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An Assessment of the Community Perceptions Associated with the Victoria Needle Exchange Program Gregg, Brian 2008

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 1  TABLE OF CONTENTS  ACKNOWLEDGEMENTS .......................................................................................................................................... 3 ABSTRACT ............................................................................................................................................................. 4 EXECUTIVE SUMMARY ............................................................................................................................................ 4 FULL REPORT....................................................................................................................................................... 12 INTRODUCTION .................................................................................................................................................... 12 SECTION 1:  LITERATURE REVIEW ........................................................................................................................ 13 WHAT ARE NEEDLE EXCHANGE PROGRAMS (NEPS)? ......................................................................................................... 13 A BRIEF HISTORY OF NEPS ........................................................................................................................................... 13 EMPIRICAL EVIDENCE SUPPORTS NEPS ........................................................................................................................... 14 THE POLITICAL POLARIZATION OVER NEPS ....................................................................................................................... 15 PUBLIC OPINIONS ASSOCIATED WITH NEPS ...................................................................................................................... 16 SECTION 2:  CONTEXTUAL REVIEW ....................................................................................................................... 16 THE STATUS QUO IN VICTORIA ....................................................................................................................................... 16 The Linkages between Homelessness, Mental Health and Addictions ........................................................................ 17 A PROFILE OF VICTORIA’S IDU POPULATION ..................................................................................................................... 18 Demographic Characteristics .................................................................................................................................. 18 Drug Use Characteristics ....................................................................................................................................... 19 Use of NEP Services ............................................................................................................................................. 20 Seroprevalence of HIV and HCV ............................................................................................................................. 20 THE LIFE OF THE VICTORIA NEP ..................................................................................................................................... 21 The Birth and Development of the Program ............................................................................................................. 21 Services Offered ................................................................................................................................................... 22 Events Leading Up to the Closure of the NEP .......................................................................................................... 23 WHY IS THIS RESEARCH NECESSARY? ............................................................................................................................. 24 SECTION 3:  SURVEY METHODS AND RESULTS ..................................................................................................... 24 METHODS ................................................................................................................................................................... 24 Why Conduct a Telephone Survey? ........................................................................................................................ 24 Survey Objectives and Design ................................................................................................................................ 25 Data Collection ..................................................................................................................................................... 25 Sampling Reliability and Error ................................................................................................................................. 25 Data Quality.......................................................................................................................................................... 26 Data Limitations .................................................................................................................................................... 27 SURVEY DATA AND RESULTS.......................................................................................................................................... 27 Participant Information ........................................................................................................................................... 27 Survey Results by Theme ...................................................................................................................................... 28 SECTION 4:  IMPLICATIONS AND OPTIONS ............................................................................................................ 32 CONCLUSIONS ..................................................................................................................................................... 35 APPENDIX ............................................................................................................................................................ 36 A. THE EVENTS LEADING TO THE CLOSURE OF THE VICTORIA NEP .................................................................................. 36 BIBLIOGRAPHY .................................................................................................................................................... 38   2  LIST OF TABLES AND FIGURES  TABLE 1 - GOALS AND METHODS ........................................................................................................................................... 6 TABLE 2 - SUMMARY OF SURVEY RESULTS, CRD 2008 (N=500) ................................................................................................. 9 TABLE 3 - THE DIFFERENT SIDES OF THE NEP DEBATE ............................................................................................................ 15 TABLE 4 - THE LINKAGES BETWEEN HOMELESSNESS, MENTAL ILLNESS AND ADDICTIONS IN VICTORIA ............................................... 17 TABLE 5 - SURVEY PARTICIPANT DATA, CRD 2008 (N=500) ..................................................................................................... 28 TABLE 6 - SUMMARY OF SURVEY RESULTS, CRD 2008 (N=500) ............................................................................................... 29  FIGURE 1 - A MAP OF THE AIDS VANCOUVER ISLAND OFFICE LOCATION, VICTORIA, 2008 .............................................................. 22 FIGURE 2 - A MAP OF THE CRD MEMBER MUNICIPALITIES, 2008 ............................................................................................... 26                                   3  ACKNOWLEDGEMENTS    This research would not have been possible without the support of several key individuals and organizations and, as such, I would like to thank all the parties who contributed to this project.  First, I would like express my appreciation to my supervisors from the Vancouver Island Health Authority--Grant Hollett, Michael Pennock, Shannon Turner and Dr. Murray Fyfe--for contributing guidance, research expertise and funding during the course of this study.   I would also like to thank my University of British Columbia research advisor, Dr. Lawrence Frank, for his support and valuable advice.  Finally, I want to thank Duncan Phillips, Karen Booth and Jenylyn Jose from MITACS (Mathematics of Information Technology and Complex Systems--a graduate student intern funding organization supported by the British Columbia Ministry of Advanced Education) as they helped me obtain an Accelerate BC research grant to support this work.                          4  ABSTRACT  This study uncovers Capital Regional District (CRD) residents’ opinions, levels of knowledge, and support or opposition towards the implementation of needle exchange program (NEP) services in Victoria, British Columbia.  In order to uncover the community perceptions associated with the Victoria NEP, a public opinion telephone survey was designed and administered to a random, geographically stratified sample (n=500) of residents within the CRD.   In obtaining a geographically stratified sample, quotas were set to ensure that a representative sample was obtained from each of the thirteen member municipalities within the region.  Descriptive statistics in the form of frequency distributions have been generated for each survey item to convey the distribution of responses concerning perceptions of specific aspects of the program.  Although the primary purpose of this research is to assess the community perceptions associated with NEP services in Victoria, it also achieves three other objectives, including: (1) providing a review of contextual information pertaining to the linkages between homelessness, mental illness and addictions challenges in the CRD, (2) placing the findings of this study into the larger body of relevant knowledge via a review of the literature, and (3) developing a brief set of evidence-based practice implications and recommendations for VIHA management.   EXECUTIVE SUMMARY  BACKGROUND INFORMATION AIDS Vancouver Island (AVI) managed Victoria’s only fixed-site needle exchange program (NEP) from 1988 until its recent closure on June 1, 2008.  Due to the closure of AVI’s fixed-site NEP, Victoria’s injection drug users must obtain sterile injection equipment from alternative sources (as of autumn 2008), including: (1) a mobile needle exchange service operated out of a van by the Victoria AIDS Resource and Community Service Society (VARCS), and (2) street outreach needle exchange services offered by the Society of Living Injection Drug Users (SOLID).  Although Victoria’s injection drug users can access sterile injection equipment through mobile service providers, it is important to note that mobile NEPs are generally thought to be less effective at reducing the harm associated with injection drug use relative to fixed-site programs (Strike et al., 2006).  With this in mind, it is important to question why Victoria’s only fixed-site NEP closed its operations.   5  The termination of the fixed-site NEP in Victoria was largely driven by community resistance to the service, which reached a climax on July 5, 2007, when fifteen Cormorant Street neighbors of AVI filed an injunction suit in the British Columbia Supreme Court to shut down AVI, labeling four defendants: AVI, the Vancouver Island Health Authority (VIHA), the British Columbia Ministry of Health and Yentl Properties (the landlords of AVI’s 1601 Blanshard Street address).  This legal action was followed by the issuance of a formal notice of complaint from Yentl properties to AVI on October 2, 2007, which offered AVI sixty days to “solve the problems” or be issued a termination of lease.  AVI was unable to meet the demands of the notice of complaint within sixty days and, as such, they were served a notice of termination of lease from Yentl Properties on November 30, 2007, which stated that AVI would have six months to find a new location for the NEP (AIDS Vancouver Island, 2008).  With the goal of relocating the NEP and other harm reduction services to a new site, VIHA decided to purchase the Saint John Ambulance building on 941 Pandora Street on March 18, 2008 (Vancouver Island Health Authority, 2008).  VIHA’s proposed relocation of the NEP to the Pandora Street location received strong opposition from several Pandora Street neighbors and, therefore, VIHA decided to delay the relocation of the program. AVI and VIHA have been looking into the possibility of relocating the needle exchange to a new site close to the downtown core.  As the primary source of funding for the NEP, VIHA needs to engage the citizens of the Capital Regional District (CRD) to determine whether or not the Victoria community supports the relocation and continuation of the program.  VIHA will be better able to pin down a suitable location for the NEP in the future if it has a strong understanding of the public perceptions associated the service.  Although the main function of this research is to assess the community perceptions associated with NEP services in Victoria, it also strives to achieve three other key objectives, including: (1) providing a review of contextual information pertaining to the linkages between homelessness, mental illness and addictions challenges in the CRD, (2) placing the findings of this study into the larger body of relevant knowledge via a review of the literature, and (3) developing  a condensed set of evidence-based practice implications and recommendations for VIHA management.   RESEARCH METHODS AND GOALS This research is based around four main methods, each of which was implemented to achieve a distinct set of goals.  As such, table 1 (on the next page) briefly describes the four main methods and the associated goals.  Although this study covers a broad range of material and achieves multiple goals, it is  6  Table 1 - Goals and Methods Methods Goals 1. Literature review:   The literature review places the findings of this study into the context of a larger body of related knowledge.  Several major online research databases, including Google Scholar, JSTOR, and EBSCOhost, were extensively searched for relevant articles pertaining to the topics listed in the goals section (to the right).    1. To discuss relevant knowledge regarding: - The history of NEPs beyond the Victoria context. - The fact that a large body of empirical evidence has documented the public health benefits of associated with NEPs. - The political polarization over NEPs. - The levels of public support associated with NEPs across different jurisdictions.   2. Contextual review:  Several key data sources are reviewed, including: (1) a series of reports compiled by the City of Victoria’s Mayor’s Task Force on Breaking the Cycle of Mental Illness, Addictions and Homelessness, (2) Health Canada’s I-Track surveys, which highlight risk behaviors among Victoria’s injection drug users, (3) Victoria Cool Aid Society`s Homeless Needs Survey, and (4) a risk-behavior survey of Victoria’s injection drug users by Stajduhar et al.  2. To provide context to the final survey results through the discussion of: - The linkages between homelessness, mental health and addictions challenges in Victoria.  - The social and demographic profile of Victoria’s injection drug users. - The life of the Victoria NEP, from its conception to its closure. - Why this research is necessary. 3. Telephone survey and data analysis:   The survey was designed by the author in consultation with VIHA management and a consultant from BC Stats.  Upon its completion, the survey was administered by BC Stats (due to time constraints) to a random, geographically stratified sample of 500 residents within the CRD between August 11 and 18, 2008.  Survey participants were selected via the random digit dialing method.  Quotas were set to ensure that a representative number of participants were selected from each CRD municipality.  Frequency distributions were generated for each item, enabling the survey to uncover the most commonly held perceptions associated with the Victoria NEP.  The margin of error for the survey is +/- 4.4%. 3. To determine CRD residents’ opinions and perceptions associated with six main themes, including: - The perceived importance of the major CRD public health challenges. - Harm reduction support. - NEP awareness. - NEP support. - The Level of support for NEPs in Victoria. - Experiences with discarded needles. 4. Policy Development:   Through a critical analysis of the findings associated with the above methods, a set of recommendations regarding the planning and delivery of Victoria’s future NEP services has been developed.   4. To translate the findings of this research into a condensed set of practice implications and recommendations for VIHA management.    7  important to note that its central objective is to survey the public opinions associated with needle exchange services in Victoria.  The other topics covered in this report are intended to provide necessary background information and context to the survey findings.    SUMMARY OF FINDINGS  A. Contextual Review Findings    The Linkages between Homelessness, Mental Health and Addictions Challenges in Victoria  - Homelessness, mental illness and addictions challenges are highly related in Victoria, with many individuals facing a co-occurrence of these problems. - At least half of Victoria`s homeless residents (over 600 people) have substance abuse problems (Victoria Cool Aid Society, 2007).  Injection Drug Use Patterns in Victoria  - Between 1,500 and 2,000 injection drug users live in the CRD (Victoria Cool Aid Society, 2007). - Aboriginal people in Victoria face a disproportionate risk of becoming addicted to injection drugs (Health Canada, 2004). - Cocaine, heroin and combinations of cocaine and heroin known as “speedballs” are Victoria’s most commonly injected drugs (Public Health Agency of Canada, 2006; Stajduhar et al., 2004). - The majority of Victoria’s injection drug users have shared needles at least once, and a significant number report doing so on a regular basis (Public Health Agency of Canada, 2006). - Public spaces are the most common places of injection drug use in Victoria, and the majority of this use occurs in the downtown area (Public Health Agency of Canada, 2006).  - Many of Victoria’s injection drug users practice a range of high-risk sexual behaviors (Health Canada, 2004; Public Health Agency of Canada, 2006). - According to recent survey data, 15.4% of Victoria’s IDUs are HIV positive, 68.5% are Hepatitis C positive (HCV), and 15.4% are both HIV and HCV positive (Public Health Agency of Canada, 2006). - Of Victoria’s injection drug users who have contracted HIV or Hepatitis C, between 20% and 30% are unaware that they are carriers of these viruses (Public Health Agency of Canada, 2006).     8  Existing Needle Exchange Services in Victoria  - NEP services are heavily used in Victoria, with approximately 400 clients using the services on a weekly basis, and 2,000 clients using the services annually (Victoria AIDS Resource and Community Service Society, 2008).  - Despite the high demand for NEP services in Victoria, community resistance and legal action against Victoria’s only fixed-site NEP led to its closure on June 1, 2008. - Sterile injection equipment is still available in Victoria, with many pharmacies carrying the necessary supplies and several non-profit agencies offering mobile NEP services.   B. Literature Review Findings  NEP History - NEPs have been widely implemented in many countries since their conception in Amsterdam in 1984 (van den Hoek et al., 1989). - In North America, the first NEPs were implemented in 1988 in Tacoma, Washington as well as several Canadian cities, including Vancouver, Toronto and Montreal (Strathdee and Vlahov, 2001).  NEP Effectiveness - A significant body of empirical research has documented the fact that NEPs can be effective at reducing the incidence of high-risk injection behaviors associated with the spread of blood-borne pathogens (World Health Organization, 2007).  Public Opinions on NEPs - Public opinion surveys regarding NEPs have produced varied results, with public support for these programs ranging from approximately 30% to 90% across different jurisdictions around the globe. - A public opinion poll administered by researchers in Vancouver found that 71% of the respondents supported the implementation of a safe injection site (Kent, 2001).  - Given the lack of research pertaining to the public opinions associated with NEPs in the Canadian context, it was difficult to predict the results of the present survey.  9  C. Survey Results  Table 2 (below) shows the survey findings.  The results are assessed in more detail in the full report.  Table 2 - Summary of Survey Results, CRD 2008 (n=500)      Number  Percent  1. Perceived Importance of CRD Public Health Issues        Public health challenges rated as “very important” or “somewhat important” 1             Water quality 488 97.6%              Food safety 484 96.8%              Homelessness 475 95.0%              Drug and alcohol addictions 473 94.6%              Air quality 470 94.0%              Wastewater and sewage treatment 470 93.9% 2. Harm Reduction Support        Harm Reduction Support             Support 353 70.6%             Oppose 93 18.6% 3. NEP Awareness         NEP Awareness             Aware 484 96.9%             Unaware 16 3.1%        Awareness of NEPs in Victoria                 Aware 231 46.2%             Unaware 231 46.2%        Perceived NEP Locations in Victoria              Downtown 52 22.4%             Cormorant Street 34 14.6%             Other 33 14.2%             Pandora Street 31 13.3%             Mobile exchange 28 12.2%             No response 25 10.8%             Blanchard Street 16 7.1%             Don't know 16 6.9%             Douglas Street 4 1.7% Note: 1 The percentages and numbers listed are based on a cumulative representation of the total percent of individuals rating each public health problem as either “very important” or “somewhat important.”    10   Number Percent 4. NEP Support         NEP Support                 Support 347 69.4%              Oppose 117 23.4%        Support for a NEP in "Your Community”                Support 313 62.6%              Oppose 153 30.6%         Support for a NEP Downtown               Support   323 64.0%              Oppose 145 29.0% 5. The Perceived Benefits and Challenges of NEPs         Perceived NEP Benefits                  Reduce disease transmission 282 56.4%              Safe needle disposal 87 17.5%              None 72 14.4%              Contact with treatment providers 61 12.3%              Support and Information 60 12.0%              Medical attention 49 9.7%              Keeps drug users safe 12 2.4%              Harm reduction 9 1.9%              Reduce healthcare costs 7 1.5%              Monitoring of drug users 5 0.9%              Centralization of drug users 4 0.8%         Perceived NEP Drawbacks                  Encourage drug use 162 32.5%              None 71 14.2%              Bad for community/local business 62 12.4%              Increased crime        46 9.1%              Lowers chance of quitting drugs 35 7.1%              Waste of funds/tax dollars 29 5.7%              Litter in surrounding areas     25 5.1%              Drugs are bad/illegal 20 4.0%              Not effective 11 2.2%              Lack of support/funding 8 1.5%              Concentration of drug users 7 1.3%     11  Number Percent 6. Discarded Needles        Found Discarded Needles in “Your Neighbourhood” in Past Six Months             Yes 67 13.5%                  No 430 85.9%             Found Discarded Needles Downtown in Past Six Months               Yes 180 36.0%             No 310 62.0%                   D. Practice Implications  Due to the highly political and potentially controversial nature of planning NEP services, it is apparent that VIHA management will need to develop a sound, evidence-based rationale for any decisions they make on this matter.  If VIHA’s primary goal is to reduce the public health consequences of injection drug use in Victoria, the findings of this research suggest that VIHA should: – Continue to develop and support aggressive strategies to address the broader challenges of homelessness, mental health and addictions in the CRD. – Engage local stakeholders to determine the future form and function of Victoria`s NEP services. – Support the implementation of a fixed-site NEP. – Ensure that future NEP services act as a “bridge to treatment.” – Design future NEP facilities to reduce the negative impacts on adjacent businesses and residents. – Encourage enhanced law enforcement near future NEP services. – Support intensified clean-up efforts of discarded needles in public spaces.   – Develop alternative modes of needle distribution. – Explore the feasibility of implementing a safe consumption site.        12  FULL REPORT  INTRODUCTION  During the summer of 2008, Victoria’s only fixed-site needle exchange program (NEP) closed its operations despite growing demand for its services (Victoria AIDS Resource and Community Service Society, 2008).  The program closed due to community resistance and a related injunction law suit that was filed against the program’s operators by a group of adjacent business owners and residents (AIDS Vancouver Island, 2008).  The community members in opposition of the program argued that public disorder and sanitation problems near the NEP were affecting local businesses and general quality of life for residents.  The closure sparked a polarized political debate in the broader Victoria community, with some individuals in support of the decision and others citing the potential public health consequences (for example, the elevated risk of needle sharing and bloodboorne pathogen transmission among the city’s injection drug users).   The termination of the NEP and the subsequent politicized public debates led the Vancouver Island Health Authority--the regional health organization that funds the Victoria NEP--to design and administer a telephone survey to 500 Capital Regional District (CRD) residents to determine the public opinions associated with the program.  This report will not only highlight the results of the survey, but it will achieve three other objectives, including:  (1) conducting a review of the literature to highlight the history, empirical information, and public opinions associated with NEPs, (2) highlighting contextual information pertaining to the linkages between homelessness, mental illness and addictions challenges in the CRD, and (3) briefly exploring key options and considerations for VIHA management prior to the planning and delivery of a future fixed-site NEP program in Victoria.    Key Research Question:  “Does the Victoria community support the continuation of a fixed-site NEP?” 13  SECTION 1:  LITERATURE REVIEW  What are Needle Exchange Programs (NEPs)? NEPs are programs that provide injection drug users access to sterile injection equipment, referrals, counseling, health education and other services.  In many parts of the world, the terms syringe exchange program (SEP) and needle and syringe program (NSP) are used interchangeably or in place of “NEP” (Strike et al., 2006).  It is important not to confuse NEPs with safe consumption sites (SCSs), which typically offer injection drug users a safe place to consume drugs as well as needle exchange services.    A Brief History of NEPs  The first NEP began its operations in Amsterdam, the Netherlands, in 1984.  The program was initially established by a drug-user organization but it was quickly adopted by the Municipal Health Department of Amsterdam and became a central component of HIV prevention among the city’s injection drug users (van den Hoek et al., 1989).  The program is still running today and Amsterdam’s injection drug users can exchange syringes at twelve clinical outposts and through a methadone bus that offers free pathogen testing services and counseling, methadone maintenance, and screening for HIV to Dutch residents (Van Ameijden and Coutinho, 1998). Since the mid-1980’s, NEPs have been implemented in developed and developing countries around the globe.  For example, a NEP was implemented as early as 1995 in Katmandu, Nepal.  Feasibility studies of existing NEPs have been conducted in Vietnam, where involvement from drug users and community members proved to be important aspects that impacted the acceptability of the programs (Quan and Abdul-Quader, 1998).  NEPs have even been implemented among the remote hill tribes of Northern Thailand and in prisons in Australia and Switzerland, where they have generally received widespread acceptance.  In North America, the first NEPs were implemented in 1988 in Tacoma, Washington as well as several Canadian cities, including Vancouver, Toronto and Montreal (Strathdee and Vlahov, 2001).   The Victoria NEP also started its operations in 1988.  In the United States, the first NEPs were implemented by nongovernmental organizations including the National AIDS Brigade and the North American Syringe Exchange Effort (Strathdee and Vlahov, 2001).  In the Canadian context, however, NEPs were initially supported by the Federal Minister of Health and now there are over two hundred NEPs operating in a range 14  of rural and urban settings across Canada (Public Health Agency of Canada, 2003).  Regardless of their location, these programs have generally focused on preventing the circulation of contaminated syringes through the provision of sterile injection equipment to injection drug users (Strike et al., 2006).    Empirical Evidence Supports NEPs  A significant body of research has documented the fact that NEPs can be effective at reducing the incidence of high-risk injection behaviors associated with the spread of blood-borne pathogens.  As early as 1986, researchers in Amsterdam found that NEP participation was associated with declines in injection frequency and needle sharing (Buning et al., 1986).  Since that time, many studies have suggested that NEPs are associated with reductions in the incidence of HIV, Hepatitis B virus (HBV) and Hepatitis C virus (HCV) infections (Normand and Vlahov, 1995; Van Ameijden and Coutinho, 1998; Lurie et al., 1993; Des Jarlais et al., 1995; Hagan et al., 1995; Vlahov et al., 1997; and Drucker et al., 1998), decreased rates of syringe reuse (Heimer et al., 1998), decreased rates of needle sharing (Vlahov et al., 1997; Bluthenthal et al., 2000; and Vertefeuille et al., 2000), and increased rates of entry into drug treatment programs (Heimer, 1998; Brooner et al., 1998; and Strathdee et al., 1999).  A range of studies have shown, for example, that NEP staff regularly refer their clients to drug treatment programs.  Several studies have also suggested that some injection drug users attend NEPs to seek admission to drug treatment centers (Strathdee et al., 1999). In light of the public health benefits associated with NEPs several major health organizations, including the World Health Organization (WHO, 2004), the United States Preventive Services Task Force (1996) and the American Medical Association (1996), view the implementation of NEPs as essential for the prevention of HIV transmission amongst injection drug users.  These organizations support the use of NEPs because empirical evidence has consistently demonstrated that doing nothing to prevent the spread of HIV, HBV, HCV and other bloodborne pathogens amongst injection drug users exacerbates avoidable public health consequences (Strike et al., 2006).   Although there is a great deal of empirical evidence supporting the effectiveness of NEPs, these services remain controversial in many jurisdictions.      15  The Political Polarization over NEPs  Despite the fact that many empirical studies have documented the public health benefits of NEPs, they have often been a source of political polarization amongst the general public and legislators.  Regardless of this, most public health officials argue that scientific evidence has consistently demonstrated that NEPs prevent the transmission of certain communicable diseases and do not increase drug use (Buchanan et al., 2003).  Although NEPs have been a source of political debate in many cities, it is important to note that the findings of the present survey (see the results in section 3) suggest that most CRD residents (approximately 70%) are supportive of these programs (Vancouver Island Health Authority, 2008).  Still, it is important to understand both sides of the polarized NEP debate.    In their article, Politics of Needle Exchange, Buchanan et al. clearly illustrate the different sides of the NEP debate through a schematic diagram (see table 3 below).  The diagram contrasts the divergent political viewpoints associated with typical proponents and opponents of NEPs.  More specifically, it illustrates NEP proponents as politically progressive individuals who believe science should guide the public health policies pertaining to NEPs.  In contrast, NEP opponents are depicted as politically conservative individuals who believe God and ethics should be the ultimate authorities guiding public health decisions.  Although the diagram oversimplifies the complexities of the debate, it provides a useful   framework so long as one understands that there is likely more of an incremental gradient between the two extreme viewpoints.   Table 3 - The Different Sides of the NEP Debate  Proponents Opponents Problem Narrowly-defined:  HIV transmission Broadly-defined:  Moral degeneration Goal HIV prevention Human improvement  Solution NEP Affirmation of the good/proscription of the bad behavior Moral orientation Progressive Orthodox /conservative Legitimate authority Science God Type of argument Empirical, scientific Normative, ethical Ethical priorities Rights The Good Ethical motivation Pragmatic Utopian Symbolic meaning of NEP Social Justice Moral degeneration Source:  Adopted from Buchanan et al., 2003 16  Public Opinions Associated with NEPs   Many researchers have designed surveys to assess the public opinions associated with NEPs across different geographic areas.   These studies have produced varied results, with public support for NEPs ranging from approximately 30% to 90% across the globe.   In the United States, public opinion surveys have found that public support towards NEPs ranges from approximately 29% to 66% (Louis Harris and Associates, 1997; Princeton Survey Research Associates, 1995), which is relatively low in comparison to the level of public support found in most other nations.  In Australia, public support towards NEPs ranges from 50% to 90% according to data gathered from several public opinion surveys that were administered between 1990 and 2004 (Australian Institute of Health and Welfare, 1999; Australian Institute of Health And Welfare, 2002; Australian Institute of Health and Welfare, 2005; Lenton and Phillips, 1997; Schwartzkoff et al., 1990; and MacDonald et al., 1999). According to the Public Health Agency of Canada, there have been no formal studies of public opinion toward injection drug use in Canada (Public Health Agency of Canada, 2003).  However, a public opinion poll administered by researchers in Vancouver found that 71% of the respondents supported the implementation of a safe consumption site (Kent, 2001).    SECTION 2:  CONTEXTUAL REVIEW  The Status Quo in Victoria  According to a recent report from the City of Victoria, the city is currently experiencing unprecedented levels of public disorder, family breakdown, poverty, homelessness, mental illnesses and drug addictions.  With the goal of reducing the prevalence of these social, economic and public health problems, Victoria Mayor Alan Lowe established the Task Force on Breaking the Cycle of Homelessness, Addictions and Mental Health in May of 2007.  In spurring on this initiative, Lowe’s objective was clear: to develop more effective solutions to deal with the problems of the addicted, mentally ill and other homeless residents on the streets of Victoria and to reduce the impact these issues are having on the city (City of Victoria, 2007a).   The Task Force discovered that there are over two hundred organizations operating in Greater Victoria to address the needs of the city’s addicted, mentally ill, or homeless people.  Of these two hundred organizations, more than twenty funding agencies are already spending approximately $76 million annually 17  on housing and mental health and addictions services to aid this segment of the population.  The Task Force also found that at least $62 million is being spent annually on other directly related services, such as hospital services, policing, jails, emergency shelters and cleaning (City of Victoria, 2007b).  Although a vast amount of resources are currently being targeted towards the problems of homelessness, mental illnesses and addictions in Victoria, these challenges are becoming more widespread.  The Linkages between Homelessness, Mental Health and Addictions The Victoria Cool Aid Society’s Homeless Needs Survey (2007) found that the CRD is home to approximately 1,242 homeless or unstably housed individuals.   However, a recent report compiled by the City of Victoria states that the homeless resident count was likely an undercount and that there is probably more than 1,500 homeless individuals in the city (City of Victoria, 2007a).  Although the Homeless Needs Survey was unable to pin down exact numbers for the current homeless population in Victoria, it uncovered a significant amount of useful information pertaining to the city’s highly linked challenges associated with mental illness, addictions and homelessness.  Table 4 (below) provides a breakdown of the Homeless Needs Survey results that are relevant to the present study.  The fact that approximately half of the region’s homeless population has substance abuse problems with alcohol and injection drugs and that many of these same individuals have also contracted HIV and HCV clearly suggest that something has to be done to improve the status quo.   Table 4 - The Linkages between Homelessness, Mental Illness and Addictions in Victoria - Approximately 1,242 CRD residents are homeless and mental illness and substance abuse are the norm among this segment of the population, with at least 40% (more than 500 people) suffering from a diagnosable mental illness. - Of Victoria’s homeless residents, at least half (over 600 people) have substance abuse problems with alcohol and injection drugs. - Heroin and crack are the most commonly used injection drugs amongst the homeless population. - It is estimated that there are 1,500 to 2,000 injection drug users (IDUs) in Victoria and, of these, approximately 40% are homeless or unstably housed. - The IDUs are generally young; 75% are male and 20% are aboriginal. - 13% of Victoria’s homeless residents are HIV positive and 74% are infected with HCV. - Public injection is common in Victoria as 30% of drug users report that the street is the most common place they inject drugs. - 25% of homeless residents have co-occurring mental health and dictions problems. Source:  Victoria Cool Aid Society, 2007 18  A Profile of Victoria’s IDU Population  Demographic Characteristics  Total Population: - Approximately 1,500 to 2,000 IDUs live in the CRD (Victoria Cool Aid Society, 2007).  Age: – The majority of Victoria’s IDUs (approximately 70%) fall between the ages of 30 and 49 (Public Health Agency of Canada, 2006; Health Canada, 2004).   – Approximately two-thirds of Victoria’s IDUs started injecting drugs before the age of 20 (Stajduhar et al., 2004).  Sex: - Survey data suggests that between 70% and 75% of Victoria’s IDUs are male (Health Canada, 2004; Public Health Agency of Canada).    Ethnicity: - Aboriginal people in Victoria face a disproportionate risk of becoming addicted to injection drugs according to recent survey data which suggests that up to 20.0% of Victoria’s IDUs are aboriginal despite the fact that aboriginals comprise less than 3.0% of the CRD population (Health Canada, 2004; Public Health Agency of Canada).  Education: - Recent survey data suggests that between 65% and 75% of Victoria’s IDUs have less than a high school education (Stajduhar et al., 2004; Health Canada, 2004; Public Health Agency of Canada, 2006).  Income: - Approximately half of Victoria’s IDUs are on social assistance and many derive income through illegal activities, including drug dealing, pan handling, squeegeeing, and involvement with the sex trade industry (Stajduhar et al., 2004). 19  Housing Status: - Almost half of IDUs report having unstable housing (Health Canada, 2004; Public Health Agency of Canada, 2006; Stajduhar et al., 2004).    Drug Use Characteristics  Drugs of Choice: - Cocaine, heroin and combinations of cocaine and heroin known as “speedballs” are Victoria’s most commonly injected drugs (Stajduhar et al., 2004; Health Canada, 2004; Public Health Agency of Canada, 2006). - Survey data has shown that other commonly injected drugs include non-prescribed morphine, methamphetamines, dilaudid, prescribed morphine, crack, and amphetamines (Health Canada, 2004; Public Health Agency of Canada, 2006).   Frequency of Injection: - Survey data suggests that the greatest proportion of IDUs in Victoria inject daily or multiple times per day (approximately 35% to 45%) (Health Canada, 2004; Public Health Agency of Canada, 2006). - Victoria has the highest proportion of daily injectors relative to the six other Canadian cities that participated in the pilot and phase one I-Track surveys (the other six participant cities were Edmonton, Quebec/Ottawa, Regina, Sudbury, Toronto, and Winnipeg).   - Many of Victoria’s IDUs inject three or more times per week (approximately 15% to 25%), once per week (approximately 15% to 20%) or less than once per week (approximately15% to 25%) (Health Canada, 2004; Public Health Agency of Canada, 2006).  Sharing of Injection Equipment: - The IDU participants in a survey conducted by Stajduhar et al. (2004) reported sharing drug paraphernalia, including needles (65%), spoons (65%), water (63%), and cotton (53%). - The I-Track phase one survey found that 70.8% of the participants borrowed needles/syringes once or occasionally, 20.8% did so sometimes or usually, and that 2.1% always did.  The survey also found that 18% of the participants reported injecting with used needles/syringes in the previous six months (Health Canada, 2004). 20  Common Locations of Drug Use: - The majority of the participants of the I-Track phase one survey reported that they had injected in the following places: public spaces (67.7%), their own home (65.7%), a friend’s place (65.0%), a hotel or motel room (47.2%), a drop-in shelter (33.5%), a parent’s or relative’s house (11.8%), a jail or corrections facility (6.7%), psychiatric institutions or detox centers (2.8%), in a vehicle (2.0%), other places (0.8%), and 3.5% did not respond (Health Canada, 2004).   - In phases one and two of the I-Track surveys, 30% of the participants reported that the street is where they injected most frequently in the past six months (Health Canada, 2004; Public Health Agency of Canada, 2006). - The I-Track phase two survey asked Victoria’s IDUs to list the Victoria neighborhoods in which they injected most often in the past six months; 57.9% listed downtown which was followed by: Fernwood (9.6%); Burnside (9.1%); Hillside-Quadra (5.1%); North Park (4.6%); Vic West (4.1%); Fairfield (3.6%); James Bay (3.0%); Harris Green (2.0%); Rockland (0.5%) and North Jubilee (0.5%).  Use of NEP Services - Approximately 400 clients per month use the NEP services (Victoria AIDS Resource and Community Service Society, 2008). - In 2005-06, approximately 2,000 clients used the NEP (Victoria AIDS Resource and Community Service Society, 2008). - The I-Track phase one survey found that 88.2% of the participants used NEP services, but this may not be an accurate figure as the study participants were recruited from NEPs (Health Canada, 2004).    Seroprevalence of HIV and HCV - The I-Track phase one survey tested participants for HIV and HCV and found that 15.4% were HIV positive, 68.5% were HCV positive, and that 15.4% were both HIV and HCV positive.  It is important to note, however, that the same survey also found that only 72.2% of the participants knew they were HIV positive and that only 79.5% knew they were HCV positive (Health Canada, 2004). - In the survey conducted by Stajduhar et al. (2004), 25% of the participants self-identified as HIV positive, 53% self-identified as HCV positive, and 90% reported that they had been tested for both HIV and HCV.  21  It is clear that Victoria’s IDU population faces a greater risk of acquiring and transmitting HIV, HCV and other bloodborne pathogens relative to the general population.  It is also evident, however, that this elevated risk is largely due to the relatively high prevalence of the sharing of injection equipment.  In order to reduce the harm associated with the high risk drug use among IDU populations, many cities--including Victoria--have implemented NEPs.  Many NEPs have been augmented with a range of services, including: testing for HIV, HBV, HCV, sexually transmitted infections (STI’s), and pregnancy, as well as immunizations, job referrals, counseling, clothing and food banks, methadone maintenance clinics and medical care (Ontario Ministry of Health and Long Term Care, 2003).  Until its recent closure on June 1, 2008, the Victoria NEP had been operating for nearly two decades, offering many of the services mentioned above in order to combat the public health risks associated with injection drug use.   The Life of the Victoria NEP  The Birth and Development of the Program  On September 17, 1985, five men--Wayne Cook, Don MacIvor, Roy Salonin, John Spencer, and Grant Sullivan--sat around a kitchen table and decided it was time to implement a NEP in Victoria to combat the Vancouver Island HIV/AIDS epidemic.  These men believed there was a need for up-to-date and accurate information and services pertaining to HIV/AIDS.  With these goals in mind, the five men formed the first Board of Directors of the organization that would become AIDS Vancouver Island (AVI) (AIDS Vancouver Island, 2003).    The society was subsequently incorporated and registered in British Columbia on January 24, 1986 under the legal name of The Vancouver Island Aids Society.  The society’s expenses were initially supported by charitable donations and a benefit.  As such, all staff members were unpaid volunteers and a small office space was acquired at no cost.  AVI began offering needle exchange services during 1987/88 through foot outreach conducted by one person.  It was not until 1989/90 that the Victoria NEP obtained a fixed site in an alley on Johnson Street.  In 1992, a VIHA-sponsored street nurse component was added to strengthen the program.  The exchange finally moved to its most recent site at 1601 Blanshard Street in 2001 (see figure 1 below for a map of the AVI office location).   In recent years, the need for HIV/AIDS-related services and programs has continued to grow steadily.  In 1996, for example, the Victoria NEP exchanged 128,000 syringes to 545 clients.  By 2005/06, 22  however, the NEP distributed 830,000 syringes to over 1,500 clients (AIDS Vancouver Island, 2008).  Despite the growing demand for NEP services in Victoria, AVI has not seen increased levels of funding (Victoria AIDS Resource and Community Service Society, 2008).  Regardless of this, AVI has continued to offer a range of harm reduction services.   Figure 1 - A Map of the AIDS Vancouver Island Office Location, Victoria, 2008     Source: Capital Regional District, 2008   Services Offered  Although the NEP is a central feature of the services offered by AVI, it is offered alongside a range of other programs and services.  For example, AVI offers education, support and advocacy for individuals who are infected with or impacted by HIV/AIDS, HCV and other communicable diseases.  AVI also provides harm reduction education to schools, the broader community and to specific target populations.  It is also important to note that the needle exchange services are offered as a part of AVI’s Street Outreach Services (SOS) program.  The SOS program offers services and support for IDUs as well as health promotion and harm reduction information, pathogen and pregnancy testing services, regular workshops and education 23  sessions, and needle disposal and clean-up services.   AVI also offers a men’s wellness program which operates to improve sexual health and reduce the transmission of HIV and other bloodborne pathogens amongst gay and bisexual men.  It is clear that AVI offers many services beyond exchanging needles (AIDS Vancouver Island, 2003).      Events Leading Up to the Closure of the NEP  Despite the fact that the services offered at the Victoria NEP are in place to reduce the transmission of communicable diseases amongst Victoria’s IDUs and other high-risk populations, the program is a source of political debate.  Although AVI’s NEP has been operating for over twenty years, it has faced growing pressure to relocate since 2006.  While many Victorians recognize the public health benefits associated with the NEP, it is also evident that many businesses, individuals and organizations are resistant to having the program located adjacent to them.  The resistance seems to be largely based around one central question: why should certain individuals or organizations have to disproportionately bear the burdens of a program that is intended to accrue benefits to everyone in the Victoria community?  The resistance is also likely partially due to the fact that the NEP has often acted as a “flashpoint” for the broader community problems of homelessness, mental illness and addictions in the city.  Community resistance to the NEP reached a climax on July 5, 2007, when fifteen Cormorant Street neighbors of AVI filed an injunction suit in the British Columbia Supreme Court to shut down AVI, labeling four defendants: AVI, VIHA, the Ministry of Health and Yentl Properties (the landlords of AVI’s 1601 Blanshard Street address).  This legal action was followed by the issuance of a formal notice of complaint from Yentl properties to AVI on October 2, 2007, which offered the agency sixty days to “solve the problems” or be issued a termination of lease.  AVI was unable to meet the demands of the notice of complaint within sixty days and, as such, they were served a notice of termination of lease from Yentl Properties on November 30, 2007 which stated that AVI would have six months to find a new location for the needle exchange service (AIDS Vancouver Island, 2008).  With this in mind, VIHA decided to purchase the Saint John Ambulance building on Pandora Street with the idea of relocating the NEP to this site.  The proposed relocation of the NEP received resistance from several Pandora Street neighbors, namely from two adjacent schools.  As such, VIHA decided to delay the relocation of the NEP to Pandora Street.  On July 1, 2008, AVI’s NEP shut down, marking the beginning of a trial mobile needle exchange service in Victoria.  For a detailed timeline of the events that led up to the closure of AVI’s NEP, please refer to the appendix (section A).    24  Why is this Research Necessary? Due to the closure of the Victoria NEP on June 1, 2008, Victoria’s only needle exchange services are currently offered through mobile programs (as of autumn, 2008).  Mobile NEPs are generally more expensive to operate (World Health Organization, 2007) and less effective at reducing the harm associated with injection drug use relative to fixed-site NEPs  (Strike et al., 2006).  As such, VIHA is looking into the possibility of relocating the NEP to a fixed location.  As the primary source of funding for the needle exchange program, VIHA needs to engage the citizens of the Capital Regional District to determine whether or not the Victoria community supports the relocation and continuation of the program.  VIHA will be better able to pin down a suitable location for the NEP if it has a strong understanding of the public perceptions associated the service.  SECTION 3:  SURVEY METHODS AND RESULTS   Methods  Why Conduct a Telephone Survey?  In order to determine the most appropriate research method for gathering data regarding the public opinions associated with NEPs a review of the literature was conducted.  The vast majority of the reviewed studies utilized telephone surveys for data collection purposes (for example, Australian National Drug Strategy Surveys, 1998, 2001 and 2004; New South Wales Health Department Survey, 1990; National Drug Research Institute/Lenton & Phillips, 1997; New South Wales Health Department/McDonald et al., 1999; and the Canadian Addition Survey, 2004).  Many of the studies also employed random, geographically stratified sampling frameworks in which participants were randomly selected from electronic or hard-copy telephone directories (for example, Australian National Drug Strategy Surveys, 1998, 2001 and 2004; New South Wales Health Department Survey, 1990; New South Wales Health Department/McDonald et al., 1999; and the Canadian Addiction Survey, 2004).  One of the reviewed studies also ensured that its sample was demographically representative of census data in terms of the age of the participants (New South Wales Health Department/McDonald et al., 1999).  All of these works successfully gathered a rich set of information on the community perceptions towards needle exchange programs and, as such, similar methods have been employed for the purposes of this research.   25  Survey Objectives and Design The telephone survey was designed by the author in consultation with VIHA management from the Planning and Community Engagement and Public Health Departments.  The survey was designed to uncover CRD residents’ opinions and perceptions associated with six main themes, including:  1. The level of importance of the CRD’s major public health challenges.   2. Harm reduction support. 3. NEP awareness. 4. NEP support. 5. NEP benefits and challenges. 6. Experiences with discarded needles.   Data Collection The survey was administered by BC Stats consultants to a random, geographically stratified sample of 500 residents within the CRD between August 11 and 18, 2008.  The CRD encompasses the thirteen municipalities of Greater Victoria (see a map of the CRD on the next page).   Survey participants were selected via the random-digit-dialing method.  Quotas were set to ensure that a representative number of participants were selected from each CRD municipality.  Sampling Reliability and Error  Reliability is a measure of the reproducibility of a survey instrument or test.  Specifically, reliability measures the precision or margin of error in a survey.  The margin of error for the present survey is +/- 4.4% at the 95% confidence level (based on the total CRD sample of 500).  This means that 19 out of 20 times, results of the sample will not be off by more than 4.4% of results that would be obtained if all qualified respondents were interviewed (assuming a 55/45 distribution on a dichotomous question).  It is important to understand that, in most cases, the margin of error will be smaller than the number presented as it has to be large enough to maintain the 95% confidence level.      26  Figure 2 - A Map of the CRD Member Municipalities, 2008  Source:  Capital Regional District    Data Quality  The findings of the survey are based upon self-reported data.  Although the validity of self-reported data is commonly questioned, research on the subject seems to suggest that survey responses are typically valid, especially if the respondents are: (1) confident that their responses will be kept confidential and anonymous, (2) certain there are no consequences in reporting the information, and (3) convinced the research is being conducted for legitimate purposes.  As such, the telephone survey method has become a widely-used, cost-effective means of conducting large-scale surveys of health-risk behaviors and associated challenges.       27  Data Limitations Although the telephone survey method is the most feasible for gathering public opinion data regarding NEPs, it is apparent those interpreting the results of this survey should consider the following limitations: Telephone Coverage:  The survey is based upon a target population of households with telephone access and, as such, individuals without telephones are excluded from the sample.  Fortunately, Canada has a high telephone coverage rate in excess of 97%.  It is important to note, however, that individuals in prisons, military facilities, hospitals, and transient populations are excluded from telephone surveys.   Self-reported Data:  Survey results are influenced by errors in individual reporting and the conditions under which the survey is conducted.    Survey Data and Results   Participant Information              Table 5 (on the next page) highlights the demographic characteristics of the survey participants.  Specifically, the table provides an age, sex and education breakdown of the 500 respondents and demonstrates the fact that participants were selected across all levels of education, from all age cohorts above the age of 18, and that both males and females were represented adequately.  The diversity of the survey respondents will ensure that the results of this study are representative of the opinions held amongst all segments of the CRD population.   Capturing the broad range of opinions regarding NEP services is the primary goal of this project and, as such, special attention was paid to ensure that an effective sampling framework was employed.         28  Table 5 - Survey Participant Data, CRD 2008 (n=500)  Number Percent (rounded) Education          Some high school 34 7%      Completed high school 76 15%      Some post-secondary 59 12%      Post-secondary diploma/certificate                        110 22%      University undergraduate 98 20%      University Graduate 115 23% Age          18-34 129 26%      35-54 181 37%      55+ 188 38% Sex          Male 236 47%      Female 264 53%   Survey Results by Theme   Table 6 (on the next page) provides a summary of the survey results.  The results are represented in aggregate form to highlight the broad public opinions associated with each survey item.  The following portion of this section will highlight the survey findings according to the six broad survey themes.  1. The Perceived Importance of CRD Public Health Issues The survey opened up with a set of questions asking the participants to rate the importance of several pre-identified CRD public health challenges, including: (1) air quality, (2) food safety, (3) homelessness, (4) wastewater and sewage treatment, (5) water quality, and (6) drug and alcohol addictions.  This set of questions was designed to enable a comparison of the perceived relative level of importance of the main public health issues in the CRD.  Table 6 highlights the results of this question and shows the cumulative percent of CRD residents rating each problem “very important” and “somewhat important.”  Upon a close   29  Table 6 - Summary of Survey Results, CRD 2008 (n=500)      Number  Percent  1. The Perceived Importance of CRD Public Health Issues        Public health challenges rated as “very important” or “somewhat important” 1             Water quality 488 97.6%              Food safety 484 96.8%              Homelessness 475 95.0%              Drug and alcohol addictions 473 94.6%              Air quality 470 94.0%              Wastewater and sewage treatment 470 93.9% 2. Harm Reduction Support        Harm Reduction Support             Support 353 70.6%             Oppose 93 18.6% 3. NEP Awareness         NEP Awareness             Aware 484 96.9%             Unaware 16 3.1%        Awareness of NEPs in Victoria                 Aware 231 46.2%             Unaware 231 46.2%        Perceived NEP Locations in Victoria              Downtown 52 22.4%             Cormorant Street 34 14.6%             Other 33 14.2%             Pandora Street 31 13.3%             Mobile exchange 28 12.2%             No response 25 10.8%             Blanchard Street 16 7.1%             Don't know 16 6.9%             Douglas Street 4 1.7% Note: 1 The percentages and numbers listed are based on a cumulative representation of the total percent of individuals rating each public health problem as either “very important” or “somewhat important.”      30   Number Percent 4. NEP Support         NEP Support                 Support 347 69.4%              Oppose 117 23.4%        Support for a NEP in "Your Community”                Support 313 62.6%              Oppose 153 30.6%         Support for a NEP Downtown               Support   323 64.0%              Oppose 145 29.0% 5. The Perceived Benefits and Challenges of NEPs         Perceived NEP Benefits                  Reduce disease transmission 282 56.4%              Safe needle disposal 87 17.5%              None 72 14.4%              Contact with treatment providers 61 12.3%              Support and Information 60 12.0%              Medical attention 49 9.7%              Keeps drug users safe 12 2.4%              Harm reduction 9 1.9%              Reduce healthcare costs 7 1.5%              Monitoring of drug users 5 0.9%              Centralizes drug users 4 0.8%         Perceived NEP Drawbacks                  Encourage drug use 162 32.5%              None 71 14.2%              Bad for community/local business 62 12.4%              Increased crime        46 9.1%              Lowers chance of quitting drugs 35 7.1%              Waste of funds/tax dollars 29 5.7%              Litter in surrounding areas     25 5.1%              Drugs are bad/illegal 20 4.0%              Not effective 11 2.2%              Lack of support/funding 8 1.5%              Concentration of drug users 7 1.3%     31  Number Percent 6. Discarded Needles        Found Discarded Needles in “Your Neighborhood” in Past Six Months             Yes 67 13.5%                  No 430 85.9%             Found Discarded Needles Downtown in Past Six Months               Yes 180 36.0%             No 310 62.0%                  look at the results, it is clear that CRD residents place a significant amount of importance on all of the identified problems, with a mere 3.7% of variation between the public health issue rated the most important --water quality (97.6%)--and the issue rated the least important--air quality (93.9%).  For the purposes of this study, it is important to note the fact that CRD residents rate drug and alcohol addictions high in importance relative to the other major challenges facing the region.   2. Harm Reduction Support The majority (70.6%) of CRD residents either “strongly support” (43.6%) or “somewhat support” (27.1%) harm reduction strategies for drug users.  This is a critical finding, as NEPs are a form of harm reduction and it will be essential for CRD residents to support the harm reduction approach if the region is going to implement a new fixed-site NEP.    3. NEP Awareness The survey participants were provided with a brief description of NEPs before they were asked to state whether or not they had ever heard of such services.  Table 6 (above) highlights the fact that 96.9% of the respondents said they had heard of NEPs and 3.1% said they had not.  Interestingly, the results of the survey simultaneously show that only 46.2% of the respondents knew of any NEP locations in the Victoria region.  It is also clear that very few of the participants knew the precise location of NEP services in Victoria.  For example, only 12.2% of the respondents were able to state the fact that the only NEP services available at the time of the survey were mobile operations (with no fixed-site address).  Similarly, few of the participants were able to cite the previous fixed-site NEP location on the corner of Blanshard and Cormorant Streets (approximately 20.0% were able to do so).  Still, most of the participants believed NEP 32  services were available in the downtown core.  The results of the survey, therefore, suggest that most CRD residents are aware of the general location of Victoria’s NEP services but most are unaware of the precise location or venue from which these services are offered.     4. NEP Support The survey data suggests that most CRD residents (69.4%) either “strongly support” (42.2%) or “somewhat support” (27.2%) NEPs.  CRD residents, thus, appear to offer a similar level of support for both NEPs and the harm reduction approach for drug users (approximately 70% support was listed for both items).  It is also important to note that approximately two-thirds of the participants stated that they would support a NEP in their own community or downtown.  This finding is important, as it underscores the fact that most CRD residents are supportive of NEPs regardless of where they are located.   5. The Perceived Benefits and Challenges of NEPs Table 6 (above) shows the perceived benefits of NEPs in the CRD.  The most commonly identified benefits identified include: reductions in disease transmission (56.4%), safe need disposal (17.5%), and the idea that NEPs act as a “bridge to treatment" (12.3%).  It is important to note, however, that almost 15.0% of the respondents listed no benefits of NEPs.    6. Discarded Needles  Most of the survey participants had not found discarded needles in Downtown Victoria in the past six months.  It is apparent, however, that more respondents reported finding discarded needles Downtown Victoria (36.1%) in comparison to in their own neighborhoods (13.5%).      SECTION 4:  IMPLICATIONS AND OPTIONS  VIHA’s Five Year Strategic Plan contains two strategic priorities that are relevant to the present study.  The first of these priorities is to improve the health of high needs populations, including the homeless population.  In order to achieve this objective, the plan states that VIHA will continue to support recommendations from the City of Victoria’s Mayor’s Taskforce on Breaking the Cycle of Mental Illness, Addictions, and Homelessness (discussed in section 2).  The second relevant strategic priority listed in 33  VIHA’s Five Year Strategic Plan states that VIHA will strive to develop integrated mental health and addictions services, including a harm reduction component.  When coupled with VIHA’s strategic priorities, the findings of this study can be translated into several practice implications for VIHA management.  The results of this research suggest that VIHA should consider the following options:  1. Developing enhanced strategies to address the broader challenges of homelessness, mental health and addictions in the CRD  The results of this research clearly document the fact that mental health and addictions challenges are highly related in the CRD.  Specifically, the contextual review in section 1 highlights the fact that a relatively large number of CRD residents face a co-occurrence of these challenges.  It is also important to note that the results of the survey suggest that the vast majority of CRD residents rate drug and alcohol addictions high in importance relative to the other major public health issues facing the region.   With these facts in mind, it is clear that VIHA management should continue to work closely with City of Victoria staff to address the recommendations developed by the Mayor’s Taskforce on Breaking the Cycle of Mental Illness, Addictions, and Homelessness.   2. Engaging local stakeholders to determine the future form and function of Victoria`s NEP services The results of the survey suggest that while most CRD residents support the continuation of NEP services in Victoria, a sizable number do not.  The fact that a significant portion of CRD residents oppose NEP services in Victoria points to the need for a high level of stakeholder involvement during the planning and delivery of future NEP services for the region.  Victoria residents will be more likely to support future NEP services if they are highly involved in the planning and delivery of future programs.      3. Implementing a fixed-site NEP Fixed-site NEPs are generally thought to be more effective at reducing the harm associated with injection drug use relative to mobile NEPs.  This concept is proving to be true in Victoria, as fewer needles have been exchanged on a monthly basis since the NEP services went mobile on June 1, 2008.  It is clear that the implementation of a fixed-site NEP will be the most effective at reducing the risk of needle sharing and disease transmission among Victoria’s injection drug user population.    34  4. Ensuring future NEP services act as a “bridge to treatment” The results of the present survey show that the most commonly identified drawback of NEPs according to CRD residents is that they encourage drug use.  It is important to note, however, that a significant body of research suggests that NEPs do not encourage drug use.  Regardless, VIHA should ensure that future needle exchange services are offered alongside a strong treatment referral system.  Given the fact that Victoria’s addictions challenges appear to be growing in severity, it is becoming increasingly essential to encourage treatment options.    5. Designing future NEP facilities to reduce the negative impacts on adjacent businesses and residents The survey results suggest that many CRD residents are concerned about the negative impacts NEP services may have on adjacent businesses and residents.  It is, therefore, clear that future NEP services should be located and designed to minimize any potential negative community impacts.  Finding a suitable location for a fixed-site NEP will require a significant amount of community dialogue.    6. Encouraging enhanced law enforcement near future NEP services Some CRD residents are concerned about the potential for increased levels of crime adjacent to NEP services.  VIHA, AVI, and the Victoria Police will need to continue to work collaboratively to reduce the elevated levels of criminal activity associated with the Victoria drug user population.    7. Supporting intensified clean-up efforts of discarded needles in public spaces Over one-third of the survey respondents had found a discarded needle in the past six months in Downtown Victoria.  As such, VIHA and the City of Victoria should collaborate to develop more effective strategies for recovering discarded needles from public spaces.  8. Developing alternative models of needle distribution Many cities around the world are experimenting with alternative models of needle distribution, including vending machine distribution, mobile operations, outreach to homes, satellite outreach sites, pharmacy distribution and peer-based outreach (Strike et al., 2006).  VIHA should determine whether or not any alternative delivery models are worth investigating for application purposes in the CRD.    35  9. Exploring the feasibility of implementing a supervised consumption site  In recent years, the Victoria community has expressed increased concern over the city’s drug-related public order problems in the downtown core, including public injecting, discarded needles, loitering and littering (Fischer, 2008).   If implemented alongside a range of integrated prevention and treatment services for injection drug users, a supervised consumption site (SCS) could be implemented to tackle many of Victoria’s drug-related public order challenges.  SCSs are programs that strive to reduce the mortality and morbidity risks among injection drug users through two key functions, including: (1) helping clients find treatment, social and health services and (2) addressing public order challenges through the provision of clean and safe designated places where pre-purchased drugs can be consumed (Fischer et al., 2002; Kimber et al., 2003).  Vancouver’s SCS, Insite, was implemented in 2003 in the form of a scientific trial and a political decision regarding the facility’s continuation is expected to be made before the end of 2008 (Fischer et al., 2008).  Regardless of the future of Insite, VIHA should consider exploring the feasibility of implementing a SCS in the Victoria context on a scientific trial basis.    CONCLUSIONS   This study highlights the close relationship between homelessness, mental health and addictions challenges in Victoria.  It also documents the need for the implementation of a range of integrated mental health and addictions services that can target and ultimately improve the health and quality of life of Victoria’s injection drug users and the Victoria community at large.  Although this report contains many findings, there are two key results of the survey that should be noted by decision-makers, including: (1) most CRD residents support the harm reduction approach for drug users, and (2) most CRD residents support the implementation of a NEP (even in their own neighborhood) in Victoria in the future.  While it is apparent that most CRD residents support the implementation a fixed-site NEP, it is also clear that many citizens hope to see a variety of programmatic changes to future operations.  It is hopeful that the findings of this research can provide timely information and guidance to the individuals faced with the task of delivering a new and improved, community-supported NEP in Victoria.        36  APPENDIX   A. The Events Leading to the Closure of the Victoria NEP  Timeline of Key Events Leading to the Closure of the Victoria NEP Date Event(s) September 2006* 1. AVI meets with Dr. Richard Stanwick, Chief Medical Health Officer for VIHA, Victoria Deputy Police Chief Bill Naughton and Victoria Mayor Alan Lowe to present a vision of an expanded needle exchange program that would be better equipped to meet the needs of the Victoria community.  During this meeting, it was determined that Mayor Lowe and Dr. Stanwick would engage in discussions with VIHA to advocate for increased funding and a new location for the Victoria NEP.   January 2007* 2. CBC’s Jeff Weaver presents a report in which he compares the problems around Victoria’s Cormorant Street to the problems on Vancouver’s Downtown Eastside.  This report marks the beginning of a flood of media articles discussing the issues surrounding Cormorant Street. 3. Cormorant Street neighbors call an emergency meeting to discuss challenges in the neighborhood.  Over fifty people attend the meeting, including Katrina Jensen, the Executive Director of AVI, and Penny Ballantyne, the City Manager for Victoria. February 16, 2007 4. A meeting between the City of Victoria, AVI, the Victoria Police and several neighbors of AVI is held at Victoria City Hall to discuss the community impacts of the needle exchange and the need to relocate the service.   February 28, 2007 5.  AVI holds a press conference to announce its commitment to working with community stakeholders and leaders to develop strategies to move the NEP to a non-residential location where services can be enhanced to tackle Victoria’s substance abuse challenges while minimizing impacts on the local community.   March 28, 2007 6. Upon the completion of a first draft of a Good Neighbor Agreement (GNA) for AVI, a meeting is held at Victoria City Hall so that feedback can be provided on the document. May 2, 2007 7. A second GNA meeting is held  May 23, 2007 8. A meeting between the City of Victoria, AVI and the Victoria Police is held at Victoria City Hall to further discuss the need to relocate the needle exchange and the barriers that might prevent this from happening.   June  11, 2007 9. The first public GNA meeting is held at Victoria City Hall. July 5, 2007 10. Fifteen Cormorant Street neighbors of AVI file an injunction suit in the British Columbia Supreme Court to shut down AVI, labeling four defendants: AVI, VIHA, the Ministry of Health and Yentl Properties (the landlords of AVI’s 1601 Blanshard Street address). July 9, 2007 11. The second public GNA meeting is held at Victoria City Hall. August 13, 2007 12. AVI cancels the third GNA meeting and postpones their participation in the GNA process until the legal case with the fifteen Cormorant Street neighbors is resolved.   37  -  -  -  -  -  -   -    September 17, 2007 13. VIHA publicly announces plans to conduct a third-party review of AVI’s needle exchange program. October 2, 2007  14. Yentl Properties issues a formal notice of complaint to AVI, giving the agency sixty days to “solve the problems” or be issued a termination of lease from their Cormorant Street address. October 29. 2007   15. VIHA and AVI publicly release VIHA’s review of AVI’s needle exchange program and an action plan outlining strategies to more effectively meet the health needs of street drug users and help improve public order in the Cormorant Street area.  VIHA also announced a $125,000 investment in the action plan. November 30, 2007 16. AVI receives a notice of termination of lease from Yentl Properties which states that they have six months to find a new location for the needle exchange service. February 2008  17. AVI implements their action plan to reduce public disorder issues around the needle exchange and finalizes an operational agreement with the Victoria police. March 6, 2008  18. News spreads that VIHA has plans to purchase the Saint John Ambulance building on Pandora Street and to move the needle exchange program to this location. March 12, 2008  19. Saint Andrews Catholic School (which is located near the Saint John Ambulance building) hosts a public meeting to discuss the relocation of the needle exchange to Pandora street.  The panel included VIHA representatives, acting police Chief Naughton and Councilor Charlayne Thornton-Joe. March 14, 2008   20. The needle exchange relocation is discussed at a Victoria City Council meeting.  Questions and concerns are raised by parents of children who attend Saint Andrew’s School, the Downtown Residents Association, and others. May 18, 2008  21. VIHA completes its purchase of the Saint John Ambulance building and announces that they will delay the move of the needle exchange program into the building. June 1, 2008  22. AVI’s needle exchange stops operating at its Cormorant Street location and begins trial mobile needle exchange services. Source: AIDS Vancouver Island, 2008. Notes: *Exact dates were unavailable these items. 38  BIBLIOGRAPHY  AIDS Vancouver Island. (2003).  About Us. Retrieved from the World Wide Web on August 15,  2008: http://www.avi.org/about.  AIDS Vancouver Island.  (2008). Timeline of Events Leading up to Needle Exchange Closure.  Australian Institute of Health and Welfare. 1998 National Drug Strategy Household  Survey: first results.  Canberra: 1999.  Australian Institute of Health and Welfare. 2001 National Drug Strategy Household  Survey: first results.  Canberra: AIHW, 2002.  Australian Institute of Health and Welfare. 2004 National Drug Strategy Household  Survey: first results.  Canberra: AIHW, 2005.  Bluthenthal, R.N., Kral, A.H., Gee, L., Erringer, E.A., and Edlin, B.R.  The effect of syringe exchange use on high-risk injection drug users: a cohort study. AIDS 14(5), pp. 605-611 (2000).  Brooner, R., Kidorf, M., King, V., Beilenson, P., Svikis, D., and Vlahov, D. (1998).  Drug abuse treatment success among needle exchange participants. Public Health Rep. 113 (suppl. 1), pp.129-139.  Buchanan, D., Shaw, S., Ford, A., & Singer, M. (2003).  Empirical Science Meets Moral Panic:  An Analysis of the Politics of Needle Exchange.  Journal of Public Health Policy, 24 (3/4), pp.427- 444.  Buning, E.C., Coutinho, R.A., van Brussell, G.H., van Santen, G.W., and van Zadelhoff.  (1986).   Preventing AIDS in drug addicts in Amsterdam.  Lancet 1:1 (8495), pp. 1435.  Capital Regional District. Atlas and Maps. (2008). Retrieved from the World Wide Web on   September 15, 2008: http://www.crd.bc.ca/maps/  City of Victoria. (2007a). Mayor’s Task Force on Breaking the Cycle of Mental Illness,  Addictions and Homelessness: Executive Summary.  Retrieved from the World Wide Web on June 20, 2008: http://www.victoria.ca/cityhall/pdfs/Tskfrc_brcycl_exctvs.pdf  City of Victoria. (2007b). Mayor’s Task Force on Breaking the Cycle of Mental Illness,  Addictions and Homelessness: Report of the Expert Panel.  Retrieved from the World Wide Web on June 20, 2008: http://www.victoria.ca/cityhall/pdfs/tskfrc_brcycl_exprtp.pdf  Des Jarlais, D.C., Hagan, H., Friedman, P., Goldberg, D., Frischer, M., Green, S., Tunving, K.,  Ljungberg, B., and Wodak, A.  (1995).  Maintaining low HIV seroprevalence in populations of injecting drug users. Journal of the American Medical Association. 274 (15), pp. 1226-1231.  39  Drucker, E., Lurie, P., Wodak, A., and Alcabes, P.  (1998). Measuring harm reduction: the  effects of needle and syringe exchange programs and methadone maintenance on the ecology of HIV.  AIDS, 12 (suppl. A), pp. 217-230.  Hagan, H., Jarlais, D.C., Friedman, S.R., Purchase, D., and Alter, M.J. (1995).   Reduced risk of  hepatitis B and hepatitis C among injection drug users in the Tacoma Syringe Exchange Program. American Journal of Public Health, 85 (11), pp. 1531-1537. Health Canada. (2004). I-Track: Enhanced Surveillance of Risk Behaviors among Injecting  Drug Users in Canada. Pilot Survey Report. February 2004.  Surveillance and Risk Assessment Division, Centre for Infectious Disease Prevention and Control.   Heimer, R. (1998). Can syringe exchange serve as a conduit to substance abuse treatment?  Journal of Substance Abuse Treatment, 15 (3), pp. 183-191. Heimer, R., Khoshnood, K, Bigg, D., Guydish, J., and Jungue, B. (1998)  Syringe use and reuse:  effects of syringe exchange programs in four cities. J. Acquir. Immune Defic. Syndr. Hum. Retrovirol. 18, S37.  Kent, H.  (2001). Is Australia's safe injection site experiment bound for Vancouver? Canadian  Medical Association Journal, 9, pp. 1332.  Lenton, S., Phillips, M. (1997).  Mobilising public support for providing needles to drug  injectors.  International Journal of Drug Policy, 8, pp. 101-110.  Louis Harris and Associates Inc poll. New York, NY: Louis Harris & Associates Inc; September 1997. Louis Harris and Associates Inc poll. New York, NY: Louis Harris & Associates Inc; October 1997. Lurie, P., Reingold, A.L., Bowser, B., Chen, D., Foley, B.A., Guydish, J., Kahn, J.G., Lane, S.,  Sorensen, J., DeCarlo, P., Harris, N., and Jones, T. S.  (1993). The public health impact of needle exchange programs in the United States and abroad. Summary, conclusions and recommendations.  Retrieved from the World Wide Web on September 23, 2008: http://www.caps.ucsf.edu/pubs/reports/pdf/NEPReportSummary1993.pdf  MacDonald, M. Rutter, S. Wodak, A. & Kaldor, J. (1999).  K2 and Kings Cross: community  attitudes to the needle syringe program, discarded syringes and public injection, 1997 and 1998.  Sydney: NSW Health Department.    Normand, J., Vlahov, D., Moses, L.E., Eds., Preventing HIV transmission: the role of sterile  needles and bleach. National Academy Press, Washington, D.C., 1995.  Ontario Ministry of Health and Long Term Care. Needle and syringe exchange programs in  Ontario, 2002. Toronto, ON: Ministry of Health and Long Term Care, 2003.  Princeton Survey Research Associates/The Henry J. Kaiser Family Foundation poll. Storrs,  Conn: Roper Center for Public Opinion Research; 1995.  40  Public Health Agency of Canada. (2003). Harm Reduction and Injection Drug Use: an  international comparative study of contextual factors influencing the development and implementation of relevant policies and programs.  Retrieved from the World Wide Web on August 15, 2008: http://www.phac-aspc.gc.ca/hepc/pubs/hridu-rmudi/canada-eng.php  Public Health Agency of Canada. (2006). I-Track: Enhanced Surveillance of Risk Behaviors  among People who Inject Drugs. Phase I Report. Surveillance and Risk Assessment Division, Centre for Infectious Disease Prevention and Control, Public Health Agency of Canada.  Quan, V.M., Chung, A., & Abdul-Quader,A.S. (1998). The feasibility of a syringe-needle- exchange program in Vietnam. Subst. Use Misuse 33,pp. 1055-1067.  Schwartzkoff, J., Spooner, S., Flaherty, B. et al.  (1990).  Community attitudes to needle and  syringe exchange and to methadone programs. Sydney: Directorate of the Drug Offensive, NSW Department of Health.    Stajduhar, K.I., Poffenroth, L., Wong, E., Archibald, C.P., Sutherland, D., & Rekart, M. (2004).  International Journal of Drug Policy, 15, pp. 171-181.  Strathdee, S.A., Celentano, D.D., Shah, N., Lyles, C., Macalino, G., Nelson, K., and Vlahov, D.   (1999).  Needle exchange attendance and health care utilization promote entry into detoxification. J. Urban Health 76(4), 448-460 (1999). Strathdee, S.A., Vlahov, D. (2001). The Effectiveness of needle exchange programs: A review of  the science and policy.  AIDScience, 1 (16), pp 1-31. Strike C, Leonard L, Millson M, Anstice S, Berkeley N, & Medd E. Ontario needle exchange  programs: Best practice recommendations. Toronto: Ontario Needle Exchange Coordinating Committee. 2006.  Vancouver Island Health Authority.  (2008). VIHA Confirms Purchase of  941 Pandora Street.   Retrieved from the World Wide Web on March 30, 2008: http://www.viha.ca/news  Van Ameijden, E. J. C.  & Coutinho, R. A.  (1998).  Maximum impact of HIV prevention  measures targeted at injecting drug users. Aids, 12 (6), pp. 625-633.  van den Hoek, J.A., van Haastrecht, H.J., Coutinho, R.A. (1989). Risk reduction among intravenous drug users in Amsterdam under the influence of AIDS. Am. J. Public Health 79(10), pp. 1355-1357.  Vertefeuille, J., Marx, M.A., Tun, W., Huettner, S., Strathdee, A., and Vlahov, D (2000). Decline in self-reported high risk injection-related behaviors among HIV seropositive participants in the Baltimore needle exchange program. AIDS and Behavior. 4 (4),  pp. 381-388.  Victoria AIDS Resource and Community Service Society. (2008). Retrieved from the World  Wide Web on July 20, 2008: http://www.varcs.org/letters/tc080507needle_van.html  41  Victoria Cool Aid Society. (2007). Housing First – Plus Supports. Homeless Needs Survey 2007:  A Pathway to Home.  Retrieved from the World Wide Web on July 21, 2008: http://www.coolaid.org/publications/HNS_Final_Report_2007.pdf  Vlahov, D., Junge, B., Brookmeyer, R., Cohn, S., Riley, E., Armenian, H., and Beilenson, P.   (1997).  Reductions in high-risk drug use behaviors among participants in the Baltimore needle exchange program. J. Acquir. Immune Defic. Syndr. Hum. Retrovirol. 16 (5), pp. 400-406.  World Health Organization. (2007). Guide to starting and managing needle and syringe  programmes.  Retrieved from the World Wide Web on September 15, 2008: www.who.int/hiv/idu/Guide_to_Starting_and_Managing_NSP.pdf   

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