for 197 (93%, 197/212)
of these clients, of whom 143 (73%, 143/197) tested positive (Figure 5.2). Forty-six
percent of RNA positive clients were found to have HCV genotypes 2 (n=6) or 3
(n=60); whereas 45 percent had genotypes 1 (n=63) or 4 (n=1). Genotype was
unavailable or non-typable for eight percent; and one client had mixed genotypes (1
and 3).

Among the 143 clients for whom qualitative HCV-RNA was positive, the mean age
was 37 years (SD 8.2) and 85 percent were male (Table 5.1). Nine percent (13/143)
of HCV-RNA positive clients identified as Aboriginal and/or Torres Strait Islander.
All but one disclosed injecting drug use and 84 percent reported injecting in the
preceding six months. Forty-five percent clients were on some form of psychiatric
medication. Two-thirds (67%) of the clients had been referred to the RHMC from
residential drug treatment agencies and 23 percent from NSPs. Median ALT level
was 63 U/L with 59 percent elevated beyond the normal range (>55 U/L). Twothirds of clients reported access to GP services.

112

Chapter 5

Table 5.1 Characteristics of HCV RNA positive clients and comparison by hepatitis C treatment referral and attendance
n=143 Referred and
(%)
attended
n = 68
A

Referred but
did not attend
n = 28
B

Not
referred
n = 47
C

p-value
(univariate)
comparing
3 outcomes

Comparing outcomes A & B

p-Value
AOR (95% CI)
(univariate)

Age (mean S.D. in years)

37 8.2

37.9 7.9

35.6 9.1

36.1 8.2

0.34

0.21

Male

121 (85)

93%

79%

77%

0.03

0.07

Aboriginal/Torres Strait Islander

13 (9)

9%

11%

9%

0.93

0.71

Referral from
NSP
Residential drug and alcohol treatment centre
Self/Family/Friend(s)

33 (23)
96 (67)
14 (10)

16%
78%
6%

29%
61%
11%

30%
55%
15%

0.10

0.20

Living with
Alone/with children
Parent(s)/Spouse/Partner
Friend(s)
Relative(s)/other

51 (36)
56 (39)
26 (18)
10 (7)

31%
51%
10%
7%

39%
32%
25%
4%

40%
26%
26%
9%

0.07

0.14

Source of income b
Temporary unemployment benefit
Pension and disability benefit
Fulltime or part-time job

95 (67)
28 (20)
18 (13)

72%
16%
12%

61%
21%
18%

65%
24%
11%

0.72

0.61

Current GP access

94 (66)

65%

57%

72%

0.39

0.49

113

Chapter 5

n=143 Referred and

(%)
attended
n = 68
A

Referred but
did not attend
n = 28
B

Not
referred
n = 47
C

p-value
(univariate)
comparing
3 outcomes

Comparing outcomes A & B

p-Value
AOR (95% CI)
(univariate)

Genotype a
1 and 4
2
3
Non-typable and unknown

62 (43)
8 (6)
61 (43)
12 (8)

46%
7%
44%
3%

50%
0%
39%
11%

36%
6%
43%
15%

0.22

0.22

ALT
ALT value U/L (median)
ALT elevated (%)

63
85 (59)

76
75%

52
46%

51
45%

<0.01
<0.01

0.60
<0.01

0.25 (0.09, 0.66)

Currently on psychiatric medication

64 (45)

40%

46%

51%

0.47

0.65

Currently on opioid substitution therapy

43 (30)

31%

21%

35%

0.47

0.35

Duration of injecting drug use (mean S.D)

18 8.8

19 8.3

17 8.1

16 9.6

0.09

0.22

Injecting drug use in preceding six months

120 (84)

72%

96%

94%

<0.01

<0.01

0.08 (0.01, 0.65)

One participant had genotype 4; Two clients reported to have no income;

114

Chapter 5
Liver clinic referral appointments were made for 96 HCV-RNA positive clients; the
other 47 were not referred for reasons including loss to follow-up (n=23) and
unwillingness to take up referral (n=20). More than 70 percent (68/96) of referred
clients attended the liver clinic with a mean of 1.3 appointment bookings (SD 0.76;
range 1-6) required for clients to attend once. However, 78 percent of those who
attended (53/68) did so at their initial referral appointment. AVT was commenced by
11 clients (Figure 5.2). By December 2010, seven of 11 clients had achieved an
SVR, one did not respond to treatment, one ceased treatment due to side effects, one
remained in treatment, and one client was lost to follow-up following transfer to an
alternative healthcare provider.

A further 15 clients expressed interest in HCV treatment, 13 of whom did not

proceed for reasons including ongoing drug use; health and/or psychological
instability (n=7); unstable housing arrangements (n=3); and family responsibilities
(n=1). Another two clients had recently started full-time employment and therefore
opted to defer treatment. Two clients were undergoing AVT assessment at the time
of data collection and were likely to commence treatment. The clinical pathways of
all clients are shown in Figure 5.2.

115

Chapter 5

Total clients during

audit (n = 479)
Screened for antiHCV test (n = 353)
HCV antibody
positive (n = 212)
Qualitative RNA
assessment test
(n = 197)
Detected in RNA
test (n = 143)
Referred to liver
clinic (n = 96)
Attended liver clinic
(n = 68)
HCV treatment
(n = 11)
7 achieved SVR,
1 on treatment,
1 non-responder,
1 stopped (side
effect)

2 being assessed and likely

to commence treatment
8in drug treatment
programme, were continuing
HCV treatment consultation
13interested but unsuitable
for treatment/deferred
30not interested in
treatment/lost to follow-up
1preferred referral to
another tertiary clinic
1died
2 could not be ascertained

Figure 5.2 Flowchart of diagnosis, referral and treatment

pathways for all clients

116

Chapter 5

5.2.2. Factors associated with referral and referral uptake

There were a number of differences between clients who were referred and those
who were not and also between those who took up the referral and those who did
not. Those who attended the referral were more likely to be male than those who did
not attend (93% cf 79%, p=0.03) (Table 5.1). ALT levels were significantly more
likely to be elevated (> 55 U/L) among clients in the referred and attended group
than those in the other two groups (referred but did not attend and not referred;
75%, 46% and 45%, p=0.001). The referred and attended group contained a
significantly lower proportion (72%) of clients who reported injecting in the
preceding six months than both the referred but did not attend (96%) and not
referred (94%) groups (p=0.001).

Multivariate logistic regression indicated that clients with elevated ALT levels (AOR
0.25; CI 0.09, 0.66) and reporting no injecting drug use in the preceding six months
(AOR 0.08; CI 0.01, 0.65) were more likely to attend referrals than those who were
referred but did not attend (Table 5.1).

5.2.3 Characteristics of clients who commenced AVT

The mean age of clients who commenced AVT was 37 years (SD 7.3; range 2156)
(Table 5.2). All 11 clients were male, and none were of Aboriginal and/or Torres
Strait Islander descent. All but one client was referred to RHMC from residential
alcohol and drug treatment agencies (Table 5.2) and none were referred from the
NSP. Nine of the 11 clients who commenced treatment had elevated ALTs prior to
referral. Six clients were genotype 2 or 3 (more treatment-responsive) and five were
117

Chapter 5
genotype 1 (more treatment-resistant). Only one treated client was on psychiatric
medication at the time of referral. All 11 treated clients reported a government
benefit as their source of income.

118

Chapter 5
Table 5.2 Comparison between those who did and did not commence HCV treatment
(among 68 liver clinic attendees)
Commenced
treatment

p-Value
(univariate)

n = 11
37 7.3

Did not
commence
treatment
n = 57
38 8.0

Male

11

52

0.58

Aboriginal/Torres Strait Islander ethnicity

0.58

Referral to RHMC from

Residential alcohol and drug treatment agency
NSP
Self/family/friend(s)

10
0
1

43
11
3

0.28

Living with
Alone/with children
Parent(s)/spouse/partner
Friend(s)
Relative(s)/other

6
4
1
0

15
31
6
5

0.32

Source of income a
Temporary unemployment benefit
Pension and disability benefit
Fulltime or part-time job

10
1
0

38
10
8

0.43

Current GP access

37

1.00

Genotype
1
2
3
Non-typable and unknown

5
1
5
0

26
4
25
2

1.00

ALT elevated

42

0.72

ALT level (median)

77

75

0.75

Currently on psychiatric medication

26

0.04

Currently on opioid substitution therapy

17

0.67

17 2.5

20 1.1

0.31

40

0.71

Age (mean S.D., years)

Duration of injecting drug use (mean S.D.

0.58

years)
Injecting drug use in preceding six months
a

One client reported to have had no income

119

Chapter 5

5.3 Discussion
The findings of this retrospective clinical audit of an NSP-based PHC clinic
demonstrate that the service successfully engages IDUs, the client group who bear
the greatest burden of HCV-related liver disease (Razali et al., 2007); and that with
appropriate support, such clients can attend referrals to a tertiary liver clinic for HCV
assessment and treatment. The relatively high rate (71%) of referral uptake among
these clients also illustrates the potential to expand HCV-related care for IDUs by
establishing effective linkages between relevant health services. Notwithstanding the
advantages of this clinical model, when compared with the number referred, uptake
is still quite low. Thus, the majority of HCV cases remain untreated in this
population and the overall burden of liver disease is likely to remain high.

5.3.1 Characteristics of referrals, non-referrals and nonattendees

Both demographic characteristics and genotype were similar among clients referred
to the liver clinic and those not referred. As might be expected, clients in the referred
and attended group were less likely to report injecting drugs in the preceding six
months than clients who were referred but did not attend or those who were not
referred. This may also be because the majority of clients in the referred and
attended group were referred to RHMC from an abstinence-based residential drug
treatment services. The high prevalence of injecting drug use in the previous six
months and psychiatric medication among clients who attended the HCV treatment
assessment suggests that factors which may have traditionally been seen by

120

Chapter 5
clinicians as barriers to initiation of AVT (Davis & Rodrigue, 2001; Dore, 2007)
may be overcome when appropriate support and encouragement can be provided.

In comparison to the past literature demonstrating poor referral uptake (16%) among
IDUs (Kimber et al., 2008) RHMCs success in ensuring a high uptake of the initial
liver clinic referrals is unique. This high attendance rate (71%) is likely to be in large
part due to the support offered by RHMC to clients, including efforts to help them
understand HCV assessment and AVT, and reminders to attend. Also RHMCs
strong links with the local residential drug treatment service helps ensure that clients
with HCV are seen by RHMC at a time in their lives where it is appropriate to offer
referral for AVT. Similar links with the liver clinic allow RHMC staff to better
provide support for appointment attendance and later treatment participation. Other
characteristics of RHMC such as anonymity for clients, convenient location in an
area where high numbers of IDUs dwell or congregate, co-location within an NSP,
appropriate opening hours, drop-in service, and availability of auxiliary services, are
also known to increase IDUs engagement with PHC (Islam, Topp, Day, et al.,
2012a; also see Chapter 3). Such features can be assumed to underlie much of the
present clinics success.

The NSP setting of this PHC service also confers advantages in achieving referral for
HCV treatment, as it provides a therapeutic context with the sustained contact
necessary to identify clients at high-risk of liver disease and to address barriers to
referral and treatment, particularly ongoing drug and alcohol use (Islam, 2010; Islam,
Reid, et al., 2012; Islam, Topp, White, et al., 2012; also see Appendix IV).
Consistent with past literature (Day et al., 2008), provision by RHMC of services

121

Chapter 5
such as HCV and liver function tests and counselling attracts clients, providing the
opportunity to increase their willingness to undertake AVT assessment. Although
prior to the establishment of RHMC in 2006, the NSP itself occasionally referred
clients to the liver clinic, not a single NSP client was known to have commenced
HCV treatment via this referral pathway.

5.3.2 Characteristics of treatment initiators

Unlike other studies (Arora et al., 2011; Lindenburg et al., 2011), no significant
difference in referral attendance and treatment initiation between clients of more and
less treatment-responsive HCV genotypes was found. This may be due to the
encouragement of every client to attend the liver clinic assessment irrespective of the
length of time since their diagnosis; indeed, around 13 percent of the clients were
newly diagnosed.

One of the strengths of this study is its real-world sample. Although just 11 clients
ultimately initiated AVT, as mentioned earlier a further 15 expressed interest in
commencing treatment, 13 of whom were deemed clinically inappropriate. Although
there are not rigid criteria for treatment appropriateness, factors such as poor
physical or psychiatric health, housing instability, chaotic drug use are considered
obstacles to treatment commencement (ASHM, 2012). Around 15 percent of clients
who took up their referral continued to attend ongoing consultations at the liver
clinic during the audit period, most of whom were in the initial stages of assessment
at the liver clinic during writing stage of this chapter; a proportion of this group is
likely to initiate AVT. It is also possible that some clients commenced treatment

122

Chapter 5
through other healthcare providers for which information is unavailable. In addition,
there are likely to be other benefits to liver clinic attendees who have not yet
received treatment, including increased understanding of the disease process, the
nature of treatment, ways to improve health (such as reducing alcohol use) and the
need to achieve lifestyle stability prior to undertaking treatment. Nevertheless, based
solely on the treatment uptake rates described herein, almost eight percent of IDUs
who were HCV RNA positive, and one-in-six IDUs who attended the liver clinic
over a four-year period initiated AVT, an important outcome given the generally low
rates of HCV treatment referral and uptake among IDUs (Grebely et al., 2006).
Previous research has shown very high rates of HCV testing among IDUs (Day &
Dolan, 2006; Iversen et al., 2011). A national survey of 2396 NSP attendees in 2010
found that 91 percent reported having been tested for HCV in their lifetime,
including 56 percent who reported having been tested in the preceding 12 months.
Among the 1274 participants who reported having previously tested positive to HCV
antibody (53% of the overall sample), lifetime and current HCV treatment rates were
12 percent and 2.6 percent, respectively (Iversen et al., 2011). The explanation for
low rates of HCV treatment among IDUs is multifactorial with potential barriers at
client, clinician, and healthcare system levels (Day, White, et al., 2003; Grebely et
al., 2008; Grebely et al., 2009; Shepard et al., 2005).

Among the sample, those who were not on psychiatric medication at assessment
were significantly more likely to commence treatment, with no other variables
significantly associated with treatment initiation. Despite a high prevalence of
characteristics traditionally considered to constitute contraindications to treatment,
and particularly ongoing illicit drug use, the high rate of liver clinic attendance

123

Chapter 5
among the sample, and relatively high rates of HCV treatment uptake and outcomes
compared to other settings (Grebely et al., 2009), demonstrate that referral of IDUs
to tertiary clinics can be effective when appropriate pathways and links are
established and maintained. Moreover, it is not possible to accurately predict which
clients will adhere to a treatment regimen (Bangsberg & Moss, 1999). Studies which
provided AVT to IDUs and NIDU controls matched for baseline demographic and
other characteristics including genotype, reported similar rates of treatment success
as measured by SVR (Mauss, Berger, Goelz, Jacob, & Schmutz, 2004; Van Thiel,
Anantharaju, & Creech, 2003). Generalisations about IDUs are unhelpful given the
heterogeneity among this population in terms of their patterns of drug use, severity
of dependence, lifestyle stability and many other factors (Dore, 2007).

5.3.3 Limitations
The study has a number of limitations. Associations between duration of infection,
and referral uptake or treatment initiation could not be examined, because the files of
early clients (around 25% of total clients) did not record duration of HCV infection.
Secondly, the majority of clients who attended the liver clinic and commenced HCV
treatment were referred from a residential treatment service and so cannot be
considered representative of the overall IDU population. However this finding
demonstrates the importance of PHC services linking effectively with residential
programs to seize the window of opportunity of linking IDUs with effective medical
care. Thirdly, the observational design makes it impossible to state conclusively that
the high rates of referral uptake are attributable to comprehensive support provided
under the RHMC model. A small number of clients attended their initial HCV

124

Chapter 5
treatment assessment while still resident in the residential treatment program, and
attendance was also supported by that service. High referral attendance rates were
also likely to be due to comprehensive discussion by RHMC nurses with clients of
appropriate timing of treatment in terms of lifestyle stability and motivation, such
that those too unstable to attend appointments were unlikely to be referred. Finally,
the small number of treated clients prohibited multivariate analyses to delineate
independent associations between treatment commencement and other variables.

5.4 Conclusion
The RHMC provides important health service delivery to a traditionally hard-toreach population and is a valuable adjunct to the tertiary liver clinic based in the
metropolitan public hospital located relatively nearby. RHMCs efforts in facilitating
high referral uptake are noteworthy. Although only a few clients finally commenced
HCV treatments it should be noted that many barriers (e.g. financial hurdle) to
treatment commencement are outside RHMCs control. Successful completion of
AVT by at least one client with a major physical disability who achieved a SVR is
one example of the potential of this service model (Chapter 4 and Islam, Reid, et al.,
2012). The RHMC addresses the lifestyle challenges of many IDUs and the barriers
that the structured appointment system of conventional services may constitute
(Merrill, Rhodes, Deyo, Marlatt, & Bradley, 2002). By providing non-judgemental
and cost-free services under a harm reduction framework, this clinic has positioned
itself as a gateway to specialist care, highlighting the potential of targeted PHC
services to facilitate reductions in liver disease burden among IDUs.

125

Chapter 5
Based on these findings, although the previous chapter found that the RHMC was
able to attract only a limited number of the target group, however, it was still able to
facilitate reductions in liver disease burden among IDUs by providing a gateway to
specialist care reducing liver disease is valuable. As has been highlighted throughout
this thesis, low-threshold healthcare services acknowledge drug use without any
judgment, and clients are not expected to abstain from drug use. This type of service
modality is likely to create a congenial environment for clients and facilitate
disclosure of crucial information relating to their drug use and other risk behaviours,
and allow providers to effectively engage clients and thus provide appropriate care.
This, however, is an assumption and it is currently unknown whether such
environments really do achieve full client disclosure of sensitive information relating
to their drug use and sexual risk behaviours. The next chapter tests this hypothesis
and describes findings from a study which examined disclosure of socially sensitive
behaviours of clients accessing two targeted PHC services, the RHMC and the
Kirketon Road Centre, the latter being one of the oldest and most iconic targeted
healthcare facility in Australia, located in Sydneys most notorious red light district,
Kings Cross. .

126

Chapter 6

CHAPTER 6
The reliability of sensitive information provided
by injecting drug users in a clinical setting of
targeted healthcare: what strategies to be
followed? 8
As outlined in Chapter 1, social desirability bias can have significant implications for
patient care in the clinical setting, and data validity in the research setting (King &
Bruner, 2003). Comprehensive service delivery in healthcare settings may be
compromised if such bias is present to a significant degree. Success of targeted
PHCs is contingent upon disclosure of what in other setting might be considered
socially stigmatising behaviour and understanding the extent to which they disclose
is important for service provision. Social desirability bias is a type of reporting bias
that occurs when individuals deny or under-report engaging in what they perceive as
socially undesirable behaviours (Rosenthal, Persinger, & Fode, 1962). This chapter
describes findings of a sub-study examining the reliability of socially sensitive
information provided by the clients attending two targeted PHC services.

Traditionally, data collection during assessment in clinical setting is performed by

clinicians with pen and paper through face-to-face interview (FFI). Some studies,
however, have shown other methods such as audio computer-assisted self8

Study reported in: Islam, M. M., Topp, L., Conigrave, K. M., van Beek, I., Maher, L., White, A.,
Rodgers, C., & Day, C. A. (2012). The reliability of sensitive information provided by injecting
drug users in a clinical setting: clinician-administered versus audio computer-assisted selfinterviewing (ACASI). AIDS Care, 24 (12), 1496-1503.

See Appendix II for a list of publications arising from this thesis.

127

Chapter 6
interviewing (ACASI) can be better at eliciting sensitive information by providing
privacy for clients (Shakeshaft et al., 2006). The research literature also suggests that
interviewer-administered FFI methods typically result in reporting of lower rates of
socially sensitive risk behaviours compared to self-administered questionnaires, a
pattern attributed to social desirability bias (White et al., 2007). Consequently, along
with their other advantages (e.g. relatively fewer resource implications), selfadministered questionnaires are commonly used to facilitate response anonymity and
reliability in the research setting. Audio computer-assisted self-interviewing
(ACASI) is a data collection

method

that

allows

respondents

to

answer

questionnaires without the direct participation of an interviewer (Des Jarlais et al.,

1999). During ACASI, questions are administered audibly and in text on a computer
screen, facilitating its use among individuals with poor literacy skills or impaired
vision or hearing.

Previous studies on the comparative reliability of data collected from drug users via
ACASI and FFI report mixed results. For example, in a study of risk behaviours
among NSP clients, Des Jarlais and colleagues (1999) found that respondents for
whom data were collected via ACASI were more likely than those assigned to FFI to
report injection with used injecting equipment, distributing used equipment, and
paying for sex. Conversely, a survey of HIV risk behaviour among adolescents in
drug treatment found significantly higher reporting of alcohol and drug use and
sexual risk behaviour among participants from whom data were collected via FFI
compared to those who undertook ACASI (Jennings, Lucenko, Malow, & Devieux,
2002).

128

Chapter 6

Together, these findings suggest the possibility of situation-specific, differential

impact of assessment via ACASI. However, these studies were limited by the fact
that the same participants did not undertake both FFI and ACASI. In just two studies
were the same IDUs asked to complete both ACASI and FFI (Ghanem, Hutton,
Zenilman, Zimba, & Erbelding, 2005; Kurth et al., 2004). However, these
participants constituted only small proportions of broader samples recruited in sexual
health settings; and in only one of the two studies were the data collected from IDUs
(assessing lifetime prevalence of receptive syringe sharing) presented separately.

The literature suggests that in NSP settings, drug use and sexual behaviours are
acknowledged by staff without judgement or sanction, and that this environment
may increase IDUs willingness to disclose risk behaviours (Rich et al., 2004). Such
disclosure is important in healthcare settings for IDUs, where blood-borne virus and
sexual health risk assessment and management are core activities. Accordingly, it
could be that in NSP and associated healthcare services such as targeted PHCs,
ACASI offers no significant benefit over FFI administered by compassionate and
non-judgemental staff.

The aim of this study was to compare responses provided by IDUs attending PHCs
co-located with an NSP to the same, potentially socially sensitive, questions via both
(i) FFI administered by a clinician of that service; and (ii) ACASI administered.
Specifically, the study examined the potential differences in:
(i) clients willingness to report sensitive information via clinical FFI and ACASI;

129

Chapter 6
(ii) responses elicited across the two interview modes according to participant
characteristics.

6.1 Method
Study participants were drawn from the Hepatitis B Acceptability and Vaccination
Incentive Trial (HAVIT), a randomised controlled trial of the efficacy of incentive
payments in increasing hepatitis B vaccination completion among IDUs (Deacon et
al., 2012). Participants were recruited from two low-threshold IDU-targeted PHCs in
Sydney, Australia the Kirketon Road Centre (van Beek, 2007) and the RHMC
(Chapter 4 and 5). As described in Chapter 2 and 3, such low-threshold facilities
remove most barriers faced by IDUs in accessing conventional health services. For
example, users do not need to abstain from drugs, services are provided free-ofcharge and on anonymous and drop-in bases.

6.1.1 Eligibility criteria

Participants deemed eligible for inclusion in HAVIT (and thus the present study)
were aged 16 years and above; had injected drugs in the preceding six months;
reported no previous HBV infection and a maximum of one previous dose of
vaccination against HBV, or unknown infection and vaccination status; were able to
provide informed consent; and were willing to be randomised, to undertake
vaccination and to attend follow-up 12 weeks post-randomisation. Exclusion criteria
were: evidence of natural or vaccine-induced immunity; serological evidence of
previous HBV infection or vaccination; mental or physical illness or disability likely
to impact capacity to complete study procedures; insufficient English language skills

130

Chapter 6
to allow provision of informed consent or reliable responses to questionnaires; HIV
infection; and refusal to undertake vaccination (Deacon et al., 2012).

6.1.2 Procedure
All participants in this study were part of the HAVIT trial. All clients attending both
clinics undergo a full clinical assessment consisting of client demographics, sexual
health, drug health and mental health issues conducted by attending clinicians
(nurses/doctors) via FFI. Consistent with standard clinical protocols, participants
firstly underwent a clinical assessment, and then eligible participants completed an
interview with ACASI. FFI data were extracted from clients medical files; and
ACASI data from the HAVIT baseline dataset. To ensure inter-interview
comparability of responses, only clients whose FFI and ACASI data collection were
conducted within a one week period were included in this analysis.

Participant characteristics reported in this chapter were drawn from HAVIT baseline
data collection via ACASI. A set of five questions (Table 6.1) that may engender
social desirability bias relating to injecting and sexual risk behaviours (Des Jarlais et
al., 1999) were administered in both interview modes, allowing examination of the
degree of concordance of these responses. The five items assessed age of onset of
injecting, lifetime and recent history of receptive syringe sharing, recent receptive
sharing of ancillary equipment, and recency of last unprotected sex. The proposed
study aims to examine difference in responses to these five questions administered
by clinicians in a clinical context via FFI compared to ACASI derived responses
collected in the research context.

131

Chapter 6

Table 6.1 Five sensitive questions that were common both in FFI and ACASI
Questions

Response type

How old were you when you first injected any drug?

In years

Did you ever re-use a needle or syringe after somebody else

Yes

had used it, including your sex partner (even if it was

No

cleaned)?
3

In the last month did you re-use a needle or syringe after

Yes

someone else had used it, including your sex partner (even if

No

it was cleaned)?
4

In the preceding month did you re-use any other injecting

Yes

equipment (such as spoons, water, filters or tourniquets) after

No

someone else had used?

5

How long ago did you last have unprotected (penetrative) sex?
(including situations where condoms broke, and even if it was
your regular sexual partner?)

Never
Year (s) ago
Month (s) ago
Week (s) ago
Day (s) ago

132

Chapter 6

6.1.3 Consent and ethics

All participants were assured confidentiality of information they provided.
Participants provided written informed consent. Ethics approval for the study was
granted by the Royal Prince Alfred Hospital, South Eastern Sydney and Illawarra
Area Health Service Northern Hospital Network and the University of NSW Human
Research Ethics Committees.

6.1.4 Data analysis

Percentage agreement (the sum of agreement divided by the sum of agreement plus
disagreement) (Hartmann, 1977) was calculated to determine the magnitude of
concordance/discordance in responses elicited by the two interview methods. This
measure thus calculates the proportion of participants whose responses match, or are
concordant, across the two data collection formats (Last, 2001). Kappa was not
considered appropriate because it is influenced by trait prevalence (distribution) and
base-rates (Spitznagel & Helzer, 1985; Uebersax, 1987). A 5-point scale captured the
most recent episode of unprotected sex by assigning the following values: never=0,
year/s ago=1, month/s ago=2, week/s ago=3 and day/s ago=4. Tests appropriate to
data format (continuous, binary, ordinal) assessed concordance/discordance of
responses across interview modes, with significant results indicative of significant
discordance. The intraclass correlation coefficient (ICC) was used to compare
participants reported age of onset of injecting, the Wilcoxon signed rank test to
compare reports of most recent unprotected sex; and McNemars Chi-square (2) to
compare reports of lifetime and recent receptive sharing of injecting equipment.
Multivariate logistic regression analyses examined potential differences between
133

Chapter 6
demographic, drug use and recruitment characteristics of participants who provided
concordant responses to all five items across the two interview modes (concordant
group) and those who provided discordant responses to one or more items
(discordant group). Odds ratios (OR) with CIs assessed associations between
covariates and concordance. Variables correlated at p<0.25 at the univariate level
were included in multivariate models, which were refined using backwards
elimination. Data were analysed using STATA (version 11).

6.2 Results
Of 178 participants recruited from the two PHCs, 171 had information collected via
both FFI and ACASI within a one week period. Participants mean age was 36.3
years (SD 8.95) and 77 percent were male (Table 6.2, column 2). Fourteen percent
identified as Aboriginal and/or Torres Strait Islander, 16 percent were born outside
Australia, and 44 percent had not completed secondary education. Most (84%)
clients reported receiving government welfare and 52 percent reported a history of
imprisonment. Twenty-seven percent reported a lifetime history of sex work; while
56 percent reported a previous mental health diagnosis.

Thirty-four percent (n=59) of participants provided concordant responses across the

two interview modes to all five items, whereas the remaining 114 participants
provided discordant responses to one or more of the five items. Percentage
agreement between responses across the two interview formats ranged from 70
percent (recency of last unprotected sex) to 89 percent (lifetime prevalence of
receptive syringe sharing; Tables 6.3 and 6.4). Compared to the responses

134

Chapter 6

Table 6.2 Demographic characteristics of 173 participants and relationship to discordance in responses to sensitive questions
Variable

Mean age in years (SD; range)

Total sample
n=173

Discordant
n=114

Concordant
n=59

Univariate relationship

Multivariate
relationship

OR (95% CI)

pvalue

AOR (95% CI)

pvalue

1.01 (0.98, 1.05)

0.53

36.27 (8.95; 20-60)

36.51

35.60

Male

133 (77)

87 (77)

46 (78)

1.00

Female

39 (23)

26 (23)

13 (22)

1.06 (0.50, 2.25)

0.89

Australian-born (%)

146 (84)

95 (83)

51 (86)

0.78 (0.32, 1.92)

0.59

English speaking background (%)

166 (96)

110 (96)

56 (95)

1.47 (0.32, 6.81)

0.62

Indigenous Australian descent (%)

25 (14)

18 (16)

7 (12)

1.39 (0.55, 3.55)

0.49

Four+ years high school education (%)

98 (57)

61 (54)

37 (63)

0.86 (0.36, 1.30)

0.25

Government benefit main source of income (%)

146 (84)

98 (86)

48 (81)

1.40 (0.60, 3.26)

0.43

Lifetime history sex work (%)

47 (27)

38 (33)

9 (15)

2.78 (1.24, 6.24)

0.01

2.78 (1.24, 6.24)

0.01

Heterosexual (reference)

155 (90)

103 (90)

52 (88)

1.00

Bisexual/Homosexual

18 (11)

11 (10)

7 (12)

0.79 (0.29, 2.17)

0.65

Lifetime history of imprisonment (%)

90 (52)

64 (56)

26 (44)

1.62 (0.86, 3.06)

0.13

Lifetime history mental health diagnosis (%)

97 (56)

63 (55)

34 (58)

0.91 (0.48, 1.71)

0.77

Current mental health medication (%)

60 (35)

40 (35)

20 (34)

1.05 (0.54, 2.04)

0.88

Gender (%)

Sexual identity (%)

135

Chapter 6

Variable

Total sample
n=173

Discordant
n=114

Concordant
n=59

Univariate relationship

Multivariate
relationship

OR (95% CI)

pvalue

AOR (95% CI)

pvalue

Heroin injected most recently (%)

91 (53)

62 (54)

29 (49)

1.23 (0.66, 2.31)

0.51

Receive most healthcare from these clinics (%)

61 (35)

42 (37)

19 (32)

1.23 (0.63, 2.39)

0.54

Has another healthcare provider (%)

103 (60)

69 (61)

34 (58)

1.13 (0.59, 2.13)

0.71

Recruitment site 1

87 (50)

63 (55)

24 (41)

1.80 (0.95, 3.41)

0.07

136

Chapter 6

elicited by ACASI, responses provided during FFI suggested a significantly higher

mean age of first injection, lower prevalence of recent receptive sharing of both
syringes and ancillary injecting equipment, and a longer duration since last
unprotected sex (Tables 6.3 and 6.4). Participants also reported a lower lifetime
prevalence of receptive syringe sharing during FFI (Table 6.3); however, the level of
discordance across interview modes for responses to this item was not statistically
significant. Thus, relative to ACASI, FFI elicited responses from participants that
may be perceived as more socially desirable on all five variables of interest, with
levels of discordance statistically significant in four cases.

Just one participant characteristic was significantly correlated at the unviariate level
with provision of one or more discordant responses (Table 6.2). Compared to
participants who provided a full set of concordant responses, those who provided one
or more discordant responses were significantly more likely to report a lifetime
history of sex work. This characteristic, along with other variables that were
correlated at p<0.25 were entered into multivariate logistic regression models, with
only history of sex work remaining significant. Thus, participants who reported a
history of sex work were more likely than those who did not to provide discordant
responses to one or more of the five socially sensitive items (OR=2.78, 95%CI 1.24,
6.24).

137

Chapter 6

Table 6.3 Comparison of responses provided in ACASI and FFI to binary items
Variable

Receptive syringe sharing, ever (n=168)

Receptive syringe sharing, preceding month (n=162)

Receptive sharing ancillary equipment, preceding

month (n=165)

ACASI

FFI

Yes (%)

No (%)

Yes (%)

96 (57)

7 (4)

No (%)

11 (7)

54 (32)

Yes (%)

11 (7)

1 (1)

No (%)

26 (16)

124 (77)

Yes (%)

23 (14)

11 (7)

No (%)

35 (21)

96 (58)

Percentage
agreement
(total)

Test statistic; p

89.29

2 =0.89; p=0.48

83.33

2 =23.15;
p<0.01

72.12

2 =12.52;
p<0.01

2 = McNemars chi-square

138

Chapter 6

Table 6.4 Comparison of responses provided in ACASI and FFI to non-binary items
Variable

FFI

ACASI

Percentage
agreement
(total)

Mean age onset of injecting (SD) (n=171)

21.4 (7.43)

20.9 (7.39)

Number of clients reported higher age (%)

32 (19)

19 (11)

Most recent unprotected sex (n=166)

Never (%)
Year/s ago (%)
Month/s ago (%)
Week/s ago (%)
Day/s ago (%)

10 (6)
50 (30)
56 (34)
24 (14)
26 (16)

10 (6)
47 (28)
46 (28)
27 (16)
36 (22)

17 (10)

33 (20)

Number of clients reported more recent

unprotected sex (%)
ICC = intraclass correlation coefficient

Test statistic; p

95% CI

70.18

ICC=0.94;
p<0.001

0.92, 0.96

69.88

Z = 2.73;
p<0.01

Z= Wilcoxon signed rank

139

Chapter 6
To further explore the significant association between history of sex work and
provision of one or more discordant responses, Pearsons 2 examined the
proportions of participants who did and did not report a history of sex work who
provided discordant responses to each of the five items. There were no significant
differences between the proportions of the two groups who provided discordant
responses to the four drug-related items (age of onset of injecting: p=0.46; history of
receptive syringe/needle sharing ever: p=0.25; receptive syringe/needle sharing in
the preceding month: p=0.34; receptive ancillary equipment sharing in the preceding
month: p=0.64). In contrast, participants who reported a history of sex work were
significantly more likely than those who did not to provide discordant responses to
the item assessing recency of last unprotected sex (42% versus 25%; 2=4.56;
p<0.05).

6.3 Discussion
Compared to responses elicited from IDUs regarding their risk behaviours during a
face-to-face clinical interview, ACASI consistently extracted responses that may be
perceived as less socially desirable, including a significantly lower age of onset of
injecting, more recent unprotected sexual intercourse and higher rates of receptive
sharing of both syringes and ancillary injecting equipment. These findings are
consistent with other studies of ACASI methodology undertaken in research rather
than clinical settings (Des Jarlais et al., 1999; Macalino, Celentano, Latkin,
Strathdee, & Vlahov, 2002; Metzger et al., 2000); and suggest that even in healthcare
settings for IDUs, where drug use is acknowledged and the environment is clinical
and non-judgmental (Rich et al., 2004), reports of sensitive behaviours relating to

140

Chapter 6
drug use and sexual practices during face-to-face clinical assessments may be underreported. Just one variable assessed in this study was associated with an increased
likelihood of provision of one or more discordant responses, namely a history of sex
work. Post-hoc exploration of this relationship indicated that participants who
reported a history of sex work were specifically more likely to provide discordant
responses to the item assessing recency of unprotected sex but not to items assessing
receptive sharing of injecting equipment, a pattern of results which may indicate
perceived greater social stigma on the part of these clients to disclose sexual rather
than injecting-related risk-taking.

Although it cannot be stated conclusively that the lower prevalence of risk behaviour
reported during FFI is attributable to social desirability bias, nor that these rates are
more valid than the higher prevalence reported with ACASI, social desirability
theory (Crowne & Marlowe, 1960) suggests systematic under-reporting of
stigmatised behaviours and that higher rates of reported risk behaviour are more
likely to be valid than lower rates. Proponents suggest that social desirability bias is
reduced during ACASI due to circumvention of the need to disclose sensitive
behaviours directly to an interviewer (Perlis, Des Jarlais, Friedman, Arasteh, &
Turner, 2004). In addition, the simultaneous visual (computer screen) and verbal
(recorded speakers) presentation of questions may encourage participants to attend
more closely to specific questions. Flexible response-time in ACASI relative to FFI
may also contribute to the differences in responses, as inherent in the latter is the
expectation implicit in typical verbal dialogue that clients will respond promptly.

141

Chapter 6
ACASI might play an important role in eliciting responses from participants that
may be perceived as less socially desirable. For example, ACASI could be used to
complement face-to-face clinical assessments and the ACASI information provided
in a risk aggregate format (e.g. client at low or high risk) to the clinician for
discussion (Wand, Guy, Donovan, & McNulty, 2011). Alternatively, a universal
precautions approach to risk behaviour can be argued for in guiding blood-borne
viral and sexually transmitted infection screening and prevention in this group. Such
a universal approach would complement (rather than replace) individually tailored
assessment and advice.

Consistent with feedback from drug users in other settings (Shakeshaft et al., 2006;
Shakeshaft, Bowman, & Sanson-Fisher, 1998), and other populations (Gerbert,
Bronstone, McPhee, Pantilat, & Allerton, 1998; Kurth et al., 2004), participants of
this study felt comfortable using ACASI. The touch-screen ACASI was an additional
advantage (Westman, Hampel, & Bradley, 2000), as it did not require participants to
have typing skills. Kurth and colleagues (2004) reported that 82 percent of
participants said ACASI allowed more honest reporting (compared to 7% for FFI,
and 9% who perceived that both interview formats were equally conducive to
honesty). ACASI has the additional advantage of reducing missing data because it
requires participants to answer each item before they can proceed (Hallforsa,
Khatapoushb, Kadushinb, Watsonb, & Saxeb, 2000). However, it is unlikely that
ACASI could fully replace FFI in the clinical setting, as history-taking is an integral
part of client/patient engagement, with the clinician responding to client priorities,
and tailoring questions to raise client awareness of health issues. Clinical assessment

142

Chapter 6
also extends beyond words to non-verbal communication; and resourcing ACASI
technology may present a major barrier in many settings.

6.3.1 Limitations
This study has several limitations. First, some of the discordance in responses
attributed to social desirability bias may reflect other inherent biases, such as
participants understandings of the different contexts clinical and research in
which the data were collected, and their (unmeasured) beliefs regarding potential
benefits to themselves and/or the broader population of IDUs that might accrue from
providing particular responses within those specific contexts. Second, these data
cannot discount possible interactions between individual clinicians and clients that
may engender a desire among some clients to provide socially desirable responses
during FFI. Indeed, these results provide some indication that this may be the case,
with recruitment site correlated in univariate analysis at p=0.07 with provision of
discordant responses to one or more socially sensitive items. At one clinic, any of a
large number of healthcare workers may conduct FFI assessments, whereas at the
other recruitment site, a single individual conducted the great majority (>90%) of
clinical assessments. Nevertheless, the difference in the proportion of clients
recruited from the two sites who provided one or more discordant responses was not
significant, suggesting that this source of variance cannot fully account for observed
discordance.

Third, a certain degree of discordance is highly likely to be due to random error/poor

recall rather than deliberately enacted social desirability bias. To examine this

143

Chapter 6
possibility, however, the responses were compared across the two interview formats
to three items considered unlikely to engender social desirability bias (date of birth,
country of birth, gender) and found no significant discordance (results not shown), a
pattern of results consistent with systematic social desirability bias in relation to the
more sensitive items. Fourth, 91 percent of participants underwent clinical FFI
followed by ACASI on the same day, and may have felt pressure to maintain
consistency in their responses between the two interviews. Additionally, as FFI
preceded ACASI, FFI may have acted as a memory prompt, leading to increased
reporting of risk behaviours during subsequent ACASI. To eliminate this potential
bias, future research should engage a cross-over design, in which half of the
participants complete ACASI first while the other half begin with FFI. Finally, the
study included only participants who met the HAVIT eligibility criteria; these results
may not be generalisable for participants found ineligible for HAVIT or to the
broader IDU population.

6.4 Conclusion
In conclusion, the findings suggest that even in targeted healthcare settings for IDUs,
where drug use is acknowledged and the environment is clinical and non-judgmental,
sensitive behaviours during face-to-face clinical assessments may be under-reported.
It is unknown if the observed reporting during face-to-face clinical assessment is
more reliable than the reporting clients would do in a conventional healthcare
setting. However, despite significantly less risk reporting in face-to-face clinical
assessment compared to ACASI, it is likely that even this extent of reporting would
not occur in a face-to-face interview in a conventional setting (Friedmann,
McCullough, & Saitz, 2001). Thus, along with tailoring their approach to an

144

Chapter 6
individuals risk profile as assessed through FFI, clinicians should adopt a universal
precautionary approach to acknowledge the likelihood that clients may choose to
disclose only selected information regarding their history and risk profile.

Although the findings show that even in targeted PHC services social stigma is not
completely eradicated, the degree of stigma is likely to be less than that observed in
conventional services, where significant proportion of clients do not feel comfortable
disclosing their drug use (Islam et al., in press), let alone injecting and sexual risk
behaviours. The results also indicate that the role of ACASI may not be limited to
data collection/research, but may extend to a range of clinical environments and to
population subgroups from whom sensitive information is currently collected via
self-report. However, as mentioned earlier, history-taking is an integral part of
client/patient engagement, initial triage and client specific assessment; therefore,
ACASI is unlikely to be an appropriate substitute in the majority of clinical contexts.
However, the results suggest that it may complement pen and paper or FFI and be a
useful adjunct for PHCs and some other clinical settings. Indeed, favourable results
were found in a Sydney study which examined the feasibility of patient-operated
computers for pre-assessment screening in general primary care settings (Shakeshaft
et al., 2006).

The findings thus far indicate that targeted healthcare services are an important
platform for providing much needed healthcare to IDUs. Chapter 4 showed that
despite lower than expected utilisation, those who access RHMC return for
continued care and exhibited high levels of referral uptake. Chapter 5 found RHMC
plays an important role by facilitating reductions in liver disease burden among IDUs

145

Chapter 6
by providing a gateway to specialist care. This current chapter has found that the
reporting of sensitive behaviour, a key criterion for an IDU-targeted service, when
measured against the gold standard of ACASI, is less than ideal. Nonetheless, the
limitation of the use of ACASI within a clinical setting, relatively high level of nondisclosure of sensitive behaviours in conventional services and relatively high return
and referral uptake rates, and the good HCV outcomes suggest that these services
and the RHMC specifically, have a role to play in addressing the health needs of
IDUs. However, the question remains as to whether these services are economically
viable. Understanding the resources required for operating a targeted service is
important for its replication or even continued functioning. The next chapter
describes findings of an economic analysis performed to estimate the cost of
augmenting an NSP with an IDU targeted PHC in inner-city Sydney and the cost per
occasion of service based on the most recent level of service utilisation.

146

Chapter 7

CHAPTER 7
The cost of providing primary healthcare services
from a needle and syringe program: a case study 9
The preceding chapters described several aspects of targeted PHC services, many of
which are crucial for replication or even continuation of these relatively new models
of healthcare. However, as mentioned in Chapter 1, a key issue for such a service is
that of resources what does it cost? Indeed, the long-term sustainability of such a
service depends on the resources required and the coverage provided. There is an
abundance of literature on IDUs overreliance of EDs and the resultant high
healthcare costs. For instance, an American community-based study found that drug
users consumed significantly more inpatient and emergency care but less outpatient
services, with excess service utilisation costs of $1000 per individual relative to nondrug users (French et al., 2000). As discussed in Chapter 2, many of these
presentations can be prevented if IDUs utilise PHC services. If targeted PHC
services are to offset this high cost of secondary and tertiary care, more information
about the cost of targeted PHC services is necessary.

Cost data must underlie meaningful evaluation of such a PHC (Creese & Parker,
1994). At the time of writing no estimates of the costs of a NSP-based PHC service
have been published. Given that the RHMC is a relatively new model of healthcare
provision subjected to limited evaluation (Chapter 3 and 4; Islam, Topp, Day, et al.,
9

Study reported in: Islam, M. M., Shanahan, M., Topp, L., Conigrave, K. M., White, A., & Day, C.
A. (Epub ahead of print). The cost of providing primary healthcare services from a needle and syringe
program: a case study. doi: 10.1111/dar.12019
See Appendix II for a list of publications arising from this thesis.

147

Chapter 7
2012a), and that the need for these services even under a universal healthcare system
(such as in Australia) remains in question (Islam, Reid, et al., 2012), it is essential to
assess the resource implications of such services. The aim of this study, therefore,
was to undertake an economic analysis to assess the additional cost (incremental
cost) of offering PHC from an existing NSP setting. The chapter also estimates the
costs of RHMCs PHC activities per occasion of service, and identifies key factors
influencing improved service utilisation by the target population.

7.2 Method
This study assessed the incremental cost of operating the RHMC. Based on standard
costing methods (Drummond, Sculpher, Torrance, O'brien, & Stoddart, 2005) and
adopting a funder perspective, the analysis of costs used the ingredients approach,
in which the total quantities of goods and services employed in service delivery are
estimated and multiplied by their respective unit price (Levin, 1983). Financial
information was obtained from administrative records, interviews and direct
observation. Actual expenditures were used rather than budget estimates. This study
analysed costs incurred during the fiscal year July 2009 to June 2010, the most
recent full year cycle for which most data were available. As per standard practice
(Creese & Parker, 1994), greater efforts were made to find information on the largest
input categories (e.g., salaries and supplies) than the lower input categories (e.g.,
staff training costs). Resources, and hence costs, were classified as capital (one-time
start-up activities, buildings and capital equipment) or recurrent (pathology tests,
vaccines) items. Apportioning of overhead costs to the NSP or the PHC was based
on activity indicators and detailed discussions with the managers of both services
and other relevant staff.
148

Chapter 7

An occasion of service is defined as either (i) clients physical presentations to the

PHC clinic; (ii) phone consultations regarding, for example, test results; (iii) formal
referrals, including writing referral letters and setting appointments for clients to
attend other health and welfare services; or (iv) follow-up on formal referrals made by
PHC staff.

Using 200910 fiscal year data, a mathematical equation (y = mx + c) assessed total

cost as a function of fixed cost and variable cost, where y is the total financial cost; m
is the variable cost (costs of pathology, medication, vaccines, dressings, consumable
test kits and day-to-day operation) required per occasion of service; x is the total
occasions of service and c is the fixed cost. Average cost per occasions of service was
estimated for both current and projected levels of service utilisation.

7.2.1 RHMC model of care

As described in Chapter 4, the RHMC is a nurse-led service comprising: a full-time
clinical nurse consultant (CNC, a specialist nurse who manages the service); a fulltime registered nurse with PHC experience with marginalised communities; and a
0.1 full-time equivalent visiting medical officer who reviews pathology results and
consults with nurses and clients as required. RHMC offer a range of laboratory
examinations, including screening for BBVs and STIs and general pathology tests
including urea, electrolytes, and liver function tests, coagulation factors and full
blood count. Other

services commonly

offered include

management of

wounds/veins/abscesses; vaccination against HBV; general health consultations;

149

Chapter 7
assessment and management of drug and mental health issues; welfare services (e.g.,
advocacy with respect to public housing); counselling; referrals to other health and
related services; and support throughout HCV assessment and antiviral therapy.
RHMC nurses maintain close links with various local services, facilitating referrals
between services and further appointments as necessary. To enhance referral uptake,
clients are provided with assistance to make appointments; and telephone or SMS
reminders are sent the day preceding appointments. Uptake of formal referrals is
regularly confirmed through direct communication with service providers. A RHMC
database, described in Chapter 4, was developed to record the number of new clients,
number of presentations per client, pathology tests performed, formal referrals made
to other organisations and successful referral uptakes.

This study was approved by the Ethics Review Committee (RPAH Zone) of the
Sydney Local Health District.

7.2.2 Cost data

Staff salaries were determined via respective administrative databases. Only gross
staff earnings were used. Additional costs to the employer (e.g. superannuation,
leave, insurance, payroll tax) were added to individual staff salaries for the study
period. Vehicle operation, fuel and maintenance costs were collected from the
relevant administrator (Sydney Local Health District Fleet Management office).
Supply invoices, order forms, price lists, catalogues and interviews with the NSP and
RHMC managers were used to estimate costs of PHC clinic consumables.
Laboratory costs were collected from the Local Health District Finance Office. This

150

Chapter 7
study was concerned only with the incremental cost of the PHC operation; therefore
only the costs, which would have been saved in the absence of the clinic, were listed
as PHC expenditure. Accordingly, administrative staff and other overhead costs were
not considered as these costs would continue to be incurred even in the absence of
the clinic.

Costs of all capital items were estimated in current value (i.e. replacement rather
than original cost). The consumer price index was used to estimate the current value
of some past capital purchases for which current market value could not be
identified. A discount rate of 10 percent (high side), as recommended by the
World Bank (Creese & Parker, 1994), was followed for the annualisation factor. The
useful life of all capital items was estimated by examining their warranty documents,
and/or consultations with relevant staff. Depreciation cost was calculated by the
straight-line method, which allocates an equal portion of the cost of fixed assets with
a multiyear life to each year (Creese & Parker, 1994).

The cost of the premises was estimated based on the rental price for similar premises
in the same area. The service used leased vehicles, thus costs in this category include
lease fees, petrol, registration, insurance, and maintenance. Building operation and
maintenance costs included electricity, water, security and safety and building
maintenance. Other operating costs included phone, fax and internet and
miscellaneous expenditure.

Sensitivity analyses were undertaken to assess the robustness of the results to

changes in key variables, but were not intended as a judgment on the probability or

151

Chapter 7
likelihood of any assumption being higher or lower than the base assumptions. The
base assumptions themselves are considered the most reasonable assessment of
likely measures. Sensitivity analyses were conducted using three discount rates (0%,
5%, 10%). It was assumed that the costs for delivering services are incurred at the
beginning of the year.

The potential number of occasions of service that could be offered in a year and
corresponding cost per occasion of service were calculated using the following
assumptions:
1. It was estimated that during a normal working day, each nurse can offer 10
quality occasions of service. Given 250 working days per year, two full-time
nurses can offer a total of 5000 (2500 each) occasions of services without
compromising quality. To adjust for the absence of nurses due to training, leave
and unforseen events, 4500 occasions of service (9 per day per nurse) were
considered realistic and conservative.
1.

The average variable costs (supplies, pathology and day-to-day operating costs)
are assumed constant for each occasion of service. A stable linear trend was
observed when monthly occasions of service and corresponding variable costs
were compared. The PHC nurses and the visiting medical officer were deemed
essential for clinics operation. Their total salaries were considered fixed costs,
as they do not change with clinics scale of the current (or proposed) utilisation.

2. Sufficient PHC clients to fully utilise the service capacity are assumed based on
past and current rate of client presentation to the service, its regular flow of clients

152

Chapter 7
from the co-located NSP and a nearby residential treatment centre, and its
location in an area frequented by illicit drug users.
3. At times of NSP staff shortages, PHC nurses may work in the NSP. To
accommodate this, 10 percent of nurses working hours and corresponding salary
were reflected under NSP costs.

7.3 Results
Table 7.1 presents the detailed cost profile for the PHC. During the 2009-10 fiscal
year, the PHC incurred a total cost of AU$250,626 (AU$1=US$1.04)
(Commonwealth Bank of Australia, 2012). The largest expense was for personnel
(69%), followed by pathology (22%). In 2009-10 fiscal year, the PHC clinic
provided 1,252 occasions of services to 220 individual clients, who each made an
average of 5.7 presentations of which 3.9 were physical presentations.

Considering the 200910 fiscal year data for the clinic, the linear equation fitted to
assess total financial costs as a function of fixed and variable costs revealed the
following relationship:

Total costs (y) = total variable costs (mx) + total fixed costs (c)
Total costs (y) = variable cost per occasion (m)

(i)

total service occasions (x) + total

fixed costs (c)

(ii)

Therefore, average cost per occasion of service =

(iii)

153

Chapter 7

Table 7.1 Estimated incremental cost of adding a PHC service to an existing NSP, 2009-10, AU$ (2009)
Resources

Source of Information

Expenditure (AU$)

Capital Costs (that last more than a year)

Equipment

Administrative record, NSP manager and

CNC

2696

Building, space

Real estate market

3900

Training, non-recurrent

Administrative record, NSP manager and

CNC

701

Recurrent Cost
Personnel

Administrative record

Supplies (injecting equipment, drugs, vaccines, small

equipment with unit cost of less than $100)

Database and paper based record

Pathology

PHC database and CNC

Vehicles operation and maintenance

Transport office, NSP manager and CNC

1,379

Building operation and maintenance

Administrative record

1,001

Training, recurrent

Administrative record, NSP manager and

CNC

3,450

Other operating cost (e.g. travel)

As above

1,261

Grand Total

With 0% discount rate; CNC: Clinical nurse consultant; (AU$1=US$1.04) (Commonwealth Bank of Australia, 2012)

172,122
8,534
55,582

250, 626

154

Chapter 7

Consequently, at the level of service utilisation for the 2009-10 fiscal year (1,252
occasions of services; 5.008 occasions of services per day by two nurses) the average
variable cost per occasion of service was AU$52.22 (Table 7.2, column 7). This is
the cost of pathology tests, vaccinations, basic medications and dressing
consumables and thus would remain constant. If service utilisation increased, for
example, to six occasions of service per day, then the average total cost per occasion
would reduce from AU$199.96 to AU$175.54 (Table 7.2). If the service was fully
utilised, when a total of 18 occasions of service per day would be offered, the
average cost per occasion of service would decrease to AU$93.32 (Table 7.2).

155

Chapter 7

Table 7.2 Current and projected average cost per occasion of service provided by the RHMC clinic (AU$)
Variable cost per
occasion of service
m

Occasion
of services
x (*)

Total variable
costs
mx

Observed
2009-10

52.22

1252 (5)

65377

184979

250355.62

199.96

Projected

52.22

1500 (6)

78327

184979

263305.70

175.54

Projected

52.22

2000 (8)

104436

184979

289414.73

144.71

Projected

52.22

2500 (10)

130545

184979

315523.76

126.21

Projected

52.22

3000 (12)

156654

184979

341632.79

113.88

Projected

52.22

3500 (14)

182763

184979

367741.82

105.07

Projected

52.22

4000 (16)

208872

184979

393850.85

98.46

Projected

52.22

4500 (18)

234981

184979

419959.88

93.32

Fixed
cost
c

Y = mx +c

Average cost per

occasion of service
y/x

All costs are in AU$ (AU$1=US$1.04) (Commonwealth Bank of Australia, 2012); *occasions of service offered per day by
two nurses during 2009-10 fiscal year.

156

Chapter 7
The estimated total costs of the PHC service with varied parameters are shown in
Table 7.3. Variation in the discount rates and rental increment caused minimal cost
differences. This was because the exact and updated costs of all recurrent items for
2009-10 were clearly sourced and collected from official documents, and thus these
costs were not discounted. However, if the CNC position were to be replaced by a
less specialist nursing position nurse then the base amount would decrease by 8.3
percent. Conversely, if the current medical officer position increased to 0.2 full-time
equivalent then the base amount would increase by 7.6 percent.

At full utilisation, the average fixed cost (base amount) per occasion of service
would be AU$41.10 ($93.32 minus $52.22; i.e., the average total cost per occasion
of service minus the average variable cost per occasion of service). Figure 7.1 shows
that the average cost per occasion of service could more than halve (AU$93.32) the
cost the clinic incurred during the 2009-10 fiscal year (AU$199.96), if it reached full
utilisation.

157

Chapter 7

Figure 7.1 Trend of average cost per occasion of service as attendance increases
up to full utilisation level

Table 7.3 Estimated cost for 2009-10 with variation of relevant parameters
Change in
respective
item

Total cost
(AU$)

Current average
cost per occasion of
service (AU$)

0%

250, 356

199.96

Rent increases by 10%

+10%

Change CNC position to RN

12%

250, 746
229, 472

200.28
183.28

MO at 0.2 FTE

+100%

269, 368

215.15

+5%

251, 121

200.58

+10%

251, 978

201.26

Parameter varied

Base amount

Discount rate on capital items

CNC: Clinical nurse consultant; RN: Registered nurse; MO: Medical officer; FTE: Full-time
equivalent.

158

Chapter 7

7.4 Discussion
The total cost of PHC services provided by RHMC during the 2009-10 fiscal year
was AU$250,626. Fixed costs accounted for the majority, with personnel costs
constituting more than two-thirds of the total cost. During this period a total of 1,252
occasions of services were provided. The average cost per occasion of service was
AU$199.96. Consistent with the findings of Chapter 4, the RHMC was underutilised,
providing five occasions of service per day; the average cost per occasion of service
could be halved to AU$93.32 if the service was fully utilised. Sensitivity analyses
confirmed that the costing findings were robust.

Although the average cost per occasion of service at observed utilisation level
appears higher than the fee (AU$57.10) a general medical practitioner receives for a
consultation under Australias universal healthcare system (Austrlian Government,
2012), it should be remembered that this clinic caters for a population dissimilar to
the general population in many respects. Many of these clients avoid conventional
healthcare services until conditions become severe, and then often present at EDs,
which carries substantial cost burden (Drumm et al., 2005; McCoy et al., 2001). For
instance, in Australia, opioid-related hospital separations for co-occurring medical
conditions such as endocarditis were estimated to cost approximately AU$25,000 per
separation between 1999/00 to 2004/05 (Riddell, Shanahan, Degenhardt, &
Roxburgh, 2008). Considerable expenditure could have been saved with appropriate
preventative care for this population (Grau, Arevalo, Catchpool, & Heimer, 2002;
Harris & Young, 2002). Likewise, the predominant causes of hospital admissions in
a cohort of IDUs in Vancouver, Canada were pneumonia and soft-tissue infections,

159

Chapter 7
directly or indirectly related to injecting (Palepu et al., 2001). This highlights the
importance of early interventions to reduce reliance on EDs and hospital admissions.

Although this study was neither intended nor able to assess the cost-benefit of this
PHC service, the overall clinical outcomes are favourable as shown in Chapter 4 and
5. Some of the notable achievements are HCV treatment assessment, successful
referrals to a tertiary liver clinic and support for successful completion of antiviral
treatment by a number of clients (Chapter 5); early diagnosis of an HIV-positive
client (Chapter 3 and Islam et al., 2011); and relatively high completion rate of
hepatitis B vaccinations (Chapter 4). These findings highlight some achievements,
and success of the enhanced model employed at RHMC. It is also important to note
that the findings incorporate the period of clinic commencement when clinic
capacity and client numbers were still growing. These achievements and
contributions of RHMC suggest the desirability of continuation of service provision
with concurrent efforts to increase throughput so that similar or better services can
be provided at a lower cost.

Although during the 2009-10 fiscal year the clinic was underutilised, compared to
previous years the total number of new clients and occasions of services were
growing, albeit slowly. Apart from the clinics commencement period, other
potential factors may have affected clinic underutilisation (or the relatively slow
increase in the number of clients accessing the service). First, Australia enjoys a
universal healthcare system where individuals can seek PHC from a general medical

160

Chapter 7
practitioner at no or minimal out-of-pocket personal expense and this may be one
reason for underutilisation.

Ongoing education of NSP workers regarding the services provided in the PHC is
necessary. Observations indicate that PHC staff working in the NSP were more
likely than NSP workers to attract clients into the PHC service. This observation
highlights the need for a strategic and consistent approach to successfully engage
clients in the PHC service; and emphasises the importance of engaging clients to
whom healthcare may be a low priority relative to other needs such obtaining food,
housing and drugs (Carr et al., 1996).

Efforts could be made to make services more attractive. Options include an increased
range of services, for example, provision of onsite Human Papilloma virus testing
(Pap smears), hepatitis A vaccination, antibiotics for bacterial infections, and
welfare support by a qualified case-worker. Although nurses often refer clients to
appropriate healthcare providers for services unavailable onsite, and facilitate
referral uptake, a significant proportion of referred clients fail to attend
appointments. Indeed some commentators have argued that for many IDUs, offering
referrals only is akin to denying those services (Nasiri, 2012). In addition, the time
currently spent arranging, facilitating and tracking referrals may be impractical once
RHMC reaches full utilisation.

Given injection-related infections are common among NSP attendees (Topp, Iversen,
Conroy, et al., 2008) and that RHMC clients are less likely to attend referrals to GP

161

Chapter 7
services than other services (Chapter 4), onsite prescribing of essential medications
such as antibiotics could be valuable. However, RHMC should have no provision of
prescribing psychoactive medications with the exception of OST, as psychoactive
prescribing often attract doctor shoppers and motivates a substantial proportion of
IDU presentations to healthcare (Darke et al., 2003; Longo, Parran, Johnson, &
Kinsey, 2000; Martyres, Clode, & Burns, 2004). Patients genuinely requiring such
medications can be referred to a nearby hospital outpatient clinic. Provision of OST
would require an increased role of the medical officer. As projected earlier (page
158), the medical officers two half days working arrangement is likely to help
address this issue. More importantly, this increased role, without substantially
increasing the cost, may help RHMC to introduce onsite OST. Given that there
remains a shortage of OST prescribers in Australia (Longman et al., 2011;
Scarborough et al., 2011), this is likely to create new opportunities for healthcare
engagement and service utilisation. For instance, if RHMC can offer OST dosing to
even 10 clients per day, some of them are likely to access onsite PHC services; this
will then substantially increase service utilisation and reduce per occasion service
cost. As the facility remains open for around half a day on Saturday and Sunday and
offers NSP services, it could be feasible to offer uninterrupted OST services even
during weekends. However the provision of OST is complicated and numerous
structural changes would be required, not least secure storage facilities for the
opioids (i.e. a safe). It would also result in some additional costs for a nurses service
during weekends, although this may still be beneficial. Alternatively, arrangements
could be made for clients to receive OST from a suitable local dosing point such as a
public outpatient clinic during weekends only. Once stable, clients could be
transferred to private clinics to reduce inappropriate client mixing and service cost.

162

Chapter 7

7.4.1 Limitations
It is not possible to estimate the proportion of NSP clients accessing PHC services
because NSP services are provided on an anonymous basis. This study considers
only the incremental costs (additional cost) of offering PHC in an established NSP
setting, thus findings may not be applicable to NSPs without the scope to
accommodate this type of clinic. The assumption that the variable cost per occasion
of service would remain constant may not be valid for the optimum service
utilisation level, as this assumption was made based on data for the study period
only. However, variable costs are less likely to increase, and more likely to decrease
with increased service utilisation. This study may not be generalisable to other
settings, particularly to developing countries where injecting drug use is prevalent
and access to healthcare poor. Australia enjoys a universal healthcare system where
individuals can seek PHC from a GP at no or minimal out-of-pocket personal
expense and this may be one reason for the underutilisation of the RHMC.

7.5 Conclusion
The average cost incurred per occasion of service from this targeted PHC facility
was influenced by its relative underutilisation. However, the average presentations
per client and the range of services provided highlight the clinics importance.
Efforts to attract more clients will potentially reduce the average cost per occasion of
service, as well as ED and hospital admissions. A more proactive engagement of
NSP clients and an increase in the range of services offered by the PHC may help
engage more clients, thereby increasing efficiency.

163

Chapter 8

CHAPTER 8
General discussion
A principal objective of PHC is to address illness, either prior to its occurrence, or
early enough in its natural history to prevent additional harm to the patient. This
objective has greater implications for IDUs than the general population, as IDUs are
more vulnerable to health problems in many aspects, as has been described
throughout this thesis. There are many pertinent questions relating to the findings of
this research that are important from an individual and public health perspective.
These include, for example, how the quality of evidence can be improved for policy
makers, how service utilisation can be improved, what volume of services should be
offered and how healthcare workers can attract those individuals in need of
healthcare. This chapter reviews the main findings from the research reported in this
thesis, followed by a discussion of the public health significance and implications of
the findings. Limitations of the research are then addressed and the generalisability
of the research to settings outside Australia, particularly to the developing world, is
discussed. Finally, the chapter highlights the need for research into the models of
PHC, their efficacy and their ultimate impact on health of IDUs.

8.1 Overview of main findings

This thesis examined the context of IDU-targeted PHC services in the healthcare
system; assessed the capacity of these services to attract the target group for which
they are designed; and reflected on the important public health role such services can
play in providing essential PHC. It has been demonstrated that IDUs encounter

164

Chapter 8
unique health challenges and frequently require care for complex health issues
(Murrill et al., 2002; Stein, 1999) and that these needs are greater than those of the
general population (Chitwood et al., 1999). However, there remains a substantial gap
between the healthcare needs of IDUs and their access to PHC. Importantly, most of
the health problems that are directly or indirectly attributable to drug dependence can
either be treated or prevented in a PHC setting. The intuitive way to address this
problem would be to increase IDUs access to PHC services. The findings of this
research, however, suggest that it is not simply a lack of services that prevents access
to care, but rather a complex interplay of factors hinders access. Healthcare need is
not always apparent to the individual IDU in the earlier stage of the problem; or at
least may not be translated into access to care, which is hampered by a range of
barriers (Chapter 2). The findings presented in Chapter 3 indicate that opportunistic
or assertive service provision, particularly from a suitable environment, is
practicable, and accessible and acceptable to the target population. As a result, these
services continue to be replicated in a growing number of settings (Des Jarlais et al.,
2009; Islam, Topp, Day, Dawson, & Conigrave, 2012b), albeit slowly. However, as
noted earlier, there are scarce data on service utilisation, client characteristics and the
costs of implementing these facilities. Therefore evaluations are crucial for
researchers and policymakers to determine the efficacy and necessity of these
services.

The findings of the literature review presented in Chapter 3 demonstrate that IDUtargeted healthcare services are accessed by the target group although the level of
utilisation varies across settings. The studies presented in Chapter 4 and 5
demonstrated the critical role such services can play in preventing and reducing the

165

Chapter 8
burden of liver disease. This particular finding is important in the Australian context
as liver disease is the most common cause of mortality among ageing opioiddependent people (Gibson, Randall, & Degenhardt, 2011), and there are considerable
barriers to HCV treatment (Doab et al., 2005; Grebely et al., 2008). IDU-targeted
PHC services acknowledge drug dependence and offer PHC services that
accommodate IDUs lifestyles. However, the research presented in Chapter 6
demonstrates that despite the low-threshold nature of these services, IDUs who
access them still may not fully disclose socially stigmatised risk behaviours. Despite
these limitations, the findings of the thesis as a whole suggest that IDU-targeted
PHC services are an important element of a public health response. The findings
presented in Chapter 7 suggest that one such service, the RHMC, is underutilised,
and associated factors include the limited range of services provided, unbalanced
skill mix of clinicians and to the lack of assertive referrals to the facility from the colocated NSP. Proactive engagement of IDUs attending the NSP and an increase in
the range of services offered by RHMC may facilitate the engagement of larger
numbers of clients, and thereby increase service efficiency. The subsequent sections
of this chapter discuss in more detail the major findings of each of the preceding
chapters and their public health implications.

8.2 Accessibility and acceptability of targeted

services
Use of healthcare services is dependent upon the accessibility and acceptability of
the service to potential users and not merely on adequacy of supply (Gulliford et al.,
2002). In every setting, different population groups will have different healthcare
needs, mandating provision of services that are appropriately differentiated to meet
166

Chapter 8
various target populations priorities. The stigma and other obstacles IDUs encounter
in accessing healthcare from conventional settings seriously affect their health, their
families and the broader community (Trewin, 2001). The findings of this thesis
suggest that IDU-targeted healthcare services are valuable for individual members of
this population who have historically been hard-to-reach via conventional healthcare
services (Noel et al., 2006; Wood et al., 2006). The relatively high return rate (82%)
and high average number of presentations (3.5) of RHMC clients, despite the limited
range of services offered, suggest that non-judgemental and free-of-charge services
provided under a harm reduction framework from appropriately designed facilities
with appropriate opening hours and provision for consultations on a drop-in basis,
are likely to increase the accessibility and acceptability of services for IDUs.

As discussed in Chapter 2, a number of barriers hinder the uptake of referrals made

from stand-alone NSP services to conventional healthcare facilities. Provision of
tailored PHC services from existing NSP premises, as in the case of RHMC, reduces
those barriers and makes the facility integrated. An IDU, for example, may not see
vaccination against HBV as worth travelling across town to obtain from a clinic
(Campbell et al., 2007) that may or may not be welcoming and tolerant. If, however,
that same vaccine is available free-of-charge from the NSP premises he/she already
attends, or in the neighbourhood where he/she lives, and is provided in a respectful
manner in conjunction with other services (e.g., sterile syringes and condoms), then
he/she may be willing to accept the service. RHMC clients relatively high rate of
hepatitis B vaccination completion and liver clinic referral uptake, found in Chapter
4, are attributable to the services integrated model.

167

Chapter 8
While it is not always feasible to ensure an integrated service, the literature is
reasonably supportive of this model. These types of care, sometimes also referred to
as collaborative care initiatives, improve process of care by reducing inappropriate
referrals (Archer et al., 2012; Gruen, Weeramanthri, Knight, & Bailie, 2004). This
approach typically aims to ensure an organised approach to patient follow-up
appointments to provide specific interventions, facilitate treatment adherence, or
monitor symptoms or adverse effects. The approach has been successful in a range of
settings such as mental health services and in rural communities. If healthcare cannot
be provided when the decision to seek it is made, then competing priorities may be
relegated to lesser priority by the time of a scheduled appointment. Health services
subsequently lose a valuable opportunity to provide care to a vulnerable and at-risk
population at an early stage of need, with potentially harmful consequences for the
individual and for the broader community (Bruce, 2012). In any healthcare
environment, individuals solicit services that they perceive to be of value. Like other
population groups, IDUs will seek out services that are of value and that are
provided in a convenient and respectful manner. If the service is quite valuable,
IDUs may undergo some measure of inconvenience and disrespect in order to obtain
the service. Attendance at a hospital ED is one such example. As the perception of
service value declines, convenience and respect become the main determinants of
willingness to access services. Bruces (2012) argument is well illustrated with
reference to the population of IDUs, the lifestyle of many of whom centres on drug
use, with other priorities assuming secondary importance.

Clients daily presence in the NSP shopfront creates convenience and access to the
services RHMC offers. The provision of opioid substitution therapy from RHMC

168

Chapter 8
could potentially create greater opportunity for engaging clients and could further
increase the perceived value of the service. The case study presented in Chapter 4
provides an example of the way in which immediate diagnosis and healthcare advice
provided to an HIV-positive client may reduce the risk of secondary HIV
transmission. This example illustrates that when IDUs eventually present seeking
healthcare, it is crucial to utilise this window of opportunity and provide healthcare
onsite immediately and, where possible, avoid referrals elsewhere as this may create
an additional barrier to care (Nasiri, 2012).

The low-threshold nature of IDU-targeted services is an important determinant of

their accessibility and acceptability. This service modality creates a congenial
environment where drug use is acknowledged and clients are treated without
judgment. This, in turn, facilitates clients disclosure of sensitive and socially
stigmatised information (Islam, Topp, Conigrave, et al., 2012). Although the
findings presented in Chapter 6 show that even in targeted PHC services perceived
social stigma may not be completely eradicated, the degree of stigma is likely to be
less than in conventional services. For instance, the findings of a separate study
(Appendix IV) among participants in the annual Australian Needle and Syringe
Program Survey (ANSPS) reveal that only one-third of the 2395 participants
reported fully disclosing their injecting to their most recent healthcare provider
(Islam et al., in press). This non-disclosure of injecting was highest among those
who most recently accessed care from a GP or medical centre, the predominant
source of recent healthcare accessed by the sample. On the contrary, clients are less
likely to hesitate to disclose their drug user identity when they access services from

169

Chapter 8
IDU-targeted facilities because drug use is acknowledged and clients do not need to
seek to hide it (Rich et al., 2004).

8.3 The role of RHMC in prevention and reduction

of liver disease
The important role of RHMC in providing HCV care, particularly HCV testing,
providing supported referrals to a tertiary liver clinic for assessment and facilitating
AVT commencement, was uncovered in Chapter 4. Targeted PHC facilities such as
RHMC would appear to be better positioned than conventional services to extend
HCV services and play an important role in reducing the burden of liver diseases
among IDUs. RHMC has achieved this outcome by accommodating lifestyle
challenges of many IDUs and addressing the barriers that the structured appointment
system of conventional services may constitute. RHMC clients relatively high rate
of hepatitis B vaccination completion, as documented in Chapter 4, also contributes
to reduced burden of liver disease among this group. However, as commented in
Chapter 4, lack of funding for hepatitis A vaccination is a clear limitation which
needs to be resolved, especially given the increased risk of morbidity among
individuals co-infected with hepatitis C and hepatitis A.

8.4 Universal Health Insurance is important but not

sufficient
Health insurance is a powerful and independent determinant of healthcare access
(Cronquist, Edwards, Galea, Latka, & Vlahov, 2001; Knowlton et al., 2001; McCoy
et al., 2001). However, as found in the retrospective study of RHMC clients reported
170

Chapter 8
in Chapter 4, although most clients were covered by Australias universal health
insurance (Medicare), non-financial barriers (e.g. fear of discrimination, social
stigma, lack of transportation) can also impede full access to healthcare (Friedman,
1994; Islam, Topp, Day, et al., 2012a). Despite longstanding bipartisan political and
public support for harm reduction-based illicit drug policy (Treloar & Fraser, 2007),
considerable social stigma remains associated with injecting drug use in Australia.
The findings of the study of healthcare access among ANSPS participants (Appendix
IV) noted earlier, in which two-thirds of participants acknowledged failing to
disclose their injecting drug use to their most recent healthcare provider, are likely to
reflect the depth of social stigma associated with injecting drug use (Islam et al., in
press).

Indeed there remains reluctance among IDUs to utilise GP services. Although GPs
are increasingly being involved into drug users healthcare, the demand still
substantially surpasses the supply. Chapter 4 documented that 62 percent of RHMC
clients also reported current access to GP services. Moreover, other research has
shown that many drug users who claim to have GP access do not disclose their drug
use and/or its extent to their GP and some access GPs in search of psychoactive
medications (Islam et al., in press; Western Australian Network of Alcohol and
Other Drug Agencies, 2009). It is of note that of all the referrals provided by the
RHMC, referrals to GPs were the least likely to be utilised (36%). This lower
attendance of referrals to GP services than to others is likely to have multifaceted
causes. First, RHMC enjoys an excellent functional relationship with most of the
centres it refers clients to, including residential rehabilitation centres and a tertiary
liver clinic. These established relationships directly and indirectly help ensure

171

Chapter 8
referral attendance. However, although RHMC collaborates with a few local GP
services, this collaboration still remains limited both in terms of its extent and
quality. Second, as GP services are locally available and appointments are relatively
easy to obtain, clients may not place a high priority on attending such referrals.
Third, when a GP referral is deemed necessary, often clients like to be referred to
their regular GP or to someone they are familiar with; however RHMC nurses may
not have a working relationship with such a large pool of GPs.

Clearly this is a complex issue, and there is no easy remedy. However, a number of
initiatives could help reduce this non-attendance. One such initiative is to increase
the role of the visiting medical officer, as described in Chapter 4, and to endeavour
to offer more of the primary care services onsite. Through their assertive
engagement, nurses could ensure that those clients who are less likely to attend a GP
referral are seen by the medical officer onsite. Tracking all GP referrals more
intensively and establishing better working relationships with more local GPs could
also be useful.

8.5 Service utilisation in different settings

An important question regarding targeted services is the level at which they are
utilised in different settings, and whether there are differences across upper, middle
and low income countries. Unfortunately, the literature from developing countries is
so scarce that almost nothing is known about service utilisation in these settings. The
facilities presented in Table 3.1 clearly illustrate the dearth of information from the
developing world. Arguably a targeted healthcare service in a developing country is

172

Chapter 8
likely to be highly utilised, as IDUs of such settings have limited other options of
healthcare. However, due to prohibition-based policies and social stigma associated
with drug use in many developing countries, provision of even basic NSP services is
challenging. Even where targeted services have been established, they have little
hope of sustainability (Islam & Conigrave, 2007a). Documentation of even minimal
information on the processes and outcomes of services established in these settings is
likely to be difficult, let alone the conduct of scientifically rigorous evaluations of
service utilisation.

In developed countries, service utilisation may depend on a number of factors such

as general healthcare provision from other facilities, location, quality and volume of
services offered from the targeted PHC facilities. Targeted PHC services in
developed countries which offer universal healthcare provision, as in Australia, may
experience lesser utilisation than services in other settings, particularly if a limited
range of services are offered. The relatively low level of utilisation of RHMC
(Chapter 4) may be the result of a number of factors. One is its limited range of
service provision, which may be inadequate in attracting a wide range of clients.
Australias universal healthcare system also may influence the underutilisation to a
degree. It could be assumed that a proportion of the 62 percent of respondents who
have regular access to GP services are already receiving adequate healthcare and so
RHMC may not be a priority to them. Had this portion not accessed quality care,
RHMC would have seen more visits of those clients. Insufficient engagement of
clients at the NSP shopfront is another reason for underutilisation. As mentioned
earlier the provision of opioid substitution therapy from RHMC could potentially
create more opportunity for engaging clients. In Australia there is a shortage of GPs

173

Chapter 8
available to prescribe OST, which results in an unmet need for OST services
(Longman et al., 2011; Scarborough et al., 2011).

As noted in Chapter 4, RHMCs medical officer attends the clinic for limited hours,
and primarily to review pathology results and discuss cases with nurses. Extending
this role of medical officer to include client consultations and prescription of nonpsychoactive medication might overcome some of the barriers these clients
experience in relation to obtaining comprehensive healthcare from conventional
setting. Although often RHMC clients are referred to other allied healthcare
providers, Nasiri (2012) argues that referrals create another barrier to healthcare
access and referral uptakes are rarely satisfactory (Kimber et al., 2008). This
challenges targeted PHC services to ensure effective follow-up of and support for
clients referred to external services. As illustrated in Chapters 4 and 5, it is possible
for targeted services to achieve good referral outcomes when effective protocol and
policies are implemented.

Whilst greater involvement of a medical officer, as described earlier and in chapter

7, may improve service utilisation, it is also likely to increase the cost per occasion
of service. This tension between increased expertise and limiting the cost of the
service needs to be carefully considered and any changes would need to be closely
evaluated to ensure such changes improve the service without creating a cost
blowout.

174

Chapter 8

8.6 Implications of the findings and future research

IDU-targeted PHC services were introduced to address the lack of PHC for IDUs or
systematic barriers to access to PHC experienced by this high-need group. As noted
in Chapter 3, few targeted PHC facilities offer comprehensive services, and the
majority function not as specialised, but rather as basic, targeted PHC services,
providing care which can be offered from conventional PHC facilities such as GP
practices. Indeed, an increasing number of GPs or medical centres around the world
offer quality and tailored services for IDUs (Ford, 2012). In Australia, GPs are
increasingly, albeit slowly, becoming more involved in IDUs PHC delivery (Islam,
Topp, Conigrave, & Day, Epub ahed of print).

Furthermore, PHC services offered from targeted facilities are mainly accessed by
IDUs; and non-drug users rarely present to these facilities (Islam, Topp, et al., Epub
ahead of print). As noted in Chapter 4, all but two clients who accessed RHMC
during the study period reported illicit drug use, and 85 percent disclosed injecting
drug use. Consequently, these healthcare services are becoming a separate healthcare
platform, with potentially far-reaching effects. First, the perception of a separate
platform may give the erroneous impression that there are separate healthcare
facilities for IDUs, although the temporal and spatial availability of these targeted
healthcare facilities and the extent of services they offer are well below the required
level (Islam, Day, et al., 2010). Conventional healthcare providers continue to show
reluctance to provide care to IDUs, and any impression that alternative services may
perform this function might exacerbate the situation (Islam, 2010). Thus targeted
services should aim to establish linkages between IDUs and conventional health
services rather than directly replace them. Drug problems are a societal issue and it is
175

Chapter 8
incumbent upon conventional services to also bear responsibility for these clients.
Until this occurs, targeted PHC facilities should play a role complementary to
conventional services for IDUs healthcare provision.

There is a dearth of literature about the quality of healthcare offered by targeted

services. As noted earlier, the range and quality of services vary across settings, as
do staffing structures and service modalities. Given IDUs who present to targeted
services for healthcare or who are offered healthcare opportunistically may have no
or limited access to conventional healthcare services, it is imperative that the
opportunity their presentation offers is utilised properly through provision of
adequate and quality services. During the review undertaken in Chapter 3, it became
apparent that these facilities rarely operate under the mainstream health budget and
mostly run on an ad-hoc basis either with the assistance of the development partners,
charity organisations or with the contingency budgets (Islam, Topp, Day, et al.,
2012a). Moreover, as services are generally offered free-of-charge, the financial
sustainability of the facilities may be vulnerable, in turn increasing the risk of
substandard service provision. Consequently, some facilities offer comprehensive
and quality healthcare, whereas others may provide few services of inadequate
quality (Chapter 3). The latter may potentially translate into inappropriate healthcare.
Clearly, there is a dilemma here as it may not be feasible to offer a wide range of
necessary complex services from these targeted PHC facilities, as found in the
literature review (Chapter 3). Thus a balance must be struck, and referrals for
services unavailable onsite should be supported and monitored so that IDUs are
provided with the care they require. RHMCs efforts in ensuring uptake of referrals

176

Chapter 8
to allied services are remarkable (Chapter 4 and 5). However, the volume of services
it offers must increase to achieve the right service provision versus referral balance.
Further research is needed on this issue.

It is also important to endeavour to attract hard-to-reach clients in need of healthcare.

While it is reasonable to offer services to all IDUs seeking care or to whom services
can be provided opportunistically, special attention should be given to those less
likely to be reached by other healthcare facilities despite their increased risk of
health problems. For instance, the 38 percent of RHMC clients who reported no
access to a GP or medical centre (Chapter 4), and the NSP clients who are apparently
in need of care but difficult to engage (Islam et al., 2011), are examples of groups
who may benefit from special attention. This would require clear identification of
these clients and prioritising them in engaging health consultations, with an assertive
approach both at the NSP shopfront and at the PHC clinic. Furthermore, greater
support and intensive monitoring of any referrals would be needed. Other novel
strategies to engage them such as targeted outreach and in-house case management
should be trialled.

Another implication of this research relates to the cost of services. Although, as the
literature suggests, targeted PHC services are likely to save costs by reducing IDU
presentations to emergency and tertiary care, the pressure on limited health budgets
posed by provision of services from these facilities may be substantial. As most of
these services can reasonably be offered from conventional facilities, this additional

177

Chapter 8
pressure arising mainly from barriers to access to conventional facilities rather than
availability of services, may continue to challenge policymakers for the foreseeable
future. Consequently, it is imperative that targeted services are made economical
relative to alternative modalities of healthcare provision. Chapter 7 demonstrated
that the average cost per occasion of service offered by RHMC during the study
period was relatively high (AU$199.96), because the service was underutilised.
Although this cost could be reduced to as little as AU$93.32 if RHMC was fully
utilised, there remains a question as to whether, or until when, its operation should
be continued if service utilisation fails to increase. However, before reaching such a
decision to discontinue services, it should be strongly acknowledged that RHMC
offers additional supports to its clients, most of whom are marginalised and with
considerable health needs. It would therefore be worth first trialling approaches to
increase service utilisation. As already described, increasing the role of medical
officer, provision of OST are worth trialling.

8.7 Generalisability of the research

The generalisability of these research findings should be evaluated from several
perspectives as generalisation in health service evaluation research is inherently
limited by the unique characteristics of the setting, the nature of the services offered
and other contextual and temporal factors (Kimber, 2005). However, the following
three criteria can be used to assess the generalisability of the findings: internal
validity, external validity and theoretical rationality.

178

Chapter 8
Criterion 1: internal validity
Criterion 1 can be used to determine whether the findings of the research were
internally valid. This is important because it is not possible to generalise an invalid
finding no matter how representative a sample may be. The major findings of this
thesis can be assessed against this criterion. The evidence from the literature is sound
enough to claim that it is not only the lack of availability of the services, but also
other factors such as stigma, low perceived priority of healthcare and client
convenience that determine IDUs access to healthcare (Chapter 2). The literature
review presented in Chapter 3, although narrative, not systematic, demonstrated that
targeted facilities acknowledge drug use, offer services with drop-in provision, often
opportunistically and/or assertively, which may facilitate healthcare provision to
IDUs for whom healthcare is a low priority. These criteria are pivotal, as they
directly reduce barriers to make services accessible and acceptable to IDUs, and can
be attributed to those arrangements and not to other possible causes. The high return
rate of RHMC clients (Chapter 4) also supports this observation of accessibility and
acceptability. This hospitable environment may assist in the engagement of HCVpositive clients and consequent reductions in the burden of liver disease among this
group, as was demonstrated by RHMCs notable outcomes with respect to
facilitating their clients HCV AVT commencement (Chapter 5). Under-reporting of
sensitive behaviours relating to drug use and sexual practices in face-to-face clinical
assessments even in healthcare settings targeting IDUs, as was described in Chapter
6, is consistent with other literature and can be primarily attributed to social stigma
(Des Jarlais et al., 1999; Macalino et al., 2002; Metzger et al., 2000). Moreover, the
study presented in Chapter 6 was methodologically sound, considers participants
from two separate targeted healthcare facilities, RHMC and the Kirketon Road

179

Chapter 8
Centre, and no significant differences were observed between the responses of
participants of the two facilities. A relatively high estimated cost per occasion of
PHC service of RHMC is mainly due to its underutilisation not for other plausible
causes. Furthermore, the estimated total cost for the PHC service is not substantially
sensitive to varied parameters (Chapter 7), as the exact and updated costs of all
recurrent items were clearly sourced and collected.

Criterion 2: external validity

Criterion 2 can be used to examine whether the outcome of interest, that is the study
findings, is likely to differ between the studies and the population to which the
findings are intended to apply. Although the political and cultural environments in
which IDU-targeted PHC services are established vary greatly, there remain a
number of common elements, as noted earlier, including a harm reduction focus,
suitable locations and drop-in arrangements. These approaches were found crucial
for targeted PHC services to be accessible and acceptable no matter where they exist
(Islam, Topp, Day, et al., 2012b). In other words, the reasons for which the
accessibility and acceptability of targeted facilities are internally valid are also
attributable to the external validity.

In the retrospective study of RHMC clients (Chapter 4), the level of utilisation of an
IDU-targeted PHC facility may have been influenced by the availability of other
healthcare platforms. Thus it is reasonable to hypothesise that if services are offered
free-of-charge in developing country settings, a targeted healthcare service may be
highly utilised, which may not be the case in developed country settings where other
factors such as the higher range of services available may have substantial influence.

180

Chapter 8
Although the absolute cost of offering services would vary across settings, this
variation may not be substantial if costs are estimated in a purchase parity ratio. Thus
there is a little possibility that the other findings would be substantially different
across settings.

Criterion 3: theoretical rationality

Criterion 3 determined whether there was a strong theoretical rationale for why the
results might not be generalisable to the broader population of IDUs. First, all the
services examined in the literature review (Chapter 3) and the RHMC offer services
under a harm reduction framework from locations convenient to the IDUs. If any
targeted healthcare facility, however, offers services from locations not convenient to
the target group then its utilisation could be limited. Whilst it would seem irrational
to offer services from an inconvenient location, this is a risk. The stigmatised nature
of injecting drug use may encourage policy makers to seek locations for such
services where IDUs will not be visible to the general public and in doing so would
run the risk of the service under-utilisation. Second, only the incremental costs of
offering PHC from RHMC was estimated, thus findings may not apply to services
without the scope to accommodate this type of clinic, that is, one which is
implemented within an existing service already frequented by the target population.
Apart from this, there is no strong theoretical reason as to why the results may not be
generalisable.

Based on the assessment of the above three criteria most of the major findings of this
research appear generalisable. IDU-targeted PHC facilities, therefore, are likely to be

181

Chapter 8
a valuable source of essential PHC for IDUs in any settings if low-threshold services
are offered under a harm reduction framework.

8.8 Limitations
As noted earlier, the case-study approach has some intrinsic limitations. For instance,
although RHMCs efforts in setting appointments for clients to allied healthcare
services and supporting uptake of those referrals were remarkable, there was no
control group to compare referral uptake with. The dearth of services nationally and
internationally (and evaluation thereof as illustrated in Chapter 3) means it was
unclear whether the referral uptake rates reported in this study were comparative
with other IDU-targeted PHCs. Despite this limitation, the relatively high uptake
(55%) of referrals to other health and welfare services is notable in comparison to
data documented for the Sydney MSIC which reported limited referral uptake among
IDUs (Kimber et al., 2008). The recommendation about increasing service utilisation
through proactive engagement of users via the NSP shopfront is specific to this type
of services and may not be appropriate for stand-alone targeted PHC services. This is
a further limitation of case-study approach.

Given the aforementioned limitations and complexity of study design, it can be

argued that the study design and methods suited to evaluation of IDU-targeted
healthcare services should be ones which are feasible, rather than the forced use of a
particular design known to be highly methodologically robust (Sanson-Fisher,
Bonevski, Green, & DEste, 2007). van Beek (2012) argues that the lack of high
level research evidence does not necessarily equate to evidence of ineffectiveness
and that the quest for high level evidence should not hinder support for the quality
182

Chapter 8
services that targeted PHC facilities appear to deliver. The case study approach
supported by a literature review, although not robust methodologically, allows
establishment of the fact that by offering PHC services tailored to IDUs needs and
suited to their lifestyle these targeted PHC facilities become accessible and
acceptable. On this backdrop, the retrospective study of RHMCs efforts in HCV
treatment assessment and AVT commencement, and the description of a novel
approach of assessing reliability of sensitive information that IDUs provide in
targeted PHC services, are important steps forward and make an important
contribution to the literature.

8.9 Conclusion
The available evidence suggests there is an ongoing need for targeted PHC services.
For IDUs, service utilisation is often determined by convenience, immediate
satisfaction and respect, unless the perceived need for services is very high. But
certainly the final shape of any facility aiming to service IDUs will be influenced
by local variables. Nonetheless, a number of common elements can be identified,
such as a harm reduction focus, suitable locations and drop-in arrangements. These
approaches are crucial irrespective of the settings of the IDU-targeted PHC service.
Tailored healthcare together with a particular focus on client convenience are other
key aspects that are pivotal to any success achieved by these targeted PHC services.

Replication of these services has lead to the perceived development of a separate

healthcare platform for IDUs, although seemingly beneficial, this separation may
have far reaching implications for IDUs care in the conventional healthcare setting,

183

Chapter 8
and which is in no way desirable. If conventional healthcare services evolve to offer
safe and accessible environments which attract IDUs, targeted healthcare services
may become unnecessary. However, this time is yet to come; to address the
knowledge gaps in this area of intervention, to help guide investment, and system
development, and to improve service provision, large scale and rigorously designed
research, tailored to the community setting is still required. Ideally, however, such
trials should be tailored to the community setting to ensure both effectiveness and
efficacy of the evaluations. In the mean time, it is imperative that IDUs are offered
acceptable and accessible healthcare even whilst awaiting quality evidence to guide
best practice. Consequently, gradual expansion and replication of PHC services for
IDUs are (and should be) continuing, although geographical coverage remains
limited.

184

Chapter 8

REFERENCES
Abouyanni, G., Stevens, L. J., Harris, M. F., Wickes, W. A., Ramakrishna, S. S., Ta, E., et al.
(2000). GP attitudes to managing drug and alcohol-dependent patients: a reluctant
role. Drug and Alcohol Review, 19, 165-170.
Aceijas, C., Oppenheimer, E., Stimson, G. V., Ashcroft, R. E., Matic, S., & Hickman, M.
(2006). Antiretroviral treatment for injecting drug users in developing and transitional
countries 1 year before the end of the "Treating 3 million by 2005. Making it happen.
The WHO strategy" ("3 by 5"). Addiction, 101, 1246-1253.
Ahern, J., Stuber, J., & Galea, S. (2007). Stigma, discrimination and the health of illicit drug
users. Drug and Alcohol Dependence, 88, 188-196.
Aitken, C. K., & Higgs, P. (2002). Severe vein damage caused by Temezepam injecting.
Australian and New Zealand Journal of Public Health, 26, 79.
Albini, T. A., Sun, R. L., Holz, E. R., Khurana, R. N., & Rao, N. A. (2007). Lemon juice and
Candida endophthalmitis in crack-cocaine misuse. British Journal of Ophthalmology,
91, 702-703.
Alter, M. J. (2002). Prevention of spread of hepatitis C. Hepatology, 36, S93-98.
Alter, M. J. (2003). Epidemiology and prevention of hepatitis B. Seminars in Liver Disease,
23, 39-46.
Alter, M. J. (2007). Epidemiology of hepatitis C virus infection. World Journal of
Gastroenterology, 13, 2436-2441.
Altet-Gomez, M. N., Alcaide, J., Godoy, P., Romero, M. A., & Hernandez del Rey, I. (2005).
Clinical and epidemiological aspects of smoking and tuberculosis: a study of 13,038
cases. International Journal of Tuberculosis and Lung Disease, 9, 430-436.

185

Chapter 8
Altice, F. L., Bruce, R. D., Walton, M. R., & Buitrago, M. I. (2005). Adherence to hepatitis B
virus vaccination at syringe exchange sites. Journal of Urban Health, 82, 151-161.
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental
disorders - fourth edition (DSM-IV). Washington D. C.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental
disorders, 4th ed., text revision (DSM-IV-TR). Washington, DC.
Amin, J., Law, M. G., Bartlett, M., Kaldor, J. M., & Dore, G. J. (2006). Causes of death after
diagnosis of hepatitis B or hepatitis C infection: a large community-based linkage
study. Lancet, 368, 938-945.
Anand, B. S., Currie, S., Dieperink, E., Bini, E. J., Shen, H., Ho, S. B., et al. (2006). Alcohol
use and treatment of hepatitis C virus: results of a national multicenter study.
Gastroenterology, 130, 1607-1616.
Anex. (2005). Primary Health Care. Bulletin (Vol. 4). Australia.
Ansari, Z. (2007). A review of literature on access to primary health care. Australian Journal
of Primary Health, 13, 80-95.
Arai, L., Britten, N., Popay, J., Roberts, H., Petticrew, M., Rodgers, M., et al. (2007). Testing
methodological developments in the conduct of narrative synthesis: a demonstration
review of research on the implementation of smoke alarm interventions. Evidence and
Policy, 3, 361-383.
Archer, J., Bower, P., Gilbody, S., Lovell, K., Richards, D., Gask, L., et al. (2012).
Collaborative care for depression and anxiety problems. Cochrane Database
Systematic Reviews, 10, CD006525.
Arora, S., Thornton, K., Murata, G., Deming, P., Kalishman, S., Dion, D., et al. (2011).
Outcomes of treatment for hepatitis C virus infection by primary care providers. New
England Journal of Medicine, 364, 2199-2207.

186

Chapter 8
Arponen, A., Brummer-Korvenkontio, H., Liitsola, K., & Salminen, M. (2008). Trust and
free will as the keys to success for the low threshold health service centers (LTHSC),
National Public Health Institute, Helsinki. Retrieved 27 December 2009 from
http://www.ktl.fi/attachments/suomi/julkaisut/julkaisusarja_b/2008/2008b24.pdf.
Helsinki: National Public Health Institute, Finland.
Arseneault, L., Cannon, M., Witton, J., & Murray, R. M. (2004). Causal association between
cannabis and psychosis: examination of the evidence. British Journal of Psychiatry,
184, 110-117.
ASHM. (2012). Decision-making in HCV.
http://www.ashm.org.au/default2.asp?active_page_id=133. Sydney.
Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine. Acute
pain

management:

scientific

evidence.

2nd

ed.

2005,

update

2007.

http://www.anzca.edu.au/resources/books-and-publications. Accessed in Sep 2008

Sep.
Australian Bureau of Statistics. 2006 Census QuickStats: Australia.
Australian Crime Commission. Illicit Drug Data Report 2010-11: Heroin.
Australian Government Department of Health and Ageing. Australian Immunisation
Handbook, 9th Edition, Canberra.
Australian Government Department of Human Services. Medicare; Available at:
http://www.humanservices.gov.au/customer/services/medicare/medicare.
Australian Primary Health Care Research Institute. What is primary health care? Retrieved
January

2011

from

http://www.anu.edu.au/aphcri/General/phc_definition.php.

Retrieved January.
Austrlian Government. (2012). MBS Online, Medicare Benefits Schedule - Item 701,
Available

at:

187

Chapter 8
http://www9.health.gov.au/mbs/fullDisplay.cfm?type=item&qt=ItemID&q=701.
(Vol. 2012). Canberra: Department of Health and Ageing.
Ball, A. L., Rana, S., & Dehne, K. L. (1998). HIV prevention among injecting drug users:
responses in developing and transitional countries. Public Health Report, 113 Suppl 1,
170-181.
Bangsberg, D. R., & Moss, A. (1999). When should we delay highly active antiretroviral
therapy? Journal of General Internal Medicine, 14, 446-448.
Barclay, D. M., 3rd, Richardson, J. P., & Fredman, L. (1995). Tuberculosis in the homeless.
Archives of Family Medicine, 4, 541-546.
Barrio, G., De La Fuente, L., Lew, C., Royuela, L., Bravo, M. J., & Torrens, M. (2001).
Differences in severity of heroin dependence by route of administration: the
importance of length of heroin use. Drug and Alcohol Dependence, 63, 169-177.
Bassetti, S., Hoffmann, M., Bucher, H. C., Fluckiger, U., & Battegay, M. (2002). Infections
requiring hospitalization of injection drug users who participated in an injection
opiate maintenance program. Clinical Infectious Diseases, 34, 711-713.
Bergenstrom, A., McLeod, R., Sharma, M., Mesquita, F., Dorabjee, J., Atun, R., et al. (2010).
How much will it cost? Estimation of resource needs and availability for HIV
prevention, treatment and care for people who inject drugs in Asia. International
Journal of Drug Policy, 21, 107-109.
Biglan, A., Ary, D., & Wagenaar, A. C. (2000). The value of interrupted time-series
experiments for community intervention research. Prevention Science, 1, 31-49.
Binks, S., Hoskins, R., Salmon, D., & Benger, J. (2005). Prevalence and healthcare burden of
illegal drug use among emergency department patients. Emergency Medicine Journal,
22, 872-873.

188

Chapter 8
Binswanger, I. A., Kral, A. H., Bluthenthal, R. N., Rybold, D. J., & Edlin, B. R. (2000). High
prevalence of abscesses and cellulitis among community recruited injection drug users
in San Francisco. Clinical Infectious Diseases, 30, 579-581.
Binswanger, I. A., Takahashi, T. A., Bradley, K., Dellit, T. H., Benton, K. L., & Merrill, J. O.
(2008). Drug users seeking emergency care for soft tissue infection at high risk for
subsequent hospitalization and death. Journal of Studies on Alcohol and Drugs, 69,
924-932.
Bluthenthal, R. N., Kral, A. H., Lorvick, J., & Watters, J. K. (1997). Impact of law
enforcement on syringe exchange programs: a look at Oakland and San Francisco.
Medical Anthropology, 18, 6183.
Bogart, L. M., Catz, S. L., Kelly, J. A., & Benotsch, E. G. (2001). Factors influencing
physicians' judgments of adherence and treatment decisions for patients with HIV
disease. Medical Decision Making, 21, 28-36.
Booth, R. E., Watters, J. K., & Chitwood, D. D. (1993). HIV risk-related sex behaviors
among injection drug users, crack smokers, and injection drug users who smoke
crack. American Journal of Public Health, 83, 1144-1148.
Boschini, A., Smacchia, C., Di Fine, M., Schiesari, A., Ballarini, P., Arlotti, M., et al. (1996).
Community-acquired pneumonia in a cohort of former injection drug users with and
without human immunodeficiency virus infection: incidence, etiologies, and clinical
aspects. Clinical Infectious Diseases, 23, 107-113.
Bradley, C. J., & Zarkin, G. A. (1996). Inpatient stays for patients diagnosed with severe
psychiatric disorders and substance abuse. Health Services Research, 31, 387-408.
Bradshaw, C. S., Pierce, L. I., Tabrizi, S. N., Fairley, C. K., & Garland, S. M. (2005).
Screening injecting drug users for sexually transmitted infections and blood borne

189

Chapter 8
viruses using street outreach and self collected sampling. Sexually Transmitted
Infections, 81, 53-58.
Brener, L., von Hippel, W., von Hippel, C., Resnick, I., & Treloar, C. (2010). Perceptions of
discriminatory treatment by staff as predictors of drug treatment completion: utility of
a mixed methods approach. Drug and Alcohol Review, 29, 491-497.
British Medical Association NHS Confederation. (2003). Investing in general practice: the
new general medical services contract. London.
Bruce, R. D. (2012). One stop shopping bringing services to drug users. International
Journal of Drug Policy, 23, 104.
Burris, S., & Davis, C. S. (2008). Blueprint for reforming access to therapeutic opioids.
Beasley School of Law, Temple University: Center for Health Law, Policy and
Practice.
Bux, D. A., Lamb, R. J., & Iguchi, M. Y. (1995). Cocaine use and HIV risk behavior in
methadone maintenance patients. Drug and Alcohol Dependence, 37, 29-35.
Campbell, J. V., Garfein, R. S., Thiede, H., Hagan, H., Ouellet, L. J., Golub, E. T., et al.
(2007). Convenience is the key to hepatitis A and B vaccination uptake among young
adult injection drug users. Drug and Alcohol Dependence, 91 Suppl 1, S64-72.
Carr, S., Goldberg, D. J., Elliott, L., Green, S., Mackie, C., & Gruer, L. (1996). A primary
health care service for Glasgow street sex workers--6 years experience of the "drop-in
centre', 1989-1994. AIDS Care, 8, 489-497.
Carroll, J. (1993). Attitudes of professionals to drug abusers. British Journal of Nursing, 2,
705-711.
Carroll, K. M., & Rounsaville, B. J. (1992). Contrast of treatment-seeking and untreated
cocaine abusers. Archives of General Psychiatry, 49, 464-471.

190

Chapter 8
Celentano, D. D., Galai, N., Sethi, A. K., Shah, N. G., Strathdee, S. A., Vlahov, D., et al.
(2001). Time to initiating highly active antiretroviral therapy among HIV-infected
injection drug users. AIDS, 15, 1707-1715.
Celentano, D. D., Vlahov, D., Cohn, S., Shadle, V. M., Obasanjo, O., & Moore, R. D. (1998).
Self-reported antiretroviral therapy in injection drug users. JAMA, 280, 544-546.
Centers for Disease Control and Prevention. (2010). Morbidity and Mortality Weekly Report.
59, 1488-1491.
Chandrasekar, P. H., & Narula, A. P. (1986). Bone and joint infections in intravenous drug
abusers. Reviews of Infectious Diseases, 8, 904-911.
Chermack, S. T., Murray, R. L., Walton, M. A., Booth, B. A., Wryobeck, J., & Blow, F. C.
(2008). Partner aggression among men and women in substance use disorder
treatment: correlates of psychological and physical aggression and injury. Drug and
Alcohol Dependence, 98, 35-44.
Cherubin, C. E., & Sapira, J. D. (1993). The medical complications of drug addiction and the
medical assessment of the intravenous drug user: 25 years later. Annals of Internal
Medicine, 119, 1017-1028.
Chitwood, D., & Comerford, M. (1990). Drugs, sex and AIDS risk. American Behavioral
Scientist, 22, 465-477.
Chitwood, D. D., McBride, D. C., French, M. T., & Comerford, M. (1999). Health care need
and utilization: a preliminary comparison of injection drug users, other illicit drug
users, and nonusers. Substance Use and Misuse, 34, 727-746.
Chitwood, D. D., McBride, D. C., Metsch, L. R., Comerford, M., & McCoy, C. B. (1998). A
comparison of the need for health care and use of health care by injection drug users,
other chronic drug users, and non-users. American Behavioral Scientist, 41, 11071122.

191

Chapter 8
Cochrane Effective Practice and Organisation of Care Group. (2003). The data collection
checklist.
Coffin, P. O., Galea, S., Ahern, J., Leon, A. C., Vlahov, D., & Tardiff, K. (2003). Opiates,
cocaine and alcohol combinations in accidental drug overdose deaths in New York
City, 1990-98. Addiction, 98, 739-747.
Cohen, M. S., Hoffman, I. F., Royce, R. A., Kazembe, P., Dyer, J. R., Daly, C. C., et al.
(1997). Reduction of concentration of HIV-1 in semen after treatment of urethritis:
implications for prevention of sexual transmission of HIV-1. AIDSCAP Malawi
Research Group. Lancet, 349, 1868-1873.
Commonwealth Bank of Australia. Currency Converter. Accessed in November 2012.
Available

at:

http://service.commbank.com.au/personal/international/tools-and-

calculators/foreign-exchange-calculator/foreign-exchange-calculator.aspx.
Commonwealth of Australia. (2007). Illicit drug use in Australia: Epidemiology, use patterns
and associated harm. J. Ross (Ed.), (Vol. 2nd Edition). Sydney: National Drug and
Alcohol Research Centre.
Creese, A., & Parker, D. (1994). Cost analysis in primary health care. Geneva: World Health
Organization.
Crofts, N., & Aitken, C. K. (1997). Incidence of bloodborne virus infection and risk
behaviours in a cohort of injecting drug users in Victoria, 1990-1995. Medical
Journal of Australia, 167, 17-20.
Cromie, S. L., Jenkins, P. L., Bowden, D. S., & Dudley, F. J. (1996). Chronic heaptitis C:
effect of alcohol on hepatitic activity and viral titre. Journal of Hepatology, 25, 821826.

192

Chapter 8
Cronquist, A., Edwards, V., Galea, S., Latka, M., & Vlahov, D. (2001). Health care
utilization among young adult injection drug users in Harlem, New York. Journal of
Substance Abuse, 13, 17-27.
Crowne, D. P., & Marlowe, D. (1960). A new scale of social desirability independent of
psychopathology. Journal of Consulting Psychology, 24, 349-354.
Darke, S., & Hall, W. (2003). Heroin overdose: research and evidence-based intervention.
Journal of Urban Health, 80, 189-200.
Darke, S., & Kaye, S. (2003). Cocaine-related fatalities in New South Wales, Australia,
1993-2000. NDARC Technical Report 171. Sydney: National Drug and Alcohol
Research Centre.
Darke, S., & Kaye, S. (2004). Attempted suicide among injecting and noninjecting cocaine
users in Sydney, Australia. Journal of Urban Health, 81, 505-515.
Darke, S., Kaye, S., McKetin, R., & Duflou, J. (2007). Physical and psychological harms of
psychostimulant use. (Vol. Technical Report No. 286). Sydney: National Drug and
Alcohol Research Centre, University of New South Wales, New South Wales,
Australia.
Darke, S., Kaye, S., McKetin, R., & Duflou, J. (2008). Major physical and psychological
harms of methamphetamine use. Drug and Alcohol Review, 27, 253-262.
Darke, S., & Ross, J. (1997). Polydrug dependence and psychiatric comorbidity among
heroin injectors. Drug and Alcohol Dependence, 48, 135-141.
Darke, S., Ross, J., & Hall, W. (1996). Overdose among heroin users in Sydney, Australia: I.
Prevalence and correlates of non-fatal overdose. Addiction, 91, 405-411.
Darke, S., Ross, J., Teesson, M., Ali, R., Cooke, R., Ritter, A., et al. (2005). Factors
associated with 12 months continuous heroin abstinence: findings from the Australian

193

Chapter 8
Treatment Outcome Study (ATOS). Journal of Substance Abuse Treatment, 28, 255263.
Darke, S., Ross, J., Teesson, M., & Lynskey, M. (2003). Health service utilization and
benzodiazepine use among heroin users: findings from the Australian Treatment
Outcome Study (ATOS). Addiction, 98, 1129-1135.
Davis, G. L., & Rodrigue, J. R. (2001). Treatment of chronic hepatitis C in active drug users.
New England Journal of Medicine, 345, 215-217.
Day, C., & Dolan, K. (2006). Correlates of hepatitis C testing among heroin injectors in
Sydney. Health Promotion Journal of Australia, 17, 70-72.
Day, C., Ross, J., & Dolan, K. (2003). Hepatitis C-related discrimination among heroin users
in Sydney: drug user or hepatitis C discrimination? Drug and Alcohol Review, 22, 317
- 321.
Day, C., & Topp, L. (2011). Commentary on Turner et al. (2011): Significant global scale-up
of harm reduction interventions and pragmatic research approaches needed to prevent
hepatitis C transmission. Addiction, 106, 1989-1990.
Day, C., Topp, L., Rouen, D., Darke, S., Hall, W., & Dolan, K. (2003). Decreased heroin
availability in Sydney in early 2001. Addiction, 98, 93-95.
Day, C., White, B., Dore, G. J., van Beek, I., Rodgers, C., Cunningham, P., et al. (2010).
Hepatitis B virus among injecting drug users in Sydney, Australia: prevalence,
vaccination and knowledge of status. Drug and Alcohol Dependence, 108, 134-137.
Day, C., White, B., Ross, J., & Dolan, K. (2003). Poor knowledge and low coverage of
hepatitis B vaccination among injecting drug users in Sydney. Australian and New
Zealand Journal of Public Health, 27, 558.

194

Chapter 8
Day, C., White, B., Thein, H. H., Doab, A., Dore, G. J., Bates, A., et al. (2008). Experience of
hepatitis C testing among injecting drug users in Sydney, Australia. AIDS Care, 20,
116-123.
Day, C. A., Islam, M. M., White, A., Reid, S. E., Hayes, S., & Haber, P. S. (2011).
Development of a nurse-led primary healthcare service for injecting drug users in
inner-city Sydney. Australian Journal of Primary Health, 17, 10-15.
de la Haye, B., Wild, S. H., Stevenson, J., Johnston, F., Blatchford, O., & Laurenson, I. F.
(2012). Tuberculosis and alcohol misuse in Scotland: a population-based study using
enhanced surveillance data. International Journal of Tuberculosis and Lung Disease,
16, 886-890.
Deacon, R. M., Topp, L., Wand, H., Day, C. A., Rodgers, C., Haber, P. S., et al. (2012).
Correlates of hepatitis B status among injecting drug users in Sydney, Australia.
Journal of Urban Health, 89, 769-778.
Deck, D., & Carlson, M. J. (2004). Access to publicly funded methadone maintenance
treatment in two western states. Journal of Behavioral Health Services and Research,
31, 164-177.
Degenhardt, L., & Barker, B. (2003). Investigating trends in cocaine and methamphetamine
mentions in accidental drug-induced dealths in Australia 1997-2002. Sydney:
National Drug and Alcohol Research Centre, University of New South Wales.
Degenhardt, L., Black, E., Breen, C., Bruno, R., Kinner, S., Roxburgh, A., et al. (2006).
Trends in morphine prescriptions, illicit morphine use and associated harms among
regular injecting drug users in Australia. Drug and Alcohol Review, 25, 403-412.
Degenhardt, L., Mathers, B., Vickerman, P., Rhodes, T., Latkin, C., & Hickman, M. (2010).
Prevention of HIV infection for people who inject drugs: why individual, structural,
and combination approaches are needed. Lancet, 376, 285-301.

195

Chapter 8
Deiss, R. G., Rodwell, T. C., & Garfein, R. S. (2009). Tuberculosis and illicit drug use:
review and update. Clinical Infectious Diseases, 48, 72-82.
Del Giudice, P. (2004). Cutaneous complications of intravenous drug abuse. British Journal
of Dermatology, 150, 1-10.
Des Jarlais, D. C., McKnight, C., Goldblatt, C., & Purchase, D. (2009). Doing harm reduction
better: syringe exchange in the United States. Addiction, 104, 1441-1446.
Des Jarlais, D. C., Paone, D., Milliken, J., Turner, C. F., Miller, H., Gribble, J., et al. (1999).
Audio-computer interviewing to measure risk behaviour for HIV among injecting
drug users: a quasi-randomised trial. Lancet, 353, 1657-1661.
Doab, A., Treloar, C., & Dore, G. J. (2005). Knowledge and attitudes about treatment for
hepatitis C virus infection and barriers to treatment among current injection drug users
in Australia. Clinical Infectious Diseases, 40 Suppl 5, S313-320.
Donoghoe, M. C., Verster, A. D., Mathers, B., & Secretariat of the Reference Group to the
United Nations on HIV and injecting drug use. (2009). WHO, UNODC, UNAIDS
technical guide for countries to set targets for universal access to HIV prevention,
treatment and care for injecting drug users. B. Malhotra (Ed.). Geneva.
Dore, G., & Sweeting, M. (2006). Drug-induced psychosis associated with crystalline
methamphetamine. Australas Psychiatry, 14, 86-89.
Dore, G. J. (2007). Enhancing hepatitis C treatment uptake and outcomes for injection drug
users. Hepatology, 45, 3-5.
Dore, G. J., Freeman, A. J., Law, M., & Kaldor, J. M. (2002). Is severe liver disease a
common outcome for people with chronic hepatitis C? Journal of Gastroenterology
and Hepatology, 17, 423-430.
Dore, G. J., Law, M., MacDonald, M., & Kaldor, J. M. (2003). Epidemiology of hepatitis C
virus infection in Australia. Journal of Clinical Virology, 26, 171-184.

196

Chapter 8
Drobniewski, F. A., Balabanova, Y. M., Ruddy, M. C., Graham, C., Kuznetzov, S. I.,
Gusarova, G. I., et al. (2005). Tuberculosis, HIV seroprevalence and intravenous drug
abuse in prisoners. European Respiratory Journal, 26, 298-304.
Drumm, R. D., McBride, D. C., Metsch, L., Neufeld, M., & Sawatsky, A. (2005). Im a
health nut!, Street drug users accounts of self-care strategies. Journal of Drug Issues,
35, 607-629.
Drumm, R. D., McBride, D. C., Metsch, L., Page, J. B., Dickerson, D., & Jones, B. (2003).
The rock always comes first: drug users accounts about using formal health care.
Journal of Psychoactive Drugs, 35, 461-469.
Drummond, M. F., Sculpher, M. J., Torrance, G. W., O'brien, B. J., & Stoddart, G. L. (2005).
Methods for the economic evaluation of health care programmes. New York: Oxford
University Press.
Dwyer, R., Topp, L., Maher, L., Power, R., Hellard, M., Walsh, N., et al. (2009). Prevalences
and correlates of non-viral injecting-related injuries and diseases in a convenience
sample of Australian injecting drug users. Drug and Alcohol Dependence, 100, 9-16.
Eakin, J. M., & Mykhalovskiy, E. (2003). Reframing the evaluation of qualitative health
research: reflections on a review of appraisal guidelines in the health sciences.
Journal of Evaluation in Clinical Practice, 9, 187-194.
EMCDDA. Direct Aid and Support Unit of OKANA. Retrieved 20 December 2009 from
http://www.emcdda.europa.eu/modules/wbs/dsp_print_project_description.cfm?proje
ct_id=2647.
EMCDDA. Low threshold service Ganslwirt, Austria. Retrieved 24 December 2009 from
http://www.emcdda.europa.eu/modules/wbs/dsp_print_project_description.cfm?proje
ct_id=5078.

197

Chapter 8
EMCDDA. Merchant's Quay health promotion unit. Retrieved 24 December 2009 from
http://www.emcdda.europa.eu/modules/wbs/dsp_print_project_description.cfm?proje
ct_id=1483.
EMCDDA. Mountview/Blakestown Community Drug Team Ltd. Retrieved 20 December
2009

from

http://www.emcdda.europa.eu/modules/wbs/dsp_print_project_description.cfm?proje
ct_id=5918.
EMCDDA. (2009e). Polydrug use: patterns and responses. European Monitoring Centre for
Drugs and Drug Addiction.
EMCDDA. A syringe exchange programme for HIV prevention among intravenous drug
users

in

Malm,

Sweden.

Retrieved

20

December

2009

from

http://www.emcdda.europa.eu/modules/wbs/dsp_print_project_description.cfm?proje
ct_id=371.
Erfan, S., Hashim, A. H., Shaheen, M., & Sabry, N. (2010). Effect of comorbid depression on
substance use disorders. Substance Abuse, 31, 162-169.
Falck, R. S., Wang, J., Carlson, R. G., & Siegal, H. A. (1997). Factors influencing condom
use among heterosexual users of injection drugs and crack cocaine. Sexually
Transmitted Diseases, 24, 204-210.
Federman, A. D., & Arnsten, J. H. (2007). Primary care affiliations of adults in a methadone
program with onsite care. Journal of Addictive Diseases, 26, 27-34.
Fernandez, J., McNeill, C., Haskew, M., & Orr, T. (2006). Low threshold: a future model for
drug service provision? An evaluation of the model used in South Islington Drug
Services. Journal of Research in Nursing, 11, 42-46.
Ferran, E., Barron, C., & Chen, T. (2002). Psychosis. Western Journal of Medicine, 176, 263266.

198

Chapter 8
Ford, C. (2012). Primary care is the best place to care for drug users. International Journal of
Drug Policy, 23, 106.
Francois, G., Hallauer, J., & Van Damme, P. (2002). Hepatitis B vaccination: how to reach
risk groups. Vaccine, 21, 1-4.
French, M. T., McGeary, K. A., Chitwood, D. D., & McCoy, C. B. (2000). Chronic illicit
drug use, health services utilization and the cost of medical care. Social Science and
Medicine, 50, 17031713.
Freund, P. D., & Hawkins, D. W. (2004). What street people reported about service access
and drug treatment. Journal of Health and Socical Policy, 18, 87-93.
Friedman, E. (1994). Money isn't everything. Nonfinancial barriers to access. Journal of
American Medical Association, 271, 1535-1538.
Friedman, H., Newton, C., & Klein, T. W. (2003). Microbial infections, immunomodulation,
and drugs of abuse. Clinical Microbiology Reviews, 16, 209-219.
Friedmann, P. D., McCullough, D., & Saitz, R. (2001). Screening and intervention for illicit
drug abuse: a national survey of primary care physicians and psychiatrists. Archives of
Internal Medicine, 161, 248-251.
Friedmann, P. D., Zhang, Z., Hendrickson, J., Stein, M. D., & Gerstein, D. R. (2003). Effect
of primary medical care on addiction and medical severity in substance abuse
treatment programs. Journal of General Internal Medicine, 18, 1-8.
Galdas, P. M., Cheater, F., & Marshall, P. (2005). Men and health help-seeking behaviour:
literature review. Journal of Advanced Nursing, 49, 616-623.
Gerada, C., Orgel, M., & Strang, J. (1992). Health clinics for problem drug misusers. Health
Trends, 24, 68-69.

199

Chapter 8
Gerbert, B., Bronstone, A., McPhee, S., Pantilat, S., & Allerton, M. (1998). Development and
testing of an HIV-risk screening instrument for use in health care settings. American
Journal of Preventive Medicine, 15, 103-113.
Ghanem, K. G., Hutton, H. E., Zenilman, J. M., Zimba, R., & Erbelding, E. J. (2005). Audio
computer assisted self interview and face to face interview modes in assessing
response bias among STD clinic patients. Sexually Transmitted Infections, 81, 421425.
Gibson, A., Randall, D., & Degenhardt, L. (2011). The increasing mortality burden of liver
disease among opioid-dependent people: cohort study. Addiction, 106, 2186-2192.
Giudice, P. D. (2004). Cutaneous complications of intravenous drug abuse. British Journal of
Dermatology, 150, 1-10.
Gonzalez Castro, F., Barrington, E. H., Walton, M. A., & Rawson, R. A. (2000). Cocaine and
methamphetamine: differential addiction rates. Psychology of Addictive Behaviors,
14, 390-396.
Gordon, R. J., & Lowy, F. D. (2005). Bacterial infections in drug users. New England
Journal of Medicine, 353, 1945-1954.
Gossop, M., Griffiths, P., Powis, B., & Strang, J. (1992). Severity of dependence and route of
administration of heroin, cocaine and amphetamines. British Journal of Addiction, 87,
1527-1536.
Gourlay, D. L., Heit, H. A., & Almahrezi, A. (2005). Universal precautions in pain medicine:
a rational approach to the treatment of chronic pain. Pain Medicine, 6, 107-112.
Grau, L. E., Arevalo, S., Catchpool, C., & Heimer, R. (2002). Expanding harm reduction
services through a wound and abscess clinic. American Journal of Public Health, 92,
1915-1917.

200

Chapter 8
Grebely, J., Conway, B., Raffa, J. D., Lai, C., Krajden, M., & Tyndall, M. W. (2006).
Hepatitis C virus reinfection in injection drug users. Hepatology, 44, 1139-1145.
Grebely, J., Genoway, K. A., Raffa, J. D., Dhadwal, G., Rajan, T., Showler, G., et al. (2008).
Barriers associated with the treatment of hepatitis C virus infection among illicit drug
users. Drug and Alcohol Dependence, 93, 141-147.
Grebely, J., Raffa, J. D., Lai, C., Krajden, M., Kerr, T., Fischer, B., et al. (2009). Low uptake
of treatment for hepatitis C virus infection in a large community-based study of inner
city residents. Journal of Viral Hepatitis, 16, 352-358.
Greenwood, J. (1992). Unpopular patients GPs' attitudes to drug users. Druglink, July/August,
8-10.
Griffith, C. C., Raval, J. S., & Nichols, L. (2012). Intravascular Talcosis due to Intravenous
Drug Use Is an Underrecognized Cause of Pulmonary Hypertension. Pulmonary
Medicine, 2012, 617531.
Grimshaw, J., Campbell, M., Eccles, M., & Steen, N. (2000). Experimental and quasiexperimental designs for evaluating guideline implementation strategies. Fam Pract,
17 Suppl 1, S11-16.
Gruen, R. L., Weeramanthri, T. S., Knight, S. E., & Bailie, R. S. (2004). Specialist outreach
clinics in primary care and rural hospital settings. Cochrane Database Systematic
Reviews, CD003798.
Gu, J., Lau, J. T., Chen, H., Chen, X., Liu, C., & Liu, J. (2010). Mental health and
interpersonal factors associated with HIV-related risk behaviors among noninstitutionalized female injection drug users who are also sex workers in China.
Women Health, 50, 20-36.

201

Chapter 8
Gulliford, M., Figueroa-Munoz, J., Morgan, M., Hughes, D., Gibson, B., Beech, R., et al.
(2002). What does 'access to health care' mean? Journal of Health Services Research
and Policy, 7, 186-188.
Guyatt, G., Oxman, A. D., Akl, E. A., Kunz, R., Vist, G., Brozek, J., et al. (2011). GRADE
guidelines: 1. Introduction-GRADE evidence profiles and summary of findings tables.
Journal of Clinical Epidemiology, 64, 383-394.
Haber, P. S., Demirkol, A., Lange, K., & Murnion, B. (2009). Management of injecting drug
users admitted to hospital. Lancet, 374, 1284-1293.
Hall, W., & Degenhardt, L. (2010). What are the policy implications of the evidence on
cannabis use and psychosis? Addiction, 105, 1332-1333.
Hall, W., & Hando, J. (1994). Route of administration and adverse effects of amphetamine
use among young adults in Syndney, Australia. Drug and Alcohol Review, 13, 277284.
Hall, W., Teesson, M., Lynskey, M., & Degenhardt, L. (1999). The 12-month prevalence of
substance use and ICD-10 substance use disorders in Australian adults: findings from
the National Survey of Mental Health and Well-Being. Addiction, 94, 1541-1550.
Hallforsa, D., Khatapoushb, S., Kadushinb, C., Watsonb, K., & Saxeb, L. (2000). A
comparison of paper vs computer-assisted self interview for school alcohol, tobacco,
and other drug surveys. Evaluation and Program Planning, 23, 149-155.
Hamers, F. F., & Downs, A. M. (2003). HIV in central and eastern Europe. Lancet, 361,
1035-1044.
Harris, H. W., & Young, D. M. (2002). Care of injection drug users with soft tissue infections
in San Francisco, California. Archives of Surgery, 137, 1217-1222.
Hartmann, D. P. (1977). Considerations in the choice of interobserver reliability estimates.
Journal of Applied Behavior Analysis, 10, 103-116.

202

Chapter 8
Havard, A., Teesson, M., Darke, S., & Ross, J. (2006). Depression among heroin users: 12Month outcomes from the Australian Treatment Outcome Study (ATOS). Journal of
Substance Abuse Treatment, 30, 355-362.
Hawkins, N. G., Sanson-Fisher, R. W., Shakeshaft, A., D'Este, C., & Green, L. W. (2007).
The multiple baseline design for evaluating population-based research. American
Journal of Preventive Medicine, 33, 162-168.
Heimer, R., Dasgupta, N., Irwin, K. S., Kinzly, M., Harvey, A. P., Givens, A., et al. (2012).
Chronic pain, addiction severity, and misuse of opioids in Cumberland County,
Maine. Addictive Behavior, 37, 346-349.
Heinzerling, K. G., Kral, A. H., Flynn, N. M., Anderson, R. L., Scott, A., Gilbert, M. L., et al.
(2006). Unmet need for recommended preventive health services among clients of
California syringe exchange programs: implications for quality improvement. Drug
and Alcohol Dependence, 81, 167-178.
Hind, C. R. (1990). Pulmonary complications of intravenous drug misuse. 2. Infective and
HIV related complications. Thorax, 45, 957-961.
Holt, M., Treloar, C., McMillan, K., Schultz, L., Schultz, M., & Bath, N. (2007). Barriers and
incentives to treatment for illicit drug users with mental health comorbidities and
complex vulnerabilities. Canberra: Department of Health and Ageing, Australian
Government.
Hope, V. (2010). Neglected infections, real harms: A global scoping of injection-related
bacterial infections and responses. The Global State of Harm Reduction 2010 (Vol.
Chapter 3.3, pp. 89-95): International Harm Reduction Association.
Hopwood, M., Treloar, C., & Bryant, J. (2006). Hepatitis C and injecting-related
discrimination in New South Wales, Australia. Drugs: education, prevention and
policy, 13, 61-75.

203

Chapter 8
Huff, M., Kinion, E., Kendra, M. A., & Klecan, T. (2006). Self-esteem: a hidden concern in
oral health. Journal of Community Health Nursing, 23, 245-255.
IKHLAS. (2009). The IKHLAS drop-in centre (drug user programme). Retrieved 29
December 2009 from http://www.ptfmalaysia.org/Ikhlas.htm.
International Harm Reduction Association. What is Harm Reduction? A position statement
from the International Harm Reduction Association.
Islam, M. M. (2010). Needle syringe program-based primary health care centers: Advantages
and disadvantages. Journal of Primary Care and Community Health, 1, 100-103.
Islam, M. M., & Conigrave, K. M. (2007a). Increasing prevalence of HIV, and persistent
high-risk behaviours among drug users in Bangladesh: need for a comprehensive
harm reduction programme. Drug and Alcohol Review, 26, 445-454.
Islam, M. M., & Conigrave, K. M. (2007b). Syringe vending machines as a form of needle
syringe programme: Advantages and disadvantages. Journal of Substance Use, 12,
203-212.
Islam, M. M., & Conigrave, K. M. (2008). HIV and sexual risk behaviors among recognized
high-risk groups in Bangladesh: need for a comprehensive prevention program.
International Journal of Infectious Diseases, 12, 363-370.
Islam, M. M., Day, C. A., & Conigrave, K. M. (2010). Harm reduction healthcare: from an
alternative to the mainstream platform? International Journal of Drug Policy, 21,
131-133.
Islam, M. M., Day, C. A., Conigrave, K. M., & Topp, L. (Epub ahead of print). Selfperceived problem alcohol use among opioid substitution treatment clients. Addictive
Behaviors, doi: http://dx.doi.org/10.1016/j.addbeh.2012.12.001.
Islam, M. M., Grummett, S., White, A., Reid, S. E., Day, C. A., & Haber, P. S. (2011). A
primary healthcare clinic in a needle syringe program may contribute to HIV

204

Chapter 8
prevention by early detection of incident HIV in an injecting drug user. Australian
and New Zealand Journal of Public Health, 35, 294-295.
Islam, M. M., Hayes, S., White, A., Day, C., Reid, S., Grummet, S., et al. (2010). Assessment
for hepatitis C treatment and referral uptake by IDUs attending a harm reduction
based primary healthcare. 7th Australian Viral Hepatitis Conference. Melbourne, 6-8
September.
Islam, M. M., Reid, S. E., White, A., Grummett, S., Conigrave, K. M., & Haber, P. S. (2012).
Opportunistic and continuing health care for injecting drug users from a nurse-run
needle syringe program-based primary health-care clinic. Drug and Alcohol Review,
31, 114-115; author reply 116-117.
Islam, M. M., Stern, T., Conigrave, K. M., & Wodak, A. (2008). Client satisfaction and risk
behaviours of the users of syringe dispensing machines: a pilot study. Drug and
Alcohol Review, 27, 13-19.
Islam, M. M., Topp, L., Conigrave, K. M., Beek, I. v., Maher, L., White, A., et al. (2012).
The reliability of sensitive information provided by injecting drug users in a clinical
setting: clinician-administered versus audio computer-assisted self-interviewing
(ACASI). AIDS Care, 24, 1496-1503.
Islam, M. M., Topp, L., Conigrave, K. M., & Day, C. A. (Epub ahed of print). Opioid
substitution therapy clients' preferences for targeted versus general primary healthcare outlets. Drug and Alcohol Review, doi: 10.1111/j.1465-3362.2012.00498.x.
Islam, M. M., Topp, L., Conigrave, K. M., White, A., Haber, P. S., & Day, C. A. (Epub ahead
of print). Are primary health care centres that target injecting drug users attracting and
serving the clients they are designed for? A case study from Sydney, Australia.
International Journal of Drug Policy, doi:10.1016/j.drugpo.2012.06.002.

205

Chapter 8
Islam, M. M., Topp, L., Day, C. A., Dawson, A., & Conigrave, K. M. (2012a). The
accessibility, acceptability, health impact and cost implications of primary healthcare
outlets that target injecting drug users: A narrative synthesis of literature.
International Journal of Drug Policy, 23, 94-102.
Islam, M. M., Topp, L., Day, C. A., Dawson, A., & Conigrave, K. M. (2012b). Primary
healthcare outlets that target injecting drug users: Opportunity to make services
accessible and acceptable to the target group. International Journal of Drug Policy,
23, 109-110.
Islam, M. M., Topp, L., Iversen, J., Day, C. A., Conigrave, K. M., & Lisa Maher on behalf of
the Collaboration of Australian NSPs. (in press). Healthcare utilization and disclosure
of injecting drug use among clients of Australias needle and syringe programs.
Australian and New Zealand Journal of Public Health.
Islam, M. M., Topp, L., White, A., Conigrave, K. M., Reid, S., Grummett, S., et al. (2012).
Linkage into specialist hepatitis C treatment services of injecting drug users attending
a needle syringe program-based primary healthcare centre. Journal of Substance
Abuse Treatment, 43, 440-445.
Iversen, J., Topp, L., & Maher, L. (2011). Australian NSP Survey National Data Report
1995-2010: Prevalence of HIV, HCV and injecting and sexual behaviour among NSP
attendees. Sydney: Kirby Institute for Infection and Immunity in Society, UNSW.
Jennings, T. E., Lucenko, B. A., Malow, R. M., & Devieux, J. G. (2002). Audio-CASI vs
interview method of administration of an HIV/STD risk of exposure screening
instrument for teenagers. International Journal of STD and AIDS, 13, 781-784.
Jensen, S., & Gregersen, M. (1991). Fatal poisoning with intravenously injected methadone
and no fresh injection marks found. International Journal of Legal Medicine, 104,
299-301.

206

Chapter 8
Joe, G. W., & Simpson, D. D. (1995). HIV risks, gender, and cocaine use among opiate users.
Drug and Alcohol Dependence, 37, 23-28.
Kaestner, R. (1999). Does Drug Use Cause Poverty? In F. J. Chaloupka, M. Grossman, W. K.
Bickel & H. Saffer (Eds.), The economic analysis of substance use and abuse: an
integration of econometrics and behavioral economic research: University of
Chicago Press.
Kandel, D. B., Huang, F. Y., & Davies, M. (2001). Comorbidity between patterns of
substance use dependence and psychiatric syndromes. Drug and Alcohol Dependence,
64, 233-241.
Kelly, J. F., & Westerhoff, C. M. (2010). Does it matter how we refer to individuals with
substance-related conditions? A randomized study of two commonly used terms.
International Journal of Drug Policy, 21, 202-207.
Kennedy, C., Neale, J., Barr, K., & Dean, J. (2001). Good practice towards homeless drug
users. Edinburgh: Scottish Homes.
Khawcharoenporn, T., Apisarnthanarak, A., Sungkanuparph, S., Woeltje, K. F., & Fraser, V.
J. (2011). Tuberculin skin test and isoniazid prophylaxis among health care workers in
high tuberculosis prevalence areas. International Journal of Tuberculosis and Lung
Disease, 15, 14-23.
Kimber, J. (2005). Role of the Sydney Medically Supervised Injecting Centre in reducing
injecting drug use-related harm: evaluating accessibility, utilisation, coverage and
selected health impacts. University of New South Wales, Sydney.
Kimber, J., Mattick, R. P., Kaldor, J., van Beek, I., Gilmour, S., & Rance, J. A. (2008).
Process and predictors of drug treatment referral and referral uptake at the Sydney
Medically Supervised Injecting Centre. Drug and Alcohol Review, 27, 602-612.

207

Chapter 8
King, L. A. (1997). Drug content of powders and other illicit preparations in the UK.
Forensic Science International, 85, 135-147.
King, M., & Bruner, G. (2003). Social desirability bias: a neglected aspect of validity testing.
Psychology and Marketing, 17, 79-103.
Knowlton, A. R., Hoover, D. R., Chung, S. E., Celentano, D. D., Vlahov, D., & Latkin, C. A.
(2001). Access to medical care and service utilization among injection drug users with
HIV/AIDS. Drug and Alcohol Dependence, 64, 55-62.
Kohli, R., Lo, Y., Howard, A. A., Buono, D., Floris-Moore, M., Klein, R. S., et al. (2005).
Mortality in an urban cohort of HIV-infected and at-risk drug users in the era of
highly active antiretroviral therapy. Clinical Infectious Diseases, 41, 864-872.
Kopnisky, K. L., Bao, J., & Lin, Y. W. (2007). Neurobiology of HIV, psychiatric and
substance abuse comorbidity research: workshop report. Brain, Behavior, and
Immunity, 21, 428-441.
Kral, A. H., Bluthenthal, R. N., Booth, R. E., & Watters, J. K. (1998). HIV seroprevalence
among street-recruited injection drug and crack cocaine users in 16 US municipalities.
American Journal of Public Health, 88, 108-113.
Kratzmann, M., Mitchell, E., Ware, J., Banach, L., Ward, J., & Ryan, J. (2011). Injecting
drug use and associated harms among Aboriginal Australians. J. Stokes (Ed.).
Canberra: Australian National Council on Drugs.
Kurth, A. E., Martin, D. P., Golden, M. R., Weiss, N. S., Heagerty, P. J., Spielberg, F., et al.
(2004). A comparison between audio computer-assisted self-interviews and clinician
interviews for obtaining the sexual history. Sexually Transmitted Diseases, 31, 719726.
Kwan, L., Ho, C. J., Preston, C., & Le, V. (2008). Puentes clinic: an integrated model for the
primary care of vulnerable populations. The Permanente Journal, 12, 10-15.

208

Chapter 8
Kwong, P. D., Mascola, J. R., & Nabel, G. J. (2012). The changing face of HIV vaccine
research. Journal of International AIDS Society, 15, 17407.
Langrod, J., Lowinson, J., & Ruiz, P. (1981). Methadone treatment and physical complaints:
A clinical analysis. International Journal of the Addictions, 16, 947-952.
Laslett, A. M., Dietze, P., & Dwyer, R. (2008). The oral health of street-recruited injecting
drug users: prevalence and correlates of problems. Addiction, 103, 1821-1825.
Last, J. M. (2001). A dictionary of epidemiology (4th ed.). New York: Oxford University
Press.
Latt, N., Conigrave, K., Saunders, J. B., Marshall, E. J., & Nutt, D. (2009). Addiction
Medicine. Oxford: Oxford University Press.
Lauretta, E., Grau, L. E., Arevalo, S., Catchpool, C., & Heimer, R. (2002). Expanding harm
reduction services through a wound and abscess clinic. American Journal of Public
Health, 92, 1915-1917.
Leigh, B. (1990). The relationship of substance use during sex to high-risk sexual behavior.
Journal of Sex Research, 27, 199-213.
Leigh, B. C., & Stall, R. (1993). Substance use and risky sexual behavior for exposure to
HIV. Issues in methodology, interpretation, and prevention. American Psychology,
48, 1035-1045.
Levin, H. M. (1983). Cost-Effectiveness: A Primer. California: Sage: Beverly Hills
Levine, O. S., Vlahov, D., & Nelson, K. E. (1994). Epidemiology of hepatitis B virus
infections among injecting drug users: seroprevalence, risk factors, and viral
interactions. Epidemiologic Reviews, 16, 418-436.
Liang, H., Wang, X., Chen, H., Song, L., Ye, L., Wang, S. H., et al. (2008).
Methamphetamine enhances HIV infection of macrophages. American Journal of
Pathology, 172, 1617-1624.

209

Chapter 8
Liao, Y., Tang, J., Liu, T., Chen, X., Liu, X., & Hao, W. (2011). A pilot study of life events
and mood disorders: self-report survey in chinese heroin-dependent individuals.
American Journal of Addictions, 20, 337-342.
Limberg, W. (2004). Natural history, treatment and prevention of hepatitis C in injecting drug
users: an overview. L. W. Jager J, Kretzschmar M, Postma M, Wiessing L (Ed.),
Hepatitis C and injecting drug user: impact, costs and policy options. Lisbon,
Portugal: European Monitoring Centre for Drugs and Drug Addiction.
Lindenburg, C. E., Lambers, F. A., Urbanus, A. T., Schinkel, J., Jansen, P. L., Krol, A., et al.
(2011). Hepatitis C testing and treatment among active drug users in Amsterdam:
results from the DUTCH-C project. European Journal of Gastroenterology and
Hepatology, 23, 23-31.
Link, B. G., & Phelan, J. C. (2006). Stigma and its public health implications. Lancet, 367,
528-529.
Link, B. G., Struening, E. L., Neese-Todd, S., Asmussen, S., & Phelan, J. C. (2001). Stigma
as a barrier to recovery: The consequences of stigma for the self-esteem of people
with mental illnesses. Psychiatric Services, 52, 1621-1626.
Linn, R. L., & Slinde, J. A. (1977). The determination of the significance of change between
pre- and posttesting periods. Review of Educational Research, 47, 121-150.
Little, R. J., D'Agostino, R., Cohen, M. L., Dickersin, K., Emerson, S. S., Farrar, J. T., et al.
(2012). The prevention and treatment of missing data in clinical trials. New England
Journal of Medicine, 367, 1355-1360.
Lloyd-Smith, E., Kerr, T., Hogg, R., Li, K., Montaner, J., & Wood, E. (2005). Prevalence and
correlates of abscesses among a cohort of injection drug users. Harm Reduction
Journal, 2.

210

Chapter 8
Lloyd-Smith, E., Wood, E., Zhang, R., Tyndall, M. W., Montaner, J. S., & Kerr, T. (2008).
Risk factors for developing a cutaneous injection-related infection among injection
drug users: a cohort study. BMC Public Health, 8, 405.
Logan, T. K., Cole, J., & Leukefeld, C. (2003). Gender differences in the context of sex
exchange among individuals with a history of crack use. AIDS Education and
Prevention, 15, 448-464.
Longman, C., Lintzeris, N., Temple-Smith, M., & Gilchrist, G. (2011). Methadone and
buprenorphine prescribing patterns of Victorian general practitioners: their first 5
years after authorisation. Drug and Alcohol Review, 30, 355-359.
Longo, L. P., Parran, T., Jr., Johnson, B., & Kinsey, W. (2000). Addiction: part II.
Identification and management of the drug-seeking patient. American Family
Physician, 61, 2401-2408.
Lora-Tamayo, C., Tena, T., & Rodriguez, A. (1994). Cocaine-related deaths. Journal of
Chromatography, A, 674, 217-224.
Louria, D. B., Hensle, T., & Rose, J. (1967). The major medical complications of heroin
addiction. Annals of Internal Medicine, 67, 1-22.
Lucas, P. J., Baird, J., Arai, L., Law, C., & Roberts, H. M. (2007). Worked examples of
alternative methods for the synthesis of qualitative and quantitative research in
systematic reviews. BMC Medical Research Methodology, 7, 4.
Macalino, G. E., Celentano, D. D., Latkin, C., Strathdee, S. A., & Vlahov, D. (2002). Risk
behaviors by audio computer-assisted self-interviews among HIV-seropositive and
HIV-seronegative injection drug users. AIDS Education and Prevention, 14, 367-378.
MacDonald, M., Crofts, N., & Kaldor, J. (1996). Transmission of hepatitis C virus: rates,
routes, and cofactors. Epidemiologic Reviews, 18, 137-148.

211

Chapter 8
Macdonald, V., Dore, G. J., Amin, J., & van Beek, I. (2007). Predictors of completion of a
hepatitis B vaccination schedule in attendees at a primary health care centre. Sexual
Health, 4, 27-30.
MacGregor, R. R., Dunbar, D., & Graziani, A. L. (1994). Tuberculin reactions among
attendees at a

methadone

clinic: relation to infection

with the human

immunodeficiency virus. Clinical Infectious Diseases, 19, 1100-1104.

Macleod, J., Oakes, R., Copello, A., Crome, I., Egger, M., Hickman, M., et al. (2004).
Psychological and social sequelae of cannabis and other illicit drug use by young
people: a systematic review of longitudinal, general population studies. Lancet, 363,
1579-1588.
MacNeil, J., & Pauly, B. (2011). Needle exchange as a safe haven in an unsafe world. Drug
and Alcohol Review, 30, 26-32.
Maher, L., Li, J., Jalaludin, B., Chant, K. G., & Kaldor, J. M. (2007). High hepatitis C
incidence in new injecting drug users: a policy failure? Australian and New Zealand
Journal of Public Health, 31, 30-35.
Maher, L., Swift, W., & Dawson, M. (2001). Heroin purity and composition in Sydney,
Australia. Drug and Alcohol Review, 20, 439-448.
Maranda, M. J., Han, C., & Rainone, G. A. (2004). Crack cocaine and sex. Journal of
Psychoactive Drugs, 36, 315-322.
Marmor, M., Des Jarlais, D. C., Friedman, S. R., Lyden, M., & el-Sadr, W. (1984). The
epidemic of acquired immunodeficiency syndrome (AIDS) and suggestions for its
control in drug abusers. Journal of Substance Abuse Treatment, 1, 237-247.
Martyres, R. F., Clode, D., & Burns, J. M. (2004). Seeking drugs or seeking help? Escalating
"doctor shopping" by young heroin users before fatal overdose. Medical Journal of
Australia, 180, 211-214.

212

Chapter 8
Mathers, B. M., Degenhardt, L., Ali, H., Wiessing, L., Hickman, M., Mattick, R. P., et al.
(2010). HIV prevention, treatment, and care services for people who inject drugs: a
systematic review of global, regional, and national coverage. Lancet, 375, 1014-1028.
Mathers, B. M., Degenhardt, L., Phillips, B., Wiessing, L., Hickman, M., Strathdee, S. A., et
al. (2008). Global epidemiology of injecting drug use and HIV among people who
inject drugs: a systematic review. Lancet, 372, 1733-1745.
Matthews, G., & Dore, G. J. (2006). The epidemiology of HIV and viral hepatitis coinfection.
In S. J. Dore GJ (Ed.), CoinfectionHIV and viral hepatitis: a guide for clinical
management. Available at: http://www.hep.org.au/documents/Coinfection-680KB.pdf
(accessed March, 2012). Sydney: ASHM.
Mauss, S., Berger, F., Goelz, J., Jacob, B., & Schmutz, G. (2004). A prospective controlled
study of interferon-based therapy of chronic hepatitis C in patients on methadone
maintenance. Hepatology, 40, 120-124.
McBride, D., VanBuren, A. H., Terry, Y. M., & Goldstein, B. J. (2000). Depresssion, drug
use and health services need, utilization and cost. In J. A. Levy, R. C. Stephens & D.
C. BcBride (Eds.), Emergency issues of the field of drug abuse in advances in medical
sociology. Stamford, Connecticut: JAI press.
McCabe, S. E., Cranford, J. A., Morales, M., & Young, A. (2006). Simultaneous and
concurrent polydrug use of alcohol and prescription drugs: prevalence, correlates, and
consequences. Journal of Studies on Alcohol, 67, 529-537.
McCoy, C. B., Metsch, L., Chitwood, D. D., & Miles, C. (2001). Drug use and barriers to use
of health care services. Substance Use and Misuse, 36, 789-806.
McCoy, C. B., Metsch, L. R., Chitwood, D. D., Rivers, J. E., McCoy, H. V., & Messiah, S.
(2000). Health services for drug users in an era of managed care: the University of

213

Chapter 8
Miami Community-based Health Services Research Center. In J. J. Levy, D. McBride
& R. Stephens (Eds.), Advances in Medical Sociology (Vol. 7).
McDonald, P. (2002). From streets to sidewalks: developments in primary care services for
injecting drug users. Australian Journal of Primary Health, 8, 65-69.
McGeary, K. A., & French, M. T. (2000). Illicit drug use and emergency room utilization.
Health Services Research, 35, 153-169.
McGuigan, F. J. (1993). Experimental psychology: methods of research: Upper Saddle River,
N.J. : Prentice Hall.
McKeown, A., Matheson, C., & Bond, C. (2003). A qualitative study of GPs' attitudes to
drug misusers and drug misuse services in primary care. Family Practice, 20, 120125.
McKetin, R., Lubman, D. I., Lee, N. M., Ross, J. E., & Slade, T. N. (2011). Major depression
among methamphetamine users entering drug treatment programs. Medical Journal of
Australia, 195, S51-55.
McKetin, R., Ross, J., Kelly, E., Baker, A., Lee, N., Lubman, D. I., et al. (2008).
Characteristics and harms associated with injecting versus smoking methamphetamine
among methamphetamine treatment entrants. Drug and Alcohol Review, 27, 277-285.
McLaren, J. A., Silins, E., Hutchinson, D., Mattick, R. P., & Hall, W. (2010). Assessing
evidence for a causal link between cannabis and psychosis: a review of cohort studies.
International Journal of Drug Policy, 21, 10-19.
McLaughlin, D. F., McKenna, H., & Leslie, J. C. (2000). The perceptions and aspirations
illicit drug users hold toward health care staff and the care they receive. Journal of
Psychiatric and Mental Health Nursing, 7, 435-441.

214

Chapter 8
McLean, S., Bruno, R., Brandon, S., & de Graaff, B. (2009). Effect of filtration on morphine
and particle content of injections prepared from slow-release oral morphine tablets.
Harm Reduction Journal, 6, 37.
McLellan, A. T., Arndt, I. O., Metzger, D. S., Woody, G. E., & O'Brien, C. P. (1993). The
effects of psychosocial services in substance abuse treatment. JAMA, 269, 1953-1959.
McNally, R. J., Bryant, R. A., & Ehlers, A. (2003). Does early psychological intervention
promote recovery from posttraumatic stress? Psychological Science in the Public
Interest, 4, 45-79.
Mehta, S. H., Genberg, B. L., Astemborski, J., Kavasery, R., Kirk, G. D., Vlahov, D., et al.
(2008). Limited uptake of hepatitis C treatment among injection drug users. Journal
of Community Health, 33, 126-133.
Merrill, J. O., Rhodes, L. A., Deyo, R. A., Marlatt, G. A., & Bradley, K. A. (2002). Mutual
mistrust in the medical care of drug users: the keys to the narc cabinet. Journal of
General Internal Medicine, 17, 327-333.
Metsch, L. R., & McCoy, C. B. (1999). Drug treatment experiences: rural and urban
comparisons. Substance Use and Misuse, 34, 763-784.
Metzger, D. S., Koblin, B., Turner, C., Navaline, H., Valenti, F., Holte, S., et al. (2000).
Randomized controlled trial of audio computer-assisted self-interviewing: utility and
acceptability in longitudinal studies. HIVNET Vaccine Preparedness Study Protocol
Team. American Journal of Epidemiology, 152, 99-106.
Miller, N., & Gold, M. (1998). Management of withdrawal syndromes and relapse prevention
in drug and alcohol dependence. American Family Physician, 58, 139-146.
Ministerial Advisory Committee on AIDS Sexual Helath and Hepatitis. (2006). Hepatitis C
virus projections working group: estimates and projections of the hepatitis C virus

215

Chapter 8
epidemic in Australia 2006. Sydney: National Centre in HIV Epidemiology and
Clinical Research, The University of New South Wales.
Monheit, B. (2010). Prescription drug misuse. Australian Family Physician, 39, 540-546.
Monitoring the AIDS Pandemic Network. (2005). MAP Report 2005: drug injection and
HIV/AIDS in Asia. (Vol. 9). Bangkok: MAP Network.
Moore, T. H., Zammit, S., Lingford-Hughes, A., Barnes, T. R., Jones, P. B., Burke, M., et al.
(2007). Cannabis use and risk of psychotic or affective mental health outcomes: a
systematic review. Lancet, 370, 319-328.
Mor, V., Fleishman, J. A., Dresser, M., & Piette, J. (1992). Variation in health service use
among HIV-infected patients. Medical Care, 30, 17-29.
Morrison, A., Elliott, L., & Gruer, L. (1997). Injecting-related harm and treatment-seeking
behaviour among injecting drug users. Addiction, 92, 1349-1352.
Morrison, C. L., & Ruben, S. M. (1995). The development of healthcare services for drug
misusers and prostitutes. Postgraduate Medical Journal, 71, 593-597.
MSIC Evaluation Committee. (2003). Final report of the evaluation of the Sydney Medically
Supervised Injecting Centre. Sydney.
Mund, P. A., Heller, D., Meissner, P., Matthews, D. W., Hill, M., & Cunningham, C. O.
(2008). Delivering care out of the box: the evolution of an HIV harm reduction
medical program. Journal of Health Care for Poor and Underserved, 19, 944-951.
Murphy, E. L., DeVita, D., Liu, H., Vittinghoff, E., Leung, P., Ciccarone, D. H., et al. (2001).
Risk factors for skin and soft-tissue abscesses among injection drug users: a casecontrol study. Clinical Infectious Diseases, 33, 35-40.
Murrill, C. S., Weeks, H., Castrucci, B. C., Weinstock, H. S., Bell, B. P., Spruill, C., et al.
(2002). Age-specific seroprevalence of HIV, hepatitis B virus, and hepatitis C virus

216

Chapter 8
infection among injection drug users admitted to drug treatment in 6 US cities.
American Journal of Public Health, 92, 385-387.
Myers, B. J. (2012). Primary health care for people who inject drugs in low and middle
income countries: A response to "The accessibility, acceptability, health impact and
cost implications of primary healthcare outlets that target injecting drug users.".
International Journal of Drug Policy, 23, 105-106.
Nasiri, B. (2012). Windows of opportunity: adapting services to the needs of people who
inject drugs. International Journal of Drug Policy, 23, 107.
National Health and Medical Research Council. (2000). How to use the evidence: assessment
and application of scientific evidence. Canberra: National Health and Medical
Research Council.
NCHECR. (2007). HIV/AIDS, viral hepatitis and sexually transmissible infections in
Australia: Annual Surveillance Report 2005. Sydney.
NCHECR. (2010). Australian NSP Survey National Data Report 2005-2009. Sydney:
National Centre in HIV Epidemiology and Clinical Research, The University of New
South Wales, Sydney, NSW.
Neale, J., Sheard, L., & Tompkins, C. N. (2007). Factors that help injecting drug users to
access and benefit from services: A qualitative study. Subst Abuse Treat Prev Policy,
2, 31.
Neale, J., Tompkins, C., & Sheard, L. (2008). Barriers to accessing generic health and social
care services: a qualitative study of injecting drug users. Health and Social Care in
the Community, 16, 147-154.
Nederhof, A. J. (1985). Methods of coping with social desirability bias: a review. European
Journal of Social Psychology, 15, 263-280.

217

Chapter 8
Nelson, P. K., Mathers, B. M., Cowie, B., Hagan, H., Des Jarlais, D., Horyniak, D., et al.
(2011). Global epidemiology of hepatitis B and hepatitis C in people who inject
drugs: results of systematic reviews. Lancet, 378, 571-583.
Nguyen, A. T., Nguyen, T. H., Pham, K. C., Le, T. G., Bui, D. T., Hoang, T. L., et al. (2004).
Intravenous drug use among street-based sex workers: a high-risk behavior for HIV
transmission. Sexually Transmitted Diseases, 31, 15-19.
NHS Employers. (2005). National enhanced service. Patients suffering from drug misuse.
England.
Noel, L., Fischer, B., Tyndall, M., Brader, R., Rehm, J., Brissette, S., et al. (2006). Health and
social services accessed by a cohort of illicit opioid users outside of treatment.
Canadian Journal of Public Health, 97, 166-170.
Norman, J., Mugavin, J., & Swan, A. (2006). Evaluation of the primary health services.
Fitzroy, Victoria: Turning Point Alcohol and Drug Centre.
Novak, S. P., & Kral, A. H. (2011). Comparing injection and non-injection routes of
administration for heroin, methamphetamine, and cocaine users in the United States.
Journal of Addictive Diseases, 30, 248-257.
O'Brien, M. S., & Anthony, J. C. (2005). Risk of becoming cocaine dependent:
epidemiological

estimates

for

the

United

States,

2000-2001.

Neuropsychopharmacology, 30, 1006-1018.

Orangio, G. R., Della Latta, P., Marino, C., Guarneri, J. J., Giron, J. A., Palmer, J., et al.
(1983). Infections in parenteral drug abusers. Further immunologic studies. American
Journal of Surgery, 146, 738-741.
Orangio, G. R., Pitlick, S. D., Della Latta, P., Mandel, L. J., Marino, C., Guarneri, J. J., et al.
(1984). Soft tissue infections in parenteral drug abusers. Annals of Surgery, 199, 97100.

218

Chapter 8
Orford, J. (1994). Empowering family and friends: a new approach to the secondary
prevention of addiction. Drug and Alcohol Review, 13, 417-429.
Palepu, A., Tyndall, M. W., Leon, H., Muller, J., O'Shaughnessy, M. V., Schechter, M. T., et
al. (2001). Hospital utilization and costs in a cohort of injection drug users. Canadian
Medical Association Journal, 165, 415-420.
Passaro, D. J., Werner, S. B., McGee, J., Mac Kenzie, W. R., & Vugia, D. J. (1998). Wound
botulism associated with black tar heroin among injecting drug users. JAMA, 279,
859-863.
Paterson, B. L., Backmund, M., Hirsh, G., & Yim, C. (2007). The depiction of stigmatization
in research about hepatitis C. International Journal of Drug Policy, 18, 364-373.
Peles, E., Schreiber, S., Linzy, S., & Adelson, M. (2010). Pathological gambling in
methadone maintenance clinics where gambling is legal versus illegal. American
Journal of Orthopsychiatry, 80, 311-316.
Perlis, T. E., Des Jarlais, D. C., Friedman, S. R., Arasteh, K., & Turner, C. F. (2004). Audiocomputerized self-interviewing versus face-to-face interviewing for research data
collection at drug abuse treatment programs. Addiction, 99, 885-896.
Perlman, D. C., Henman, A. R., Kochems, L., Paone, D., Salomon, N., & Des Jarlais, D. C.
(1999). Doing a shotgun: a drug use practice and its relationship to sexual behaviors
and infection risk. Social Science and Medicine, 48, 1441-1448.
Perrone, J., & Nelson, L. S. (2012). Medication Reconciliation for Controlled Substances An "Ideal" Prescription-Drug Monitoring Program. New England Journal of
Medicine.
Pettigrew, T. F., & Tropp, L. R. (2006). A meta-analytic test of intergroup contact theory.
Journal of Personality and Social Psychology, 90, 751-783.

219

Chapter 8
Pollack, H. A., Khoshnood, K., Blankenship, K. M., & Altice, F. L. (2002). The impact of
needle exchange-based health services on emergency department use. Journal of
General Internal Medicine, 17, 341-348.
Popay, J., Roberts, H., Sowden, A., Petticrew, M., Arai, L., Rodgers, M., et al. (2006).
Guidance on the conduct of narrative synthesis in systematic reviews. Final Report
Lancaster, Institute of Health Research, Lancaster: ESRC Methods Programme.
Porter, J. (1999). The street/treatment barrier: treatment experiences of Puerto Rican injection
drug users. Substance Use and Misuse, 34, 1951-1975.
Porter, J., Coyte, P. C., Barnsley, J., & Croxford, R. (1999). The effects of fee bundling on
dental utilization. Health Services Research, 34, 901-921.
Poulin, C., Alary, M., Bernier, F., Carbonneau, D., Boily, M. C., & Joly, J. R. (2001).
Prevalence of Chlamydia trachomatis and Neisseria gonorrhoeae among at-risk
women, young sex workers, and street youth attending community organizations in
Quebec City, Canada. Sexually Transmitted Diseases, 28, 437-443.
Queensland Injectors Health Network. Fungal eye infection from buprenorphine injection.
Available

at:

http://www.quihn.org/index.php?option=com_content&view=article&id=67:warning.
Retrieved 12 December 2012.
Ramasamy, P., Lintzeris, N., Sutton, Y., Taylor, H., Day, C. A., & Haber, P. S. (2010). The
outcome of a rapid hepatitis B vaccination programme in a methadone treatment
clinic. Addiction, 105, 329-334.
Razali, K., Thein, H. H., Bell, J., Cooper-Stanbury, M., Dolan, K., Dore, G., et al. (2007).
Modelling the hepatitis C virus epidemic in Australia. Drug and Alcohol Dependence,
91, 228-235.

220

Chapter 8
Reece, A. S. (2008). An intriguing association between dental and mental pathology in
addicted and control subjects: a cross-sectional survey. British Dental Journal, 205,
E22.
Reece, S. (2009). Dental health in addiction. Australian Dental Journal, 54, 185-186.
Rees, V., Saitz, R., Horton, N. J., & Samet, J. (2001). Association of alcohol consumption
with HIV sex- and drug-risk behaviours among drug users. Journal of Substance
Abuse Treatment, 21, 129-134.
Regen, M., Murphy, S., & Murphy, T. (2002). Drug users lay consultation processes:
Symptom identification and management. Social Networks and Health, 8, 323-341.
Reyes, J. C., Robles, R. R., Coln, H. M., Marrero, C. A., Castillo, X., & Melndez, M.
(1995). M. tuberculosis and HIV infection among crack and injection drug users in
San Juan, Puerto Rico [abstract]. American Public Health Association 123rd annual
meeting and exhibition. Oct 29-Nov 2. Washington. San Diego.
Rhodes, T., Briggs, D., Kimber, J., Jones, S., & Holloway, G. (2007). Crack-heroin speedball
injection and its implications for vein care: qualitative study. Addiction, 102, 17821790.
Rich, J. D., McKenzie, M., Macalino, G. E., Taylor, L. E., Sanford-Colby, S., Wolf, F., et al.
(2004). A syringe prescription program to prevent infectious disease and improve
health of injection drug users. Journal of Urban Health, 81, 122-134.
Riddell, S., Shanahan, M., Degenhardt, L., & Roxburgh, A. (2008). Estimating the costs of
drug-related hospital separations in Australia. Australian and New Zealand Journal of
Public Health, 32, 156-161.
Ritter, A. (2009). How do drug policy makers access research evidence? International
Journal of Drug Policy, 20, 70-75.

221

Chapter 8
Robbins, J. L., Wenger, L., Lorvick, J., Shiboski, C., & Kral, A. H. (2010). Health and oral
health care needs and health care-seeking behavior among homeless injection drug
users in San Francisco. Journal of Urban Health, 87, 920-930.
Roberts, W. C. (2002). Pulmonary talc granulomas, pulmonary fibrosis, and pulmonary
hypertension resulting from intravenous injection of talc-containing drugs intended
for oral use. Proceedings (Baylor University. Medical Center), 15, 260-261.
Robinson, P. G., Acquah, S., & Gibson, B. (2005). Drug users: oral health-related attitudes
and behaviours. British Dental Journal, 198, 219-224, discussion 214.
Roche, A., Furay, C., & Saunders, J. (1991). General practitioners experiences of patients
with drug and alcohol problems. British Journal of Addiction, 86, 263-275.
Roche, A. M. (1996). Increasing primary care providers willingness to intervene in alcoholand drug-related problems: a review. Substance Abuse, 17, 201-217.
Roche, P. W., Krause, V., Konstantinos, A., Bastian, I., Antic, R., Brown, L., et al. (2008).
Tuberculosis notifications in Australia, 2006. Communicable Diseases Intelligence,
32, 1-11.
Room, R., Rehm, J., Trotter, R. T., Paglia, A., & stn, T. B. (2001). Cross-cultural views on
stigma valuation parity and societal attitudes towards disability. Seattle: WA:
Hofgrebe and Huber.
Rosenthal, R., Persinger, G. W., & Fode, K. L. (1962). Experimenter bias, anxiety, and social
desirability. Perceptual and Motor Skills, 15, 73-74.
Ross, D., Lo, F., McKim, R., & Allan, G. M. (2008). A primary care/multidisciplinary harm
reduction clinic including opiate bridging. Substance Use and Misuse, 43, 1628-1639.
Ross, M. W., Gold, J., Wodak, A., & Miller, M. E. (1991). Sexually transmissible diseases in
injecting drug users. Genitourinary Medicine, 67, 32-36.

222

Chapter 8
Ross, M. W., Hwang, L. Y., Zack, C., Bull, L., & Williams, M. L. (2002). Sexual risk
behaviours and STIs in drug abuse treatment populations whose drug of choice is
crack cocaine. International Journal of STD and AIDS, 13, 769-774.
Rowe, J. (2004). Needles and syringes to care and counselling: The need for innovative
primary health care to meet the needs of street-based injecting drug users. Australian
Journal of Primary Health, 10, 49-55.
Rowe, J. (2005). Access Health: Providing primary health care to vulnerable and
marginalised populations - a practice paper. Australian Journal of Primary Health,
11, 32-37.
Rowe, J. (2012). Clients are central to any independent and rigorous evaluation of the
services they use. International Journal of Drug Policy, 23, 103-104.
Roxburgh, A., & Burns, L. (2008). Cannabis use among sentinel groups of drug users in
Australia: Findings from the Illicit Drug Reporting System (IDRS) and the Ecstasy
and Related Drugs Reporting System (EDRS). Drug Trends Bulletin. Sydney:
National Drug and Alcohol Research Centre.
Rychetnik, L., Frommer, M., Hawe, P., & Shiell, A. (2002). Criteria for evaluating evidence
on public health interventions. Journal of Epidemiology and Community Health, 56,
119-127.
Saitz, R., Horton, N. J., Larson, M. J., Winter, M., & Samet, J. H. (2005). Primary medical
care and reductions in addiction severity: a prospective cohort study. Addiction, 100,
70-78.
Salmon, A. M., Dwyer, R., Jauncey, M., van Beek, I., Topp, L., & Maher, L. (2009).
Injecting-related injury and disease among clients of a supervised injecting facility.
Drug and Alcohol Dependence, 101, 132-136.

223

Chapter 8
Salvalaggio, G. (2008). Patient-Provider Rapport in the Health Care of People Who Inject
Drugs. University of Alberta, Edmonton, Alberta.
Sanson-Fisher, R. W., Bonevski, B., Green, L. W., & D'Este, C. (2007). Limitations of the
randomized controlled trial in evaluating population-based health interventions.
American Journal of Preventive Medicine, 33, 155-161.
Sapico, F. L., & Montgomerie, J. Z. (1980). Vertebral osteomyelitis in intravenous drug
abusers: report of three cases and review of the literature. Reviews of Infectious
Diseases, 2, 196-206.
Sarin, E., Samson, L., Sweat, M., & Beyrer, C. (2011). Human rights abuses and suicidal
ideation among male injecting drug users in Delhi, India. International Journal of
Drug Policy, 22, 161-166.
Scarborough, J., Eliott, J., & Braunack-Mayer, A. (2011). Opioid substitution therapy--a
study of GP participation in prescribing. Australian Family Physician, 40, 241-245.
Scheidegger, C., & Zimmerli, W. (1989). Infectious complications in drug addicts: sevenyear review of 269 hospitalized narcotics abusers in Switzerland. Reviews of
Infectious Diseases, 11, 486-493.
Scott, J., Winfield, A., Kennedy, E., & Bond, C. (2000). Laboratory study of the effects of
citric and ascorbic acids on injections prepared with brown heroin. International
Journal of Drug Policy, 11, 417-422.
Selwyn, P. A., Budner, N. S., Wasserman, W. C., & Arno, P. S. (1993). Utilization of on-site
primary care services by HIV-seropositive and seronegative drug users in a
methadone maintenance program. Public Health Report, 108, 492-500.
Selwyn, P. A., Hartel, D., Lewis, V. A., Schoenbaum, E. E., Vermund, S. H., Klein, R. S., et
al. (1989). A prospective study of the risk of tuberculosis among intravenous drug

224

Chapter 8
users with human immunodeficiency virus infection. New England Journal of
Medicine, 320, 545-550.
Semple, S. J., Zians, J., Strathdee, S. A., & Patterson, T. L. (2009). Sexual marathons and
methamphetamine use among HIV-positive men who have sex with men. Archives of
Sexual Behavior, 38, 583-590.
Shakeshaft, A., Fawcett, J., Mattick, R. P., Richmond, R., Wodak, A., Harris, M. F., et al.
(2006). Patient-driven computers in primary care: their use and feasibility. Health
Education, 106, 400-411.
Shakeshaft, A. P., Bowman, J. A., & Sanson-Fisher, R. W. (1998). Computers in communitybased drug and alcohol clinical settings: are they acceptable to respondents? Drug and
Alcohol Dependence, 50, 177-180.
Shamliyan, T. A., MacDonald, R., Shaukat, A., Taylor, B. C., Yuan, J. M., Johnson, J. R., et
al. (2009). Antiviral therapy for adults with chronic hepatitis B: a systematic review
for a National Institutes of Health Consensus Development Conference. Annals of
Internal Medicine, 150, 111-124.
Shepard, C. W., Finelli, L., & Alter, M. J. (2005). Global epidemiology of hepatitis C virus
infection. Lancet Infectious Diseases, 5, 558-567.
Sheridan, J., & Barber, N. (1996). Drug misusers experiences and opinions of community
pharmacists and community pharmacy services. Pharmaceutical Journal, 257, 325327.
Silins, E., Conigrave, K. M., Rakvin, C., Dobbins, T., & Curry, K. (2007). The influence of
structured education and clinical experience on the attitudes of medical students
towards substance misusers. Drug and Alcohol Review, 26, 191-200.
Simmonds, L., & Coomber, R. (2009). Injecting drug users: a stigmatised and stigmatising
population. International Journal of Drug Policy, 20, 121-130.

225

Chapter 8
Singh, M. A harm reduction programme for injecting drug users in Nepal. Retrieved 10
November 2009 from
http://www.kit.nl/exchange/html/1997_2_a_harm_reduction_progra.asp.
Singh, M. (1998). Harm Reduction and Street-Based Program: Looking into Nepal.
Substance Use and Misuse, 33, 1069-1074.
Small, W., Van Borek, N., Fairbairn, N., Wood, E., & Kerr, T. (2009). Access to health and
social services for IDU: the impact of a medically supervised injection facility. Drug
and Alcohol Review, 28, 341-346.
Small, W., Wood, E., Lloyd-Smith, E., Tyndall, M., & Kerr, T. (2008). Accessing care for
injection-related infections through a medically supervised injecting facility: a
qualitative study. Drug and Alcohol Dependence, 98, 159-162.
Smith-Rohrberg, D., Mezger, J., Walton, M., Bruce, R. D., & Altice, F. L. (2006). Impact of
enhanced services on virologic outcomes in a directly administered antiretroviral
therapy trial for HIV-infected drug users. Journal of Acquired Immune Deficiency
Syndromes, 43 Suppl 1, S48-53.
Solowij, N., Stephens, R., Roffman, R. A., & Babor, T. (2002). Does marijuana use cause
long-term cognitive deficits? JAMA, 287, 2653-2654; author reply 2654.
Solowij, N., Stephens, R. S., Roffman, R. A., Babor, T., Kadden, R., Miller, M., et al. (2002).
Cognitive functioning of long-term heavy cannabis users seeking treatment. JAMA,
287, 1123-1131.
Spearman, P. (2006). Current progress in the development of HIV vaccines. Current
Pharmaceutical Design, 12, 1147-1167.
Spitznagel, E. L., & Helzer, J. E. (1985). A proposed solution to the base rate problem in the
kappa statistic. Archives of General Psychiatry, 42, 725-728.

226

Chapter 8
Stafford, J., & Burns, L. (2010). Australian Drug Trends 2010. Findings from the Illicit Drug
Reporting System (IDRS). Sydney: National Drug and Alcohol Research Centre.
Stafford, R. A., & Petway, J. M. (1977). Stigmatization of men and women problem drinkers
and their spouses. Differential perception and leveling of sex differences. Journal of
Studies on Alcohol, 38, 2109-2121.
Stein, M. (1999). Medical consequences of substance use. Psychiatric Clinics of North
America, 22, 351-370.
Stein, M., & Samet, J. (1993). The linkage of primary care services with substance abuse
treatment: new opportunities for academic generalists. Journal of General Internal
Medicine, 8, 106-107.
Stein, M. D. (1990). Medical complications of intravenous drug use. Journal of General
Internal Medicine, 5, 249-257.
Stein, M. D., Hanna, L., Natarajan, R., Clarke, J., Marisi, M., Sobota, M., et al. (2000).
Alcohol use patterns predict high-risk HIV behaviours among active injections drug
users. Journal of Substance Abuse Treatment, 18, 359-363.
Stein, M. D., O'Sullivan, P. S., Ellis, P., Perrin, H., & Wartenberg, A. (1993). Utilization of
medical services by drug abusers in detoxification. Journal of Substance Abuse, 5,
187-193.
Sterk, C. E., Elifson, K. W., & Theall, K. (2000). Women and drug treatment experiences: A
generational comparison of mothers and daughters. Journal of Drug Issues, 30, 839862.
Stimson, G., Jarlais, D. C. D., & Ball, A. (1998). Drug injecting and HIV infection. London:
UCL Press Limited.

227

Chapter 8
Stoove, M. A., Gifford, S. M., & Dore, G. J. (2005). The impact of injecting drug use status
on hepatitis C-related referral and treatment. Drug and Alcohol Dependence, 77, 8186.
Strang, J., McCambridge, J., Best, D., Beswick, T., Bearn, J., Rees, S., et al. (2003). Loss of
tolerance and overdose mortality after inpatient opiate detoxification: follow up study.
BMJ, 326, 959-960.
Strathdee, S. A., Palepu, A., Cornelisse, P. G., Yip, B., O'Shaughnessy, M. V., Montaner, J.
S., et al. (1998). Barriers to use of free antiretroviral therapy in injection drug users.
JAMA, 280, 547-549.
Strathdee, S. A., Patrick, D. M., Currie, S. L., Cornelisse, P. G., Rekart, M. L., Montaner, J.
S., et al. (1997). Needle exchange is not enough: lessons from the Vancouver
injecting drug use study. AIDS, 11, F59-65.
Strenta, A. C., & Kleck, R. A. (1985). Physical disability and the attribution dilemma:
perceiving the causes of social behavior. Journal of Social and Clinical Psychology,
3, 129-142.
Strenta, A. C., & Kleck, R. E. (1984). Physical disability and the perception of social
interaction: its not what you look at but how you look at it. Personality and Social
Psychology Bulletin, 10, 279-288.
Sweet, M. (2012). Indigenous health professionals working in the alcohol and drug field
deserve better. Crickey, June 12.
Swift, W., & Copeland, J. (1996). Treatment needs and experiences of Australian women
with alcohol and other drug problems. Drug and Alcohol Dependence, 40, 211-219.
Tantam, D., Donmall, M., Webster, A., & Strang, J. (1993). Do general practitioners and
general psychiatrists want to look after drug misusers? Evaluation of a non-specialist
treatment policy. British Journal of General Practice, 43, 470-474.

228

Chapter 8
Tawk, H. M., Vickery, K., Bisset, L., Lo, S. K., Selby, W., & Cossart, Y. E. (2006). The
current pattern of hepatitis B virus infection in Australia. Journal of Viral Hepatitis,
13, 206-215.
Taylor, J., Fulop, N., & Green, J. (1999). Drink, illicit drugs and unsafe sex in women.
Addiction, 94, 1209-1218.
Te, H. S., & Jensen, D. M. (2010). Epidemiology of hepatitis B and C viruses: a global
overview. Clinics in Liver Disease, 14, 1-21, vii.
Topp, L. (2012). ATS use and risk-taking behaviours. In S. Allsop & N. Lee (Eds.),
Perspectives on ampthetamine-type stimulants. I.P. Communications. Melbourne.
Topp, L., Day, C. A., Iversen, J., Wand, H., & Maher, L. (2011). Fifteen years of HIV
surveillance among people who inject drugs: the Australian Needle and Syringe
Program Survey 1995-2009. AIDS, 25, 835-842.
Topp, L., Iversen, J., Baldry, E., & Maher, L. (Epub ahead of print). Housing Instability
among People Who Inject Drugs: Results from the Australian Needle and Syringe
Program Survey. Journal of Urban Health, doi: 10.1007/s11524-012-9730-6.
Topp, L., Iversen, J., Conroy, A., Salmon, A. M., & Maher, L. (2008). Prevalence and
predictors of injecting-related injury and disease among clients of Australia's needle
and syringe programs. Australian and New Zealand Journal of Public Health, 32, 3437.
Topp, L., Iversen, J., Wand, H., Day, C., Kaldor, J., & Maher, L. (2008). Representativeness
of injecting drug users who participate in HIV surveillance: results from Australia's
Needle and Syringe Program Survey. Journal of Acquired Immune Deficiency
Syndromes, 47, 632-638.

229

Chapter 8
Topp, L., Maher, L., & Kaldor, J. (2009). Transmission of hepatitis C virus. In G. Dore, M.
Temple-Smith & A. Lioyd (Eds.), Hepatitis C: an expanding perspective. Melbourne:
IP Communications.
Treloar, C., & Fraser, S. (2007). Public opinion on needle and syringe programmes: avoiding
assumptions for policy and practice. Drug and Alcohol Review, 26, 355-361.
Treloar, C., & Hopwood, M. (2004). Infection control in the context of hepatitis C disclosure:
implications for education of healthcare professionals. Education for Health
(Abingdon), 17, 183-191.
Trewin, D. (2001). Family and community issues. Illicit drug use, sources of Australian
data. Canberra: Australian Bureau of Statistics.
Tumbarello, M., Tacconelli, E., de Gaetano, K., Ardito, F., Pirronti, T., Cauda, R., et al.
(1998). Bacterial pneumonia in HIV-infected patients: analysis of risk factors and
prognostic indicators. J Acquir Immune Defic Syndr Hum Retrovirol, 18, 39-45.
Uebersax, J. S. (1987). Diversity of decision-making models and the measurement of
interrater agreement. Psychological Bulletin, 101, 140-146.
Umbricht-Schneiter, A., Ginn, D. H., Pabst, K. M., & Bigelow, G. E. (1994). Providing
medical care to methadone clinic patients: referral vs on-site care. American Journal
of Public Health, 84, 207-210.
UNAIDS. (1999). UNAIDS best practice collection: Drug user programme, Ikhlas
Community Centre, Pink Triangle, Malaysia. Retrieved15 October 2009 from
http://www.greenstone.org/greenstone3/nzdl?a=d&c=unaids&d=HASH4a2403552a0
2d729115e57.1&sib=1&p.a=q&p.sa=&p.s=TextQuery&p.c=unaids.
UNAIDS.

(2009).

HIV

prevention

among

injecting

drug

users.

Availabel

at:

http://search2.unaids.org/custom/search.asp; accessed in March 2012. 24th Meeting

of the UNAIDS Programme Coordinating Board. Geneva.

230

Chapter 8
UNAIDS. UNAIDS global report on the global AIDS epidemic 2010. Available at:
http://www.unaids.org/globalreport/Global_report.htm; accessed in March 2012.
UNODC. (2008). World Drug Report 2008. Vienna: United Nations Office on Drugs and
Crime.
van Asten, L. C., Boufassa, F., Schiffer, V., Brettle, R. P., Robertson, J. R., Hernandez
Aguado, I., et al. (2003). Limited effect of highly active antiretroviral therapy among
HIV-positive injecting drug users on the population level. European Journal of Public
Health, 13, 347-349.
van Beek, I. (2007). Case study: accessible primary health care-a foundation to improve
health outcomes for people who inject drugs. International Journal of Drug Policy,
18, 329-332.
van Beek, I. (2012). Maybe not perfect but surely good enough? International Journal of
Drug Policy, 23, 108.
van den Hoek, A. (1997). STD control in drug users and street youth. Genitourinary
Medicine, 73, 240-244.
Van Thiel, D. H., Anantharaju, A., & Creech, S. (2003). Response to treatment of hepatitis C
in individuals with a recent history of intravenous drug abuse. American Journal of
Gastroenterology, 98, 2281-2288.
Vento, S., Garofano, T., Renzini, C., Cainelli, F., Casali, F., Ghironzi, G., et al. (1998).
Fulminant hepatitis associated with hepatitis A virus superinfection in patients with
chronic hepatitis C. New England Journal of Medicine, 338, 286-290.
Volkow, N. D., Wang, G. J., Fowler, J. S., Telang, F., Jayne, M., & Wong, C. (2007).
Stimulant-induced enhanced sexual desire as a potential contributing factor in HIV
transmission. American Journal of Psychiatry, 164, 157-160.

231

Chapter 8
Walshe, J. M., & Wolff, H. H. (1952). Primary carcinoma of the liver following viral
hepatitis report of two cases. Lancet, 2, 1007-1010.
Wand, H., Guy, R., Donovan, B., & McNulty, A. (2011). Developing and validating a risk
scoring tool for chlamydia infection among sexual health clinic attendees in Australia:
a simple algorithm to identify those at high risk of chlamydia infection. BMJ Open, 1,
http://bmjopen.bmj.com/content/early/2011/2002/2016/bmjopen-2010000005.full.pdf.
Warner-Smith, M., Darke, S., Lynskey, M., & Hall, W. (2001). Heroin overdose: causes and
consequences. Addiction, 96, 1113-1125.
Wasley, A., & Alter, M. (2000). Epidemiology of hepatitis C: geographic differences and
temporal trends. Seminars in Liver Disease, 20, 1-16.
Wasserheit, J. N. (1992). Epidemiological synergy. Interrelationships between human
immunodeficiency virus infection and other sexually transmitted diseases. Sexually
Transmitted Diseases, 19, 61-77.
Watson, B., Conigrave, K. M., Wallace, C., Whitfield, J. B., Wurst, F., & Haber, P. S. (2007).
Hazardous alcohol consumption and other barriers to antiviral treatment among
hepatitis C positive people receiving opioid maintenance treatment. Drug and Alcohol
Review, 26, 231-239.
Wei, G., Moss, J., & Yuan, C. S. (2003). Opioid-induced immunosuppression: is it centrally
mediated or peripherally mediated? Biochem Pharmacol, 65, 1761-1766.
Weigl, M., Busch, M., Eggerth, A., Horvath, I., Knaller, C., Trscherl, E., et al. (2009).
Report on the drug situation 2009. Retrieved 20 December 2009 from
http://www.goeg.at/media/download/berichte/DrugSituation2009_Austria.pdf.

232

Chapter 8
Weisner, C., Mertens, J., Parthasarathy, S., Moore, C., & Lu, Y. (2001). Integrating primary
medical care with addiction treatment: a randomized controlled trial. JAMA, 286,
1715-1723.
Werner, S. B., Passaro, D., McGee, J., Schechter, R., & Vugia, D. J. (2000). Wound botulism
in California, 1951-1998: recent epidemic in heroin injectors. Clinical Infectious
Diseases, 31, 1018-1024.
Western Australian Network of Alcohol and Other Drug Agencies. (2009). WANADA GP
Access

(pilot)

project

evaluation

summary,

Available

at:

www.wanada.org.au/Download.../72-GP-Access-Project-Evaluation.html.
Westman, J., Hampel, H., & Bradley, T. (2000). Efficacy of a touchscreen computer based
family cancer history questionnaire and subsequent cancer risk assessment. Journal of
Medical Genetics, 37, 354-360.
White, B., Day, C., & Maher, L. (2007). Self reported risk behaviour among injecting drug
users: self versus assisted questionnaire completion. AIDS Care, 19, 441-447.
Williams, D. (2005). The policy context for substance misuse services in primary care. R.
Winyard (Ed.), Substance Misuse In Primary Care - a multi-disciplinary approach:
Oxford.
Wingood, G. M., & DiClemente, R. J. (1998). The influence of psychosocial factors, alcohol,
drug use on African-American women's high-risk sexual behavior. American Journal
of Preventive Medicine, 15, 54-59.
Winstock, A. R., Lea, T., & Sheridan, J. (2008). Patients' help-seeking behaviours for health
problems associated with methadone and buprenorphine treatment. Drug and Alcohol
Review, 27, 393-397.

233

Chapter 8
Wolfe, D. (2007). Paradoxes in antiretroviral treatment for injecting drug users: access,
adherence and structural barriers in Asia and the former Soviet Union. International
Journal of Drug Policy, 18, 246-254.
Wood, E., Tyndall, M., Zhengou, Q., Zhang, R., Montaner, J., & Kerr, T. (2006). Service
uptake and characteristics of injection drug users utilizing North Americas first
medically supervised safer injecting facility. American Journal of Public Health, 96,
770-773.
World Health Organization. (1993). The ICD-10 classification of mental and behavioural
disorders - diagnostic criteria for research. Geneva: World Health Organization.
World Health Organization. (2000). Guide to drug abuse epidemiology.

(Vol.

WHO/MSD/MSB/00.3). Geneva.
World Health Organization. (2004). Best practice in HIV/AIDS prevention and care for
injecting drug abusers. The Triangular Clinic in Kermanshah, Islamic Republic of
Iran. Regional Office for the Eastern Mediterranean (Ed.). Cairo.
World Health Organization. (2009). Management of common health problems of drug users.
Retrieved 15 July 2011 from
http://www.searo.who.int/en/Section10/Section18/Section356_4609.htm. New Delhi.
Wright, N. M., & Tompkins, C. N. (2006). How can health services effectively meet the
health needs of homeless people? British Journal of General Practice, 56, 286-293.
Yuan, C. S., Foss, J. F., O'Connor, M., Moss, J., & Roizen, M. F. (1998). Gut motility and
transit changes in patients receiving long-term methadone maintenance. Journal of
Clinical Pharmacology, 38, 931-935.
Zahari, M. M., Hwan Bae, W., Zainal, N. Z., Habil, H., Kamarulzaman, A., & Altice, F. L.
(2010). Psychiatric and substance abuse comorbidity among HIV seropositive and

234

Chapter 8
HIV seronegative prisoners in Malaysia. American Journal of Drug and Alcohol
Abuse, 36, 31-38.

235

Appendices

Appendix I: PRISMA Checklist

Section/topic
TITLE
Title
ABSTRACT
Structured summary

INTRODUCTION
Rationale
Objectives

METHODS
Protocol and registration

# Checklist item

Reported on page #

1 Identify the report as a systematic review, meta-analysis, or

both.

Not applicable, it was a narrative

synthesis

2 Provide a structured summary including, as applicable:

background; objectives; data sources; study eligibility criteria,
participants, and interventions; study appraisal and synthesis
methods; results; limitations; conclusions and implications of
key findings; systematic review registration number.

Not applicable as the review sits as a

chapter in the thesis

3 Describe the rationale for the review in the context of what is

already known.

Page 46

4 Provide an explicit statement of questions being addressed with

reference to participants, interventions, comparisons, outcomes,
and study design (PICOS).

Page 46

5 Indicate if a review protocol exists, if and where it can be

accessed (e.g., Web address), and, if available, provide
registration information including registration number.

Not applicable - scoping study revealed

that a systematic review was not
possible with the existing literature.

236

Appendices

Section/topic

# Checklist item

Reported on page #

Eligibility criteria

6 Specify study characteristics (e.g., PICOS, length of follow-up)

and report characteristics (e.g., years considered, language,
publication status) used as criteria for eligibility, giving
rationale.

Page 49

Information sources

7 Describe all information sources (e.g., databases with dates of

coverage, contact with study authors to identify additional
studies) in the search and date last searched.

Page 47-49

Search

8 Present full electronic search strategy for at least one database,

including any limits used, such that it could be repeated.

Page 47

Study selection

9 State the process for selecting studies (i.e., screening, eligibility, Page 47-49
included in systematic review, and, if applicable, included in
the meta-analysis).

Data collection process

10 Describe method of data extraction from reports (e.g., piloted

forms, independently, in duplicate) and any processes for
obtaining and confirming data from investigators.

Data extraction was not performed as

literature precluded any effort of
performing a systematic review

Data items

11 List and define all variables for which data were sought (e.g.,
PICOS, funding sources) and any assumptions and
simplifications made.

Not applicable

Risk of bias in individual

studies

12 Describe methods used for assessing risk of bias of individual

studies (including specification of whether this was done at the
study or outcome level), and how this information is to be used
in any data synthesis.

Page 47-49

Summary measures

13 State the principal summary measures (e.g., risk ratio,

difference in means).

Not applicable

237

Appendices

Section/topic

# Checklist item

Reported on page #

Synthesis of results

14 Describe the methods of handling data and combining results of

studies, if done, including measures of consistency (e.g., I2) for
each meta-analysis.

Not applicable

Risk of bias across studies

15 Specify any assessment of risk of bias that may affect the

cumulative evidence (e.g., publication bias, selective reporting
within studies).

Not applicable

Additional analyses

16 Describe methods of additional analyses (e.g., sensitivity or

subgroup analyses, meta-regression), if done, indicating which
were pre-specified.

Not applicable

17 Give numbers of studies screened, assessed for eligibility, and

included in the review, with reasons for exclusions at each
stage, ideally with a flow diagram.

Page 47

Study characteristics

18 For each study, present characteristics for which data were

extracted (e.g., study size, PICOS, follow-up period) and
provide the citations.

Not applicable

Risk of bias within studies

19 Present data on risk of bias of each study and, if available, any

outcome level assessment (see item 12).

Not applicable

Results of individual
studies

20 For all outcomes considered (benefits or harms), present, for

each study: (a) simple summary data for each intervention
group (b) effect estimates and confidence intervals, ideally with
a forest plot.

Not applicable

Synthesis of results

21 Present results of each meta-analysis done, including

confidence intervals and measures of consistency.

Not applicable

RESULTS
Study selection

238

Appendices

Section/topic

# Checklist item

Reported on page #

Risk of bias across studies

22 Present results of any assessment of risk of bias across studies

(see Item 15).

Not applicable

Additional analysis

23 Give results of additional analyses, if done (e.g., sensitivity or

subgroup analyses, meta-regression [see Item 16]).

Not applicable

24 Summarize the main findings including the strength of evidence

for each main outcome; consider their relevance to key groups
(e.g., healthcare providers, users, and policy makers).

Page 68

Limitations

25 Discuss limitations at study and outcome level (e.g., risk of

bias), and at review-level (e.g., incomplete retrieval of
identified research, reporting bias).

Page 72-74

Conclusions

26 Provide a general interpretation of the results in the context of

other evidence, and implications for future research.

Provided 74-75

27 Describe sources of funding for the systematic review and other

support (e.g., supply of data); role of funders for the systematic
review.

Page v-vi

DISCUSSION
Summary of evidence

FUNDING
Funding

From: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA
Statement. PLoS Med 6(6): e1000097. doi:10.1371/journal.pmed1000097

239

Appendices

Appendix II: Research projects undertaken as part of the candidature

Study
Literature review

Contribution
Literature mapping,
searching, analysis
and writing

Sample

Methodology
Narrative synthesis

Papers arising from the research

Islam M M et al (2012). International Journal of
Drug Policy, 23, 94-102.
Islam M M et al (2012). International Journal of
Drug Policy, 23, 109-110.
Islam M M et al (2010). International Journal of
Drug Policy, 21, 131-133.

Empirical study
examining client
characteristics, service
accessibility and
acceptability

Study design, data

collection, analysis
and manuscript
writing.

Drug users (n=

384)

Retrospective
study, case study

Islam, M. M. (2010). Journal of Primary Care

and Community Health, 1, 100103.
Islam M M et al (2012). International Journal of
Drug Policy, [Epub ahead of print]
doi:10.1016/j.drugpo.2012.06.002.
Islam, M. M. et al (2011). Australian and New
Zealand Journal of Public Health, 35, 294-295.
Islam M M et al (2012). Drug and Alcohol
Review, 31, 114-115; author reply 116-117.

Empirical study
examining role of

Study design, data

collection, analysis

Injecting drug
users (n= 479)

Retrospective
longitudinal design

Islam M M et al (2012). Journal of Substance

Abuse Treatment,43, 440-445.
240

Appendices

targeted PHCs in
reducing burden of
liver disease
Empirical study
examining the
reliability of socially
sensitive information
in targeted PHC setting
Empirical study
examining the cost of
PHC services being
offered from targeted
facility.

and manuscript
writing.
Data collection,
analysis and
manuscript writing

Injecting drug
users (n = 171)

Cross sectional
study

Islam M M et al (2012). AIDS Care, 24, 14961503

Study design, data

collection, analysis
and manuscript
writing.

Costing analysis

Islam, M. M et al (Epub ahead of print). doi:

10.1111/dar.12019

241

Appendices

Appendix III: List of publications arising from and

supporting this thesis
Peer reviewed publication arising from thesis
a)

Islam, M. M., Day, C. A., & Conigrave, K. M. (2010). Harm reduction

healthcare: from an alternative to the mainstream platform? International
Journal of Drug Policy, 21, 131-133.

b)

Islam, M. M., Topp, L., Day, C. A., Dawson, A., & Conigrave, K. M.
(2012). The accessibility, acceptability, health impact and cost implications
of primary healthcare outlets that target injecting drug users: A narrative
synthesis of literature. International Journal of Drug Policy, 23, 94-102.

c)

Islam, M. M., Topp, L., Day, C. A., Dawson, A., & Conigrave, K. M.
(2012). Primary healthcare outlets that target injecting drug users:
Opportunity to make services accessible and acceptable to the target group.
International Journal of Drug Policy, 23, 109-110.

d)

Islam, M. M. (2010). Needle syringe program-based primary health care

centers: Advantages and disadvantages. Journal of Primary Care and
Community Health, 1, 100103.

e)

Islam, M. M., Topp, L., Conigrave, K. M., White, A., Haber, P. S., & Day,
C. A. (Epub ahead of print). Are primary health care centres that target
injecting drug users attracting and serving the clients they are designed for?
A case study from Sydney, Australia. International Journal of Drug Policy,
doi:10.1016/j.drugpo.2012.06.002.

242

Appendices
f)

Islam, M. M., Grummett, S., White, A., Reid, S. E., Day, C. A., & Haber, P.
S. (2011). A primary healthcare clinic in a needle syringe program may
contribute to HIV prevention by early detection of incident HIV in an
injecting drug user. Australian and New Zealand Journal of Public Health,
35, 294-295.

g)

Islam, M. M., Reid, S. E., White, A., Grummett, S., Conigrave, K. M., &
Haber, P. S. (2012). Opportunistic and continuing health care for injecting
drug users from a nurse-run needle syringe program-based primary healthcare clinic. Drug and Alcohol Review, 31, 114-115; author reply 116-117.

h)

Islam, M. M., Topp, L., White, A., Conigrave, K. M., Reid, S., Grummett,
S., Haber, P. S., & Day, C. (2012). Linkage into specialist hepatitis C
treatment services of injecting drug users attending a needle syringe programbased primary healthcare centre. Journal of Substance Abuse Treatment, 43,
440-445.

i)

Islam, M. M., Topp, L., Conigrave, K. M., Beek, I. v., Maher, L., White, A.,
Rodgers, C., & Day, C. A. (2012). The reliability of sensitive information
provided by injecting drug users in a clinical setting: clinician-administered
versus audio computer-assisted self-interviewing (ACASI). AIDS Care, 24,
1496-1503

j)

Islam, M. M., Shanahan, M., Topp, L., Conigrave, K. M., White, A., & Day,
C. A. (Epub ahead of print). The cost of providing primary healthcare
services from a needle and syringe program: a case study. Drug and Alcohol
Review, doi: 10.1111/dar.12019

243

Appendices

Other peer reviewed publications supporting this thesis

undertaken during the candidature
k)

Day, C. A., Islam, M. M., White, A., Reid, S. E., Hayes, S., & Haber, P. S.
(2011). Development of a nurse-led primary healthcare service for injecting
drug users in inner-city Sydney. Australian Journal of Primary Health, 17,
10-15.

l)

Islam, M. M., Topp, L., Conigrave, K. M., & Day, C. A. (Epub ahead of
print). Opioid substitution therapy clients preferences for targeted versus
general primary healthcare outlets. Drug and Alcohol Review. doi:
10.1111/j.1465-3362.2012.00498.x

m)

Islam, M. M., Day, C. A., Conigrave, K. M., & Topp, L. (Epub ahead of
print). Self-perceived problem alcohol use among opioid substitution
treatment clients. Addictive Behaviors,doi:10.1016/j.addbeh.2012.12.001

n)

Islam, M. M., Topp, L., Iversen, J., Day, C. A., Conigrave, K. M., & Lisa
Maher on behalf of the Collaboration of Australian NSPs. (in press).
Healthcare utilization and disclosure of injecting drug use among clients of
Australias needle and syringe programs. Australian and New Zealand
Journal of Public Health.

244

Appendices

Conference presentations
Islam, M. M., White, A., Day, C., Topp, L., Conigrave, K. M., Reid, S., Grummet,
S., Haber, P.S. Assessing the model of care and service utilisation of a nurse led lowthreshold primary healthcare in a needle syringe programme setting in inner-city
Sydney. Paper presented in the Australasian Professional Society on Alcohol and
other Drugs conference, November 14-16, 2011 Hobart, Australia.

Deacon, R. M., Topp, L., Day, C., Islam, M. M., Wand, H., VanBeek, I., & Maher,
L. (2011). Knowledge, acceptability and barriers to hepatitis B vaccination among
people who inject drugs. Poster presented in the Australasian Professional Society on
Alcohol and other Drugs conference, November 14-16, 2011 Hobart, Australia.

Islam, M. M., White, A., Day, C., Topp, L., Conigrave, K. M., Reid, S., Grummet,
S., Haber, P.S. Linkage into specialist hepatitis C treatment services of injecting drug
users attending needle syringe programme-based primary healthcare centre. Poster
presented in the 2nd International Symposium on Hepatitis in Substance Users,
September 15-16, 2011 Brussels, Belgium.

Islam, M. M., Haber, P.S., Day, C., Topp, L., Conigrave, K. M., White, A., Reid, S.
A nurse led low-threshold primary healthcare in an inner-city needle syringe
programme: four years experience. Paper presented in the 13th annual meeting of the
International Society for Addiction Medicine (ISAM), September 6-10, 2011 Oslo,
Norway.

245

Appendices
Islam, M. M., Topp, L., Day, C., Conigrave, K. M., Haber, P.S. Sex and drugs in
inner-city Sydney: Sexual risk behaviours and barriers to safe sex among drug users
accessing low-threshold primary healthcare. Advances in Public Health and Health
Services Research at UNSW, Third Annual Symposium 2011, UNSW, August 5,
2011 Sydney, Australia.

Islam, M. M., White, A., Day, C., Topp, L., Conigrave, K. M., Haber, P.S. The
Redfern Harm Minimisation Clinic: clietn uptake and outcomes. Paper presented in
the inter-departmental Substance Abuse Research Group (ISARG) symposium, the
University of Sydney, June 15, 2011 Sydney, Australia.

Islam, M. M., Hayes, S., White, A., Day, C., Reid, S., Grummet, S., Haber, P. S.
Assessment for hepatitis C treatment and referral uptake by IDUs attending a harm
reduction based primary healthcare. 7th Australian Viral Hepatitis Conference,
September, 6-8, 2010 Melbourne, Australia.

White, A., Reid, S., Day, C., Hayes, S., Grummet, S., Islam, M., & Haber, P.
(2010). NSP based primary healthcare linking IDUs with GPs. Poster presented in
the Australasian Professional Society on Alcohol and other Drugs conference,
November 1-4, 2009 Darwin, Australia.

246

Appendix IV

(a) Islam, M. M., Day, C. A., & Conigrave, K. M. (2010). Harm reduction healthcare:
from an alternative to the mainstream platform? International Journal of Drug Policy,
21, 131-133.

247

International Journal of Drug Policy 21 (2010) 131133

Contents lists available at ScienceDirect

International Journal of Drug Policy

journal homepage: www.elsevier.com/locate/drugpo

Commentary

Harm reduction healthcare: From an alternative to the mainstream platform?

M. Mozul Islam a,b, , Carolyn A. Day c,b , Katherine M. Conigrave b,d,e
a

School of Public Health & Community Medicine, University of New South Wales, Sydney, Australia
Drug Health Services, Royal Prince Alfred Hospital, Sydney, Australia
Discipline of Addiction Medicine, Central Clinical School, Sydney Medical School, University of Sydney, Australia
d
Sydney Medical School, University of Sydney, Australia
e
National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
b
c

a r t i c l e

i n f o

Article history:
Received 1 October 2009
Received in revised form
31 December 2009
Accepted 5 January 2010

Keywords:
Harm reduction
Illicit drug user
Needle syringe programme
Low-threshold primary healthcare

a b s t r a c t
Despite a plethora of health-related problems, access to primary healthcare is often limited for drug users
(DUs). Many seek care at emergency departments and tertiary hospitals because of late presentation of
illness. The costs to both DUs and the health system are such that harm reduction based healthcare centres (HRHCs) have been established in various settings and utilising a variety of models. These provide
a range of medical and sometimes social services, in one, integrated, low-threshold facility, including
(or closely linked with) programs such as needle syringe provision. In some countries these HRHCs are
becoming an alternative healthcare system for DUs. However, the need to provide such services on a
broad, public health scale, in a sustainable, cost-effective manner, raises the question as to whether such
programmes should be mainstreamed. This commentary provides insights on advantages and disadvantages to mainstreaming HRHCs, and approaches and barriers to achieving this. Two approaches suggest
themselves: (i) providing harm reduction services through the regular healthcare system, or (ii) more
closely integrating HRHCs with mainstream services. Funding and stigma are major barriers to mainstreaming. Diverse national policies towards DUs, healthcare systems and contexts, necessitate different
approaches. Because of the various barriers to mainstreaming, any steps towards mainstreaming should
be taken whilst maintaining the option of continuing the current targeted harm reduction services.
2010 Elsevier B.V. All rights reserved.

Drug users (DUs) are at risk of a wide range of health problems (Latt, Conigrave, Saunders, Marshall, & Nutt, 2009) arising
from non-sterile injecting practices, complications of the drug itself
or of the lifestyle associated with drug use and dependence. Furthermore, unrelated health problems, such as diabetes, may be
neglected because of drug dependence. However, despite their
increased healthcare needs, DUs do not have the required access
to care or may be reluctant to use conventional services (McCoy,
Metsch, Chitwood, & Miles, 2001). Consequently, their health may
deteriorate to a point at which emergency treatment is required
(McDonald, 2002), with considerable costs to both the DUs and
the health system. Accordingly harm reduction based healthcare
centres (HRHCs) for DUs have been established across a range of settings utilising a variety of models. These HRHCs provide integrated,
low-threshold services, within a harm-reduction framework, targeting DUs and sometimes include social and/or other services.
Where a particular service is not provided, referral and assistance

Corresponding author at: Drug Health Service, Royal Prince Alfred Hospital,
Missenden Rd, Camperdown, NSW 2050, Australia. Fax: +61 2 9515 5779.
E-mail addresses: mikhokan143@yahoo.com, z3117237@student.unsw.edu.au
(M.M. Islam).

with access is available. HRHCs are typically delivered through, or

in close partnerships with, harm reduction outlets such as needle
syringe programmes (NSPs), supervised injecting facilities or opioid
substitution clinics.
HRHCs vary widely and as described by Stein and Samet (1993),
may be either distributive, providing basic harm reduction services and simple healthcare with facilitated referrals to specialist
services, such as the DU-targeted low-threshold centres in Finland
(Arponen, Brummer-Korvenkontio, Liitsola, & Salminen, 2008) or
one-stop-shops where a range of services including specialist services are provided onsite, for example the Kirketon Road Centre
in Sydney, Australia (van Beek, 2007). The services being offered
by HRHCs cover needle and syringe provision, low-threshold
primary healthcare, hepatitis B and A vaccinations, counselling,
and sometimes opioid maintenance therapy. Some centres offer
hepatitis, HIV treatment (van Beek, 2007) and dental care. The
literature suggests that HRHCs improve the overall health status of DUs and save on the health budget by reducing episodes
in emergency departments and tertiary hospitals (Friedmann,
Hendrickson, Gerstein, Zhang, & Stein, 2006). Favourable feedback
from these healthcare services continues to encourage development of similar facilities elsewhere. In some settings, HRHCs
are becoming an alternative healthcare system for DUs, rather

0955-3959/$ see front matter 2010 Elsevier B.V. All rights reserved.
doi:10.1016/j.drugpo.2010.01.001

248

132

M.M. Islam et al. / International Journal of Drug Policy 21 (2010) 131133

than merely a referral point (Des Jarlais, McKnight, Goldblatt, &

Purchase, 2009).
The need to provide such services on a broad, public health scale
and in a cost-effective manner raises the question as to whether the
programmes should continue as an alternative healthcare platform
for DUs. Mainstreaming harm reduction into conventional healthcare delivery, that is increasing the provision of NSP and other harm
reduction initiatives through the mainstream health sector, has
some clear advantages. After all, ensuring coverage of sterile injecting equipment is the fundamental business of NSP. In many parts
of the world, this coverage is nowhere near the required level.
The provision of targeted healthcare services to DUs may burden
already scarce resources, possibly at the expense of simple needle and syringe provision (Maher & Iversen, 2009). As suggested
by Maher and Iversen, continued HIV/AIDS exceptionalism, may
be detrimental to the required NSP coverage and the basic prevention of BBVI. Mainstreaming, on the other hand, may potentially
increase the coverage of needle syringe distribution/exchange. Furthermore, in the absence of an AIDS crisis mentality, it may be
difcult to maintain even the present level of services for DUs
within a separate delivery system (Des Jarlais et al., 2009). Along
with DUs, the HRHCs are also stigmatised, and mainstreaming may
help reduce that stigma and normalise the provision of harm reduction services, paving the way to a sustainable framework. Using
existing systems of care for providing harm reduction health services would also be less costly (Saitz, Horton, Larson, Winter, &
Samet, 2005) as the infrastructure is already in place.
From an organisational standpoint two approaches to mainstreaming suggest themselves: (i) providing harm reduction
services through the regular healthcare system, or (ii) more closely
integrating HRHCs with mainstream healthcare services.
Providing NSPs/HRHCs services through the regular healthcare
system would require that system to adopt a harm reduction
approach and offer appropriate services to DUs with dignity (Des
Jarlais et al., 2009). This attitudinal change cannot be achieved
overnight. Even general practitioners (GPs), the rst point of contact for DUs in many parts of the world, remain fearful of demands
DUs might put on them (Abouyanni et al., 2000), feel they lack the
skill or condence to deal with DUs; and believe that DUs will be
difcult and/or aggressive. Many express concerns about the effectiveness, compliance and safety of opioid maintenance, lack of time
or remuneration, possible disruption to their practices, and the fear
of turning their practices into drug and alcohol clinics if they care
for a large number of DUs (Abouyanni et al., 2000). Specic attention on these issues in medical education appears to have had only a
modest impact (Silins, Conigrave, Rakvin, Dobbins, & Curry, 2007).
Providing harm reduction services through mainstream healthcare centres has led to positive outcomes in some settings. The
involvement of the primary healthcare sector (especially of ofcebased practitioners), alongside specialised treatment centres, has
permitted France and the UK to greatly improve accessibility of
substitution opioid treatments (Hedrich, Pirona, & Wiessing, 2008).
In France, for example, an estimated 84,500 DUs were receiving
high-dosage buprenorphine treatment in 2003 of which 90% was
provided by GPs. Similarly providing substance use treatment and
HIV prevention amongst DUs through Irans primary healthcare
system was found to be feasible (Mojtahedzadeh et al., 2008), and
participants who received daily needle exchange/condoms stayed
in substance use treatment longer than those who did not.
The second optioncloser integration of HRHCs with mainstream healthcare services could take several forms. In terms of
funding, staff management and policy-guidelines, HRHCs in many
settings are already part of the mainstream health structure. For
example, in Australia, France and some other countries HRHCs are
typically funded by the government. Yet because non-drug users
rarely access HRHCs they still function as an alternative health

platform for DUs. Encouraging non-drug users to access HRHCs for

general health issues may help reduce drug user stigma, and in
that way HRHCs may gradually become an better integrated part
of the mainstream health system. This is already done to a limited
extent in some services which offer treatment to other high risk
groups such as youth or sex workers (van Beek, 2007). In developing
countries where there is a huge shortage of qualied health professionals, HRHCs could be mainstreamed with fewer constraints.
Non-drug users of poor and disadvantaged backgrounds would be
likely to willingly use HRHCs if a range of quality services were
provided. However, in developed countries the availability of other
healthcare outlets and the stigma associated with DUs is likely to
be a substantial deterrent.
A further obstacle to integration is cost. Most HRHC services are
necessarily offered free-of-charge; increased use of these services
by non-drug users may require the implementation of a payment
system, and this could result in healthcare access inequity if services are provided free-of-charge to DUs only. Although cost may
not be an issue in settings with universal healthcare, it is likely to
be a signicant problem for settings which rely on private, donor
funded or philanthropic services, most notably in developing countries. Furthermore, in any setting, for DUs who do not have health
insurance, or for undocumented immigrants and other individuals engaged in illegal or covert behaviours, ofce-based healthcare
may not be affordable and loss of anonymity may also be a barrier
to access.
However, issues related to stigma remain a barrier even in
settings with universal healthcare. Nonetheless, if successfully integrated into the mainstream, HRHCs can provide a fertile training
ground for medical staff. Medical students and residents can meet
drug dependent patients in a normal setting and gain an appropriate sense of hope and compassion in caring for this population
(Stein & Samet, 1993). This in turn would help facilitate future
mainstreaming.
On one hand providing harm reduction services through the
mainstream health system may help increase the geographical
availability of such services. However most NSPs and HRHCs are
located at neighbourhoods with a high concentration of drug use
and/or places where DUs congregate. In these locations and through
either xed-site and/or mobile outreach facilities with suitable service hours, HRHCs increase coverage of healthcare services to DUs.
The managers of conventional healthcare outlets may not be prepared to locate them in places suitable for DUs or be able to ensure
exible opening hours. Therefore, closer integration of HRHCs with
the mainstream, rather than replacement by mainstream services,
may be the more appropriate option.
Furthermore, if comprehensive drug-treatment services are not
included in HRHCs then many would function not as specialised
services, but rather as simple, targeted primary healthcare services
within a distributive model (Stein & Samet, 1993). Such a model
makes it the responsibility of the HRHC to build links with DU
friendly services and enhance referral uptake and follow-up. This
in turn may enhance mainstreaming/integration as more external
services become experienced in dealing with the complex needs of
DUs. However, as with many models of primary healthcare delivery
to DUs, sound evidence for the effectiveness of this approach is lacking. Even HRHCs offering comprehensive drug treatment can be a
part of an integrated healthcare system provided there is an agreed
arrangement. For example, once treatment of DUs is stabilised, care
may be transferred to the primary care setting. However, again the
challenge lies in overcoming the difculty of securing primary care
appointments for DUs, who are often underinsured or uninsured.
There is an increasing number of ofce-based practitioners in
developed countries engaging in management of DUs. Although
these are not HRHCs (as they are not primarily for DUs) they
play an important role in mainstreaming harm reduction activities.

249

M.M. Islam et al. / International Journal of Drug Policy 21 (2010) 131133

However, this situation is much more problematic in developing settings, where authorities are mostly unwilling to accept
harm reduction principles and any being implemented are largely
by NGOs and voluntary organisations. The existing drug control
laws are often unfavourable to harm reduction. For example in
Bangladesh existing laws make it obligatory for physicians and
family heads to supply information on drug addiction to lawenforcement agencies (Islam & Conigrave, 2007). Although in
recent years concerned agencies have started to acknowledge harm
reduction principles, these principles are not yet accommodated in
existing laws. In such an unsupportive regulatory situation GPs may
be reluctant to handle drug dependent individuals. Even in countries where substitution therapy has been introduced recently (e.g.
India), GP involvement in this is not achievable overnight.
Any option for mainstreaming will require government funding. Although such arrangements are enjoyed by many developed
countries, in developing countries the lions share of funding for
care of DUs comes from development partners, and absorbing such
services into the general health system will be a huge burden for
governments. Development partners in this context could play an
inuential role, and it is encouraging that harm reduction is now
accepted by most major UN agencies including WHO, UNAIDS,
UNICEF, the World Bank, and the Global Fund to Fight AIDS, Tuberculosis and Malaria.
Stigma is likely to remain a signicant barrier to mainstreaming
even in well funded health systems, reducing DUs willingness to
access services, and providers ability to deliver quality care (Day,
Ross, & Dolan, 2003; Islam, Wodak, & Conigrave, 2008; Simmonds
& Coomber, 2009). In contrast, at NSPs, drug treatment centres or
HRHCs drug use is acknowledged without judgement or sanction
and this atmosphere of respect may increase DUs likelihood of
disclosing their health problems and engaging with services (Rich
et al., 2004). Moreover, the advantages of an independent, alternative system include responsiveness to the needs of the DUs,
organisational exibility, innovation and, most importantly, providing services within a harm-reduction frameworktreating DUs
with dignity and respect (Des Jarlais et al., 2009). Hence, HRHCs
in this context are a valuable and essential alternative healthcare
platform.
This raises further issues as there is considerable diversity
in national policies towards DUs, differences in national healthcare systems and contexts, particularly across upper, middle and
low-income countries. In many developing countries simple NSP
provision is facing difculties due to prohibition-based policies and
socio-cultural stigma associated with drug use. Even where HRHCs
have been established there is often little hope of sustainability.
Mainstreaming for those settings is still a long way off. Therefore,
it is unlikely that there will be a single best answer for all settings.
Clearly there are arguments for both alternative and mainstream
service provision. Steps towards mainstreaming can be piloted

133

in settings where stigma is less and policymakers support harm

reduction principles. However, as there are considerable risks, any
step towards mainstreaming should be taken whilst maintaining
the option of continuing the current forms of targeted harm reduction services.
References
Abouyanni, G., Stevens, L. J., Harris, M. F., Wickes, W. A., Ramakrishna, S. S., Ta, E.,
et al. (2000). GP attitudes to managing drug- and alcohol-dependent patients:
A reluctant role. Drug and Alcohol Review, 19, 165170.
Arponen, A., Brummer-Korvenkontio, H., Liitsola, K., & Salminen, M. (2008).
Trust and free will as the keys to success for the low threshold health
service centers (LTHSC). Helsinki: National Public Health Institute. Available at: http://www.ktl./attachments/suomi/julkaisut/julkaisusarja b/2008/
2008b24.pdf Accessed 27.12.09
Day, C., Ross, J., & Dolan, K. (2003). Hepatitis C-related discrimination among heroin
users in Sydney: Drug user or hepatitis C discrimination? Drug and Alcohol
Review, 22, 317321.
Des Jarlais, D. C., McKnight, C., Goldblatt, C., & Purchase, D. (2009). Doing harm reduction better: Syringe exchange in the United States. Addiction, 104(9), 14411446.
Friedmann, P., Hendrickson, J. C., Gerstein, D. R., Zhang, Z., & Stein, M. D. (2006).
Do mechanisms that link addiction treatment patients to primary care inuence subsequent utilization of emergency and hospital care? Medical Care, 44,
815.
Hedrich, D., Pirona, A., & Wiessing, L. (2008). From margin to mainstream: The
evolution of harm reduction responses to problem drug use in Europe. Drugs:
Education, Prevention and Policy, 15(6), 503517.
Islam, M. M., & Conigrave, K. M. (2007). Increasing prevalence of HIV, and persistent
high-risk behaviours among drug users in Bangladesh: Need for a comprehensive harm reduction programme. Drug and Alcohol Review, 26(4), 445454.
Islam, M., Wodak, A., & Conigrave, K. M. (2008). The effectiveness and safety of
syringe vending machines as a component of needle syringe programmes in
community settings. International Journal of Drug Policy, 19(6), 436441.
Latt, N., Conigrave, K., Saunders, J. B., Marshall, E. J., & Nutt, D. (2009). Addiction
medicine. Oxford: Oxford University Press.
Maher, L., & Iversen, J. (2009). Syringe exchange in the United States: Doing the
simple things better? Addiction, 104(9), 14481450.
McCoy, C. B., Metsch, L., Chitwood, D. D., & Miles, C. (2001). Drug use and barriers to
use of health care services. Substance Use and Misuse, 36, 789806.
McDonald, P. (2002). Prom streets to sidewalks: Developments in primary care
services for injecting drug users. Australian Journal of Primary Health, 8, 6569.
Mojtahedzadeh, V., Razani, N., Malekinejad, M., Vazirian, M., Shoaee, S., Saberi
Zafarghandi, M. B., et al. (2008). Injection drug use in rural Iran: Integrating
HIV prevention into Irans rural primary health care system. AIDS and Behavior,
12(4 Suppl.), S712.
Rich, J. D., McKenzie, M., Macalino, G. E., Taylor, L. E., Sanford-Colby, S., Wolf, F.,
et al. (2004). A syringe prescription program to prevent infectious disease and
improve health of injection drug users. Journal of Urban Health, 81(1), 122134.
Saitz, R., Horton, N. J., Larson, M. J., Winter, M., & Samet, J. H. (2005). Primary medical
care and reductions in addiction severity: A prospective cohort study. Addiction,
100(1), 7078.
Silins, E., Conigrave, K. M., Rakvin, C., Dobbins, T., & Curry, K. (2007). The inuence of structured education and clinical experience on the attitudes of medical
students towards substance misusers. Drug and Alcohol Review, 26, 191200.
Simmonds, L., & Coomber, R. (2009). Injecting drug users: A stigmatised and stigmatising population. International Journal of Drug Policy, 20(2), 121130.
Stein, M., & Samet, J. (1993). The linkage of primary care services with substance
abuse treatment: New opportunities for academic generalists. Journal of General
Internal Medicine, 8, 106107.
van Beek, I. (2007). Case study: Accessible primary health careA foundation to
improve health outcomes for people who inject drugs. International Journal of
Drug Policy, 18(4), 329332.

250

Appendix IV

(b) Islam, M. M., Topp, L., Day, C. A., Dawson, A., & Conigrave, K. M. (2012). The
accessibility, acceptability, health impact and cost implications of primary healthcare
outlets that target injecting drug users: A narrative synthesis of literature.
International Journal of Drug Policy, 23, 94-102.

251

International Journal of Drug Policy 23 (2012) 94102

Contents lists available at SciVerse ScienceDirect

International Journal of Drug Policy

journal homepage: www.elsevier.com/locate/drugpo

Review

The accessibility, acceptability, health impact and cost implications of primary

healthcare outlets that target injecting drug users: A narrative synthesis of
literature
M. Mozul Islam a,b, , Libby Topp c , Carolyn A. Day b,d , Angela Dawson e , Katherine M. Conigrave b,d,f
a

School of Public Health & Community Medicine, University of New South Wales, Sydney, Australia
Drug Health Service, Royal Prince Alfred Hospital, Sydney, Australia
c
Viral Hepatitis Epidemiology and Prevention Program, The Kirby Institute (formerly known as the National Centre in HIV Epidemiology and Clinical Research), University of New
South Wales, Sydney, Australia
d
Discipline of Addiction Medicine, Central Clinical School, Sydney Medical School, University of Sydney, Australia
e
Health Services and Practice Research Group, Faculty of Nursing, Midwifery and Health, University of Technology, Sydney, Australia
f
National Drug and Alcohol Research Centre, University of New South Wales, Australia
b

a r t i c l e

i n f o

Article history:
Received 29 May 2011
Received in revised form 8 August 2011
Accepted 17 August 2011
Keywords:
Primary healthcare
Injecting drug users
Harm reduction
Narrative synthesis

a b s t r a c t
Background: Injecting drug users (IDUs) are at increased risk of health problems ranging from injectingrelated injuries to blood borne viral infections. Access to primary healthcare (PHC) is often limited for
this marginalised group. Many seek care at emergency departments and some require hospital admission
due to late presentation. The costs to both the individual and the health system are such that policymakers in some settings have implemented IDU-targeted PHC centres, with a number of models employed.
However, there is insufcient evidence on the effectiveness of these centres to inform health service planning. A systematic review examining such interventions is not possible due to the heterogeneous nature
of study designs. Nevertheless, an integrative literature review of IDU-targeted PHC may provide useful
insights into the range of operational models and strategies to enhance the accessibility and acceptability
of these services to the target population.
Methods: Available literature describing the impact of IDU-targeted PHC on health outcomes, cost implications and operational challenges is reviewed. A narrative synthesis was undertaken of material sourced
from relevant journal publications, grey literature and policy documents.
Results: Several models have proven accessible and acceptable forms of PHC to IDUs, improving the overall
healthcare utilisation and health status of this population with consequent savings to the health system
due to a reduction in visits to emergency departments and tertiary hospitals.
Conclusions: Although such ndings are promising, there remains a dearth of rigorous evaluations of these
targeted PHC, with the public health impact of such outlets yet to be systematically documented.
2011 Elsevier B.V. All rights reserved.

Introduction
Injecting drug users (IDUs) are at risk of many health problems
(Latt, Conigrave, Saunders, Marshall, & Nutt, 2009) arising from
non-sterile injecting practices, injecting-related injuries, direct
drug effects and/or lifestyle factors associated with drug dependence. Furthermore, unrelated health problems may be neglected
due to a preoccupation with drug use. Despite their increased

Corresponding author at: Drug Health Service, King George V Bldg, Royal Prince
Alfred Hospital, Missenden Rd., Camperdown, NSW 2050, Australia. Tel.: +61 2 9395
0496; fax: +61 2 9515 5779.
E-mail addresses: mikhokan143@yahoo.com, m.m.islam@unsw.edu.au
(M.M. Islam).

need, many IDUs are for a variety of reasons reluctant to access

healthcare from conventional outlets (Day, Ross, & Dolan, 2003;
French, McGeary, Chitwood, & McCoy, 2000). For example, the
costs associated with medical treatment and transportation (Rowe,
2004), and the stigma and discrimination perceived by IDUs
within healthcare settings (Day et al., 2003) can hinder access
to care (McCoy, Metsch, Chitwood, & Miles, 2001). For many,
healthcare needs are complicated by homelessness and exacerbated by poor nutrition, mental health problems, abuse or
violence, chronic and infectious conditions, difculty maintaining
hygiene, and chaotic drug use (Anex, 2005; Rowe, 2004; Wright
& Tompkins, 2006). Even when services are accessed, healthcare
may take a lower priority than obtaining food, clothing, shelter and raising enough money to support drug use (Carr et al.,
1996).

0955-3959/$ see front matter 2011 Elsevier B.V. All rights reserved.
doi:10.1016/j.drugpo.2011.08.005

252

M.M. Islam et al. / International Journal of Drug Policy 23 (2012) 94102

Conventional medical services structured appointment systems may not suit IDUs lifestyles, resulting in dissatisfaction with
services (Merrill, Rhodes, Deyo, Marlatt, & Bradley, 2002). Criminal sanctions against drug use pose further barriers (Bluthenthal,
Kral, Lorvick, & Watters, 1997), particularly where the legal
status of interventions is ambiguous, negative attitudes persist, or law enforcement agencies are not well-informed about
medical approaches (Burris & Davis, 2008). IDUs with children may also avoid presenting to mainstream health services,
for fear of being referred to child protection services (Anex,
2005).
Although generalist medical practitioners (GPs) are often the
rst point of healthcare contact for drug-dependent patients
(Teesson, Hall, Lynskey, & Degenhardt, 2000) and GPs are increasingly involved in drug-related healthcare, many GPs lack the skill
or condence to deal with drug users; have concerns about the
effectiveness, compliance and safety of opioid substitution therapy
(OST); and fear that IDUs or OST patients will be difcult, aggressive
or demanding (Abouyanni et al., 2000). Other perceived barriers
include lack of time and remuneration for managing these complex
patients; concerns regarding possible disruption to their practices;
fear of turning their practices into drug and alcohol clinics if they
care for a signicant number of IDUs; and the limited support provided to GPs by public drug and alcohol services (Abouyanni et al.,
2000). Moreover, attention to these issues in medical education
has had only modest impact (Silins, Conigrave, Rakvin, Dobbins, &
Curry, 2007).
Given these barriers, a signicant proportion of IDUs postpone treatment until conditions become severe (Drumm, McBride,
Metsch, Neufeld, & Sawatsky, 2005; McCoy et al., 2001) resulting in a reliance on emergency departments and hospitals (French
et al., 2000) which consequently experience additional pressure
and signicant cost implications. The predominant causes of hospital admission in a cohort of IDUs in Vancouver, Canada were
pneumonia and soft-tissue infections, directly or indirectly related
to injecting (Palepu et al., 2001), highlighting the importance
of targeted preventive primary healthcare. In Australia, opioidrelated hospital separations for co-occurring medical conditions
such as endocarditis are estimated to cost, on average, approximately AU$25,000 per separation (Riddell, Shanahan, Roxburgh, &
Degenhardt, 2007).
Barriers to healthcare and the considerable costs of emergency
treatments have led authorities in some settings to establish IDUtargeted PHC centres. This review denes IDU-targeted PHC as
primary healthcare services that include low-threshold healthcare
mainly targeting IDUs. Such centres remove most barriers faced
by IDUs in accessing traditional health services. The key harm
reduction interventions offered to IDUs are needle and syringe programmes (NSPs) and/or OST, coverage of which varies considerably
across the world (Mathers et al., 2010). PHC centres may be colocated with such services in order to facilitate their utilisation
amongst the target population. Although IDU-targeted PHC centres are increasingly being established across a range of settings
and utilising a variety of models, a systematic review on this topic
has not been conducted. Moreover, a scoping exercise undertaken
as part of this study identied that relevant literature is widely
dispersed across a number of disciplines and includes qualitative
and quantitative study designs. This review synthesizes available
documentation in order to facilitate the evidence-base for rational
decision making.
The aims of this descriptive review are to:

(a) outline operational models of IDU-targeted PHC and assess the

accessibility and acceptability of these services to the target
population; and

95

(b) synthesize the ndings from evaluations of these PHC with

respect to their impact on health outcomes, cost implications
and operational challenges.

Methods
A comprehensive search was undertaken of the electronic
databases Medline, Medscape, Current Contents, HealthSTAR,
Addiction Abstracts and CINAHL from 1966 to the present. Search
terms entered were primary healthcare for intravenous drug
users, targeted primary healthcare for drug users, primary
healthcare for marginalised population, healthcare for IDUs,
primary health clinic for drug users, healthcare from needle
syringe programme outlet, syringe exchange programme based
healthcare, opportunistic healthcare for drug users, drug users
targeted healthcare, harm reduction based healthcare and primary health services for drug users. Hand searching of reference
lists was also undertaken. As targeted PHC for drug users is a relatively recent innovation and there are likely to be service-related
documents not yet located in the peer-reviewed literature, the
grey literature was also searched, primarily via the Google search
engine using identical search terms. Relevant websites (for example, the European Monitoring Centre for Drugs and Drug Addiction
[EMCDDA]) were also searched.
Inclusionexclusion criteria were developed, based upon a
checklist derived from this reviews aims and the quality of
methods, ndings and interpretation (Eakin & Mykhalovskiy,
2003), to assess the literature identied through the search strategy. Articles/reports that described implementation or evaluation
or outcomes of interventions and epidemiological studies were
included in this review, as these are likely to report factors shaping
implementation, acceptability and accessibility. A total of 35 papers
concerning targeted PHC for drug users were identied. Eighteen peer-reviewed articles identied through electronic database
searching directly or indirectly described PHC that targets IDUs.
An additional three articles and two reports located through handsearching the reference lists of papers were also included.
Narrative synthesis was employed to analyse the selected material as per current guidelines (Arai et al., 2007; Popay et al.,
2006). This methodology is well suited to this study as onethird of the retrieved literature described implementation studies
or process evaluations characterised by considerable diversity in
their methodology, design and/or data collection technique (Lucas,
Baird, Arai, Law, & Roberts, 2007). Moreover, narrative synthesis is appropriate in this context to identify the factors shaping
the implementation of IDU-targeted PHC, (i) their accessibility, (ii)
acceptability and (iii) operational challenges, which are vital to policymakers. Documentation was examined and data coded under
these three themes. In addition, the material was interrogated to
establish impacts upon health outcomes and cost implications.
The review focuses on the most common models for IDUtargeted PHC which are those co-located with NSPs and/or OSTs
or other similar services targeting IDUs. PHC in ofce-based practitioner settings such as those provided by individual GPs are not
considered, as these do not usually target IDUs specically, and are
difcult to delineate as they operate under a plethora of models.
The small number of supervised injecting facilities which provide
onsite PHC are also considered outside the scope of this review
as they differ markedly from the more common models of IDUtargeted PHC centres. The literature around services provided by
supervised injecting facilities has to date focussed on elements
related to their core mandate, namely the provision of a supervised
place to inject. Limited information, and no outcome evaluations,
are available on the PHC provided by these services; thus inclusion
of this information would add little to this review.

253

96

M.M. Islam et al. / International Journal of Drug Policy 23 (2012) 94102

Primary healthcare is dened as socially appropriate, universally accessible, scientically sound rst level care supported
by integrated referral systems in a way that addresses health
inequalities; maximises community and individual self-reliance,
participation and control; and involves collaboration and partnership with other sectors to promote public health. It includes health
promotion, illness prevention, treatment and care of the sick, community development, and advocacy and rehabilitation (Australian
Primary Health Care Research Institute, 2005). More specically, as
dened by the WHO (World Health Organization, 2009), primary
healthcare for IDUs refers to a comprehensive harm-reduction
package including outreach; peer-led interventions; information, education and communication; condoms; sterile injecting
equipment; and effective drug treatment including OST; early identication and treatment of sexually transmissible infections (STIs)
and blood-borne viral infections (BBVIs) and other drug use-related
illnesses; and care, treatment and support for HIV infected drug
users.
Denitions of the terms accessibility and acceptability abound
in the medical literature (Ansari, 2007). This review connes accessibility to two indicators: (i) is the service located in a suitable
place, for example, a place where drug users congregate, or a neighbourhood with a high concentration of drug use? and (ii) has the
service attempted to reduce barriers known to impede IDUs access
to healthcare? Service acceptability was indicated by measures
such as clients return rate; perceived friendliness of and/or ease of
communication with staff; and uptake of referrals to other services
(Rowe, 2004).
Operational models were categorised by three major variables:
main services provided, workforce prole and exibility of service
delivery, for example, outreach and/or drop in capacity.

Results
Operational models
Twenty of 35 papers described implementation of IDUtargeted PHC, with information concerning workforce prole,
range of services and/or service modality (Table 1). The underlying approaches vary. They may be distributive, providing
basic harm reduction services and simple healthcare with facilitated referrals to specialist services (Stein & Samet, 1993), such
as the IDU-targeted low-threshold centres in Finland (Arponen,
Brummer-Korvenkontio, Liitsola, & Salminen, 2008). Others are
one-stop-shops where a range of services, including specialist services, are provided onsite (Stein & Samet, 1993), for example the
Kirketon Road Centre in Sydney, Australia (van Beek, 2007).
The services offered vary across settings. Services provided at
the majority of IDU-targeted PHC centres include NSPs, wound/vein
care, doctor/nurse consultations, testing for BBVIs and STIs, urinalysis and pregnancy testing, hepatitis B and A vaccinations and
counselling. Some centres offer OST and hepatitis and HIV treatment (van Beek, 2007), dental care (EMCDDA, 2009a). Some centres
provide on-site mental health services (Kwan, Ho, Preston, & Le,
2008; Norman, Mugavin, & Swan, 2006; Ross, Lo, McKim, & Allan,
2008). The majority of centres also offer social and/or welfare services, including meals, telephone and sometimes internet facilities,
rest-rooms, coffee and snacks, legal services (Arponen et al., 2008;
EMCDDA, 2009b; IKHLAS, 2009; Kwan et al., 2008; Norman et al.,
2006); haircuts (IKHLAS, 2009); and/or showers and washing facilities (Arponen et al., 2008).
An important subset of IDU-targeted PHC is NSP-based PHC.
NSPs in many settings have been augmented to incorporate PHC
services for IDUs. For instance, one-third of NSP-based primary
healthcare outlets in USA provide onsite medical care (Des Jarlais,

McKnight, Goldblatt, & Purchase, 2009). In 2008, most NSPs in the

USA offered clinical services, including counselling and/or testing
for HIV (87%), hepatitis C (65%), sexually transmitted infections
(55%), and tuberculosis (31%). Eighty-nine percent provided referrals to drug dependence treatment (Centers for Disease Control and
Prevention, 2010).
Accessibility and acceptability of IDU-targeted PHC
Accessibility
The majority of IDU-targeted PHC centres described in the literature are located (or co-located) in neighbourhoods with high
concentrations of drug use, red-light districts and/or places where
drug users congregate to buy drugs or access services (e.g. OSTs or
NSPs). About half of the papers emphasised the appropriate location
of their service(s) as facilitating accessibility (Table 1). All except
four PHC centres also provided on-site NSP; of those four, three
were co-located with an NSP and the fourth did not mention NSP
services. A recurrent theme is that NSPs/OSTs attract clients, and
providers utilise this opportunity to engage clients in healthcare
(Carr et al., 1996; Morrison & Ruben, 1995).
Enhancement of NSPs to include PHC is feasible (Day et al., 2011;
Pollack, Khoshnood, Blankenship, & Altice, 2002) because IDUs trust
NSPs (Lauretta, Grau, Arevalo, Catchpool, & Heimer, 2002). Altice
and colleagues found that completion of the hepatitis B vaccination schedule amongst IDUs attending an NSP was substantially
higher than amongst groups referred to other services, suggesting that NSPs may effectively provide preventive healthcare (Altice,
Bruce, Walton, & Buitrago, 2005).
No IDU-targeted PHC reviewed used structured appointment
systems. Most patients were seen on an informal, walk-in, rstcome rst-served basis. Anonymity was a salient theme highlighted
in almost all the articles/documents reviewed. Anonymous access
removes barriers for undocumented immigrants and individuals
engaged in other illegal or covert behaviours (Harris & Young,
2002). Some centres followed a needs-based opening hours system;
for example, the drop-in centre in Glasgow offered healthcare from
7.30 p.m. to midnight to accommodate work practices of female sex
workers, most of whom were drug users (Carr et al., 1996). Similarly, the mobile outreach clinics of Kirketon Road Centre offered
PHC seven evenings a week to meet the needs of street-based IDUs
and sex-workers (van Beek, 2007). Suitable service hours are pivotal to increased access and continuity of care for marginalised
groups (Carr et al., 1996).
The majority of IDU-targeted PHC centres offered outreach services and some had mobile arrangements to facilitate coverage
of a wide geographical area and offer services to hidden populations. Almost all outlets provided services free-of-charge to
remove nancial barriers to healthcare. Health insurance or government healthcare benets were not required to access services.
Outreach services and mobile arrangements increased accessibility by covering wider geographical areas, taking services to those
who might not present until a late stage. For example, the Community Health Care Van, a mobile outlet in New Haven, USA, targeted
out-of-treatment IDUs with medical and social services at four locations. The timing and location of the van reected the schedule of
New Haven NSP (Pollack et al., 2002). Similarly, operating seven
evenings a week, the outreach bus of Kirketon Road Centre was
tted out as a mobile clinic and visited street locations where sex
work and injecting drug use occur (van Beek, 2007).
Acceptability
One evaluation examined both clients and managers feedback on service acceptability (Norman et al., 2006) and another
study examined clients satisfaction (Harris & Young, 2002). A further 13 reports discussed acceptability based on authors own

254

Table 1
Services provided, stafng and reported accessibility and acceptability of primary healthcare outlets for IDUs.
The centre (reference)

CHCV, New Haven, USA

(Pollack et al., 2002)
CityWide harm reduction, New
York, USA (Mund et al., 2008)

Health clinics for problem drug

users, London, UK (Gerada
et al., 1992)
ISIS Clinic, San Francisco, USA
(Harris & Young, 2002)
Kirketon Road Centre (KRC),
Sydney, Australia (van Beek,
2007)
Living Room, Melbourne,
Australia (Norman et al.,
2006)
Low-threshold health service
centres for IDUs, Finland
(Arponen et al., 2008)
Low-threshold service,
Ganslwirt, Vienna, Austria
(EMCDDA, 2009b; Weigl
et al., 2009)
Maryland Centre, Liverpool, UK
(Morrison & Ruben, 1995)
Merchants Quay, Dublin,
Ireland (EMCDDA, 2009c)
Next Door, Melbourne,
Australia (Norman et al.,
2006) 
Puentes Clinic, San Jose, USA
(Kwan et al., 2008)
Redfern Harm Minimisation
Clinic, Sydney, Australia (Day
et al., 2011)
SEP for HIV prevention, Malmo,
Sweden (EMCDDA, 2009e)

Major services provided

Stafng

Facility

Reported
accessibility

Reported
acceptability

OST

HCV/HIV
treatment

Hepatitis B
vaccination

Social and
welfare
services

Other basic
medical
services

Medical

Nursing

Counselling

Outreach

Drop-in

High concentration
of injecting drug use
Neighbourhood with
high HIV and
drug-related
mortality rates
Large numbers of
street-based IDUs

+/

NM

NM

NM

Red-light area

NM

Red-light district

Large numbers of
street-based
IDUs/Drug hot spot

Under-serviced part
of the city with
pockets of drug use
Peripheries of
deprived housing
estates
San Francisco general
hospital
Red-light area

NM

NM

NM

NM

NM

NM

+/+

Drug hot spot

Mainly in cities with

high prevalence of
drug use
Large numbers of
street-based IDUs

+*

+*

NM

High rates of drug

use
High rates of drug
use
Drug hot spot

NM

+/

Co-located with
outpatient OST clinic
Large number of
Aboriginal IDUs and
high rates of drug use
In an outpatient
clinic, drug affected
area

+/

=
/

NM

NM

NM
97

NSP

M.M. Islam et al. / International Journal of Drug Policy 23 (2012) 94102

Direct aid and support unit of

Okana, Athens, Greece
(EMCDDA, 2009a)
Drop-in centre, Glasgow, UK
(Carr et al., 1996)
Drop-in centre, IKHLAS, Chow
Kit, Malaysia (UNAIDS, 1999)
(i) Foster Street, (ii) Health
Works, (iii) Access Health,
Melbourne, Australia
(Norman et al., 2006) 
HAHRC, Alberta, Canada (Ross
et al., 2008)

Placement of primary
healthcare

255

Abbreviations: HAHRC = Health and Harm Reduction Clinic. CHCV = Community Health Care Van. ISIS = Integrated Soft Tissue Infection Services. SEP = Syringe Exchange Programme.  = As all information required for this table
/ = Close collaboration with detoxication and
were not available, managers of respective outlets were contacted for required information. # = Close links with NSP. NM = Not mentioned. OMP = Opioid maintenance programme. =
substitution units. = Currently not available but referral is available almost from all the centres. = Paramedic staff. * = About half of the centres have this facility.

Services have been presented in alphabetical order.

+
+
+
+
+
+
+
+

/
+
High rates of drug
use

+
+
+
+
+
+
+
+
+
+/+
+
High levels of drug
use and HIV

+
+
+
+
+

+
NM

/
+

The Lifesaving and Life-giving

Society (LALS), Kathmandu,
Nepal (Singh, 1997, 1998)
The Triangular Clinic in
Kermanshah, Iran (World
Health Organization, 2004)
Wound and abscess clinic,
Oakland, USA (Lauretta et al.,
2002)

Areas frequented by
drug users

M.M. Islam et al. / International Journal of Drug Policy 23 (2012) 94102

98

perceptions (Table 1). Features reported to enhance acceptability include client anonymity, condentiality, non-judgemental
and friendly staff attitudes, a harm reduction service provision
framework, drop-in arrangements and no-cost services (Table 2).
Providing a welcoming environment, ensuring a place where
clients can have time out (Kwan et al., 2008), responsivity to client
needs, the employment of peer workers and women-only (or specic group) times are also important (Norman et al., 2006). Most
reports describe a user-friendly approach to service delivery and
do not pressure clients, thus avoiding alienation and increasing
the likelihood of continuing engagement. Some IDU-targeted PHC
centres combine workers duties in both outreach and xed-site
settings, as some clients engaged by the outreach service prefer to
consult a familiar worker in the xed location (McDonald, 2002).
In a snapshot survey conducted for evaluating seven IDUtargeted PHC centres in Victoria, Australia, 97% of clients reported
that they liked staff; 92% found services non-judgemental; 89%
felt they could discuss their health problems openly; and 95%
reported they felt safe (Norman et al., 2006). Similarly, 86% of
patients expressed positive views on the Integrated Soft Tissue
Infection Service Clinic in San Francisco; and 92% reported that
they were denitely or very likely to recommend the clinic to
others (Harris & Young, 2002). Indeed, all reports described a substantial improvement in attracting new clients. However, none
of the studies employed rigorous, independent measures most
measures were subjective and relied on client and staff selfreports.
An important aspect of acceptability is difculties experienced
in accessing other available healthcare services, which to some
extent determines the degree of acceptability of these targeted
PHC centres. For instance, in a study on two of the oldest IDUtargeted PHC outlets in London, Gerada and colleagues found that
only 38% of clients were registered with a GP (Gerada, Orgel, &
Strang, 1992). Even those registered expressed reluctance to attend
GPs. Although not an extensive study by design, the authors commented that most patients were grateful for access to medical care
and used the facilities appropriately. However, methods used to
measure acceptability were not described.
The tendency of a growing number of IDU-targeted PHC centres to provide a wide range of healthcare, social and/or welfare
services increases their acceptability to clients (Morrison, Elliott, &
Gruer, 1997). Sometimes references prepared for housing departments, welfare agencies, police or courts and the provision of
meals (Carr et al., 1996; EMCDDA, 2009d; IKHLAS, 2009) may take
precedence for clients, but can facilitate the adjunct offer of healthcare (Morrison & Ruben, 1995). Consequently, homeless drug users
are an important client group for most IDU-targeted PHC centres
(Harris & Young, 2002; Kwan et al., 2008; Norman et al., 2006;
Rowe, 2005).
Four articles reported clients return rate and/or frequency of
service utilisation as an indicator of acceptability. An internal
le-audit of 200 clients of inner-city Sydneys Redfern Harm Minimisation Clinic (an NSP-based PHC) revealed that 90% made at least
one return visit (Day et al., 2011). The authors argued that this
high return rate was largely attributable to systematic follow-up
and co-location with an NSP. Twenty-eight percent (n = 370) of all
rst-time-contacts that attended Dublins Merchants Quay health
promotion unit during an 18-month period re-visited during the
3-month follow-up. At follow-up, 18% of attendees who reported
at baseline no history of HIV testing at rst visit, had undertaken
testing; and 10% who reported at baseline not being vaccinated
against hepatitis B had undertaken vaccination (EMCDDA, 2009c).
More than half of initial clients of Puentes clinic, San Jose regularly
used its services 5 years after opening, implying that the clinic functions as a medical home for this population (Kwan et al., 2008).
The Maryland Centre in Liverpool (United Kingdom) provided 5308

256

M.M. Islam et al. / International Journal of Drug Policy 23 (2012) 94102

99

Table 2
Key themes associated with accessibility, acceptability and operational problems of IDU-targeted PHC centres.
Associated with accessibility

Associated with acceptability

Associated with operational problems

Suitable location (e.g. NSP/OSTs, etc.)

Flexibility in appointment and drop-in arrangements
Condentiality/anonymity (no fear of notication to authorities)
Cost-free services
Opening hours based on need

Harm reduction based service provision

Arrangement of social and welfare services
Tailored to the lifestyle of client group
Reluctance to attend conventional healthcare outlets

Financial sustainability
Unknown service quality

medical consultations, an average of more than seven per client

(Morrison & Ruben, 1995).
Impacts on health outcomes
Receipt of PHC by drug users is associated with reduced severity of drug dependence. Two randomised controlled trials showed
that patients with drug-related medical conditions were signicantly more likely to achieve abstinence or report reduced opiate
use and improved medical outcomes in the onsite care group (PHC
included within the drug treatment programme) than the independent care group (PHC and drug treatment provided separately)
(McLellan, Arndt, Metzger, Woody, & OBrien, 1993; Weisner,
Mertens, Parthasarathy, Moore, & Lu, 2001). In a retrospective
cohort study, patients who received onsite PHC demonstrated signicantly reduced severity of dependence compared to patients
who received offsite PHC, but not necessarily improvement in
other health outcomes (Friedmann, Zhang, Hendrickson, Stein, &
Gerstein, 2003). A more recent study found that receipt of PHC
in a distributive model by drug-dependent adults was associated with reduced problems and severity of dependence over a
24-month period (Saitz, Horton, Larson, Winter, & Samet, 2005).
However, the centre did not target solely IDUs. An evaluation
of Finnish IDU-targeted low-threshold PHC concluded that PHC
and harm reduction services are effective in engaging hard-toreach IDUs and preventing BBVI transmission (Arponen et al.,
2008).
Referrals are made from IDU-targeted PHC centres to a range of
services including GPs, hospital emergency departments, tertiary
outpatient clinics, infectious disease, general medicine, surgery,
orthopaedic, gynaecology/obstetrics, psychiatry and welfare services, but limited information is available on referral uptake. A
recent study of Redfern Harm Minimisation Clinics (Sydney) clients
showed that 65% of clients who were positive for hepatitis C PCR
attended at least one referral to a tertiary liver clinic (Islam, Hayes,
et al., 2010). An Australian evaluation which assessed 12 PHC centres and ancillary programmes accessed mainly by IDUs, found that
clients reported these targeted PHC centres as their base and a
means to access other services, with the majority also reporting
contact with a GP in the preceding 6 months. Rates of GP contact
were much higher than those found in a needs analysis conducted
in 1999 with a similar population. However, the survey, intended
only to provide a snapshot, was conducted with a convenience
sample of just 10 clients per xed site. In addition, the self-report
data were limited by potential social desirability bias (Norman et al.,
2006).
Around half of IDU-targeted PHC centres offer assessment and
testing for STIs and one-third offer onsite treatment. A recent casereport from an NSP-based PHC demonstrated that the provision of
PHC from an NSP can facilitate the early diagnosis of HIV and help
prevent the spread of BBVIs and STIs (Islam et al., 2011). The Triangular Clinic in Kermanshah, Iran that has been conceptualised
to address three critical issues in drug misuse intervention: harm
reduction, STI treatment and HIV care, found that the majority
of HIV-positive clients substantially changed their risk behaviours
(World Health Organization, 2004).

Cost implications
Although there are no data on the cost-effectiveness of IDUtargeted PHC, a wound and abscess clinic conducted in an NSP in
Oakland was reported to have provided economical treatment and
aftercare for injection-associated soft tissue infections. The visit
cost was estimated at US$5 per patient, much less than the estimated costs at hospital outpatient settings (Lauretta et al., 2002).
The Integrated Soft Tissue Infection Service Clinic in San Francisco
dramatically reduced emergency department visits (33.9%), surgical service admissions (47.3%), inpatient acute care bed days
(33.7%), and operating room procedures (71%), saving approximately US$8.7 million in the rst year of operation (Harris & Young,
2002). A full-scale implementation of Community Health Care Van,
New Haven was associated with more than 20% reduction in emergency department visits, suggesting potentially huge cost savings
(Pollack et al., 2002).
Operational challenges
Reported operational challenges include lack of funding/resources, difculties in retaining clients, limited range of
services, police harassment and staff shortages. For example, an
evaluation of the Ganslwirt Centres OST programme in Vienna
indicated that treatment often ends prematurely and suddenly
due to staff uctuations in the outpatient clinic (Weigl et al., 2009).
Prejudice and suspicion towards their ethos and clients have
forced some IDU-targeted PHC centres to relocate, sometimes to
locations where client accessibility has been considerably reduced
(Arponen et al., 2008).
The quality of healthcare services from IDU-targeted PHC centre
is not clearly documented in the existing literature. Some services offer comprehensive and quality healthcare, whereas others
have capacity to provide limited services, potentially of inadequate
quality. Satisfaction was the most commonly recorded quality
measure, albeit in less than a quarter of the services reviewed.
Other quality measure such as scope, completeness, effectiveness,
efciency and safety of interventions (Donoghoe, Verster, Mathers,
& Secretariat of the Reference Group to the United Nations on HIV
and injecting drug use, 2009) were rarely recorded.
Discussion
This review illustrates the barriers to IDUs access to mainstream
healthcare services and suggests that IDU-targeted PHC centres, by
providing non-judgemental and cost-free services under a harm
reduction framework, are likely to increase the accessibility and
acceptability of PHC to this population. Providing anonymous services from a suitable location, preferably where IDUs dwell or
congregate, and with appropriate opening hours, drop-in provision,
and peripheral services may potentially increase IDUs engagement
and satisfaction with these services. Targeted PHC outlets have the
potential to mitigate IDUs perceived barriers to access to healthcare delivered in traditional settings. The provision of accessible
and acceptable services which are responsive to the needs of this

257

100

M.M. Islam et al. / International Journal of Drug Policy 23 (2012) 94102

population is valuable, facilitating a reduced reliance on inappropriate and cost-ineffective emergency department care.
The majority of IDU-targeted PHC centres provide a limited set
of medical services which tend to relate directly or indirectly to
drug use. Although the constraints of the literature precluded systematic comparisons of accessibility and acceptability to that of GPs
or other conventional PHC outlets, results concerning accessibility
and acceptability are nevertheless important because IDU-targeted
PHC centres are tailored to, and seek to make contact with, people
who may not be committed to lifestyle change. Consequently, the
relationship between NSP staff and their regular clients facilitates
healthcare provision. Thus, equipping NSPs, drug treatment centres
or other drug-related services with PHC support may facilitate IDUs
access to healthcare. Referral-only linkage systems to conventional
PHC centres may be insufcient for IDUs, whereas on-site services
may lead to better outcomes (Campbell et al., 2007). Augmenting
NSPs and similar services to include PHC may save resources by
building on existing infrastructure and increasing early access to
treatment.
Not all IDU-targeted PHC models suit all settings; the type of
facility that is most appropriate will be inuenced by, amongst
other characteristics, the availability, affordability and assistance
of other services; the geographical area; and patterns of drug use
amongst target populations; existing drug policy; and level of tolerance; and social stigma associated with illicit drug use. However,
for any health service to be accessible and credible to IDUs, a nonjudgmental and client-centred philosophy is essential. Thus, the
benets of targeted PHC are mostly enjoyed in settings where harm
reduction is accepted either explicitly in national policy documents
and/or through the implementation or tolerance of harm reduction
interventions. Even where harm reduction is considered to oppose
the existing drug policy and is only grudgingly tolerated, offering
PHC in conjunction with NSPs has the potential to enable the outlet
to function as a medical centre for IDUs.
Providing health and social services beyond syringe distribution
can improve the attractiveness of NSP services. Hence, IDU-targeted
PHC centres are in this context a valuable and essential healthcare
platform. It is, however, important to ensure that the provision
of ancillary services does not inadvertently restrict NSP coverage
by consuming available funds. Harm reduction is still woefully
under-funded (Bergenstrom et al., 2010). It might, therefore, be
reasonable to consider the gradual mainstreaming of these services into traditional healthcare delivery (Islam, Day, & Conigrave,
2010). However, achieving mainstreaming is challenging and it
is unlikely that there will be a single best answer for all settings due to substantial geographical, cultural, policy and practice
variation.
An important concern yet to be addressed in the literature is the
quality of healthcare offered by IDU-targeted PHC centres. Given
that these centres vary across settings in terms of services provided,
the workforce employed and service modalities, it is inevitable that
service quality will also vary. Moreover, services are offered free-ofcharge, and with many IDU-targeted PHCs offering other essential
services like NSPs or OSTs within limited budgets, nancial sustainability of the centres may be tenuous, which may impact on service
breadth and quality. For example, HIV and hepatitis B testing
were temporarily suspended at a service in Nepal due to funding constraints (Singh, 1997). Further research is needed on this
issue.
IDUs endure a plethora of health problems and experience a
range of barriers to accessing healthcare. Developing targeted PHC
has substantial potential to reduce harm and improve healthcare
for marginalised IDUs. As NSPs and drug treatment services are regularly accessed by IDUs, these centres could be enhanced to include
PHC outlets. Such PHCs may improve IDUs health and reduce
health expenditure by reducing tertiary service utilisation. Further

evaluation using robust research designs is necessary to clearly

establish the effectiveness and cost-effectiveness of these PHC outlets.
This review suffers a range of limitations. There are no doubt
other services that have not been discussed in the published literature. Moreover, only literature published in English was reviewed.
Furthermore, there is a dearth of published material that outlines
obstacles encountered in establishing and implementing services.
Most reports are case-studies or process evaluations; some are
published only in grey literature; and rigorous effectiveness and
cost-effectiveness evaluations are lacking, which impacts on the
rigour of the study and quality of results. Having not undergone
peer review, information found in grey material may not be generalisable to other contexts. It is nevertheless important to include
grey literature in a review as excluding material that is not widely
available may introduce a methodological bias and hence the study
cannot be considered exhaustive. Findings from PHC targeting IDUs
in abstinence-oriented policy settings would enrich this review,
however, all documents retrieved were from settings where harm
reduction is either accepted or tolerated. Discussion of other setting
characteristics that may impact upon accessibility, acceptability
and health outcomes is considered beyond the scope of this review.
Due to limited literature from developing countries, acceptability was examined on the same terms for all settings including those
with and without universal healthcare provisions. The narrative
synthesis approach relies on a high level of trust in assumptions
made by the authors. Implementation is rarely the focus of published reports of interventions, particularly those published in
peer-reviewed journals where brevity is an editorial requirement.
Although some implementation data may be found interspersed
throughout the text and predominantly in the discussion section,
where authors provide an explanation for the effectiveness, in
many cases these explanations are not empirically supported. There
is a pressing need for careful evaluation of key outcomes, particularly differences in tertiary healthcare utilisation by IDUs and
referral uptake and outcomes. Other important questions remain,
such as whether the one-stop shop or distributive model is
more effective and/or cost-effective in improving the health of
IDUs (Stein & Samet, 1993). Well-designed studies are required to
address such questions.
In conclusion, the ndings of this review indicate that IDUtargeted PHC centres provide non-judgemental and cost-free
services under a harm reduction framework and can increase the
accessibility and acceptability of primary healthcare for IDUs. However, there is a dearth of rigorous evaluations of these targeted
PHC centres, with the public health impact of such outlets yet to
be systematically documented. Until such services are supported
to undertake rigorous outcome evaluations that clearly document
their public health impact, challenges will remain in attracting the
funding necessary to implement these targeted PHC and, where
appropriate, expand and scale-up the services they deliver.
Acknowledgements
The rst author is supported by a University International Postgraduate Award of University of New South Wales. C.D. is supported
by a National Health and Medical Research Council (NHMRC) Public
Health Post Doctoral Fellowship.
References
Abouyanni, G., Stevens, L. J., Harris, M. F., Wickes, W. A., Ramakrishna, S. S., Ta, E.,
et al. (2000). GP attitudes to managing drug- and alcohol-dependent patients:
A reluctant role. Drug and Alcohol Review, 19, 165170.
Altice, F. L., Bruce, R. D., Walton, M. R. & Buitrago, M. I. (2005). Adherence to hepatitis
B virus vaccination at syringe exchange sites. Journal of Urban Health: Bulletin of
the New York Academy of Medicine, 82, 151161.

258

M.M. Islam et al. / International Journal of Drug Policy 23 (2012) 94102

Anex. (2005). Primary health care Australia: Bulletin.
Ansari, Z. (2007). A review of literature on access to primary health care. Australian
Journal of Primary Health, 13, 8095.
Arai, L., Britten, N., Popay, J., Roberts, H., Petticrew, M., Rodgers, M., et al. (2007).
Testing methodological developments in the conduct of narrative synthesis:
A demonstration review of research on the implementation of smoke alarm
interventions. Evidence & Policy, 3, 361383.
Arponen, A., Brummer-Korvenkontio, H., Liitsola, K. & Salminen, M. (2008).
Trust and free will as the keys to success for the low threshold health service
centers (LTHSC). Helsinki, Finland: National Public Health Institute. Retrieved
27 December 2009 from http://www.ktl./attachments/suomi/julkaisut/
julkaisusarja b/2008/2008b24.pdf
Australian Primary Health Care Research Institute. (2005). What is primary
health care? Canberra, Australia: APHCRI. Retrieved January 2011 from
http://www.anu.edu.au/aphcri/General/phc denition.php
Bergenstrom, A., McLeod, R., Sharma, M., Mesquita, F., Dorabjee, J., Atun, R., et al.
(2010). How much will it cost? Estimation of resource needs and availability
for HIV prevention, treatment and care for people who inject drugs in Asia.
International Journal of Drug Policy, 21, 107109.
Bluthenthal, R. N., Kral, A. H., Lorvick, J. & Watters, J. K. (1997). Impact of law enforcement on syringe exchange programs: A look at Oakland and San Francisco.
Medical Anthropology, 18, 6183.
Burris, S. & Davis, C. S. (2008). Blueprint for reforming access to therapeutic opioids.
Beasley School of Law, Temple University: Center for Health Law, Policy and
Practice.
Campbell, J. V., Garfein, R. S., Thiede, H., Hagan, H., Ouellet, L. J., Golub, E. T., et al.
(2007). Convenience is the key to hepatitis A and B vaccination uptake among
young adult injection drug users. Drug Alcohol Depend, 91(Suppl. 1), S64S72.
Carr, S., Goldberg, D. J., Elliott, L., Green, S., Mackie, C. & Gruer, L. (1996). A primary
health care service for Glasgow street sex workers 6 years experience of the
drop-in centre, 19891994. AIDS Care, 8, 489497.
Centers for Disease Control and Prevention. (2010). Morbidity and Mortality Weekly
Report, 59, 14881491.
Day, C., Ross, J. & Dolan, K. (2003). Hepatitis C-related discrimination among heroin
users in Sydney: Drug user or hepatitis C discrimination? Drug and Alcohol
Review, 22, 317321.
Day, C. A., Islam, M. M., White, A., Reid, S. E., Hayes, S. & Haber, P. S. (2011). Development of a nurse-led primary healthcare service for injecting drug users in
inner-city Sydney. Australian Journal of Primary Care, 17, 1015.
Des Jarlais, D. C., McKnight, C., Goldblatt, C. & Purchase, D. (2009). Doing harm reduction better: Syringe exchange in the United States. Addiction, 104, 14411446.
Donoghoe, M.C., Verster, A.D., Mathers, B., & Secretariat of the Reference Group to the
United Nations on HIV and injecting drug use (2009). In B. Malhotra (Ed.), WHO,
UNODC, UNAIDS technical guide for countries to set targets for universal access to
HIV prevention, treatment and care for injecting drug users, Geneva: World Health
Organization.
Drumm, R. D., McBride, D. C., Metsch, L., Neufeld, M. & Sawatsky, A. (2005). Im a
health nut!, Street drug users accounts of self-care strategies. Journal of Drug
Issues, 35, 607629.
Eakin, J. M. & Mykhalovskiy, E. (2003). Reframing the evaluation of qualitative health
research: Reections on a review of appraisal guidelines in the health sciences.
Journal of Evaluation in Clinical Practice, 9, 187194.
EMCDDA. (2009a). Direct aid and support unit of OKANA. Retrieved 20
December 2009 from http://www.emcdda.europa.eu/modules/wbs/dsp print
project description.cfm?project id=2647
EMCDDA. (2009b). Low threshold service Ganslwirt, Austria. Retrieved 24
December 2009 from http://www.emcdda.europa.eu/modules/wbs/dsp print
project description.cfm?project id=5078
EMCDDA. (2009c). Merchants quay health promotion unit. Retrieved 24 December
2009 from http://www.emcdda.europa.eu/modules/wbs/dsp print project
description.cfm?project id=1483
EMCDDA (2009d). Mountview/Blakestown Community Drug Team Ltd. Retrieved 20
December 2009 from http://www.emcdda.europa.eu/modules/wbs/dsp print
project description.cfm?project id=5918.
EMCDDA (2009e). A syringe exchange programme for HIV prevention among
intravenous drug users in Malm, Sweden. Retrieved 20 December 2009 from
http://www.emcdda.europa.eu/modules/wbs/dsp print project description.
cfm?project id=371.
French, M. T., McGeary, K. A., Chitwood, D. D. & McCoy, C. B. (2000). Chronic illicit
drug use, health services utilization and the cost of medical care. Social Science
& Medicine, 50, 17031713.
Friedmann, P. D., Zhang, Z., Hendrickson, J., Stein, M. D. & Gerstein, D. R. (2003). Effect
of primary medical care on addiction and medical severity in substance abuse
treatment programs. Journal of General Internal Medicine, 18, 18.
Gerada, C., Orgel, M. & Strang, J. (1992). Health clinics for problem drug misusers.
Health Trends, 24, 6869.
Harris, H. W. & Young, D. M. (2002). Care of injection drug users with soft tissue
infections in San Francisco, California. Archives of Surgery, 137, 12171222.
IKHLAS. (2009). The IKHLAS drop-in centre (drug user programme). Retrieved 29
December 2009 from http://www.ptfmalaysia.org/Ikhlas.htm
Islam, M. M., Day, C. A. & Conigrave, K. M. (2010). Harm reduction healthcare: From
an alternative to the mainstream platform? International Journal of Drug Policy,
21, 131133.
Islam, M. M., Grummett, S., White, A., Reid, S. E., Day, C. A. & Haber, P. S. (2011).
A primary healthcare clinic in a needle syringe program may contribute to HIV

101

prevention by early detection of incident HIV in an injecting drug user. Australian

and New Zealand Journal of Public Health, 35, 294295.
Islam, M. M., Hayes, S., White, A., Day, C., Reid, S., Grummet, S., et al. (2010). Assessment for hepatitis C treatment and referral uptake by IDUs attending a harm
reduction based primary healthcare. In 7th Australian viral hepatitis conference
Melbourne, 68 September.
Kwan, L., Ho, C. J., Preston, C. & Le, V. (2008). Puentes clinic: An integrated model for
the primary care of vulnerable populations. The Permanente Journal, 12, 1015.
Latt, N., Conigrave, K., Saunders, J. B., Marshall, E. J. & Nutt, D. (2009). Addiction
medicine. Oxford: Oxford University Press.
Lauretta, E., Grau, L. E., Arevalo, S., Catchpool, C. & Heimer, R. (2002). Expanding
harm reduction services through a wound and abscess clinic. American Journal
of Public Health, 92, 19151917.
Lucas, P. J., Baird, J., Arai, L., Law, C. & Roberts, H. M. (2007). Worked examples of
alternative methods for the synthesis of qualitative and quantitative research
in systematic reviews. BMC Medical Research Methodology, 7, 4.
Mathers, B. M., Degenhardt, L., Ali, H., Wiessing, L., Hickman, M., Mattick, R. P.,
et al. (2010). HIV prevention, treatment, and care services for people who inject
drugs: A systematic review of global, regional, and national coverage. Lancet,
375, 10141028.
McCoy, C. B., Metsch, L., Chitwood, D. D. & Miles, C. (2001). Drug use and barriers to
use of health care services. Substance Use & Misuse, 36, 789806.
McDonald, P. (2002). Prom streets to sidewalks: Developments in primary care
services for injecting drug users. Australian Journal of Primary Health, 8, 6569.
McLellan, A. T., Arndt, I. O., Metzger, D. S., Woody, G. E. & OBrien, C. P. (1993).
The effects of psychosocial services in substance abuse treatment. JAMA, 269,
19531959.
Merrill, J. O., Rhodes, L. A., Deyo, R. A., Marlatt, G. A. & Bradley, K. A. (2002). Mutual
mistrust in the medical care of drug users: The keys to the narc cabinet. Journal
of General Internal Medicine, 17, 327333.
Morrison, A., Elliott, L. & Gruer, L. (1997). Injecting-related harm and treatmentseeking behaviour among injecting drug users. Addiction, 92, 1349 1352.
Morrison, C. L. & Ruben, S. M. (1995). The development of healthcare services for
drug misusers and prostitutes. Postgraduate Medical Journal, 71, 593597.
Mund, P. A., Heller, D., Meissner, P., Matthews, D. W., Hill, M. & Cunningham, C.
O. (2008). Delivering care out of the box: the evolution of an HIV harm reduction medical program. Journal of Health Care for the Poor and Underserved, 19,
944951.
Norman, J., Mugavin, J. & Swan, A. (2006). Evaluation of the primary health services.
Fitzroy, Victoria: Turning Point Alcohol and Drug Centre.
Palepu, A., Tyndall, M. W., Leon, H., Muller, J., OShaughnessy, M. V., Schechter, M.
T., et al. (2001). Hospital utilization and costs in a cohort of injection drug users.
Canadian Medical Association Journal, 165, 415420.
Pollack, H. A., Khoshnood, K., Blankenship, K. M. & Altice, F. L. (2002). The impact of
needle exchange-based health services on emergency department use. Journal
of General Internal Medicine, 17, 341348.
Popay, J., Roberts, H., Sowden, A., Petticrew, M., Arai, L., Rodgers, M., et al. (2006).
Guidance on the conduct of narrative synthesis in systematic reviews. Final Report
Lancaster, Institute of Health Research, Lancaster: ESRC Methods Programme.
Riddell, S., Shanahan, M., Roxburgh, A., & Degenhardt, L. (2007). The cost of drug
related hospital stays in Australia, 19992005. NDARC Technical Report Number
285. Sydney: National Drug and Alcohol Research Centre, University of New
South Wales.
Ross, D., Lo, F., McKim, R. & Allan, G. M. (2008). A primary care/multidisciplinary
harm reduction clinic including opiate bridging. Substance Use & Misuse, 43,
16281639.
Rowe, J. (2004). Needles and syringes to care and counselling: The need for innovative primary health care to meet the needs of street-based injecting drug users.
Australian Journal of Primary Health, 10, 4955.
Rowe, J. (2005). Access health: Providing primary health care to vulnerable and
marginalised populations A practice paper. Australian Journal of Primary Health,
11, 3237.
Saitz, R., Horton, N. J., Larson, M. J., Winter, M. & Samet, J. H. (2005). Primary medical
care and reductions in addiction severity: A prospective cohort study. Addiction,
100, 7078.
Silins, E., Conigrave, K. M., Rakvin, C., Dobbins, T. & Curry, K. (2007). The inuence of structured education and clinical experience on the attitudes of medical
students towards substance misusers. Drug and Alcohol Review, 26, 191200.
Singh, M. (1997). A harm reduction programme for injecting drug users in
Nepal. Retrieved 10 November 2009 from http://www.kit.nl/exchange/html/
1997 2 a harm reduction progra.asp
Singh, M. (1998). Harm reduction and street-based program: looking into Nepal.
Substance Use & Misuse, 33, 10691074.
Stein, M. & Samet, J. (1993). The linkage of primary care services with substance
abuse treatment: New opportunities for academic generalists. Journal of General
Internal Medicine, 8, 106107.
Teesson, M., Hall, W., Lynskey, M. & Degenhardt, L. (2000). Alcohol- and druguse disorders in Australia: Implications of the National Survey of Mental
Health and Wellbeing. The Australian and New Zealand Journal of Psychiatry, 34,
206213.
UNAIDS. (1999). UNAIDS best practice collection: drug user programme, Ikhlas
Community Centre, Pink Triangle, Malaysia. Retrieved 15 October 2009
from
http://www.greenstone.org/greenstone3/nzdl?a=d&c=unaids&d=
HASH4a2403552a02d729115e57.1&sib=1&p.a=q&p.sa=&p.s=TextQuery&p.c=
unaids.

259

102

M.M. Islam et al. / International Journal of Drug Policy 23 (2012) 94102

van Beek, I. (2007). Case study: Accessible primary health care-a foundation to
improve health outcomes for people who inject drugs. International Journal of
Drug Policy, 18, 329332.
Weigl, M., Busch, M., Eggerth, A., Horvath, I., Knaller, C., Trscherl, E., et al.
(2009). Report on the drug situation. Retrieved 20 December 2009 from
http://www.goeg.at/media/download/berichte/DrugSituation2009 Austria.pdf
Weisner, C., Mertens, J., Parthasarathy, S., Moore, C. & Lu, Y. (2001). Integrating primary medical care with addiction treatment: A randomized controlled trial.
JAMA, 286, 17151723.

World Health Organization. (2004). Best practice in HIV/AIDS prevention and care
for injecting drug abusers. Cairo: The Triangular Clinic in Kermanshah, Islamic
Republic of Iran. Regional Ofce for the Eastern Mediterranean.
World Health Organization. (2009). Management of common health problems of drug users. New Delhi: WHO. Retrieved 15 July 2011 from
http://www.searo.who.int/en/Section10/Section18/Section356 4609.htm
Wright, N. M. & Tompkins, C. N. (2006). How can health services effectively meet
the health needs of homeless people? The British Journal of General Practice: The
Journal of the Royal College of General, 56, 286293.

260

International Journal of Drug Policy 23 (2012) 103110

Contents lists available at SciVerse ScienceDirect

International Journal of Drug Policy

journal homepage: www.elsevier.com/locate/drugpo

Responses

Clients are central to any independent and rigorous evaluation of the services
they use
James Rowe
School of Global Studies, Social Science and Planning, RMIT University, Melbourne 3001, Victoria, Australia

In 2005, I spent a year onsite at a newly established primary

health centre (PHC), designed to meet the needs of street-based
injecting drug users (IDUs) as well as homeless individuals and
sex workers attracted to the area due to the nearby street sex market and the long-established needle and syringe program (NSP) in
the adjoining building. The NSP managed by the same organisation had served as the site for preliminary research conducted
into the health care needs of those who would become the centres
clients.
Engaged to conduct an on-going evaluation of the service, I documented a service accessible, welcomed and thoroughly embraced
as opposed to merely accepted by the clientele, several of who
partook in regular interviews throughout the year in addition to the
150 who lled in quarterly surveys as a key component of quarterly
reports provided to the centres management. The nal evaluation
has a number of valuable ndings for health planning but was of
most value to the service that commissioned the research and to
the health authorities who are the facilitys key source of funding.
The report (Rowe, 2006) a 205-page document with objective
measures in addition to a focus on client contributions may hold
general lessons for health design but there is a need for any
attempt to draw on such evaluations to appreciate the specic cultural and political inuences that have shaped the service and the
centrality of clients to evaluate the success or otherwise of
PHCs.
The continued nature of my on-site evaluation allowed the service to evolve to address issues raised by clients that affected the
service operating as prociently as possible. For example, female
clients with histories of physical, sexual and emotional abuse communicated the (unintended) intimidation they experienced when
sharing spaces with large, physically imposing men. This was
instrumental in establishing separate spaces for women and female
only service hours.
The philosophy of clients serving as key informants, best placed
to inform the primary health centres management, from its initial

Tel.: +61 3 9925 2319; fax: +61 3 9925 3088.

E-mail address: james.rowe@rmit.edu.au

design and stafng, to the continued evolution of the PHC appears

under-valued by Islam, Topp, Day, Dawson, and Conigrave (2012);
one of a number of issues compromising their ability to meet their
ambitious objectives.
The authors suggest that certain evaluations lack objective, evaluative merit. Noting the high rates of client satisfaction, they state,
however, none of the studies employed rigorous, independent
measures but cited client reports. I can only speak for my deliberate reliance on client input: unless clients of PHCs are central to
their design and operation, then these services may well not prove
acceptable to those whose needs they are established to meet. The
notion that client contributions to evaluations of services established to meet their needs robs an evaluation of objectivity and
rigour is misjudged.
Further, an understanding of comparative studies demands an
awareness of the fact that policy responses including the design
and operation of PHCs are shaped by political structures and
institutions that dene government and its roles in different jurisdictions, as, indeed, they are shaped by the means and effects
of political socialisation on the public, prevalent cultural values,
religious inuence, and ever-evolving local attitudes. Seeking to
synthesize the ndings of evaluations of PHCs from Melbourne and
Sydney may be achievable given the relatively comparable political
and cultural context of Australias populous south-eastern states at
this time. But the authors attempt to draw on common models
of IDU-targeted PHC, is greatly weakened by a failure to acknowledge the vast cultural and political differences that limit a narrative
synthesis of services across as broad an international spectrum as
Australia, Finland, Iran, Nepal, the United States and the UK (across a
period of 15 years). The authors admit the mainstreaming of PHCs
in health services is perhaps too great a challenge given geographical, cultural, policy and practice variation. This applies equally for
an international review of PHCs (and one that only uses those published in English).
There is insufcient evidence on the effectiveness of the PHC
using the means employed by the paper in question. This does
not mean that valuable lessons cannot be drawn from evaluative
studies in the appropriate cultural context in which each is set.
Perhaps, in future, complete evaluation reports, as provided to the

0955-3959/$ see front matter 2011 Elsevier B.V. All rights reserved.

261

104

J. Rowe / International Journal of Drug Policy 23 (2012) 103110

key health services that fund and seek to build on such research,
should be sought out for such attempted reviews. This would be
far more productive than an analysis that, the authors admit, is
limited by a reliance on papers restricted by just what can be communicated in journals given editorial demands for brevity. In doing
so, they might nd there is not so much a dearth of rigorous evaluations, but that these are not found via a search of academic
databases.

References
Islam, M. M., Topp, L., Day, C. A., Dawson, A. & Conigrave, K. M. (2012). The accessibility, acceptability, health impact and cost implications of primary healthcare
outlets that target injecting drug users: A narrative synthesis of literature. International Journal of Drug Policy, 23(2), 94102.
Rowe, J. (2006). Access health: Towards best practice in the delivery of primary health
care. Melbourne: Salvation Army Crisis Services.
doi:10.1016/j.drugpo.2011.09.009

One stop shopping Bringing services to drug users

R. Douglas Bruce
Yale University School of Medicine, Yale University School of Public Health, Yale University AIDS Program, 135 College Street, Suite 323, New Haven, CT 06510-2283, United States

Drug users often come into contact with healthcare systems,

but this care is episodic and not specic to the unique needs of
drug users. A visit to an emergency department for an abscess or
an urgent care clinic for STI screening, for example, may be the most
that many drug users encounter. A failure to provide comprehensive healthcare for drug users is a failure to provide a service to a
group that should be a public health, and therefore a primary care,
priority. One reason for the failure to deliver needed primary care
services to drug users has been the requirement that drug users
access normal primary care services services which are unlikely
to be organized to meet the specic needs of drug users. In this
issue of IJDP, Islam and colleagues report on several models of
primary healthcare delivery to injection drug users that resulted
in increased healthcare utilisation, improvements in health status
and overall cost savings (Islam, Topp, Day, Dawson, & Conigrave,
2012). Embedded in that discussion are a few key themes on service
delivery for drug users.
In any healthcare environment, individuals solicit services they
perceive to be of value. Drug users are no different and will seek
out services that are of value and provided in a convenient and
respectful manner. If the service is quite valuable, the drug user may
undergo some measure of inconvenience and disrespect in order to
obtain the service. Attendance at the emergency department is one
such example. As the perception of service value declines, however, convenience and respect become the main determinants of
accessing services. A drug user, for example, may not see hepati-

Tel.: +1 203 737 6133; fax: +1 203 737 5143.

E-mail address: robert.bruce@yale.edu

tis B vaccination as worth travelling across town to obtain from a

clinic that may or may not be respectful. If, however, that same vaccine is given on a mobile unit in the neighbourhood where the drug
user lives and is provided in a respectful manner with other services
(e.g., clean syringes and condoms), then the drug user is often more
than willing to benet from the service. The key to service delivery
for drug users then, is to nd what is valuable to the drug user and
then to add public health interventions to that service. This was the
rationale for adding HIV testing or hepatitis B vaccination to needle and syringe programme sites. This was the rationale for adding
hepatitis C and HIV treatment into methadone clinics, creating one
stop shopping multiple services that a drug user may need in a
place where the drug user already frequents. And this should be the
guiding principle for primary health care services directed towards
drug users. Behaviour change is very difcult even for the most
motivated of people this is something the 12 steps has taught for
decades. So if behaviour change is difcult, the key to the successful
creation of primary care services to drug users is to ascertain the
motivation for the drug user and to capitalize on that motivation.
And this all starts with a nonjudgmental conversation with a drug
user, because how else can we know someones motivations?
Reference
Islam, M. M., Topp, L., Day, C. A., Dawson, A., & Conigrave, K. M. (2012). The accessibility, acceptability, health impact and cost implications of primary healthcare
outlets that target injecting drug users: a narrative synthesis of literature. International Journal of Drug Policy, 23(2), 94102.
doi:10.1016/j.drugpo.2011.09.008

262

J. Rowe / International Journal of Drug Policy 23 (2012) 103110

105

Primary health care for people who inject drugs in low and middle income
countries
Bronwyn J. Myers a,b,
a
b

Alcohol and Drug Abuse Research Unit, Medical Research Council of South Africa, South Africa
Department of Psychiatry and Mental Health, University of Cape Town, South Africa

Much has been written about needle and syringe programmes

(NSPs), opioid substitution treatment (OST) and antiretroviral
(ARV) therapies as essential components of evidence-based harm
reduction initiatives for people who inject drugs (PWIDs) (see for
example Mathers et al., 2010). In contrast, signicantly less attention has been given to the provision of primary health care (PHC) for
people who inject drugs (PWIDs), even though these services may
contribute to better outcomes for other harm reduction services
such as OST. As PWIDs often face structural barriers to accessing
conventional PHC (Day et al., 2011), PHC services targeted at PWIDs
specically have been touted as a way of overcoming these obstacles. The evidence base for these targeted services however has
been limited. Islam, Topp, Day, Dawson, and Conigraves (2012)
synthesis of the literature on PHC services targeted at PWIDs is
timely and represents one of the rst attempts to establish an evidence base in support of these services.
In this synthesis of the literature, the authors provide a summary
of factors associated with accessible and acceptable PHC. Accessible services were based at a suitable and accessible location, had
exible appointment scheduling, had needs-based operating hours
and were affordable. Services were seen as acceptable when they
provided other harm reduction services, provided ancillary social
and welfare services, and were not associated with conventional
health care. Based on these ndings, the authors argue that the best
means of ensuring adequate uptake of PHC by PWIDs is to augment
existing NSPs and other harm reduction services (which already
have a high degree of accessibility and acceptability) to include
PHC. Whilst this makes sense for higher income countries that have
relatively good NSP and OST service coverage, it makes less sense
for low and middle income countries (LMICs). The burning issue
for these countries is not whether PHC services targeted at PWIDs
have public health benets, but how these services can be implemented when NSP and OST services are absent or service coverage
is poor. Although Islam et al. (2012) acknowledge that contextual
inuences may shape how PHC services for PWIDs are provided;
they fail to discuss the way PHC can be provided in contexts of
limited NSP and OST coverage.
In LMIC contexts, it might be worth considering how services
for other vulnerable and marginalised groups can be expanded to
include health care for PWIDs. Surveys of most at risk populations
(MARPs) have consistently found signicant overlap between various MARPS including men who have sex with men, sex workers, and

Correspondence address: Alcohol and Drug Abuse Research Unit, Medical

Research Council of South Africa, PO Box 19070, Tygerberg 7505, South Africa.
Tel.: +27 21 938 0350.
E-mail addresses: bmyers@mrc.ac.za, Bronwyn.Myers@mrc.ac.za

PWIDs (Johnston et al., 2010; Parry, Petersen, Carney, Dewing, &

Needle, 2008). Often organisations serving these MARPs are located
in highly accessible areas and already provide PHC (typically related
to sexual and/or reproductive health and BBVI testing) to their
clients. Given that some of their clientele will be injecting drugs, it
may be possible to expand these services to include PHC related to
injection drug use specically. In contexts where injection drug use
is relatively rare and/or harm reduction services limited, this may
be an efcient and acceptable way of providing targeted services
for PWIDs.
Another possibility for LMICs is to mainstream services for
PWIDs into conventional PHC. Whilst Islam et al. (2012) mention gradual mainstreaming of targeted PHC services for PWIDs as
an end-goal, they do not reect upon the conditions required to
make mainstreaming successful. For lower income countries one
of the issues will be around the type of workforce that is needed.
Islam et al.s (2012) review suggests a reliance on health care professionals and it is unclear whether there is space for peer-led
services. Peer-led services may be more acceptable to countries facing dire shortages in health care workers. Peer-led services may also
improve the acceptability of mainstreamed PHC to PWIDs. Certainly
in Africa, there has been growing reliance on peers and (nonprofessional) community health workers to provide basic PHC services,
especially relating to HIV/AIDS (Philips, Zachariah, & Venus,
2008).
In conclusion, it is clear from this review that there are many
unanswered questions about the implementation of PHC for PWIDs.
Islam et al. (2012) note the absence of studies comparing the
relative effectiveness of PHC targeted at PWIDs and conventional PHC. Without evidence that targeted PHC services are more
effective and hold greater cost-benets than conventional care,
I fear that policy makers will ignore evidence provided by this
review that targeted services are acceptable to and accessible for
PWIDs.
References
Day, C. A., Islam, M. M., White, A., Reid, S. E., Hayes, S. & Haber, P. S.
(2011). Development of a nurse-led primary healthcare service for injecting drug users in inner-city Sydney. Australian Journal of Primary Health, 17,
1015.
Islam, M. M., Topp, L., Day, C. A., Dawson, A., & Conigrave, K. M. (2012).
The accessibility, acceptability, health impact and cost implications of
primary healthcare outlets that target injecting drug users: A narrative synthesis of literature. International Journal of Drug Policy, 23(2), 94
102.
Johnston, L., Holman, A., Dahoma, M., Miller, L. A., Kim, E., Mussa, M., et al. (2010). HIV
risk and the overlap of injecting drug use and high-risk sexual behaviours among
men who have sex with men in Zanzibar (Unguja), Tanzania. The International
Journal of Drug Policy, 21, 485492.

263

106

J. Rowe / International Journal of Drug Policy 23 (2012) 103110

Mathers, B. M., Degenhardt, L., Ali, H., Wiessing, L., Hickman, M., Mattick, R. P.,
et al. (2010). HIV prevention, treatment, and care services for people who inject
drugs: A systematic review of global, regional and national coverage. Lancet, 375,
10141028.
Parry, C. D. H., Petersen, P., Carney, C., Dewing, S. & Needle, R. (2008). Rapid assessment of drug use and sexual HIV risk patterns among vulnerable drug-using

populations in Cape Town, Durban and Pretoria, South Africa. Journal of Social
Aspects of HIV/AIDS Research Alliance, 5, 113119.
Philips, M., Zachariah, R. & Venis, S. (2008). Task shifting for antiretroviral treatment
delivery in sub-Saharan Africa: Not a panacea. Lancet, 371, 682684.
doi:10.1016/j.drugpo.2011.09.014

Primary care is the best place to care for drug users

Chris Ford a,b,1
a
b

General Practice Principal, London, United Kingdom

International Doctors for Healthy Drug Policies, Lonsdale Medical Centre, 24 Lonsdale Road, London NW6, United Kingdom

I have worked with patients who have drug problems in primary

care/general practice for over 25 years and feel it is the best place
to provide services. I was therefore hopeful and excited to read this
paper from its title. However, by the end of it, I felt some disappointment. Throughout myself and my GP colleagues at the Lonsdale
Medical Centre, our primary care practice, have always treated the
person, not the drug, providing the whole range of general medical
services including HIV and hepatitis C care, needle exchange, psychological interventions and opioid substitution treatment in the
same environment as all other patients. This is something that Lonsdale has championed with other primary care doctors, through the
UK Substance Misuse Management in General practice (SMMGP)
network (http://www.smmgp.org.uk/). So I agree with Islam et al.s
(2012) conclusions that providing non-judgmental and cost-free
services under a harm reduction framework can increase the accessibility and acceptability of primary healthcare for IDUs. But I
disagree that this care should be separated out from that of other
patients.
I concede that we are all often remiss at undertaking rigorous evaluations of Primary Care Centres and hence cant always
show the public health impact of this type of care, and so risk not
getting adequate funding. But what we do have testimony to is
the hundreds of patients who benet from this method of care
delivery.

E-mail address: chrishelen.ford@virgin.net

Clinical Director, International Doctors for Healthy Drug Policies, Lonsdale Medical Centre, 24 Lonsdale Road, London NW6, United Kingdom.

Other problems with this synthesis are language with terms

not being claried (primary care, general practice, ofce-based
practice, etc.) and there is little acknowledgement of the marked
variation in primary care and general practice around the world.
Comparing even the UK system with the Australian or US primary
care, I feel is impossible.
This leads me to a comment on the UK literature used in this
review, most of which is now out of date (being published in 1992
and 1996). Since then there has been a quiet revolution in the care
of people who use drugs in the UK. The number of general practices
working with patients with drug problems has gone from 0.2% in
1995 to over 40%, many specialist services are headed up by primary care clinicians and SMMGP provides a support and training
network for all those working in primary care, as well as a training programme run by the Royal College of General Practitioners
(RCGP Certicate in Drug Dependency Part 1 and 2). Over the 17
years of SMMGP and the 10 years that this training programme
have been available and building up, we have undertaken audits,
presentations, written reports and the odd paper: we have often
talked about the need for robust evaluation of them but somehow
caring for the patients has always taken precedence! Perhaps the
best response to this paper will be to undertake that work now.
Reference
Islam, M. M., Topp, L., Day, C. A., Dawson, A. & Conigrave, K. M. (2012). The accessibility, acceptability, health impact and cost implications of primary healthcare
outlets that target injecting drug users: A narrative synthesis of literature. International Journal of Drug Policy, 23(2), 94102.

doi:10.1016/j.drugpo.2011.09.013

264

J. Rowe / International Journal of Drug Policy 23 (2012) 103110

107

Windows of opportunity: Adapting services to the needs of people who inject

drugs
Bijan Nasiri
Center for Health Evaluation and Outcome Sciences, Vancouver, BC, Canada

One way to look at the issues raised by Islam, Topp, Day, Dawson,
and Conigrave (2012) is to look at health care needs and services
through the lens of people who inject drugs. If you are down to the
level of basic needs and lacking minimum standard of safety and
security as many people who inject drugs are the Maslow hierarchy of needs starts from food, clothing and shelter. If energy and
body reserves are left, and depending on the availability of support
services and on the knowledge and motivation of individuals, people who inject might seek HIV rapid testing or an emergency room
visit for an infected injection site. Service seeking will be strongly
guided by short-term need and immediate satisfaction, especially
when there is no regular way of life requiring a strategic plan and
goal oriented thinking. Injectors who are homeless have more constraints on their life as they lack one of the most important basic
survival needs, making them prone to other problems. A history of
traumatic life experiences is one of the frequent ndings in routine
screening. The issue of concurrent disorder is another confounding
problem that makes service provision more complicated.
If we try to formulate the needs of people who inject drugs
from our own lens and our classic preoccupation with the normal
individual, our model would not necessarily be utilised or even
considered as a desirable and accessible service for someone who
injects drugs.
Unfortunately most service providers dont have the basic comprehensive set of services that a drug user needs. So rather than
providing all services in a regular visit, the drug user ends up with
being referred to other services to cover the rest of their needs:
in real life this is a kind of denial of offering important services to
them and replacing it with the name of referral.
People who inject drugs have numerous personal, interpersonal,
environmental, economical and bio-psycho social barriers to overcome just simply to be able to seek services. When they do seek
help, we as service providers are often not ready to use this window of opportunity. We therefore need to adopt new approaches,
and an aggressive remodelling of the classic medical model to a
more community based, low threshold one stop shop model.

E-mail address: bijan.nasiri1@gmail.com

To address the complexity of the needs of people who inject

drugs, there is an absolute need for a continuum of care, and the
integration of different levels of primary, secondary and tertiary
health care so that drug users carrying many health problems are
able to navigate the system easily, and do not fall into cracks. In
this setting the role of primary health centres must be to adapt to
the everyday changes of need of this highly dynamic and mobile
population. This means being exible regarding times of operation,
staff skills, and knowledge of everyday health care demands. It also
means a change from a xed service provision model to a mixed
model (both xed site and mobile), and having an acceptable grey
zone of service delivery one level before regular primary health care
model. Basic level services might need to operate without the need
for regular registration and paper work, in order to overcome fear
of stigma and maintain condentiality.
Low threshold health care workers need to be multi functional,
and need to draw on the potentially huge peer support workforce,
which will bring a whole context of user friendly, non judgmental
pragmatic services. The later issue is important based on the fact
of resource limitations which will direct us to shift from a costly
pure medical model to cost effective combination models. In the
new model primary care doctors play a role of public health educator, health care manager, and community leader. They are a single
member of a big team with shared care model including amongst
nurses, social workers, peer support workers, health care workers,
and mental health workers.
It is possible that by a comparison of the needs of people who
inject drugs in different settings (demographic, geographic, economic, level of need, etc.) that we might come up with client
matched service provision models. Further ongoing research and
feasibility studies are needed to investigate which models are
appropriate for which sub population of people who inject, including those in prison, and those with developmental issues and
concurrent disorders.
Reference
Islam, M. M., Topp, L., Day, C. A., Dawson, A. & Conigrave, K. M. (2012). The accessibility, acceptability, health impact and cost implications of primary healthcare
outlets that target injecting drug users: A narrative synthesis of literature. International Journal of Drug Policy, 23(2), 94102.
doi:10.1016/j.drugpo.2011.09.012

265

108

J. Rowe / International Journal of Drug Policy 23 (2012) 103110

Maybe not perfectbut surely good enough?

Ingrid van Beek
Kirketon Road Centre, Kings Cross, NSW, Australia

This paper by Islam, Topp, Day, Dawson, and Conigrave (2012)

highlights the fact that despite there being a range of primary
health care (PHC) models operating throughout the world focused
on the prevention of HIV and other transmissible infections, which
have apparently proven acceptable and accessible to people who
inject drugs (PWID), the evidence for their effectiveness is patchy
at best. This presumably renders them vulnerable when competing for scarce public health resources with other interventions for
which there is such evidence. And as the authors suggest, this also
potentially limits their ability to inform future health planning and
be replicated in new settings.
This situation leads one to consider how lucky we may have
been that the era of evidence based policy making was not yet
upon us when HIV unexpectedly turned up on the worlds doorstep
requiring an immediate response, given that evidence of effectiveness necessarily follows intervention! But even then, the ability
to demonstrate this using the more rigorous high level research
methodologies is probably exceptional.
The reasons for the lack of evidence are multiple and not easily
overcome. First, PHC services are rarely funded to undertake such
research and academic research centres have shown little interest
in pursuing this type of work to date, which is probably related to
the limited research monies allocated to this sphere of work.
Second, there are methodological challenges involved in disentangling the relative impacts of the wide range of blood borne
infection (BBI) prevention strategies that PWID are potentially
exposed to in various settings across time. There are also significant ethical issues associated with the randomisation of people
with serious health issues, and who have poor access to healthcare
in general, to one and not another type of intervention, let alone the
use of a placebo as a control condition. Blinding clinicians and/or
participants is also rarely practicable.
Longitudinal prospective observational studies of communityrecruited cohorts of PWID using a case-control methodology
potentially provide a way forward, albeit not as rigorous. But there
may be reasons affecting individuals use of a PHC facility including
their injecting risk behaviour prole, which cannot readily be
controlled for, that may inuence the results. These studies are
also very human resource intensive with nancial implications,
particularly given how long it can take to render signicant
meaningful results given the insensitivity and low frequencies of
the events being examined.
The less sophisticated pre and post-intervention evaluation
methodologies are often confounded by variables that cannot easily be controlled for, such as changes in drug using patterns across
time and the transience of many high risk PWID. This also affects
the level of exposure to the intervention and ability to follow up service users, many of whom may also prefer to remain anonymous

E-mail address: ingrid.vanbeek@sesiahs.health.nsw.gov.au

and/or uncontactable for obvious reasons. These also need to be

instituted prior to interventions being implemented, or better still,
for a period before this to enable collection of relevant baseline data.
So the assessment of the effectiveness of service models that are
already operating often ends up being conned to internal service
evaluation efforts, which mostly include analyses of utilisation
data and client satisfaction surveys. Whilst service activity may
be a good indicator of service processes, it is no substitute for
outcome indicators such as BBI incidence. But even if serial BBI
testing needed for this can feasibly be undertaken, the numbers at
a clinic level are unlikely to be high enough, which along with the
lack of a control condition, make it impossible to conclude with
any condence that any trends detected are directly related to the
specic intervention.
In-house client satisfaction surveys are limited by their subject
selection bias, clients who currently use a particular service presumably being more likely to value it than those who do not. Clients
self-report can also be affected by social desirability bias, which is
known to be more prevalent in clinical settings.
These are just some of the reasons why there is a dearth of
evidence demonstrating the effectiveness of targeted PHC models
in preventing BBIs amongst PWID. But the important question is
whether this should this be a barrier to their replication. I would
hope not.
Whilst I strongly support evidence-based approaches to drug
policy-making and clinical practice in general and agree with the
authors recommendation that targeted PHC services should be
supported to undertake outcome evaluations to document their
public health impact, I think we need to be realistic about the extent
to which this can ever be achieved.
There is also a need to be mindful that the lack of high level
research evidence does not equate to evidence of ineffectiveness
and not to let our admirable ambitions for perfect evidence get in
the way of supporting the good services that PHC centres undoubtedly deliver.
The irrefutable evidence is that PWID have historically had
poor access to PHC despite often having complex health needs;
that PWID with complex needs are additionally vulnerable to
HIV and other BBIs; that targeted PHC centres addressing such
needs are accessed and considered acceptable by such high risk
PWID taken together should sufce as evidence that these
models are appropriate and should be supported and replicated
where possible.
Reference
Islam, M. M., Topp, L., Day, C. A., Dawson, A. & Conigrave, K. M. (2012). The accessibility, acceptability, health impact and cost implications of primary healthcare
outlets that target injecting drug users: A narrative synthesis of literature. International Journal of Drug Policy, 23(2), 94102.
doi:10.1016/j.drugpo.2011.09.011

266

Appendix IV

(c) Islam, M. M., Topp, L., Day, C. A., Dawson, A., & Conigrave, K. M. (2012).
Primary healthcare outlets that target injecting drug users: Opportunity to make
services accessible and acceptable to the target group. International Journal of Drug
Policy, 23, 109-110.

267

J. Rowe / International Journal of Drug Policy 23 (2012) 103110

109

Primary healthcare outlets that target injecting drug users: Opportunity to make
services accessible and acceptable to the target group
M. Mozul Islam a,b, , Libby Topp c , Carolyn A. Day b,d , Angela Dawson e , Katherine M. Conigrave b,d,f
a

School of Public Health & Community Medicine, University of New South Wales, Sydney, Australia
Drug Health Service, Royal Prince Alfred Hospital, Sydney, Australia
Viral Hepatitis Epidemiology and Prevention Program, The Kirby Institute (formerly known as the National Centre in HIV Epidemiology and Clinical Research), University of New
South Wales, Sydney, Australia
d
Discipline of Addiction Medicine, Central Clinical School, Sydney Medical School, University of Sydney, Australia
e
Health Services and Practice Research Group, Faculty of Nursing, Midwifery and Health, University of Technology, Sydney, Australia
f
National Drug and Alcohol Research Centre, University of New South Wales, Australia
b
c

Six experts from different regions of the world commented on

our original paper (Islam, Topp, Day, Dawson, & Conigrave, 2012)
and despite their different opinions and perspectives, all agree that
providing anonymous, non-judgmental and free-of-charge services
under a harm reduction framework can increase the accessibility and acceptability of primary healthcare (PHC) for injecting
drug users (IDUs). Nasiri (2012) and Bruce (2012) point out that
the conventional model of healthcare will fail if we presume the
needs of IDUs based on our own understandings; we must listen
to and observe our clients and adapt services accordingly. Both
Nasiri and Bruce recommend integrated, accessible services for
IDUs, a notion supported by the literature (Campbell et al., 2007;
Umbricht-Schneiter, Ginn, Pabst, & Bigelow, 1994). Nasiri goes so
far as to argue that for many IDUs, offering referrals only is akin to
denying services.
Rowe (2012) points out the political and cultural environment in
which PHC services for IDUs are established vary greatly. Nonetheless, we identied a number of common elements, including a
harm reduction focus, suitable locations and drop-in arrangements.
These approaches are crucial whether IDU-targeted health services
are in Sydney, Nepal or Iran. As Nasiri and Bruce point out, service
utilisation by IDUs is often determined by convenience, immediate
satisfaction and respect, unless the perceived need for services is
very high. But certainly the nal shape of any facility aiming to
service IDUs will be inuenced by local variables.
Myers (2012) identies the difculties of offering PHCs to IDUs
in low and middle income countries where needle and syringe programs (NSPs) and opioid substitution treatment services are either
absent or coverage is poor. She suggests that existing services for
similarly high-risk populations, such as sex-workers and men who
have sex with men, may be well suited to providing PHC for IDUs;
that indeed, given the considerable overlap in these populations,
such services may be expanded to provide NSP. This makes good
sense for countries where services for these high-risk groups exist,
however many developing countries lack even minimal services
for these groups (Islam & Conigrave, 2008). In such settings, continued attempts to gradually mainstream harm reduction services

Corresponding author at: School of Public Health & Community Medicine, University of New South Wales, Sydney, Australia. Tel.: +61 40304 5033;
fax: +61 2 9361 2498.
E-mail addresses: mikhokan143@yahoo.com, m.m.islam@unsw.edu.au
(M. Mozul Islam).

(Islam, Day, & Conigrave, 2010) may be the only viable option.
Myers supports this suggestion and also recommends consideration of peer-led services, an approach well worth exploration in
resource-poor settings.
As Ford (2012) notes, it is difcult to measure the effectiveness
of existing healthcare services, such as general practices (GPs), in
caring for the needs of IDUs. Although we specically excluded
ofce-based PHC services from our original review, we strongly
agree that direct support for GPs in caring for IDUs is valuable and
there is much to learn from the experience of such initiatives. Clinicians, however, are likely to vary considerably in their level of
preparedness and ability to deal with IDUs, regardless of available
support (McKeown, Matheson, & Bond, 2003).
van Beeks (2012) comments address concerns raised by Rowe
and Ford, in particular the difculties of collecting robust evidence
on the effectiveness of IDU-targeted PHC services. This, of course,
is one reason why the scientic literature on this subject is so
sparse. Any study which could accurately measure effectiveness
would most likely be expensive and in reality, may need to be
implemented as part of the establishment phase of a series of
PHC centers. Multiple baseline methodology is one approach advocated where an RCT is either impractical or ethically indefensible
(Sanson-Fisher, Bonevski, Green, & DEste, 2007). We contend that
more discussion and access to published evaluations, even those
employing below gold standard methodology, will increase discourse about appropriate methods of evaluation. This in turn may
lead to the development of evaluation-guidelines which can foster
quality assessments, suitable for publication in academic journals,
thereby increasing the accessibility of relevant literature to policymakers and service providers. Evaluations would necessarily, as
Rowe points out, include client feedback. However, as highlighted
by van Beek, client feedback is limited by selection bias, because
only clients who are reasonably satised with a service (or desperate) tend to continue to use that service. Feedback may also be
subject to social desirability bias.
The available evidence, revealing barriers to service access and
the late presentation of seriously ill IDUs to hospital, suggests the
ongoing need for targeted PHC services. If conventional healthcare
facilities evolve to offer safe and accessible environments which
attract IDUs, targeted healthcare outlets may no longer be a priority. However, this time is yet to come. Undoubtedly, rigorous
evaluation is still required to guide policymakers and clinicians in
further improving service provision. However, it is imperative that
IDUs are offered acceptable and accessible healthcare even whilst
we await quality evidence to guide best practice. Consequently,

268

110

J. Rowe / International Journal of Drug Policy 23 (2012) 103110

gradual expansion and replication of PHC for IDUs are (and should
be) continuing, although geographical coverage remains limited.
References
Bruce, R. D. (2012). One stop shopping Bringing services to drug users. International
Journal of Drug Policy, 23(2), 104.
Campbell, J. V., Garfein, R. S., Thiede, H., Hagan, H., Ouellet, L., Golub, E. T., et al.
(2007). Convenience is the key to hepatitis A and B vaccination uptake among
young adult injection drug user. Drug and Alcohol Dependence, 91S, S64S72.
Ford, C. (2012). Primary care is the best place to care for drug users. International
Journal of Drug Policy, 23(2), 106.
Islam, M. M., & Conigrave, K. M. (2008). HIV and sexual risk behaviors among recognized high-risk groups in Bangladesh: Need for a comprehensive prevention
program. International Journal of Infectious Disease, 12, 363370.
Islam, M. M., Day, C. A., & Conigrave, K. M. (2010). Harm reduction healthcare: From
an alternative to the mainstream platform? International Journal of Drug Policy,
21, 131133.
Islam, M. M., Topp, L., Day, C. A., Dawson, A., & Conigrave, K. M. (2012). The accessibility, acceptability, health impact and cost implications of primary healthcare

outlets that target injecting drug users: A narrative synthesis of literature. International Journal of Drug Policy, 23(2), 94102.
McKeown, A., Matheson, C., & Bond, C. (2003). A qualitative study of GPs attitudes
to drug misusers and drug misuse services in primary care. Family Practice, 20,
120125.
Myers, B. J. (2012). Primary health care for people who inject drugs in low and middle
income countries. International Journal of Drug Policy, 23(2), 105.
Nasiri, B. (2012). Windows of opportunity: Adapting services to the needs of people
who inject drugs. International Journal of Drug Policy, 23(2), 107.
Rowe, J. (2012). Clients are central to any independent and rigorous evaluation of the services they use. International Journal of Drug Policy, 23(2), 103
104.
Sanson-Fisher, R. W., Bonevski, B., Green, L. W., & DEste, C. (2007). Limitations of
the randomized controlled trial in evaluating population-based health interventions. American Journal of Preventive Medicine, 33, 155162.
Umbricht-Schneiter, A., Ginn, D. H., Pabst, K. M., & Bigelow, G. E. (1994). Providing
medical care to methadone clinic patients: Referral vs on-site care. American
Journal of Public Health, 84, 207210.
van Beek, I. (2012). Maybe not perfect but surely good enough? International Journal
of Drug Policy, 23(2), 108.
doi:10.1016/j.drugpo.2011.11.001

269

Appendix IV

(d) Islam, M. M. (2010). Needle syringe program-based primary health care centers:
Advantages and disadvantages. Journal of Primary Care and Community Health, 1,
100103.

270

Commentary

Needle Syringe Program-Based Primary

Health Care Centers: Advantages and
Disadvantages

Journal of Primary Care & Community Health

1(2) 100103
The Author(s) 2010
Reprints and permission:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/2150131910369684
http://jpc.sagepub.com

M. Mofizul Islam, MSc

Abstract
Needle syringe programs (NSPs) are now on a strong platform mainly because of their crucial role in controlling/containing
blood-borne virus infections. In many parts of the world, NSPs are gradually augmenting their role as a primary health care
centers. Health care from NSPs are found to be better accessible by injecting drug users (IDUs). However, these outlets
are becoming a separate source of health care for IDUsmainly because (i) nondrug users very rarely access these and
(ii) IDUs do not access other sources of primary care readily. Moreover, offering health care from NSPs is also relatively
cost-intensive, therefore, has some disadvantages.The aim of this commentary is to examine and discuss the advantages and
disadvantages of NSP-based primary health care outlets.The benefits NSPs can accrue through offering health care services
are immense, as an NSP is a critical junction for service providers to offer health care services to IDUs, who traditionally
have been hard to reach by conventional health care. Despite some disadvantages, NSP-based health care is very valuable
for IDUs until they are duly taken care by the conventional health care centers.
Keywords
needle syringe program, primary care, injecting drug users, low-threshold health care, syringe exchange

Needle syringe programs (NSPs) or syringe exchange programs (SEPs) increase access to and encourage utilization
of sterile injecting equipment for injecting drug users
(IDUs) who cannot or will not stop taking drugs. The benefits of NSPs are now well perceived, and NSPs are on a
strong platform mainly because of their crucial role in controlling/containing blood-borne virus infections.1 However,
in many parts of the world, NSPs are gradually augmenting
their role as a primary health care centers. For example, in
2007 slightly fewer than half of the NSPs in the USA provided hepatitis A & B vaccination.2 Forty percent provided
naloxone for reversing opioid overdoses, 33% provided onsite medical care, and 7% provided buprenorphine treatment. A majority of programs provided food, clothing, and
personal hygiene products. Similarly, many NSPs in Australia, Europe, Asia, and South America offer various
degrees of preventative primary health care to their clients.3-6 These NSP-based health care outlets are of the lowthreshold type. To reduce the threshold of access, such
outlets usually choose suitable locations and opening hours,
drop-in provisions, offer free-of-charge services, and are
not linked to an obligation of the client to be or to become
drug-free. Health care from NSPs were found to be better
accessible by IDUs.4 However, these outlets are becoming

a separate source of health care for IDUs, mainly because

nondrug users very rarely access these and IDUs do not
access other sources of primary care readily. Becoming a
separate source, and offering health care that is relatively
cost-intensive,7 has some disadvantages. This may raise
several questions even among some proponents of harm
reduction let alone its opponents. The aim of this commentary is to examine and discuss the advantages and disadvantages of NSP-based primary health care.

Advantages
NSP-based primary health care outlets were found to be
suitable and, hence, accessible to IDUs as NSPs alone
attract a wide range of IDUs.8 This opportunity in an
NSP setting of having the target group, who do not have
the required access to care or may be reluctant to use
School of Public Health & Community Medicine, The University of New
South Wales, Sydney, Australia
Corresponding Author:
M. Mofizul Islam, MSc, Drug Health Services, King George V Bldg, Royal
Prince Alfred Hospital, Missenden Road, NSW 2050, Australia;
Email: m.m.islam@unsw.edu.au

271

101

Islam
Table 1. Major advantages and disadvantages of NSP-based primary health care
Advantages

Disadvantages

1. Opportunistic offer of health care

2. Increased spatial and temporal availability of health care
3. NSP outlet is trustworthy for injecting drug users
4. Cost-effective mode of health care
5. Targeted and comprehensive service
6. Normalizing needle syringe distribution/exchange

1. May consume funding used for NSP coverage

2. May provide a wrong notion
3. Quality of services may not always be adequate

NSP, needle syringe program.

conventional service outlets,9 can be used effective for

offering health care.10 A recent evaluation on NSP-based
low-threshold health care in Finland found that syringe and
needle exchange are the best way to get clients to come to
the services.4 In an effort to examine the use of recommended preventive services (eg, BBV test, hepatitis B vaccination) by IDUs of 23 NSPs throughout California,
Heinzerling et al found that for NSP clients who had
received recommended services, the majority reported having received the service from an NSP, suggesting that NSPs
are often the only source of preventive services for their
marginalized, high-risk clients.10
Distance, travel time, and cost of transportation to and
from the conventional health care centers are some recognized major barriers to health care for IDUs.11 Moreover,
health care needs of IDUs may take a lower priority than
more immediate concerns. Their chaotic lifestyle and drug
dependency can also negatively affect an individuals ability to access health care12 and may make attendance at
appointment to a separate health care center unpredictable.
A recent study of IDUs attending a Supervised Injecting
Facility in Sydney found that only 1 in 6 of those referred to
drug-treatment centers presented to the specified service.13
As a majority of the NSPs are located at neighborhoods
with a high concentration of drug use and/or places where
IDUs congregate, health care from NSPs, either from a
fixed-site or a mobile van, is likely to minimize those barriers and increase the spatial and temporal availability of
health care services.14
Meeting patients in settings where trust has already been
established is an important way to begin a therapeutic relationship.15 IDUs have grown to trust NSPs.16 The relationship
between NSP staff and their regular clients is an added advantage. Thus IDUs in an NSP setting are more likely to disclose
their health problems and engage with services as drug use is
acknowledged without judgment or sanction.17 An evaluation
in Victoria, Australia, on NSP-based primary health care centers accessed mainly by IDUs found that 89% of users
believed they could discuss their health problems openly.5
A significant proportion of IDUs often postpone treatment until conditions become severe,9,12 resulting in an

over-reliance on emergency departments (EDs) and hospitals18 that experience additional pressure and significant
cost. For example, in Vancouver, Canada, injection-related
infections account for the majority of hospital visits among
IDUs.19 Primary health care services for IDUs were found
to reduce ED visits and hospitalizations.20,21 Augmenting
NSPs to include primary health care is likely to be further
cost-saving and more cost-effective as they build on existing infrastructure. Although as yet there are no data on the
cost-effectiveness of NSP-based primary health care, a
wound and abscess clinic in USA, held concurrently with a
NSP, provided economical treatment and aftercare for
injection-associated soft tissue infections. The visit cost
was estimated at $5 per patient much less than the estimated
costs (range from $185 to $360, excluding medications and
physician fees) at the hospital outpatient settings.16
Development of primary health care in an NSP setting is
intrinsically targeted for the IDUs. These targeted services
are likely to be responsive to the needs of the users, organizationally flexible, and most importantly, providing services within a harm reduction frameworktreating IDUs
with dignity and respect.2 Moreover, providing NSP, primary health care and sometimes social/welfare services
from the same center make the outlet one-stop shop for
IDUs. Opportunity of receiving essential services from the
same premise also reduces structural barriers, which are
critical for IDUs service accessibility.11
Along with IDUs, the needle syringe distribution/
exchange outlet is also stigmatized. For example, despite
Australia being a leading country in harm reduction, a survey of 500 people showed that one third of respondents
believed NSP encouraged drug use. An overwhelming 20%
of people thought NSP dispensed drugs and a further 40%
were unsure.22 NSP sites offer anonymity as no names are
required at an NSP, but entering the site may identify the
client as a drug user. However, offering health care services
from NSP sites potentially medicalizes the center. Thus, an
NSP plus health care from the same premise as a center of
medical care is likely to minimize the degree of stigma for
both clients and center, therefore, a good strategy to improve
the attractiveness of NSP services.

272

102

Journal of Primary Care & Community Health 1(2)

Disadvantages

Discussion

Services from NSP outlets are necessarily offered free-ofcharge. With a very few exceptions, NSPs in most parts of
the world face a huge funding crisis. Particularly in developing countries, NSPs are largely supported by development partners, nongovernment organizations (NGOs), and/
or charity organizations. While syringe exchange is relatively cheap and cost-effective, providing other health and
social services can be resource-intensive and may burden
already scarce resources,7 and at NSP settings this health
care may come potentially at the expense of simple NSP
coverage. After all, ensuring coverage of sterile injecting
equipment is the fundamental business of NSPs. For example, during sixth-round surveillance in Bangladesh, it was
found that the NGOs that were previously conducting interventions among IDUs were no longer working there, but
instead newly funded NGOs were preparing to start. Their
dependence on national and international funding makes
program sustainability uncertain.23
Services offered from NSPs are mainly accessed by
IDUs; nondrug users rarely come to these outlets. Consequently, this health care is becoming a separate health care
source, which has some far-reaching effects. First, becoming a separate source has potential to give a wrong notion
that IDUs are better taken care by NSP-based health care
centers. Some even wrongfully consider that these outlets
are specialized services for IDUs. It may also be unreasonable to place expectations on NSPs, and those who work in
them, that they are somehow responsible for the wide range
of social and other health issues affecting people who inject
drugs.7 Moreover, the extent and availability of NSP-based
health care is nowhere near the required level. Second, in
the absence of an AIDS crisis mentality, it may be very difficult to maintain even the current level of services for IDUs
within a separate delivery system.2 Already some providers
of conventional health care are reluctant to take care of
IDUs; any wrong notion, therefore, can exacerbate the situation further.
One of the important concerns that has not been revealed
in the literature is the quality of health care services from
NSPs. NSP-based health care varies across the settings in
terms of range of services, staff pattern, service modalities,
and also its service quality. Some centers offer comprehensive
and quality health care, whereas some others may provide
very few services with inadequate quality. For example, clinic
staff of drop-in-centers (DICs) run by CARE-Bangladesh
were found to have limited tolerance toward drug users.
This translates into inappropriate treatment of most of the
clients at the DICs and reluctance on the part of the clients
to seek health services, due to the way they are treated.24
Moreover, as services are offered free-of-charge, financial
sustainability of the centers is likely to be in jeopardy, and
this in turn may compel toward a substandard quality of
services. Further research is needed on this issue.

NSP is a critical junction for service providers to offer health

care services to IDUs, who traditionally have been hard-toreach by conventional health care. Services being offered are
mostly targeted for IDUs and selective in nature; although
some centers offer comprehensive primary health care services. However, the benefits that NSPs can accrue through
offering health care services are immense. This possibly
accounts for a growing number of NSPs augmented primary
health care services. Although NSPs are primarily for distributing/exchanging sterile injecting equipment, the provision of
health care services from NSPs came out of dire needs.
Despite some disadvantages, the reality is that for many IDUs,
this NSP-based health care is the only source of primary care.
The importance of this health care is crucial particularly in
developing country settings where IDUs access to conventional health care is extremely limited by their affordability.
However, it is important to ensure that the provision of these
health care services does not limit inadvertently the further
development or expansion of NSP services.7
On one hand, health care from NSPs is likely to increase
clients turnover to the service outletsas offering health
care has potential to medicalize NSPs; on the other hand, the
NSP itself might hinder nondrug users access to these outlets. Although arguably NSPs are meant to provide services
to IDUs, nondrug users access to these outlets for general
health issues may help reduce drug user stigma, and in that
way, these outlets may gradually become a better integrated
part of the mainstream health system. This is already done to
a limited extent in some services that offer treatment to other
high-risk groups such as youth or sex workers.25 Integration
to mainstream health care may not be an important factor at
this stage, but in many parts of the world, the rapid expansion of NSP-based health care is likely to raise questions in
the near future as to whether these outlets should continue as
a separate health care source for IDUs. After all, the drug
problem is not a separate issue of the society; therefore, at
the end of the day, it is the task and the duty of the conventional services to bear their share of the responsibility to help
this group of clients. However, until that task is duly performed in conventional health care centers, NSP-based
health care is very valuable for IDUs.
Acknowledgments
The author thanks the referee who reviewed the earlier version of
this paper for his/her constructive suggestions. It is really helpful
to receive comments that offer constructive suggestion/advice as
opposed to simply criticisms. The author is supported by a
University International Postgraduate Award (UIPA) scholarship
of University of New South Wales for his Ph.D. program.

Declaration of Conflicting Interests

The author declared no potential conflicts of interests with respect
to the authorship and/or publication of this article.

273

103

Islam
Financial Disclosure/Funding
The author acknowledges the support of UIPA scholarship of
UNSW.

References
1. NCHECR. Return on Investment 2: Evaluating the Costeffectiveness of Needle and Syringe Programs in Australia.
http://www.health.gov.au/internet/main/publishing.nsf/Content/
C562D0E860733E9FCA257648000215C5/$File/retcov.pdf.
Accessed in November 2009.
2. Des Jarlais DC, McKnight C, Goldblatt C, Purchase D. Doing
harm reduction better: syringe exchange in the United States.
Addiction. 2009;104:1441-1446.
3. Reid S, White A, Day C, Stern T, Haber P, and REPIDU Primary Health Care Clinic Steering Committee. REPIDU primary health care clinic: extending health care for injecting
drug users. Poster presented at: the Australian Professional
Society on Alcohol and other Drugs (APSAD) Conference;
Sydney, Australia; 2008.
4. Arponen A, Brummer-Korvenkontio H, Liitsola K, Salminen
M. Trust and Free Will as the Keys to Success for the Low
Threshold Health Service Centers (LTHSC), National Public Health Institute, Helsinki. http://www.ktl.fi/attachments/
suomi/julkaisut/julkaisusarja_b/2008/2008b24.pdf. Accessed
December 27, 2009.
5. Norman J, Mugavin J, Swan A. Evaluation of the Primary
Health Services. Fitzroy, Victoria: Turning Point Alcohol and
Drug Centre; 2006.
6. IKHLAS. The IKHLAS Drop-in Centre (Drug User Programme). http://www.ptfmalaysia.org/Ikhlas.htm. Accessed
December 29, 2009.
7. Maher L, Iversen J. 2006. Syringe exchange in the
United States: doing the simple things better? Addiction.
2006;104:1448-1450.
8. Gerada C, Orgel M, Strang J. Health clinics for problem drug
misusers. Health Trends. 1992;24:68-69.
9. McCoy CB, Metsch L, Chitwood DD, Miles C. Drug use
and barriers to use of health care services. Subst Use Misuse.
2001;36:789-806.
10. Heinzerling KG, Kral AH, Flynn NM, et al. Unmet need for
recommended preventive health services among clients of
California syringe exchange programs: implications for quality improvement. Drug Alcohol Depend. 2006;81:167-178.
11. Rowe J. Needles and syringes to care and counselling: the need
for innovative primary health care to meet the needs of streetbased injecting drug users. Aust J Prim Health. 2004;10:49-55.
12. Drumm RD, McBride DC, Metsch L, Neufeld M, Sawatsky
A. Im a health nut!, Street drug users accounts of self-care
strategies. J Drug Issues. 2005;35:607-629.

13. Kimber J, Mattick RP, Kaldor J, van Beek I, Gilmour S, Rance

JA. Process and predictors of drug treatment referral and referral uptake at the Sydney Medically Supervised Injecting Centre. Drug Alcohol Rev. 2008;1-11.
14. Islam MM, Day C, Conigrave KM. Harm reduction health
care: from an alternative to the mainstream platform? Int J
Drug Policy. 2010;21:131-133.
15. Kwan L, Ho CJ, Preston C, Le V. Puentes clinic: an integrated
model for the primary care of vulnerable populations. Permanente J. 2008;12:10-15.
16. Lauretta E, Grau LE, Arevalo S, Catchpool C, Heimer R.
Expanding harm reduction services through a wound and
abscess clinic. Am J Public Health. 2002;92:1915-1917.
17. Rich JD, McKenzie M, Macalino GE, et al. A syringe prescription program to prevent infectious disease and improve health
of injection drug users. J Urban Health. 2004;81:122-134.
18. French MT, McGeary KA, Chitwood DD, McCoy CB.
Chronic illicit drug use, health services utilization and the cost
of medical care. Soc Sci Med. 2000;50:1703-1713.
19. Palepu A, Tyndall MW, Leon H, et al. Hospital utilization and
costs in a cohort of injection drug users. CMAJ. 2001;165:415420.
20. Harris HW, Young DM. Care of injection drug users with
soft tissue infections in San Francisco, California. Arch Surg.
2002;137:1217-1222.
21. Pollack HA, Khoshnood K, Blankenship KM, Altice FL. The
impact of needle exchange-based health services on emergency department use. J Gen Intern Med. 2002;17:341-348.
22. Anex. Community Consulted for the First Time on Attitudes
Towards Drugs. Australian Drugs Conference; Melbourne,
Australia, 2009. http://www.australiandrugsconference.org
.au/downloads/Community%20Consulted%20for%20the%20
First%20Time.pdf. Accessed January 2010.
23. Islam MM, Conigrave KM. Increasing prevalence of HIV, and
persistent high-risk behaviours among drug users in Bangladesh: need for a comprehensive harm reduction programme.
Drug Alcohol Rev. 2007;26:445-454.
24. CARE-Bangladesh. Drug Users at Risk to HIV. Documenting Our Experience 2000-2005. V.C. Knight, editor. Dhaka.
https://www.careinternational.org.uk/download.php?id=462.
Accessed 20 October 2009.
25. van Beek I. Case study: accessible primary health carea
foundation to improve health outcomes for people who inject
drugs. Int J Drug Policy. 2007;18:329-332.

Bio
M. Mofizul Islam, MSc (Medicine), is a University International
Post-graduate Award (UIPA) supported doctoral student of
UNSW, Australia.

274

Appendix IV

(e) Islam, M. M., Topp, L., Conigrave, K. M., White, A., Haber, P. S., & Day, C. A.
(2012). Are primary health care centres that target injecting drug users attracting and
serving the clients they are designed for? A case study from Sydney, Australia.
International

Journal

of

Drug

Policy,

[Epub

ahead

of

print]

doi:10.1016/j.drugpo.2012.06.002.

275

G Model
DRUPOL-1115; No. of Pages 7

ARTICLE IN PRESS
International Journal of Drug Policy xxx (2012) xxxxxx

Contents lists available at SciVerse ScienceDirect

International Journal of Drug Policy

journal homepage: www.elsevier.com/locate/drugpo

Research paper

Are primary health care centres that target injecting drug users attracting and
serving the clients they are designed for? A case study from Sydney, Australia
M. Mozul Islam a,b , Libby Topp c , Katherine M. Conigrave b,d,e , Ann White f , Paul S. Haber g,h ,
Carolyn A. Day g,
a

School of Public Health and Community Medicine, University of New South Wales, Australia
Drug Health Service, Royal Prince Alfred Hospital, Sydney, Australia
c
Viral Hepatitis Epidemiology and Prevention Program, the Kirby Institute (formerly the National Centre in HIV Epidemiology and Clinical Research),
University of New South Wales, Australia
d
Sydney Medical School, University of Sydney, Australia
e
National Drug and Alcohol Research Centre, University of New South Wales, Australia
f
Redfern Harm Minimisation Clinic, Sydney Local Health District, Australia
g
Discipline of Addiction Medicine, Central Clinical School, Sydney Medical School, University of Sydney, Australia
h
Sydney South West Area Health Service, Australia, Australia
b

a r t i c l e

i n f o

Article history:
Received 3 April 2012
Received in revised form 7 June 2012
Accepted 8 June 2012
Keywords:
Low-threshold healthcare
Harm reduction
Injecting drug users
Primary health care

a b s t r a c t
Background: Low-threshold primary healthcare (PHC) centres targeting injecting drug users (IDUs) are
increasingly being created to offer preventative and opportunistic services. However, no data are available on the characteristics of clients who utilise such services, or the effectiveness of these services in
facilitating prevention or treatment.
Method: A retrospective clinical record audit examined the characteristics, service utilisation patterns
and referral uptake of 384 clients presenting to a low-threshold PHC service in Sydney, Australia.
Results: Of the 384 clients, 85% were IDUs. Sixty-two percent reported also having access to a general medical practitioner (GP), with this group more likely to report taking benzodiazepines or other psychoactive
medication. Despite this relatively high level of GP access, only 50% were fully vaccinated against hepatitis
B virus (HBV). Testing for blood-borne viral and sexually transmitted infections were the most common
reasons for presentation to the PHC. Most (82%) clients made at least one return visit, with an average of
3.5 presentations per client. All clients were offered HBV vaccination where indicated (n = 145); and more
than half (55%) of referrals to external services were attended. Clients accessing this PHC were younger,
more likely to be male and born outside Australia than IDUs attending needle syringe programs (NSPs)
in Australias most populous state, New South Wales.
Conclusion: Results suggest that this low-threshold PHC service was underutilised and its role as a lowthreshold healthcare outlet remains limited. Further research is needed to more clearly delineate the
health and economic benets of this model.
2012 Elsevier B.V. All rights reserved.

Introduction
Injecting drug users (IDUs) experience a wide range of health
problems (Darke & Ross, 1997; Haber, Demirkol, Lange, & Murnion,
2009; Stein, 1999). Although most of these problems are treatable and/or preventable, IDUs have limited access to conventional
health services (Morrison, Elliott, & Gruer, 1997) or experience
barriers to accessing these services. As a result, they often postpone seeking help until health conditions become severe (Drumm,

Corresponding author at: Drug Health Service, King George V Bldg, Royal Prince
Alfred Hospital, Missenden Rd, Camperdown, NSW 2050, Australia.
Tel.: +61 2 9515 8817; fax: +61 2 9515 5779.
E-mail address: carolyn.day@sydney.edu.au (C.A. Day).

McBride, Metsch, Neufeld, & Sawatsky, 2005; McCoy, Metsch,

Chitwood, & Miles, 2001), resulting in over-reliance on emergency
departments and subsequent hospitalisation (French, Fang, & Balsa,
2010; Haber et al., 2009). This in turn creates pressure on hospital
resources, incurs unnecessary cost and often results in poorer outcomes (Binswanger et al., 2008). To address these challenges and
to provide opportunistic healthcare, in several countries primary
healthcare (PHC) centres have been established to offer various
degrees of preventative and therapeutic healthcare services targeting IDUs or similarly vulnerable groups. These services are
provided, for instance, through opioid substitution therapy clinics
and/or needle syringe programs (NSPs), or stand alone PHC centres. Such services usually offer low-threshold care, removing most
of the barriers that IDUs report in accessing traditional healthcare services (Islam, Topp, Day, Dawson, & Conigrave, 2012b).

0955-3959/$ see front matter 2012 Elsevier B.V. All rights reserved.
http://dx.doi.org/10.1016/j.drugpo.2012.06.002

Please cite this article in press as: Islam, M. M., et al. Are primary health care centres that target injecting drug users attracting and serving the clients they are designed for? A case study from Sydney, Australia. International Journal of Drug Policy (2012),
http://dx.doi.org/10.1016/j.drugpo.2012.06.002

276

G Model
DRUPOL-1115; No. of Pages 7

ARTICLE IN PRESS
M.M. Islam et al. / International Journal of Drug Policy xxx (2012) xxxxxx

Service provision is typically non-judgemental and wherever possible anonymous, although anonymity can usually only be provided
where services remain in-house and can rarely be extended to
referrals. Healthcare providers in these settings generally have
extensive experience in working with IDUs and knowledge of their
common medical and psychiatric co-morbidities and risk exposures. In addition to service provision at point of contact, clients
are also referred to other health and social services as required.
Although these IDU-targeted PHC centres are increasing in number, albeit slowly and within a limited geographical range, recent
commentators have pointed to the lack of information about the
clients who utilise such services, and the potential effectiveness of
such services in meeting the health needs of their target population
(Islam et al., 2012b; Myers, 2012).
In July 2006 the Redfern NSP in inner-city Sydney, Australia was
augmented with a PHC outlet targeting IDUs. The Redfern Harm
Minimisation Clinic (RHMC) is a nurse-led drop-in service with
a sessional (4 h per week) visiting medical ofcer providing clinical supervision for nurses and patient consultations on referral
from the nurse. RHMC was set up to provide a limited range of
primary healthcare services with a specic focus to blood-borne
virus prevention and treatment. The service range was determined based on a needs analysis survey of the target population
(unpublished data) and the WHO denition of PHC for IDUs (World
Health Organization, 2009). Clients present to the clinic without
appointments, generally referred from the NSP shopfront or nearby
outpatient drug treatment or residential drug treatment services.
The nurse-led nature of the service precludes clients from obtaining
benzodiazepines and other prescribed psychoactive medications,
an issue that complicates health service utilisation by heroin users
(Darke, Ross, Teesson, & Lynskey, 2003).
This study aims to investigate whether the RHMC is attracting
and retaining its target client group, and to examine indicators
of its effectiveness in providing preventative and other healthcare. Specically, this study examines characteristics, drug use, risk
behaviour and general medical practitioner (GP) access of clients
presenting to this low-threshold targeted PHC; compares these
characteristics with those of broader samples of IDUs in New South
Wales (Iversen et al., 2011), Australias most populous state and
that in which the RHMC is located; documents clients reasons for
presentation; and investigates uptake of referrals made to other
health and social services.

Method
This study extracted data using a retrospective clinical le audit
and then analysed and compared this data with published data on
the characteristics of clients attending NSPs in New South Wales
(Iversen et al., 2011). Data collection and analysis were approved
by the Ethics Committee of Sydney South West Area Health Service
(RPAH Zone).

Service provision
During initial client assessments, nurses record details about
clients demographic characteristics, access to GP services, interpersonal relationships including dependents, and ve domains: (i)
drug and alcohol use; (ii) blood-borne virus risks and status; (iii)
mental health; (iv) sexual and reproductive health; and (v) general
health. This full assessment is updated every 12 months among
returning clients. Referrals are based on the assessment and client
preferences. To enhance referral uptake, clients are provided with
assistance to make appointments; and telephone or SMS reminders
are sent the day preceding appointments.

Based on the assessment, a range of laboratory examinations

may be offered, including screening for blood-borne virus and
sexually transmitted infections, general pathology tests including
urea, electrolytes, creatinine, liver function tests, coagulation factors and full blood count. Other services commonly offered include
care and management for wounds/veins/abscesses; vaccination
against hepatitis B virus (HBV); sexually transmitted infection
treatment; general health consultations; drug and mental health
issues; welfare services (e.g., advocacy with respect to public housing); counselling; referrals to other health and related services;
support throughout hepatitis C virus assessment and treatment;
and provision of hepatitis C antiviral therapy to a small number of
clients (Islam et al., 2012a). Although RHMC does not provide opioid substitution therapy from its premises, it is closely linked to the
opioid substitution therapy clinic of a nearby drug health service,
and facilitates referrals of and transport for its clients to that opioid
substitution therapy clinic.
The nurses of this PHC centre maintain close links with a number
of local services including a tertiary liver clinic and drug treatment
services (including an opioid substitution therapy clinic and nearby
residential drug treatment service) and an Aboriginal (Indigenous
Australian) community controlled medical service. These relationships allow staff to facilitate referrals to and from each service
and further appointments as necessary. Referrals to other services
can be either formal (written referral, or appointments booked
on clients behalf) or informal (clients make their own arrangements to access recommended services). Nurses of this centre
support clients to attend referrals, including by telephone and/or
text message reminders. Uptake of formal referrals is conrmed
through direct communication with the services to which clients
are referred. Client self-reports serve as the record of uptake of
informal referrals.
Data collection and analysis
We performed an audit of les for all clients who accessed
this targeted PHC between July 2006 and December 2009 (n = 384
client les). Key variables were extracted manually from clients
intake assessments, progress notes and serological testing results
by the rst author, entered into a Filemaker Pro software database
and analysed using STATA (version 11). Signicance of differences between groups was analysed using chi-square and Fishers
exact test for categorical variables, and independent sample ttests for continuous variables. Statistical signicance was set at
p < 0.05. Multivariable logistic regression, using backward elimination, derived adjusted odds ratios (AOR) and associated 95%
condent intervals (CI) controlling for variables associated at
p < 0.15 with access to GP services on univariate analysis.
The Australian Needle and Syringe Program Survey (ANSPS)
sample recruited in New South Wales between 2006 and 2009 was
used as a comparative baseline to determine differences between
RHMC clients and broader populations of IDUs. The ANSPS is an
annual cross-sectional survey of Australian NSP attendees, and
previous research has demonstrated that ANSPS participants are
representative of the broader population of NSP clients (Topp et al.,
2008). Weighted percentage of
relevant
 variables from ANSPS was
calculated using the formula
Pi Xi / Xi , where Pi is the percentage of variable for year i, and Xi is the total sample size for that
year.
Results
Sample characteristics
Clients mean age was 35.5 years [standard deviation (SD) 9.4
years] and the majority (76%) were male. Most (77%) were born in

Please cite this article in press as: Islam, M. M., et al. Are primary health care centres that target injecting drug users attracting and serving the clients they are designed for? A case study from Sydney, Australia. International Journal of Drug Policy (2012),
http://dx.doi.org/10.1016/j.drugpo.2012.06.002

277

ARTICLE IN PRESS

G Model
DRUPOL-1115; No. of Pages 7

M.M. Islam et al. / International Journal of Drug Policy xxx (2012) xxxxxx

Table 1
Patterns of substance use by clients of RHMC in the preceding 12 months (n = 363).
Prevalence
n (%)

Alcohol
Methamphetamine
Heroin
Cannabis
Benzodiazepines
Cocaine
Methadone
Ecstasy/LSD
MS-Contin and/or Oxycontin
Buprenorphine
Codeine
a

247 (68)
210 (58)
209 (58)
183 (50)
130 (36)
117 (32)
99 (27)
60 (17)
70 (19)
26 (7)
13 (4)

Routea

Frequency of usea

Injecting (%)

Non-injecting (%)

Daily or more (%)

Weekly or more (less

than daily) (%)

Less than weekly

(%)

161 (77)
199 (95)

9 (7)
95 (81)
43 (43)

60 (86)
11 (42)

247 (100)
49 (23)
10 (5)
183 (100)
121 (93)
22 (19)
56 (57)
60 (100)
10 (14)
15 (58)
13 (100)

116 (47)
59 (28)
120 (57)
116 (63)
44 (34)
33 (28)
66 (67)
3 (5)
16 (23)
14 (54)
5 (38)

66 (27)
66 (31)
33 (16)
26 (14)
36 (28)
27 (23)
20 (20)
13 (22)
18 (26)
6 (23)
3 (23)

65 (26)
85 (40)
56 (27)
41 (22)
50 (38)
57 (49)
13 (13)
44 (73)
36 (51)
6 (23)
5 (38)

Among those who reported using.

Australia; 11% identied as Aboriginal and/or Torres Strait Islander

(Indigenous Australian); 82% reported receiving government welfare; and 12% were employed. Eighty-ve percent reported a
history of injecting drug use; almost 15% were non-injecting drug
users (NIDUs); while just two reported having never used illicit
drugs. More than half (53%) of clients reported being referred
from nearby residential drug treatment services; 20% from the colocated NSP; and the remainder from other healthcare services
(7%), family members or friends (2%) or self-referrals (18%). Other
than residential treatment clients, almost all other PHC clients were
existing NSP clients, regardless of from where they indicated they
were referred.
Patterns of drug use
Information on drug use was available for 363 clients (Table 1).
Alcohol was the substance used by the largest proportion of clients
in the preceding 12 months, followed by methamphetamine and
heroin. However, heroin was the drug used most frequently during this period, followed by alcohol and cannabis. Heroin (58%)
was the drug reportedly injected most often (daily or more)
among IDUs. Among NIDUs, the most prevalent drug used in the
preceding 12 months was alcohol. Almost a third (31%) of all
IDUs reported injecting medications intended for oral use (benzodiazepines, methadone, buprenorphine and/or other prescribed
opioids).
Blood-borne virus serological status, vaccination uptake and
injecting risk behaviours
At baseline, 18% of 384 clients tested positive to hepatitis B
core antibody (HBcAb) indicating past exposure to HBV, 96% of
whom were IDUs. Forty percent reported past HBV vaccination,
although only half of these reported completing the multi-dose
series. Of those who underwent hepatitis C antibody screening, 62%
(201/325) tested positive. Qualitative RNA was performed for 170
of the hepatitis C antibody positive clients, of whom 67% tested
positive.
Reports of receptive sharing of injecting equipment were common: 79% of IDUs reported a lifetime history of sharing, and 56%
acknowledged having shared in the preceding 12 months.
Current access to GP services
Sixty-two percent of clients reported having access to a regular
GP. Access to a GP was more common among women (AOR 2.84,
95% CI 1.49, 5.44) and older clients (AOR 1.05, 95% CI 1.021.08)
after controlling for other variables (Table 2). Clients who reported

use of buprenorphine (AOR 3.99, 95% CI 1.12, 14.24) and/or benzodiazepines (AOR 1.83, 95% CI 1.08, 3.11) in the preceding 12 months,
and those currently prescribed mental health medications, mostly
antidepressants and/or antipsychotics (AOR 2.81, 95% CI 1.70, 4.64),
were signicantly more likely than other clients to report regular
GP access.
Comparison between IDUs accessing RHMC and broader samples
of IDUs
IDUs accessing RHMC differed in a number of ways from NSP
clients who participated in the ANSPS in New South Wales during 20062009 (Table 3). RHMC clients were more likely to be
male; aged 25 years; and born in countries other than Australia
(all p < 0.01); and less likely to report receptive syringe sharing
in the preceding month (6% versus 16%). When looking only at
RHMC clients who were referred from the NSP, this group was more
likely to be male (p = 0.03) and less likely to be born in Australian
(p < 0.01) than ANSPS participants, but there was no difference in
age between the two groups (p = 0.68).
Main reasons for presentation
The most common reasons for initial presentation to RHMC
were blood-borne virus testing and/or vaccination (57%), sexual
health assessment or sexually transmitted infection checkup (18%), drug-related health issues (18%) and social services/counselling (5%). Just 2% of presentations were for welfare
services and other assistance. One-quarter of clients presented
seeking more than one service.
Service uptake and referral
Most clients (82%) accessed RHMC more than once, with a
mean of 3.5 (SD 3.2) presentations per client. All clinically eligible
clients (n = 145) were offered HBV vaccination, of whom 50% completed the three-dose series, while 19% received 2 doses. Among
those who received HBV vaccination, 40% were referred to RHMC
from the NSP shopfront. A total of 269 referrals to other health and
welfare services were made for 224 clients, 85% of which were formal. Referrals were made most frequently to the tertiary liver clinic
(29%) and GP services (26%). Where indicated, clients were referred
to sexual health services for hepatitis A vaccination. The majority
of informal referrals were made to GP services.
More than half (55%) of the 269 referrals were attended, while
23% were not taken up, and the outcomes of 22% could not be ascertained. Referral uptake was highest for the liver clinic (69%) and
drug treatment services (55%). Clients who were referred to and

Please cite this article in press as: Islam, M. M., et al. Are primary health care centres that target injecting drug users attracting and serving the clients they are designed for? A case study from Sydney, Australia. International Journal of Drug Policy (2012),
http://dx.doi.org/10.1016/j.drugpo.2012.06.002

278

ARTICLE IN PRESS

G Model
DRUPOL-1115; No. of Pages 7

M.M. Islam et al. / International Journal of Drug Policy xxx (2012) xxxxxx

Table 2
Correlates of access to GP services among 359 RHMC clients.
n

(%)

Current GP accessa
No
n = 120

Yes
n = 239
Age (years)

359

Gender
Female
Male

358
88
270

Used buprenorphine in preceding 12

months
Yes
No

350

Used benzodiazepines in preceding

12 months
Yes
No
History of taking mental health
medications
Yes
No

24
326

36 (SD 0.6)
(25)
(75)

(7)
(93)

350
129
221

(37)
(63)

343
170
173

(50)
(50)

33 (SD 0.8)

239
71
168

119
17
102

231

119

21
210

3
116

231

119

98
133

31
88

225

118

133
92

37
81

Univariate relationship

Multivariate relationshipb

OR (95% CI)

p-Value

AOR (95% CI)

p-Value

1.04 (1.011.06)

<0.01

1.05 (1.02 1.08)

<0.01

2.54 (1.414.54)

<0.01

2.84 (1.49 5.44)

<0.01

3.87 (1.13 13.24)

0.03

3.99 (1.12 14.24)

0.03

2.09 (1.29 3.40)

<0.01

1.83 (1.08 3.11)

0.02

3.16 (1.98 5.07)

<0.01

2.81 (1.704.64)

<0.01

Information regarding GP access was not available for 25 clients.

Complete information for this multivariate model was available for 340 clients. AOR = adjusted odds ratio. Other variables that were signicant only in univariate model
history of diagnosis of mental health problem, alcohol drinking in the past 12 months.
b

attended the liver clinic were signicantly older than those who
did not attend (38.7 versus 34.6 years; t = 2.01, p = 0.047). Referrals to GPs were the least likely to be attended with 36% of those
referred not attending (Table 4).
Discussion
The results of this audit of three-and-a-half years of operation
of a low-threshold PHC associated with an NSP suggest underutilisation of the service. RHMC appeared to have limited capacity to
attract clients from the NSP shopfront, the main group the service was designed to serve. However, despite these limitations, the

results also highlight the fundamental role such a service can play in
offering essential healthcare to high-risk poly-drug users. Although
62% of participants reported regular access to a GP, 50% of these
participants remained unvaccinated against HBV. This is consistent
with low immunisation coverage among IDUs more broadly (Day
et al., 2010), despite government recommendations and vaccination subsidies (DOHA, 2008). Indeed, that IDUs who report regular
GP access would nevertheless attend the RHMC implicitly indicates
barriers to receiving appropriate services from their GPs.
Clients who had recently used prescribed benzodiazepines were
more likely to report regular access to GPs, even after controlling
for other known correlates (Galdas, Cheater, & Marshall, 2005). This

Table 3
Comparison between RHMC attendees and NSW ANSPS participants 20062009.
Variable

RHMC

ANSPS, NSWa

p-Value

Mean age
Age <25 years (%)
Male (%)
Aboriginal/Torres Strait Islander (%)
Born in Australia (%)
Receptive syringe sharing last month (%)
Any treatment/therapy for drug use (%)
HCV antibody positive (%)
Most prevalent illicit drug (%)

35.5
14
76
11
80
6
89
62
Heroin (58%)
Methamphetamine
(58%)

37b
9
63
14
85
16
78
67
Heroin (37%)
Methamphetamine
(25%)

<0.01
<0.01
<0.01
0.09
<0.01
<0.01
0.09
0.06

a
b
c

Weighted gures for the period: 20062009.

Weighted mean of the medians.
These two variables are not directly comparable as RHMC assesses drugs used in the last 12 months, whereas ANSPS assesses the last drug injected.

Table 4
Referrals and referral uptake for health and welfare services.
Referrals (n = 269)
Tertiary liver clinic (n = 78)
General practitioner (n = 69)
Drug treatment services (n = 38)
Sexual health clinic (n = 31)
Community mental health/counselling (n = 24)
Welfare/aboriginal medical service/other (n = 29)
Total

Did not attend

n (%)

Unknown
n (%)

54 (69)
30 (43)
21 (55)
14 (45)
10 (42)
18 (62)

24 (31)
25 (36)
4 (11)
7 (23)
0 (0)
1 (3)

0 (0)
14 (20)
13 (34)
10 (32)
14 (58)
10 (34)

147 (55)

43 (23)

75 (23)

Attended
n (%)

Please cite this article in press as: Islam, M. M., et al. Are primary health care centres that target injecting drug users attracting and serving the clients they are designed for? A case study from Sydney, Australia. International Journal of Drug Policy (2012),
http://dx.doi.org/10.1016/j.drugpo.2012.06.002

279

G Model
DRUPOL-1115; No. of Pages 7

ARTICLE IN PRESS
M.M. Islam et al. / International Journal of Drug Policy xxx (2012) xxxxxx

tendency of some IDUs to attend health services primarily to seek

psychoactive medications (Darke et al., 2003) is circumvented by a
nurse-led service, as in Australia nurses cannot generally prescribe
medication. Indeed, in some settings NSP-based PHCs are the major
or even only source of preventive services (e.g., blood-borne virus
testing and vaccinations) for their clients (Heinzerling et al., 2006).
Around half of the clients were referred from a local residential
drug treatment service. Although clients from the residential drug
treatment service are encouraged to use RHMC, it is not mandatory
and it is not used by all such clients. Relapse to injecting following discharge from residential drug treatment or detoxication is
common (Darke et al., 2005). The period immediately following residential drug treatment is particularly dangerous in terms of both
overdose (Strang et al., 2003) and injecting risk behaviours (Havard,
Teesson, Darke, & Ross, 2006). Engagement with a service that provides both NSP and PHC and that is independent of the residential
treatment program, may increase clients willingness to later access
the service during this high-risk post-discharge period. Although
these data were not systematically collated in this study, anecdotal reports suggest that a substantial proportion of residential drug
treatment clients continued to access RHMC after discharge from
rehabilitation.
Patterns of drug use
Both IDUs and NIDUs in the present sample reported relatively
high prevalences of alcohol use. Although information about the
level of unsafe drinking is unavailable, 21% of IDUs reported their
drug of concern was alcohol. Concurrent alcohol use is potentially
problematic for IDUs, given the high prevalence of hepatitis C infection and alcohols potential to exacerbate liver disease (Cromie,
Jenkins, Bowden, & Dudley, 1996) and diminish hepatitis C treatment outcomes (Anand et al., 2006). Alcohol also increases the risk
of overdose when consumed with opioids (Warner-Smith, Darke,
Lynskey, & Hall, 2001) and unsafe injecting and sexual behaviours
(Rees, Saitz, Horton, & Samet, 2001; Stein et al., 2000). IDUs with
alcohol problems are a potential target group for brief alcohol
interventions, which have been successfully delivered in similar
contexts such as opioid treatment (Watson et al., 2007). Further
exploration of the role and outcomes of brief intervention in the
IDU-targeted PHC setting may be warranted.
Comparison between IDUs accessing RHMC and ANSPS
participants
Compared to ANSPS participants, IDUs accessing RHMC reported
lower rates of receptive sharing of syringes in the preceding month
(16% versus 6%). Notably, the majority of clients were initially
referred to RHMC from abstinence-based residential drug treatment centre, where they had resided for more than one month.
However, even RHMC clients referred from NSP reported lower
rates of receptive sharing (6%) in the preceding month than ANSPS
participants. The differences in reported risk may be exaggerated
by the method of survey administration the ANSPS is designed for
self-completion whereas RHMC nurses assess risk via face-to-face
interviews, which may be subject to greater social desirability bias
(White, Day, & Maher, 2007). Alternatively, clients of this targeted
PHC service may have greater concerns for health than other IDUs,
which may manifest as reductions in risk behaviours.
RHMC engaged a higher proportion of non-Australian born
clients than who participated in the ANSPS across New South Wales
during the years 20062009. This may be attributable to a small
local population of illegal migrant IDUs known to use the service
and who are unable to access Australias universal healthcare system (Medicare). RHMC or similar clinics are therefore the only
available healthcare providers for such groups. The preponderance

of male and younger clients relative to ANSPS samples (Table 3) can

be explained by the fact that 53% of our sample was referred from
nearby drug treatment centres which, from June 2007, referred
only male clients. These clients were also younger than the clients
referred from the NSP shopfront.
The proportion of Aboriginal/Torres Strait Islanders in this sample is much higher than among the general population (11% versus
2%) (Australian Bureau of Statistics, 2006), but similar to the proportion of Indigenous people in ANSPS samples (Topp, Day, Iversen,
Wand, & Maher, 2011). This is consistent with the overrepresentation of Indigenous Australians among disadvantaged groups, and
their corresponding heightened risk of drug misuse (Kratzmann
et al., 2011).
Referral uptake
Although scant research has documented referral uptake among
IDUs, the relatively high uptake (55%) of referrals to other health
and welfare services is notable in comparison to past literature
demonstrating limited referral uptake among IDUs (Kimber et al.,
2008). High uptake is likely attributable to the established referral
linkage between RHMC and other relevant organisations and the
comprehensive support and SMS/phone reminder system implemented by RHMC nurses to facilitate referral uptake.
Although many of the clients were covered by Medicare,
non-nancial barriers (e.g., discrimination, social stigma, lack of
transportation) can also impede access to healthcare among IDUs
(Friedman, 1994; Islam et al., 2012b). Although 62% of clients
reported current access to GP services, as noted above, many drug
users who claim to have GP access do not disclose their drug use
and/or its extent to their GP (WANADA, 2009). Indeed the study
highlights a clear reluctance to utilise GP services. Among all referrals provided by RHMC, GPs referrals were the least likely to be
utilised (36%). This apparent failure of GP services to be attractive
to marginalised population with substantial health needs requires
attention at both the policy and practice level.
Currently, the RHMCs part-time medical ofcer attends the
clinic for 4 h a week, primarily to review pathology results and
discuss cases with nurses. Extending this role to include more
client consultations and prescription of non-psychoactive medication might overcome some of the barriers these clients experience
in relation to obtaining comprehensive healthcare from GPs.
The RHMC was not funded to provide hepatitis A vaccination.
Accordingly 14% clients were referred to a sexual health clinic
primarily for this purpose. However, for over half of this group,
attendance either did not occur (23%) or could not be ascertained
(32%). This is of concern given the high prevalence (5060%) of hepatitis C among Australian IDUs (NCHECR, 2010), and the increased
risk of morbidity if co-infected with hepatitis A (Vento et al., 1998).
Hepatitis A vaccination would be an important intervention for
PHCs associated with NSPs to offer.
Study limitations
As with any clinical le audit, there were instances of incomplete
data. For example, the les of some early clients (around 10% of
RHMC clients) did not have information on GP access.
During three and a half years this PHC service was utilised by
384 clients, equating to an average of two new clients per week,
fewer than might be considered ideal, although ndings incorporated the period of clinic commencement when clinic capacity and
client numbers were still growing. The anonymity requirements of
the existing NSP service prevent us extracting the proportion of NSP
clients accessing PHC from this targeted outlet. The RHMC appears
to be underutilised. More proactive engagement of clients at the

Please cite this article in press as: Islam, M. M., et al. Are primary health care centres that target injecting drug users attracting and serving the clients they are designed for? A case study from Sydney, Australia. International Journal of Drug Policy (2012),
http://dx.doi.org/10.1016/j.drugpo.2012.06.002

280

G Model
DRUPOL-1115; No. of Pages 7

ARTICLE IN PRESS
M.M. Islam et al. / International Journal of Drug Policy xxx (2012) xxxxxx

NSP shopfront and an increase in the range of services offered may

attract more clients.
Finally, while overall clients of this PHC outlet differ from the
broader population of New South Wales NSP clients on a number
of characteristics (Iversen et al., 2011), this observed difference is
mainly due to the attendance of clients referred or recently discharged from residential drug treatment centre. This difference,
however, highlights the capacity of RHMC to cater for the needs
of various client groups, including NIDU, for many of whom this
targeted PHC remains the only source of healthcare.
The cost-effectiveness of this and similar services is yet to be
determined. The cost of such services must be balanced against
cost savings of reduced hospitalisation and reduced incidences of
chronic disease. Universal access to healthcare under the Australian
healthcare system, the limited range of services RHMC offer and
insufcient engagement of IDUs in NSP shopfront provide some
explanation for the apparent under-utilisation of the clinic. Underutilisation of this type of service, however, is an unlikely scenario
in a developing world setting where there is widespread poverty
and healthcare is often costly, such service therefore may be highly
utilised.
Undoubtedly, rigorous evaluation is still required to guide policymakers and clinicians in further improving service provision.
However, it is imperative that IDUs are offered acceptable and
accessible healthcare even while we await quality evidence to guide
best practice.
Conclusion
A low-threshold PHC targeting IDUs, such as RHMC, can also
attract a range of clients including NIDUs who have considerable healthcare needs. Many of these clients were not regularly
accessing other healthcare, and among those who were, psychoactive medication seeking may have been an important motivation.
Clients return rate to this targeted PHC centre and successful referral uptake demonstrate that the service is well accepted by the
client group. However, RHMC appears to be underutilised and
its role as a low-threshold healthcare outlet remains limited. A
more proactive engagement of clients at the NSP shopfront and
an increase in the range of services offered by the RHMC may help
attract more clients.
Acknowledgments
We thank the staff and steering committee of RHMC. The rst
author is supported by a University International Postgraduate
Award of University of New South Wales.
References
Anand, B. S., Currie, S., Dieperink, E., Bini, E. J., Shen, H., Ho, S. B., et al. (2006). Alcohol
use and treatment of hepatitis C virus: Results of a national multicenter study.
Gastroenterology, 130, 16071616.
Australian Bureau of Statistics. (2006). 2006 Census QuickStats: Australia.
Australian Government Department of Health and Ageing (DOHA). (2008). Australian
immunisation handbook (9th ed.). Canberra.
Binswanger, I. A., Takahashi, T. A., Bradley, K., Dellit, T. H., Benton, K. L., & Merrill,
J. O. (2008). Drug users seeking emergency care for soft tissue infection at high
risk for subsequent hospitalization and death. Journal of Studies on Alcohol and
Drugs, 69, 924932.
Cromie, S. L., Jenkins, P. L., Bowden, D. S., & Dudley, F. J. (1996). Chronic heaptitis
C: Effect of alcohol on hepatitic activity and viral titre. Journal of Hepatology, 25,
821826.
Darke, S., & Ross, J. (1997). Polydrug dependence and psychiatric comorbidity among
heroin injectors. Drug and Alcohol Dependence, 48, 135141.
Darke, S., Ross, J., Teesson, M., Ali, R., Cooke, R., Ritter, A., et al. (2005). Factors associated with 12 months continuous heroin abstinence: Findings from the Australian
Treatment Outcome Study (ATOS). Journal of Substance Abuse Treatment, 28,
255263.

Darke, S., Ross, J., Teesson, M., & Lynskey, M. (2003). Health service utilization and
benzodiazepine use among heroin users: Findings from the Australian Treatment Outcome Study (ATOS). Addiction, 98, 11291135.
Day, C., White, B., Dore, G. J., van Beek, I., Rodgers, C., Cunningham, P., et al.
(2010). Hepatitis B virus among injecting drug users in Sydney Australia: Prevalence, vaccination and knowledge of status. Drug and Alcohol Dependence, 108,
134137.
Drumm, R. D., McBride, D. C., Metsch, L., Neufeld, M., & Sawatsky, A. (2005). Im a
health nut!, Street drug users accounts of self-care strategies. Journal of Drug
Issues, 35, 607629.
French, M. T., Fang, H., & Balsa, A. I. (2010). Longitudinal analysis of changes in
illicit drug use and health services utilization. Health Services Research (published
online: 9 December).
Friedman, E. (1994). Money isnt everything. Nonnancial barriers to access. Journal
of American Medical Association, 271, 15351538.
Galdas, P. M., Cheater, F., & Marshall, P. (2005). Men and health helpseeking behaviour: Literature review. Journal of Advanced Nursing, 49,
616623.
Haber, P. S., Demirkol, A., Lange, K., & Murnion, B. (2009). Management of injecting
drug users admitted to hospital. Lancet, 374, 12841293.
Havard, A., Teesson, M., Darke, S., & Ross, J. (2006). Depression among heroin users:
12-Month outcomes from the Australian Treatment Outcome Study (ATOS).
Journal of Substance Abuse Treatment, 30, 355362.
Heinzerling, K. G., Kral, A. H., Flynn, N. M., Anderson, R. L., Scott, A., Gilbert, M. L., et al.
(2006). Unmet need for recommended preventive health services among clients
of California syringe exchange programs: Implications for quality improvement.
Drug and Alcohol Dependence, 81, 167178.
Islam, M. M., Reid, S. E., White, A., Grummett, S., Conigrave, K. M., &
Haber, P. S. (2012). Opportunistic and continuing health care for injecting drug users from a nurse-run needle syringe program-based primary
health-care clinic. Drug & Alcohol Review, 31, 114115, author reply 116
117.
Islam, M. M., Topp, L., Day, C. A., Dawson, A., & Conigrave, K. M. (2012). The accessibility, acceptability, health impact and cost implications of primary healthcare
outlets that target injecting drug users: A narrative synthesis of literature. International Journal of Drug Policy, 23, 94102.
Iversen, J., Topp, L., & Maher, L. (2011). Australian NSP Survey National Data
Report 19952010. Sydney: The Kirby Institute, UNSW. Available at:
http://www.med.unsw.edu.au/NCHECRweb.nsf/resources/NSP Complete2/$le
/ANSPS.1995 2010-rev.pdf Accessed September 2011
Kimber, J., Mattick, R. P., Kaldor, J., van Beek, I., Gilmour, S., & Rance, J. A.
(2008). Process and predictors of drug treatment referral and referral uptake
at the Sydney Medically Supervised Injecting Centre. Drug & Alcohol Review,
111.
Kratzmann, M., Mitchell, E., Ware, J., Banach, L., Ward, J., & Ryan, J. (2011). In J.
Stokes (Ed.), Injecting drug use and associated harms among Aboriginal Australians.
Canberra: Australian National Council on Drugs.
McCoy, C. B., Metsch, L., Chitwood, D. D., & Miles, C. (2001). Drug use and
barriers to use of health care services. Substance Use & Misuse, 36, 789
806.
Morrison, A., Elliott, L., & Gruer, L. (1997). Injecting-related harm and
treatment-seeking behaviour among injecting drug users. Addiction, 92,
13491352.
Myers, B. J. (2012). Primary health care for people who inject drugs in low
and middle income countries: A response to The accessibility, acceptability, health impact and cost implications of primary healthcare outlets that
target injecting drug users. International Journal of Drug Policy, 23, 105
106.
NCHECR. (2010). Australian NSP Survey National Data Report 20052009. Sydney:
National Centre in HIV Epidemiology and Clinical Research, The University of
New South Wales, Sydney, NSW.
Rees, V., Saitz, R., Horton, N. J., & Samet, J. (2001). Association of alcohol consumption
with HIV sex- and drug-risk behaviours among drug users. Journal of Substance
Abuse Treatment, 21, 129134.
Stein, M. (1999). Medical consequences of substance use. Psychiatric Clinics of North
America, 22, 351370.
Stein, M. D., Hanna, L., Natarajan, R., Clarke, J., Marisi, M., Sobota, M.,
et al. (2000). Alcohol use patterns predict high-risk HIV behaviours among
active injections drug users. Journal of Substance Abuse Treatment, 18, 359
363.
Strang, J., McCambridge, J., Best, D., Beswick, T., Bearn, J., Rees, S., et al. (2003). Loss of
tolerance and overdose mortality after inpatient opiate detoxication: Follow
up study. BMJ, 326, 959960.
Topp, L., Day, C. A., Iversen, J., Wand, H., & Maher, L. (2011). Fifteen years of HIV
surveillance among people who inject drugs: The Australian Needle and Syringe
Program Survey 19952009. AIDS, 25, 835842.
Topp, L., Iversen, J., Wand, H., Day, C., Kaldor, J., & Maher, L. (2008). Representativeness of injecting drug users who participate in HIV surveillance: Results
from Australias Needle and Syringe Program Survey. Journal of Acquired Immune
Deciency Syndromes, 47, 632638.
Vento, S., Garofano, T., Renzini, C., Cainelli, F., Casali, F., Ghironzi, G., et al.
(1998). Fulminant hepatitis associated with hepatitis A virus superinfection
in patients with chronic hepatitis C. New England Journal of Medicine, 338,
286290.
Warner-Smith, M., Darke, S., Lynskey, M., & Hall, W. (2001). Heroin overdose: Causes
and consequences. Addiction, 96, 11131125.

Please cite this article in press as: Islam, M. M., et al. Are primary health care centres that target injecting drug users attracting and serving the clients they are designed for? A case study from Sydney, Australia. International Journal of Drug Policy (2012),
http://dx.doi.org/10.1016/j.drugpo.2012.06.002

281

G Model
DRUPOL-1115; No. of Pages 7

ARTICLE IN PRESS
M.M. Islam et al. / International Journal of Drug Policy xxx (2012) xxxxxx

Watson, B., Conigrave, K. M., Wallace, C., Whiteld, J. B., Wurst, F., & Haber, P. S.
(2007). Hazardous alcohol consumption and other barriers to antiviral treatment
among hepatitis C positive people receiving opioid maintenance treatment. Drug
and Alcohol Review, 26, 231239.
Western Australian Network of Alcohol and Other Drug Agencies (WANADA).
(2009). WANADA GP Access (pilot) project evaluation summary. Available at:
www.wanada.org.au/Download./72-GP-Access-Project-Evaluation.html

White, B., Day, C., & Maher, L. (2007). Self reported risk behaviour among injecting drug users: Self versus assisted questionnaire completion. AIDS Care, 19,
441447.
World Health Organization. (2009). Management of common health problems of
drug users. Retrieved from: http://www.searo.who.int/en/Section10/Section18/
Section356 4609.htm. New Delhi.

Please cite this article in press as: Islam, M. M., et al. Are primary health care centres that target injecting drug users attracting and serving the clients they are designed for? A case study from Sydney, Australia. International Journal of Drug Policy (2012),
http://dx.doi.org/10.1016/j.drugpo.2012.06.002

282

Appendix IV

(f) Islam, M. M., Grummett, S., White, A., Reid, S. E., Day, C. A., & Haber, P. S. (2011).
A primary healthcare clinic in a needle syringe program may contribute to HIV
prevention by early detection of incident HIV in an injecting drug user. Australian
and New Zealand Journal of Public Health, 35, 294-295.

283

Letters
A composite score with a maximum total of 33 was calculated
for each application. The scoring system weighted each domain as
follows: coverage (10 points), accuracy (8 points), applicability (6
points), user-friendliness (6 points) and accountability (3 points).
The final composite score for each application was converted to a
percentage with applications scored as good (70%), fair (50-69%)
or poor (49%).
Of the 403 applications located, 92 met inclusion criteria for
downloading, but 35 did not meet the inclusion criteria on closer
examination and three had technical problems. Overall, eight
applications were rated as good. They were five calorie and physical
activity counters and three BMI or weight trackers. Thirty-two
of the applications were rated as fair and 14 were rated as poor. The
applications that were rated as good had better coverage and accuracy
scores compared to those rated as fair or poor. Less than a third of all
applications had complete accuracy. All applications scored well for
user-friendliness, but scored poorly for authors accountability. The
USDA Nutrient Database of Foods was used in all applications and
energy intake was tracked with calories instead of kilojoules, the
measure used in Australia. As many manufactured and takeaway foods
consumed in the US differ to those commonly eaten in Australia the
applicability for Australians is limited.
Thus, while the majority of applications did not score well,
those rated as good may be a useful adjunct treatment to health
professionals advice to assist their patients weight loss efforts. The
assessment tool devised to rate the applications may be useful for
future use with new applications and some customisation of the good
applications, such as the use of Australian food databases, is indicated.

References
1. Australian Bureau of Statistics. 4364.0 - National Health Survey 2007-08:
Summary of Results. Canberra (AUST): ABS; 2009.
2. Charles J, Britt H, Knox S. Patient perception of their weight, attempts to lose
weight and their diabetes status. Aust Fam Physician. 2006;35(11):925-8.
3. Eysenbach G, Powell J, Kruss O, Sa ER. Empirical studies assessing the quality
of health information for consumers on the World Wide Web: A systematic
review. JAMA. 2002;287(20):2691-700.
4. Gasser R, Brodbeck D, Degen M, Luthiger J, Wyss R, Reichlin S. Persuasiveness
of a mobile lifestyle coaching application using social facilitation. Lecture
Notes In Computer Science. 2006;3962:27-38.
5. Silberg WM, Lundberg GD, Musacchio RA. Assessing, controlling and assuring
the quality of medical information on the Internet. JAMA. 1997;277(15):1244-5.
5. Dietitians Association of Australia. Best Practice Guidelines for the Treatment
of Overweight and Obesity in Adults. Canberra (AUST): DAA; 2006.
7. National Health and Medical Research Council. Clinical Practice Guidelines
for the Management of Overweight and Obesity in Adults. Canberra (AUST):
Commonwealth of Australia; 2003.
8. National Health and Medical Research Council. Dietary Guidelines for
Australians: A Guide to Healthy Eating. Canberra (AUST): Commonwealth
Department of Health and Ageing; 2005.
9. Ainsworth BE, Haskell WL, Whitt MC, Irwin ML, Swartz AM, Strath SJ, et
al. Compendium of physical activities: an updated activity codes and MET
intensities. Med Sci Sport Exer. 2000;32(9):S498-S516.
10. National Health and Medical Research Council. Nutrient Reference Values for
Australia [Internet]. Canberra (AUST): Commonwealth of Australia; 2006
[cited 2010 Sep]. Available from: http://www.nrv.gov.au/nutrients/index.htm
11. US Agriculture Research Service. National Nutrient Database for Standard
Reference [Internet]. Washington (DC): United States Department of
Agriculture; 2010 [cited 2010 Sep]. Available from http://www.ars.usda.gov/
main/site_main.htm?modecode=12-35-45-00

Correspondence to: Margaret Allman-Farinelli, Associate Professor

Clinical Nutrition and Dietetics, School of Molecular Bioscience,
Biochemistry Building (G08), The University of Sydney, NSW 2006;
e-mail: margaret.allmanfarinelli@sydney.edu.au

294

doi: 10.1111/j.1753-6405.2011.00708.x

A primary healthcare clinic in

a needle syringe program may
contribute to HIV prevention by
early detection of incident HIV
in an injecting drug user
M. Mofizul Islam
School of Public Health & Community Medicine,
University of New South Wales

Sarah Grummett, Ann White

Redfern Harm Minimisation Clinic, New South Wales

Sharon E. Reid, Carolyn A. Day, Paul S. Haber

Sydney Medical School, University of Sydney,
New South Wales

Injecting drug users (IDUs) have a large number of unmet health

needs and often report barriers to accessing general practitioners
(GPs). Transmission of HIV among IDUs, with the potential for
outbreaks in these marginalised high-risk populations, has been
repeatedly documented1 and remains a serious risk to a population
with low HIV prevalence. Delayed diagnosis may allow continuing
high-risk behaviour and further HIV transmission. In some parts of
the world, needle syringe programs (NSPs) have been enhanced to
offer low-threshold primary healthcare (PHC) services to IDUs.2
Enhanced NSPs typically provide non-judgemental and often
anonymous services allowing clients to disclose socially sensitive
high-risk behaviours,3 and to access harm minimisation, primary
healthcare services and referrals for other healthcare. This model of
care has not been widely adopted in Australia. The Redfern Harm
Minimisation Clinic (RHMC) is a nurse-run service, established in
2006, with a sessional visiting medical officer and support from the
local hospital network.4 Clients present without appointments from
the NSP front counter or surrounding drug rehabilitation services.
We describe an incident HIV case detected in the RHMC and discuss
its implications for HIV prevention in this population.
A 28-year-old man, who was an intermittent IDU (mainly
methamphetamines) and was recently HIV negative, presented to
the NSP service. He had a background of mild developmental delay,
learning disorder and depression. A brief risk assessment revealed he
had had unprotected anal insertive and receptive sexual intercourse
with a man 16 hours beforehand. The client was in a hurry and would
not wait for phlebotomy. The client was referred to the PEP (Post
Exposure Prophylaxis) Hotline for advice, but would not stay long
enough to allow the registered nurse (RN) to assist him with the call.
The RN provided him with education, the relevant contact numbers
and advised him to return to the clinic at the earliest opportunity.
The client attended the clinic four days later and following pre-test
counselling was screened for HIV. Upon receiving a positive Western
blot HIV result, the client was contacted and attended the following
day for post-test counselling, support and referral for specialist care.
RHMC established an accelerated referral protocol for HIV services
at its commencement and the client was escorted to the sexual health

AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH

2011 The Authors. ANZJPH 2011 Public Health Association of Australia

2011 vol. 35 no. 3

284

Letters
centre by the clinic RN and continues in its care. RHMC provides
ongoing support via regular follow-up of the client, assistance with
appointments and ancillary services. The client has obtained advice
and resources for safer sex practices to minimise the risk of further
HIV transmission, including condoms and lubricant and advice to
disclose his HIV status to current and future sex-partners.
Staff of the RHMC have a specific interest and skills in the
management of people with drug dependence in whom a chaotic
lifestyle may lead to neglect of healthcare needs in the face of more
immediate concerns related to obtaining food, shelter and money to
support their drug use.5 In contrast to conventional medical services,
the RHMC welcomes active IDUs and offers drop-in arrangements.
Most clients are seen on a walk-in, first-come first-served basis, with
an emphasis on informality.4 The anonymous and confidential access
to healthcare removes barriers for individuals engaged in illegal,
covert and/or stigmatised activities.6
Identification of this HIV case underscores how clinics of this type
can extend healthcare support to the IDU subgroup, whose lifestyles
put them at high risk. Co-location with NSP is a key advantage
for this type of service by providing opportunistic and continuous
healthcare to IDUs who face barriers to accessing care elsewhere.
The brief and opportunistic healthcare advice initially provided to
the client reduced the risk that some of his future and current sex
partners might acquire HIV infection.
Successful treatment, management and prevention of HIV requires
establishing a therapeutic relationship with a range of healthcare
providers. This is particularly challenging to achieve in active IDUs.
Transmission of HIV among IDUs is now one of the leading modes
of incident HIV infection. Provision of primary health and other
services, beyond syringe distribution, is a strategy that can facilitate
early diagnosis of HIV and increase the uptake of effective prevention
strategies, improving the capacity of NSP services to achieve their
central goal of preventing the spread of blood-borne virus infection.
Hence, NSP-based primary healthcare, such as the RHMC, is a
valuable component of the overall HIV prevention strategy.

References
1. Hamers FF, Downs AM. HIV in central and eastern Europe. Lancet.
2003;361(9362):1035-44.
2. Islam MM, Day C, Conigrave KM. Harm reduction healthcare: from an
alternative to the mainstream platform? International. Int J Drug Policy.
2010;21(2):131-3.
3. Rich JD, McKenzie M, Macalino GE, Taylor LE, Sanford-Colby S, Wolf F, et
al. A syringe prescription program to prevent infectious disease and improve
health of injection drug users. J Urban Health. 2004;81(1):122-34.
4. Day CA, Islam MM, White A, Reid SE, Hayes S, Haber PS. Development of
a nurse-led primary healthcare service for injecting drug users in inner-city
Sydney. Aust J Prim Care. 2011;17(1):10-15.
5. Carr S, Goldberg DJ, Elliott L, Green S, Mackie C, Gruer L. A primary health
care service for Glasgow street sex workers--6 years experience of the drop-in
centre, 1989-1994. AIDS Care. 1996;8(4):489-97.
6. Harris HW, Young DM. Care of injection drug users with soft tissue infections
in San Francisco, California. Arch Surg. 2002;137(11):1217-22.

Correspondence to: Carolyn A. Day, Senior Lecturer, Sydney

Medical School, the University of Sydney, Drug Health Services,
King George V Bldg, RPAH, Missenden Rd, Campderdown, NSW;
e-mail: carolyn.day@sydney.edu.au

2011 vol. 35 no. 3

doi: 10.1111/j.1753-6405.2011.00709.x

The impact of smoke-free laws

on business revenue in hotels
and licensed clubs in South
Australia
David L. John
School of Health Sciences, University of South Australia

Jacqueline A. Bowden
Tobacco Control Research & Evaluation Program,
Cancer Council South Australia

Caroline L. Miller
Cancer Control Programs, Cancer Council South Australia

Legislation to make all enclosed areas in South Australian hotels

and licensed clubs smoke-free was introduced on 1 November
2007.1 While smoke-free policies reduce exposure to secondhand
tobacco smoke, they are inevitably accompanied by claims from
industry that such legislation leads to adverse business sales in
the hospitality industry.2 Previous studies examining the impact of
smoke-free restaurant laws have demonstrated no adverse effect on
sales in restaurants and cafes, but the number of published studies
examining the effect of these laws in hotels and licensed clubs in
Australia is limited.
Our study was designed to examine the economic impact of the
smoke-free law on business revenue for hotels and licensed clubs in
South Australia. We obtained seasonally adjusted monthy turnover
data for hotels and licensed clubs from July 2002 to June 2008 from
the Australian Bureau of Statistics Retail Business Survey,11 and
adjusted for inflation using the ABS Consumer Price Index (CPI).12
To account for underlying economic trends, unemployment and
population changes, we followed the procedure suggested by Glantz
and Smith4,5 whereby the ratio of monthly turnover for hotels and
licensed clubs to total monthly retail turnover (minus hotels and
licensed clubs turnover) in South Australia was computed. This
ratio (hereafter called RATIO) would be expected to decrease if
the implementation of the smoke-free law had an adverse effect on
retail turnover.
Linear regression was used to examine the effect of the smokefree legislation on RATIO. To control for secular trend, a difference
transformation was applied. This transformed variable was then used
as the outcome (dependent) variable and a dummy (intervention)
variable representing the timing of the smoke-free legislation was
set up as a predictor (independent) variable. Once the series was detrended, we used Ljung Box Q statistics to test the hypothesis of no
autocorrelation.13 The presence of significant autocorrelation in most
time series usually means techniques such as ordinary least squares
(OLS) regression are not recommended, with analysts preferring
instead such techniques as autoregressive integrated moving average
(ARIMA) models developed by Box and Jenkins.14 This technique
was not required in the present analysis as the serial dependence
(autocorrelation) of the data disappeared once the series had been
made stationary.

AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH

295

2011 The Authors. ANZJPH 2011 Public Health Association of Australia

285

Appendix IV

(g) Islam, M. M., Reid, S. E., White, A., Grummett, S., Conigrave, K. M., & Haber, P. S.
(2012). Opportunistic and continuing health care for injecting drug users from a
nurse-run needle syringe program-based primary health-care clinic. Drug and Alcohol
Review, 31, 114-115; author reply 116-117.

286

R E V I E W

Drug and Alcohol Review (January 2012), 31, 114115

DOI: 10.1111/j.1465-3362.2011.00390.x

LETTER TO THE EDITOR

Opportunistic and continuing health care for injecting drug users

from a nurse-run needle syringe program-based primary
health-care clinic
dar_390

114..115

SirNeedle syringe programs (NSPs) are an important

point of contact with injecting drug users (IDUs) and
can play a crucial role in the provision of essential
health care. Accordingly, in some parts of the world,
NSPs have been enhanced to offer low-threshold
primary health-care services [1].These enhanced NSPs
typically provide non-judgemental and often anonymous services allowing clients to access harm minimisation, primary health care, welfare services and
referrals for other health care. This model of care has
not been widely adopted in Australia, in part because:
(i) this is a relatively new model of health care with
limited published evidence of effectiveness [2]; (ii)
belief that IDUs, like the general population, have
adequate access to health care under the universal
health insurance system; (iii) the notion that harm
reduction should be limited to delivery of sterile injecting equipment and that primary health care is a separate issue; and (iv) cross-organisational barriers and
administrative constraints. Amidst these obstacles a few
NSP-based primary health-care centres have led the
way to address the unmet health-care needs of IDUs.
The Kirketon Road Centre at Kings Cross in Sydney,
established in 1987, is one of the pioneers in primary
health care for IDUs [3]. Following on, in 2001, as part
of the Saving Lives strategy, the Victorian State Government provided funding to establish primary health
services for street-based IDUs in five areas of Melbourne with high drug usage rates [4].
The Redfern Harm Minimisation Clinic (RHMC),
Sydney, established in 2006 [2], provides primary
health care to IDUs via an enhanced NSP model. It is
a nurse-run service co-located with an existing NSP,
with a sessional visiting medical officer. Clients present
on a walk-in, first-come first-serve basis from the NSP
shopfront or are referred by local health-care services.
We describe an example of how opportunistic health
care and support provided by the RHMC to an IDU
with a longstanding physical disability enabled commencement of HCV treatment and viral clearance.
This 42-year-old man was an IDU with a long history
of polydrug use. He had known HCV infection for
several years, longstanding visual impairment and chal-

lenges with mobility, social isolation and difficult interpersonal interactions. He presented to the NSP
requesting sterile injecting equipment as he was intermittently injecting drugs despite being on opioid maintenance treatment for 4 years, currently receiving
buprenorphine. His frequency of injecting had reduced
in recent years and he had considered HCV treatment
before, but the barriers to accessing appointments in a
tertiary centre were considered too great. Furthermore,
his HCV infection, which was of the treatment resistant genotype 1, also contributed to his considering
treatment as neither worthwhile nor feasible. Over a
period of several NSP service visits, the registered nurse
at RHMC engaged him in discussions about HCV
treatment and ways to circumvent perceived barriers.
Ultimately, through liaison with the nearby tertiary liver
clinic, an individualised care plan was developed for
HCV treatment. To support treatment adherence,
RHMC staff drove the patient to the tertiary liver clinic
monthly to pick up medication and attend specialist
appointments, supervised self-administration of weekly
interferon injections, filled a dosette box with oral antiviral (ribavirin) medication every 2 weeks, performed
periodic blood tests as per HCV protocol, assessed and
managed side-effects of treatment, including mood disturbance, provided ongoing emotional and other
support, liaised with the methadone clinic where necessary to maintain opioid maintenance treatment and
reminded him (via SMS and phone) about upcoming
or missed appointments. The patient successfully completed all 48 weeks of treatment and achieved a sustained virological response. The patient attributed his
success to the ongoing support and care he received
from the RHMC.
This is just one example of the type of the specialist
care that can be provided by an NSP-based primary
health-care clinic. Clearly, co-location with NSP is an
added advantage for this type of service and has the
potential of providing both opportunistic and continuing health care. This patient is still in regular contact
with RHMC. Successful treatment, management and
prevention of HCV requires a trusting relationship with
health-care providers who can provide practical but

2011 Australasian Professional Society on Alcohol and other Drugs

287

Letter to the Editor

expert help for patients with complex needs to implement a challenging health-care plan. The role of
RHMC in treatment of HCV has been detailed more
fully in a recent study [5]. Providing health and other
services, beyond syringe distribution, is a strategy that is
reported to improve the perceived worth of NSP services [6]. The NSP-based primary health care like the
RHMC is a valuable health-care platform with capacity
to treat complex cases that may be difficult to treat in
other settings.
Key words: primary health care, needle syringe
program, injecting drug use, Hepatitis C, low-threshold
health care.
M. Mofizul Islam
School of Public Health and Community Medicine,
University of New South Wales
Sydney, NSW, Australia
Drug Health Service, Royal Prince Alfred Hospital
Sydney, NSW, Australia
E-mail: m.m.islam@unsw.edu.au,
mikhokan143@yahoo.com
Sharon E. Reid
School of Public Health, Sydney Medical School,
University of Sydney
Sydney, NSW, Australia
Drug Health Service, Royal Prince Alfred Hospital
Sydney, NSW, Australia
Ann White & Sara Grummett
Redfern Harm Minimisation Clinic
Sydney, NSW, Australia
Katherine M. Conigrave
Drug Health Service, Royal Prince Alfred Hospital
Sydney, NSW, Australia
Sydney Medical School, University of Sydney
Sydney, NSW, Australia
National Drug and Alcohol Research Centre,
University of New South Wales
Sydney, NSW, Australia
Paul S. Haber
Discipline of Addiction Medicine, Central Clinical School,
Sydney Medical School, University of Sydney
Sydney, NSW, Australia
Sydney South West Area Health Service
Sydney, NSW, Australia

115

References
[1] Islam MM, Day CA, Conigrave KM. Harm reduction
healthcare: from an alternative to the mainstream platform?
Int J Drug Policy 2010;21:1313.
[2] Islam MM, Topp L, Day C, Dawson A, Conigrave KM.
The accessibility, acceptability, public health impact and
cost implications of primary healthcare outlets that target
injecting drug users: a narrative synthesis of literature. Int J
Drug Policy (in press). DOI: 10.1016/j.drugpo.2011.08.005.
[3] van Beek I. Case study: accessible primary health carea
foundation to improve health outcomes for people who inject
drugs. Int J Drug Policy 2007;18:32932.
[4] Norman J, Mugavin J, Swan A. Evaluation of the primary
health services. Fitzroy, Victoria: Turning Point Alcohol and
Drug Centre, 2006.
[5] Islam MM, Hayes S, White A, et al. Assessment for hepatitis
C treatment and referral uptake by IDUs attending a harm
reduction based primary healthcare. 7th Australian Viral
Hepatitis Conference; Melbourne, 68 September, 2010.
[6] MacNeil J, Pauly B. Needle exchange as a safe haven in an
unsafe world. Drug Alcohol Rev 2011;30:2632.

2011 Australasian Professional Society on Alcohol and other Drugs

288

R E V I E W

Drug and Alcohol Review (January 2012), 31, 116117

DOI: 10.1111/j.1465-3362.2011.00389.x

LETTER TO THE EDITOR

Response to Islam et al.: Opportunistic and continuing health care

for injecting drug users from a nurse-run needle syringe
program-based primary health-care clinic
dar_389

SirIslam et al. [1] describe how ongoing contact with

appropriately experienced clinical staff at an enhanced
needle syringe program (NSP) in Sydney enabled a
blind person who injected drugs to overcome a range of
barriers, both real and perceived, to hepatitis C (HCV)
treatment at a nearby hospital-based tertiary liver
clinic.This person was then able to adhere to a 48 week
course of treatment with good clinical outcome. Apart
from improving his personal health outlook, this also
has a potentially wider impact from a secondary HCV
prevention perspective.
The authors attribute this outcome to the opportunity provided by the NSP regularly accessed by this
person being co-located with a nurse-led primary
health-care (PHC) clinic. This seems likely given that
people of this demographic background have traditionally had poor access to such care despite having higher
and more complex needs than the general population.
The World Health Organization (WHO) first articulated primary health care as a philosophical approach to
health care encompassing concepts of accessibility,
acceptability, affordability and equity, as part of its
Declaration of Alma Ata in 1978 [2]. WHO has subsequently recognised the integrated (one-stop shop)
community-based PHC model as best practice in the
prevention and treatment of HIV and other bloodborne infections (BBIs) among people who inject drugs
(PWID). This is particularly important when these
co-occur with other health issues, such as tuberculosis
and mental health issues that will benefit from a centrally coordinated and multidisciplinary approach. And
yet, as the authors note, low threshold PHC centres
targeting the often complex health and psychosocial
needs of PWID remain exceptional in the Australian
context. This contrasts with elsewhere in the world
where NSP is often integrated with targeted PHC, particularly in the USA [3] where in fact most NSPs offer
clinical services, including testing for blood borne and
sexually transmissible infections.
Meanwhile, PWID with complex needs are known
to be at particularly high risk of BBIs, leading to their
recognition as a priority population in the city where
this enhanced NSP is located. But this has yet to trans-

116..117

late into funding support for NSP services to enable

such needs to be addressed. In fact, initiatives to significantly increase the amount of clean injecting equipment provided without commensurate additional
funding suggest that this is likely to occur at the expense
of any enhanced aspects of existing programs.
Ideally there would be sufficient funds to provide
unlimited access to affordable clean injecting equipment in all places and at all times and the most marginalised PWID would have ready access to targeted
PHC services able to address those health and psychosocial issues associated with injecting risk behaviour.
Scarce public health resources are certainly a barrier to
such a multi-pronged approach to preventing HCV
among PWID.
The disease-focused nature of funding sources may
be another barrier. NSP-dedicated funding within the
BBI funding stream is increasingly quarantined in order
to preserve it for this specific purpose only and not
PHC, however targeted towards high risk PWID this
may be. There are similar concerns about the funding
allocated to illicit drug use and mental health being
potentially diluted by supporting more whole of
person PHC models. Like the BBI funding stream,
these funding bases are usually siloed from their central
source at the Health Department level all the way down
to the clinical coalface, often stopping short of the PHC
level altogether. The limited integration of HIV and
HCV treatment in Australian community-based drug
treatment settings to date, despite their obvious synergies, further attests to such concerns.
Custodians of these highly specialised funding bases
are often tempted to direct PWID to the PHC system
established for the general community in Australia,
which has been funded through its Medicare arrangement. This universal health insurance scheme funds
medical services provided by general (medical) practitioners on a fee-for-service basis. However, evidence
suggests that there are significant barriers to the functional utilisation of this resource by those groups most
in need, such as privacy concerns. Advocating for
additional funds would be greatly assisted if one
were able to draw upon research evidence for the

2011 Australasian Professional Society on Alcohol and other Drugs

289

Letter to the Editor

cost-effectiveness of more comprehensive PHC

approaches in preventing BBI, particularly in priority
populations. But there is a dearth of such evidence
published in the scientific literature, and this is unlikely
to change in the foreseeable future.
However, what is readily available are case studies,
such as this. While essentially anecdotal, one would
hope that readers will be able to draw upon their own
experience and plain common sense to realise that no,
this person would not have otherwise accessed HCV
treatment or now be free of the virus had it not been for
the existence of the PHC-enhanced NSP. He is unlikely
to have developed the necessary trust and rapport with
someone who could prepare him for what was involved
to make the leap of faith needed to venture into the
tertiary health-care systema system that is often
openly hostile and unwelcoming of people who engage
in stigmatised behaviours, such as illicit drug use. And
he would have been unlikely to have gotten through the
long and often arduous course of HCV treatment with
its potential side-effects, both physical and psychological, had it not been for the day-to-day support of a team
who could address these all the while encouraging him
forward. Is it the case that research evidence isnt
needed after all to know that enhanced NSP models
like this one should be supported?
Perhaps what is needed is a population-focused strategy instead of the current disease-specific approach to

117

the range of complex health issues faced by marginalised populations, such as PWID, and a corresponding
funding framework that would enable the delivery of a
range of relevant services by a multidisciplinary team in
the one location convenient to the affected community.
Sounds like best practice to me!
Key words: primary health care, needle syringe
program, people who inject drugs.
Ingrid van Beek
South Eastern Sydney Local Health District,
Kirketon Road Centre
Sydney, NSW, Australia
E-mail: ingrid.vanbeek@sesiahs.health.nsw.gov.au

References
[1] Islam M, Reid S, White A, Grummett S, Conigrave K, Haber
P. Opportunistic and continuing health care for injecting
drug users from a nurse-run needle syringe program-based
primary health-care clinic. Drug Alcohol Rev 2011; DOI:
10.1111/j.1465-3362.2011.00390.x.
[2] World Health Organization (WHO). Declaration of AlmaAta. 1978. Available at: http://www.who.int/hpr/NPH/docs/
declaration_almaata.pdf (accessed 26 September 2011).
[3] Centers for Disease Control and Prevention. Morbidity and
Mortality Weekly Report. Syringe Exchange Programs,
United States 2008 November 19, 2010;59(45):148891.

2011 Australasian Professional Society on Alcohol and other Drugs

290

Appendix IV

(h) Islam, M. M., Topp, L., White, A., Conigrave, K. M., Reid, S., Grummett, S., Haber,
P. S., & Day, C. (2012). Linkage into specialist hepatitis C treatment services of
injecting drug users attending a needle syringe program-based primary healthcare
centre. Journal of Substance Abuse Treatment, 43, 440-445.

291

Journal of Substance Abuse Treatment 43 (2012) 440445

Contents lists available at SciVerse ScienceDirect

Journal of Substance Abuse Treatment

Linkage into specialist hepatitis C treatment services of injecting drug users attending
a needle syringe program-based primary healthcare centre
M. Mozul Islam, M.Sc., M.Phil. a, b, Libby Topp, Ph.D. c, Katherine M. Conigrave, FAChAM, FAFHPM, Ph.D. b, d, e,
Ann White, R.N., R.M. f, Sharon E. Reid, M.P.H., FRACGP, DRANZCOG, Dip.Paed f, g, Sara Grummett, R.N. f,
Paul S. Haber, FRACP, FAChAM, M.D. b, d, Carolyn A. Day, Ph.D. h,
a

School of Public Health and Community Medicine, University of New South Wales, Australia
Drug Health Service, Royal Prince Alfred Hospital, Sydney, Australia
Viral Hepatitis Epidemiology and Prevention Program, the Kirby Institute, University of New South Wales, Australia
d
Sydney Medical School, University of Sydney, Australia
e
National Drug and Alcohol Research Centre, University of New South Wales, Australia
f
Redfern Harm Minimisation Clinic, Sydney Local Health District, Australia
g
School of Public Health, Sydney Medical School, University of Sydney, Australia
h
Discipline of Addiction Medicine, Central Clinical School, Sydney Medical School, University of Sydney, Australia
b
c

a r t i c l e

i n f o

Article history:
Received 7 December 2011
Received in revised form 15 May 2012
Accepted 2 July 2012
Keywords:
HCV treatment
Hepatitis C
Injecting drug users
Needle syringe program
Primary healthcare

a b s t r a c t
Injecting drug users (IDUs), the key risk population for hepatitis C virus (HCV) infection, constitute just a
small proportion of HCV treatment clients. This study describes an HCV treatment assessment model
developed by an inner-city IDU-targeted primary healthcare (PHC) facility and, using a retrospective clinical
audit, documents predictors of successful referrals to a tertiary liver clinic. Between July 2006-December
2010, 479 clients attended the PHC, of whom 353 (74%) were screened for HCV antibody. Sixty percent (212/
353) tested positive, of whom 93% (197/212) were screened for HCV-RNA with 73% (143/197) positive.
Referrals to a tertiary liver clinic were provided to 96 clients, of whom 68 (71%) attended. Eleven clients
commenced antiviral therapy (AVT), with seven achieving sustained virological responses by December 2010.
Clients who had not recently injected drugs and those with elevated ALT levels were more likely to attend the
referrals, while those not prescribed psychiatric medications were more likely to commence AVT. The
relatively high uptake of referrals, the number of individuals commencing AVT and nal treatment outcomes
are reasonably encouraging, highlighting the potential of targeted PHC services to facilitate reductions in liver
disease burden among IDUs.
2012 Elsevier Inc. All rights reserved.

1. Introduction
The high prevalence of hepatitis C virus (HCV)-related liver
disease among injecting drug users (IDUs) is a serious global health
concern (Shepard, Finelli, & Alter, 2005). In Australia, it was
estimated that at the end of 2005 approximately 264,000 people
had been exposed to HCV, and 5300 were living with HCV-related
cirrhosis (Razali et al., 2007). Eighty-two percent of those testing
positive to HCV antibody were estimated to have been exposed
through injecting drug use. In the absence of effective therapeutic
intervention, the number of people living with HCV-related cirrhosis
is estimated to increase to 25,000 by 2020 (Dore, Law, MacDonald, &
Kaldor, 2003). Despite increasing safety and efcacy of HCV

Corresponding author. Drug Health Services, King George V Bldg, RPAH, Missenden
Rd, Campderdown, NSW 2050, Australia. Tel.: +61 2 9515 8817; fax: +61 2 9515 5779.
E-mail address: carolyn.day@sydney.edu.au (C.A. Day).

treatment, assessment and uptake among IDUs remain low for

multiple reasons, including the chaotic lifestyles and competing
priorities often engendered by drug dependence (Mehta et al., 2008).
Other issues such as lack of treatment support and difculties
navigating the complex tertiary healthcare system are also important
(Stoove, Gifford, & Dore, 2005), leading to calls for improved
integration between relevant services.
Needle syringe program (NSP)-based primary healthcare (PHC)
has the potential to effectively reach IDUs and provide them
preventive and other healthcare services (Islam, Topp, Day, Dawson,
& Conigrave, 2012). Screening for and management of HCV infection is
an aim of such services, however, little is known about their impact on
the uptake and outcomes of referral of clients for HCV antiviral
therapy (AVT) assessment. This study examines (i) the patterns and
correlates of uptake of referrals to a tertiary liver clinic; and (ii)
subsequent AVT initiation, among IDUs referred from Redfern Harm
Minimisation Clinic (RHMC), an NSP-based IDU-targeted PHC service
located in inner-city Sydney.

0740-5472/$ see front matter 2012 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jsat.2012.07.007

292

M.M. Islam et al. / Journal of Substance Abuse Treatment 43 (2012) 440445

2. Method
2.1. Setting and service provision
The RHMC (PHC service) is a nurse-led service comprising a
clinical nurse consultant (a specialist nurse) and a registered nurse
specialising in PHC with marginalised communities; a case-worker;
and a 0.1 full-time equivalent visiting medical ofcer who reviews
pathology results and consults with nurses and clients as required.
The RHMC and the NSP shopfront are co-located with a shared
entrance within a multidisciplinary center. Clients may be referred to
RHMC from the NSP, from nearby drug treatment and from
rehabilitation centers, or other community-based health services.
Clients may continue attending the RHMC and/or the NSP according to
their own wishes and clinical advice. Services are provided both by
appointment and on a drop-in (Day et al., 2011) basis, and clients'
presence in the NSP shopfront is often utilised opportunistically to
provide care (Islam, Reid, et al., 2012).
During client's initial visit nurses perform assessments on ve
domains: (i) drug and alcohol use; (ii) blood borne virus (BBV) risks
and status; (iii) mental health; (iv) sexual and reproductive health;
and (v) general health. Other services commonly offered include care
and management for wounds, veins and abscesses; hepatitis B
vaccination; general health consultations; welfare services; counselling; referrals to other health services; and support throughout HCV
assessment and antiviral therapy. RHMC service provision has been
described elsewhere (Day et al., 2011).
2.2. Characteristics of the cohort
During the rst four years of operation (July 2006-December
2010), 479 clients accessed RHMC. Clients' mean age was 35 years
[standard deviation (SD) 9.0 years] and the majority (77%) were
male. Most (78%) were born in Australia and 13% identied as being of
Aboriginal and/or Torres Strait Islander (Indigenous) descent. Eightysix percent reported a history of injecting drug use. Reasons for initial
presentation included BBV testing and/or vaccination (75%), sexual
health assessment/STI screening (25%), drug-related health issues
(20%) and psychosocial services/counselling (5%). Heroin was the
most common drug of concern in the preceding 12 months,
nominated by 42% of clients, followed by methamphetamine (27%)
and alcohol (25%).

441

AVT assessment. RHMC staff make appointments on behalf of

clients and inform them of the time and location. A reminder is
sent to clients via SMS or voicemail the day before the
appointment. Immediately following the referral visit, the liver
clinic's senior nurse informs RHMC of the referral outcome. Clients
who fail to attend are immediately contacted by RHMC to
facilitate a second appointment. If a client does attend an
appointment, RHMC staff offer support around future appointments and clinical services. Support and monitoring continues for
as long as required. Depending on client needs, liver clinic staff
may consult with the client at RHMC. The service is able to
support complex clients throughout assessment and treatment.
For example, a client living with a major physical disability was
successfully treated and ultimately achieved a sustained virological
response (SVR), the accepted indicator of successful treatment
(Islam, Reid, et al., 2012).
2.4. Data collection and analysis
Key variables were extracted manually from the intake assessment, progress notes and laboratory results by one author (MI);
entered into a Filemaker Pro database and analysed using STATA
(version 11). AVT information was collected directly from client selfreports at clinical settings by RHMC nurses, and corroborated through
checking against the liver clinic database. Data collection and analysis
was approved by the Sydney South West Area Health Ethics Review
Committee (RPAH zone).
Data analysis was conducted using chi-square and Fisher's exact
test for categorical variables, and independent sample t-tests for
continuous variables. One way analysis of variance (ANOVA) and its
non-parametric equivalent (Kruskal-Wallis test) were conducted
where there were three categories of outcome (referred and
attended; referred but did not attend; not referred). Statistical
signicance was set at pb0.05. Multivariate logistic regression
analysis derived adjusted odds ratios (AOR) and 95% condence
intervals (CI) to assess associations between attendance at the liver
clinic (binary outcome: referred and attended and referred but did not
attend) and socio-demographic, drug use and other potential
covariates. Backward elimination procedures were followed, with
univariate predictors that were signicant at pb0.25 considered for
the multivariate regression model.
3. Results

2.3. The RHMC model of HCV care

3.1. Client prole

An HCV treatment-assessment model of care was developed

for IDUs attending RHMC (Fig. 1). All clients who are diagnosed
HCV positive by qualitative or quantitative polymerase chain
reaction (PCR) (Roche COBAS Amplicator, Roche Diagnostics,
Sydney, Australia) are encouraged to attend the liver clinic for

Seventy-four percent (n=353) of 479 clients who accessed RHMC

during the audit period underwent HCV antibody screening, and 60%
(212/353) of them tested HCV positive. Qualitative HCV-RNA testing
was performed for 197 (93%, 197/212) of these clients, of whom 143
(73%, 143/197) tested positive (Fig. 2). Forty-six percent of RNA

HCV Ab +ve

RNA positive

HCV test

If consent to
referral obtained,
referral to tertiary
liver clinic and
directions
provided

Phone client
with
appointment
details,
reiterate
location

RNA negative

HCV Ab ve

Ongoing
support and
reassessment
of risk

If consent to referral
not obtained, periodic
monitoring and offer
of referral

SMS
reminder 1
day prior to
appointment

Check if
client
attended
appointment

Attended

Check any
further needs
(GP referral,
further
pathology, next
appointment)

Could not attend.

Follow-up with client,
determine need for
another appointment

Fig. 1. Flowchart of the referral pathways for HCV positive clients at the RHMC.

293

442

M.M. Islam et al. / Journal of Substance Abuse Treatment 43 (2012) 440445

positive clients were found to have HCV genotypes 2 (n=6) or 3 (n=

60); whereas 45% had genotypes 1 (n=63) or 4 (n=1). Genotype
was unavailable or non-typable for 8%; and one client had mixed
genotypes (1 and 3).
Among the 143 clients for whom qualitative HCV-RNA was
positive, the mean age was 37 years (SD8.2) and 85% were male
(Table 1). Nine percent (13/143) of HCV-RNA positive clients
identied as Aboriginal and/or Torres Strait Islander. All but one
disclosed injecting drug use and 84% reported injecting in the
preceding six months. Forty-ve percent were on some form of
psychiatric medication. Two-thirds (67%) had been referred to the
RHMC from residential drug treatment agencies and 23% from NSPs.
Median ALT level was 63 U/L with 59% elevated beyond the normal
range (N55 U/L). Two-thirds of clients reported access to GP services.
Liver clinic referral appointments were made for 96 HCV-RNA
positive clients; the other 47 were not referred for reasons including
loss to follow-up (n=23) and unwillingness to take up referral (n=
20). More than 70% (68/96) of referred clients attended the liver clinic
with a mean of 1.3 appointment bookings (SD 0.76; range 16)
required for clients to attend once. However, 78% of those who
attended (53/68) did so at their initial referral appointment. AVT was
commenced by 11 clients (Fig. 2). By December 2010, seven of this
group had achieved an SVR, one did not respond to treatment, one
ceased treatment due to side effects, one remained in treatment, and
one client was lost to follow up following transfer to an alternative
healthcare provider.
A further 15 clients expressed interest in HCV treatment, 13 of
whom did not proceed for reasons including ongoing drug use; health
and/or psychological instability (n=7); unstable housing arrangements (n=3); and family responsibilities (n=1). Another two clients
had recently started full-time employment and therefore opted to
defer treatment. Two clients were undergoing AVT assessment at the
time of data collection and were likely to commence treatment. The
clinical pathways of all clients are shown in Fig. 2.

Screened for antiHCV test (n = 353)

HCV antibody
positive (n = 212)
Qualitative RNA
assessment test
(n = 197)

2 being assessed and likely

to commence treatment

Detected in RNA
test (n = 143)

8in drug treatment

programme, were continuing
HCV treatment consultation

Referred to liver
clinic (n = 96)

HCV treatment
(n = 11)
7 achieved SVR,
1 on treatment,
1 non-responder,
1 stopped (side effect)
1 lost to follow-up

There were a number of differences between clients who were

referred and those who were not and also between those who took up
the referral and those who did not. Those who attended the referral
were more likely to be male than those who did not attend (93% cf
79%, p=0.03) (Table 1). ALT levels were signicantly more likely to be
elevated (N55 U/L) among clients in the referred and attended group
than those in the other two groups (referred but did not attend and not
referred; 75%, 46% and 45%, p=0.001). The referred and attended group
contained a signicantly lower proportion (72%) of clients who
reported injecting in the preceding six months than both the referred
but did not attend (96%) and not referred (94%) groups (p=0.001).
Multivariate logistic regression indicated that clients with elevated
ALT levels (AOR 0.25; CI 0.09, 0.66) and reporting no injecting drug
use in the preceding six months (AOR 0.08; CI 0.01, 0.65) were more
likely to attend referrals than those who were referred but did not
attend (Table 1).
3.3. Characteristics of clients who commenced AVT
The mean age of clients who commenced AVT was 37 years (SD
7.3; range 2156) (Table 2). All 11 clients were male, and none were
of Aboriginal and/or Torres Strait Islander descent. All but one client
was referred to RHMC from residential alcohol and drug treatment
agencies (Table 2) and none were referred from the NSP. Nine of the
11 clients who commenced treatment had elevated ALTs prior to
referral. Six clients were genotype 2 or 3 (more treatmentresponsive) and ve were genotype 1 (more treatment-resistant).
Only one treated client was on psychiatric medication at the time of
referral. All 11 treated clients reported a government benet as their
source of income.
4. Discussion
The ndings of this retrospective clinical audit of an NSP-based
PHC clinic demonstrate that the service successfully engages IDUs, the
client group who bear the greatest burden of HCV-related liver disease
(Razali et al., 2007); and that with appropriate support, such clients
can attend referrals to a tertiary liver clinic for HCV assessment and
treatment. The relatively high rate (71%) of referral uptake among
these clients also illustrates the potential to expand HCV-related care
for IDUs by establishing effective linkages between relevant health
services. Notwithstanding the advantages of this clinical model, when
compared with the number referred, uptake is still quite low. Thus,
the majority of HCV cases remain untreated in this population and the
overall burden of liver disease is likely to remain high.

Total clients during

audit (n = 479)

Attended liver clinic

(n = 68)

3.2. Factors associated with referral and referral uptake

n=57

13interested but unsuitable

for treatment/deferred
30not interested in
treatment/lost to follow-up
1preferred referral to
another tertiary clinic
1died
2 could not be ascertained

Fig. 2. Flowchart of diagnosis, referral and treatment pathways for all clients.

4.1. Characteristics of referrals, non-referrals and non-attendees

Both demographic characteristics and genotype were similar
among clients referred to the liver clinic and those not referred. As
might be expected, clients in the referred and attended group were less
likely to report injecting drugs in the preceding six months than
clients who were referred but did not attend or those who were not
referred. This may also be because the majority of clients in the referred
and attended group were referred to RHMC from an abstinence-based
residential drug treatment services. The high prevalence of injecting
drug use in the previous six months and psychiatric medication
among clients who attended the HCV treatment assessment suggests
that factors which may have traditionally been seen by clinicians as
barriers to initiation of AVT (Davis & Rodrigue, 2001; Dore, 2007) may
be overcome with appropriate support and encouragement.
The high attendance rate (71%) for the initial liver clinic referral
appointment is likely to be in large part due to the support offered by
RHMC to clients, including efforts to help them understand HCV

294

M.M. Islam et al. / Journal of Substance Abuse Treatment 43 (2012) 440445

443

Table 1
Characteristics of HCV RNA positive clients and comparison by hepatitis C treatment referral and attendance.

Age (meanS.D. in years)

Male
Aboriginal/Torres Strait Islander
Referral from
NSP
Residential drug and alcohol
treatment centre
Self/Family/Friend(s)
Living with
Alone/with children
Parent(s)/Spouse/Partner
Friend(s)
Relative(s)/other
Source of incomeb
Temporary unemployment benet
Pension and disability benet
Fulltime or part-time job
Current GP access
Genotypea
1 and 4
2
3
Non-typable and unknown
ALT
ALT value U/L (median)
ALT elevated (%)
Currently on psychiatric medication
Currently on opioid
substitution therapy
Duration of injecting drug use
(meanS.D. in years)
Injecting drug use in
preceding six months
a
b

n=143
(%)

Referred and
attended
(A), n=68

Referred
but did
not attend
(B), n=28

Not referred (C),

n=47

378.2
121 (85)
13 (9)

37.97.9
93%
9%

35.69.1
79%
11%

36.18.2
77%
9%

.34
.03
.93

.21
.07
.71

33 (23)
96 (67)

16%
78%

29%
61%

30%
55%

.10

.20

14 (10)

6%

11%

15%

51
56
26
10

(36)
(39)
(18)
(7)

31%
51%
10%
7%

39%
32%
25%
4%

40%
26%
26%
9%

.07

.14

95
28
18
94

(67)
(20)
(13)
(66)

72%
16%
12%
65%

61%
21%
18%
57%

65%
24%
11%
72%

.72

.61

.39

.49

62 (43)
8 (6)
61 (43)
12 (8)

46%
7%
44%
3%

50%
0%
39%
11%

36%
6%
43%
15%

.22

.22

63
85 (59)
64 (45)
43 (30)

76
75%
40%
31%

52
46%
46%
21%

51
45%
51%
35%

b.01
b.01
.47
.47

.60
b.01
.65
.35

188.8

198.3

178.1

169.6

.09

.22

120 (84)

72%

96%

94%

b.01

b.01

p-value
(univariate)
comparing
3 outcomes

Comparing outcomes A & B

p-Value (univariate)

AOR (95% CI)

0.25 (0.09 to 0.66)

0.08 (0.01 to 0.65)

One participant had genotype 4.

Two clients reported to have no income.

assessment and AVT, and reminders to attend. Also RHMC's strong

links with the local residential drug treatment service helps ensure
that clients with HCV are seen by RHMC at a time in their lives where
it is appropriate to offer referral for AVT. Similar links with the liver
clinic allow RHMC staff to better provide support for appointment
attendance and later treatment participation. Other characteristics of
RHMC such as anonymity for clients, convenient location in an area
where high numbers of IDUs dwell or congregate, co-location within
an NSP, appropriate opening hours, drop-in service, and availability of
auxiliary services, are also known to increase IDUs' engagement with
PHC (Islam, Topp, Day, Dawson, & Conigrave, 2012). Such features can
be assumed to underlie much of the present clinic's success.
The NSP setting of this PHC service also confers advantages in
achieving referral for HCV treatment, as it provides a therapeutic
context with the sustained contact necessary to identify clients at
high-risk of liver disease and to address barriers to referral and
treatment, particularly ongoing drug and alcohol use (Islam, 2010).
Consistent with past literature (Day et al., 2008), provision by RHMC
of services such as HCV and liver function tests and counselling
attracts clients, providing the opportunity to increase their willingness to undertake AVT assessment. Although prior to the
establishment of RHMC in 2006, the NSP itself occasionally referred
clients to the liver clinic, not a single NSP client was known to have
commenced HCV treatment via this referral pathway.
4.2. Characteristics of treatment initiators
Unlike other studies (Arora et al., 2011; Lindenburg et al., 2011)
we found no signicant difference in referral attendance and

treatment initiation between clients of more and less treatmentresponsive HCV genotypes. This may be due to the encouragement of
every client to attend the liver clinic assessment irrespective of the
length of time since their diagnosis; indeed, around 13% of our clients
were newly diagnosed.
One of the strengths of this study is its real-world sample.
Although just 11 clients ultimately initiated AVT, a further 13
expressed interest in commencing treatment, but were deemed
clinically inappropriate based on their physical, psychiatric, drug
dependence and/or housing characteristics. Around 15% of clients
who took up their referral continued to attend ongoing consultations
at the liver clinic during the audit period, most of whom were in the
initial stages of assessment at the liver clinic during manuscript
preparation; a proportion of this group is likely to initiate AVT. It is
also possible that some clients commenced treatment through other
healthcare providers for which information is unavailable. In addition,
there are likely to be other benets to liver clinic attendees who have
not yet received treatment, including increased understanding of the
disease process, the nature of treatment, ways to improve health
(such as reducing alcohol use) and the need to achieve lifestyle
stability prior to undertaking treatment. Nevertheless, based solely on
the treatment uptake rates described herein, 7.7% of IDUs who were
HCV RNA positive, and one in six IDUs who attended the liver clinic
over a four-year period initiated AVT, an important outcome given
the generally low rates of HCV treatment referral and uptake among
IDUs (Grebely et al., 2006). A national survey of n=2396 NSP
attendees in 2010 found that 91% reported having been tested for
HCV in their lifetime, including 56% who reported having been tested
in the preceding 12 months. Among the 1274 participants who

295

444

M.M. Islam et al. / Journal of Substance Abuse Treatment 43 (2012) 440445

Table 2
Comparison between those who did and did not commence HCV treatment (among 68
liver clinic attendees).

Age (meanS.D., years)

Male
Aboriginal/Torres
Strait Islander ethnicity
Referral to RHMC from
Residential alcohol and
drug treatment agency
NSP
Self/family/friend(s)
Living with
Alone/with children
Parent(s)/spouse/partner
Friend(s)
Relative(s)/other
Source of incomea
Temporary unemployment
benet
Pension and disability
benet
Fulltime or part-time job
Current GP access
Genotype
1
2
3
Non-typable and unknown
ALT elevated
ALT level (median)
Currently on psychiatric
medication
Currently on opioid
substitution therapy
Duration of injecting drug
use (meanS.D. in years)
Injecting drug use
in preceding six months
a

Commenced
treatment
n=11

Did not commence

treatment n=57

377.3
11
0

388.0
52
6

.58
.58
.58

10

43

.28

0
1

11
3

6
4
1
0

15
31
6
5

.32

10

38

.43

10

0
7

8
37

5
1
5
0
9
77
1

26
4
25
2
42
75
26

1.00

17

.67

172.5

201.1

.31

40

.71

p-Value
(univariate)

1.00

4.3. Limitations
The study has a number of limitations. First, we were not able to
examine associations between duration of infection, and referral
uptake or treatment initiation, because the les of early clients
(around 25% of total clients) did not record duration of HCV infection.
Secondly, the majority of clients who attended the liver clinic and
commenced HCV treatment were referred from a residential treatment service and so cannot be considered representative of the
overall IDU population. However this nding demonstrates the
importance of PHC services linking effectively with residential
programs to seize the window of opportunity of linking IDUs with
effective medical care. Thirdly, the observational design makes it
impossible to state conclusively that the high rates of referral uptake
are attributable to comprehensive support provided under the RHMC
model. A small number of clients attended their initial HCV treatment
assessment while still resident in the residential treatment program,
and attendance was also supported by that service. High referral
attendance rates were also likely to be due to comprehensive
discussion by RHMC nurses with clients of appropriate timing of
treatment in terms of lifestyle stability and motivation, such that
those not stable enough to attend appointments were unlikely to be
referred. Finally, the small number of treated clients prohibited
multivariate analyses to delineate independent associations between
treatment commencement and other variables.
4.4. Implications

.72
.75
.04

One client reported to have had no income.

reported having previously tested positive to HCV antibody (53% of

the overall sample), lifetime and current HCV treatment rates were
12% and 2.6%, respectively (Iversen, Topp, & Maher, 2011). The
explanation for low rates of HCV treatment among IDUs is multifactorial with potential barriers at client, clinician, and healthcare
system levels (Day, Ross, & Dolan, 2003; Grebely et al., 2008; Grebely
et al., 2009; Shepard et al., 2005).
Among our sample, those who were not on psychiatric medication
at assessment were signicantly more likely to commence treatment,
with no other variables signicantly associated with treatment
initiation. Despite high prevalence of characteristics traditionally
considered to constitute contraindications to treatment, and particularly ongoing illicit drug use, the high rate of liver clinic attendance
among our sample, and relatively high rates of HCV treatment uptake
and outcomes compared to other settings (Grebely et al., 2009),
demonstrate that referral of IDUs to tertiary clinics can be effective
when appropriate pathways and links are established and maintained.
Moreover, it is not possible to accurately predict which clients will
adhere to a treatment regimen (Bangsberg & Moss, 1999). Studies
which provided AVT to IDUs and non-IDU controls matched for
baseline demographic and other characteristics including genotype,
reported similar rates of treatment success as measured by SVR
(Mauss, Berger, Goelz, Jacob, & Schmutz, 2004; Van Thiel, Anantharaju, & Creech, 2003). Generalisations about IDUs are unhelpful given
the heterogeneity among this population in terms of their patterns of
drug use, severity of dependence, lifestyle stability and many other
factors (Dore, 2007).

The RHMC provides important health service delivery to a

traditionally hard-to-reach population and is a valuable adjunct to
the tertiary liver clinic based in the metropolitan public hospital
located relatively nearby. Successful completion of AVT by at least one
client with a major physical disability who achieved a SVR is one
example of the potential of this service model (Islam, Reid, et al.,
2012). The RHMC addresses the lifestyle challenges of many IDUs and
the barriers that the structured appointment system of conventional
services may constitute (Merrill, Rhodes, Deyo, Marlatt, & Bradley,
2002). By providing non-judgemental and cost-free services under a
harm reduction framework, this clinic has positioned itself as a
gateway to specialist care, highlighting the potential of targeted PHC
services to facilitate reductions in liver disease burden among IDUs.
Acknowledgments
We thank Stephen Hayes for his assistance with the study. We
acknowledge the continuing support of the RHMC steering committee. The rst author's doctoral research is supported by a University
International Post-graduate Award from the University of New South
Wales. The last two authors are supported by NHMRC fellowships.
References
Arora, S., Thornton, K., Murata, G., Deming, P., Kalishman, S., Dion, D., et al. (2011).
Outcomes of treatment for hepatitis C virus infection by primary care providers.
New England Journal of Medicine, 364, 21992207.
Bangsberg, D. R., & Moss, A. (1999). When should we delay highly active antiretroviral
therapy? Journal of General Internal Medicine, 14, 446448.
Davis, G. L., & Rodrigue, J. R. (2001). Treatment of chronic hepatitis C in active drug
users. New England Journal of Medicine, 345, 215217.
Day, C., Ross, J., & Dolan, K. (2003). Hepatitis C-related discrimination among heroin
users in Sydney: Drug user or hepatitis C discrimination? Drug and Alcohol Review,
22, 317321.
Day, C. A., Islam, M. M., White, A., Reid, S. E., Hayes, S., & Haber, P. S. (2011).
Development of a nurse-led primary healthcare service for injecting drug users in
inner-city Sydney. Australian Journal of Primary Health, 17, 1015.
Day, C. A., White, B., Thein, H. H., Doab, A., Dore, G. J., Bates, A., et al. (2008). Experience
of hepatitis C testing among injecting drug users in Sydney, Australia. AIDS Care, 20,
116123.
Dore, G. J. (2007). Enhancing hepatitis C treatment uptake and outcomes for injection
drug users. Hepatology, 45, 35.

296

M.M. Islam et al. / Journal of Substance Abuse Treatment 43 (2012) 440445

Dore, G. J., Law, M., MacDonald, M., & Kaldor, J. M. (2003). Epidemiology of hepatitis C
virus infection in Australia. Journal of Clinical Virology, 26, 171184.
Grebely, J., Conway, B., Raffa, J. D., Lai, C., Krajden, M., & Tyndall, M. W. (2006). Hepatitis
C virus reinfection in injection drug users. Hepatology, 44, 11391145.
Grebely, J., Genoway, K. A., Raffa, J. D., Dhadwal, G., Rajan, T., Showler, G., et al. (2008).
Barriers associated with the treatment of hepatitis C virus infection among illicit
drug users. Drug and Alcohol Dependence, 93, 141147.
Grebely, J., Raffa, J. D., Lai, C., Krajden, M., Kerr, T., Fischer, B., et al. (2009). Low uptake of
treatment for hepatitis C virus infection in a large community-based study of inner
city residents. Journal of Viral Hepatitis, 16, 352358.
Islam, M. M. (2010). Needle syringe program-based primary health care centers: Advantages and disadvantages. Journal of Primary Care & Community Health, 1, 100103.
Islam, M. M., Reid, S. E., White, A., Grummett, S., Conigrave, K. M., & Haber, P. S. (2012a).
Opportunistic and continuing health care for injecting drug users from a nurse-run
needle syringe program-based primary health-care clinic. Drug and Alcohol Review,
31, 114115 [author reply 116117].
Islam, M. M., Topp, L., Day, C. A., Dawson, A., & Conigrave, K. M. (2012b). The
accessibility, acceptability, health impact and cost implications of primary
healthcare outlets that target injecting drug users: a narrative synthesis of
literature. International Jouranl of Drug Policy, 23, 94102.
Iversen, J., Topp, L., & Maher, L. (2011). Australian NSP survey national data report 1995
2010. Sydney: The Kirby Institute, UNSW Accessed in September 2011. http://
www.med.unsw.edu.au/NCHECRweb.nsf/resources/NSP_Complete2/$le/ANSPS.
1995_2010-rev.pdf.

445

Lindenburg, C. E., Lambers, F. A., Urbanus, A. T., Schinkel, J., Jansen, P. L., Krol, A., et al.
(2011). Hepatitis C testing and treatment among active drug users in Amsterdam:
Results from the DUTCH-C project. European Journal of Gastroenterology and
Hepatology, 23, 2331.
Mauss, S., Berger, F., Goelz, J., Jacob, B., & Schmutz, G. (2004). A prospective controlled
study of interferon-based therapy of chronic hepatitis C in patients on methadone
maintenance. Hepatology, 40, 120124.
Mehta, S. H., Genberg, B. L., Astemborski, J., Kavasery, R., Kirk, G. D., Vlahov, D., et al.
(2008). Limited uptake of hepatitis C treatment among injection drug users. Journal
of Community Health, 33, 126133.
Merrill, J. O., Rhodes, L. A., Deyo, R. A., Marlatt, G. A., & Bradley, K. A. (2002). Mutual
mistrust in the medical care of drug users: the keys to the narc cabinet. Journal of
General Internal Medicine, 17, 327333.
Razali, K., Thein, H. H., Bell, J., Cooper-Stanbury, M., Dolan, K., Dore, G., et al. (2007).
Modelling the hepatitis C virus epidemic in Australia. Drug and Alcohol Dependence,
91, 228235.
Shepard, C. W., Finelli, L., & Alter, M. J. (2005). Global epidemiology of hepatitis C virus
infection. Lancet Infectious Diseases, 5, 558567.
Stoove, M. A., Gifford, S. M., & Dore, G. J. (2005). The impact of injecting drug use status
on hepatitis C-related referral and treatment. Drug and Alcohol Dependence, 77,
8186.
Van Thiel, D. H., Anantharaju, A., & Creech, S. (2003). Response to treatment of hepatitis
C in individuals with a recent history of intravenous drug abuse. American Journal of
Gastroenterology, 98, 22812288.

297

Appendix IV

(i) Islam, M. M., Topp, L., Conigrave, K. M., Beek, I. v., Maher, L., White, A., Rodgers,
C., & Day, C. A. (2012). The reliability of sensitive information provided by injecting
drug users in a clinical setting: clinician-administered versus audio computer-assisted
self-interviewing (ACASI). AIDS Care, 24, 1496-1503.

298

This article was downloaded by: [UNSW Library]

On: 01 February 2013, At: 02:15
Publisher: Routledge
Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House,
37-41 Mortimer Street, London W1T 3JH, UK

AIDS Care: Psychological and Socio-medical Aspects of

AIDS/HIV
Publication details, including instructions for authors and subscription information:
http://www.tandfonline.com/loi/caic20

The reliability of sensitive information provided by

injecting drug users in a clinical setting: Clinicianadministered versus audio computer-assisted selfinterviewing (ACASI)
M. Mofizul Islam
c

a b

, Libby Topp , Katherine M. Conigrave

g

Maher , Ann White , Craig Rodgers & Carolyn A. Day

b d e

, Ingrid van Beek , Lisa

School of Public Health & Community Medicine, University of New South Wales, Sydney,
Australia
b

Drug Health Service, Royal Prince Alfred Hospital, Sydney, Australia

The Kirby Institute (formerly the National Centre in HIV Epidemiology and Clinical
Research), University of New South Wales, Sydney, Australia
d

Sydney Medical School, University of Sydney, Sydney, Australia

National Drug and Alcohol Research Centre, University of New South Wales, Sydney,
Australia
f

Kirketon Road Centre, Sydney, Australia

Redfern Harm Minimisation Clinic, Local Health District, Sydney, Australia

Version of record first published: 28 Mar 2012.

To cite this article: M. Mofizul Islam , Libby Topp , Katherine M. Conigrave , Ingrid van Beek , Lisa Maher , Ann White , Craig
Rodgers & Carolyn A. Day (2012): The reliability of sensitive information provided by injecting drug users in a clinical setting:
Clinician-administered versus audio computer-assisted self-interviewing (ACASI), AIDS Care: Psychological and Socio-medical
Aspects of AIDS/HIV, 24:12, 1496-1503
To link to this article: http://dx.doi.org/10.1080/09540121.2012.663886

PLEASE SCROLL DOWN FOR ARTICLE

Full terms and conditions of use: http://www.tandfonline.com/page/terms-and-conditions
This article may be used for research, teaching, and private study purposes. Any substantial or systematic
reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to
anyone is expressly forbidden.
The publisher does not give any warranty express or implied or make any representation that the contents
will be complete or accurate or up to date. The accuracy of any instructions, formulae, and drug doses should
be independently verified with primary sources. The publisher shall not be liable for any loss, actions, claims,
proceedings, demand, or costs or damages whatsoever or howsoever caused arising directly or indirectly in
connection with or arising out of the use of this material.

299

AIDS Care
Vol. 24, No. 12, December 2012, 1496
1503

The reliability of sensitive information provided by injecting drug users in a clinical setting:
Clinician-administered versus audio computer-assisted self-interviewing (ACASI)
M. Mozul Islama,b*, Libby Toppc, Katherine M. Conigraveb,d,e, Ingrid van Beekf, Lisa Maherc, Ann Whiteg,
Craig Rodgersf and Carolyn A. Dayd
a
School of Public Health & Community Medicine, University of New South Wales, Sydney, Australia; bDrug Health Service,
Royal Prince Alfred Hospital, Sydney, Australia; cThe Kirby Institute (formerly the National Centre in HIV Epidemiology and
Clinical Research), University of New South Wales, Sydney, Australia; dSydney Medical School, University of Sydney, Sydney,
Australia; eNational Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia; fKirketon Road
Centre, Sydney, Australia; gRedfern Harm Minimisation Clinic, Local Health District, Sydney, Australia

Downloaded by [UNSW Library] at 02:15 01 February 2013

(Received 7 September 2011; final version received 31 January 2012)

Research with injecting drug users (IDUs) suggests greater willingness to report sensitive and stigmatised
behaviour via audio computer-assisted self-interviewing (ACASI) methods than during face-to-face interviews
(FFIs); however, previous studies were limited in verifying this within the same individuals at the same time point.
This study examines the relative willingness of IDUs to report sensitive information via ACASI and during a
face-to-face clinical assessment administered in health services for IDUs. During recruitment for a randomised
controlled trial undertaken at two IDU-targeted health services, assessments were undertaken as per clinical
protocols, followed by referral of eligible clients to the trial, in which baseline self-report data were collected via
ACASI. Five questions about sensitive injecting and sexual risk behaviours were administered to participants
during both clinical interviews and baseline research data collection. Percentage agreement determined the
magnitude of concordance/discordance in responses across interview methods, while tests appropriate to data
format assessed the statistical significance of this variation. Results for all five variables suggest that, relative to
ACASI, FFI elicited responses that may be perceived as more socially desirable. Discordance was statistically
significant for four of the five variables examined. Participants who reported a history of sex work were more
likely to provide discordant responses to at least one socially sensitive item. In health services for IDUs,
information collection via ACASI may elicit more reliable and valid responses than FFI. Adoption of a universal
precautionary approach to complement individually tailored assessment of and advice regarding health risk
behaviours for IDUs may address this issue.

Keywords: reliability; injecting drug use; risk reporting/disclosure; primary healthcare; socially desirable
behaviours; stigma

Introduction
Social desirability bias is a type of reporting bias that
occurs when individuals deny or under-report engaging in what they perceive as socially undesirable
behaviours (Rosenthal, Persinger, & Fode, 1962).
Social desirability bias can have significant implications for patient care in the clinical setting, and data
validity in the research setting (King & Bruner, 2003).
Comprehensive service delivery in healthcare settings
may be compromised if such bias is present to a
significant degree.
Interviewer-administered face-to-face interview
(FFI) methods typically result in reporting of lower
rates of socially sensitive risk behaviours compared to
self-administered questionnaires, a pattern attributed
to social desirability bias (White, Day, & Maher,
2007). Consequently, along with their other advantages (e.g., relatively fewer resource implications),

self-administered questionnaires are commonly used

to facilitate response anonymity and reliability.
Audio computer-assisted self-interviewing (ACASI)
is a data collection method that allows respondents to
answer questionnaires without the direct participation of an interviewer (Des Jarlais et al., 1999).
During ACASI, questions are administered audibly
and in text on a computer screen, facilitating its use
among individuals with poor literacy skills or impaired vision or hearing.
Previous studies on the comparative reliability of
data collected from drug users via ACASI and FFI
report mixed results. For example, in a study of risk
behaviours among needle syringe programme (NSP)
clients, Des Jarlais et al. (1999) found that respondents for whom data were collected via ACASI were
more likely than those assigned to FFI to report
injection with used injecting equipment, distributing

*Corresponding author. Email: m.m.islam@unsw.edu.au, mikhokan143@yahoo.com

ISSN 0954-0121 print/ISSN 1360-0451 online
# 2012 Taylor & Francis
http://dx.doi.org/10.1080/09540121.2012.663886
http://www.tandfonline.com

300

Downloaded by [UNSW Library] at 02:15 01 February 2013

AIDS Care 1497

used equipment and paying for sex. Conversely, a
survey of HIV risk behaviour among adolescents in
drug treatment found significantly higher reporting of
alcohol and drug use and sexual risk behaviour
among participants from whom data were collected
via FFI compared to those who undertook ACASI
(Jennings, Lucenko, Malow, & Devieux, 2002).
Together, these findings suggest the possibility of
situation-specific, differential impact of assessment
via ACASI. However, these studies were limited by
the fact that the same participants did not undertake
both FFI and ACASI. In just two studies were the
same injecting drug users (IDUs) asked to complete
both ACASI and FFI (Ghanem, Hutton, Zenilman,
Zimba, & Erbelding, 2005; Kurth et al., 2004).
However, these participants constituted only small
proportions of broader samples recruited in sexual
health settings; and in only one of the two studies
were the data collected from IDUs (assessing lifetime
prevalence of receptive syringe sharing) presented
separately.
The literature suggests that in NSP settings, drug
use and sexual behaviours are acknowledged by staff
without judgement or sanction, and that this environment may increase IDUs willingness to disclose
risk behaviours (Rich et al., 2004). Such disclosure is
important in healthcare settings for IDUs, where
blood-borne virus and sexual health risk assessment
and management are core activities. Accordingly, it
could be that in NSP and associated healthcare
services ACASI offers no significant benefit over
FFI administered by compassionate and non-judgemental staff.
The aim of this study was to compare responses
provided by IDUs attending health services colocated with an NSP to the same, potentially socially
sensitive questions administered via both (1) FFI
administered by a clinician of that service and (2)
ACASI. Specifically, we examined potential differences in (1) clients willingness to report sensitive
information via clinical FFI and ACASI and (2)
responses elicited across the two interview modes
according to participant characteristics.

Method
Study participants were drawn from the Hepatitis B
Acceptability and Vaccination Incentive Trial (HAVIT), a randomised controlled trial of the efficacy of
incentive payments in increasing hepatitis B vaccination completion among IDUs (Topp et al., 2011).
HAVIT recruited from two low-threshold health
centres that target IDUs in Sydney, Australia (Day
et al., 2011; van Beek, 2007). Such low-threshold

centres remove most barriers faced by IDUs in

accessing traditional health services, by providing,
for example, services free-of-charge and on anonymous and drop-in bases (Islam, Topp, Day, Dawson, & Conigrave, 2012). Participants deemed eligible
for inclusion in HAVIT (and thus the present study)
were aged 16 years and above; had injected drugs in
the preceding six months; reported no previous HBV
infection and a maximum of one previous vaccination
dose, or unknown infection and vaccination status;
were able to provide informed consent; and were
willing to be randomised, to undertake vaccination
and to attend follow-up 12 weeks post-randomisation. Exclusion criteria were: evidence of natural or
vaccine-induced immunity; serological evidence of
previous HBV infection or vaccination; mental or
physical illness or disability likely to impact capacity
to complete study procedures; insufficient English
language skills to allow provision of informed consent or reliable responses to questionnaires; HIV
infection; and refusal to undertake vaccination (Deacon et al., in press).
Participant characteristics reported in this study
were drawn from HAVIT baseline data collection,
which occurred via ACASI in private following
assurances of confidentiality. Consistent with standard clinical protocols, participants firstly underwent
a clinical assessment conducted by attending clinicians (nurses/doctors) via FFI, covering client demographics, sexual health, drug health and mental
health issues. Five questions that may engender social
desirability bias (Des Jarlais et al., 1999) relating to
injecting and sexual risk behaviours were administered in both interview modes, allowing examination
of the degree of concordance of these responses. The
five items assessed age of onset of injecting, lifetime
and recent history of receptive syringe sharing, recent
receptive sharing of ancillary equipment and recency
of last unprotected sex. FFI data were extracted from
clients medical files; and ACASI data from the
HAVIT baseline data-set. To ensure inter-interview
comparability of responses, only clients whose FFI
and ACASI data collection were conducted within a
one week period were included in this analysis.
Participants provided written informed consent.
Ethics approval for the study was granted by the
Royal Prince Alfred Hospital, South Eastern Sydney
and Illawarra Area Health Service Northern Hospital
Network and the University of New South Wales
Human Research Ethics Committees.
Data analysis
Percentage agreement (the sum of agreement divided by the sum of agreement plus disagreement)

301

Downloaded by [UNSW Library] at 02:15 01 February 2013

1498 M.M. Islam et al.

(Hartmann, 1977) was calculated to determine the
magnitude of concordance/discordance in responses
elicited by the two interview methods. This measure
thus calculates the proportion of participants whose
responses match, or are concordant, across the two
data collection formats (Last, 2001). Kappa was not
considered appropriate because it is influenced by
trait prevalence (distribution) and base-rates (Spitznagel & Helzer, 1985; Uebersax, 1987). A 5-point
scale captured the recent episode of unprotected sex
by assigning the following values: never  0, year[s]
ago 1, month[s] ago 2, week[s] ago  3 and
day[s] ago 4. Tests appropriate to data format
(continuous, binary, ordinal) assessed concordance/
discordance of responses across interview modes,
with significant results indicative of significant discordance. The intraclass correlation coefficient (ICC)
was used to compare participants reported age of
onset of injecting, the Wilcoxon signed rank test to
compare reports of recent unprotected sex; and
McNemars Chi-square (x2) to compare reports of
lifetime and recent receptive sharing of injecting
equipment. Multivariate logistic regression analyses
examined potential differences between demographic,
drug use and recruitment characteristics of participants who provided concordant responses to all five
items across the two interview modes (concordant
group) and those who provided discordant responses
to one or more items (disconcordant group). Odds
ratios (OR) with 95% confidence intervals (CIs)
assessed associations between covariates and concordance. Variables correlated at p B0.25 at the univariate level were included in multivariate models,
which were refined using backwards elimination.
Data were analysed using STATA (version 11).

Results
Of 178 participants recruited from the two PHCs, 171
had information collected via both FFI and ACASI
within a one week period. Participants mean age was
36.3 years (SD98.95) and 77% were male (Table 1,
column 2). Fourteen per cent identified as Aboriginal
and/or Torres Strait Islander, 16% were born outside
Australia and 44% had not completed secondary
education. Most (84%) clients reported receiving
government welfare and 52% reported a history of
imprisonment. Twenty-seven per cent reported a
lifetime history of sex work; while 56% reported a
previous mental health diagnosis.
Thirty-four per cent (N 59) of participants
provided concordant responses across the two interview modes to all five items, whereas the remaining
N 114 participants provided discordant responses

to one or more of the five items. Percentage agreement between responses across the two interview
formats ranged from 70% (recency of last unprotected sex) to 89% (lifetime prevalence of receptive
syringe sharing; Tables 2 and 3). Compared to the
responses elicited by ACASI, responses provided
during FFI suggested a significantly higher mean
age of first injection, lower prevalence of recent
receptive sharing of both syringes and ancillary
injecting equipment and a longer duration since last
unprotected sex (Tables 2 and 3). Participants also
reported a lower lifetime prevalence of receptive
syringe sharing during FFI (Table 2); however, the
level of discordance across interview modes for
responses to this item was not statistically significant.
Thus, relative to ACASI, FFI elicited responses from
participants that may be perceived as more socially
desirable on all five variables of interest, with levels of
discordance statistically significant in four cases.
Just one participant characteristic was significantly correlated at the univariate level with provision
of one or more discordant responses (Table 1).
Compared to participants who provided a full set of
concordant responses, those who provided one or
more discordant responses were significantly more
likely to report a lifetime history of sex work. This
characteristic, along with other variables that were
correlated at p B0.25 were entered into multivariate
logistic regression models, with only history of sex
work remaining significant. Thus, participants who
reported a history of sex work were more likely than
those who did not to provide discordant responses to
one or more of the five socially sensitive items
(OR  2.78, 95%CI 1.24, 6.24).
To further explore the significant association
between history of sex work and provision of one
or more discordant responses, Pearsons x2 examined
the proportions of participants who did and did not
report a history of sex work who provided discordant
responses to each of the five items. There were no
significant differences between the proportions of the
two groups who provided discordant responses to the
four drug-related items (results not shown). In contrast, participants who reported a history of sex work
were significantly more likely than those who did not
to provide discordant responses to the item assessing
recency of last unprotected sex (42% versus 25%;
x2 4.56; p B0.05).

Discussion
Compared to responses elicited from IDUs regarding
their risk behaviours during a face-to-face clinical
interview, ACASI consistently extracted responses

302

Table 1. Demographic characteristics of 173 participants and relationship to discordance in responses to sensitive questions.

Downloaded by [UNSW Library] at 02:15 01 February 2013

Univariate relationship
Variable
Mean age in years (SD; range)

Total sample
(N173)
36.27 (8.95; 20
60)

Discordant
(N 114)
36.51

Concordant
(N 59)
35.60

OR (95% CI)

p-value

1.01 (0.98, 1.05)

0.53

Gender (%)
Male
Female
Australian-born (%)
English speaking background (%)
Indigenous Australian descent (%)
Four  years high school education (%)
Government benefit main source of income (%)
Lifetime history sex work (%)

133
39
146
166
25
98
146
47

(77)
(23)
(84)
(96)
(14)
(57)
(84)
(27)

87
26
95
110
18
61
98
38

(77)
(23)
(83)
(96)
(16)
(54)
(86)
(33)

46
13
51
56
7
37
48
9

(78)
(22)
(86)
(95)
(12)
(63)
(81)
(15)

1.00
1.06
0.78
1.47
1.39
0.86
1.40
2.78

(0.50,
(0.32,
(0.32,
(0.55,
(0.36,
(0.60,
(1.24,

2.25)
1.92)
6.81)
3.55)
1.30)
3.26)
6.24)

0.89
0.59
0.62
0.49
0.25
0.43
0.01

Sexual identity (%)

Heterosexual (reference)
Bisexual/Homosexual
Lifetime history of imprisonment (%)
Lifetime history mental health diagnosis (%)
Current mental health medication (%)
Heroin injected recently (%)
Receive most healthcare from these clinics (%)
Has another healthcare provider (%)
Recruitment site 1

155
18
90
97
60
91
61
103
87

(90)
(11)
(52)
(56)
(35)
(53)
(35)
(60)
(50)

103
11
64
63
40
62
42
69
63

(90)
(10)
(56)
(55)
(35)
(54)
(37)
(61)
(55)

52
7
26
34
20
29
19
34
24

(88)
(12)
(44)
(58)
(34)
(49)
(32)
(58)
(41)

1.00
0.79
1.62
0.91
1.05
1.23
1.23
1.13
1.80

(0.29,
(0.86,
(0.48,
(0.54,
(0.66,
(0.63,
(0.59,
(0.95,

2.17)
3.06)
1.71)
2.04)
2.31)
2.39)
2.13)
3.41)

0.65
0.13
0.77
0.88
0.51
0.54
0.71
0.07

Multivariate relationship
AOR (95% CI)

2.78 (1.24, 6.24)

p-value

0.01

AIDS Care 1499

303

1500 M.M. Islam et al.

Table 2. Comparison of responses provided in ACASI and FFI to binary items.
ACASI
Variable

FFI

Receptive syringe sharing, ever (N 168)

Receptive syringe sharing, preceding month
(N 162)
Receptive sharing ancillary equipment,
preceding month (N165)

Yes (%) No (%)

Yes (%)
No (%)
Yes (%)
No (%)
Yes (%)
No (%)

96 (57)
11 (7)
11 (7)
26 (16)
23 (14)
35 (21)

Percentage
agreement (total)

Test statistic, p

89.29

x2 0.89; p0.48

83.33

x2 23.15; pB0.01

72.12

x2 12.52; pB0.01

7 (4)
54 (32)
1 (1)
124 (77)
11 (7)
96 (58)

Note: x2, McNemars chi-square.

Downloaded by [UNSW Library] at 02:15 01 February 2013

Table 3. Comparison of responses provided in ACASI and FFI to non-binary items.

Variable

FFI

Mean age onset of injecting (9SD) 21.4 (97.43)

(N 171)
Number of clients reported higher
32 (19)
age (%)
Recent unprotected sex (N 166)
Never (%)
Year[s] ago (%)
Month[s] ago (%)
Week[s] ago (%)
Day[s] ago (%)
Number of clients reported recent
unprotected sex (%)

10 (6)
50 (30)
56 (34)
24 (14)
26 (16)
17 (10)

ACASI

Percentage
agreement (total)

20.9 (97.39)

70.18

ICC  0.94; p B.001 0.92,0.96

69.88

Z  2.73; p B0.01

Test statistic, p

95% CI

19 (11)

10 (6)
47 (28)
46 (28)
27 (16)
36 (22)
33 (20)

Note: ICC, intraclass correlation coefficient; Z, Wilcoxon signed rank.

that may be perceived as less socially desirable,

including a significantly lower age of onset of
injecting, recent unprotected sexual intercourse and
higher rates of receptive sharing of both syringes and
ancillary injecting equipment. These findings are
consistent with other studies of ACASI methodology
undertaken in research rather than clinical settings
(Des Jarlais et al., 1999; Macalino, Celentano, Latkin,
Strathdee, & Vlahov, 2002; Metzger et al., 2000); and
suggest that even in healthcare settings for IDUs,
where drug use is acknowledged and the environment
is clinical and non-judgmental (Rich et al., 2004),
reports of sensitive behaviours relating to drug use
and sexual practices during face-to-face clinical
assessments may be under-reported. Just one variable
assessed in this study was associated with an increased likelihood of provision of one or more
discordant responses, namely a history of sex work.
Post-hoc exploration of this relationship indicated
that participants who reported a history of sex work

were specifically more likely to provide discordant

responses to the item assessing recency of unprotected
sex but not to items assessing receptive sharing of
injecting equipment, a pattern of results which may
indicate perceived greater social stigma on the part of
these clients to disclose sexual than injecting-related
risk-taking.
Although we cannot state conclusively that the
lower prevalence of risk behaviour reported during
FFI is attributable to social desirability bias, nor that
these rates are more valid than the higher prevalence
reported with ACASI, social desirability theory
(Crowne & Marlowe, 1960) suggests systematic
under-reporting of stigmatised behaviours and that
higher rates of reported risk behaviour are more
likely to be valid than lower rates. Proponents suggest that social desirability bias is reduced during
ACASI due to circumvention of the need to disclose
sensitive behaviours directly to an interviewer (Perlis,
Des Jarlais, Friedman, Arasteh, & Turner, 2004).

304

Downloaded by [UNSW Library] at 02:15 01 February 2013

AIDS Care 1501

In addition, the simultaneous visual (computer
screen) and verbal (recorded speakers) presentation
of questions may encourage participants to attend
more closely to specific questions. Flexible responsetime in ACASI relative to FFI may also contribute to
the differences in responses, as inherent in the latter is
the expectation implicit in typical verbal dialogue that
clients will respond promptly.
Audio computer-assisted self-interviewing might
play an important role in eliciting responses from
participants that may be perceived as less socially
desirable. For example, ACASI could be used to
complement face-to-face clinical assessments and the
ACASI information provided in a risk aggregate
format (e.g., client at low or high risk) to the clinician
for discussion (Wand, Guy, Donovan, & McNulty,
2011). Alternatively, a universal precautions approach to risk behaviour can be argued for in guiding
blood-borne viral and sexually transmitted infection
screening and prevention in this group. Such a
universal approach would complement (rather than
replace) individually tailored assessment and advice.
Consistent with feedback from drug users in other
settings (Shakeshaft, Bowman, & Sanson-Fisher,
1998), and other populations (Gerbert, Bronstone,
McPhee, Pantilat, & Allerton, 1998; Kurth, et al.,
2004), our participants felt comfortable using ACASI. The touch-screen ACASI was an additional
advantage (Westman, Hampel, & Bradley, 2000).
Kurth et al. (2004) reported that 82% of participants
said ACASI allowed more honest reporting (compared to 7% for FFI, and 9% who perceived that
both interview formats were equally conducive to
honesty). ACASI has the additional advantage of
reducing missing data because it requires participants
to answer each item before they can proceed (Hallforsa, Khatapoushb, Kadushinb, Watsonb, & Saxeb,
2000). However, it is unlikely that ACASI could fully
replace FFI in the clinical setting, as history-taking is
an integral part of client/patient engagement, with the
clinician responding to client priorities, and tailoring
questions to raise client awareness of health issues.
Clinical assessment also extends beyond words to
non-verbal communication; and resourcing ACASI
technology may present a major barrier in many
settings.
Our study has several limitations. First, some of
the discordance in responses attributed to social
desirability bias may reflect other inherent biases,
such as participants understandings of the different
contexts
clinical and research
in which the data
were collected, and their (unmeasured) beliefs regarding potential benefits to themselves and/or the broader population of IDUs that might accrue from
providing particular responses within those specific

contexts. Second, our data cannot discount possible

interactions between individual clinicians and clients
that may engender a desire among some clients to
provide socially desirable responses during FFI.
Indeed, our results provide some indication that this
may be the case, with recruitment site correlated in
univariate analysis at p0.07 with provision of
discordant responses to one or more socially sensitive
items. At one clinic, any of a large number of
healthcare workers may conduct FFI assessments,
whereas at the other recruitment site, a single
individual conducted the great majority (90%) of
clinical assessments. Nevertheless, the difference in
the proportion of clients recruited from the two sites
who provided one or more discordant responses was
not significant, suggesting that this source of variance
cannot fully account for observed discordance.
Third, a certain degree of discordance is highly
likely to be due to random error/poor recall rather
than deliberately enacted social desirability bias. To
examine this possibility, however, we compared
responses provided across the two interview formats
to three items considered unlikely to engender social
desirability bias (date of birth, country of birth,
gender) and found no significant discordance (results
not shown), a pattern of results consistent with the
notion of systematic social desirability bias in relation
to the more sensitive items. Fourth, 91% of participants underwent clinical FFI followed by ACASI on
the same day, and may have felt pressure to maintain
consistency in their responses between the two interviews. Additionally, as FFI preceded ACASI, FFI
may have acted as a memory prompt, leading to
increased reporting of risk behaviours during subsequent ACASI. To eliminate this potential bias, future
research should engage a cross-over design, in which
half of the participants complete ACASI first while
the other half begin with FFI. Finally, our study
included only participants who met HAVIT eligibility
criteria, and as such, results may not be generalisable
to the broader IDU population.
In conclusion, the role of ACASI may not be
limited to data collection/research, but may extend to
a range of clinical environments and to population
subgroups from whom sensitive information is currently collected via self-report. Although ACASI is
unlikely to be appropriate for many clinical contexts,
our results suggest that it may complement pen-andpaper FFI. Along with tailoring their approach to an
individuals risk profile as assessed through FFI,
clinicians should adopt a universal precautionary
approach to acknowledge the likelihood that clients
may choose to disclose only selected information
regarding their history and risk profile.

305

1502 M.M. Islam et al.

Acknowledgements
The HAVIT study, through which some of the data
reported here were collected, was supported by National
Health and Medical Research Council (NHMRC) Project
Grant # 510104 (CIA Maher). The authors would like to
acknowledge the coordinated efforts and dedication of the
clinical and research teams at the Redfern Harm Minimisation Clinic and the Kirketon Road Centre, and particularly
Dr Rachel Deacon, the HAVIT study coordinator. Lisa
Maher is supported by the award of an NHMRC Senior
Research Fellowship. The first authors doctoral research is
supported by a University International Post-graduate
Award from the University of New South Wales. The last
author is supported by NHMRC fellowships.

Downloaded by [UNSW Library] at 02:15 01 February 2013

References
Crowne, D.P., & Marlowe, D. (1960). A new scale of social
desirability independent of psychopathology. Journal
of Consulting Psychology, 24, 349
354.
Day, C.A., Islam, M.M., White, A., Reid, S.E., Hayes, S.,
& Haber, P.S. (2011). Development of a nurse-led
primary healthcare service for injecting drug users in
inner-city Sydney. Australian Journal of Primary
Health, 17(1), 10
15.
Deacon, R.M., Topp, L., Wand, H., Day, C.A., Rodgers,
C., Haber, P.S. . . . Maher, L. (in press). Correlates of
hepatitis B status among injecting drug users in
Sydney, Australia. Journal of Urban Health.
Des Jarlais, D.C., Paone, D., Milliken, J., Turner, C.F.,
Miller, H., Gribble, J., . . . Friedman, S.R. (1999).
Audio-computer interviewing to measure risk behaviour for HIV among injecting drug users: A quasirandomised trial. Lancet, 353(9165), 1657
1661.
Gerbert, B., Bronstone, A., McPhee, S., Pantilat, S., &
Allerton, M. (1998). Development and testing of an
HIV-risk screening instrument for use in health care
settings. American Journal of Preventive Medicine,
15(2), 103
113.
Ghanem, K.G., Hutton, H.E., Zenilman, J.M., Zimba, R.,
& Erbelding, E.J. (2005). Audio computer assisted self
interview and face to face interview modes in assessing
response bias among STD clinic patients. Sexually
Transmitted Infections, 81(5), 421
425.
Hallforsa, D., Khatapoushb, S., Kadushinb, C., Watsonb,
K., & Saxeb, L. (2000). A comparison of paper vs
computer-assisted self interview for school alcohol,
tobacco, and other drug surveys. Evaluation and
Program Planning, 23, 149
155.
Hartmann, D.P. (1977). Considerations in the choice of
interobserver reliability estimates. Journal of Applied
Behavior Analysis, 10(1), 103
116.
Islam, M.M., Topp, L., Day, C.A., Dawson, A., &
Conigrave, K.M. (2012). The accessibility, acceptability, health impact and cost implications of primary
healthcare outlets that target injecting drug users: A
narrative synthesis of literature. International Journal
of Drug Policy, [Epub ahed of print] doi: 10.1016/
j.drugpo.2011.08.005

Jennings, T.E., Lucenko, B.A., Malow, R.M., & Devieux,

J.G. (2002). Audio-CASI vs interview method of
administration of an HIV/STD risk of exposure
screening instrument for teenagers. International Journal of STD & AIDS, 13(11), 781
784.
King, M., & Bruner, G. (2003). Social desirability bias: A
neglected aspect of validity testing. Psychology and
Marketing, 17, 79
103.
Kurth, A.E., Martin, D.P., Golden, M.R., Weiss, N.S.,
Heagerty, P.J., Spielberg, F., . . . Holmes, K.K. (2004).
A comparison between audio computer-assisted selfinterviews and clinician interviews for obtaining the
sexual history. Sexually Transmitted Diseases, 31(12),
719
726.
Last, J.M. (2001). A dictionary of epidemiology (4th ed).
New York, NY: Oxford University Press.
Macalino, G.E., Celentano, D.D., Latkin, C., Strathdee,
S.A., & Vlahov, D. (2002). Risk behaviors by audio
computer-assisted self-interviews among HIV-seropositive and HIV-seronegative injection drug users. AIDS
Education and Prevention, 14(5), 367
378.
Metzger, D.S., Koblin, B., Turner, C., Navaline, H.,
Valenti, F., Holte, S. . . . Seage, G.R. 3rd. (2000).
Randomized controlled trial of audio computer-assisted self-interviewing: Utility and acceptability in
longitudinal studies. HIVNET Vaccine Preparedness
Study Protocol Team. American Journal of
Epidemiology, 152(2), 99
106.
Perlis, T.E., Des Jarlais, D.C., Friedman, S.R., Arasteh, K.,
& Turner, C.F. (2004). Audio-computerized self-interviewing versus face-to-face interviewing for research
data collection at drug abuse treatment programs.
Addiction, 99(7), 885
896.
Rich, J.D., McKenzie, M., Macalino, G.E., Taylor, L.E.,
Sanford-Colby, S., Wolf, F., . . . Stein, M.D. (2004). A
syringe prescription program to prevent infectious
disease and improve health of injection drug users.
Journal of Urban Health, 81(1), 122
134.
Rosenthal, R., Persinger, G., & Fode, K. (1962). Experimenter bias, anxiety, and social desirability. Perceptual
& Motor Skills, 15, 73
74.
Shakeshaft, A.P., Bowman, J.A., & Sanson-Fisher, R.W.
(1998). Computers in community-based drug and
alcohol clinical settings: Are they acceptable to respondents? Drug & Alcohol Dependence, 50(2), 177

180.
Spitznagel, E.L., & Helzer, J.E. (1985). A proposed solution
to the base rate problem in the kappa statistic. Archives
of General Psychiatry, 42(7), 725
728.
Topp, L., Day, C., Wand, H., Deacon, R., Beek, I.v.,
Haber, P. . . . on behalf of the Hepatitis Acceptability
and Vaccine Incentives Trial (HAVIT) Study Group.
(2011). A randomized controlled trial of contingency
management to increase hepatitis B vaccination completion among people who inject drugs in Australia.
Drug and Alcohol Review, 30(Suppl. 1), 86 (peer
reviewed conference abstract).
Uebersax, J.S. (1987). Diversity of decision-making models
and the measurement of interrater agreement.
Psychological Bulletin, 101(1), 140
146.

306

AIDS Care 1503

Westman, J., Hampel, H., & Bradley, T. (2000). Efcacy of
a touchscreen computer based family cancer history
questionnaire and subsequent cancer risk assessment.
Journal of Medical Genetics, 37(5), 354
360.
White, B., Day, C., & Maher, L. (2007). Self reported risk
behaviour among injecting drug users: Self versus
assisted questionnaire completion. AIDS Care, 19(3),
441
447.

Downloaded by [UNSW Library] at 02:15 01 February 2013

van Beek, I. (2007). Case study: Accessible primary health

care
a foundation to improve health outcomes for
people who inject drugs. International Journal of Drug
Policy, 18(4), 329
332.
Wand, H., Guy, R., Donovan, B., & McNulty, A. (2011).
Developing and validating a risk scoring tool for
chlamydia infection among sexual health clinic attendees in Australia: A simple algorithm to identify those
at high risk of chlamydia infection. BMJ Open,
Retrieved from http://bmjopen.bmj.com/content/
early/2011/02/16/bmjopen-2010-000005.full.pdf

307

Appendix IV

(j) Islam, M. M., Shanahan, M., Topp, L., Conigrave, K. M., White, A., & Day, C. A.
(Epub ahead of print). The cost of providing primary healthcare services from a
needle and syringe program: a case study. Drug and Alcohol Review, doi:
10.1111/dar.12019

308

bs_bs_banner

R E V I E W

Drug and Alcohol Review (2012)

DOI: 10.1111/dar.12019

The cost of providing primary health-care services from a needle

and syringe program: A case study
M. MOFIZUL ISLAM,1,2 MARIAN SHANAHAN,3 LIBBY TOPP,4
KATHERINE M. CONIGRAVE,2,5,6 ANN WHITE7 & CAROLYN A. DAY8
1

School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia, 2Drug Health
Service, Royal Prince Alfred Hospital, Sydney, Australia, 3Drug Policy Modelling Program, National Drug and Alcohol
Research Centre, University of New South Wales, Sydney, Australia, 4Viral Hepatitis Epidemiology and Prevention
Program, the Kirby Institute, University of New South Wales, Sydney, Australia, 5Sydney Medical School, University of
Sydney, Sydney, Australia, 6National Drug and Alcohol Research Centre, University of New South Wales, Sydney,
Australia, 7Redfern Harm Minimisation Clinic, Sydney Local Health District, Sydney, Australia, and 8Discipline of
Addiction Medicine, Central Clinical School, Sydney Medical School, University of Sydney, Sydney, Australia

Abstract
Introduction and Aims. Targeted primary health-care services for injecting drug users have been established in several
countries to reduce barriers to health care, subsequent poor health outcomes and the considerable costs of emergency treatment.
The long-term sustainability of such services depends on the resources required and the coverage provided.This study assesses
the additional cost required to operate a nurse-led primary health care in an existing needle syringe program setting, estimates
the costs per occasion of service and identifies key factors influencing improved service utilisation. Design and Methods.
Using standard costing methods and the funder perspective, this study estimates costs using the ingredients approach where the
costs of inputs are based on quantities and unit prices (the ingredients). Results. During the 20092010 fiscal year, the
primary health-care clinic provided 1252 occasions of service to 220 individuals, who each made an average of 3.9
presentations. A total cost of AU$250 626 was incurred, 69% of which was for personnel and 22% for pathology. During the
study period the average cost per occasion of service was AU$199.96, which could be as low as AU$93.32 if the clinic reached
its full utilisation level. Discussion and Conclusions. Although the average number of presentations per client was
satisfactory, the clinic was underutilised during the study period. Proactive engagement of clients at the needle syringe program
shopfront and an increased range of services offered by the clinic may help to attract more clients. [Islam MM, Shanahan M,
Topp L, Conigrave KM, White A, Day CA. The cost of providing primary health-care services from a needle and
syringe program: A case study. Drug Alcohol Rev 2012]
Key words: injecting drug use, primary health care, needle syringe program, cost analysis, low-threshold health care.

Introduction
Injecting drug users experience a wide range of health
problems [13]. Although most of these problems are
treatable and/or preventable, a range of complex barriers limit drug users access to conventional health services [4,5]. Even when health care is essential, it may
take a lower priority than obtaining food, housing and
drugs [6,7], potentially resulting in delayed help

seeking [8,9] and subsequent over-reliance on emergency departments and hospitalisation [2,10]. This in
turn creates pressure on hospital resources, unnecessary cost and often poorer outcomes [11]. An American
community-based study found that, relative to nondrug users, drug users consumed significantly more
inpatient and emergency care but less outpatient services, with excess service utilisation costs of $1000 per
individual [12].

M. Mofizul Islam, MSc, Doctoral candidate, Marian Shanahan, PhD, Senior Lecturer, Health Economist, Libby Topp, PhD, Senior Lecturer,
Katherine M. Conigrave, FAChAM, FAFHPM, PhD, Addiction Medicine Specialist, Professor, Ann White, RN, RM, Clinical Nurse Consultant,
Carolyn A. Day, PhD, Associate Professor. Correspondence to Mr M. Mofizul Islam, Drug Health Services, King George V Bldg, RPAH,
Missenden Rd, Camperdown, NSW 2050, Australia. Tel: +61 2 9515 9726; Fax: +61 2 9515 5779; E-mail: m.m.islam@unsw.edu.au
Received 30 June 2012; accepted for publication 5 November 2012.
2012 Australasian Professional Society on Alcohol and other Drugs

309

M. M. Islam et al.

To facilitate appropriate health-care utilisation

among this population, targeted primary health-care
(PHC) services have been established in several countries to offer various degrees of preventative and therapeutic health-care services [13]. These services are
often provided through opioid substitution therapy
clinics and/or needle syringe programs (NSPs), a model
that facilitates provision of both opportunistic and continuing health care [14]. For example, in 2007 onethird of NSPs in the USA provided onsite medical care
[15]. These are usually low-threshold PHC facilities
and reduce many of the barriers injecting drug users
may experience while accessing conventional services
[13]. The Harm Minimisation Clinic in inner-city
Sydney, one such low-threshold facility established in
2006 [16], provides PHC to injecting drug users via an
enhanced NSP model. Like other low-threshold facilities, it provides a drop-in, free-of-charge, nonjudgemental and anonymous service [13], allowing
clients to access harm reduction, PHC and welfare
services and referrals for other health care.
A key issue for such a service is that of resources
what does it cost? Indeed, the long-term sustainability
of such a service depends on the resources required
and the coverage provided. Cost data must underlie
meaningful evaluation of such a PHC [17]. To our
knowledge, no estimates of the costs of an NSP-based
PHC service have been published. Given that the
Harm Minimisation Clinic is a relatively new model
of PHC provision subjected to limited evaluation
[13], and that the need for these facilities under a
universal health-care system (such as implemented in
Australia) remains under question [14], it is essential
to assess the resource implications of such services.
The aim of this study, therefore, was to undertake an
economic analysis to assess the additional (incremental) cost of offering PHC from an existing NSP
setting. The paper also estimates the costs of clinics
PHC activities per occasion of service, and identifies key
factors influencing improved service utilisation by the
target population.
Methods
This study assessed the incremental cost of operating a
nurse-led PHC service colocated with the existing NSP.
Based on standard costing methods [18] and adopting
a funder perspective, the analysis of costs used the
ingredients approach, in which the total quantities of
goods and services used in service delivery are estimated and multiplied by their respective unit price
[19]. Financial information was obtained from administrative records, interviews and direct observation.
Actual expenditures were used rather than budget estimates.We analysed costs incurred during the fiscal year

July 2009 to June 2010, the most recent full year cycle
for which most data were available. As per standard
practice [17], greater efforts were made to find information on the largest input categories (e.g. salaries and
supplies) relative to the lower input categories (e.g. staff
training costs). Resources, and hence costs, were classified as capital (one-time start-up activities, buildings
and capital equipment) or recurrent (pathology tests,
vaccines) items. Apportioning of overhead costs to the
NSP or the PHC was based on activity indicators and
detailed discussions with the managers of both services
and other relevant staff. This study assessed the additional cost required for the operation of the PHC
service over and above that of the NSP. Thus, all costs
incurred because of the existence of the PHC were
included in the analysis.
Occasions of service are defined as either: (i) clients
physical presentations to the PHC clinic; (ii) phone
consultations regarding, for example, test results; (iii)
formal referrals, including writing referral letters and
setting appointments for clients to attend other health
and welfare services; or (iv) follow up on formal referrals made by PHC staff.
Using 20092010 fiscal year data, a mathematical
equation (y = mx + c) assessed total cost as a function of
fixed cost and variable cost, where y is the total financial
cost; m is the variable cost (costs of pathology, medication, vaccines, dressings, consumable test kits and dayto-day operation) required per occasion of service; x is
the total occasions of service and c is the fixed cost.
Average cost per occasion of service was estimated for
both current and projected levels of service utilisation.
Harm Minimisation Clinic model of care
The clinic is a nurse-led service comprising: a full-time
clinical nurse consultant (a specialist nurse who
manages the service); a full-time registered nurse with
PHC experience with marginalised communities; and a
0.1 full-time equivalent visiting medical officer who
reviews pathology results and consults with nurses and
clients as required.
During initial presentation, nurses conduct a full
assessment and record details about clients demographic characteristics, access to general medical practitioner services, interpersonal relationships including
dependents; and five domains: (i) drug and alcohol use;
(ii) blood-borne virus risks and status; (iii) mental
health; (iv) sexual and reproductive health; and (v)
general health. This full assessment is updated annually
among returning clients.
Based on the assessment, a range of laboratory
examinations may be offered, including screening for
blood-borne virus and sexually transmitted infections
and general pathology tests including urea, electrolytes

2012 Australasian Professional Society on Alcohol and other Drugs

310

The cost of providing PHC from a NSP

and liver function tests, coagulation factors and full

blood count. Other services commonly offered include
management of wounds/veins/abscesses; vaccination
against hepatitis B virus; general health consultations;
assessment and management of drug and mental health
issues; welfare services (e.g. advocacy with respect to
public housing); counselling; referrals to other health
and related services; and support throughout hepatitis
C virus assessment and antiviral therapy. Nurses maintain close links with various local services, facilitating
referrals between services and further appointments as
necessary. To enhance referral uptake, clients are provided with assistance to make appointments; and telephone or short message service (SMS) reminders are
sent the day preceding appointments. Uptake of formal
referrals is regularly confirmed through direct communication with service providers. A database records the
number of new clients, number of presentations per
client, pathology tests performed, formal referrals made
to other organisations and successful referral uptakes.
This study was approved by the Ethics Review Committee (Royal Prince Alfred Hospital Zone) of the
Sydney Local Health District.
Cost data
Staff salaries were determined via respective administrative databases. Only gross staff earnings were used.
Additional costs to the employer (e.g. superannuation,
leave, insurance, payroll tax) were added to individual
staff salaries for the study period. Vehicle operation,
fuel and maintenance costs were collected from
Sydney Local Health District Fleet Management
office. Supply invoices, order forms, price lists, catalogues and interviews with the NSP and the clinic
managers were used to estimate costs of PHC clinic
consumables. Laboratory costs were collected from
the Local Health District Finance Office. This study
was concerned only with the incremental cost of the
PHC operation; therefore only the overhead costs,
which would have been saved in the absence of the
clinic, were listed as PHC expenditure.
Costs of all capital items were estimated in current
value (i.e. replacement rather than original cost). The
consumer price index was used to estimate the current
value of some past capital purchases for which current
market value could not be identified. A discount rate of
10% (high side), as recommended by the World Bank
[17], was followed for the annualisation factor. The
useful life of all capital items was estimated by examining their warranty documents, and/or consultations
with relevant staff. Depreciation cost was calculated by
the straight-line method, which allocates an equal
portion of the cost of fixed assets with a multiyear life to
each year [17].

The cost of the premises was estimated based on

the rental price for similar premises in the same area.
The service used leased vehicles, thus costs in this
category include lease fees, petrol, registration, insurance and maintenance. Building operation and maintenance costs included electricity, water, security and
safety and building maintenance. Other operating
costs included phone, fax and internet and miscellaneous expenditure.
Sensitivity analyses were undertaken to assess the
robustness of the results to changes in key variables, but
were not intended as a judgement on the probability or
likelihood of any assumption being higher or lower than
the base assumptions.The base assumptions themselves
are considered the most reasonable assessment of likely
measures. Sensitivity analyses were conducted using
three discount rates, 0%, 5% and 10%. We assumed
that the costs for delivering services are incurred at the
beginning of the year.
The potential number of occasions of service that
could be offered in a year, and corresponding cost per
occasion of service, were calculated using the following
assumptions:
1. It was estimated that during a normal working
day, nurses effectively see patients for 6 h (excluding a meal break, time taken to transport clinical
samples to the pathology service and time spent
staffing the NSP shopfront). During these hours,
each nurse can offer 10 quality occasions of
service. Given 250 working days per year, two
full-time nurses can offer a total of 5000 (2500
each) occasions of services without compromising
quality. To adjust for the absence of nurses due to
training, leave and unforeseen events, an estimate
of 4500 occasions of service (9 per day per nurse)
was considered realistic and conservative.
2. The average variable costs (supplies, pathology
and day-to-day operating costs) were assumed
constant for each occasion of service. A stable
linear trend was observed when monthly occasions of service and corresponding variable costs
were compared. The PHC nurses and the visiting
medical officer were deemed essential for the clinics operation.Their total salaries were considered
fixed costs, as they do not change with clinics
scale of the current (or proposed) utilisation.
3. Sufficient PHC clients to fully utilise service
capacity were assumed based on past and current
rate of client presentation to the service, its regular
flow of clients from the colocated NSP and a
nearby residential treatment centre, and its location in an area frequented by illicit drug users.
4. At times of NSP staff shortages, PHC nurses may
work in the NSP shopfront.To accommodate this,
2012 Australasian Professional Society on Alcohol and other Drugs

311

M. M. Islam et al.

10% of nurses working hours and corresponding

salary were reflected under NSP costs.
Results
Table 1 presents the detailed cost profile for the PHC
clinic. During the 20092010 fiscal year, the PHC
incurred a total cost of AU$250 626. The largest
expense was for personnel (69%), followed by pathology (22%). In 20092010 fiscal year, the clinic provided 1252 occasions of service to 220 individual
clients, who each made an average of 5.7 presentations
of which 3.9 were physical presentations.
Considering the 20092010 fiscal year data for the
clinic, the linear equation fitted to assess total financial
costs as a function of fixed and variable costs showed
the following relationship:

Total costs ( y ) = total variable costs (mx )

+ total fixed costs (c )

(1)

Total costs ( y ) = variable cost per occasion (m )

total service occasions ( x ) (2)
+ total fixed costs (c )
Consequently, at the level of service utilisation for the
20092010 fiscal year (1252 occasion of services; 5.008
occasion of services per day by two nurses), the average
variable cost per occasion of service was AU$52.22
(Table 2, column 2). This is the cost of pathology tests,
vaccinations, basic medications and dressing consumables and thus would remain constant. If service utilisation increased, for example, to six occasions of service
per day, then the average total cost per occasion would
reduce from AU$199.96 to AU$175.54 (Table 2). If

Table 1. Estimated incremental cost of adding a primary health-care (PHC) service to an existing NSP, 20092010, AU$ (2009)

Source of information

Expenditure
(AU$)

Administrative record, NSP manager and CNC

Real estate market
Administrative record, NSP manager and CNC
Administrative record
Transport office, NSP manager and CNC
Administrative record
Administrative record, NSP manager and CNC

2 696
3 900
701
172 122
1 379
1 001
3 450

Resources
Fixed cost (c)
Equipment
Building, space
Training, non-recurrent
Personnel
Vehicles operation and maintenance
Building operation and maintenance
Training, recurrent
Variable cost (m)
Supplies (injecting equipment, drugs, vaccines,
small equipment with unit cost of less than $100)
Pathology
Other operating cost (e.g. travel)
Grand total

Database and paper based record

8 534

PHC database and CNC

As above

55 582
1 261
250 626

With 0% discount rate. CNC, clinical nurse consultant; NSP, needle syringe program.

Table 2. Current and projected average cost per occasion of service provided by the Harm Minimisation Clinic (AU$)

Observed 20092010
Projected
Projected
Projected
Projected
Projected
Projected
Projected

Variable cost per

occasion of service
m

Occasion of
services
x (a)

Total variable
costs
mx

Fixed
cost
c

Y = mx + c

Average cost per

occasion of service
y/x

52.22
52.22
52.22
52.22
52.22
52.22
52.22
52.22

1252 (5)
1500 (6)
2000 (8)
2500 (10)
3000 (12)
3500 (14)
4000 (16)
4500 (18)

65 377
78 327
104 436
130 545
156 654
182 763
208 872
234 981

184 978
184 978
184 978
184 978
184 978
184 978
184 978
184 978

250 355
263 305
289 414
315 523
341 632
367 741
393 850
419 959

199.96
175.54
144.71
126.21
113.88
105.07
98.46
93.32

All costs are in AU$. aOccasions of service offered per day by two nurses during 20092010 fiscal year.
2012 Australasian Professional Society on Alcohol and other Drugs

312

The cost of providing PHC from a NSP

the service was fully utilised, when a total of 18 occasions of service per day would be offered, the average
cost per occasion of service would decrease to
AU$93.32 (Table 2).
The estimated total costs of the PHC service with
varied parameters are shown in Table 3. The variables
that were assessed in the sensitivity analysis were the
discount rate on capital items, rental price of the
premises, replacement of the clinical nurse consultant
position by a less specialist nurse and the working hours
of the medical officer.Variation in the discount rates and
rental increment caused minimal cost differences. This
was because the exact and updated costs of all recurrent
items for 20092010 were clearly sourced and collected
from official documents, and thus these costs were not
discounted. However, if the clinical nurse consultant
position were to be replaced by a less specialist nursing
position nurse then the base amount would decrease by
8.3%. Conversely, if the current medical officers posi-

tion increased to 0.2 full-time equivalent then the base

amount would increase by 7.6%.
At full utilisation, the average fixed cost (base
amount) per occasion of service would be AU$41.10
($93.32 minus $52.22; i.e. the average total cost per
occasion of service minus the average variable cost per
occasion of service). Figure 1 shows that the average
cost per occasion of service could more than halve
(AU$93.32) the cost the clinic incurred during the
20092010 fiscal year (AU$199.96), if it reached full
utilisation.
Discussion
The total cost of PHC services provided by a nurseled PHC service colocated with an established NSP
during the 20092010 fiscal year was AU$250 626.
Fixed costs accounted for the majority, with personnel
costs constituting more than two-thirds of the total

Table 3. Estimated cost for 20092010 with variation of relevant parameters

Parameter varied
Base amount
Discount rate on capital items
Rent increases by 10%
Change CNC position to RN
MO at 0.2 FTE

Change in
respective
item (%)

Total cost
(AU$)

Current average
cost per occasion
of service (AU$)

0
+5
+10
+10
-12
+100

250 356
251 121
251 978
250 746
229 472
269 368

199.96
200.58
201.26
200.28
183.28
215.15

CNC, clinical nurse consultant; RN, registered nurse; MO, medical officer; FTE, full-time equivalent.

Figure 1. Trend of average cost per occasion of service as attendance increases up to full utilisation level. FTE, full-time equivalent; MO,
medical officer; RN, registered nurse.
2012 Australasian Professional Society on Alcohol and other Drugs

313

M. M. Islam et al.

cost. During this period a total of 1252 occasions of

services were provided. The average cost per occasion
of service was AU$199.96. The PHC service was
underutilised, providing five occasions of service per
day; the average cost per occasion of service could be
halved to AU$93.32 if the service was fully utilised.
Sensitivity analyses confirmed that the costing findings
were robust.
Although the average cost per occasion of service at
observed utilisation level appears higher than the fee
(AU$57.10) a general medical practitioner receives
for a consultation under Australias universal healthcare system [20], it should be remembered that this
clinic caters for a population dissimilar to the general
population in many respects. Many of these clients
avoid conventional health-care services until conditions become severe, and then often present at emergency departments, a behavioural pattern associated
with substantial cost burden [8,9]. For instance, in
Australia, opioid-related hospital separations for cooccurring medical conditions such as endocarditis
were estimated to cost approximately AU$25 000 per
separation between 1999/2000 and 2004/2005 [21].
Considerable expenditure could have been saved with
appropriate preventative care for this population
[22,23]. Likewise, the predominant causes of hospital
admissions in a cohort of injecting drug users in Vancouver, Canada were pneumonia and soft-tissue infections, directly or indirectly related to injecting [24].
This emphasises the importance of early interventions
to reduce reliance on emergency departments and
hospital admissions.
Although this study was neither intended nor able to
assess the costbenefit of this PHC service, the overall
clinical outcomes are favourable. These include hepatitis C treatment assessment, referrals to a tertiary liver
clinic and support to successful completion of antiviral
treatment by a number of clients [14,25]; early diagnosis of an HIV-positive client [26]; and 573 doses of
hepatitis B vaccinations administered during 2009
2010 (unpublished data). It is also important to note
that the findings incorporate the period of clinic commencement when clinic capacity and client numbers
were still growing. Clients initial health assessments
usually take more time than that required for other
defined occasions of service. Thus in the full operational stage, the intake of new clients is likely to
decrease and the typically less intensive follow up of
ongoing clients will increase. At that stage, nurses will
be able to offer a higher number of occasions of service,
which will eventually reduce variable and total cost per
occasion of service. Nevertheless, rigorous determination of whether the benefits of the PHC clinic outweigh
its costs would require a full economic evaluation such
as a cost-effectiveness analysis.

Although during the 20092010 fiscal year the clinic

was underutilised, compared with previous years the
total number of new clients and occasions of services
were growing, albeit slowly. Apart from the clinics
commencement period, other potential factors may
have affected clinic underutilisation (or the relatively
slow increase in the number of clients accessing the
service). First, Australia enjoys a universal health-care
system where individuals can seek PHC from a general
medical practitioner at no or minimal out-of-pocket
personal expense and this may be one reason for
underutilisation.
Second, observations indicate that while PHC nurses
worked in the NSP shopfront they were more likely
than NSP workers to attract clients into the PHC
service. This observation emphasises the need for a
strategic and consistent approach to successfully
engage clients in the PHC service; and emphasises the
importance of engaging clients to whom health care
may be a low priority relative to other needs such
obtaining food, housing and drugs [6]. Ongoing education of NSP workers regarding the services provided
in the PHC is necessary.
Third, the clinics limited range of PHC services
may have restricted its capacity to attract potential
clients. Thus efforts should be made to make services
more attractive. Options include an increased range of
services, for example, provision of onsite Pap tests,
hepatitis A vaccination, antibiotics for bacterial infections and welfare support by a qualified case-worker.
Although nurses often refer clients to appropriate
health-care providers for services not available onsite
and facilitate referral uptake, a significant proportion
of referred clients fail to attend appointments [27].
Indeed some commentators have argued that for
many injecting drug users, offering referrals only is
akin to denying those services [28]. Given injectionrelated infections are common among NSP attendees
[29] and that PHC clients are less likely to attend
general medical practitioner than other referrals [27],
onsite prescribing of essential medications such as
antibiotics may be necessary. In addition, the time
currently spent arranging, facilitating and tracking
referrals may be impractical once the clinic reaches
full utilisation.
Limitations
It was not possible to estimate the proportion of NSP
clients accessing PHC services because NSP services
are provided on an anonymous basis. This study considers only the incremental costs of offering PHC in an
established NSP setting, thus findings may not apply to
NSPs without the scope to accommodate this type
of clinic. The assumption that the variable cost per

2012 Australasian Professional Society on Alcohol and other Drugs

314

The cost of providing PHC from a NSP

occasion of service would remain constant may not be

valid for the optimum service utilisation level, as this
assumption was made based on data for the study
period only. However, variable costs are less likely to
increase, and more likely to decrease with increased
service utilisation. This study may not be generalisable
to other settings, particularly to developing countries
where injecting drug use is prevalent and access to
health care poor. In low-resource settings where
poverty is widespread and health care is costly, a model
of no-cost accessible health care is likely to be highly
utilised.
Conclusion
The average cost incurred per occasion of service from
this targeted PHC facility was influenced by its relative
underutilisation. However, the average number of presentations per client and the range of services provided
emphasise the clinics importance. Efforts to attract
more clients will potentially reduce the average cost per
occasion of service, as well as emergency department
and hospital admissions. A more proactive engagement
of NSP clients and an increase in the range of services
offered by the PHC may help engage more clients,
thereby increasing efficiency.
Acknowledgements
The first author was supported by a University International Postgraduate Award of University of New South
Wales.The authors are indebted to Prof. Paul Haber, Mr
Simon Vong, Mr Paolo Pereira, Mr Wyndham Timmins,
Ms Linda Jones, Mr Jason Larkin, Mr Brenton Bragg,
Ms Amy Ting and Ms Robyn Drew, who assisted with
the provision of essential information.
References
[1] Stein M. Medical consequences of substance use. Psychiatr
Clin North Am 1999;22:35170.
[2] Haber PS, Demirkol A, Lange K, Murnion B. Management
of injecting drug users admitted to hospital. Lancet
2009;374:128493.
[3] Darke S, Ross J. Polydrug dependence and psychiatric
comorbidity among heroin injectors. Drug Alcohol Depend
1997;48:13541.
[4] Neale J, Tompkins C, Sheard L. Barriers to accessing
generic health and social care services: a qualitative study of
injecting drug users. Health Soc Care Community
2008;16:14754.
[5] Morrison A, Elliott L, Gruer L. Injecting-related harm and
treatment-seeking behaviour among injecting drug users.
Addiction 1997;92:134952.
[6] Carr S, Goldberg DJ, Elliott L, et al. A primary health care
service for Glasgow street sex workers6 years experience of
the drop-in centre, 19891994. AIDS Care 1996;8:489
97.

[7] Bruce RD. One stop shoppingbringing services to drug

users. Int J Drug Policy 2012;23:104.
[8] McCoy CB, Metsch L, Chitwood DD, Miles C. Drug use
and barriers to use of health care services. Subst Use Misuse
2001;36:789806.
[9] Drumm RD, McBride DC, Metsch L, Neufeld M, Sawatsky A. Im a health nut! Street drug users accounts of
self-care strategies. J Drug Issues 2005;35:60729.
[10] French MT, Fang H, Balsa AI. Longitudinal analysis of
changes in illicit drug use and health services utilization.
Health Serv Res 2011;46:87799.
[11] Binswanger IA, Takahashi TA, Bradley K, et al. Drug users
seeking emergency care for soft tissue infection at high risk
for subsequent hospitalization and death. J Stud Alcohol
Drugs 2008;69:92432.
[12] French MT, McGeary KA, Chitwood DD, McCoy CB.
Chronic illicit drug use, health services utilization and the
cost of medical care. Soc Sci Med 2000;50:170313.
[13] Islam MM, Topp L, Day CA, Dawson A, Conigrave KM.
The accessibility, acceptability, health impact and cost
implications of primary healthcare outlets that target injecting drug users: a narrative synthesis of literature. Int J Drug
Policy 2012;23:94102.
[14] Islam MM, Reid SE, White A, et al. Opportunistic and
continuing health care for injecting drug users from a nurserun needle syringe program-based primary health-care
clinic. Drug Alcohol Rev 2012;31:11415; author reply
11617.
[15] Des Jarlais DC, McKnight C, Goldblatt C, Purchase D.
Doing harm reduction better: syringe exchange in the
United States. Addiction 2009;104:14416.
[16] Day CA, Islam MM, White A, et al. Development of a
nurse-led primary healthcare service for injecting drug users
in inner-city Sydney. Aust J Prim Health 2011;17:10
15.
[17] Creese A, Parker D. Cost analysis in primary health care.
Geneva: World Health Organization, 1994.
[18] Drummond MF, Sculpher MJ, Torrance GW, OBrien BJ,
Stoddart GL. Methods for the economic evaluation of
health care programmes. New York: Oxford University
Press, 2005.
[19] Levin HM. Cost-effectiveness: a primer. California, CA:
Sage Beverly Hills, 1983.
[20] Australian Government. MBS Online, Medicare Benefits
ScheduleItem 701. Canberra: Department of Health and
Ageing, 2012. Available at: http://www9.health.gov.au/mbs/
fullDisplay.cfm?type=item&qt=ItemID&q=701 (accessed
October 2012).
[21] Riddell S, Shanahan M, Degenhardt L, Roxburgh A.
Estimating the costs of drug-related hospital separations
in Australia. Aust N Z J Public Health 2008;32:156
61.
[22] Harris HW, Young DM. Care of injection drug users with
soft tissue infections in San Francisco, California. Arch
Surg 2002;137:121722.
[23] Grau LE, Arevalo S, Catchpool C, Heimer R. Expanding
harm reduction services through a wound and abscess
clinic. Am J Public Health 2002;92:191517.
[24] Palepu A, Tyndall MW, Leon H, et al. Hospital utilization
and costs in a cohort of injection drug users. CMAJ
2001;165:41520.
[25] Islam MM, Topp L, White A, et al. Linkage into specialist
hepatitis C treatment services of injecting drug users
attending a needle syringe program-based primary healthcare centre. J Subst Abuse Treat 2012;43:4405.
2012 Australasian Professional Society on Alcohol and other Drugs

315

M. M. Islam et al.

[26] Islam MM, Grummett S, White A, et al. A primary healthcare clinic in a needle syringe program may contribute to
HIV prevention by early detection of incident HIV in an
injecting drug user. Aust N Z J Public Health 2011;35:
2945.
[27] Islam MM, Topp L, Conigrave KM, et al. Are primary
health care centres that target injecting drug users attracting
and serving the clients they are designed for? A case study
from Sydney, Australia. Int J Drug Policy 2012;
doi:10.1016/j.drugpo.2012.06.002.

[28] Nasiri B. Windows of opportunity: adapting services to the

needs of people who inject drugs. Int J Drug Policy
2012;23:107.
[29] Topp L, Iversen J, Conroy A, Salmon AM, Maher L. Prevalence and predictors of injecting-related injury and disease
among clients of Australias needle and syringe programs.
Aust N Z J Public Health 2008;32:347.

2012 Australasian Professional Society on Alcohol and other Drugs

316

Appendix IV

(k) Day, C. A., Islam, M. M., White, A., Reid, S. E., Hayes, S., & Haber, P. S. (2011).
Development of a nurse-led primary healthcare service for injecting drug users in
inner-city Sydney. Australian Journal of Primary Health, 17, 10-15.

317

CSIRO PUBLISHING

www.publish.csiro.au/journals/py

Practice & Innovation

Australian Journal of Primary Health, 2011, 17, 1015

Development of a nurse-led primary healthcare service

for injecting drug users in inner-city Sydney
Carolyn A. Day A,F, M. Mozul Islam B,C, Ann White C, Sharon E. Reid C,D,E, Stephen Hayes C
and Paul S. Haber A,E
A

Discipline of Addiction Medicine, Central Clinical School (C39), Sydney Medical School, University of Sydney,
NSW 2006, Australia.
B
School of Public Health and Community Medicine, University of NSW, Sydney, NSW 2052, Australia.
C
Harm Minimisation Services, Drug Health Services, Sydney South West Area Health Service,
103105 Redfern Street, Redfern, NSW 2016, Australia.
D
Drug Health Services, Royal Prince Alfred Hospital, Missenden Road, Camperdown, NSW 2050, Australia.
E
School of Public Health (A27), Sydney Medical School, University of Sydney, NSW 2006, Australia.
F
Corresponding author. Email: carolyn.day@sydney.edu.au

Abstract. Injecting drug users (IDUs) experience numerous health problems, but report barriers to utilising general
practitioners (GPs). A nurse-led Harm Minimisation-based Primary Healthcare (HMPH) service for IDUs was established
within a needle and syringe program in inner-city Sydney with Area Health Service medical support and clinical governance.
This paper aimed to describe the HMPH service, review service utilisation and assess nurses perceptions of their work with
IDUs. A review of the most recent 200 clinic les was undertaken. Service utilisation, GP and other health service use and
access were extracted and analysed using SPSS. A semi-structured qualitative interview with clinic nurses regarding their
experience working with IDUs and local GPs was conducted and analysed. Since its inception in mid-2006, the service has
been utilised by 417 clients. Of the most recent 200 les, blood-borne virus and sexually transmitted infection screening were
the primary reason for presentation (64.5%). At least one follow-up visit was attended by 90% of clients. A total of 62% of
clients reported consulting a GP in the last 12 months. The service provided 102 referrals. Nurses believed that IDUs tend to
utilise GPs ineffectively and that self-care is a low priority, but that they can support IDUs to overcome some barriers to GPs
and facilitate access. Targeted primary health care services led by nurses with focussed medical support and co-located with
needle and syringe programs can ll an important gap in delivering and facilitating health care to IDUs.

Introduction
Injecting drug users (IDUs) face numerous health-related
problems due to injecting and drug dependence, including: bloodborne viral infections (BBVI), skin and soft-tissue infections,
comorbid mental health problems and other general health issues
related to poor living conditions, nutrition and lifestyle factors.
Although the early introduction of needle and syringe programs
(NSP) in Australia resulted in the very low prevalence of HIV
infection (<2%) among IDUs (Commonwealth Department of
Health and Aging 2002), the prevalence of hepatitis C virus
(HCV) infection has remained high, with more than 50% of NSP
attendees being anti-HCV positive (NCHECR 2008). Similarly,
hepatitis B virus (HBV) infection is also high among IDUs 54%
were HBV core antibody positive in a recent study of inner-city
IDUs (Day et al. 2010), and injecting drug use remains the most
common mode of transmission among newly acquired cases in
Australia (NCHECR 2007). Moreover, HBV vaccination uptake
(Topp et al. 2009), completion (MacDonald et al. 2007) and
knowledge (Day et al. 2003b) among IDUs are low. Non-viral
injection-related injury and disease is also common 40% of
IDUs surveyed across three Australian states reported at least one
 La Trobe University 2011

episode of a potentially serious injection-related injury or disease,

with skin abscess the most common (Dwyer et al. 2009).
High rates of mental health co-morbidity have been reported
among IDUs in Australia (Darke and Ross 1997), including high
rates of suicidality (Darke and Ross 2002; Darke and Kaye 2004).
Among a sample of predominantly injecting opioid users entering
drug treatment, more than a quarter met the criteria for current
major depression (Teesson Havard et al. 2005), a third reported at
least one suicide attempt in their lifetime (Darke et al. 2004) and
lifetime prevalence of trauma was 92%, with 41% having a
history of post-traumatic stress disorder (Mills et al. 2005).
Although less documented, the general health of many IDUs
is also poor (Darke et al. 2003). IDUs require a range of general
health care not necessarily specic to drug injection. Hepatitis A
has been reported to occur more commonly among IDUs
(Delpech et al. 2000; Gilroy et al. 2000). Gynaecological
problems including high levels of cervical neoplasia (Reece
2007a) and very low levels of contraceptive use (Banwell et al.
2003) have been documented among female IDUs. Anaemia,
due to poor nutrition and other physiological causes, was found
among female IDUs in a US study (Semba et al. 2002). Poor oral
10.1071/PY10064

1448-7527/11/010010

318

Nurse-led service for injecting drug users

health (Reece 2007b; Laslett et al. 2008) and inappropriate diet

(Zador et al. 1996) are also common.
High rates of unemployment and disability mean IDUs are
generally unable to pay for medical services. The available
evidence suggests that accessing even basic health care services
can be difcult for this population, because of a lack of specialised
primary healthcare (PHC) services and discrimination from
mainstream services (Day et al. 2003a). There is some evidence
that many general practitioners (GPs) lack condence dealing
with drug users (Abouyanni et al. 2000). The corollary is high
rates of tertiary care admissions, usually for preventable
conditions (Roxburgh and Degenhardt 2007; Roxburgh and
Degenhardt 2008). Principal diagnoses of physical or general
health problems often accompany opioid-related hospital
separations up to 54% for Australian hospital separations from
19932004. The most costly drug-associated hospital separations
are preventable and include low birthweight, non-A non-B
hepatitis and infective endocarditis (Riddell et al. 2007a).
To address the unmet health needs of IDUs, the Redfern
Drug Health Service implemented a Harm Minimisation-based
Primary Healthcare service (HMPM) led by a clinical nurse
consultant. The available evidence suggests that appropriately
trained nurses can deliver a similar quality of care as doctors in the
primary care setting and that client satisfaction is higher with
nurses (Laurant et al. 2004). Moreover, nurse practitioners have
been found to be appropriate for addressing the primary care
needs of IDUs (Hooke et al. 2001).
Despite the clear need for increased PHC, and evidence that
such integrated care can improve addiction outcomes (Friedmann
et al. 2003), there are few precedents in the Australian setting.
The Kirketon Road Centre in Sydneys King Cross is an
internationally acclaimed PHC facility targeting, among others,
IDUs (Van Beek 2007) and has demonstrated the important role
nurses can play in delivery of this type of PHC (Hooke et al.
2001). The Redfern HMPH, however, operates as an adjunct PHC
facility through an existing and established NSP, and is staffed
primarily by nurses with minimal medical support. Such a model
directly addresses the goals of the Commonwealths Strategies in
HIV/AIDS (Commonwealth Department of Health and Ageing
2005b) and HCV (Commonwealth Department of Health and
Ageing 2005a) to reduce transmission and improve the
health of people living with such infections. Accessibility and
appropriateness of health care are principles extolled in these
policy frameworks. The World Health Organisation (2004) and
Joint United Nations Program on HIV/AIDS (2005) policy
frameworks for HIV/AIDS prevention among IDU also endorse a
PHC model of service provision.
In this paper, we aim to: (i) describe the Redfern HMPM
service; (ii) review service utilisation, client return-rate and access
to GP services; and (iii) describe nurses perceptions of their
work with IDUs.
The service
The HMPM provides one of the rst contact points between
health care workers and IDUs. The NSP provides a range of
harm minimisation services, including the provision of injecting
equipment, needle disposal containers, outreach services, safe
injecting and safe sex resources, referral to other health care

Australian Journal of Primary Health

11

services (such as hepatitis C, drug treatment services, sexual

health and mental health services) health promotion activities and
operates syringe vending machines. The service is situated within
close proximity to public transport and is located within one of the
Sydneys largest drug markets (Gibson et al. 2003). The HMPM
clinic is located within the existing NSP.
The clinic is a nurse-led service comprising: a clinical nurse
consultant (CNC) and registered nurse (RN) specialising in PHC
with marginalised communities; in-house case-worker trained
in the comprehensive intake assessment; and a part-time
visiting medical ofcer (0.1 full time equivalent) for reviewing
pathology results and to consult with nurses and clients for
further medical assessment where needed. Establishment of
the service was coordinated by a multidisciplinary steering
committee with representation from the NSP, health service
managers and clinicians.
Clinical governance for this clinic was maintained according
to Sydney South West Area Health Service (SSWAHS), NSW
policy. Policy and procedure documents were developed and
reviewed by the Steering Committee before formal approval
and implementation. Clinical supervision was provided to
participating nursing and medical staff. The adverse event
reporting system implemented throughout NSW Health Service
was implemented at this site.
Clients access clinical service through a drop-in or
appointment system and referrals are taken from other
community-based health services. The initial intake assessments
are performed by both RNs and the case-worker. The case-worker
provides education, counselling, advocacy and a referral service
to clients. The nurses, because of their training, provide a more indepth clinical assessment; collecting blood and other pathology
specimens on-site thereby maximising clients participation
in BBVI and sexually transmitted infection (STI) screening.
The nurses also provide extended clinical support where clinical
conditions common to IDUs arise, for example, BBVIs,
vaccinations, sexual health, mental health, women and mens
health, and skin infections. Where appropriate, clients are referred
beyond the clinic to an existing community-based network of
health care services (including drug treatment, mental health,
sexual health, general practice and medical specialist care).
Wherever possible, clients are referred back to their own GPs or
linked in with local GPs known to the service and to work with
drug-using populations.
The clinic is an integrated model of care involving a
multidisciplinary team approach that blends both the one-stop
shop with facilities to manage and treat a variety of conditions
with the distributive model, whereby patients are assessed for a
variety of conditions and then referred on for more specialised
care (Stein et al. 1993). Coordination and follow up of care is
encouraged by clinic nurses maintaining contact with clients and
by providing opportunistic and formal (e.g. via phone, SMS,
letters) appointment reminders.
Methods
Clinic audit
From July 2006 to February 2010, 417 les were opened.
The most recent 200 les were included for review (July 2008
to February 2010) to ensure accuracy and completion, and to

319

12

Australian Journal of Primary Health

exclude les opened during the pilot and inception phases of the
clinic. Data from the most recent (to the end of February 2010)
200 paper-based les of clients attending the HMPH were
manually extracted and entered into an SPSS (version 17.0)
database. Key variables were obtained from the assessment (or
intake) form, and laboratory results and included details on
demographic information, drug health, clinical and laboratory
results. HIV, HCV and HBV testing and vaccination (HBV)
history and treatment were collected. Permission to review the
les was granted by the SSWAHS Ethics Review Committee
(RPAH Zone).
Nursing experience
Qualitative data concerning the clinic nurses experience of their
work with IDUs and local GPs was gathered using a semistructured interview. The interview schedule was developed to
determine nurses experience of working in the clinic and with the
client group; there was particular focus on referral to and from
GPs. The data was collected via a focus group discussion with
the three nurses who worked at the clinic. The interview was
recorded, transcribed and analysed to identify key themes. The
nurse participants checked the transcript for delity, and reviewed
the results and interpretation.
Results
Sample characteristics
Sample characteristics are presented in Table 1. The majority of
the sample were male (77.5%) and aged a median of 35 years
(1972 years). The sample typically consisted of polydrug users
(76%), but the most frequently reported primary drugs of concern
were heroin (34%) and methamphetamine (24%).
Presentations
BBVI and STI screening were the primary reasons for
presentation at the clinic (64.5%); other primary reasons for
presentation were more varied and included vaccination (21.5%),
general health assessment (4.5%), referral to other health care
(4.5%) and drug health assessment (2.5%). More than half the
sample (61%) reported having a regular GP.
Approximately half the sample reported previous needle/
syringe sharing (51.5%). HCV screening was conducted for 179
clients in the sample, 58% were positive. A total of 94 clients in
the sample underwent HCV RNA testing, 70% were positive.
Opportunistic hepatitis B vaccination was offered to all eligible
clients (n = 101). Within the study period, the three-dose schedule
was completed by 59%; 23% received two doses and 19%
received one dose only.
More than half the sample (59%) reported either having been
treated by a psychiatrist or mental health professional, or a prior
admission to a psychiatric facility. Data were unavailable for 10%
of the sample. History of a previous major physical health
problem was reported by almost half the sample (46%).
Trend of service utilisation and clients return rate
The number of new clients in the last year increased signicantly
compared with the previous year (137 vs 103; P < 0.01). At least
one follow-up visit was attended by 90% of the sample. A recent

C. A. Day et al.

(last 12 months) GP visit was reported by 62% of the sample,

almost 10% higher than reported by the initial 200 clients.
Qualitative data from semi-structured interviews
with nurses
The key themes identied from the HMPH clinic nurses
interview about their experience of linking IDUs with GPs were
related to ineffective GP utilisation, the drug using lifestyle,
barriers and facilitators to GP access.
IDUs tend to utilise GPs ineffectively with nurses describing
clients use as being either random if [they] need to use a GP it is
just random . . . a medical centre . . . wherever they can nd [one],
crisis driven dont go for regular check-ups until something is a
crisis and then more likely to utilise an emergency department or
only for specic needs, including prescription drug seeking they
also have a doctor who will give them prescription drugs. Given
the nature and resultant lifestyle of drug dependence, self-care is a
low priority for many IDUs: every waking moment is about
getting on, about using and then about getting on again, so going
to a doctor doesnt really get in there. . ..
Several barriers to accessing GPs were described and
included: previous negative experience, waiting for an
appointment, hostile receptionists, being judged, being lectured
and fear of the unknown; If they cant get an appointment today
and it is like in a weeks time, which is general for most GPs, they
wont remember; they just dont want to be lectured, to feel
shame and embarrassment and dont really want to bring it [their
drug use] up.
Facilitators that seemed most effective from the HMPH
nurse experience were: a exible GP in terms of quick access or
no appointment needed, close geographical location, assisting
clients to make appointments, letters of introduction and relevant
pathology results (faxed to GP), discussion of reason for referral,
and emotional preparation for the visit.
Discussion
These initial data from the HMPH clinic demonstrate a high level
of PHC need among those using the service. Clients reported
accessing the HMPH for a variety of reasons, but most commonly
BBVI and STI screening, which is consistent with the ndings
of Hooke et al. (2001). The demographic proles of clients are
similar to NSP clients recruited for the national NSP survey,
which are broadly representative of NSP clients (Topp et al.
2008). Based on these data, it would appear the target population
are accessing the clinic.
The prevalence of BBVIs testing among IDUs has previously
been found to be high (Day and Dolan 2006; Day et al. 2008), but
a recent study found that targeted PHC was identied by IDUs as
a preferable location for testing, especially among clients who
had previously used such a service (Day et al. 2008). This is
particularly relevant as difculty keeping appointments has
been identied as one of the most common barriers to BBVI
testing among IDUs (Day et al. 2008) and was indeed identied
by the HMPH nurses in this study. Given the clinic operates on a
drop-in basis and offers a Client Appointment Reminder
System, it would appear to be addressing this need.
Many clients (61%) reported having a regular GP, but it is
unclear what proportion of clients typically seeks GP care for

320

Nurse-led service for injecting drug users

Australian Journal of Primary Health

13

Table 1. Demographic, risk behaviours and hepatitis related information of 200 clients
BBVI, blood-borne viral infections; HBcAb+ve, Hepatitis B core antibody positive; IDU, injecting drug user; NSP, needle and
syringe program; STI, sexually transmitted infection; WHOs, We Help Ourselves
Variable
Median age (range)

Frequency (%)
35 (1972)

Sex
Male
Female
Transgender

155 (77.5)
44 (22)
1 (0.5)

Country of birth
Australia
Other
Information unavailable

160 (80)
30 (15)
10 (5)

Injecting drug user

IDU
Non-IDU
Non-drug user/unknownA
Primary reason for presentation
BBVIs and/or STIs screening
Vaccination
Drug health assessment
Referral to other healthcare
General health assessment
Other
Referral from
WHOs (drug rehabilitation)
NSP
Self
Community mental health
Family member/friend
Referral out (107 clients)B
Liver clinic
GP
Sexual health services
Drug health services
Welfare services and/or others
Mental health services
Aboriginal medical health services
Referral uptake (127 clients)
Attended
Did not attend
Unknown
Regular GP access
Yes
No
Information unavailable

167 (84)
26 (13)
7 (3)
129 (64.5)
43 (21.5)
5 (2.5)
9 (4.5)
9 (4.5)
5 (2.5)

116 (58)
66 (33)
12 (6)
4 (2)
2 (1)
45 (36)
26 (20)
24 (19)
12 (9)
10 (8)
6 (5)
4 (3)
57 (56)
16 (16)
29 (28)

Variable

Frequency (%)

Shared needle/syringe in the past

None
15
610
1150
>50
Unknown
Not applicable (non-IDU)
Last unprotected sex
Never
Days ago
Weeks ago
<6 months
612 months
>12 months
Information unavailable
Hepatitis C (179 clients)
Antibody negative
Antibody positive
Performed RNA qualitative test
Qualitative RNA detected
Qualitative RNA not detected

75 (43)
104 (58)
94 (90)
66 (70)
28 (30)

Hepatitis B
Previous infection (HBcAb+ve)
Unknown (information unavailable)
Eligible and agreed to vaccinationC
Received 1 dose only
Received 2 doses only
Received 3 doses/completed
Returned at least once after 1st visit

48 (24)
20 (10)
101 (50)
19 (19)
23 (23)
59 (59)
182 (91)

Average number of presentation

Ever treated mental health problem
Yes
No
Information unavailable
Alcohol use in the past 12 months
Daily
Weekly or more (less than daily)
Less than weekly
Social/occasionally/monthly
Information unavailable

49 (24.5)
49 (24.5)
22 (11)
21 (10.5)
11 (5.5)
15 (7.5)
33 (16.5)
6 (3)
7 (2)
9 (5)
114 (57)
12 (6)
27 (14)
25 (13)

118 (59)
61 (31)
21 (10)
65 (33)
77 (39)
16 (8)
27 (13)
15 (7)

121 (61)
55 (27)
24 (12)

Some clients avoid initial assessment. BSome clients received more than one referral, CHBsAb level is <mL/IU.

drug-related issues. Nurses experience indicates that many of

them are less likely to use GPs and other conventional health care
services appropriately or effectively. It may be that clients are
willing to disclose only limited aspects of their drug using
behaviour to their regular GP, whereas the targeted nature of
the HMPH clinic may provide a less threatening environment
(perceived or real). Although not IDU specic, the literature
suggests PHC clients are more satised with nurse-delivered care
(Laurant et al. 2004) and this type of nurse-led model may be a

useful initial point of health care access for this population. It may
also provide clients with an opportunity for continuous primary
health care, and support and guidance to assist in the navigation of
the broader health system.
The current clinic data indicates excellent HBV vaccination
outcomes. Despite being a high-risk group, IDUs typically
report very low rates of vaccination completion (MacDonald
et al. 2007). At the time of review, 59% of clients who
commenced HBV vaccination had completed all three schedules,

321

14

Australian Journal of Primary Health

this compares with 21% in a recent study of at-risk clients

attending another PHC clinic (MacDonald et al. 2007). Reasons
for this exceptionally high rate of completion warrant further
exploration.
The large proportion of clients with a history of mental health
problems is not surprising and is consistent with previous ndings
(Teesson et al. 2005; Hides et al. 2007). Although clients undergo
a mental health assessment, a validated screening tool is not used
and the review did not elicit specic information on either mental
health diagnoses or referrals. Although the actual prevalence of
mental health disorders cannot be determined, the data presented
herein indicate it is high, and that clinic facilitates appropriate
mental health referrals and management.
In Australia, opioid-related hospital separations for cooccurring medical conditions, such as endocarditis, has been
estimated to cost, on average, approximately $25 000 per
separation (Riddell et al. 2007b). Existing literature shows that
targeted PHC reduces IDUs use of emergency department and/
or tertiary health care, indicating it is a cost-saving approach
(Pollack et al. 2002). This nurse-led model with limited, albeit
necessary, medical support is therefore likely to be cost-saving,
as such further work on the economic benets of this model is
warranted.
Limitations
Direct data on service uptake (i.e. proportion of overall NSP
clients) was unavailable for the current study. For the current
investigation, although data on client return rate after the rst visit
was determined, average rate of follow up, additional care and
referral outcomes were unavailable. These are important
measures and should comprise outcomes of further evaluations.
These preliminary data do not constitute a formal evaluation of
the service and should not be interpreted as such. More research is
needed to formally evaluate both service uptake and clients
health outcomes. Although longitudinal cohort, casecontrol and
linkage studies would provide robust evaluation data, level one
evidence in the form of randomised controlled trials or, perhaps
more applicable, multiple baseline or step-wedged designs
(Hawkins et al. 2007) are needed, but such evidence is only
possible with the expansion of HMPH services.
More information is also needed on the clients experience.
The qualitative data provides only nurses views, but lacks users
comments. Future studies should consider experience from users
and providers, and include local GPs.
Conclusion
This report described the establishment of a new model of primary
health care delivery to a marginalised population of innermetropolitan IDUs. A large number of les have been opened,
representing signicant clinic activity and client throughput for a
newly established service. These numbers indicate that the clinic
is acceptable to clients and is accessed by a reasonable crosssection of the NSP clients to which it is targeted. Its effort to link
IDUs with GPs and other health care services is enormously
important. This service is likely to be cost-saving and the high
client return rate offers continuity of care and is indicative of need
and utilisation.

C. A. Day et al.

Conicts of interest
None declared.
Acknowledgements
The authors wish to thank the Redfern Drug Health Service clients and staff,
and the Primary Healthcare Clinic Steering Committee: Director, Medical
Director, Harm Minimisation Manager, Primary Care CNC, Primary Care
Medical Ofcer, Area Operational Nurse Manager, Hepatitis Coordinator
RPAH and Sydney Medical School representative. CD and PH are supported
by NHMRC fellowships.

References
Abouyanni G, Stevens LJ, Harris MF, Wickes WA, Ramakrishna SS, Ta E,
Knowlden SM (2000) GP attitudes to managing drug- and alcoholdependent patients: a reluctant role. Drug and Alcohol Review 19,
165170. doi:10.1080/713659318
Banwell C, Bammer G, Main N, Gifford SM, OBrien M (2003) Disturbingly
low levels of contraception among women living with hepatitis C.
Australian and New Zealand Journal of Public Health 27, 620626.
doi:10.1111/j.1467-842X.2003.tb00609.x
Commonwealth Department of Health and Aging (2002) Return on
investment in needle and syringe exchange programs in Australia.
(Commonwealth Department of Health and Aging: Canberra)
Commonwealth Department of Health and Ageing (2005a) National
hepatitis C strategy 20052008. (Commonwealth Government of
Australia: Canberra)
Commonwealth Department of Health and Ageing (2005b) National HIV/
AIDS strategy 20052008. (Commonwealth Government of Australia:
Canberra)
Darke S, Kaye S (2004) Attempted suicide among injecting and non injecting
cocaine users in Sydney, Australia. Journal of Urban Health 81, 505515.
doi:10.1093/jurban/jth134
Darke S, Ross J (1997) Polydrug dependence and psychiatric comorbidity
among heroin injectors. Drug and Alcohol Dependence 48, 135141.
doi:10.1016/S0376-8716(97)00117-8
Darke S, Ross J (2002) Suicide among heroin users: rates, risks factors
and methods. Addiction 97, 13831394. doi:10.1046/j.1360-0443.2002.
00214.x
Darke S, Ross J, Teesson M, Lynskey M (2003) Health service utilization and
benzodiazepine use among heroin users: Findings from the Australian
Treatment Outcome Study (ATOS). Addiction 98, 11291135.
doi:10.1046/j.1360-0443.2003.00430.x
Darke S, Ross J, Lynskey M, Teesson M (2004) Attempted suicide among
entrants to three treatment modalities for heroin dependence in the
Australian Treatment Outcome Study (ATOS): Prevalence and risk
factors. Drug and Alcohol Dependence 73, 110. doi:10.1016/
j.drugalcdep.2003.08.008
Day C, Dolan K (2006) Correlates of hepatitis C testing among heroin users
in Sydney. Health Promotion Journal of Australia 17, 7072.
Day C, Ross J, Dolan K (2003a) Hepatitis C-related discrimination among
heroin users in Sydney: drug user or hepatitis C discrimination? Drug and
Alcohol Review 22, 317321. doi:10.1080/0959523031000154463
Day C, White B, Ross J, Dolan K (2003b) Poor knowledge and low coverage
of hepatitis B vaccination among injecting drug users in Sydney.
Australian and New Zealand Journal of Public Health 27, 558.
Day CA, White B, Thein HH, Doab A, Dore G, Bates A, Holden J, Maher L
(2008) Experience of HIV and hepatitis C testing among injecting drug
users in Sydney, Australia. AIDS Care 20, 116123. doi:10.1080/
09540120701426524
Day CA, White B, Dore GJ, Van Beek I, Rodgers C, Cunningham P, Wodak A,
Maher L (2010) Hepatitis B virus among injecting drug users in Sydney,
Australia: Prevalence, vaccination and knowledge of status. Drug and
Alcohol Dependence 108, 134137. doi:10.1016/j.drugalcdep.2009.
11.013

322

Nurse-led service for injecting drug users

Australian Journal of Primary Health

Delpech VC, Thackway SV, Young LC, Pontivivo G, Smedley EJ,

Morgan KR, Ferson MJ (2000) Outbreak of hepatitis A among illicit
drug users in southeast Sydney. The Medical Journal of Australia 172,
143.
Dwyer R, Topp L, Maher L, Power R, Hellard M, Walsh N, Jauncey M,
Conroy A, Lewis J, Aitken C (2009) Prevalences and correlates of nonviral injecting-related injuries and diseases in a convenience sample
of Australian injecting drug users. Drug and Alcohol Dependence 100,
916. doi:10.1016/j.drugalcdep.2008.08.016
Friedmann PD, Zhang Z, Hendrickson J, Stein MD, Gerstein DR (2003) Effect
of primary medical care on addiction and medical severity in substance
abuse treatment programs. Journal of General Internal Medicine 18, 18.
doi:10.1046/j.1525-1497.2003.10601.x
Gibson A, Degenhardt L, Topp L, Day C, Hall W, Dietze P, McKetin R (2003)
Global and Australian heroin markets. National Drug and Alcohol
Research Centre, University of New South Wales, NDARC Technical
Report No. 167, Sydney.
Gilroy NM, Tribe I, Passaris I, Hall R, Beers MY (2000) Hepatitis A in
injecting drug users: a national problem. The Medical Journal of Australia
172, 142143.
Hawkins NG, Sanson-Fisher RW, Shakeshaft A, DEste C, Green LW (2007)
The multiple baseline design for evaluating population-based research.
American Journal of Preventive Medicine 33, 162168. doi:10.1016/
j.amepre.2007.03.020
Hides L, Lubman DI, Devlin H, Cotton S, Aitken C, Gibbie T, Hellard M
(2007) Reliability and validity of the Kessler 10 and Patient Health
Questionnaire among injecting drug users. The Australian and New
Zealand Journal of Psychiatry 41, 166168. doi:10.1080/0004867060
1109949
Hooke E, Bennett L, Dwyer R, Van Beek I, Martin C (2001) Nurse
practitioners: an evaluation of the extended role of nurses at the Kirketon
Road Centre in Sydney, Australia. The Australian Journal of Advanced
Nursing 18, 2028.
Joint United Nations Program on HIV/AIDS (2005) Intensifying HIV
prevention: UNAIDS Policy Position Paper. UNAIDS, Geneva.
Laslett A-M, Dwyer DE, Dietze P (2008) The oral health of street-recruited
injecting drug users: prevalence and correlates of problems. Addiction
103, 18211825. doi:10.1111/j.1360-0443.2008.02339.x
Laurant M, Reeves D, Hermens R, Braspenning J, Grol R, Sibbald B (2004)
Substitution of doctors by nurses in primary care. Cochrane Database of
Systematic Reviews 2, CD001271. doi:10.1002/14651858.CD001271.
pub2
MacDonald V, Dore G, Amin J, Beek I (2007) Predictors of completion of
a hepatitis B vaccination schedule in attendees at a primary sexual health
care facility. Sexual Health 4, 2730. doi:10.1071/SH06008
Mills KL, Lynskey M, Teesson M, Ross J, Darke S (2005) Post-traumatic
stress disorder among people with heroin dependence in the Australian
treatment outcome study (ATOS): prevalence and correlates. Drug and
Alcohol Dependence 77, 243249. doi:10.1016/j.drugalcdep.2004.08.
016
NCHECR (2007) HIV/AIDS, viral hepatitis and sexually transmissible
infections in Australia Annual Surveillance Report 2007. National Centre
in HIV Epidemiology and Clinical Research, University of New South
Wales, Sydney.
NCHECR (2008) Australian NSP Survey National Data Report 20032007.
National Centre in HIV Epidemiology and Clinical Research, University
of New South Wales, Sydney.

15

Pollack HA, Khoshnood K, Blankenship KM, Altice FL (2002) The impact of

needle exchange-based health services on emergency department use.
Journal of General Internal Medicine 17, 341348.
Reece A (2007a) Lifetime prevalence of cervical neoplasia in addicted and
medical patients. Australian and New Zealand Journal of Obstetrics and
Gynaecology 47, 419423. doi:10.1111/j.1479-828X.2007.00769.x
Reece AS (2007b) Dentition of addiction in Queensland: poor dental status
and major contributing drugs. Australian Dental Journal 52, 144149.
doi:10.1111/j.1834-7819.2007.tb00480.x
Riddell S, Shanahan M, Roxburgh A, Degenhardt L (2007a) The cost of
drug-related hospital stays in Australia, 19992005. National Drug
and Alcohol Research Centre, University of NSW, Technical Report
No. 285, Sydney.
Riddell S, Shanahan M, Roxburgh A, Degenhardt L (2007b) The cost of
drug related hospital stays in Australia, 19992005. NDARC Technical
Report Number 285. National Drug and Alcohol Research Centre,
University of New South Wales, Sydney.
Roxburgh A, Degenhardt L (2007) Hospital stays related to illicit drugs in
Australia, 19932004. National Drug and Alcohol Research Centre,
University of NSW, Technical Report No. 261, Sydney.
Roxburgh A, Degenhardt L (2008) Characteristics of drug-related hospital
separations in Australia. Drug and Alcohol Dependence 92, 149155.
doi:10.1016/j.drugalcdep.2007.07.020
Semba RD, Shah N, Strathdee SA, Vlahov D (2002) High prevalence of
iron deciency and anemia among female injection drug users with and
without HIV infection. Journal of Acquired Immune Deciency
Syndromes: JAIDS 29, 142144.
Stein MD, Samet JH, OConnor PG (1993) The linkage of primary care
services with substances abuse treatment: new opportunities for
academic generalists. Journal of General Internal Medicine 8, 106107.
doi:10.1007/BF02599995
Teesson M, Havard A, Fairbairn S, Ross J, Lynskey M, Darke S (2005)
Depression among entrants to treatment for heroin dependence in the
Australian Treatment Outcome Study (ATOS): prevalence, correlates
and treatment seeking. Drug and Alcohol Dependence 78, 309315.
doi:10.1016/j.drugalcdep.2004.12.001
Topp L, Iversen J, Wand H, Day C, Kaldor J, Maher L (2008)
Representativeness of injecting drug users who participate in HIV
surveillance results from Australias Needle and Syringe Program
Survey. JAIDS Journal of Acquired Immune Deciency Syndromes 47,
632638. doi:10.1097/QAI.0b013e31816a1d68
Topp L, Day CA, Dore GJ, Maher L (2009) Poor concordance between
serological and self-reported HBV status among injecting drug users:
a review. Drug and Alcohol Review 28, 669675. doi:10.1111/j.14653362.2009.00060.x
Van Beek I (2007) Case Study: Accessible primary health carea foundation
to improve health outcomes for people who inject drugs. The International
Journal on Drug Policy 18, 329332. doi:10.1016/j.drugpo.2006.11.005
World Health Organization (2004) Effectiveness of sterile needle and syringe
programming in reducing HIV/AIDS among injecting drug users.
(WHO: Geneva)
Zador D, Lyons Wall PM, Webster I (1996) High sugar intake in a group of
women on methadone maintenance in south western Sydney, Australia.
Addiction 91, 10531061. doi:10.1111/j.1360-0443.1996.tb03601.x

Manuscript received 6 September 2010, accepted 11 January 2011

http://www.publish.csiro.au/journals/py

323

Appendix IV

(l) Islam, M. M., Topp, L., Conigrave, K. M., & Day, C. A. (Epub ahead of print).
Opioid substitution therapy clients preferences for targeted versus general primary
healthcare outlets. Drug and Alcohol Review, doi: 10.1111/j.1465-3362.2012.00498.x

324

bs_bs_banner

R E V I E W

Drug and Alcohol Review (2012)

DOI: 10.1111/j.1465-3362.2012.00498.x

BRIEF REPORT

Opioid substitution therapy clients preferences for targeted versus

general primary health-care outlets
M. MOFIZUL ISLAM1,2, LIBBY TOPP3, KATHERINE M. CONIGRAVE2,4,5 & CAROLYN A. DAY4
1

School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia, 2Drug Health
Service, Royal Prince Alfred Hospital, Sydney, Australia, 3Viral Hepatitis Epidemiology and Prevention Program, The
Kirby Institute, University of New South Wales, Sydney, Australia, 4Discipline of Addiction Medicine, Central Clinical
School (C39), University of Sydney, Sydney, Australia, and 5National Drug and Alcohol Research Centre, University of
New South Wales, Sydney, Australia

Abstract
Introduction and Aims. Opioid substitution therapy (OST) ideally constitutes a window of opportunity for the provision
of essential primary health care (PHC) for OST clients. In the absence of such opportunities, however, OST clients access PHC
from existing outlets, either general services or those targeted to specific groups.This study examined OST clients current main
source and preferred future outlets of PHC services and correlates of preferences. Design and Methods. Anonymous
interviews conducted with n = 257 clients of two public OST clinics in Sydneys inner-west. Results. Overall, 61% (n = 158)
of participants reported currently accessing PHC primarily from general outlets (general practitioners or medical centres: 51%,
hospital/emergence departments: 10%) and the remainder (39%, n = 99) from outlets that target specific groups (e.g.
Aboriginal Medical Services, OST prescriber/clinics, drug user-targeted PHCs). Twenty-two percent reported discomfort
disclosing drug use to their current PHC providers. However, the majority were satisfied with the care they received and reported
a preference to remain with their current PHC providers for a range of reasons, most commonly familiarity with and trust in
staff (56%) and not feeling judged about their drug use (49%). Nevertheless, 28% reported that they would access PHC
through their OST clinic if it were available. Discussion and Conclusions. PHC outlets that target specific groups appear
to have an ongoing and important role in providing accessible health care to OST clients. [Islam MM, Topp L, Conigrave
KM, Day CA. Opioid substitution therapy clients preferences for targeted versus general primary health-care outlets.
Drug Alcohol Rev 2012]
Key words: primary health care, opioid substitution therapy, injecting drug use.

Introduction
Opioid substitution therapy (OST) clients have substantial primary health-care (PHC) needs, yet limited
research has examined their access to PHC [1]. In
Australia, the main sources of PHC are private general
practitioners (GP) or medical centres staffed with GPs
and occasionally with other clinicians. Public hospital
emergency departments (ED) offer secondary, tertiary
and emergency care.

Medical care for drug users that is located onsite or

close to drug treatment programs has been associated
with increased continuity of care and follow up [2,3],
increased use of preventive services, better health
outcomes [4], reduced reliance on ED and hospital
services [57] and decreased illicit drug use [8].Yet, few
such services have been implemented [9], leaving
clients to arrange their PHC from existing general
outlets, including GPs or hospitals, or from PHC
centres that target specific groups, such as Australias

M. Mofizul Islam MSc, MPhil, Doctoral candidate, Libby Topp PhD, Senior Lecturer, Katherine M. Conigrave FAChAM, FAFHPM, PhD,
Senior Staff Specialist and Professor, Carolyn A. Day PhD, Associate Professor. Correspondence to Mr M. Mofizul Islam, Drug Health
Services, Level 6, KGV Bld, Royal Prince Alfred Hospital, Missenden Road, Camperdown, NSW 2050, Australia. Tel: +61 (0)2 9395 0496;
Fax: +61 (0)2 9515 5779; E-mail: mikhokan143@yahoo.com, m.m.islam@unsw.edu.au
Received 29 February 2012; accepted for publication 2 August 2012.
2012 Australasian Professional Society on Alcohol and other Drugs

325

M. M. Islam et al.

Aboriginal Medical Services (AMS) or the small

number of drug user-targeted PHCs [10,11]. These
targeted outlets usually offer services tailored to the
specific client population.
Little is known about OST clients main source of
and satisfaction with PHC services and preferences for
future PHC outlets. In this study of OST clients, we
examined: (i) current main source of PHC services,
subsequently categorised as either general or targeted;
(ii) satisfaction with care received from current providers; and (iii) preferred source of future PHC and
underlying reasons for this preference.
Methods
A secondary analysis was conducted of data collected
during a broader study examining the relative efficacy
of research reimbursement. Over two 3-day periods in
2011, all clients dosing at two inner-western Sydney
public OST clinics were invited to participate in an
anonymous survey. Complete information was available
for n = 257 (response rate 72%; 264/368). Participants provided verbal consent and were reimbursed
AU$20 as either cash or shopping voucher following
the interviewer-administered survey. Ethical approval
was obtained from the Royal Prince Alfred Hospital
Zone of the Sydney Local Health District.
The PHC outlets currently accessed or preferred for
the future were classified as general if services were
provided by GPs, medical centres, hospitals or EDs;
or targeted where outlets target specific groups, for
example drug users (e.g. Kirketon Road Centre [10],
Redfern Harm Minimisation Clinic [11]), OST clients
or Aboriginal people. AMSs provide PHC services to
the Aboriginal population in a similar manner to other
targeted outlets. AMSs are designed to be flexible to
increase access to health care for a subpopulation
with traditionally poor access to mainstream services.
Further, like injecting drug users, many Aboriginal
individuals bear a complex burden of physical and
mental ill health and have either experienced or fear
discrimination in these settings.
Differences between (i) participants who reported
currently accessing targeted services and those who did
not; and (ii) participants who reported preferences for
either general or targeted facilities, were tested using
Pearsons and McNemars chi-square (c2) for categorical variables and independent t-tests for continuous
variables.
Results
Participants had a mean age of 39.1 years (range
2058); 55% were male and 29% Indigenous Australian
(Table 1). Ninety-three percent of participants reported

a history of injecting and 54% were classified by the

Severity of Dependence Scale [12] as dependent on the
illicit drug used most frequently in the preceding
6 months. Three-quarters (78%) of participants were
maintained on methadone and 22% on buprenorphine
or buprenorphine/naloxone.
Sixty-one percent of participants currently accessed
PHC primarily from general and 39% from targeted
outlets (Table 1). Hospital/EDs were the primary PHC
source for 10% of participants and an AMS was
reported by 53% (39/74) of Indigenous clients.
Participants reported disclosing their drug use to
their PHC provider fully (78%), partially (11%) or not
at all (11%). Participants who accessed drug usertargeted PHC services were more likely to report disclosing their drug use (90%) than those who accessed
PHC elsewhere (74%) (c2 = 5.61, P = 0.02). Most
(69%) participants reported no difficulties in obtaining
an appointment with their current PHC provider and
most were very satisfied (44%) or satisfied (40%) with
their health care. Forty-three percent had accessed an
established drug user-targeted PHC.
A majority of those accessing both targeted (85%)
and general (80%) PHC services reported a preference
to remain with their current providers. Familiarity and
trust in the staff (56%), not feeling judged and ease of
drug use disclosure (49%) were the most common
reasons given for this preference. However, a significantly higher proportion of participants accessing
general outlets preferred targeted outlets for future
PHC than the proportion who preferred to switch
in the other direction (12% vs. 6%, MacNemars
c2 = 5.57, P = 0.02). Aboriginal participants (c2 = 6.36,
P = 0.01) and those with a history of injecting (c2 =
3.43, P = 0.06) were most likely to prefer targeted
outlets. Twenty-eight percent of participants reported
that they would feel most comfortable accessing PHC
services from OST clinics if available.
Discussion
The majority of clients of these two OST clinics rely
primarily on general PHC outlets, but utilisation of
costly hospital/ED services by 10% for PHC remains a
concern. Despite high rates of current illicit drug
dependence, 22% of participants did not fully disclose their drug use to providers. This has significant
implications for their health care. Almost one-third of
participants reported some difficulties in making
appointments with their PHC provider [13]. Nevertheless, most clients reported a preference to remain with
their current provider. This preference may reflect,
in part, the perceived importance of continuity of
care [14], or may represent a concern that a future
provider may be prejudiced against them as drug users.

2012 Australasian Professional Society on Alcohol and other Drugs

326

PHC for OST clients

Table 1. OST client characteristics (n = 257) by future preference for PHC

Total sample
Variable

Prefer targeted outlets Prefer general outlets

n = 257 (column %)

Mean age, years [standard deviation; range]

39.1 [ 8.50; 2058]
Gendera
Male
142 (56)
Female
112 (44)
Indigenous Australian identity
Yes
75 (29)
No
182 (71)
History of injecting drug use
Yes
240 (93)
No
17 (7)
Dependent (by SDS)b on main illicit drug
used in past 6 months
Yes
138 (54)
No
118 (46)
History of mental health diagnosis
152 (59)
OST type
Methadone
204 (79)
Buprenorphine/buprenorphine and naloxone
53 (21)
Currently accessing PHC fromc,d
General outlets
158 (61)
Targeted outlets
99 (39)
Feel comfortable fully disclosing drug usec
Yes
202 (78)
No or partial disclosure
58 (22)
Difficulty in getting appointmentc
Yes/sometimes
79 (31)
No
176 (69)
Satisfaction with current PHCc
Very satisfied
112 (44)
Satisfied
102 (40)
Neither satisfied/dissatisfied
22 (9)
Dissatisfied
9 (4)
Very dissatisfied
10 (4)
History of accessing health care from
111 (43)
a drug user-targeted PHC outlete,f
Reasons for preferenceg
Know/trust the staff
142 (56)
Would not feel judged/could tell them the
124 (49)
truth
Credibility/they know about drug use
79 (31)
Anonymous/confidential
58 (23)
No appointment required/drop in
41 (16)

n = 116 (row %)

n = 141 (row %)

P-value

39.5 [ 8.53; 2256]

39.0 [ 8.40; 2058]

0.63

63 (44)
52 (46)

79 (56)
60 (54)

0.74

43 (57)
73 (40)

32 (43)
109 (60)

0.01

112 (47)
4 (24)

128 (53)
13 (76)

0.06

62 (45)
53 (45)
63 (41)

76 (55)
65 (55)
89 (59)

1.00

98 (48)
18 (34)

106 (52)
35 (66)

0.07

31 (20)
83 (85)

123 (80)
15 (15)

<0.01

85 (42)
29 (54)

115 (58)
25 (46)

0.14

40 (51)
75 (43)

39 (49)
101 (57)

0.23

51 (46)
42 (41)
14 (64)
6 (67)
2 (20)
63 (57)

61 (54)
60 (59)
8 (36)
3 (33)
8 (80)
48 (43)

0.09

<0.01

68 (48)
59 (48)

74 (52)
65 (52)

0.27
0.39

38 (48)
24 (41)
21 (51)

41 (52)
34 (59)
20 (49)

0.48
0.55
0.37

0.15

Three were transgender; bSDS, Severity of Dependence Scale [12]; cfew observations were missing; drefers to usual source of PHC
in the past 12 months; efor example, Kirketon Road Centre or Redfern Harm Minimisation Clinic; frefers to lifetime access;
g
multiple responses allowed. OST, opioid substitution therapy; PHC, primary health care.

Regardless, efforts to make current PHC services more

responsive to the lifestyles and high health-care needs of
OST clients may lead to improved health outcomes
among this population, although the challenges in
achieving these changes are substantial.
Some obstacles identified by participants, namely
stigma and difficulties setting appointments, and the

reported lack of drug use-related preventive care in

general outlets [15] may be addressed by provision
of onsite PHC at OST clinics. Clients regular contact with clinics also provides a unique opportunity
to deliver opportunistic and continuing health care
[2,16]. Further, a therapeutic environment responsive
to clients needs, and including integrated PHC, may
2012 Australasian Professional Society on Alcohol and other Drugs

327

M. M. Islam et al.

improve clients engagement and retention in OST

treatment [17]. It may also minimise stigma, improve
service utility and referral uptake [2], and reduce
ED/hospital use [6]. Such services may also be less
costly than establishing separate targeted services.
Notably, 28% of participants reported a preference for
OST clinics for future PHC if available, suggesting that
any such future services would require capacity for only
a proportion of OST clients.

[2]

[3]

[4]

Limitations
[5]

Participants may not be representative of the broader

OST population and self-reported data may be subject
to social desirability and other response bias. Both clinics
provide additional specialised services (e.g. hepatitis,
womens health) and some clients may have erroneously
identified these as their primary PHC source. Participants were not asked whether they would prefer their
OST to be provided by their current PHC provider, a
model of service provision, which would offer the advantages of service integration while freeing-up OST clinic
capacity. However, Australia continues to encounter
a shortage of GPs prepared to prescribe OST, despite
long-standing efforts to encourage this [18]. Finally, the
preference for targeted outlets is likely to have been
influenced by the relatively high proportion of Aboriginal participants, who have the option of an AMS.
Primary health-care outlets that target specific
groups appear to have an ongoing important role in
providing accessible health care to OST clients. Given
the benefits of onsite PHC, OST clinics can be augmented to offer PHC. However, use of mainstream
PHC services should still be encouraged.

[6]

[7]

[8]

[9]

[10]

[11]

[12]

Acknowledgements
This study was funded by a University of New South
Wales (UNSW) Faculty of Medicine Research Grant.
The Kirby Institute is funded by the Australian Government Department of Health and Ageing and is affiliated
with the Faculty of Medicine, UNSW.The first authors
doctoral research is supported by a University International Post-graduate Award from UNSW. The authors
are indebted to study participants; to Dr Rachel Deacon,
Ms Sarah Hutchinson and Ms Lucia Evangelista for
their assistance with data collection; and to Professor
Paul Haber, Ms Elaine Doherty, Ms Maggie Tynan,
Dr Ken Curry and the clinical teams at recruitment sites
in Royal Prince Alfred and Canterbury Drug Health
Services for their support of this research.
References
[1] Islam MM, Topp L, Day CA, Dawson A, Conigrave KM.
Primary healthcare outlets that target injecting drug users:

[13]
[14]

[15]

[16]

[17]

[18]

opportunity to make services accessible and acceptable to

the target group. Int J Drug Policy 2012;23:10910.
Umbricht-Schneiter A, Ginn DH, Pabst KM, Bigelow GE.
Providing medical care to methadone clinic patients: referral vs on-site care. Am J Public Health 1994;84:20710.
Selwyn PA, Budner NS, Wasserman WC, Arno PS. Utilization of on-site primary care services by HIVseropositive
and seronegative drug users in a methadone maintenance
program. Public Health Rep 1993;108:492500.
Litwin AH, Soloway I, Gourevitch MN. Integrating services
for injection drug users infected with hepatitis C virus with
methadone maintenance treatment: challenges and opportunities. Clin Infect Dis 2005;40 (Suppl 5):S33945.
Laine C, Hauck WW, Gourevitch MN, Rothman J, Cohen
A, Turner BJ. Regular outpatient medical and drug abuse
care and subsequent hospitalizations of persons who use
illicit drugs. JAMA 2001;285:235562.
Weisner C, Mertens J, Parthasarathy S, Moore C, Lu Y.
Integrating primary medical care with addiction treatment:
a randomized controlled trial. JAMA 2001;286:171523.
Friedmann PD, Hendrickson JC, Gerstein DR, Zhang Z,
Stein MD. Do mechanisms that link addiction treatment
patients to primary care influence subsequent utilization of
emergency and hospital care? Med Care 2006;44:815.
Friedmann PD, Zhang Z, Hendrickson J, Stein MD, Gerstein DR. Effect of primary medical care on addiction and
medical severity in substance abuse treatment programs. J
Gen Intern Med 2003;18:18.
Islam MM, Topp L, Day CA, Dawson A, Conigrave KM.
The accessibility, acceptability, health impact and cost
implications of primary healthcare outlets that target injecting drug users: a narrative synthesis of literature. Int J Drug
Policy 2012;23:94102.
van Beek I. Case study: accessible primary health carea
foundation to improve health outcomes for people who
inject drugs. Int J Drug Policy 2007;18:32932.
Day CA, Islam MM, White A, Reid SE, Hayes S, Haber PS.
Development of a nurse-led primary healthcare service for
injecting drug users in inner-city Sydney. Aust J Prim
Health 2011;17:1015.
Gossop M, Darke S, Griffiths P, et al. The Severity of
Dependence Scale (SDS): psychometric properties of the
SDS in English and Australian samples of heroin, cocaine
and amphetamine users. Addiction 1995;90:60714.
Bruce RD. One stop shoppingbringing services to drug
users. Int J Drug Policy 2012;23:104.
Ettner SL. The relationship between continuity of care and
the health behaviors of patients: does having a usual physician make a difference? Med Care 1999;37:54755.
Amaral-Sabadini MB, Saitz R, Souza-Formigoni ML. Do
attitudes about unhealthy alcohol and other drug (AOD)
use impact primary care professionals readiness to implement AOD-related preventive care? Drug Alcohol Rev
2010;29:65561.
Islam MM, Reid SE, White A, Grummett S, Conigrave
KM, Haber PS. Opportunistic and continuing health care
for injecting drug users from a nurse-run needle syringe
program-based primary health-care clinic. Drug Alcohol
Rev 2012;31:11415, author reply 11617.
Broome KM, Simpson DD, Joe GW. Patient and program
attributes related to treatment process indicators in
DATOS. Drug Alcohol Depend 1999;57:12735.
Scarborough J, Eliott J, Braunack-Mayer A. Opioid substitution therapya study of GP participation in prescribing.
Aust Fam Physician 2011;40:2415.

2012 Australasian Professional Society on Alcohol and other Drugs

328

Appendix IV

(m) Islam, M. M., Day, C. A., Conigrave, K. M., & Topp, L. (Epub ahead of print). Selfperceived problem alcohol use among opioid substitution treatment clients. Addictive
Behaviors,doi:10.1016/j.addbeh.2012.12.001

329

AB-03839; No of Pages 4
Addictive Behaviors xxx (2012) xxxxxx

Contents lists available at SciVerse ScienceDirect

Addictive Behaviors

Short Communication

Self-perceived problem with alcohol use among opioid substitution treatment clients

Q1 3

M. Mozul Islam a, c, Carolyn A. Day b, c,, Katherine M. Conigrave b, c, d, Libby Topp e

School of Public Health and Community Medicine, University of New South Wales, Australia
Discipline of Addiction Medicine, Sydney Medical School (C39), University of Sydney, Australia
Drug Health Service, Royal Prince Alfred Hospital, Sydney, Australia
d
National Drug and Alcohol Research Centre, University of New South Wales, Australia
e
Viral Hepatitis Epidemiology and Prevention Program, The Kirby Institute, University of New South Wales, Australia
b
c

a b s t r a c t

Article history:
Received 14 June 2012
Received in revised form 21 October 2012
Accepted 2 December 2012
Available online xxxx

O
R
R

Keywords:
Alcohol
Opioid substitution therapy
Substance dependence
AUDIT
Self-perception

Background and aim: Excessive alcohol use increases mortality and morbidity among opioid substitution therapy (OST) clients. Regular attendance for OST dosing presents key opportunities for screening and treatment.
However, individuals' perception of their alcohol consumption as problematic or otherwise may impact their
willingness to change. This study examines patterns of alcohol consumption among OST clients, perceptions
of their own use and correlates of excess consumption.
Methods: Condential, structured interviews were conducted with 264 clients of two Sydney OST clinics. Alcohol consumption was assessed using the Alcohol Use Disorders Identication Test (AUDIT); and illicit drug
dependence with the Severity of Dependence Scale.
Results: Forty-one percent of the participants scored 8 on the AUDIT (AUDIT-positive), indicating excessive
alcohol use. The higher a participant's AUDIT score, the more likely they were to demonstrate insight into the potential problems associated with their drinking (linear trend, pb 0.01). However, only half of AUDIT-positive participants believed they drank too much and/or had a problem with alcohol. One-third had discussed their
drinking with OST staff, and a similar proportion reported a history of alcohol treatment. AUDIT-positive participants were more likely than others to be classied as dependent on an illicit drug in the last six months (AOR=
1.76, 95% CI:1.003.09), report a history of alcohol treatment (AOR= 5.70, 95% CI:2.8311.48) and believe it is
safe to drink 4+ standard drinks in one session (AOR=5.30, 95% CI:2.7910.06).
Conclusions: OST clients with AUDIT scores 8 appear to underestimate the risks associated with their alcohol
consumption. Regular assessments of alcohol use and targeted brief alcohol interventions may improve health
outcomes among OST clients.
2012 Published by Elsevier Ltd.

i n f o

a r t i c l e
10
11
12
13
14
15
17
16
18
19
20
21
22
23
24

R
O

4
5
6
7
8

Q3 2

48
47

1. Introduction

50

Excessive alcohol consumption among opioid substitution therapy

(OST) clients is associated with increased morbidity and a range of
poor treatment outcomes (Gossop, Browne, Stewart, & Marsden,
2003; Ostapowicz, Watson, Locarnini, & Desmond, 1998). Heavy
drinking exacerbates progression of hepatitis C virus (HCV) infection
to cirrhosis. This is of concern given the high prevalence of HCV infection among OST clients (approximately 70%) (Watson et al., 2007).
Excessive alcohol use also negatively impacts OST outcomes (Craig
& Olson, 2004), increases relapse to illicit drug use (Stenbacka, Beck,
Leifman, Romelsjo, & Helander, 2007) and affects metabolism of
methadone (Kreek, 1990). In addition, OST clients drinking excessively but not engaged in alcohol treatment were 7080% more likely to
terminate their OST program (Rowan-Szal, Chatham, & Simpson,

53
54
55
56
57
58
59
60
61
62

U
N

51
52

49

Corresponding author at: Drug Health Service, King George V Bldg, Royal Prince Alfred
Hospital, Missenden Rd, Camperdown, NSW 2050, Australia. Tel.: +61 2 9515 8817;
fax: +61 2 9515 5779.
E-mail address: carolyn.day@sydney.edu.au (C.A. Day).

25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
46
45

2000). The prevalence of concurrent substance use disorders and

drug intoxication is high among OST clients who drink heavily
(Nyamathi et al., 2009); and alcohol increases the risk of fatal opioid
overdose (White & Irvine, 1999), particularly when consumed with
other depressants (Darke & Zador, 1996).
Among the general population, we know that many drinkers underestimate the risk of harm from their alcohol use (Chomynova, Miller, &
Beck, 2009). However, to our knowledge, no previous study has examined OST clients' perception of their alcohol use. Many OST clients may
be surrounded by substance users, so they may be unaware that they
use alcohol excessively, and underestimate the risk which may have
disproportionate impacts. Individuals' perception of their susceptibility
to illness is an important determinant of whether they act to reduce the
risks of illness and/or seek health care (Brewer, Weinstein, Cuite, &
Herrington, 2004). OST clients' regular attendance for dosing or medical
review presents ready opportunities for screening and interventions.
Screening for alcohol use, however, remains underutilized (Teplin,
Raz, Daiter, Varenbut, & Plater-Zyberk, 2007).
The purposes of this study are to (i) explore OST clients' perceptions
of their own alcohol consumption compared with self-reported

0306-4603/$ see front matter 2012 Published by Elsevier Ltd.

http://dx.doi.org/10.1016/j.addbeh.2012.12.001

Please cite this article as: Islam, M.M., et al., Self-perceived problem with alcohol use among opioid substitution treatment clients, Addictive Behaviors (2012), http://dx.doi.org/10.1016/j.addbeh.2012.12.001

330

63
64
65
66
67
68
69
70
71
72 Q4
73
74
75
76
77
78
79
80
81
82

107

2.1. Measures

108

Alcohol use was assessed with the AUDIT (Babor et al., 2001), which
provides 35 response options per question. Participants were classied
into two groups on the basis of their total AUDIT score: AUDIT-negative
participants, who scored b 8, and AUDIT-positive participants, who
scored 8. A score 8 is considered indicative of excessive alcohol use,
with a score of 815 suggesting hazardous drinking, 1619 suggesting
harmful alcohol use and 20+ suggesting likely alcohol dependence
(Babor et al., 2001). Alcohol consumption was recorded in Australian
standard drinks (10 g/drink) (NHMRC, 2012).
Dependence on the illicit drug used most often in the preceding
six months was assessed by Severity of Dependence Scale (SDS), a
5-item multiple-choice questionnaire (Gossop et al., 1995). Total
SDS scores indicative of dependence are 3 + for cocaine (Kaye &
Darke, 2002) and benzodiazepines (Ross & Darke, 1997) and 4 + for
all other drugs (Gossop et al., 1995; Topp & Mattick, 1997).
To assess perceptions of safe drinking, the participants were asked
whether they (i) believe they drink too much; (ii) have a problem
with alcohol; (iii) had discussed their alcohol use with OST staff;
(iv) had a history of alcohol treatment; and (v) the amount of alcohol
they perceive it is safe to drink in one session.

104
105

109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126

Q6 127

102
103

100
101

98
99

96
97

94
95

92
93

90

Q5 91

2.2. Data analysis

129

136
137

To examine correlates of excessive alcohol use, AUDIT-positive and

AUDIT-negative clients were compared. Odds ratios (OR) with 95% condence intervals (CI) were used to assess univariate associations between AUDIT classication and demographic and drug use variables,
with signicance set at p0.05. Using backward elimination, multivariate logistic regression derived adjusted odds ratios (AOR), controlling
for variables associated with AUDIT classication at p0.25 on univariate
analysis. The MantelHaenszel chi-square for linear trend (2trend) was
used to assess trends in proportions. Data were analyzed using STATA.

138

3. Results

139

One-fth (21%) of the 264 participants reported a history of treatment for an alcohol problem (Table 1). This included in-patient

132
133
134
135

140

128

130
131

4. Discussion

198

Consistent with previous studies, which report excessive alcohol

consumption in up to 50% of OST clients, our ndings indicate a
high prevalence (41%) of excessive alcohol consumption based on
the AUDIT (Hillebrand, Marsden, Finch, & Strang, 2001; Watson et
al., 2007). Although there is a trend for participants with a higher
AUDIT score to report more insight into the risk of their drinking,

199

106

Data were collected from two OST clinics located within the
Sydney Local Health District, Australia. During OST dosing hours of
two, three-day periods at each clinic in 2011, all clients who dosed
(except those who attended local residential rehabilitation services,
for whom participation was impracticable) were invited to participate in a 2030 minute, anonymous and condential interview.
Clients who receive their OST dose at these free public clinics are typically either in their rst three months of OST, or are unable to transfer to pharmacy dosing due to instability or nancial difculty. Clients
were reimbursed for their participation with either AUD$20 cash or
AUD$20 voucher. A notice advertising the study was placed in the
clinics' waiting rooms prior to recruitment. Clients could only participate once during each three-day period. The data reported here were
derived from the rst interview for each client.
Participants provided informed verbal consent to participate.
Individuals were ineligible if they were intoxicated or had insufcient
English language skills. Only two clients needed to be excluded for
the latter reason. The study was approved by the Ethics Review Committee of the Sydney Local Health District.

88
89

R
O

2. Method

141
142

87

detoxication (14%), rehabilitation (10%) and more than one type of

treatment (9%). Less than 2% reported current alcohol treatment.
Use of an illicit drug via a range of routes during the preceding six
months was reported by 72% of the participants. Among these, 37%
reported having used heroin most often, while 19% reported
methamphetamine. SDS scores indicated that 53% of this group were
dependent on the illicit drug they had used most often in the past six
months.
One third (32%; n = 85) of the participants reported that during
the preceding year they did not consume alcohol, while a further
30% (n = 79) drank monthly or less often. Almost one-third (30%) of
the participants reported drinking six or more standard drinks on
an occasion, either monthly (8%); weekly (11%) or daily/almost
daily (11%). Overall, 41% of the participants' (n = 107) scores were
classied as AUDIT-positive, 46% of whom were further categorized
as hazardous drinkers; 11% as harmful; and 43% as likely dependent
(Babor et al., 2001).
Of AUDIT-positive participants, half reported a perception that they
drink too much, while two participants were unsure. Similarly, 51% believed they have a problem with alcohol and three participants were
unsure. Just over one-third (36%) of AUDIT-positive participants
reported discussing alcohol with OST clinic staff, and 37% reported
past alcohol treatment. Ten percent (n= 15) of AUDIT-negative participants also reported a history of alcohol treatment, and six of those did
not drink at all in the preceding 12 months.
On univariate analysis, participants who perceived >4 standard alcoholic drinks as safe to drink in one session were signicantly more
likely to be classied as AUDIT-positive, as were those with histories
of injecting drug use, a mental health diagnosis, and/or prior alcohol
treatment (Table 1, columns 36). Multivariable logistic regression reveals that compared to AUDIT-negative participants, AUDIT-positive
participants were more likely to perceive >4 standard drinks (40 g
ethanol) as safe to consume in one session (AOR= 5.30, CI 2.79
10.06), to be classied by the SDS as dependent on an illicit drug
(AOR= 1.76, CI 1.003.09), and to report past alcohol treatment
(AOR= 5.70, CI 2.8311.48).
The higher a participant's AUDIT score, the more likely they were
to report indicators of insight into the risk associated with their
drinking patterns (Table 2). Whereas only 20% of hazardous drinkers
reported that they drank too much, this increased to 42% of harmful
drinkers and 85% of likely dependent drinkers ( 2trend = 156.91;
p b 0.01). Similar proportions perceived that they had a problem
with alcohol ( 2trend = 138.33; p b 0.01). The likely dependent drinkers
were more likely to have discussed their alcohol consumption with
OST clinic staff (52%) than the hazardous (22%) or harmful (33%)
drinkers ( 2trend = 65.31; p b 0.01). Among AUDIT-positive participants, 37% reported prior alcohol treatment, 65% of whom were likely
dependent, 33% harmful and 2% hazardous drinkers. More harmful
(50%) and hazardous (45%) than likely dependent (39%) drinkers considered it was safe for them to consume >4 in a session ( 2trend =
18.24; p b 0.01).
Among AUDIT-positive participants, men were more likely than
women to believe that drinking >4 standard drinks in one session
is safe (53% vs 31%; p = 0.02). There were no other gender differences
in participants' perceptions of whether they drank too much, had a
problem with alcohol, had discussed alcohol with the OST staff, and/
or reported a history of alcohol treatment (results not shown).

85
86

drinking; and (ii) assess correlates of excessive alcohol use as dened

by the World Health Organization's (WHO) 10-item Alcohol Use Disorders Identication Test (AUDIT) (Babor, Higgins-Biddle, Saunders, &
Monteiro, 2001).

83
84

M.M. Islam et al. / Addictive Behaviors xxx (2012) xxxxxx

Please cite this article as: Islam, M.M., et al., Self-perceived problem with alcohol use among opioid substitution treatment clients, Addictive Behaviors (2012), http://dx.doi.org/10.1016/j.addbeh.2012.12.001

331

143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
181
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197

200
201
202
203
204

M.M. Islam et al. / Addictive Behaviors xxx (2012) xxxxxx

t1:1
t1:2
t1:3

Table 1
Demographic and substance use characteristics of the sample compared with AUDIT score.
Variable

Total sample
n = 264

AUDIT-positive
AUDIT-negative
Univariate
(AUDIT 8) n = 107 (AUDIT b 8) n= 157 relationship

t1:4

a
b
c

HosmerLemeshow p = 0.96.
Among participants who reported a history of incarceration.
Among participants who reported a history of injecting drugs.

p-Value

0.21

88 (56)
1.00
68 (43)
0.97 (0.59, 1.60)
1 (1)
2.93 (0.26, 33.08)
126 (80)
0.85 (0.47, 1.55)
84 (54)
1.11 (0.68, 1.82)
127 (81)
1.09 (0.58, 2.01)
152 (97)
0.85 (0.22, 3.23)
43 (27)
1.13 (0.66, 1.95)
111 (71)
1.36 (0.77, 2.39)
143 (91)
1.54 (0.70, 3.37)
142 (90)
3.66 (1.03, 12.98)
19.2 (5.2; 1141) 1.01 (0.96, 1.06)
85 (54)
1.67 (1.00, 2.78)
48 (31)
1.47 (0.88, 2.46)

0.91
0.38
0.60
0.68
0.78
0.81
0.66
0.29
0.28
0.04
0.77
0.05
0.14

121 (77)
23 (15)
13 (8)

1.00
0.47 (0.20, 1.11)
1.04 (0.44, 2.49)

0.08
0.92

1.00
0.85 (0.52, 1.39)
0.83 (0.50, 1.37)

0.53
0.46

1.00
0.92
1.28
1.05
1.00
1.62

0.80
0.51
0.93
1.00
0.06

1.76 (1.00, 3.09)

0.05

73 (46)
84 (54)
70 (45)

R
O

38.6 (8.7; 2058) 1.02 (0.99, 1.05)

45
60
27
10
15
76

(29)
(38)
(17)
(6)
(10)
(48)

Mean age, years (SD; range)

39.1 (8.5; 2058) 39.9 (8.2; 2256)
Gender (%)
Male
148 (56)
60 (56)
Female
113 (43)
45 (42)
Transgender
3 (1)
2 (2)
Australian-born (%)
209 (79)
83 (78)
Completed 4+ years of high school (%)
144 (55)
60 (56)
English speaking background (%)
215 (81)
88 (82)
Government benet as main source of income (%)
255 (97)
103 (96)
Identied as aboriginal or Torres Strait Islander (%)
75 (28)
32 (30)
193 (73)
82 (77)
History of adult or juvenile imprisonmentb (%)
Heterosexual (%)
236 (89)
93 (87)
History of injecting drug use ever (%)
246 (93)
104 (97)
c
19.3 (5.3; 1041) 19.4 (5.4; 1040)
Mean age of onset of injecting (SD; range)
History of mental health diagnosis (%)
156 (59)
71 (66)
Currently on mental health medication (%)
90 (34)
42 (39)
Type of opioid substitution therapy (OST) (%)
Methadone
210 (80)
89 (83)
Buprenorphine/naltrexone
31 (12)
8 (7)
Buprenorphine
23 (9)
10 (9)
Duration of current period of OST
Less than two years
127 (48)
54 (50)
Two or more years
137 (52)
53 (50)
Used other drug(s) in the last month (%)
113 (43)
43 (41)
Drugs used most often in past six months (%)
None
75 (28)
30 (28)
Heroin
97 (37)
37 (35)
Methamphetamine
50 (19)
23 (21)
Cocaine
17 (6)
7 (7)
Other
25 (10)
10 (9)
Dependent on main illicit drug used in the last six
140 (53)
64 (60)
months according to SDS (%)
History of alcohol treatment (%)
55 (21)
40 (37)
Perceive >40 g alcohol is safe in one session (%)
67 (25)
46 (43)

15 (10)
21 (13)

(0.50,
(0.62,
(0.36,
(0.40,
(0.99,

1.71)
2.63)
3.06)
2.52)
2.68)

5.65 (2.92, 10.94) b0.01

4.88 (2.68, 8.88) b0.01

5.70 (2.83, 11.48) b0.01

5.30 (2.79, 10.06) b0.01

205
206

O
R
R

t1:38
t1:39
t1:40

p-Value AOR (95% CI)a

OR (95% CI)

t1:36
t1:37

Multivariate
relationship

t1:5
t1:6
t1:7
t1:8
t1:9
t1:10
t1:11
t1:12
t1:13
t1:14
Q2t1:15
t1:16
t1:17
t1:18
t1:19
t1:20
t1:21
t1:22
t1:23
t1:24
t1:25
t1:26
t1:27
t1:28
t1:29
t1:30
t1:31
t1:32
t1:33
t1:34
t1:35

t2:1
t2:2

Table 2
Relationships between AUDIT score, perception of an alcohol problem and history of alcohol treatment.

209
210
211
212
213
214
215
216

U
N

207
208

217

AUDIT-positive participants appear to underestimate the risks associated with excessive alcohol consumption, which is likely to affect
their motivation to change. Just ve participants were currently undertaking alcohol treatment. The majority of the harmful and hazardous drinkers and almost half of the likely dependent drinkers had
never undertaken alcohol treatment. Sixteen percent of those with a
history of alcohol treatment scored 17 on the AUDIT, suggesting current low-risk alcohol consumption. This is contrary to early natural
history studies suggesting that less than 5% of dependent drinkers
ever return to controlled drinking (Vaillant, 1997). Although the limitations of self-report need consideration, it is also possible that the
opioid effect of maintenance treatment partially suppresses craving
(Nava, Manzato, Leonardi, & Lucchini, 2008).

Alcohol intoxication is a major concern for clients receiving OST,

and in particular those maintained on methadone. Clients who
present for opioid dosing while intoxicated are reviewed to determine whether they can be safely administered their regular dose
(MHDAO, 2006). To avoid dose reduction or scrutiny, some clients
may avoid drinking excessively before presenting for dosing but
drink after dosing with consequent risk of over-sedation. Similarly,
clients may not disclose alcohol use or its extent accurately during periodic review to avoid negative attitudes or consequences. Improved
assessment techniques, effective review methods, and combined
pharmacological and behavioral interventions are required to address
the problem of alcohol misuse in OST settings (Anton et al., 2006). Periodic screening of and feedback to clients may help minimize risk

t2:3

AUDIT-negative
participants

AUDIT-positive
participants

Categories among AUDIT-positive drinkers

t2:4

n= 157

n = 107

Hazardous
n = 49

Harmful
n = 12

Likely dependent
n = 46

0 (0)
4 (3)
5 (3)
15 (10)
21 (13)

54
55
39
40
46

10
12
11
13
22

5 (42)
5 (41)
4 (33)
1 (8)
6 (50)

39
38
24
26
18

t2:5
t2:6
t2:7
t2:8
t2:9

Reported drink too much (%)

Self-perceived problem with alcohol (%)
Discussed alcohol use with OST clinic (%)
History of alcohol treatment (%)
>4 standard drinks perceived as safe to consume
in single session (%)

(50)
(51)
(36)
(37)
(43)

(20)
(24)
(22)
(27)
(45)

(85)
(83)
(52)
(57)
(39)

2trend

p-Value

156.91
138.33
65.31
42.43
18.24

b0.01
b0.01
b0.01
b0.01
b0.01

Please cite this article as: Islam, M.M., et al., Self-perceived problem with alcohol use among opioid substitution treatment clients, Addictive Behaviors (2012), http://dx.doi.org/10.1016/j.addbeh.2012.12.001

332

218
219
220
221
222
223
224
225
226
227
228
229
230

252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
270
271
272
273
274
275
276
277
278

Q7 279

R
O

250
251

248
249

246
247

Carroll, K. M., Ball, S. A., Nich, C., O'Connor, P. G., Eagan, D. A., Frankforter, T. L., et al.
(2001). Targeting behavioral therapies to enhance naltrexone treatment of opioid
dependence: Efcacy of contingency management and signicant other involvement. Archives of General Psychiatry, 58, 755761.
Chomynova, P., Miller, P., & Beck, F. (2009). Perceived risks of alcohol and illicit drugs:
Relation to prevalence of use on individual and country level. Journal of Substance
Use, 14, 250264.
Craig, R. J., & Olson, R. E. (2004). Predicting methadone maintenance treatment outcomes
using the Addiction Severity Index and the MMPI-2 Content Scales (Negative Treatment Indicators and Cynism scales). The American Journal of Drug and Alcohol Abuse,
30, 823839.
Darke, S., & Zador, D. (1996). Fatal heroin overdose: A review. Addiction, 91, 17651772.
Deering, D., Frampton, C., Horn, J., Sellman, D., Adamson, S., & Potiki, T. (2004). Health
status of clients receiving methadone maintenance treatment using the SF-36
health survey questionnaire. Drug and Alcohol Review, 23, 273280.
Dobler-Mikola, A., Httenschwiler, J., Meili, D., Beck, T., Bni, E., & Modestin, J. (2005).
Patterns of heroin, cocaine, and alcohol abuse during long-term methadone maintenance treatment. Journal of Substance Abuse Treatment, 29, 259265.
Feldman, F., Chatton, A., Khan, R., Khazaal, Y., & Zullino, D. (2011). Alcohol-related brief
intervention in patients treated for opiate or cocaine dependence: A randomized
controlled study. Substance Abuse Treatment, Prevention, and Policy, 6, 22.
Gossop, M., Browne, N., Stewart, D., & Marsden, J. (2003). Alcohol use outcomes and
heavy drinking at 45 years among a treatment sample of drug misusers. Journal
of Substance Abuse Treatment, 25, 135143.
Gossop, M., Darke, S., Grifths, P., Hando, J., Powis, B., Hall, W., et al. (1995). The Severity
of Dependence Scale (SDS): Psychometric properties of the SDS in English and Australian
samples of heroin, cocaine and amphetamine users. Addiction, 90, 607614.
Hillebrand, J., Marsden, J., Finch, E., & Strang, J. (2001). Excessive alcohol consumption
and drinking expectations among clients in methadone maintenance. Journal of
Substance Abuse Treatment, 21, 155160.
Kaye, S., & Darke, S. (2002). Determining a diagnostic cut-off on the Severity of Dependence Scale (SDS) for cocaine dependence. Addiction, 97, 727731.
Kreek, M. (1990). Drug interaction in humans related to drug abuse and its treatment.
Modern Methods in Pharmacology, 6, 265282.
Lobmaier, P., Kornor, H., Kunoe, N., & Bjorndal, A. (2008). Sustained-release naltrexone
for opioid dependence. Cochrane Database of Systematic Reviews, CD006140.
Magura, S., & Rosenblum, A. (2000). Modulating effect of alcohol use on cocaine use.
Addictive Behaviors, 25, 117122.
Mental Health and Drug & Alcohol Ofce (MHDAO) (2006). Clinical guidelines for
methadone and buprenorphine treatment of opioid dependence. Available at:
http://www.health.nsw.gov.au/policies/gl/2006/GL2006_019.html; Accessed in March
2012. In NSW Department of Health (Ed.), (Sydney)
National Health and Medical Research Council (NHMRC) (2012). The Australian standard
drink. Alcohol guidelines: Reducing the health risks. Available at: http://www.nhmrc.
gov.au/your-health/alcohol-guidelines, Accessed in March 2012. Canberra
Nava, F., Manzato, E., Leonardi, C., & Lucchini, A. (2008). Opioid maintenance therapy
suppresses alcohol intake in heroin addicts with alcohol dependence: Preliminary
results of an open randomized study. Progress in Neuro-Psychopharmacology &
Biological Psychiatry, 32, 18671872.
Nyamathi, A., Cohen, A., Marsee, M., Shoptaw, S., Greengold, B., de Castro, V., et al.
(2009). Correlates of alcohol use among methadone-maintained adults. Drug and
Alcohol Dependence, 101, 124127.
Ostapowicz, G., Watson, K. J., Locarnini, S. A., & Desmond, P. V. (1998). Role of alcohol in
the progression of liver disease caused by hepatitis C virus infection. Hepatology,
27, 17301735.
Ross, J., & Darke, S. (1997). Benzodiazepine dependence and psychopathology among heroin users in Sydney, Technical Report Number 50. Sydney, Australia: National Drug
and Alcohol Research Centre, University of New South Wales.
Rowan-Szal, G. A., Chatham, L. R., & Simpson, D. D. (2000). Importance of identifying
cocaine and alcohol dependent methadone clients. The American Journal on Addictions, 9, 3850.
Senbanjo, R., Wolff, K., & Marshall, J. (2007). Excessive alcohol consumption is associated
with reduced quality of life among methadone patients. Addiction, 102, 257263.
Stenbacka, M., Beck, O., Leifman, A., Romelsjo, A., & Helander, A. (2007). Problem drinking in relation to treatment outcome among opiate addicts in methadone maintenance treatment. Drug and Alcohol Review, 26, 5563.
Strang, J., Grifths, P., Powis, B., Fountain, J., Williamson, S., & Gossop, M. (1999). Which
drugs cause overdose among opiate misusers? Study of personal and witnessed
overdoses. Drug and Alcohol Review, 18, 253261.
Teplin, D., Raz, B., Daiter, J., Varenbut, M., & Plater-Zyberk, C. (2007). Screening for alcohol use patterns among methadone maintenance patients. The American Journal
of Drug and Alcohol Abuse, 33, 179183.
Topp, L., & Mattick, R. P. (1997). Choosing a cut-off on the Severity of Dependence Scale
(SDS) for amphetamine users. Addiction, 92, 839845.
Vaillant, G. E. (1997). The natural history of alcoholism and its relationship to liver
transplantation. Liver Transplantation and Surgery, 3, 304310.
Watson, B., Conigrave, K. M., Wallace, C., Whiteld, J. B., Wurst, F., & Haber, P. S. (2007).
Hazardous alcohol consumption and other barriers to antiviral treatment among
hepatitis C positive people receiving opioid maintenance treatment. Drug and
Alcohol Review, 26, 231239.
White, J., & Irvine, R. (1999). Mechanisms of fatal opioid overdose. Addiction, 94,
961972.

244
245

242
243

240
241

238
239

237

235
236

233
234

underestimation. Recent research in community methadone clinics

demonstrated that screening for excessive alcohol use and delivering
brief interventions can signicantly reduce alcohol consumption
(Feldman, Chatton, Khan, Khazaal, & Zullino, 2011).
Consistent with previous studies, excessive alcohol consumption
was signicantly associated among this sample with dependence on
an illicit drug (Dobler-Mikola et al., 2005; Nyamathi et al., 2009). Possible reasons for the combined use of drugs and alcohol include the
seeking of additive sedative or euphoric effects (Strang et al., 1999)
or to counteract the adverse or unwanted effects of intoxication or
withdrawal (Magura & Rosenblum, 2000), or common risk factors
(e.g. mental illness). Regardless of the drivers for this behavior, this
pattern is of concern. Although weaning off OST and subsequent use
of opioid antagonists such as naltrexone are an option in treatment
of comorbid alcohol and opioid dependence (Lobmaier, Kornor,
Kunoe, & Bjorndal, 2008), outcomes for naltrexone for treatment of
opioid dependence remain inferior to OST (Carroll et al., 2001).
Clients with AUDIT scores of 20 + are, no doubt, the most vulnerable group and thus in need of the most intensive attention. Clients
scoring in the hazardous or harmful range would also benet from intervention, particularly given the risk associated with intoxication
among OST clients. Better outcomes may also be achieved by these
groups as they are likely to be either non-dependent or in the earlier
stages of dependence.
This study's limitations include the relatively small sample recruited
from urban public OST clinics, who may not be representative of
the general OST population. Although the AUDIT is a well-validated
questionnaire, no measure of problematic alcohol consumption is
100% accurate. Furthermore, drinking and drug use histories were
self-reported, and so may be subject to social desirability bias. In
addition, the variables considered to reect perceived problems with alcohol were not psychometrically validated. The study did not assess
other factors related to insight, such as current willingness to accept
treatment.
Despite these limitations, the ndings are valuable and suggest that,
consistent with ndings among the general population, OST clients who
consume excess alcohol underestimate the associated risk. Individuals'
perception of their susceptibility to illness is an important determinant
of behavior change and healthcare utilization (Brewer et al., 2004). This
is a concern given that OST clients are a population with poor health
(Deering et al., 2004), and are likely to be adversely affected by excessive alcohol consumption. OST programs should consider policies that
ensure early identication of co-morbid substance use problems and
stepped or integrated interventions covering the full range of substance
use disorders (Senbanjo, Wolff, & Marshall, 2007). Regular assessment
of OST clients' alcohol use prole, along with tailored and targeted interventions, is likely to improve the health and social outcomes for
this population.

231
232

M.M. Islam et al. / Addictive Behaviors xxx (2012) xxxxxx

Acknowledgments
This research was supported by a UNSW Faculty of Medicine research grant. The
authors gratefully acknowledge the clinical teams at the two recruitment sites, particularly Professor Paul Haber, Elaine Doherty, Maggie Tynan and Dr Ken Curry, and the
research interviewers, Dr Rachel Deacon, Sarah Hutchinson and Lucia Evangelista of
the Drug Health Services of Royal Prince Alfred Hospital. The rst author's doctoral research was supported by a University International Post-graduate Award from UNSW.

286

References

287
288
289
290
291
292
293
294

Anton, R. F., O'Malley, S. S., Ciraulo, D. A., Cisler, R. A., Couper, D., & Donovan, D. M.
(2006). Combined pharmacotherapies and behavioral interventions for alcohol dependence: The COMBINE study: A randomized controlled trial. JAMA: The Journal of
the American Medical Association, 295, 20032017.
Babor, T., Higgins-Biddle, J., Saunders, J., & Monteiro, M. (2001). AUDIT: The Alcohol Use
Disorders Identication Test. Geneva: World Health Organization.
Brewer, N. T., Weinstein, N. D., Cuite, C. L., & Herrington, J. E. (2004). Risk perceptions
and their relation to risk behavior. Annals of Behavioral Medicine, 27, 125130.

280
281
282
283
284
285

295
296
297
298
299
300
301
302
303
304
305
306
307
308
309
310
311
312
313
314
315
316
317
318
319
320
321
322
323
324
325
326
327
328
329
330
331
332
333
334
335
336
337
338
339
340
341
342
343
344
345
346
347
348
349
350
351
352
353
354
355
356
357
358
359
360
361
362
363
364
365
366
367
368
369
370
371
372
373
374
375
376
377

378

Please cite this article as: Islam, M.M., et al., Self-perceived problem with alcohol use among opioid substitution treatment clients, Addictive Behaviors (2012), http://dx.doi.org/10.1016/j.addbeh.2012.12.001

333

Appendix IV

(n) Islam, M. M., Topp, L., Iversen, J., Day, C. A., Conigrave, K. M., & Lisa Maher on
behalf of the Collaboration of Australian NSPs. (in press). Healthcare utilization and
disclosure of injecting drug use among clients of Australias needle and syringe
programs. Australian and New Zealand Journal of Public Health.

334

Healthcare utilisation and disclosure of injecting drug use among clients of Australias needle
and syringe programs
M. Mofizul Islam1, 2, 3, Libby Topp 1, Jenny Iversen 1, Carolyn Day 3, 4, Katherine M Conigrave 3,4, 5,
and Lisa Maher 1, 2 on behalf of the Collaboration of NSPs*
1. Viral Hepatitis Epidemiology and Prevention Program, The Kirby Institute University of New
South Wales, Australia
2. School of Public Health and Community Medicine, University of New South Wales, Australia
3. Drug Health Service, Royal Prince Alfred Hospital, Sydney, Australia
4. Sydney Medical School, University of Sydney, Sydney, Australia
5. National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
*The collaboration of Australian NSPs (2011):
Australian collaboration of Needle and Syringe Programs (2011): ACON; Anglicare Tasmania;
Albury CHC; Barwon Health Service; Biala NSP; Cairns NSP; Central Access Service; Central Coast
Harm Reduction Services; Clarence CHC; DASSA; Directions ACT; First Step Program; Health
ConneXions; Health Information Exchange; Health Works; Hindmarsh Centre; Hunter Harm
Reduction Services; Inner Space; Kirketon Road Centre; Kobi House; North Coast Harm Reduction
Services; North Richmond CHC; Northern Territory AIDS Council; NUAA; Nunkuwarrin Yunti Inc.;
QUIHN NSP Services; Redfern Harm Minimisation Centre; Salvation Army Launceston; SAVIVE
CNP Services; SHARPS; Sydney West NSP Services; TasCHARD NSP Services; Townsville
ATODS; WA AIDS Council; Wagga Wagga CHC; WASUA and West Moreton NSP.
Word count: 3000 (without table, acknowledgement and reference)
Abstract word: 255
Corresponding author:

Professor Lisa Maher

The Kirby Institute, University of New South Wales, Sydney
CFI Building
Corner Boundary and West Streets
Darlinghurst, NSW 2010, Sydney, Australia
Phone: +61 02 9385 0900
Fax: +61 02 9385 0920
Email: L.Maher@kirby.unsw.edu.au

Running Head: Healthcare utilisation and disclosure of injecting drug use

335

Abstract
Background: People who inject drugs (PWID) report limited access to healthcare, and may
avoid disclosing drug use. Delayed treatment increases the risk of complications and
consequent costly utilisation of emergency departments. Health service utilisation was
examined among participants in the Australian Needle and Syringe Program Survey
(ANSPS), an annual cross-sectional sero-survey of needle syringe program (NSP) attendees.
Methods: An anonymous questionnaire was self-completed by 2,395 NSP clients throughout
Australia. Multivariable logistic regressions identified variables independently associated
with (i) disclosure of injecting to the most recent healthcare provider; and (ii) recent
presentation to emergency departments.
Results: Seventy-eight percent of participants reported accessing healthcare in the preceding
12 months, most commonly from GPs (64%); providers targeting PWID including opioid
substitution therapy prescribers, NSP-based primary healthcare services (17%); and
emergency departments (14%). Reasons for presentation included general health issues
(46%); medication seeking (17%); and both (37%). Participants who recently accessed
healthcare [adjusted odds ratio (AOR) 1.36; 95% confidence intervals (CI) 1.06, 1.75] or had
previously visited their most recent provider (AOR 1.75; CI 1.36, 2.25) were more likely to
disclose injecting drug use. Participants presenting to a GP or medical centre (AOR 0.65;
CI0.53, 0.81) were less likely than others to disclose injecting. Those accessing emergency
departments were more likely to report recent imprisonment (AOR 1.48; CI 1.01, 2.17).
Conclusions: Despite Australias universal healthcare system and harm reduction policies,
NSP-participants remain reluctant to disclose injecting, potentially hindering appropriate care
and highlighting the need for multiple entry points to the healthcare system, including NSPs
and opioid substitution therapy clinics.
Key words: Injecting drug use, needle syringe program, healthcare, disclosure, emergency
department.

336

Introduction
People who inject drugs (PWID) experience a range of health problems arising from nonsterile injecting practices and complications of the drug(s) injected or of the lifestyle
associated with illicit drug use and dependence.1 Access to primary healthcare is often limited
for this marginalised group2 due to barriers including costs associated with medical treatment
and transportation, and stigma and discrimination experienced by PWID within healthcare
settings.3 Even when PWID are in need of help, healthcare may assume a lower priority than
obtaining food, clothing, shelter and generating income or other activities designed to support
drug use.4 Given these barriers, PWID are more likely than non-injecting drug users and the
general population to delay seeking healthcare until conditions become severe.5, 6 This in turn
may lead to a significant mortality and morbidity,7 reliance on emergency departments and
inpatient care8 resulting in significant costs and additional pressures on the healthcare
system.9

Even when services are accessed, PWID may not disclose their drug use or its extent to
healthcare providers10 due to fear of stigma and discrimination and/or concerns about legal,
child welfare, immigration, employment and/or housing ramifications.3 Such disclosure may
impact on the quality of healthcare received, as accurate diagnoses, treatment and
management may be compromised in the absence of a full history. Such concerns have led to
the establishment of primary healthcare centres targeting PWID;2 however, geographical
coverage of such targeted providers remains limited, leaving the majority of clients to access
care from mainstream providers.
Despite barriers to healthcare and consequent poor health outcomes, healthcare utilisation
among PWID has received little research attention.11 Studies to date have been confined to
samples in drug treatment settings12-14 or to data collected incidentally during the course of

337

other investigations.15 Furthermore, utilisation of costly emergency departments by PWID for

complications that can be prevented or treated by primary healthcare services and other
providers remains a concern.8,

16

This is particularly relevant in settings with universal

healthcare systems and harm reduction-based drug policies, where primary healthcare should
be readily accessible.17 However, there are significant gaps in the literature about these
problems. The Australian Needle Syringe Program Survey (ANSPS) draws on needle and
syringe program (NSP) attendees who are representative of the broader Australian needle
syringe program population18 and therefore provides a useful data to explore these issues.
Since 1995, ANSPS has provided annual point prevalence estimates to monitor patterns of
blood-borne viral infection and risk behaviours among NSP clients.19, 20 Using ANSPS data
collected in 2011, this exploratory, descriptive study documented patterns of healthcare
utilisation among a large, national sample of NSP clients. Specifically, the study aimed to:
(i) Identify patterns of healthcare utilisation by ANSPS participants; and
(ii) Assess demographic and drug use characteristics associated with:
a. disclosure of injecting drug use to the most recent healthcare provider; and
b. recent presentation to an emergency departments.

Methods
The ANSPS methodology is described in detail elsewhere.19,

20

Briefly, all PWID who

attended participating NSPs during the October 2011 survey period were invited to selfcomplete a brief questionnaire covering demographics; drug and alcohol use and treatment
history; injecting and sexual risk; history of HIV and hepatitis C diagnosis and treatment;
history and recency of medical care utilisation; type of service and reasons for access; and
disclosure of injecting drug use to the most recent provider. Fifty-three of Australias 85
primary NSP sites participated in the 2011 ANSPS, from which was recruited a sample of

338

2,395 clients corresponding to a 41% response rate. Respondents provided informed verbal
consent for their voluntary, anonymous and unreimbursed participation. Assistance with
survey completion was available upon request, although the great majority of participants
indicate self-completion. Ethical approval for the ANSPS was provided by relevant
institutional, jurisdictional and site-specific ethics committees, including the University of
New South Wales Human Research Ethics Committee.

Outcomes
Based on the questionnaire item Does that healthcare provider/service (i.e., accessed most
recently) know you inject drugs?, for which the response options were (i) No, (ii) Yes, but not
the full details and (iii) Yes, knows everything, the sample was divided into groups labelled
no disclosure and full/partial disclosure of injecting drug use. Comparison between
full/partial versus no disclosure was considered providing most important piece of
information, particularly for those who do not disclose at all, and also ensuring brevity of the
manuscript. Based on the item, Where did you go the last time you sought medical care?, the
sample was divided into groups labelled emergency department and other provider.
A provider was classified as targeted if drug users were one of the main target groups; for
example, opioid substitution therapy prescribers, PWID-targeted primary healthcare centres,
NSP or detoxification/rehabilitation centres.

Statistical Analyses
Chi-square (2) and Fishers exact tests were used to examine differences between groups for
categorical variables, and independent sample t-tests for continuous variables. Statistical
significance was set at p<0.05. Multivariable logistic regression examined correlates of
injecting drug use disclosure (no disclosure versus partial/full disclosure) and most recent

339

episode of healthcare accessed from an emergency department (yes versus no). Variables that
were associated on univariate analysis at the p<0.15 level were considered candidate
variables for logistic regression modelling. Final models were derived using stepwise
backwards elimination. Multicollinearity was assessed; and goodness of fit was examined
using the HosmerLemeshow test. Data were analysed using STATA (version 11).21

Results
Sample characteristics
Participants (n=2,395) had a mean age of 37.7 years (SD 9.4; range 16-65) and 67% were
male (Table 1). The majority (87%) identified as heterosexual. Eleven percent of participants
reported a history of incarceration in the preceding 12 months and 12% identified as
Aboriginal and/or Torres Strait Islander (Indigenous). In the month prior to the survey, 49%
had injected daily or more frequently; and 16% had engaged in receptive syringe sharing.
Heroin was the drug most often last injected (34%). Seventy-nine percent of participants
reported a history of drug treatment including opioid substitution therapy, detoxification
and/or counselling, with 46% currently in treatment. Participants with a history of treatment
were older than those with no such history (38.3 versus 35.9 years; p<0.001).

340

Table 1: Demographic, drug use and risk characteristics associated with disclosure of injecting to most recent medical care provider
Variable

n=2395

Disclosure of injecting to most recent

healthcare provider

Univariable association
Full or partial vs no disclosure

Full or partial
disclosure n=1512

No disclosure
n=806

OR (95% CI)

p-value

37.5 (9.5; 16-65)

38.2 (9.1; 16-65)

36.9 (9.9; 17-64)

1.02 (1.01-1.02)

0.001

Male (reference group)

67

65

71

1 (-)

Female

33

35

29

1.35 (1.12-1.63)

0.001

<1

<1

Excluded

Mean age (SD; range)

Gender (%)

Transgender

<1

Indigenous descent (%)

12

12

11

1.17 (0.89-1.54)

0.258

Imprisoned in last 12 months (%)

11

12

1.50 (1.11-2.04)

0.009

Sexual identity (%)

0.006

Heterosexual

87

86

87

1 (-)

Bisexual

10

1.45 (1.05-2.01)

0.026

Homosexual

0.64 (0.42-0.97)

0.036

Frequency of injecting last month (%)

0.240

Daily or more often

49

49

50

1 (-)

More than weekly

24

25

22

1.15 (0.92-1.43)

0.215

Less than weekly

27

26

28

0.93 (0.76-1.14)

0.511
<0.001

Drug injected most recently (%)

Heroin

34

38

25

1 (-)

Methamphetamine

27

27

28

0.64 (0.51-0.80)

<0.001

Morphine/other opioids

15

14

18

0.52 (0.40-0.67)

<0.001

Methadone/burpenorphine/suboxone

13

13

13

0.66 (0.49-0.87)

0.004

341

Steroids

0.16 (0.10-0.25)

<0.001

Other

0.48 (0.33-0.70)

<0.001

Receptive sharing needles or syringes last month (%)

16

16

16

0.96 (0.74-1.24)

0.743

Receptive sharing other equipment last month (%)

33

33

31

1.11 (0.91-1.36)

0.306

Treatment of drug dependence (%)

<0.001

Current treatment

46

53

34

1 (-)

Past treatment

33

34

31

0.72 (0.58-0.88)

0.002

No treatment history

21

14

35

0.25 (0.20-0.32)

<0.001

80

83

74

1.65 (1.34-2.04)

<0.001

Accessed medical care last 12 months (%)

Motivation for most recent presentation (%)

<0.001

General health issue only

46

45

49

1 (-)

Medication only

17

15

20

0.82 (0.64-1.04)

0.107

37

40

31

1.37 (1.13-1.67)

0.002

64

60

71

0.61 (0.50-0.73)

<0.001

17

21

10

2.39 (1.84-3.10)

<0.001

Hospital Emergency Department

14

15

13

1.22 (0.94-1.58)

0.135

Community Health Center

1.83 (1.25-2.68)

0.002

Aboriginal Medical Services

1.05 (0.66-1.68)

0.830

Other

1.13 (0.64-2.02)

0.668

Visited most recent medical care provider previously (%)

80

85

72

2.31 (1.86-2.85)

<0.001

Both
Most recent medical care provider accessed (%)

GP or medical center
Targeted provider

Some participants reported more than one medical care provider, thus each type of facility was treated as an independent binary variable. Targeted providers comprised OST

prescribers, PWID-targeted PHCs, NSP, detox/rehabilitation centers.

342

Patterns of healthcare utilisation

Eighty percent of participants reported having accessed healthcare in the preceding 12
months (Table 1), including a significantly higher proportion of women than men (87%
versus 76%, p<0.001). General practitioners (GPs) or medical centres were the providers
most commonly last accessed (64%), followed by targeted providers (comprising opioid
substitution therapy prescribers, PWID-targeted primary healthcare centres, NSP, and
detoxification/rehabilitation centres; 17%) and emergency departments (14%). Just under half
(46%) reported that a general health issue had motivated them to seek medical care on the
most recent occasion. Seventeen percent reported seeking a medication (potentially including
opioid substitution therapy), and 37% reported that services were accessed for both general
health issues and medications. Eighty percent of participants had accessed the same medical
care provider prior to the most recent visit. Thirty-five percent of participants fully disclosed
their injecting to their most recent healthcare provider and 34% reported partial disclosure
and the remainder (31%) did not disclose their injecting drug use.

Correlates of disclosure of injecting to the most recent healthcare provider

A number of variables had significant univariable associations with disclosure of injecting
drug use to the most recent healthcare provider (Table 1). Variables positively associated
with disclosure were age, having accessed healthcare in the preceding 12 months, accessed
targeted providers or community health centres most recently, prior use of the most recently
accessed provider and being motivated to seek the most recent episode of care by both
medication and general health issues. The effect of sexual identity revealed that compared to
heterosexuals, bisexuals were more likely and homosexuals were less likely to disclose
injecting. In terms of gender, women were more likely than men to fully/partially disclose
injecting. The effect of most recent medical care provider accessed indicated that those who

343

most recently accessed a GP or medical centre were less likely than others to disclose
injecting. Two other variables were found significant one was drugs injected most
recently where drugs other than heroin users were less likely to disclose injecting; and the
second was drug treatment where participants who were not currently in drug treatment
were less likely to disclose injecting.
Multivariable logistic regression revealed that participants who had accessed healthcare in the
preceding 12 months (AOR 1.36; CI 1.06, 1.75) or had previously visited their most recent
provider (AOR 1.75; CI 1.36, 2.25) were more likely than others to report fully or partially
disclosing their injecting to the most recent provider. Conversely, effects of drug injected
most recently reveals that compared to recent heroin injectors, those who recently injected
morphine and other opioids (AOR 0.58; CI 0.43, 0.78), methadone/burpenorphine/suboxone
(AOR 0.55; CI 0.40, 0.76), steroids (AOR 0.54; CI 0.31, 0.95), or other drugs (AOR 0.61; CI
0.40, 0.95) were less likely to disclose injecting. The association with treatment of drug
dependence shows those who report either no (AOR 0.29; CI 0.22, 0.38), or prior (AOR
0.74; CI 0.58, 0.92) drug treatment were less likely than participants currently receiving
treatment to disclose injecting. Those who most recently visited a GP or medical centre
(AOR 0.65; CI 0.53, 0.81) were less likely than others to disclose injecting.

344

Table 2: Correlates of disclosure of injecting to most recent medical care provider

Variable

Multivariable relationship
(Full or partial vs no
disclosure)
AOR (95% CI)

p-value
<0.001

Drug injected most recently (%)

1 (-)

Methamphetamine

0.94 (0.72-1.23)

0.663

Morphine/other opioids

0.58 (0.43-0.78)

<0.001

Methadone/burpenorphine/suboxone

0.55 (0.40-0.76)

<0.001

Steroids

0.54 (0.31-0.95)

0.032

Other

0.61 (0.40-0.95)

0.027

Heroin

<0.001

Treatment of drug dependence (%)

1 (-)

Past treatment

0.74 (0.58-0.92)

0.011

No treatment history

0.29 (0.22-0.38)

<0.001

1.36 (1.06-1.75)

0.014

Current treatment

Accessed healthcare last 12 months (%)

0.014

Motivation for most recent presentation (%)

1 (-)

Medication only

0.77 (0.59-1.02)

0.072

Both

1.19 (0.95-1.48)

0.125

Most recent facility accessed was GP or medical centre (%)

0.65 (0.53-0.81)

<0.001

Visited most recent medical care provider previously (%)

1.75 (1.36-2.25)

<0.001

General health issue only

Correlates of emergency department utilisation

Hospital emergency departments were the provider most recently accessed by 14% of
respondents (Table 1), 78% of whom had accessed an emergency department in the preceding
12 months. Those who most recently accessed healthcare from an emergency department
were more likely than those who did not to report recent imprisonment (AOR 1.48; CI 1.01,
2.17), and having accessed an emergency department previously (AOR 0.67; CI 0.49, 0.91).
The effect of drug injected most recently shows those who injected steroids were less likely

345

(AOR 0.15; CI 0.04, 0.62) than those who injected heroin to report accessing emergency
department for their last episode of medical care. Participants who most recently accessed a
healthcare facility seeking medication only (AOR 0.51; CI 0.33, 0.79) or both medication and
general healthcare (AOR 0.77; CI 0.58, 1.02) were less likely than those who accessed purely
for general healthcare to report accessing emergency department most recently.

Table 3: Correlates of hospital emergency department utilisation at most recent presentation

Variable

Imprisoned in last 12 months (%)

Most recently accessed

provider: Emergency
Department

Multivariable
relationship

Yes
n=321

No
n=1935

AOR (95% CI)

p-value

41 (14)

180 (10)

1.48 (1.01-2.17)

0.042

Drug injected most recently (%)

0.034

Heroin

99 (31)

658 (34)

1 (-)

Methamphetamine

96 (30)

513 (27)

1.18 (0.85-1.63)

0.331

Morphine/other opioids

51(16)

302 (16)

1.18 (0.80-1.74)

0.398

Methadone/burpenorphine/suboxone

45 (14)

247 (13)

1.25 (0.83-1.88)

0.278

Steroids

4 (1)

99 (5)

0.15 (0.04-0.62)

0.009

Others

25 (8)

112 (6)

1.65 (0.98-2.79)

0.061

237 (75)

1567 (83)

0.67 (0.49-0.91)

0.011

Visited last medical care provider previously (%)

Main reason for visit seeking medication (%)

0.005

General health issue only

165 (54)

861 (46)

1 (-)

Medication only

38 (12)

316 (17)

0.51 (0.33-0.79)

0.002

Both

105 (34)

706 (37)

0.77 (0.58-1.02)

0.067

Discussion
The proportions of ANSPS participants reporting accessing healthcare in the preceding 12
months and previously accessing their most recent provider give some indication of
continuity of care for this group. However, alarmingly only one-third of those who accessed
healthcare on the most recent occasion for a general health issue reported fully disclosing

346

their injecting drug use and similar proportion reported not disclosing at all. Participants
likelihood of disclosing their injecting drug use to the most recent provider who they had
previously accessed indicates the benefit of continuity of care. Intriguingly GPs and medical
centres were the most common sources of recent care, although the majority of participants
who accessed these providers did not disclose their injecting. While the recent healthcare
access, continuity of care and substantial GP involvement are encouraging, the use of an
emergency department for the most recent occasion of care by 14% of participants remains a
concern. Efforts should be made to reduce this utilisation of emergency department by
providing alternative service.

Prevalence of healthcare utilisation in the last 12 months among ANSPS participants broadly
reflects that of the general Australian population. Although the items are not directly
comparable, 81% of Australians aged15 years in the 2009 Australian Patient Experience
Survey reported consulting a GP at least once during the preceding 12 months.22 A similar
study on access to healthcare by PWID at an NSP in Pittsburgh, USA found that 77% were
not engaged in drug treatment and 67% had visited a GP in the preceding 12 months,23 with
financial difficulty being the main barrier to access. In comparison to this finding, and given
documented barriers to healthcare access among PWID,6,

24, 25

our results which suggest

approximately equivalent access are encouraging, and potentially reflect Australias universal
healthcare system. However, substantial research continues to document the poor health
status of PWID,1, 26-28 indicating that such equivalence of access does not necessarily result in
equivalent health outcomes.

Substantial non-disclosure of injecting drug use was evident in our study; just one-third of
participants reported full disclosure to the most recent provider. Disclosure is likely to

347

facilitate more accurate diagnoses and to avoid potential interactions between illicit drugs and
prescribed medications. Moreover, while non-disclosure may be motivated by a legitimate
fear of stigmatisation or discrimination,29 PWID who fail to disclose may be at risk of being
perceived as dishonest or manipulative by providers, potentially compromising the patientprovider interaction. That 64% of participants reported last accessing a GP or medical centre
is encouraging given previous documentation of low rates of GP comfort and confidence with
this population.30,

31

However, these participants were less likely than those who most

recently accessed other providers to disclose their injecting drug use. Clearly there are
important public health implications of this substantial non-disclosure, as given that PWID
are at the heightened risks of blood-borne viral infections and other medical and mental
health disorders, which may go unrecognised. The onus of disclosure must nevertheless fall
partially to providers, whose responsibility it is to provide an environment in which PWID
feel confident that disclosure will not result in discrimination.32 Even so, providers could
usefully assume that some clients may choose to disclose only selected information regarding
their drug use history and risk profile.33

Previous research suggests that providing healthcare in settings where trust is already
established, where PWID perceive little or no stigma and where care is provided
opportunistically, better meets the needs of this group.2, 34 Many PWID regularly utilise and
trust NSPs and opioid substitution therapy clinics,35 creating a potential environment for
opportunistic and ongoing healthcare provision. The provision of opportunistic care in such
settings also has the potential to attract PWID who may avoid seeking care until perceived
need is high.36 Providing basic and preventive healthcare from NSPs and opioid substitution
therapy clinics may reduce utilisation of emergency departments and acute medical care
services by PWID.37 In 2007, 33% of NSPs in the USA reported providing onsite medical

348

care, and 7% provided buprenorphine treatment

38

. In Australia, the Kirketon Road Centre,

established in Sydneys Kings Cross in 1987, is perhaps the best known example of a primary
healthcare for PWID.39 This service provides a combination of NSP, primary healthcare,
opioid substitution therapy and a range of specialist services. In 2001, the Victorian State
Government established primary healthcare services for street-based PWID in five areas of
Melbourne with high rates of drug use 40 and in 2006, the Redfern Harm Minimisation Clinic
was established in Sydney to provide primary healthcare via an enhanced NSP model.41

A study of PWID aged 18-29 years in New York found that 21% of participants used an
emergency department the last time they received care,42 a higher proportion than among our
sample (14%). However, given that Australia, unlike many other settings, provides universal
healthcare, it is of concern that emergency departments were the most recent healthcare
provider for 14% of our participants. Although recent emergency department users were less
likely than others to report accessing that provider previously, three-quarters reported having
accessed an emergency department in the past. High rates of emergency department
presentations have previously been documented among illicit drug users,43 for issues
including overdose,44 injecting-related injuries and infections9 and drug and alcohol-related
injuries.45 The resource implications arising from emergency department utilisation can be
reduced by providing accessible, acceptable and continuous primary healthcare services
tailored for PWID.37, 46 In our study, participants with a history of imprisonment were more
likely than others to report recent emergency department use. This could reflect the
consequences of imprisonment, including unintended overdose immediately after release47, 48,
loss of continuity of healthcare and of stable housing, and difficulties finding employment
because of a criminal record.47 Alternatively imprisonment could be an indicator of more
severe drug dependence and more chaotic lifestyle.

349

Our study has several limitations. The response rate among this sample was 41%, which is
within the range of all ANSPS survey years (range 38%-60%).49 While the overall profile of
participants is typical of the broader Australian NSP population,18 the external validity of our
results cannot be assessed. Although the self-completion of the ANSPS questionnaire reduces
social desirability bias50 , the brief and self-complete format necessarily precludes detailed
explanations of complex constructs such as disclosure, individual interpretations of which are
likely to vary. The associations demonstrated here between healthcare access and
demographic and risk characteristics are correlational only; the cross-sectional nature of our
data precludes definitive statements on the temporal or causal nature of any such
relationships. Participants may have been affected by the primacy bias51 in responding to the
most recent medical care facility they accessed and may have opted to select response options
provided by the questionnaire rather than to name other facilities, such as community
pharmacy, which were not specifically listed.

Despite the existence of a universal healthcare system and longstanding bipartisan political
support for harm reduction illicit drug policy, considerable social stigma remains associated
with injecting drug use in Australia. Our finding of substantial non-disclosure of injecting
drug use to the most recent healthcare provider suggests ongoing concerns in relation to
stigma and discrimination. Non-disclosure of injecting was highest among those who most
recently accessed care from a GP or medical centre the predominant source of recent
healthcare accessed by our sample. Given the potential implications of non-disclosure for
quality of care, and our finding that a significant minority of PWID utilise emergency
departments for care, the provision of primary healthcare through existing services such as
NSPs and opioid substitution therapy clinics which target PWID has the potential to alleviate

350

these concerns. Such arrangements, however, should in no way discourage PWID from
accessing mainstream healthcare. While PWID in our sample reported similar rates of
healthcare utilisation to the general population, the significant mortality and morbidity
associated with injecting drug use,7,

52

and ongoing barriers to disclosure of drug use and

continuity of care3, 6, 10 indicate a need to provide this population with multiple entry points to
the healthcare system.

Acknowledgements
The ANSPS is funded by the Australian Government Department of Health and Ageing. The
views expressed in this publication do not necessarily represent the position of the Australian
Government and the Australian Government played no role in the analysis, manuscript
drafting or decision to submit for publication. The Kirby Institute is affiliated with the
Faculty of Medicine, University of New South Wales. Lisa Maher is supported by a National
Health and Medical Research Council Senior Research Fellowship. The authors wish to
acknowledge the generosity of survey participants and the support of participating Needle
and Syringe Programs, the ANSPS National Advisory Committee, and laboratory staff at St
Vincents Centre for Applied Medical Research and the New South Wales State Reference
Laboratory for HIV at St Vincents Hospital, Sydney.

351

Reference
1.

Latt N, Conigrave K, Saunders JB, Marshall EJ, Nutt D. Addiction Medicine. Oxford:
Oxford University Press; 2009.

2.

Islam MM, Topp L, Day CA, Dawson A, Conigrave KM. The accessibility,
acceptability, health impact and cost implications of primary healthcare outlets that
target injecting drug users: A narrative synthesis of literature. International Journal of
Drug Policy. 2012 Mar;23(2):94-102.

3.

Neale J, Tompkins C, Sheard L. Barriers to accessing generic health and social care
services: a qualitative study of injecting drug users. Health and Social Care in the
Community. 2008;16(2):14754.

4.

Carr S, Goldberg DJ, Elliott L, Green S, Mackie C, Gruer L. A primary health care
service for Glasgow street sex workers--6 years experience of the "drop-in centre',
1989-1994. AIDS Care. 1996 Aug;8(4):489-97.

5.

Drumm RD, McBride DC, Metsch L, Neufeld M, Sawatsky A. Im a health nut!,

Street drug users accounts of self-care strategies. Journal of Drug Issues.
2005;35:60729.

6.

McCoy CB, Metsch L, Chitwood DD, Miles C. Drug use and barriers to use of health
care services. Substance Use & Misuse. 2001;36:789806.

7.

Stoove MA, Dietze PM, Aitken CK, Jolley D. Mortality among injecting drug users in
Melbourne: a 16-year follow-up of the Victorian Injecting Cohort Study (VICS).
Drug and Alcohol Dependence. 2008 Aug 1;96(3):281-5.

8.

French MT, McGeary KA, Chitwood DD, McCoy CB. Chronic illicit drug use, health
services utilization and the cost of medical care. Social Science & Medicine.
2000;50:170313.

352

9.

Palepu A, Tyndall MW, Leon H, Muller J, O'Shaughnessy MV, Schechter MT, et al.
Hospital utilization and costs in a cohort of injection drug users. Canadian Medical
Association Journal. 2001 Aug 21;165(4):415-20.

10.

Western Australian Network of Alcohol and Other Drug Agencies. WANADA GP

Access

(pilot)

project

evaluation

summary,

Available

at:

www.wanada.org.au/Download.../72-GP-Access-Project-Evaluation.html; 2009.
11.

Myers BJ. Primary health care for people who inject drugs in low and middle income
countries: A response to "The accessibility, acceptability, health impact and cost
implications of primary healthcare outlets that target injecting drug users.".
International Journal of Drug Policy. 2012 Oct 24;23(2):105-6.

12.

Umbricht-Schneiter A, Ginn DH, Pabst KM, Bigelow GE. Providing medical care to
methadone clinic patients: referral vs on-site care. American Journal of Public Health.
1994 Feb;84(2):207-10.

13.

Stein MD, O'Sullivan PS, Ellis P, Perrin H, Wartenberg A. Utilization of medical

services by drug abusers in detoxification. Journal of Substance Abuse.
1993;5(2):187-93.

14.

Sheridan J, Wheeler A, Walters C. Health problems and help-seeking activities of

methadone maintenance clients at Auckland Methadone Service (AMS): potential for
community pharmacy service expansion? Harm Reduct J. 2005;2:25.

15.

Wright NM, Tompkins CN. How can health services effectively meet the health needs
of homeless people? British Journal of General Practice. 2006 Apr;56(525):286-93.

16.

McGeary KA, French MT. Illicit drug use and emergency room utilization. Health
Services Research. 2000 Apr;35(1 Pt 1):153-69.

353

17.

Gray SD, Fatovich DM, McCoubrie DL, Daly FF. Amphetamine-related presentations
to an inner-city tertiary emergency department: a prospective evaluation. Medical
Journal of Australia. 2007 Apr 2;186(7):336-9.

18.

Topp L, Iversen J, Wand H, Day C, Kaldor J, Maher L. Representativeness of

injecting drug users who participate in HIV surveillance: results from Australia's
Needle and Syringe Program Survey. Journal of Acquired Immune Deficiency
Syndromes. 2008 Apr 15;47(5):632-8.

19.

MacDonald MA, Wodak AD, Dolan KA, van Beek I, Cunningham PH, Kaldor JM.
Hepatitis C virus antibody prevalence among injecting drug users at selected needle
and syringe programs in Australia, 1995-1997. Collaboration of Australian NSPs.
Medical Journal of Australia. 2000 Jan 17;172(2):57-61.

20.

MacDonald M, Wodak AD, Ali R, Crofts N, Cunningham PH, Dolan KA, et al. HIV
prevalence and risk behaviour in needle exchange attenders: a national study. The
Collaboration of Australian Needle Exchanges. Medical Journal of Australia. 1997
Mar 3;166(5):237-40.

21.

StataCorp. Stata Statistical Software: Release 11; 2009.

22.

Australian Bureau of Statistics. Health services: patient experiences in Australia,

2009. Available at:
http://www.abs.gov.au/ausstats/abs@.nsf/detailspage/4839.0.55.0012009. Canberra;
2010.

23.

Cisneros GO, Douaihy AB, Kirisci L. Access to Healthcare Among Injection Drug
Users at a Needle Exchange Program in Pittsburgh, PA. Journal of Addiction
Medicine. 2009 Jun;3(2):89-94.

354

24.

Merrill JO, Rhodes LA, Deyo RA, Marlatt GA, Bradley KA. Mutual mistrust in the
medical care of drug users: the keys to the narc cabinet. Journal of General Internal
Medicine. 2002;17:32733.

25.

Drumm RD, McBride DC, Metsch L, Page JB, Dickerson D, Jones B. The rock
always comes first: drug users accounts about using formal health care. Journal of
Psychoactive Drugs. 2003;35:4619.

26.

Chitwood DD, McBride DC, French MT, Comerford M. Health care need and
utilization: a preliminary comparison of injection drug users, other illicit drug users,
and nonusers. Substance Use & Misuse. 1999 Mar-Apr;34(4-5):727-46.

27.

Falck RS, Wang J, Carlson RG. Health status of illicit stimulant drug users in rural
Ohio. Journal of Psychoactive Drugs. 2007 Nov;Suppl 4:401-5.

28.

Chen CY, Lin KM. Health consequences of illegal drug use. Current Opinion in
Psychiatry. 2009 May;22(3):287-92.

29.

von Hippel C, Brener L. Specificity of Discrimination: Does It Matter From Whence

It Comes? Journal of Applied Social Psychology. 2012;42(4):1029-42.

30.

Abouyanni G, Stevens LJ, Harris MF, Wickes WA, Ramakrishna SS, Ta E, et al. GP
attitudes to managing drug and alcohol-dependent patients: a reluctant role. Drug and
Alcohol Review. 2000;19:165-70.

31.

Silins E, Conigrave KM, Rakvin C, Dobbins T, Curry K. The influence of structured

education and clinical experience on the attitudes of medical students towards
substance misusers. Drug and Alcohol Review. 2007;26:191-200.

32.

Hopwood M, Treloar C, Bryant J. Hepatitis C and injecting-related discrimination in

New South Wales, Australia. Drugs: Education, Prevention and Policy. 2006;13:6175.

355

33.

Islam MM, Topp L, Conigrave KM, Beek Iv, Maher L, White A, et al. The reliability
of sensitive information provided by injecting drug users in a clinical setting:
clinician-administered versus audio computer-assisted self-interviewing (ACASI).
AIDS Care. 2012;24(12):1496-503.

34.

Kwan L, Ho CJ, Preston C, Le V. Puentes clinic: an integrated model for the primary
care of vulnerable populations. The Permanente Journal. 2008;12(1):10-5.

35.

Lauretta E, Grau LE, Arevalo S, Catchpool C, Heimer R. Expanding harm reduction

services through a wound and abscess clinic. American Journal of Public Health.
2002 Dec;92(12):1915-7.

36.

Bruce RD. One stop shopping bringing services to drug users. International Journal
of Drug Policy. 2012;23(2):104.

37.

Pollack HA, Khoshnood K, Blankenship KM, Altice FL. The impact of needle
exchange-based health services on emergency department use. Journal of General
Internal Medicine. 2002 May;17(5):341-8.

38.

Des Jarlais DC, McKnight C, Goldblatt C, Purchase D. Doing harm reduction better:
syringe exchange in the United States. Addiction. 2009 Sep;104(9):1441-6.

39.

van Beek I. Case study: accessible primary health care-a foundation to improve health
outcomes for people who inject drugs. International Journal of Drug Policy. 2007
Aug;18(4):329-32.

40.

Norman J, Mugavin J, Swan A. Evaluation of the primary health services: Fitzroy,

Victoria: Turning Point Alcohol and Drug Centre; 2006.

41.

Day CA, Islam MM, White A, Reid SE, Hayes S, Haber PS. Development of a nurseled primary healthcare service for injecting drug users in inner-city Sydney.
Australian Journal of Primary Health. 2011;17:10-5.

356

42.

Cronquist A, Edwards V, Galea S, Latka M, Vlahov D. Health care utilization among

young adult injection drug users in Harlem, New York. Journal of Substance Abuse.
2001;13(1-2):17-27.

43.

Kerr T, Wood E, Grafstein E, Ishida T, Shannon K, Lai C, et al. High rates of primary
care and emergency department use among injection drug users in Vancouver.
Journal of Public Health (Oxf). 2005 Mar;27(1):62-6.

44.

Ochoa KC, Hahn JA, Seal KH, Moss AR. Overdosing among young injection drug
users in San Francisco. Addictive Behavior. 2001 May-Jun;26(3):453-60.

45.

Bogstrand ST, Normann PT, Rossow I, Larsen M, Morland J, Ekeberg O. Prevalence

of alcohol and other substances of abuse among injured patients in a Norwegian
emergency department. Drug and Alcohol Dependence. 2011 Sep 1;117(2-3):132-8.

46.

Harris HW, Young DM. Care of injection drug users with soft tissue infections in San
Francisco, California. Archives of Surgery. 2002 Nov;137(11):1217-22.

47.

Moller LF, Matic S, van den Bergh BJ, Moloney K, Hayton P, Gatherer A. Acute
drug-related mortality of people recently released from prisons. Public Health. 2010
Nov;124(11):637-9.

48.

Binswanger IA, Stern MF, Deyo RA, Heagerty PJ, Cheadle A, Elmore JG, et al.
Release from prison--a high risk of death for former inmates. New England Journal of
Medicine. 2007 Jan 11;356(2):157-65.

49.

Iversen J, Topp L, Maher L. Australian NSP Survey National Data Report 1995-2010:
Prevalence of HIV, HCV and injecting and sexual behaviour among NSP attendees.
Sydney: Kirby Institute for Infection and Immunity in Society, UNSW; 2011.

50.

White B, Day C, Maher L. Self reported risk behaviour among injecting drug users:
self versus assisted questionnaire completion. AIDS Care. 2007 Mar;19(3):441-7.

357

51.

Choi BC, Pak AW. A catalog of biases in questionnaires. Preventing chronic disease.
2005 Jan;2(1):A13.

52.

Topp L, Iversen J, Conroy A, Salmon AM, Maher L. Prevalence and predictors of

injecting-related injury and disease among clients of Australia's needle and syringe
programs. Australian and New Zealand Journal of Public Health. 2008 Feb;32(1):347.

358

MRN
Surname
Given Names
Address

INTAKE / ASSESSMENT FORM

Redfern Harm Minimisation Clinic

DOB
Sex
Hospital/Facility

Medicare Number: _

ALLERGIES:
DATE:

TIME:

CLINICIAN NAME:

DESIGNATION:

Title: _______ Surname: ___________________________

Given Name2:_________________________

___________

Given Name: ____________________________

Preferred Name/Alias (please circle):_____________________

DOB: _____/_____/__________ Age: __________ Sex: Male Female

Other

Not stated

Street Address: ___________________________________________________________________________

Suburb: ______________________________________________________ Postcode: __________________
Ph No: Home: ______________________ Work: ______________________ Other: _____________________
Fathers Full Name: ________________________________ Mothers Maiden Name: ____________________
Country of Birth: ______________________________ Ethnicity: _____________________________________
Is client of Aboriginal or Torres Strait Islander origin?

No

Aboriginal Yes Torres Strait Islander Yes

Aboriginal and Torres Strait Islander

01Yes

DV form completed: 01Yes

02No

Child Protection form completed: 01Yes

02No

Source of Referral to Treatment

01 Self
13 Non-Residential Community Health Centre
02 Family Member/Friend
14 Other Non-Health Service Agency
03 General Practitioner
15 Police Diversion
04 Medical Officer/Specialist
16 Court Diversion
05 Psychiatric Hospital
17 Other Criminal Justice Setting
06 Other Hospital
18 Workplace (EAP)
07 Residential Community Mental Health Care Unit
19 Family and Child Protection Services
08 Residential Alcohol and Other Drug Treatment Agency
20 Needle and Syringe Program
09 Other Residential Community Care Unit
21 Medically Supervised Injecting Centre
10 Education Institution
98 Other
11 Non-Residential Community Mental Health Centre
99 Not Stated / Inadequately Described
12 Non-Residential Alcohol and Other Drug Treatment Agency

Referral Agency: _______________________________________________Phone:____________________

Primary Reason for Presentation

Secondary Reason for Presentation

DV
CP
BBV ass.
DH ass.
MH ass.
SH ass.
Psychosocial
Counselling
Vein Care
Wound Care
Residential Rehab

Welfare
Antenatal
Postnatal

HEP B Immunisation
SH Screen
Womens Health
Inpatient residential
Withdrawal Management
Outpatient withdrawal
Day Program Rehab.

DV
CP
BBV ass.
DH ass.
MH ass.
SH ass.
Psychosocial
Counselling
Vein Care
Wound Care
Residential Rehab

Welfare
Antenatal
Postnatal

HEP B Immunisation
SH Screen
Womens Health
Inpatient residential
Withdrawal Management
Outpatient withdrawal
Day Program Rehab

Presenting Issue / Comments:

359

WHAT AGE DID YOU FIRST INJECT:________________________

DRUG HISTORY FOR THE PAST:

3 MONTHS

6 MONTHS

LONGEST TIME DRUG FREE SINCE FIRST INJECTING:___________________________

12 MONTHS
MAIN DRUG OF ISSUE THIS VISIT: ____________________________

Drug Category

Opioids
(e.g. Heroin, MS Contin,
Oxycontin, tramadol,
Panadeine Forte,
Methadone)
* L = Licit / I = Illicit
B = Both

Amphetamine
(e.g. Speed)

Methamphetamine
(e.g. Ice)

Cocaine
Benzodiazepines *
(e.g. Valium, Serapax)

Alcohol
Cannabis
Nicotine
Steroids
Party Drugs
(e.g. Ecstasy, Trip)

Other:

Drug used

Frequency Of Use
Daily, Weekly, Monthly

Amount Used Per

Day

Last Used

Route of
Administration

IDU
IMI
Smoke Oral

Snort
Insert

IDU
Smoke
IDU
Smoke
IDU
Smoke
IDU
Smoke
IDU
Smoke
IDU
Smoke
IDU
Smoke
IDU
Smoke
IDU
Smoke

IMI
Oral
IMI
Oral
IMI
Oral
IMI
Oral
IMI
Oral
IMI
Oral
IMI
Oral
IMI
Oral
IMI
Oral

Snort
Insert
Snort
Insert
Snort
Insert
Snort
Insert
Snort
Insert
Snort
Insert
Snort
Insert
Snort
Insert
Snort
Insert

IDU
Smoke
IDU
Smoke
IDU
Smoke
IDU
Smoke
IDU
Smoke

IMI
Oral
IMI
Oral
IMI
Oral
IMI
Oral
IMI
Oral

Snort
Insert
Snort
Insert
Snort
Insert
Snort
Insert
Snort
Insert

360

ID label here

Principal Source of Income (tick one box only)

Living Arrangement (tick one box only)

01
02
03
04
05
06
07
08
98
99

01
02
03
04
05
06
07
08
98
99

Alone
Spouse/Partner
Alone with child(ren)
Spouse/partner and child(ren)
Parent(s)
Other relative(s)
Friend(s)
Friend(s)/parent/s/relative(s) and child(ren)
Other
Not stated/inadequately described

07
08
09
10
98
99

Shelter/Refuge
Prison/Detention Centre
Caravan on a serviced site
No usual residence/homeless
Other
Not Known

Full-time Employment
Part-time Employment
Temporary Benefit (e.g. unemployment)
Pension (e.g. aged, disability)
Student Allowance
Dependant on others
Retirement Fund
No Income
Other
Not Stated / Inadequately Described

Usual Accommodation (tick one box only)

01
02
03
04
05
06

Rented house or flat (public or private)

Privately owned house or flat
Boarding House
Hostel/Supported Accommodation Service
Psychiatric home/hospital
Alcohol/Other Drug Treatment Residence

Previous D&A Treatment (tick all relevant)

Detox
Residential withdrawal management
Outpatient withdrawal management
Self/Home withdrawal
Rehabilitation
Residential Rehabilitation
Day Program Residential Activities
Pharmacotherapy
Methadone
Buprenorphine
Buprenorphine/Naloxone
Naltrexone
Alcohol
Acamprosate /Campral
Disulfiram /Antabuse
Naltrexone
Other Maintenance Therapy
Smoking Cessation

No. of Treat.

Year of 1st

Year last Treat.

Other
Interventions

No. of Treat.

Year of 1st

Length of Treat.

Highest Dose

No. of Treat.

Year of 1st

Length of Treat.

Comments/further relevant information: ..........................................................................................................................................

.................................................................................................

361

Blood Bourne Virus Assessment

(also use as HIV and HCV Pre-test discussion)

BBV Transmission Risks (including injecting)

Have you ever injected drugs? ............................................................................................... .01 Yes

02

No

02

No

02

No

02

No

Age first injected & drug: age, ..drug

Have you ever had a hepatitis-like illness and/or jaundice: .. 01 Yes

When: ..

Details: .

Have you ever had a blood transfusion/blood product (before 1990)? .01 Yes
If yes, when? .
Have you ever been to prison? ..01 Yes
If yes, year last released ...
If yes, did you engage in any risk behaviour?................................................................................... 01 Yes

02

No

Do you have tattoos/body piercing?.........................................................................................01 Yes

02

No

If yes: Professional Pre 1990?................................................................................................... 01 Yes

02

No

Home made/In prison 01 Yes

02

No

Was the risk? injecting and/or sexual

No: . days weeks

When did you last inject?

months

years

What has been your injectable drug of choice in last 12 months? (tick one only)
heroin

cocaine amphetamine methadone

Benzo Other

How many times have you used a fit after someone else? (including sexual partner)
never

2-5x

6-10x 11-50x

>50x Date last shared? ..

never shared
tourniquet

Have you shared injecting paraphernalia?

needle syringe spoon filter H2O

straw Date last shared? .........................

Specific risk episodes in last 12 months .

Barrier to safer use:

FILE IN CLINICAL RECORD

BINDING MARGIN - NO WRITING

..

Test
HIV
HCV
HBV
HAV

Last tested

Result

Results received

01Yes
+ve 02 -ve
01 Yes
01 +ve
02 -ve
01 Yes
01 +ve
02 -ve
01 Yes
01 +ve
02 -ve
If a positive result to any of the above, year first diagnosed
01

HIV .

Vaccination
HBV VAX
HAV VAX

HCV

1st vax
01Yes
01Yes

02No
02No

2nd vax
01Yes
01Yes

02No
02No

02 No
02 No
02 No
02 No

03
03
03
03

Unknown
Unknown
Unknown
Unknown

HBV

3rd vax
01Yes

02No

04 Never Tested
04 Never Tested
04 Never Tested
04 Never Tested

HAV .

Completed
01 Yes
01 Yes

02 No 03 Unknown
02 No 03 Unknown

362

Blood Bourne Virus Assessment Cont.

SEXUAL HEALTH ASSESSMENT including unsafe sex Transmission Risks
These questions relate to any unprotected penetrative sex: 01 since your last HIV test

02 if never tested

(unprotected sex includes with regular partner and a broken condom)

Who do you prefer to have sex with?

01 male

02 female 03 Both

Have you ever worked in the sex industry?

01 Yes

02 No

Do you currently work in the sex industry?

01 Yes

02 No

Parlour

Street Private

If Yes,
Last unprotected, penetrative sex?

Never * days

*NB: if 72 hours since LUSI offer PEP (see protocol)

Is PEP required:

(includes regular partner and a broken condom)

04 Transgender

Yes, in last 12/12 Yes, > 12/12 ago

week
01Yes

Stripper

months

Escort

years

02No

How many different partners have you had UPSI with over the past 12 months or since last HIV test?
(includes regular partner and a broken condom)

Were these partners? male

None 1 2-5 6-10

female

both

transgender

11-50

sex worker

>50
prisoner

HIV positive

(tick multiple if applies)

Did you have UPSI whilst overseas? In last 12/12

Ever
Did you have UPSI with a traveller from overseas?
Did you have?

vaginal sex
anal sex
oral

01Yes

02No

Country:

01Yes

02No

Country:

01Yes

02No

Country: .

insertive
insertive
give

receptive
receptive
receive (NB: consider swabs and lesion educ.)

Describe specific risk episodes: .

..
Barriers to safe sex: .
Last screened for STI: ..
Did you receive treatment: 01Yes

02No

Results, STI detected:

01Yes

02No

? Diagnosis: ..

Describe treatment e.g. medications and have symptoms resolved?

Do you have any abnormal symptoms at the moment?

Discharge vagina/penis (circle)

01Yes

02No

01Yes

02No

Odour 01Yes

(If Yes, please describe below)

02No

Pain / tingling / burning (circle)

Describe:
.
Do you have or have you been diagnosed with genital warts, (describe)? .....

Do you have or have you been diagnosed with genital herpes, (describe)?
.

363

WOMENS HEALTH Assessment

PAP HISTORY
Ever had a Pap smear

01Yes

02No

When? Result

Describe abnormal result and treatment if any: HPV

CIN Treatment ..
.
01Yes

02No

Gardasil Vax completed 01Yes

02No

Is Follow-up required?

Referral attended (see file notes for details) 01Yes

Vax required 01Yes

Breast Self Examination discussion and demonstration attended?

02No

01Yes

Referral for same 01Yes

02No
02No

02No

Family Hx of Breast Cancer - Mother, Grandmothers, aunties detail .

MENSTRUAL HISTORY
LMP usual cycle ..
Inter menstrual bleeding?

01Yes

02No

01Yes

Post coital bleeding?

02No

...

OBSTETRIC HISTORY
Never pregnant

currently pregnant

G... P No. of Miscarriages/TOP....................................

No. of vaginal deliverys No. Caesarean sections No. of children alive ..

Comments: ..
.
Number of children Age and gender.

Who has custody of children? .

.
Child Protection Issues:

01Yes

02No

current

past

...................................................

CONTRACEPTION
Nil, but required

Nil, not required

Nil, planning pregnancy

Condoms

OCP name? . Implanon date inserted

Depot Provera, last injection . next due .

Diaphragm

IUD, date inserted ..

Comments: ..
..

364

MENS HEALTH
Testicular Self Examination discussion attended?

01Yes

02No

Referral?

01Yes

02No

Comments:
01Yes

Prostate information and education attended?

02No

Referral?

01Yes

02No

Comments: .
Emotional health discussed e.g. depression, anxiety..

Number of children Age and gender.

Who has custody of children? ..

Child Protection Issues:

01Yes

02No

/ current

past

...................................................

MENTAL HEALTH Assessment

Have you ever been treated by a psychiatrist, a mental health practitioner or admitted to a mental health facility?
01Yes

02No

Comments: ....................................................................................................
.
Have you ever attempted self-harm?

01Yes

02No

If yes, please describe: ..

Have you ever thought about or attempted Suicide?

01Yes

02No

If yes, please describe:

..
Any current suicidal ideation?

01Yes

02No

If yes, specify details of plans, access to means etc: ...

Current prescribed mental health medication

Past prescribed mental health medication .

Clients description of current and recent mood state (anxious, depressed, agitated, stable, optimistic, happy,
pessimistic etc): ..
Clinicians description of current mental state: .................................................................................................................
...........................................................................................................................................................................................

365

GENERAL HEALTH
Temp ______________ Pulse _____________ B/P _____________________Weight ______________Kg

ALLERGIES: (To what, and describe signs and symptoms of reaction)

..
..

Skin e.g. rashes: ..

..
CNS: e.g. fits, loss of consciousness, head injuries: .
..
CVS: e.g. endocarditis, Hypertension, Cholesterol:
..
Resp: e.g. asthma: ..
.
GIT: e.g. hepatitis, cirrhosis, Renal:
..
Endo: e.g. diabetes, thyroid: ..
..
Operations:
.
Other relevant health issues: .

Family Health
Maternal (Gma, Gda, aunty and uncle)
e.g. heart disease, cancer, diabetes: .

Paternal (Gma, Gda, aunty and uncle)

e.g. heart disease, cancer, diabetes .
..
Current Prescribed Medications: .

When did you last see a doctor .. Why? ..

Do have a current GP? . 01Yes

02No

GP Details Name: .. Address: ..

Suburb: . Telephone: .
When did you last see this GP?

Reason

Dental Health: Last time seen by a dentist: ..

366

Social
Current Stressors: .
Supports:

Legal History
Current issues: ..
Require assistance:

367

ID label here

Pre-Test Discussion Checklist for HIV and Hepatitis C

Discuss and ensure understanding of:

Confidentiality .
What the test measures
-

Mode of virus transmission

-

Safer sex / safer injecting ..

Negative result
-

HIV vs. AIDS .

Hepatitis

Preventative aspects
-

HIV, Hep A, Hep B, Hep C .

Blood, semen, vaginal fluids ..
Relative risks
Level of risk of this client in view of risk behaviour reported .
.

Prognosis
-

Antibodies vs. virus (HIV/Hep B/C)

Window periods .

What this means ..

Vaccination (Hep B) .

Positive result
-

Attitude to a positive result ..

What this means for self and others ..
Relationships / support networks
Travel / insurance / workplace implications ..
Negotiating safer sex / safe injecting .
Informing potential partners .

Retest Post Window Period

3 months HIV: yes
6 months HCV: yes

Date:
no when? .
no when? .

Print clinicians name:

Signature & designation:

368

ID label here

BBV Health Post test Discussion Checklist Form

Please complete this page after providing client with test results

Review meaning of test result

Review of risk assessment and preventative aspect (safe sex and injecting practices)
Need to retest post window period? (also consider risk behaviour since tested)
Retest

Window Period
3 months HIV: yes
6 months HCV: yes

no when?
no when? .

Describe Risks since last test:

.

Print clinicians name: Date:

Signature & designation: ...

369

Clinic Database
Calendar

New

Delete

Find

ID:

REPORTS

Date of Registration:

New registrations

Date of Birth:

No. of clients

client initial:

Occasions of service

Gender:

Service contacts
BBV info/treatment
BBV screening pathology
Urine for STI
Hepatitis B Vax

Assessment

Activity on assessment

Pathology Results

Daily Activity Data

Date Created

370

Assessment
Front Desk Registration

Find

Registration ID:
Date of Birth:
client initial:
Gender:
Entry Creation Date:
Demographics

Drug Treatment

Drug Use

BBV Health

BBV Health History

Sexual Health

Gender& Mental Health

General Health

File No:
MRN:
Date of assessment:
Date of birth:
Age at assessment:
Gender:

Male

Female

Transgender

Current suburb of residence:

Aboriginal or Torres Strait Islander:

Yes

No

Unknown

Country of birth:
Highest level of education completed:
Source of referral:
Primary reason for referral:
Secondary reason for referral:
Principal source of income:
Usual accommodation:
Living arrangements:

371

To

Assessment
Front Desk Registration

Find

Registration ID:
Date of Birth:
client initial:
Gender:
Entry Creation Date:
Demographics

Drug Treatment

Drug Use

BBV Health

BBV Health History

Sexual Health

Opioid Treatment Program:

Yes

No

Most recent treatment episode:

Inpatient/resi withdrawal management:

Yes

No

Time since last treatment episode:

Outpatient withdrawal management:

Yes

No

Residential Rehabilitation:

Yes

No

Day Program Residential Activities:

Yes

No

Naltrexone:

Yes

No

Buprenorphine:

Yes

No

Buprenorphine/Naloxone:

Yes

No

Slow Release Oral Morphine:

Yes

No

Methadone:

Yes

No

Acamprosate:

Yes

No

Disulfiram:

Yes

No

Other Maintenance Pharmacotherapy:

Yes

No

Gender& Mental Health

General Health

Other:

372

To

Assessment
Front Desk Registration

Find

Registration ID:
Date of Birth:
client initial:
Gender:
Entry Creation Date:
Demographics

Drug Treatment

Drug Use

BBV Health History

First Drug Injected:

What age did you first inject:

Drug history for the past:

BBV Health

3 months

Drug Category

6 months

12 months

Frequency of use

Sexual Health

Gender& Mental Health

General Health

Longest time drug free since first injecting:

Never used
Last used

Route of administration

Heroin:
Methadone:
Other Opioids:
Other Opioids:
Amphetamine:
Methamphetamine:
Cocaine:
Benzodiazepenes:
Alcohol:
Cannabinoids:
Steroids:
Party Drugs:
Other:

373

To

Assessment
Front Desk Registration

Find

Registration ID:
Date of Birth:
client initial:
Gender:
Entry Creation Date:
Demographics

Drug Treatment

Drug Use

BBV Health

BBV Health History

Sexual Health

Did you have a blood transfusion before 1990:

Have you ever been to prison:

Gender& Mental Health

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

General Health

If yes, year last released:

Do you have tattoos/body piercing:

Have you ever used a fit after someone else:

How many times have you ever used a fit after someone else:
When did you last use a fit after someone esle (including your sex partner):

Have you ever used any other drug-using paraphernalia after someone else:
When did you last use other paraphernalia after someone else (including your sex partner):

374

To

Assessment
Front Desk Registration

Find

Registration ID:
Date of Birth:
client initial:
Gender:
Entry Creation Date:
Demographics

Drug Treatment

Last HIV Test:

Last HIV Result:
Last HCV Test:
Last HCV Result:
Last HBV Test:
Last HBV Result:
Last HAV Test:
Last HAV Result:

Drug Use

<3 months
Positive
<3 months
Positive
<3 months
Positive
<3 months
Positive

BBV Health

3-12 months
Negative

HepB vaccine:

Doses:

HepA vaccine:

Doses:

>12 months

>12 months

Gender& Mental Health

General Health

Has had in the past

Never tested/Can't remember

Has had in the past

Never tested/Can't remember

Don't know/ indeterminate

3-12 months
Negative

>12 months

Sexual Health

Never tested/Can't remember

Don't know/ indeterminate

3-12 months
Negative

>12 months

Don't know/ indeterminate

3-12 months
Negative

BBV Health History

Has had in the past

Never tested/Can't remember

Don't know/ indeterminate

Has had in the past

375

To

Assessment
Front Desk Registration

Find

Registration ID:
Date of Birth:
client initial:
Gender:
Entry Creation Date:
Demographics

Drug Treatment

Who do u prefer to have sex with:

Last screened for STI:

Drug Use

Male

BBV Health

Female

Days Ago

STI Detected:

Yes

No

Any abnormal symptoms now:

Yes

No

Have u ever worked in sex-industry:

Yes

No

Currently involved in sex work:

Yes

No

Last Unprotected sex:

Was this person:

Days Ago
Male

Both

Weeks ago

No

General Health

Transgender
<6 months

Weeks ago
Both

<6 months

6-12 months

>12 months

Never/can't remember

6-12 months

>12 months

Never/can't remember

Transgender

Last UPSI mode (Anal):

Yes

Gender& Mental Health

UPSI Partner 12Months:

Current or past diagnosis of genital warts and/or herpes:

UPSI in Overseas ever:

Sexual Health

Unknown

Female

Last UPSI mode (Vaginal):

BBV Health History

Yes

Last UPSI mode (Oral):

No

UPSI with Travelers ever :

376

To

Assessment
Front Desk Registration

Find

Registration ID:
Date of Birth:
client initial:
Gender:
Entry Creation Date:
Demographics

Drug Treatment

Drug Use

BBV Health

BBV Health History

Sexual Health

Gender& Mental Health

General Health

FEMALE
Ever had a pap smear:

Yes

No

Your last pap smear:

Currently pregnant:

Yes

No

Number of Children:

<2 years

>2 years

Was it:

Normal

Abnormal

Dont know

MALE
Testicular self exam discussion attended:

Yes

No

Prostate Info and education attended:

Yes

No

Number of Children:

MENTAL HEALTH
Yes

No

Ever attempted self-harm:

Yes

No

Current suicide ideation:

Yes

No

Current mental health medication:

Yes

No

Past metal health medication:

Yes

No

Ever treated by a psychiatrist or mental health facility:

Client's description of current mood:

377

To

Assessment
Front Desk Registration

Find

Registration ID:
Date of Birth:
client initial:
Gender:
Entry Creation Date:
Demographics

Drug Treatment

Drug Use

BBV Health

BBV Health History

Sexual Health

Gender& Mental Health

Endocrine Disorder:

Yes

No

Blood Dyscrasias:

Yes

No

Gastro Intestinal Disorder:

Yes

No

Respiratory Disorder:

Yes

No

Cerebro Vascular Disorder:

Yes

No

Musculo Skeletal Disorder:

Yes

No

Central Nervous System Disorder:

Yes

No

Genito Urinary System Disorder:

Yes

No

Integumentary Disorder:

Yes

No

Relevant Family Health History:

Yes

No

Allergies:

Yes

No

Family Health history:

Do you have a regular GP:

Yes

No

When did u last see this GP/a Doctor:

Last time seen by a dentist:

Cancer

Heart Disease

Last 12 months

1-2 years

General Health

Diabetes

>2 years

Prescribed Medication:

378

To

Haemach

Neve

Assessment
Front Desk Registration

Find

Registration ID:
Date of Birth:
client initial:
Gender:
Entry Creation Date:
Demographics

Drug Treatment

Drug Use

BBV Health

BBV Health History

Is the client a current smoker?:

Yes

No

Is the client a past smoker?:

Yes

No

When did they last quit smoking:

<12 months

Sexual Health

1-5 years ago

>5 years

1-5 years ago

>5 years

Gender& Mental Health

General Health

How many cigarettes a day did/do they smoke:

Have they ever attempted to quit:
When was the last quit attempt:
Longest period of absitence:

Yes

No

<12 months
<6 months

6-12 months

1-5 years

>5 years

379

To

Activities on assessment
Front Desk Registration

Find

Registration ID:
Date of Birth:
Client's initial:
Gender:
Entry Creation Date:
Major Activity

Assessment Type

Treatment

Consult

Other

Time Spent (minutes):

Initial Service:

Clinic health promotion

Assessment

Treatment

Consult

Results Review

Follow-up

Practitioner:
Comments:

380

Activities on assessment
Front Desk Registration

Find

Registration ID:
Date of Birth:
Client's initial:
Gender:
Entry Creation Date:
Major Activity

Assessment Type

Drug Health:

Yes

No

BBV Health:

Yes

No

Sexual Health:

Yes

No

Mental Health:

Yes

No

General Health

Yes

No

Gender Health

Yes

No

Other assessment:

Yes

No

Treatment

Consult

Other

381

Activities on assessment
Front Desk Registration

Find

Registration ID:
Date of Birth:
Client's initial:
Gender:
Entry Creation Date:
Major Activity

Assessment Type

General:

Yes

No

Blood Tests:

Yes

No

Dressing:

Yes

No

Urine:

Yes

No

Pregnancy Test:

Yes

No

Vaccination:

Yes

No

PAP:

Yes

No

Medication:

Yes

No

Treatment

Consult

Other

382

Activities on assessment
Front Desk Registration

Find

Registration ID:
Date of Birth:
Client's initial:
Gender:
Entry Creation Date:
Major Activity

Assessment Type

Treatment

Consult

Detox:

Yes

No

Contraception advice:

Yes

No

Rehab:

Yes

No

NSP:

Yes

No

Housing:

Yes

No

Psychosocial:

Yes

No

Counselling:

Yes

No

Drug Health Info:

Yes

No

OTP:

Yes

No

BBV Info:

Yes

No

Welfare/Community:

Yes

No

Sexual Health Info:

Yes

No

Peer Support:

Yes

No

Mental Health Info:

Yes

No

Follow-up:

Yes

No

General Health Info:

Yes

No

Drug treatment:

Yes

No

Women's Health Info:

Yes

No

Results:

Yes

No

Pregnancy Info:

Yes

No

Women's Health:

Yes

No

Other

383

Activities on assessment
Front Desk Registration

Find

Registration ID:
Date of Birth:
Client's initial:
Gender:
Entry Creation Date:
Major Activity

Question of the month:

Assessment Type

Yes

No

Treatment

Consult

Other

Don't Know

Other responses:

384

Pathology Results
Front Desk Registration

Find

Registration ID:
Date of Birth:
Client's initial:
Gender:
Entry Creation Date:
Virology

HBV Vaccination

HIV test date:

HIV test result:
HIV results collected:

Positive
Yes

Negative

Equivocal

No

HBV results collected:

Hep A IgG antibody:

Positive
Yes

Negative

Equivocal

Equivocal

EIA Pos

No

HCV RNA Qualitative date:

10 mlU/ml

<10 mlU/ml

HCV RNA (qualitative):

Detected

HCV RNA results collected:

Positive

Negative

Equivocal

HBsAg test date:

HBsAg test result:

HCVAb test result:

HCV results collected:

HBcAb test date:

HBcAb test result:

General Pathology Results

HCVAb test date:

HBsAb test date:

HBsAb test result:

STI

Not detc
Yes

EIA Neg

No

Genotyping date:
HCV genotype:

Positive
Yes
Positive

Negative

Equivocal

No

ALT date:
ALT result:

Negative

Equivocal/other

Hep A IgM antibody:

Normal
Positive

Elevated
Negative

Equivocal/other

385

Pathology Results
Front Desk Registration

Find

Registration ID:
Date of Birth:
Client's initial:
Gender:
Entry Creation Date:
Virology

HBV Vaccination

STI

General Pathology Results

Hepatitis B Vaccination - date dose 1 given:

Hepatitis B Vaccination - dose 1 given:

Yes

No

Yes

No

Yes

No

Hepatitis B Vaccination - date dose 2 given:

Hepatitis B Vaccination - dose 2 given:
Hepatitis B Vaccination - date dose 3 given:
Hepatitis B Vaccination - dose 3 given:
Immune response - date of test
HBsAb ml/IU:
HBsAb status:
HBsAb results collected/discussed:

Immune (10 mlU/ml)

Yes

Not immune (<10 mlU/ml)

No

HepB Booster given:

386

Pathology Results
Front Desk Registration

Find

Registration ID:
Date of Birth:
Client's initial:
Gender:
Entry Creation Date:
Virology

HBV Vaccination

STI

General Pathology Results

Urine PCR (gonorrhoea) date:

Urine PCR (gonorrhoea):

Positive

Negative

Equivocal

Positive

Negative

Equivocal

Positive

Negative

Equivocal

Urine PCR (chlamydia) date:

Urine PCR (chlamydia):
Syphilis date:
Syphilis:

387

Pathology Results
Front Desk Registration

Find

Registration ID:
Date of Birth:
Client's initial:
Gender:
Entry Creation Date:
Virology

HBV Vaccination

Cholesterol test date:

Cholesterol:

Normal

Abnormal

AFP result:

Normal

Abnormal

Urine (m/c/s) result:

Abnormal

Normal

Abnormal

Normal

Abnormal

Normal

Abnormal

Normal

Abnormal

Swab test date:

FBC (Haemoglobin):

Normal

Abnormal

Swab result:

FBC (platelets):

Normal

Abnormal

Coags test date:

FBC (WhiteBlood Cell Count):

Normal

Abnormal

Coags result:
Pap smear date:

LFT test date:

Normal

Abnormal

Pap smear result:

Other abnormal pathology result:

Iron (Fe) studies test date:

Iron (Fe) studies result:

Normal

Urine (m/c/s) test date:

Full blood count test date:

LFT result:

General Pathology Results

AFP test date:

Blood sugar test date:

Blood sugar:

STI

Normal

Abnormal

Yes

No

If yes, what are the abnormalities:

388

Daily Activity
Front Desk Registration

Find

Registration ID:
Date of Birth:
client initial:
Gender:
Entry Creation Date:
Daily Activity Data

Service Type

Date:

Referrals

Client Returned:

Time spent:

Yes

Comments

No

Returned after visit 1:

Initial service:
Practitioner:
Face to face contact:

Yes

No

Phone contact:

Yes

No

Letter contact:

Yes

No

Appointment attended:

Yes

No

389

Daily Activity
Front Desk Registration

Find

Registration ID:
Date of Birth:
client initial:
Gender:
Entry Creation Date:
Daily Activity Data

Clinic health promotion:

Assessment:

Treatment:

Consult:

Other:

Service Type

Psychological
Drug health
BBV info

Sex health
Mental health
General health

Full clinical assessment

Drug health
BBV health
General
Blood tests
Detox
Rehab
Housing

Gender health
Pregnancy info
Steroid info

Sexual health
Mental health
General health

Dressing/wounds
Urine
Counselling
OTP
Welfare/community

Results- check, access

Correspondence
Administration

Referrals

Vein care
Domestic violence
Child protection

Gender health
Domestic violence
Child protection

Pregnancy test
Vaccination
Peer support
Results
Gender health

Client appointment
Phone contact with client
Unplanned client contact

Comments

Other

Vein care
Other

Pap smear
Other
Pregnancy advice
Contraception advice
Other
Follow-up with services re: cl
Phone/letter follow-up
MO review results

Case review
Other

390

Daily Activity
Front Desk Registration

Find

Registration ID:
Date of Birth:
client initial:
Gender:
Entry Creation Date:
Daily Activity Data

Informal referral:
Formal referral:

Yes

Service Type

Referrals

Comments

No

General practitioner
Residential D & A Treatment agency
Non-residential D & A Treatment agency
Community Mental Health
Court diversion
Family and child protection service
MSIC
AMS
Support services-ADIS, SMART, NUAA
Welfare community services
Drug Health Services - OTP, counselling
Counselling (not drug specific)
RPA liver clinic

Sexual Health Service

Other

391

Daily Activity
Front Desk Registration

Find

Registration ID:
Date of Birth:
client initial:
Gender:
Entry Creation Date:
Daily Activity Data

Service Type

Referrals

Comments

Comments:

392