This course was developed as part of the Unitaid LADB Trial

<country partner>

BASELINE TRAINING FOR PEER WORKERS

AND HARM REDUCTION PRACTITIONERS

Safer �Injecting

Trainer introductions - who are we?

Key HCV Portfolio Partnerships

THE UNITAID HEPATITIS C PORTFOLIO ON HEPATITIS C IN LOW- AND MIDDLE-INCOME COUNTRIES

Key HCV Portfolio Partnerships

THE UNITAID HEPATITIS C PORTFOLIO ON HEPATITIS C IN LOW- AND MIDDLE-INCOME COUNTRIES

Acknowledgements

This course was originally developed by Coact for a Frontline AIDS Project working with the Federal Ministry of Health in Nigeria to implement the countries first needle and syringe programme pilot. The Nigerian Technical Working Group members advised on the development of the implementation training programme.

The European Network of People who Use Drugs (EuroNPUD) re-developed the NSP implementation training into two one-day courses – Safer Injecting and Naloxone Saves Lives.

The EuroNPUD Safer Injecting course is the basis of the Unitaid Hepatitis C Portfolio Safer Injecting course which has been extended and redesigned to support this project on low dead space needles and syringes in Low- and Middle-Income Countries.

Photos of injecting paraphernalia were used with kind permission of Exchange Supplies https://www.exchangesupplies.org. Other photos were shot by Mat Southwell from Coact or commissioned from Nigel Brunsdon from Injecting Advice https://nigelbrunsdon.com.

SESSION 1��Introductions and Reasons for Injecting

LEARNING OBJECTIVES

To understand the reasons for injecting and the associated risks

Ground Rules

Whole �Group �Exercise

INTRODUCTION EXERCISE

Ice Breaker: �Animal Connections

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Name

Where you are from?

What is your connection with injecting?

What animal best symbolises your character – tell us why ?

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Safer �Injecting

SESSION 1

Introductions, icebreaker exercise & exploration of motivations for injecting drugs �

SESSION 2

Circulation system overview, vein health, types of injection and related risks �

SESSION 3

Needles, syringes and preparing drugs for injection�

SESSION 4

Taking drugs by injection and disposal of injecting equipment

Divide into groups of 8 – 10 people

One person writes on the flipchart paper for the group

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TASK

Why might these people start injecting drugs?

Small �Group �Exercise

SUMMARY PRESENTATION�Why Start Injecting?

Morning Tea Break

SESSION 2��Circulation System. Needles and Syringes.

LEARNING OBJECTIVES

To understand the basics of the circulation system and taking care of vein health

To become familiar with the equipment used to prepare a drug for injection 

To learn about types of injecting and related risks

Let’s play Pin Point!

Let’s play Pin Point to learn more about the circulation system and where people might inject

Pin Point

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On the wall is a paper outline of a body

Use the post it note needles and syringes �to show where you can inject drugs

Use green post it notes to show low risk

Use yellow post it notes to show medium risk

Use orange post it notes to show high risk

Whole �Group �Exercise

SUMMARY PRESENTATION�Pin Point

safer areas

greater risk areas

high risk areas

• Heart is a pump that adds oxygen to the blood
• The oxygen rich blood is pumped out through arteries
• Blood in the arteries is bright red and fast moving
• The blood returns to the heart through the veins
• Blood in the veins is slower moving and dark red
• People inject drugs into the veins and towards the heart

PRESENTATION�Circulation System

Image by macrovector on Freepik

• Inject slowly towards the heart
• Inject drugs in the inside of the vein
• Avoid flushing as it collapses the internal structure of the vein
• Missing the vein can delay or lose the effect of drug
• Injecting the drug solution outside the vein can cause abscesses

PRESENTATION�Protecting Vein Health

• When a needle gets blunt, this is what it looks like
• Imagine what it would do to your veins
• You’ve only got one set of veins. If you take care of them, they’ll last you longer
• This is why having wide access to sterile needles and syringes is so important

PRESENTATION�Sharp needles support �vein health

PRESENTATION�About IM (intra-muscular) Injecting

Arm / Deltoid

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These are the two places you can inject IM

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Buttock / Glutenous

Relax the muscle you’re injecting into to reduce risk of bruising

• People who inject drugs (PWID) divert needles and syringes from hospital and clinics or pretend to have a medical condition to a community pharmacist, when injecting paraphernalia is criminalised .
• In the past, international development programmes have purchased the needles and syringes that were commonly being used rather than consulting PWID on their informed preferences.
• When injecting is rushed PWID may pour the drug in the back of a syringe and mix it by drawing up blood, water or an antihistamine solution and shaking (cold shake method).
• Brown heroin that is not “cooked up” or filtered so it will not go through a fine insulin combination needle and syringe.
• Single use vaccine needles and syringes are NOT suitable for PWID.
• Large needles cause more scarring which is used by the police to identify PWID.

PRESENTATION�Oversize Needles and Syringes

Participants will be given Glitterbug Potion to put on their hands to illustrate bacteria and viruses

Different participants are given:

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Participants are asked to clean their hands ready so they can inject

Small �Group �Exercise

Handwashing exercise

• The Glitterbug Potion glows
• Turn off the main lights
• Turn on the UV TORCH
• Which option worked best?

Small �Group �Exercise

The big reveal

PRESENTATION�Hand washing ��DO YOUR BEST WITH WHAT YOU HAVE!

• Remove all jewellery before washing
• Wash your hands and injecting site with warm running water and soap for at least 10 – 15 seconds (longer if visibly dirty).
• Remember to pay careful attention to your fingertips and between your fingers and hand creases
• Dry hands with paper towel
• Remember to swab the injecting site with an alcohol wipe (in one direction)

PRESENTATION�Hand washing - best option:

From AIVL Hand washing fact Sheet 3 https://issuu.com/aivl/docs/handwashing.factsheet.soap-and-wash#google_vignette

Dirty hit

Lunch Break

SESSION 3��Preparing a drug for injection

LEARNING OBJECTIVE

To understand the process �of preparing drugs for injection and �applying safer injecting practices

Whole �Group �Exercise

ICEBREAKER EXERCISE

The leg and arm shaker

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• Everyone stand up and move apart
• Hold out your legs and arms to make sure you have space
• As a group, follow the instructions of the group leader:
• First shake you right hand 5 times and count out loud, �then shake your left leg 5 times, then shake your right hand �5 times, and then shake your left hand 5 times
• Second shake you right hand 4 times, then shake your �left leg 4 times, then shake your right hand 4 times, �and then shake your left hand 4 times
• Let’s count down together!

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A warm-up exercise

WHAT IS DEAD SPACE?

• Dead space is the space between the needle and the plunger when the plunger is pressed all the way down to the end of the syringe. This is the space where blood remains after the needle and syringe has been used. �

WHY IS THE AMOUNT OF DEAD-SPACE IMPORTANT?  

• Some needles and syringes have more dead space than others and this can mean that more blood and drug is left behind after injecting. This blood could contain viruses like HIV, hepatitis C or hepatitis B. The lower the dead space, the less blood left behind and the lower the risk of getting or passing on viruses if the needle & syringe is reused.  

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What is Dead Space?

Image credit: Exchange Supplies UK

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High and Low Dead Space Syringes

HIGH DEAD SPACE SYRINGES/NEEDLES

Needles and syringes (that come as a separate syringe and detachable needle) are high dead space – a larger amount of blood is left inside the needle and syringe after injection (after the plunger is fully depressed).

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LOW DEAD SPACE SYRINGES

Standard insulin 1mL fixed needle and syringe units and other fixed needle and syringes are naturally low dead space – there is very little room for any blood to stay after injection (once plunger is fully depressed).

Low Dead Space ‘Fixed’ Syringe/Needle Unit

High Dead Space Syringe with separate Needle

REDUCED DEAD SPACE SYRINGES

• The top of the plunger partially fills the high dead space
• Can be used with normal high dead space needles
• Dead Space = 45-50 mL

PRESENTATION�Other types of needles and syringes

LOW DEAD SPACE NEEDLES

• The needle has a plastic spike that fills the dead space between the end of the plunger and the tip of the syringe (see image below)
• Comes in different gauges/sizes and can be used with standard high dead space syringes.
• Dead Space = 22ul or lower (approx. 80% less than standard HDS)

• 1mL 27G fixed needle syringe: mixed colours
• Same size and use
• Coloured plungers to reduce risk of accidental sharing

• 1mL 27G fixed needle Insulin syringe
• 13mm (½ inch) fixed needle
• Fine and shortest
• IV injection inner and back of arms, hands and feet
• Smaller volumes of liquid - heroin
• Common medical uses so potentially more discreet

Both types have 27 Guage needle which is firmer to deal with heavy scarring given past use of oversize needles

FGD STARTER KIT�Low Dead Space Syringe Options

• 2mL luer lock syringe
• Twist and secure lock that connects with any low dead space needle
• Coloured plungers to reduce risk of accidental sharing
• Suitable for injecting 1ml ampoules of liquid

• 5mL luer lock syringe
• Same twist lock connection
• Suitable for injecting larger volumes of liquid such as multiple ampoules

FGD PRESENTATION�Luer Lock Syringe Options

• Yellow 30G 13mm (½ inch) low dead space needle
• Finest and shortest
• IV injection inner and back of arms, hands and feet

• Orange 25G 16mm (5/8 inch) low dead space needle
• Firmer and longer
• IV injection inner arm – step down option and heavy scarring

• Orange 25G 25mm (1 inch) low dead space needle
• Firm and long
• IV injection groin
• Intramuscular injection in deltoid / upper arm muscle or buttock

• Blue 23G 25mm (1 inch) low dead space needle
• Strong and long
• Drawing up from ampoule
• IV injection groin if heavy scarring

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FGD PRESENTATION�Low Dead Space Needle Options & Suggested Uses

• Yellow 30G 13mm (½ inch) low dead space needle
• Finest and shortest
• IV injection inner and back of arms, hands and feet

• Orange 25G 16mm (5/8 inch) low dead space needle
• Firmer and longer
• IV injection inner arm – step down option and heavy scarring

• Orange 25G 25mm (1 inch) low dead space needle
• Firm and long
• IV injection groin
• Intramuscular injection in deltoid / upper arm muscle or buttock

• Blue 23G 25mm (1 inch) low dead space needle
• Strong and long
• Drawing up from ampoule
• IV injection groin if heavy scarring

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FGD PRESENTATION�Low Dead Space Needle Options & Suggested Uses

• Consider what you’re injecting (and where- IM or IV) as this will inform your needle & syringe choice
• The choice of needle and syringe
• The smaller and finer the better
• Long and firm enough to reach the target vein
• Big enough syringe and gauge needle for drug solution
• Street water soluble drugs – white heroin or cocaine - should be filtered
• “Cooking up” brown heroin with an acid turns it into an injectable form that should be filtered
• Pharmaceutical drugs in an ampoule – Pethidine or Ketamine – are ready for injection

PRESENTATION�Preparing and Administering an Injection

PRESENTATION�Equipment needed for injecting

NEEDLE

SYRINGE

SPOON

WATER

(ACID)

LIGHTER

FILTER

ALCOHOL WIPE

TOURNIQUET

• Wash your hands in the best way possible
• Clean the area where you plan to inject
• Create a “Protected Using Space” with a magazine page – collect all the equipment you need for your injection in one place
• Prepare your drug for administration
• Use sterile water or the best water you can find
• If necessary convert the drug with an acid
• Filter your drug solution
• Keep your needle sharp and protected

PRESENTATION�Safer Injecting Preparation - Good Practice

• Required with non-injectable forms of drugs such as brown heroin or crack cocaine
• Vit C or Citric acid – buy in pharmacy or sachets provided by Needle and Syringe Programme
• Too much acid stings if injected and hardens the vein leading to vein collapse
• Use as little acid as possible – start small, add a little bit at a time, use as little as possible
• Dissolve the drug not the cutting agent – no “clear wash”

PRESENTATION�Using an acid

• Dangers of using juice from opened lemons – risk of injecting a fungus that can damage lens of the eyes
• Vinegar is harsh acid to be avoided if possible
• Only use lemon juice from freshly open lemons
• Citic acid and vitamin C can be brought in packets from pharmacists but watch out for cross contamination.
• Citric acid and Vitamin C sachets are provided by NSPs.

ILLUSTRATION�Acid Hierarchy - different types �of acids

Whole �Group �Exercise

What water should I use to prepare my injection?

PRESENTATION�Choosing �the best water for injection

Image credit: Exchange Supplies UK

Use the best water you can for the situation you are in

Afternoon Break

SESSION 4��Administering �a drug by injection

LEARNING OBJECTIVES

To understand the process of administering drugs by injection and applying safer injecting practices

To understand safer disposal practice for needles and syringes

• Tourniquet help bring up the vein making it easier to inject
• Shake your arm loosely down below your heart – gravity will help your veins bulge
• Put your tourniquet on your tourniquet as shown – allows for quick release
• Once tourniquet in place, pump your fist to bring up the vein
• Once you have inserted the needle, release tourniquet before injecting your drug solution
• Avoid sharing tourniquets
• Rubber tubing is better than hard belts or wire that can cause soft tissue damage

PRESENTATION�The role of �a tourniquet

• Use tourniquet
• Vein choice and rotating sites you inject in
• Clean vein by wiping in one direction with alcohol wipe
• Insert needle at a similar angle to the vein direction to pierce vein
• Change to “insert needle at the same angle the vein runs in - this will vary for everyone. Keep needle and syringe stable, release tourniquet and inject the drug solution slowly.
• If draw back does not result in “show of blood” adjust needle and syringe. Change needle if you need to pierce skin several times to find the vein
• Once drug solution injected, press down with cotton wool or clean tissue on injection site
• Safely dispose of needle and syringe
• Clean away injecting paraphernalia and clean injection area

PRESENTATION�How to use �a tourniquet

Small �Group �Exercise

Taking Drugs by Injection

FULL KIT INSPECTION

• Divide participants into 4 small groups
• Each group will be given a ‘mock drug’
• Set out on the table is paraphernalia used for injecting and non-injecting drug use and some other miscellaneous household goods
• Each group is asked to collect the paraphernalia required to prepare their ‘mock drug’ for injection
• Once your group has gathered the required equipment, you should practice preparing the ‘mock drug’ for injection 
• Once you are confident that you have the required equipment and know the required steps then call over a Trainer to validate your learning

Questions and Answers

STANDARDS IN SAFER DISPOSAL 

• Encourage PWID to recap their own needles before putting them in a sharps bin or plastic water bottle to reduce the risk of needles piercing containers.
• Only recap your own needles to reduce the risk of needle-stick injury.
• Sharps bins ideal – only fill two thirds full.
• Pragmatic disposal – see-through plastic water bottles.
• Mother bins – gather together personal bins for safe onward storage.
• Understand how people are returning safely through secondary disposal sites, fixed-site disposal sites, or through a friend’s bin.
• Understand barriers to safe returns without judgement.
• Don’t limit access to sterile injecting equipment as a strategy to promote returns.
• Count returns based on estimates for different size bins.

Safe Disposal of Injecting Equipment

Litter pickers

CLEANING UP DISCARDED INJECTING EQUIPMENT SAFELY:

• Don’t directly handle �used injecting equipment
• Use grabbers or needle resistant gloves
• Take sharps bin as close as you can to the injecting litter
• Wear robust footwear �to avoid needle stick injuries

Disposal �Good Practice

Put needles and syringes directly into sharps bin and dispose via medical waste

Wear strong boots to avoid needle stick injuries

Kevlar gloves for safe disposal of drug litter

Cleaning Needles, Syringes, Barrels as a last resort

Rinse, Bleach, Flush

If you can’t get a sterile syringe, you can:

1. wait until you do
2. use your drugs another way - smoke, snort, swallow, shaft
3. clean a syringe you have used before
4. clean a syringe someone else has used

How to clean a syringe:

• do your best handwash option
• do this in a clean, safe space where possible
• then rinse, bleach, flush
• be sure to do this with all parts, including the cap.
• you need three containers:
• One with clean, cold tap water (can add a very small bit of detergent to loosen blood particles)
• One with full-strength (undiluted) bleach
• One with clean, cold tap water.

CLEANING NEEDLES, SYRINGES, BARRELS AS A LAST RESORT

RINSE, BLEACH, FLUSH

rinse

bleach

flush

3 steps:

1. rinse - draw up detergent + water (or plain water) from first cup to fill the syringe, squirt water down the sink. repeat at least 5 times.
2. bleach - take the syringe/barrel apart and put it in the second container - make sure it’s completely covered. soak for at least 2 minutes. if you can’t wait, other option is fill the syringe with bleach and shake well for at least 30 seconds. do this 2 times, or more - squirting out into the sink after each shake.
3. flush - draw up fresh water from the third container, shake it then squirt it out into sink. Repeat at least 6 times

CLEANING NEEDLES, SYRINGES, BARRELS AS A LAST RESORT

RINSE, BLEACH, FLUSH

From AIVL Guide to Cleaning Used Syringes: https://issuu.com/aivl/docs/cleaning_used_syringes

rinse

bleach

flush

Course Handouts

Exchange Supplies

Safer Injecting Handbook

Accessible, practical and maintained practice resource

Harm Reduction International

Low dead space syringes: Analysis and benefits for people who inject drugs

Low Dead Space Syringe Report

Technical Resources

Eurosider is a European project for practitioners promoting Safer Injecting Practice for People who Inject Drugs

Eurosider Project

ITSESI (Individually Tailored Support and Educational Supervised injection) �European Training Manual

https://www.correlation-net.org/eurosider/

The End - Thank You!