Metropolitan Needle and Syringe Vending Machine Trial: Evaluation ReportSexual Health and Blood-borne Virus Program,December 2014

health.wa.gov.au

ContentsBackground 3

Armadale 4The trial 5Location of the NSVM 5Specifications and installation of the NSVM 5Promotion of the NSVM 5

Methodology 6Staff experience 6Client experience 6Operational issues 6Level of use of NSVM 6Success of the machines 7

Results 7Distribution data 7Operational issues 7Client experience 8Staff experience 8Products vended 9Injecting-related health information 9Inappropriate disposal 9

Discussion and conclusion 9Recommendations 10

Appendix 11Appendix A – NSVM specifications 11Appendix B – NSVM photos 12Appendix C – NSVM products 13Appendix D – NSVM flyer 13Appendix E – feedback questionnaire 14Appendix F – NSVM signage 18

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BackgroundThe primary public health strategy in Australia to prevent the transmission of blood-borne viruses (such as HIV, hepatitis B and hepatitis C) amongst and from people who inject drugs is to provide access to sterile needles and syringes.

In Western Australia, the Poisons Act 1964 and the Poisons Regulations 1965 were amended in 1994 to provide a legislative framework for needle and syringe provision to take place through needle and syringe programs (NSPs) approved by the Chief Executive Officer, Department of Health.

The provision of needles and syringes as a strategy to reduce the transmission of blood-borne viruses is supported by:

Poisons Act 1964

Poisons Regulations 1965

WA Health Networks - Hepatitis C Model of Care Implementation Plan 2010-2014

WA Health Networks - HIV Model of Care Implementation Plan 2010-2014

Drug and Alcohol Interagency Strategic Framework for Western Australia 2011-2015

National Drug Strategy 2009-2015

National Aboriginal and Torres Strait Islander Blood Borne Viruses and Sexually Transmissible Infections Strategy 2014-2017

National Hepatitis C Virus Strategy 2014-2017

National Hepatitis B Strategy 2014-2017

National HIV Strategy 2014-2017

National Needle and Syringe Programs Strategic Framework 2010-2014.

As part of an integrated approach to reduce the harms associated with injecting drug use (IDU), in particular the transmission of blood-borne viruses, the Sexual Health and Blood-borne Virus Program (SHBBVP), of the WA Department of Health (WADoH), in collaboration with HepatitisWA, adopted a strategy to roll out Needle and Syringe Vending Machines (NSVMs) in selected regional areas of WA.

Following the successful implementation of these regional NSVMs, the SHBBVP made the decision to look at trialling the installation of NSVMs at outer metropolitan hospitals in Perth, in partnership with HepatitisWA. Some of the reasons for this were:

Needle and Syringe Programs (NSP) are an evidence-based public health measure aiming to reduce the transmission of blood-borne viruses such as HIV, hepatitis B and hepatitis C, through the provision of sterile needles and syringes to injecting drug users.

The report Return on investment 2: evaluating the cost-effectiveness of needle and syringe programs in Australia 20091 states that for ‘every dollar invested in NSPs, more than four dollars were returned (additional to the investment) in healthcare cost-savings in the short-term (ten years) if only direct costs are included; greater returns are expected

1 Department of Health and Ageing, 2009, Return on investment 2: Evaluating the cost-effectiveness of needle and syringe programs in Australia 2009

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over longer time horizons’. The report also included an analysis of individual states and territories, and notes that ‘the spending of $12.9m in the funding of NSPs in Western Australia from year 2000-2009 has resulted in a saving of $124m in healthcare costs, with more than 19,000 Disability Adjusted Life Years saved with a net financial saving of $111m’.

NSPs have operated formally in WA since 1987. The Poisons Act 1964 was amended in 1994 to allow approved organisations to provide sterile injecting equipment to people who inject drugs. Current models of NSP operating in WA include Needle and Syringe Exchange Programs (NSEP), hospital and health service based NSP, pharmacy, and NSVMs.

In 2007, the SHBBVP commissioned a review of the statewide NSP. The review aimed to identify gaps in existing services and opportunities for improving the accessibility, quality and effectiveness of NSP services. The review recommended that consideration be given to introducing vending machines in those locations where there is a high level of unmet demand.

Currently in WA, NSVMs operate at Busselton, Carnarvon, Esperance, Geraldton, Kalgoorlie, Manjimup and Nickol Bay hospitals. While there are occasionally issues with the mechanical operation of the machines, they have generally been well received by management and staff of these hospitals,

In the metropolitan area, after-hours access to needles and syringes is limited to pharmacies, the majority of which close by midnight. Only one pharmacy is open after this time, which is a 24-hour pharmacy located in Mount Lawley.

NSVMs are considered a complementary service to other methods of needle and syringe provision. As injecting drug use occurs during all hours of the day and is not confined to the hours that services are open, NSVMs can provide after-hours access to sterile needles and syringes, as well as retain customer anonymity and improve availability and access in areas that, for a variety of reasons, are unable to provide staffed outlets.

ArmadaleThe City of Armadale is approximately 30kms south east of Perth CBD with an estimated population of 65,000, which has been projected to increase to 100,000 over the next ten years. Armadale city centre is located at the major crossroads of the Albany and South Western Highways and is part of the Perth rail network.2

The population of Armadale has a median age of 34 years, median total personal income of $621 per week, an average household size of 2.7 and approximately 2.8% of the population identify as Indigenous (n = 1,743). In the Perth metropolitan areas as a whole there is a median age of 36 years, median total personal income of $668 per week, an average household size of 2.6 and approximately 1.5% identify as Indigenous.3

In 2012, almost 140,000 sterile needles and syringes were distributed in the areas of Armadale and Kelmscott through local pharmacies (31%) and the WA AIDS Council (WAAC) needle and syringe exchange van (69%), which is located at a local park for 2 hours each week on a Friday afternoon. Prior to the NSVM trial, Armadale Health Service did not operate any kind of NSP.

2 City of Armadale, 2014, http://www.armadale.wa.gov.au/Home/Your_Community/Community_Profile 3 Australian Bureau of Statistics, 2011 Census Data, http://www.abs.gov.au/websitedbs/censushome.nsf/home/data?opendocument#from-banner=LN

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The trialThe SHBBVP approached the Executive Director of Armadale Health Service in June 2013 to propose a three month trial of an NSVM at the hospital site. The Armadale Health Service agreed to proceed with the trial and negotiations began to progress the project in July 2013. The intention would be to undertake the trial over a three month period and retain the NSVMs at the site for an additional month while the evaluation was undertaken. During this time the machines were provided on loan from ASP Healthcare.

Location of the NSVMStaff at the hospital identified a potential site and, on visiting the hospital, staff from the SHBBVP and HepatitisWA agreed that the proposed site would be appropriate. The location was within sight of the main entrance to the hospital without being close enough to create concerns with confidentiality, the area was well lit, under cover and had a short-term car parking bay close by.

A decision was made to install two NSVMs to reduce the impact of potential vandalism or malfunction. This would mean that if one machine was out of order for any reason, clients would still be able to access sterile equipment from the other machine. This was felt to be particularly important as Armadale Health Service were not previously operating an NSP so with only one machine, there would be no ‘back-up’ if it was out of order.

Specifications and installation of the NSVMThe NSVM was a three column mechanical model with capacity to hold 57 units or packs (19 per column), with packs priced at $3 each. Detailed specifications of the NSVMs can be found at Appendix A and a photo of the machines at Appendix B.

Two different products were available through the machines, the Fitstick® 3 Plus and the Fitstick® 5 Plus. Details of the contents of these packs can be found at Appendix C.

The machines were installed by staff from ASP Healthcare in November 2013 and the relevant staff at Armadale Health Service were provided with training in the operation and maintenance of the NSVMs. The machines were operational from the beginning of December 2013.

Promotion of the NSVMAs there was no existing NSP at the site, promotion was important in raising awareness of the new machines among the injecting drug using (IDU) community. This was done in a number of ways:

1. A flyer was developed to inform potential clients of the new machine, when it would be operational, where it was located, cost of products and that the machines would only take $1 coins (see Appendix D).

2. Staff working on the WAAC mobile NSEP in the area spoke to clients about the NSVM and handed out flyers.

3. Staff at the WA Substance Users’ Association (WASUA), other WAAC NSEP sites and Palmerston Association Mandurah distributed flyers to clients.

4. HepatitisWA and the SHBBVP undertook a workshop with pharmacy staff in the Armadale area around NSP, viral hepatitis and to inform them of the new NSVMs and request support in promoting the new service.

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5. Pharmacies in the area received phone calls and information via mail, including flyers, to provide information on the NSVMs and encourage promotion to customers accessing injecting equipment.

The intention was that the machine would operate 24 hours a day, 7 days per week.

A pamphlet holder was ordered by the SHBBVP and delivered to Armadale Health Service so that relevant health information could be made available to people accessing the vending machines.

A decision was made initially not to install disposal units beside the NSVMs but inappropriate disposal would be monitored and the need for disposal units assessed further if required.

MethodologyThere were a number of components to the evaluation of the NSVMs to try and determine whether the machines should be retained at the Armadale site.

Staff experienceA meeting was held between hospital staff, SHBBVP and HepatitisWA to gather feedback on how staff felt the trial had gone and to discuss any issues experienced during the trial. A follow-up questionnaire (Appendix E) was also left for staff to complete providing an additional opportunity for staff to provide feedback on their experiences, and an opportunity for any staff who weren’t present at the meeting to provide feedback.

Client experienceAs ethics approval would be required to gather formal client feedback, and it was not feasible to gain ethics approval in the proposed timeframe, other NSEPs were asked whether they had heard any anecdotal feedback from people in the area who may or may not have used the machine. The WA AIDS Council mobile NSEP was particularly useful for gaining an insight into clients’ views on the NSVMs. The NSP Coordinator at Armadale Health Service was also provided with a log book to record any feedback provided by clients accessing the NSVMs.

Operational issuesA log book was provided to the Armadale Health Service NSP Coordinator to record any issues experienced with the operation of the NSVMs. Once completed, this log book was then provided to the SHBBVP and staff were also provided with an opportunity to discuss operational issues at the post-trial meeting attended by SHBBVP, HepatitisWA and hospital staff.

Level of use of NSVMA log book was provided to the Armadale Health Service NSP Coordinator to record the number of packs vended through the NSVMs. Data was also examined using the FITS Database to see whether the installation of the NSVMs had any impact on distribution of needles and syringes through other sites in the area.

Success of the machinesThe SHBBVP examined the various components of the evaluation to determine whether the machines should remain at the Armadale site or be returned to ASP Healthcare at the end of

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the evaluation period. This involved discussion with staff at Armadale Health Service to decide whether the machines would continue to operate from the site.

ResultsThere were a number of components to the evaluation of the NSVMs to try and determine whether the machines should be retained at the Armadale site.

Distribution dataData on distribution of needles throughout WA is collated centrally in the FITS Database. Data from pharmacies is based on the volume of equipment ordered by pharmacies and is provided by the suppliers. Data from NSEPs is provided by the organisation operating the NSEP based on actual numbers of needles given out through the various NSEP sites.

To identify whether the introduction of the NSVMs at Armadale Health Service had an impact on distribution of equipment through other sites in the area, data was extracted from FITS from 1 December 2012 to 28 February 2014. This allowed a comparison to be made over the period of the trial (December 2013 to February 2014) relative to the same period the previous year.

Pharmacy data did not appear to be affected by the introduction of the NSVMs with figures remaining fairly consistent with those prior to the installation of the NSVMs. There were some fluctuations in numbers but there is no evidence to suggest that this was as a result of the NSVMs at Armadale Health Service, and again, this is consistent with historical data.

Data from the WAAC NSEP sites at Armadale, Forrestfield, Fremantle (fixed-site) and Gosnells/Maddington also did not appear to be affected by the installation of the NSVMs with numbers remaining fairly consistent between December 2012 and February 2014.

Operational issuesThe NSP Coordinator was provided with a log book to detail any issues experienced during the trial. There were a small number of issues with the machines either vending Fitpacks without money being put into the machines, and also the machines not dispensing when money had been put in the machines, but at the beginning of the trial, these issues were infrequent.

Feedback from staff at the meeting held following the end of the three month trial, in March 2014, was that there had been other issues in addition to the above. There were coin jams repeatedly in the machines resulting in them both being out of order at the same time over one weekend.

In early April staff at the hospital reported that one machine was out of order and the other had been vandalised, though was still operational. It was then discovered following the Easter long weekend, in mid-April, that the second machine was also out of order. As the machine was still full, it was assumed that it had not been operational over the weekend. At the end of April the second machine was vandalised.

ASP Healthcare, who supplied the vending machines, and are based in New South Wales, were informed of the issues with the machines when they initially malfunctioned; however they were unable to send a member of staff to repair them until 30th April. Both machines were successfully repaired on this date and were able to be used by clients once again.

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Further issues were experienced with the operation of the machines as a result of ongoing vandalism to the internal mechanisms of the machines. This caused the machines to be frequently out of order until staff had the capacity to resolve the issues.

Client experienceSome anecdotal feedback was received from staff engaging with clients accessing the WA AIDS Council mobile NSEP, which is located in Armadale for two hours on a Friday afternoon each week. A number of clients were aware of the NSVM at Armadale Hospital, though around one third of those who said they had used the machine, experienced issues with the machine taking their money but not providing them with Fitpacks. One client reported being aware of the NSVMs through information provided at a pharmacy, but the majority had heard about them through word of mouth. Many people who had not used the machines had said that they would access needles and syringes from them if they needed to, and overall they were considered to be a good thing. It was reported that one client felt uncomfortable accessing the NSVMs as they were in view of the hospital entrance and a small number of clients felt the needles did not feel ‘fresh’, though it is unclear why this was the case.

No feedback was collected by staff at the hospital relating to comments made by clients about the NSVMs.

Staff experienceStaff identified issues with clients going to the hospital reception to ask for Fitpacks and for change to use in the vending machines. This issue was flagged at the meeting with hospital staff following the three month trial. To try and prevent this from happening, the SHBBVP provided signs to be displayed on the machines stating that Fitpacks would not be provided through the hospital reception, change would not be given, and to provide details of alternate locations to access equipment if the machines are out of order (see Appendix F).

It was reported that emergency department staff did not appear to have any objections to the machines, though some of the other hospital staff did have issues with the machines on a personal level, but this seemed to abate. Concerns were flagged by staff at the internal hospital pharmacy around clients trying to access Fitpacks there when the machines were out of order, but this was not an issue.

The biggest issues experienced by staff related to capacity and sustainability of the service. One staff member took on the majority of the workload in maintaining the vending machines and did not have the capacity to check the machines on a daily basis. The added time taken to resolve issues with maintenance of the machines due to coin jams and vandalism further increased this workload. With only one staff member taking on the majority of the workload, there were also concerns about how sustainable the service would be when this staff member was absent from work or was to cease employment at Armadale Health Service.

There was an understanding among staff of the benefits of NSP and the value of NSVMs, but due to the workload, there was a preference not to keep the machines.

Following the meeting held with staff at Armadale Health Service, a number of questionnaires were left for staff to complete and return to SHBBVP to provide additional feedback to the trial. These questionnaires were not returned so there is no feedback from staff who were unable to attend the meeting.

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Products vendedDistribution of equipment sold through the vending machines was recorded in a log book provided to the NSP Coordinator by the SHBBVP. It was intended that numbers of packs sold would be monitored on a daily basis to identify any trends, such as whether the machine was more popular on particular days. Unfortunately, due to staff capacity, numbers were only recorded at times of restocking so it has not been possible to identify any trends in distribution.

From the commencement of the machine operating, at the beginning of December 2013, to the 7th March 2014, a total of 437 packs were vended. Sales were fairly consistent during this time with an average of 32.5 packs sold per week, or 4.6 packs per day. Initially the Fitstick 5 Plus products were most popular with clients, probably due to the fact that both packs cost the same but the 5 pack contained 5 needles compared to 3 in the Fitstick 3 Plus product (which also contained water and spoons, see Appendix C). Later on during the trial there was an increase in the number of Fitstick 3 Plus products vended but this is most likely to be due to the Fitstick 5 Plus products running out and there being a delay in the delivery of additional stock.

Injecting-related health informationA pamphlet holder was provided by the SHBBVP to be placed next to the NSVMs where injecting-related health information could be provided to clients accessing the machines. At the time of installation, a decision was made by hospital staff not to mount the pamphlet holder unless a need for this was identified.

Inappropriate disposalStaff reported a small number of cases where needles and syringes had been discarded and posed a risk to the public and staff. A member of the public reported that a needle had been discarded in one of the bins at the hospital and was concerned about the risk this posed, particularly to children. Needles were also discarded in toilets, including on the baby changing area. This highlighted a need to look at the possibility of introducing sharps bins to encourage individuals to dispose of their used equipment appropriately.

Environmental Health at the City of Armadale reported that Armadale does have problems with inappropriately discarded needles and syringes with staff regularly inspecting public spaces, and regularly receive complaints from the public about this. There was however, no evidence to suggest that the introduction of the vending machines had contributed to this issue.

Discussion and conclusionFollowing the initial intended trial period of three months, the machines remained in place while the evaluation was undertaken. Due to ongoing delays in obtaining completed feedback questionnaires from staff at Armadale Health Service, the loan of the machines from ASP Healthcare was kindly extended to allow the machines to remain in place.

Repeated efforts were made to obtain copies of the feedback questionnaires however SHBBVP were advised that they would be taken to the Armadale Health Service Management Team Meeting and then an overall response submitted to SHBBVP. Numerous meetings were cancelled and no feedback questionnaires were received.

In August 2014 a letter was received from Armadale Health Service requesting the removal of the machines, which was followed up by a meeting between Armadale Health Service and SHBBVP. Staff at Armadale Health Service reported that the machines had been out of order

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for some time due to issues with vandalism and a lack of staff capacity to dedicate to fixing the machines. There was some discussion around how the issue with vandalism could be addressed. Proposed strategies were considered, however these were not feasible:

potentially re-locating the machines (an appropriate alternate location could not be identified)

attempting to adapt the machines to prevent vandalism (this was followed up with the supplier of the machines, but there would be no way for the machines to be completely vandal-proof)

installation of CCTV (but this would involve an initial cost to set up and may not have any impact).

The reasons for the ongoing vandalism are not clear and there is no evidence to identify whether it was being vandalised by the same people repeatedly or different individuals. It may have been vandalised by people wanting to access the packs but could not afford, or did not want to pay for them, or may have been related to resistance to the machines being located at the site. It is interesting to note that although there have been some cases of vandalism to the NSVMs in regional areas, this has not been an ongoing problem, unlike in Armadale.

In conclusion, the model of the machine and ongoing incidents of vandalism made it very difficult to maintain the needle and syringe vending machine service. The issue lay more with the product (the NSVMs) than the delivery of an NSP service itself. The Executive Director stated that if it was not for the ongoing issues with vandalism and staff time taken to resolve these issues, Armadale Health Service would have been happy to continue providing NSP through the NSVMs.

A final decision was made to remove the machines and they were taken down to be returned to the supplier in September 2014.

RecommendationsThe trial of a needle and syringe vending machine at an outer-metropolitan hospital has been a useful learning experience and can help in identifying potential issues to overcome in providing similar services at other sites in the future. As a result of this trial, it is recommended that the SHBBVP and other stakeholders:

investigate alternative models of needle and syringe vending machines for use in WA

look at other possible sites for needle and syringe vending machines in outer-metropolitan areas

consider whether it might be appropriate to introduce needle and syringe dispensing machines to make needles and syringes available through vending machines at no cost to clients

investigate other models of needle and syringe provision.

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AppendixAppendix A – NSVM specificationsSpecifications of proposed NSVM:

Dimensions of the machine: 1,060mm High x 500mm Wide x 345mm Deep.

57 units or packs (or similar item of an appropriate size) can be accommodated in the machine in total; 19 units in each of the 3 columns.

There are 3 pull mechanisms (release levers), one for each of the columns. The machine is of a mechanical type and does not require power to operate.

Three different packs can be dispensed from the machine provided they are all the same price – a different type for each of the columns or two columns of one type of pack and one of another type of pack.

In any case, whether one, two or three different products were to be dispensed, label(s) are to be affixed externally to the appropriate column on the machine to advise clients of the contents.

The current configuration for coins is 3 x $1 coins but this can be varied (up or down) by $1 increments. As above, each pack / item in any / all of the columns must be at the same (i.e. one) price.

To dispense, the client needs to insert 3 x $1coins into the coin slot (labelled) and then pull one of the three release levers. Where the unit is stocked with one type of pack, if a particular column is empty of product, obviously, the client needs to try the next lever and so on to the third, should the first two columns be empty. If the machine is entirely empty, the client needs to simply push the coin return button and the coins will be refunded (they drop into a refunded coin holder).

If, at any time before a release lever is pulled, the client changes their mind about purchasing a pack, they need simply to press the coin return button and the coins will be returned.

The product is dispensed into a collection holder at the front near the bottom of the machine once coins have been inserted and release lever pulled.

To stock the packs into the machine, the front of the machine is opened (left side hinged door, opening forward, right to left) and each of the packs is simply placed onto a shelf in the machine. An instruction leaflet on loading the machine is provided with each unit, and at the time of installation of the machine, staff will be instructed on the process.

The machine is secured by two padlocks (provided) one at the top and one at the bottom. Additionally, the coin collection box is secured by a key lock (lock and key provided) and by a security pad as well.

The vending machines are configured for mounting on a brick or masonry wall, but may be mounted on another surface type.

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Appendix B – NSVM photos

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Appendix C – NSVM products

Fitstick 3 Pluswholesale price per unit $2.41

Fitstick 5 Pluswholesale price per unit $1.83 plus GST

3 x Fitstick containers3 x BD 29G 1mL insulin syringes3 x 2mL water ampoules3 x plastic spoons3 x alcohol swabs3 x cotton balls

5 x Fitstick containers5 x BD 29G 1mL insulin syringes5 x alcohol swabs5 x cotton balls

Appendix D – NSVM flyer

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Appendix E – feedback questionnaire

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Appendix F – NSVM signage

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© Department of Health 2014

Copyright to this material is vested in the State of Western Australia unless otherwise indicated. Apart from any fair dealing for the purposes of private study, research, criticism or review, as permitted under the provisions of the Copyright Act 1968, no part may be reproduced or re-used for any purposes whatsoever without written permission of the State of Western Australia.

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