To our knowledge, this is the first study from Eastern Europe describing barriers and potential opportunities for pharmacy-based HIV prevention interventions for IDUs. In several countries, pharmacies are involved in syringe exchange, distributing or selling low price kits containing injecting equipment, providing treatment for addiction, dispensing methadone, supervising methadone consumption, and providing information on drug misuse and HIV prevention.12,13,23–26
Pharmacists in our study believed that HIV/AIDS was a serious social and public health issue; they valued the work of SEPs but held a strongly negative position toward IDUs and against the idea of involving pharmacies in actual harm reduction service delivery. Resistance was explained by concerns that IDUs would steal from the pharmacy, endanger staff, and scare away other customers; these reactions are similar to those seen in other studies.27–29
However, the pharmacists did not feel that syringe sales would increase drug use or increase injecting (and therefore more discarded syringes) near pharmacies as has been found previously.27,28
Although selling syringes over-the-counter is allowed in Estonia, several pharmacist participants refused to sell syringes to IDUs because of an individual or pharmacy policy not to sell to anyone who looked or acted suspiciously. Previously, it has been found that pharmacists who supported the idea of selling syringes to IDUs were also supportive of syringe exchange in their pharmacies.30,31
Disposal of syringes was a concern among all the pharmacist focus group members, although some pharmacies already have sharps boxes in their premises for drug misusers.16
Similar concern over exchange or disposal of syringes has been stated previously.16,31
Possible solutions could be distributing personal disposal boxes or distributing clean syringes using referral cards.25,31
The evidence indicates that many pharmacists are willing to offer advice to IDUs.16,31,32
However, in our focus groups, the pharmacists’ experiences were that IDUs are not interested in counselling, and it is difficult for pharmacists to find enough time, although they were willing to provide information leaflets. Leaflets could contain information on drug misuse, safer intravenous drug injection, safe disposal, prevention of various diseases, and referrals to drug treatment centres.
To some extent, pharmacists saw themselves as part of the public health system, but HIV and AIDS prevention was not a priority. Commercial interests also have a substantial impact on decisions about pharmacy policies. An important finding is the pharmacists’ lack information about IDUs and available harm reduction services. There is a clear need for education of pharmacists to promote the understanding that harm reduction is a broader public health issue and not primarily about the IDUs.33
Educational programmes should stress the current understanding that drug addiction is a chronic, relapsing, treatable medical condition.34
Pharmacists themselves expressed the need for guidance about how to deal with drug misusers. For successful training, professional pharmacy associations should be involved, and involving pharmacists in planning the interventions should help to break down barriers.
In general, IDUs were positive toward pharmacies, although they have detected stigma from pharmacists and other customers. They were aware that some pharmacists sell syringes selectively. Such stigma may reduce the effectiveness of harm reduction services because it may prevent IDUs from accessing or utilizing the services.33
Therefore, addressing negative attitudes should be a priority to encourage the process of service delivery.12,30
IDUs reported that SEPs and pharmacies were their main sources for acquiring clean syringes and stated that syringes could be obtained with relative ease. IDUs emphasized the need for wider access to other injection paraphernalia. Kits containing a syringe, needle, spoon, filter, and sterile sponge were viewed positively by IDUs. Distribution of clean injecting equipment including water and sharps containers has been shown to have a positive effect on IDU behaviour.13
In Estonia, within limited resources, it would be possible to modify the restrictions prohibiting the sale of sterile water without a prescription.
The need for syringes to be available near where drugs are sold has previously been described.35
When IDUs have a dose of drugs, they will typically want to use the drug immediately and will not want to spend much time searching for a clean syringe, hence, acquiring syringes needs to be very easy. It would be reasonable to start involving pharmacies in high drug use areas or those that are open 24 h and to find pharmacists willing to be public health educators. Developing relationships with SEPs and sharing their knowledge and experiences in cooperation with IDUs could improve the current situation.
One limitation of the study could be the self-selection bias in participation of pharmacists’ focus groups. We could not determine if the pharmacists who decided not to participate in the focus groups were more or less favourable towards providing services to IDUs. However, the purpose of the pharmacist focus groups was not to quantify potential support for providing services to IDUs, but rather to identify the issues related to providing such services. We did feel that all of the important issues were identified in the first three focus groups, and that conducting additional focus groups, or recruiting pharmacists who had originally declined to participate (perhaps through larger incentives) would not have produced a different set of relevant issues.
The results from both the pharmacists and IDUs are very valuable for understanding barriers and the potential improvement of harm reduction within pharmacies in Estonia. Although data were gathered by means of focus groups and are not necessarily generalizable to other locations, we see the knowledge gathered as potentially useful input for pharmacy-based interventions in the Eastern European region.
In conclusion, a large proportion of IDUs rely on pharmacies as their source for clean needles. However, there is substantial resistance among pharmacists against syringe sale and the provision of other HIV prevention efforts among IDUs. Nevertheless, continuous education of pharmacists on drug use, HIV prevention issues, and practical guidance on how to work/counsel an IDU client can remove some barriers. Clearly, pharmacists need up-to-date information on harm reduction and health services available for IDUs in the region to link their clients with the services they need. In addition, pharmacists should be engaged in developing appropriate interventions, selecting pharmacists who are motivated to work with IDUs and/or pharmacists from high drug use areas who could give the most benefit and allow positive experiences to build.