Some readers of the Journal of Addictions Nursing might be familiar with an island in the North Atlantic Ocean called Iceland, and some might not. Iceland has the population of about 329,000 people and an area of 103,000 km2, making it one of the most sparsely populated countries in Europe. Iceland is volcanically and geologically active and has a number of glaciers. Despite its high latitude outside the Arctic Circle, the climate in Iceland is tempered as the island is warmed by the Gulf Stream. The largest city and the capital, Reykjavik, is situated in the southwest, and over two thirds of Iceland's population live there. Iceland is a small proud nation, and Icelanders highly value independence and self-sufficiency.
Similar to people in other Westernized countries, Icelanders use various psychoactive substances with the exception of heroin as, for some reason, it is not being imported. Despite this fact, intravenous drug use is a reality in Iceland, and the current drugs of choice for intravenous drug users (IDUs) are morphine or methylphenidate (Ritalin). Thus, IDUs in Iceland, like IDUs in other countries, are at risk for intravenous drug-use-related infections such as HIV and Hepatitis C (Hep-C). The actual size of the IDU population in Iceland is unknown, but based on data from the main substance abuse treatment center, it has been estimated that there are around 400-550 regular IDUs in Iceland (SAA-Vogur National Center of Addiction Medicine, 2010).
Limited information was available before 2007 about the behavior of IDUs regarding sharing or reusing injection equipment. To shed some light on this important topic, a mixed methods study was conducted for 3 months in 2007 in the main substance abuse treatment center as well as at the dual-diagnosis inpatient unit at the University Hospital-Landspitali. There were 69 participants, of whom 72% were men and 27.5% women. The age range was 18-35 years. Furthermore, 47.8% knew that they were Hep-C infected, and one participant knew he or she was HIV positive. Qualitative data from this study indicated that IDUs believed that Hep-C infection was inevitable once they started to inject. In addition, 3 of 11 interviewed knew that HIV was a blood-borne virus, but nine thought it could only be transmitted through unprotected sex (Gunnarsdo[spacing acute]ttir & Gu[eth, icelandic]mundsdo[spacing acute]ttir, 2008). Results from this study indicated that an HIV outbreak among IDUs could be pending and that the prevalence of Hep-C among them could increase. Clearly, something is needed to be done, and professionals in the field of addictions and infections called for the implementation of evidence-based interventions that would help to reduce incidences of these infections among IDUs in Iceland. However, what should be done?
Harm Reduction International states that harm reduction (HR) 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. HR benefits people who use drugs as well as their families and community (Harm Reduction International, n.d.). Thus, the focus of HR is on reducing the harm associated with the use of psychoactive drugs for people unable or unwilling to stop. The HR approach is strongly committed to public health and human rights, and the emphasis is on understanding the specific risks and harm associated with the use of specific drugs. Furthermore, the aim is to determine what causes these risks and harm and what can be done to reduce them.
HR interventions such as opioid substitution therapy, housing first, drug consumption rooms, and needle exchanges have been shown to be effective in reducing HIV and Hep-C infections and deaths by overdose among IDUs. Research also indicates that HR approaches are practical, feasible, safe, and cost-effective (Harm Reduction International, n.d.). Thus, it should not come as a surprise that the World Health Organization (WHO) strongly supports HR in societies where intravenous drug use is a fact. WHO states that it "strongly supports harm reduction as an evidence-based approach to HIV prevention, treatment and care, for people who inject drugs." The agency recommends a comprehensive package that includes, but is not limited to, a needle exchange program, opioid substitution therapy, HIV testing and counseling, HIV treatment and care, information, education and risk reduction counseling, and condom distribution (WHO, n.d.).
Iceland has a well-established socialized healthcare system, which includes services for HIV testing, treatment, and care. Opioid substitution therapy has been readily available at the main detox and treatment center, but needle exchange services were not available despite the prevalence of IDUs in Iceland. The only way for IDUs to obtain clean injection equipment was to buy it at a local pharmacy.
The Reykjavik Red Cross responded to the call for mobile needle exchange services and launched, in October 2009, a "health trailer" staffed by nurse volunteers who provided needle exchange services, primary care, and health promotion to visitors. This HR effort was originally designed as a 1-year development project. The health trailer operated on HR principles and went out twice a week to areas where two soup kitchens were located. The primary project development focus was to connect and gain trust within the IDU population. In 12 months, 65 individuals made 144 visits to the trailer. In 90 of those visits, the main purpose was needle exchange, but other reasons were wound assessment and dressing, injection site assessment, suture removal, and mental health support.
Interviews and focus group data suggested that the trailer's location was limiting visits as few IDUs attended the soup kitchen. Furthermore, the trailer's voluminous size prevented access to areas where IDUs usually gathered in different parts of the capital area. Thus, in further development of the program, it was decided to explore ways to obtain a smaller, more compact vehicle and establish additional stop routes that covered all places in the capital area where IDUs were known to hang out. For the project's second year (2010), therefore, the priority was on acquiring a more suitable vehicle. Because of numerous grants, it was possible to buy a used ambulance and customize it to fit the project's needs.
A new stop route was developed, the shifts' hours were expanded, and the number of site visits was increased to four times a week. Training was held for new volunteers, both nurses and laymen. The project was named Fru Ragnhei[eth, icelandic]ur-needle exchange, and the first shift site visit in the customized vehicle was on February 21, 2011. Data from 2011 suggest that, because of the altered vehicle, the needle exchange services were more accessible to IDUs in the capital area as the visits increased six-fold compared with those in 2010. In 2012, the visits continued to increase and expanded to 1,514; almost 90% of them or 1,339 were for needle exchange services.
Fru Ragnhei[eth, icelandic]ur-needle exchange also started a collaboration with the homeless shelter for women run by the Reykjavik Red Cross, the daily drop-in center for marginalized people run by the Salvation Army, and a mobile outreach service for marginalized people run by the city of Reykjavik. The collaboration included training of volunteers and staff in HR and safe injection instructions as well as providing supplies of clean injection equipment for these sites. Furthermore, members of the steering committee of Fru Ragnhei[eth, icelandic]ur-needle exchange held numerous lectures and talks about HR in academic settings and in various agencies that provide services for people who are marginalized and who use psychoactive substances.
The number of visits to Fru Ragnhei[eth, icelandic]ur-needle exchange were similar in 2013 and 2014. This could indicate that the mobile needle exchange services had reached a state of saturation in its current form. However, consultants within the IDU population enlightened the steering committee that some IDUs did not have access to the services as they were not able to come to the scheduled stop sites.
Thus, the next step in developing Fru Ragnhei[eth, icelandic]ur-needle exchange services was to start a delivery service at the end of 2014. The project acquired a mobile phone that IDUs could call or text to ask for needle exchange services at a meeting point of their choosing at any location in the capital area. This adjunct was a success, and for reasons unknown, there are mostly women who use this way of connecting with Fru Ragnhei[eth, icelandic]ur-needle exchange. The data for 2015 indicated that the number of visits was rising steadily over the course of the year to 1,002 visits. In January, the visits were 21, with a steady increase to 136 in December. The prevalence of IDUs is not on the rise in Iceland so this increase in visits suggests that Fru Ragnhei[eth, icelandic]ur is gaining the trust of service users and they value the benefits of using this mobile service. As before, the main reasons for visits were needle exchange services, but there is some indication that visitors are increasingly dropping by to consult with the nurse volunteers about health-related issues such as abscesses or other signs of bacterial infections at injection sites. Therefore, the steering committee is in the process of developing a collaboration with the emergency department and infectious disease units at the Landspitali Hospital where the goal is early intervention-emphasizing the mobile health services as a point of access to care.
Before the beginning of the Fru Ragnhei[eth, icelandic]ur-needle exchange project, the HR approach to services for active psychoactive substance users in Iceland was limited. Furthermore, HR had limited distribution and was rarely the underlying method guiding services for marginalized people in Iceland.
The Reykjavik Red Cross, the steering committee of Fru Ragnhei[eth, icelandic]ur-needle exchange, and its pioneering volunteers have changed this. Now, 5 years later, there is an increased understanding among healthcare and social service professionals, the public, and public agencies that HR compliments prevention and treatment and should be integrated with services for people who are not willing or able to stop using drugs. One indication of these changed views happened in Spring 2014 when a parliamentary resolution was passed in the parliament, which directed the Minister of Health to form a committee tasked to develop a policy intended to reduce the harm of psychoactive substance use. The committee was formed in September 2014 and is scheduled to complete its task in the coming weeks.
Finally, a major step was taken in January 2015 toward HR for IDUs in Iceland. The Board of Public Health and the pharmaceutical company Gilead joined forces in a groundbreaking public health project with the goal of eradicating Hep-C infections in Iceland. It is estimated that, in Iceland, around 800-1,000 persons are Hep-C positive and everyone will be treated with the drug Harvoni. An epidemiological study will take place simultaneously to explore the project's long- and short-term effects on disease burden and the cost of long-term healthcare services (Ministry of Welfare, n.d.). Active IDUs will have access to the Hep-C treatment. Currently, the project leaders and the Fru Ragnhei[eth, icelandic]ur-needle exchange steering committee are discussing how the mobile needle exchange can expand services for tailoring treatment to active IUD needs.
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