harm reduction services and interventions in catalonia

How HIV and HCV can be halted in PWIDs with good drug policy

Xavier Major Roca

Xavier.major@gencat.cat

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Where is Catalonia ?Territory: 32.000 km2Population: 7.000.000Own language and culture

Barcelona

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Causality of deaths among men and women between 29 and 39 years in Catalonia 1983-2003

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5

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ECDC & EMCDDA GUIDANCE. Prevention and control of infectious diseases among people who inject drugs. October 2011

7 Key interventions1. Access to syringes and injecting

material2. Treatment for drug addiction: Opiates

substitution treatment3. Vaccinations4. Screening of infections5. Treatment of Infectious diseases6. Health Education: safer injection, safer

sex, BBV prevention, ….7. Combined interventions adapted to

drug users and to the local conditions: outreach work, drop in centres, drug consumption rooms,...

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Effectiveness depends on Coverage

You need good coverage and accessibility

Percentage of opioid-dependent people on OST

Low 20% Mid 40% High

WHO, UNODC, UNAIDS TECHNICAL GUIDE for countries to set targets for universal access to HIV prevention, treatment and care for injecting drug users2012 REVISION

Number of needles–syringes distributed per PWID per year

Low 100 Mid 200 High

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11

2698

3709

5116

6274

73207915

8480 84418334885889458931

500

1500

2500

3500

4500

5500

6500

7500

8500

9500

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

PEOPLE ON MMT

Annual breakdown

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Coverage of NSP. Syringes distributed from 1993 to 2011

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Law 20/1985 of July the 25th, on prevention and treatment of addictive behaviour:

– Drug addiction is an ordinary disease – It does not make differences between

legal and illegal drugs regarding care provision

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REACH A HIGH LEVEL POLITICAL CONSENSUS:

• Not use drugs for political aims what prevent from getting stuck in ideological (and moral) discussions and focus on scientific based and pragmatic approaches

Two parliamentarian (1996 and 2006) agreements passed by unanimity of all political parties

Pre contemplation

Contemplation

Preparation

Action

Maintenance

Relapse

Stage of Changes

Prochaska J.O. & DiClemente C.

Harm reduction

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– Opioid substitution therapy: Methadone– Syringe exchange programmes – Prisons: NSP and methadone in all prisons and all wings– Outreach work: Street work, Mobile units, Peer involvement,…– Low threshold centres (drop in) with social and health care– Supervised consumption rooms – BBV tests & counselling (rapid tests) + HBV/HVA vaccinations– Access to HIV and hepatitis treatment– Health care workshops for active drug users: Safe injecting, safer

sex, overdose prevention and response– Promotion and support of drug users and patient organisations– Heroin trial

HARM REDUCTION INTERVENTIONS IN CATALONIA

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People on Substitution TherapyYearly breakdown

High coverage: > 60% of opiate drug users

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SPAIN: NUMBER OF PEOPLE ON METHADONE AND PERCENTAGE OF THE TOTAL INMATE POPULATION

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Syringes distributed from 1993 to 2011 in Catalonia

Mid coverage: just over 100 syringes x IDU x year

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X

NSP in Prisons: Starting up year by prison in Catalonia

Overdose prevention programme2009-2013

Professionals trained

Drug users trained

Kits distributed

HRS 614 2049 4383

DTC 162 891 897

TTCC 231 1798 0

TOTAL 1.007 4738 5280

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Drug addiction care and treatment network

Drop in: 14 (10 Drug Consumption room.)Mobile Units: 6 ( 3 DCR)Street work: 8(DCR: 13)

Drug treatment centres

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Therapeutic C.Units: 18Places: 392

Detox units: 11Beds: 64

Dual Diagnosis Units: 6Crisis Units: 1

Social rehabilitation centres:28 day centres and social rehabilitation schemes18 rehabilitation apartments132 Places on rehabilitation apartments

Safe consumption rooms

Number of consumptions 2007 - 2014

Safe consumption rooms

Number of people 2007 - 2014Between 37-44% are foreigners

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Some impacts of these strategies

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757113613

41681881

1093 1429

257 8660

2000

4000

6000

8000

10000

12000

14000

No

mb

re u

su

ari

s

Heroin Cocaine

Admissions to treatment for the first time

Admissions to treatment

Drug users in treatmentEstimation of problem drug users

Retention in treatment of opiate users in the city of Barcelona

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1993 1998 2002 2008 20120

10

20

30

40

50

60

70

80

90

Injecting risk Behaviours (last 6 months)

Injected with an used syringe Passed on a used syringeShared paraphernalia

%

Injecting drug users attending Harm reduction facilities

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HIV infection cases by transmission route. Catalonia 2001-2013

La estimación de la incidencia del VIH entre nuevos inyectores (que hace 5 años o menos que se inyectan) es de 8,71/100 casos por año y de 25,6/100 en el caso del VHC. (Folch C, 2012)

Prevalence among IDU recruited from Harm Reduction Facilities (antibody test – HIV & HCV)

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AIDS cases by transmission route. Catalonia 1981-2013Acces to ARV treatment

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Mortality by overdose in the city of Barcelona, 1990-2012

0

20

40

60

80

100

120

140

160

180

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

2010

2012 s

et

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18

15

,7

11

,3

10

,7

9,6 9

8,3

5

33

,7

31

,8

28

,1

24

,3

21

,7

20

,8

19

,6

0

5

10

15

20

25

30

35

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Prevalence of antibodies of HIV & HCV in the Catalan prisons: 2006-2012

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14 drop in centres

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13 supervised consumption rooms (2 with smoking room)

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6 mobile units

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8 street work teams

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6 teams provide health prevention trainings:

•Safer sex,

•Safe injecting,

•Overdose prevention

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What we learned

– Addiction is a chronic disease (diabetes, asthma, hypertension,...)

– Treatment is effective but only abstinence based treatment: Low contact and retention in treatment

– Injecting drug users are exposed to very important health risks (HIV, Hepatitis C & B, overdoses,...)

– Success in care with a drug users is not only abstinence– The longest the time you are in contact with the drug user

the better the outcome: Put in place services & strategies to keep in touch with them

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Challenges we face now

• We need Heroin Assisted Treatment• NSP in prisons still face a big opposition: Low

coverage• Access to hepatitis C treatment• Drug users stigmatisation (Nimby attitudes still

impinge the implementation of services and programmes)

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THANK YOU

xavier.major@gencat.cat