Used Needles and Syringes Disposal Management

USED NEEDLES AND SYRINGES DISPOSAL MANAGEMENT

Documentation of Practice at Green Dot DIC, PSI-IDU Supported by KSAPS, Bangalore Urban, Karnataka
August 2011
This publication was commissioned by the Technical Support Unit of the Karnataka State AIDS Prevention Society. Citation: USED NEEDLES AND SYRINGES DISPOSAL MANAGEMENT: Documentation of Practice at Green Dot DIC, PSI-IDU, Supported by KSAPS, Bangalore, Karnataka, 2011. Contributors: Mr. John Anthony, Mr. Joseph Francis Munjattu, Mr. Ajay Pal, Mr. Senthil Kumaran Murugan, Ms. Elizabeth Michael, Mr. Rajnish Ranjan Prasad, Ms. K S Poornima and M. Nagesha. Layout and Design: M. B. Suresh Kumar (ARTWIST Design Lab) Copies Printed: 200
Contents
Acknowledgements ...........................................................................................................................................04 List of Acronyms .................................................................................................................................................05 What is this document about? ...........................................................................................................................06 Who is this document for?..................................................................................................................................06 1 Introduction ..............................................................................................................................................07 2 Background ...............................................................................................................................................09 3 Waste Disposal Management ....................................................................................................................11 4 Budgeting for Used Needles and Syringes Management ...........................................................................17 5 Staff Training and Monitoring ...................................................................................................................19 6 Community Sensitisation ..........................................................................................................................20 7 Conclusion.................................................................................................................................................21 Flow Diagram: Collection and Disposal of Injecting Equipment..........................................................................23 References .........................................................................................................................................................24
Waste Disposal ManageMent

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ACknowledgements
We would like to acknowledge following organizations for their contribution in preparing this documentNational AIDS Control Organization (NACO) Karnataka State AIDS Prevention Society (KSAPS) Technical Support Unit, KSAPS Karnataka Health Promotion Trust (KHPT) Public Health Foundation of India (PHFI) Population Services International (PSI) We would like to acknowledge following individuals for their role and support in preparing this document Dr. Subash Chandra Ghosh (Programme Officer, TI, NACO) Ms. Salma K Fahim IAS (Project Director, KSAPS) Mr. Vijay Hugar (Joint Director, TI, KSAPS) Mr. John Anthony (Team Leader, TSU) Mr. Joseph Francis (Team Leader, TI, TSU) Mr. Ajay Pal (Programme Officer, TI, TSU) Dr. Praveen.G (Clinical Specialist, TSU) Ms.Sapna Ravindran (State Programme Manager, PSI, Karnataka) Mr. M. Nagesha (Programme Officer, IDU-TI1 project, PSI, Karnataka) We would also like to acknowledge Ms. Priya Pillai who assisted in writing this document.
lIst oF ACRonYms
AIDS ART DIC HIV IDUs KSAPS MSM NACO Acquired Immune Deficiency Syndrome Anti-Retroviral Therapy Drop-in-Centre Human Immunodeficiency Virus Injecting Drug Users Karnataka State AIDS Prevention Society Men having Sex with Men National AIDS Control Organisation NACP NSEP NSP ORW PE PSI SACS TI TSU National AIDS Control Programme Needle Syringe Exchange Programme Needle Syringe Programme Outreach Worker Peer Educator Population Services International State AIDS Control Society Targeted Intervention Technical Support Unit

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whAt Is thIs doCument About?

Injecting drug use is today recognised as a primary route of transmission of HIV in India and elsewhere. As per the sentinel surveillance report 2008-2009, in many states of India, increasing trends of HIV infections are noted among Injecting Drug Users (IDUs) and Men who have sex with Men (MSM), as compared to declining infections among female sex workers1. Though there are only 200,000 IDUs in the county2, the burden of HIV on them is significant and expanding. The IDUs have one of the highest rates of HIV among the High Risk Groups with the HIV positivity rate among the IDUs being 7.2% compared to 0.36% in general population3. The high positivity rate is a result of multi-person reuse of contaminated syringes and other injecting equipments among IDUs. The epidemic is spread through sexual transmission from the IDUs to their female sexual partners, and through perinatal transmission to newborns, thus leading to the spread of HIV to the general population4. National AIDS Control Organisation (NACO) has adopted harm reduction as a strategy to prevent HIV among IDUs. Multiple interventions have been designed to provide HIV prevention services for the IDUs. These include needle syringe exchange, behaviour change communication, condom distribution and referral to a number of health services, right at their doorstep. The Needle Syringe Exchange Programme (NSEP) involves both distribution of new needle/syringe and collection and disposal of used needle/syringe. NACO has developed guidelines that detail the methods for safe disposal of used needles and syringes. The purpose of this document is to describe management of disposable needles and syringes, currently being followed at green Dots DIC, which is a targeted intervention for IDUs. The project managed by PSI is being funded by KSAPS.
Who is this document for?

The document is primarily for programme managers in other TIs and State Aids Control Societies (SACS) implementing the Targeted intervention programme with the IDU community, under NACP III. It aims to help organisations understand the process of operationalising the NACO guidelines to ensure safe disposal of used needles and syringes.
1 2 3 4
NACO. Injecting Drug Use: Strategy Report for NACP IV Planning; 2010 ibid NACO.Draft document - Implementation of Opioid Substitution Therapy in Government Health Care Facilities for Injecting Drug Users The U.S. Presidents Emergency Plan for AIDS Relief (PEPFAR). Comprehensive HIV Prevention for People Who Inject Drugs, Revised Guidance. July 2010
IntRoduCtIon
The establishment of worlds first official needle syringe programme followed an outbreak of Hepatitis B among Injecting Drug Users (IDUs) in Amsterdam in 19835. The response to this epidemic was the supply of sterile injection equipment to IDUs. Currently, needle syringe exchange programmes (NSEP) operate officially in over 40 countries and is considered to be a central component of any comprehensive and effective HIV prevention programme . Today, the NSEP have expanded to include not just access to sterile injecting
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and decrease in HIV transmission by as much as 33-42% in some settings8. Evaluation studies of NSPs have consistently confirmed that these programmes increase the availability of sterile injection equipment, reduce the quantities of contaminated needles and other injection equipment in circulation, reduce the risk of new HIV infections, and result in referrals to other services, such as Anit-Retroviral Therapy (ART) for those eligible9. Further, NSP is an important public health practice as syringe exchange provides an opportunity for sustained contact between NSP staff and the person exchanging the injection equipment10. In India, the IDUs constitute one of the high risk groups of Human Immunodeficiency Virus (HIV) with the prevalence rate among them being 7.23% (sentinel surveillance 2007)11. The NSEP is a key component of the Targeted Interventions (TI) implemented by NACO to
equipment but also, strategies for collection, disinfection and appropriate disposal of used needles and syringes. Numerous studies have established the effectiveness of needle syringe programme (NSP) in achieving marked decrease in drug-related risk behavior (e.g., sharing of injection equipment, unsafe injection practices and frequency of injections), by as much as 60%7,
5 6 7
WHO. Effectiveness of Sterile Needle and Syringe Programming in Reducing HIV/AIDS among Injecting Drug Users; Evidence for Action Technical Papers; World Health Organisation, 2004. i.b.id. Institute of Medicine. (2007). Preventing HIV Infection among Injecting Drug Users in High Risk Countries: An Assessment of the Evidence. Washington, DC: National Academies Press cited in The U.S. Presidents Emergency Plan for AIDS Relief (PEPFAR). Comprehensive HIV Prevention for People Who Inject Drugs , Revised Guidance. July 2010 Wodak, A., & Cooney, A. (2006); World Health Organization. (2004) cited in PEPFAR, July 2010. Institute of Medicine (2007); Wodak, A., & Cooney, A.(2006); Normand, J., Vlahov, D., & Moses L. (1995); and Farrell, M., et al. (2007), cited in PEPFAR. July 2010. The U.S. Presidents Emergency Plan for AIDS Relief (PEPFAR). Comprehensive HIV Prevention for People Who Inject Drugs , Revised Guidance. July 2010 NACO. Guidelines on safe disposal of Used Needles and Syringes in the Context of Targeted Intervention for Injecting Drug Users. June 2009.
8 9 10 11
address HIV prevalence among the IDUs12. The goal of NSEP is to ensure that every injecting act is covered with a safe needle/syringe13. The NSEP involves distribution of a new needle/ syringe to the IDU client and taking back the used needle/syringe from the client in a safe and proper manner14 . NACO in its guidelines for safe disposal of used needles and syringes has identified multiple hazards15 associated with improper collection and disposal of used needles and syringes (N/S). One, if the used N/S are not collected in a safe manner from the client or the field, the outreach workers (ORWs) or peer educators (PEs) involved in collection risk the chance of pricking themselves with the used sharps. This increases their vulnerability to the transmission of HIV or other blood borne infections. Two, needles and syringes that are not properly stored and lay scattered in public places can result in reuse of contaminated
N/S by the IDUs. This increases their own risk to HIV and other blood borne infections or disease including HIV/Hepatitis B and C. Three, the scattered N/S may also lead to children playing with these sharps, thus endangering them to the possibility of HIV transmission and other infections. Four, safe collection and disposal of syringes can prevent the resale of used N/S. Finally, the scattering of used N/S can antagonise the larger community towards the IDUs and increase their resistance to the overall programme with the IDUs. In short, inappropriate segregation, collection, transport, handling, storage, and disposal of N/S pave the way for potential public health and environmental hazards. Thus, the distribution of sterile injection equipment, exchange of sterile syringes for used syringes and safe disposal of used injection equipment can effectively impact the prevention of HIV transmission among and through injecting drug users.
12 13 14 15
i.b.i.d. NACO. IDU A Manual on Working with Injecting Drug Users a Trainers Manual NACO. Guidelines on safe disposal of Used Needles and Syringes in the Context of Targeted Intervention for Injecting Drug Users. June 2009. ibid
bACkgRound
The Population Services International (PSI) began its India operations in 1988. Today, it is present in 22 states and union territories with programmes that focus on HIV/AIDS and other sexually transmitted infections, reproductive health, malaria prevention and child survival. PSI has HIV programmes in over 60 countries around the world, with a variety of services to reduce HIV incidence, and to improve access to HIV care and treatment around the world. The comprehensive package of services from PSI to reduce HIV transmission includes HIV counselling and testing, male circumcision, prevention of mother-to-child transmission and family planning/HIV integration. The HIV counselling includes risk-reduction interventions for those who test HIV-negative and referral and linkages to positive living support groups for people who test HIV-positive. Furthermore, it has initiatives such as condom social marketing, targeted communication for concurrent sexual partnerships, and injecting drug use interventions16. PSIs work with injecting drug users involve programmes to help reduce drug-related harms, to prevent the initiation into injecting drug use and to promote the cessation of drug use with opioid substitution therapy17. Interventions specific to reducing drugrelated harms include peer education about the risks of injecting (including both HIV and Hepatitis C infection as well as wound care), the promotion of HIV counselling and testing, behavior change communication to increase correct and consistent condom use, distribution of sterile injecting equipment to reduce needle sharing, and the distribution of the drug naloxone to prevent overdose death18. The HIV/AIDS prevention programme, among Injecting Drug Users (IDUs), by Population Services International (PSI) in Karnataka state was initiated in August 2008. It began with one drop-in-centre (DIC) for the whole of Bangalore Urban district. In the first year, the programme focused on identification of IDUs and distribution of needles/syringes and condoms. It also involved community sensitisation about the IDU project and the available free services.
16 17 18
http://www.psi.org/our-work/healthy-lives/hiv ibid ibid
The programme19 identified about 919 IDUs, out of which 6 were female. The IDUs were spread across 203 sites in 8 locations. The lack of proximity of the DIC became a constraint for many of the IDUs to visit the DIC for uptake of services. Hence, to enable access to services for more IDUs, two TIs were started one in Lingarajapuram and Shivaji Nagar for 501 IDUs and the second in Chamrajpet for 300 IDUs. Currently, the outreach of these TIs includes 494 and 423 IDUs respectively. The programme currently reaches out to 500 IDUs with the services, out of which, 65 are sexually active male IDUs, and one is a female sex worker (FSW). There is one HIV positive IDU undergoing ART treatment. The DIC has a monthly regular contact of 460-480 IDUs. The average age group of the IDUs is between 30-40 years. The male IDUs are mainly employed as drivers, rag pickers, call centre employees, small business owners, staff of de-addiction centres and some students. Majority of the female IDUs are students and also includes a FSW and housewives whose husbands are drug addicts.
The used needle/syringe waste disposal programme started in the second year. Before the start of the programme, the used needles/syringes were collected and stored in plastic bags at the DIC. The waste disposal programme was initiated to address, the potential health hazards to the health workers and the larger community, posed by the improper storage. This document details out the used needle/syringe disposal management intervention adapted by the Green Dot DIC, at their sites in Lingarajapuram and Shivaji Nagar, of PSI, India.
19
All factual details of the programme sourced from Interview with M.Nagesha, Programme Officer, IDU-TI project, PSI on July 26, 2011.
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wAste dIsposAl mAnAgement

The Green Dot DIC reaches out to 500 IDUs in 63 hotspots in Lingarajapuram and Shivaji Nagar area with the NSEP intervention. The outreach is done through 2 outreach workers (ORWs) and 12 peer educators (PEs). The waste disposal management in this DIC strictly follows the NACO guidelines on the safe disposal of used needles and syringes (N/S). The guidelines state the need for training of the outreach staff on proper collection and safe disposal of used N/S. It also explains the various stages and steps involved in waste disposal management. The various stages involved in waste disposal management as per NACO guidelines are as follows: 1. Collection of the used injecting equipment 2. Storage of the used injecting equipment at the centre 3. Disinfection of the used injecting equipment 4. Final disposal from the centre The used N/S is collected in a puncture proof plastic box, marked with a biohazard warning sign and biohazard written prominently on the body of the box. The box for used needles (figure 1) is a long, bright red box with a detachable lid. The lid has a hole with a flap for inserting the needles into the box. The box for used syringes is a rectangular white plastic box with a lid for closure. The biohazard sign on the box denotes that the box carries infectious materials. The sizes of the boxes are determined by the comfort of the field staff in carrying them during the collection of used needles and syringes. The used needles box is a 1.5 litre box and has a maximum capacity of 1000 needles/syringes. On a regular day, in a single visit, the ORW or PE will collect about 50-150 needles and syringes. As the collection is done on a regular basis, the number of needles and syringes found at the fixing spots never exceed the volume of the box.
a. Collection of Used Needles/Syringes and their Segregation

The used needles and syringes are collected by the ORW or PE during their visits to the hotspots. The ORW or PE visits the field every day with a set of instruments for the safe collection of used N/S. He carries with him a bag containing two boxes one for used needles and other for used syringes - forceps and hand gloves.
Fig 1: Puncture proof plastic box for used needles
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The ORW or PE first wears the gloves (figure 2), takes out the forceps and picks the needle and syringe with the forceps. The gloves are thick and orange coloured unlike the thin clinical gloves. The used N/S is picked from the syringe end with the forceps. The needle with the hub is separated from the syringe using the opening of the box (figure 3). Only the needle with the hub is deposited into the box. Once the box is filled to the capacity, the lid of the container is secured tightly. The syringes dismantled from the equipment are collected into a separate used syringes box (figure 4). There is no biohazard sign marked on this box.
The manual transfer of sharp waste from one container to another is avoided. Once the used needles and syringes boxes are filled, the ORW or PE deposits them at the DIC.
b. Storage at the Drop-In-Centre

At the DIC, the filled boxes are handed over to the counsellor who is primarily in charge of collection. The counsellor first puts on the mask and gloves and takes the boxes from the ORW or PE. The used needle and syringe containers are kept securely in a closed room away from easy access. They are not kept in places of common use. The containers (figure 5) are bin shaped and opaque blue in colour. They are large, sturdy and closed with a lid. Both the bins are clearly marked indicating the content inside.
Fig 2: PE wearing the gloves before collecting used N/S Fig 3: Needle being separated from the syringe
Fig 4: Box for collecting used syringes
Fig 5: Plastic containers for storing used N/S at the DIC
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The storage room is well lit and easy to clean. A warning sign to not touch these boxes is also placed appropriately, visible to anyone entering the room. The places for used needles and syringes are separate, at a distance from each other and marked with a sign indicating the material inside.
Fig 6: Label on top of used syringes box
c. Stock Management of Puncture Proof Boxes

The ORW or PE deposits the boxes at the DIC. The counsellor issues new boxes in return for the filled boxes with used needles and syringes. Each of the boxes issued is labelled (figure 6) with the name of the ORW to whom it is issued and the date of issue. This helps to avoid possible loss of boxes and ease the process of counting of the boxes. On return of the used box, the records are entered and a new label is pasted on the box. The label contains the name of the next person to which the box is issued along with the date of issue.
Fig 7: Fresh stock of boxes at the DIC
To avoid stock out, the DIC maintains sufficient fresh stock of boxes for used needles and syringes (figure 7), forceps and gloves. These are separately stored in a closed room away from the used needles and syringes. The boxes, forceps and gloves are wrapped in plastic wrap for additional protection. The counsellor maintains a record of the number of boxes received, collected and distributed. Once the boxes are deposited at the DIC, the counselllor along with the ORW counts and enters into the register (figure 8) the number of needles and syringes collected. The needles and syringes are counted using forceps and are not manually handled.
Fig 8: Register for maintaining records
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The information entered into the register includes the date of receiving the filled boxes, the name of the PE/ORW/Counsellor/Community Member from whom it is received, the number of used syringes and needles collected from these boxes and a column for remarks if any. The counting and subsequent entry into the record is done on the same day or latest by the following day. In the absence of the counsellor, the responsibility for collection and maintenance of records is undertaken by the ORW or Programme Manager. The condition of the gloves, forceps and boxes are checked for any possible damage each time the PE or ORW visits the DIC with the collected used needles and syringes. In the event of any damage to the gloves, forceps or boxes, they are replaced with new stock. This is a precautionary measure to prevent the danger to an ORW or PE from a needle prick during their next round of collection. It is mandatory for a PE to carry gloves, forceps and boxes used for collection on his every visit to the DIC to drop the used N/S.
d. Disinfection at the DIC

The needles and syringes used by the clients tend to have blood within them, which can cause infections such as HIV or Hepatitis B/C, and lead to other pathogens being passed on from the client to others handling these needles and syringes20. The disinfection process helps to kill these micro-organisms and ready the needles and syringes for safe handling21. At the DIC, the disinfection process is done by the counsellor (figure 9) once every week. The counsellor wears the mask and the gloves and prepares the disinfectant solution. The solution is made by diluting 100gms of bleaching powder in 15-20 litres of water. The solution is thoroughly mixed using the forceps.
20
NACO. Guidelines on safe disposal of Used Needles and Syringes in the Context of Targeted Intervention for Injecting Drug Users. June 2009. ibid
21
Fig 9: Counsellor disinfecting used N/S
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The needles with the hub are emptied into a blue perforated plastic bin. The bin filled with syringes/needles is then dropped into a red bucket with the solution. The needles/syringes are soaked for 1.5 hours. The solution is occasionally stirred, using forceps, to activate the cleaning process. They are soaked for more than the mandated time suggested in the NACO guidelines as the needles/syringes carry considerable amount of blood within them and requires time to be cleaned well. First, the syringes are cleaned followed by the needles with the hub. The disinfected needles and syringes are then transferred into different containers with lid. The disinfected needles and syringes are stored in separate containers and away from the used needles and syringes. As with the used N/S containers, these bins (figure 10) are also closed containers similar in size and shape but in different colour. They are also marked with a sign, large and visible, indicating the content inside. The used needles and syringes boxes are cleaned regularly. Once the used needles and syringes are removed from the boxes, the same day evening, these boxes are dipped in a bucket with soap water, surf and bleaching powder till next morning. The following day, the boxes are cleaned with a brush and dried in the sun before being reissued.
Fig 10 : Plastic containers for storing disinfected used N/S at DIC
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e. Materials Used for Disposal of Sharp Waste

The following materials are available at the TI for the disposal of sharp waste: 1. Puncture proof boxes numbered and marked with biohazard symbol 2. Thick rubber gloves 3. Large forceps 4. Plastic bin with sieve 5. Plastic bin without sieve 6. Disinfectant solution bleach 7. Large plastic bins (blue for disinfected syringes and green for disinfected needles)
f. Final Disposal from the Drop-In-Centre

For the final disposal of waste from the DIC, it has tied up with a private waste collection agency - MARIDI ECO INDUSTRIES PVT. LTD. On the first or second Thursday of every month the disinfected needles and syringes from the DIC are collected by the agency. Every month, the DIC supplies a volume of around 4000-5000 needles and syringes. The cost for final disposal is Rs. 2000 per month for up-to a maximum of 40kgs of needles and syringes. For every kilogram above that, the rate is fixed on a per kg basis. The monthly collection has so far been less than 30kgs.
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budgetIng FoR used needles And sYRInges mAnAgemen

A single disinfection process cleans about 3 kgs of used needles and syringes and requires 10-15 litres of water. The cost and duration of usage of the other materials required for disinfection vary. A recurring cost of Rs.5 is incurred for the mask used by the counsellor. A fresh mask is used for every round of disinfection. The gloves cost Rs.180 for a pair and require to be replaced every three months. The forceps cost Rs.175 and are replaced every six months. A 250gm packet of bleaching powder costing Rs.20 can be used for two rounds of disinfection. About 100gm of bleaching powder is used during a single round of disinfection. Two buckets, one each for the disinfected needles and syringes, cost Rs.200 each and can be used for a period ranging between twelve to twenty four months. Table 1 below shows the total cost incurred for a single round of collection, disinfection, storage and disposal of used needles and syringes.
Table 1: Costing of used needle & syringe management

Item BD sharp puncture proof box Plastic Box Pair of rubber Gloves (2 pieces) Tong total (peer Cost) Mask Bleaching Powder Surf Powder External Agency Final Disposal Used during disinfection Used during disinfection of used needle & syringe 25 masks per month 2 Kg per month 2 Kg per month Collect used needles Collect used syringes Used during collecting needles & syringes from field purpose Quantity 1 1 1 1 Cost (Rs) 295 40 160 175 670 125 200 200 2000
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total (monthly Cost) Bucket (2 for Used need & syringe and other 2 for disinfected Used for safe storage need & syringe Plastic Bin (1 with hole and other without hole) Plastic Box (1 KG) for keeping Bleaching Powder Brush For disinfection Used during disinfection of used need & syringe For cleaning needle & syringe box total (one time Cost) 4 2 1 1
2525 800 530 50 15 1395
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stAFF tRAInIng And monItoRIng

The ORWs and PEs are trained by the Programme Manager using the NACO guidelines, supported by guidance from the Technical Support Unit (TSU). The new ORWs and PEs are given a one day training, which involves a field visit to demonstrate the safe method of collection of used N/S and its subsequent storage and disposal at the DIC. The new staff members also undergo practice sessions to familiarise themselves with the process of collection, storage and disposal. The Programme Manager visits the field along with ORWs on every alternate day, thus monitoring the adherence of the staff to the waste disposal procedures. The PEs are trained and monitored by the ORWs (box 1) and additionally by the Programme Manager during his visits to the field. A PE is always accompanied by an ORW during his rounds for the collection of used needles and syringes. Additionally, the Project Director for the IDU programme visits the TI thrice a month. During these visits, meetings with the staff are held twice a month, where issues, if any, involved in the process of disinfection are discussed. Specifically, any administrative issue such as a delay in the procurement of materials required for the disinfection process, which cannot be managed at the TI level, are brought to her notice and action sought. Further, the Project Director is also informed about issues such as non-compliance from the TI staff on mandatory guidelines to be followed during waste disposal and peer calendars not being filled by the peer.

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CommunItY sensItIsAtIon
Box 1:
Monitoring of Peer Educators

They (ORWs) will stand separately and observe what we do. They will not interfere with our work. They will see if the way we collect the syringe is right, whether we take the whole set of needle and syringe or just the needle? They will notice the new IDUs we interact with, the messages we give them and their responses - Saif.S, a peer educator with Green Dot DIC, Shivajinagar TI, in an interview on August 8. During the field visits, discussions are held with the IDUs to sensitise them and raise their awareness (box 2) about the dangers of randomly throwing the used N/S. Twice a month, DIC level meetings and four times a month, hot spot level meetings are held where information about services, safe injecting, HIV/AIDS, and disposal of used N/S are provided. Repeated sessions are conducted as for most part of the day the IDUs tend to be in a state of intoxication. Reinforcement of messages is important in such a context for it to be assimilated by the IDUs. The Programme Manager, ORW, Counsellor and some PEs take turns to conduct the training.
Further, to ease the process of collection of used needles and syringes, the ORWs and PEs along with the IDUs fix definite spots where the used N/S will be kept. This aids in easier collection of used needles and syringes, and reduction of potential health risks for the larger community.
Box 2:
Increasing Awareness
we are getting protection from disease. If the needles are thrown around, children will play with it and get harmed. Also, those who dont have money may take these needles and use them. Sometimes, people get curious about these needles and start experimenting by injecting themselves with it. This will lead to new people getting into drug use. Now, we collect the needles and syringes, return to the madam at the DIC and get new ones - Aejaz, a peer educator with Green Dot DIC, Shivajinagar TI, in an interview on August 8.
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ConClusIon
The Needle and Syringe Exchange Programme is one among the four specific interventions22 provided to the IDUs to reduce their vulnerability to HIV/AIDS. The IDU community articulated many benefits that have accrued to them (box 3) and the larger community as a result of the targeted intervention programme23. The most significant among those is the reduction in the risk of HIV transmission through the sharing of contaminated needles and syringes. Prior to the start of the NSEP, a single needle was shared by five to six IDUs, while now a new N/S is used for every shot. They are also aware of the health hazards that random throwing of used N/S can cause to the larger community. Today, they actively cooperate and participate with the ORWs and PEs to help find and collect the used N/S. The locations or spots for injecting themselves with drugs are carefully chosen, away from those frequented by the general public. A fixed spot is decided for disposal of the used N/S. This reduces the chance of used N/S being strewn around unnoticed by the collection agents (ORWs or PEs), avoiding a potential hazard for larger community members, especially children who tend to play with these. In addition to the obvious health benefits, the IDUs see a clear economic advantage from the programme. They save a minimum of Rs.6 per day as they no longer have to buy N/S from a medical shop. They get sufficient number of N/S either from the DIC or from the peers or ORWs.
22
The presence of the DIC and the services provided through them benefit the IDUs in many ways. For them, the DIC is a safe resting space away from the fear of police or the sight of the larger community. The DIC provides a de-stigmatised environment for the IDUs to access medical services, where they can confidently discuss their issues with the doctor, as compared to private clinics or other general hospitals. The access to medical services through the doctor at the DIC reduces their chances of contracting infectious diseases. A wrong shot while injecting can lead to the formation of abscess and will require treatment. The doctor at the DIC educates the IDUs about safe injecting methods, proper injecting techniques and appropriate selection of injecting sites in the body to prevent abscess formation or the management of abscess care. Finally, the DIC is also a recreational space for the IDU community, where they meet their friends, play and watch television together. Engagement in group activities provides them with a distraction, thus taking their attention away from the need to use drugs. An indirect outcome of this is the reduction in drug usage since the IDUs tend to inject drugs continuously, when they are unoccupied, outside of the DIC. The psychosocial support through counselling also helps them to reduce their drug usage and deal better with addiction.
Other interventions provided to IDUs as part of the targeted interventions under NACP III include abscess management and other health services, detoxification/de-addiction and rehabilitation, and oral substitution therapy (OST). NACO. IDU A Manual on Working with Injecting Drug Users a Trainers Manual Focus Group Discussion on the benefits of Targeted Intervention programme, specifically of the Needle Syringe Disposal Management, with 8 IDUs in Shivaji Nagar TI.
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21
Box 3: Towards Better Health

I joined as peer educator three months back and was told how HIV spreads among the IDUs through the sharing of used needle and syringe. They trained me to collect used N/S, bring them to the office, enter the records and get new N/S issued. Today, I provide services to 42 IDUs and meet 15 to 19 in a week, take them for regular ICTC blood tests every six months, counsel them to find a safe place to fix and avoid public places, encourage them to visit the DIC and tell them about its benefits, and also educate them about condom usage. Personally, I have reduced the type and frequency of my drug usage. Before knowing about Green Dot, I used to use drug in dry wells with garbage, shit thrown in, school compounds, railway tracks and playgrounds. Now, I take N/S from the ORW, fix in my home bathroom, keep all the used stuff in plastic bag and give it to the DIC. From using brown sugar, heroine, ganja and pain killer, I now use only pain killer. I also inject myself with only one strip of pain killer in a day as compared to six strips before the programme. In my role as peer educator, by collecting the used needles and syringes, I save people from dying by preventing infections through blood. I protect the health of not just my friends but also the larger community. I can identify new fixers, know how HIV spreads and how I can help the society to reduce its spread. Mosses J, a peer educator with Green Dot DIC, Shivajinagar TI, in an interview on July 2011.
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Flow Diagram: Collection and Disposal of Injecting Equipment
Used N/S collected in the hotspot or brought by the client
Collect used needles and syringes in separate puncture proof boxes
Needles and Syringes counted and entered into the records
Used N/S emptied into separate colour coded large plastic bins with lids
Empty used needles with the hub into plastic bin with sieve for disinfection
Transfer the disinfected syringes into a blue plastic bin with lid
Immerse the plastic bin with sieve into a large plastic bin with disinfectant solution for 1-1.5 hrs
Empty used syringes into plastic bin with sieve for disinfection
Immerse the plastic bin wtih sieve with used needles into the bin wtih disinfectant solution for 1-1.5 hrs
Transfer the disinfected needles into a green plastic bin with lid
Disinfected N/S collected in large plastic bins with lids closed
Waste treatment agency collects the disinfected N/S once a month
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ReFeRenCes
1. National AIDS Control Organisation (2010). Injecting Drug Use: Strategy Report for NACP IV Planning 2. National AIDS Control Organisation, Draft document Implementation of Opioid Substitution Therapy in Government Health Care Facilities for Injecting Drug Users 3. The U.S. Presidents Emergency Plan for AIDS Relief (PEPFAR) (2010). Comprehensive HIV Prevention for People Who Inject Drugs, Revised Guidance 4. World Health Organisation (2004). Effectiveness of Sterile Needle and Syringe Programming in Reducing HIV/AIDS among Injecting Drug Users - Evidence for Action Technical Papers
5. National AIDS Control Organisation (2009). Guidelines on safe disposal of Used Needles and Syringes in the Context of Targeted Intervention for Injecting Drug Users 6. National AIDS Control Organisation. IDU A Manual on Working with Injecting Drug Users a Trainers Manual 7. http://www.psi.org/our-work/healthy-lives/hiv
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: IHAT, 2011

Used Needles and Syringes Disposal Management

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USED NEEDLES AND SYRINGES DISPOSAL MANAGEMENT