General observations
Since its creation in 2011, almost 2,000 PWUD have benefited from the HaRePo program. PWUD using HaRePo have increased from 42 consumers in 2011 to 881 consumers in 2018 (Fig. S1a). The number of parcels sent increased concomitantly. More than 10,000 parcels have been sent to date, from 71 parcels in 2011 to 3,118 parcels in 2018 (Fig. S1b). This accounts for more than 6 million HR-related items (including 1,720,295 syringes). Most of the HR paraphernalia sent corresponds to items used in injection practices: intravenous injection/intramuscular injection/plug [97%]; and inhalation/snorting [3%] (Fig. S1c). An important amount of information concerning HR practices was sent within each parcel, including flyers, videos on USB memory stick or CD-rom, and others. The number of HR items distributed by HaRePo has grown steadily from less than forty-five thousand per year in 2011 to more than 1,5 million per year in 2018 (Fig. S1c). The success of the program is partially due to “word of mouth” communication between consumers benefiting from the program, in particular through a well-know forum used by PWUD in France called “psychoactive”.
- “ Me and my friend saw your add on the Psychoactif website which says that SAFE is setting up a service to access injection equipment by post. We would like to have more information on this service.”
Consumer profile
HaRePo address the specific needs of consumers who are not accessing classical HR centres
HaRePo is more accessed by women (25%) than classical HR centres. Women represent 18% of the CAARUD consumer cohort [26]. We did not identify a unique motivation for women to enter the program and the following testimonies suggest that motivations might be quite diverse:
- “I am an eternal drug addict. I take subutex. I have the misfortune to shoot it. I appreciated your cream as my arms are now less marked. In addition I can filter the products and I have the HR equipment I need. I am not putting myself in danger. You have no idea how much you are relieving the weight of my guilt. Finally I really take into account that I need to get away from drugs. I am no longer alone facing all this. Thank you”.
- “HaRePo changed my life. I live in a small town and the only pharmacy selling injection kits is 15 km away and it sells them for 3 € each, so I usually use 2 kits for 1 month. Now I can finally do 1 session / 1 syringe!”
- “I am afraid of going to the CAARUD alone. I am afraid to be judged. I am a pretty anxious person”. - “I am a drug addict. It is difficult for me to find HR equipment. I don’t really know the addresses of centres in my town. I do not have money to buy injections kits in pharmacies and I am afraid of people's gaze at me and my drug problem. I would like to know how much material can I order for a daily consumption of heroin and oxycodone. Among other things, I have heard of "wheel filters" which seems to be very effective in filtering out the excipients of oxycodone but are difficult to find in my situation”.- “I do not want to go to HR centres because I am afraid to lose my daughter’s custody. I don’t want to expose neither my child nor myself”.
Among program beneficiaries, the number of people engaging in chemsex (Drug use for or during sex) is increased steadily from one in 2012 to 119 in 2018. A total of 170 people engaging in chemsex have benefited from the program. They represent 9% of the total HaRePo beneficiaries and 11% in 2018. The chemsex practice does not only concern consumers in the urban zones (18% of consumers live in areas of low or very low urban density). HaRePo consumers have a stable accommodation 87% versus 50% in CAARUD [27]. Ten percent of consumers live in an accommodations belonging to a third party (i.e. family, friends…) and only 3% of consumers do not have a stable accommodation (Fig. 2a).
Consumers profile
Most consumers (82%) accessing the program are injectors and 94% of them have combined practices: injection and/or inhalation and/or snorting. Most of the people engaging in chemsex declared themselves to be ’slamming’ (the action of injecting drugs in a sexual context). A small proportion of PWUD do not inject drugs. The structure of our dataset did not allow us estimating whether there are significant differences depending on their consumption practices. Therefore, we presented here results of both groups (injectors and non-injectors).
The most common substances used are opioids (1035 consumers) like heroin (484 consumers), Buprenorphine (280 consumers), Skenan® (255 consumers) and methadone (16 consumers), in addition to oxycodone and Oxycontin®. Moreover, 735 respondents are stimulants consumers with 406 of them consuming cocaine and 329 consuming crack/freebase. Finally, 152 consumers declare consuming New Psychoactive Substances (NSP), primarily 4-methyl-N-ethylcathinone (4-MEC) and x-methylmethcathinone (X-MMC) (Fig. 2b). However, most of PWUD in the program declare to use multiple drugs.
Consumer motivations
Consumers decide to use the HaRePo program for different reasons. The first reason declared by 680 consumers is because of the distance between where they live and the nearest HR centre. The majority of those consumers live in small towns where there are no low threshold structures. The second reason mentioned (442 consumers) is difficulties with the local HR centres like non-compatible service hours, or when HR centres do not have materials or only in insufficient quantities. The third reason for consumers (310 consumers) to join HaRePo instead of HR centres is consumers seek for anonymity and fear of stigma. This result was confirmed by consumers’ testimonies:
- “This service is really great, really suitable for people who, like me, want real anonymity.”
- “Very few people around me are aware of my drug use (two "friends"), and even my family does not know anything about my treatment and it is very good like that at the moment because I hardly need to speak about it. I buy my injection kit in pharmacies but would like filters because I reuse the same syringes at least 4 times and there are only two filters per kit ... the cotton I use filters less well and is not sterile. You will tell me that I could go to a centre or AIKD, I do not dare, I am afraid that friends or acquaintances, worse, my colleagues would pass by and see me exchanging my syringes, entering the centre or because they are inside.”
- “It's very small here!!! And then, small or not, I know few people who accept the idea that one of their "colleagues" or "partners" is addicted! “
We noted that anonymity was particularly often mentioned by consumers practicing chemsex:
- “In fact, I practice slam and saw the recrudescence of HCV contamination (I was infected). I do not dare to go to CAARUD because I will be immediately stigmatized, and the automatic injection kit dispenser is always empty”.
- “I need equipment for injecting and snorting. A friend with whom I practice slam and chemsex told me about you. I do not go to an association because few people know that I use drugs. I do so only in sexual practices. I really do not have a lot of tools. I use the syringe of a friend and I do not want to do it again. To snort I use a ticket or something like that. Is it possible to communicate only through the internet because I am too afraid by phone?”
- “My schedule (working hours) does not correspond at all with CAARUD’s customer services hours”.
- “I practice slam and I live in a small village, and I do not have a vehicle”
- “I practice chemsex, I slam since some time with some partners and I use 3-MMC. In fact, I am a little ashamed to go buy injection kits in pharmacy because of their reaction. So I use or scrounge material from my partners, but some grumble a little”
- “I realize that many slammers are in the same situation. Finding injection kits in pharmacies is very complicated and the new people adopting this practice do not know needle syringe exchange structures or do not want to go to such structures”
Several other motivations were mentioned: during holidays where the centres are closed (196 consumers), similar difficulties encountered with pharmacies (173 consumers), lack of information about HR programs and tools which exist (170 consumers), not able to go to HR centres because of disability for instance (81 consumers) and finally for personal reasons such as shame (65 consumers). Additionally, we observed that consumers sometimes declare more than one reason that incited them to join the program (Fig. 2c).
- “I myself am a consumer but I have so far found it very difficult to get equipment, not knowing the address of centres in my city, not having the funds to request in pharmacies and knowing the fear of people's gaze on my consumption”.
Motivations to join the program vs. consumers’ residential area
Using linear models, we estimated how rapidly PWUD enter the program and if this entrance rate depends on their residential area (Fig. S2). We observed that on average, 0.06 PWUD per 100,000 habitants enter the program each year (Table 1).
Nevertheless, this rate was not significantly different between the four residential zones (density zones). This means that the density zone (urban or rural) does not play an important rule in new HaRePo consumers. Nevertheless, using Pearson’s Chi-square tests, we found that residential area has an influence on consumer motivations to join HaRePo. We observed that HaRePo consumers living in zones type 1 and 2 (large and intermediate cities) mainly use the program because they feel they do not fit in with PWUD who frequent classical HR centres (p<0.001) and because they need timely materials (ex: HR tools) (p<0.05). Moreover, the principal reason for PWUD living in zones type 3 and 4 (semi-rural and rural areas, respectively) to join the program is their distance from classical HR centres (p<0.0001) (Table 2).
Results show that HaRePo receives PWUD from urban and rural population but the reasons to join the program are different.
Program impact
The program seems to induce a positive feedback loop in its consumers. They improve their practices based on remote but trustworthy communication. Furthermore, the percentage of people that, after accessing the program, never reuse and/or share HR tools have increased. Indeed, 71% to 72% of beneficiaries never reuse syringes and 81% never reuse needles. Concerning other HR items, the level of improvement varies from 14% to 49% (Fig. 3a). Regarding sharing practices, 98% to 99% of consumers declare never sharing syringes and 99% for needles. Moreover, the percentage of consumers that never share other kinds of HR paraphernalia once they have joined HaRePo improved from 9% to 26% (Fig. 3b). In addition, between 39% and 53% of HaRePo consumers declared that the perception of their own health status and physical appearance (e.g. the appearance of injection points, swelling of extremities, veins) has clearly improved (Fig. 4a). Finally, depending on the practices 44% to 80% of beneficiaries report that since they entered into the program the safety of their consumption practices (injection, inhalation and snorting) has improved or greatly improved (Fig. 4b).