Public injecting, harm reduction services

Public injecting drug use and the local harm reduction services

József Rácz

Public injecting

Blue Point Drug Counselling and Outpatient Centre: Contact Cafe

8th district of Budapest

Injecting and sexual risk behaviours

Local harm reduction services

Risks of injecting: HIV, HCV

Data on needle exchange

Characteristics of the clientele

Harm reduction methods

Summary of a large scale study on needle exchange (Australia, 2009)

Public injecting scenes and shooting galleries

„Hurry up”, „rushed” injecting: sharing, neglecting safer injecting, discarded needles, more difficult access to needle exchange services

Searching clothes (jack-ups): needles’ legal status

Greater use of ‘discretion’ on the part of police has alsobeen recommended as a measure that may ensure that enforcement operations do not interfere with public health efforts – agreement between needle exchange services and police: this is not legal, but the police follows the recommendations (Hungary)

Drug market enforcement approaches interact with and transform various practices and social dynamics in the broaderrisk environment of IDU, and thereby constitute a potentsource of harm within drug markets

Street-level drug problems will appear elsewhere when the police crack down the public drug scene

Role of the police

Kerr et al., 2005;Small et al., 2006

•More illegal drug use

•More illegal drug using populations

•More difficult access to services

•New strategy maintaining public order and public health goals

Blue Point Drug Counselling and Outpatient Centre

8th district of Budapest with the placement of needle exchange program of Blue Point: the Contact Cafe

General background of 8th district

The VIII. district of Budapest faces a number of difficulties. This is an area where there are multiple social, health, livelihood, community, etc.. problems.

The drug and social problems are much higher compared to other districts.

The legal and illegal drugs and the presence of a large number of consumers in a very open drugscene requires various and several care providers at different levels to be present.

In particular, there are many addicts living in the district who are suspicious of institutional care, which is a high-threshold care service.

The legal and illegal drug use associated with poor living conditions and low social status seriously increases the risk of spreading diseases. The clients with health problems often do not turn to a doctor or do not ask for care and treatment.

Cultrual diversity – including Roma culture - is one of the characteristics of the disctrict. There are large differences of inhabitants concerning ethnicity, nationality, education and housing, and social status and health.

(The „Integrated Rehabilitation Strategy for Urban Development” of the capital places an emphasis on refurbishing the district, but this is impossible without dealing with social problems.)

The well-defined part of the disctict’s inhabitants are living in poor conditions, bad housing, has poor health culture, poor mental status and is low skilled and unemployed.

The socio-cultural background

Dezső Tamás’s photos

Feeling of the 8th district

(Semi)Public injecting sites

social workerwith visibility coat

Druglitter

Shooting galleryType 1

Shooting galleryType 2

Csoki 36 ys old, heroin dependent. His wife, Zita 35 ys old, heroin dependent. Their son, Csabika 17 ys old, heroin dependent.

„At the deepnest of drug world”Baptis Charity „Street Front”, Marcell Miletics, Miklós Barcs, Péter Borbély

Discarded needles, drug litter

Routes of transmitting infections

Defining the points of harm reduction interventions:•See -s!

Most difficult interventions

Common needle use

Sharing:Needles/SyringesFilterCookingWaterNeedles for preparation of drug solution

Direct sharingIndirect sharing

•Same syringes

•Backloading

•Frontloading

Activities at needle exchange programHarm reduction goals

Reaching out „hidden” injecting drug users: oureach and street work

Prevention of infections, especially:oHIVoHCV - injecting equipments/paraphernalia!oOther communicable diseases

• Only contact with helping services: low threshold service – only contact with majority society: ponts of treatment contacts/admissions

Needle exchange, outreach and street work + collecting syringesProviding information, education, counselling

Testing or referral to testingSexual risk behaviours – prevention (condoms)

First aid, referral to medical treatmentReferrals to other cares (health or social care)

Clients involvement – empowermentRehabilitation and reintegration

Activities: 4-8 p.m., 6x a week

Collecting dirty needles Most important for the local community & for the local self-government

Special programs at needle exchange (Contact Cafe)

Ladys’ Night: clients as well as helpers are women: once a week•Traumatization•PTSD•Sex workers•Sexual problems

Cooperation with „Sober Babies” Association•For pregnant injecting drug using women•For mothers with babies

Decreasing the digital edge•Computer literacy + social network site use

„User friendly milieu”

Roma culture on YouTube (videos watched by our clients)

Legal open sceneSwiss „needle parks: 1980s-1990s: failure – re-designing of the Swiss drug policy

Incidence of regular heroin users(Nordt és Stohler, 2006)

Results:New heroin users referred to treatment in two ys.4% yearly decrease in the number of problem heroin users.

Needle Park in Zürich, 1992

Risks of (public) injecting

The ranges around the estimates in this table define the boundaries within which the actual numbers lie, based on the best available information.

Regional HIV and AIDS statistics and features 2009

TOTAL 33.3 million[31.4 million – 35.3 million]

2.6 million[2.3 million – 2.8 million]

Adults and children newly infected with HIV

Adults and children living with HIV

Sub-Saharan Africa

Middle East and North Africa

South and South-East Asia

East Asia

Central and South America

Caribbean

Eastern Europe and Central Asia

Western and Central Europe

North America

Oceania







270 000[240 000 – 320 000]

92 000[70 000 – 120 000]

130 000[110 000 – 160 000]

70 000[44 000 – 130 000]

460 000[400 000 – 530 000]

770 000[560 000 – 1.0 million]

240 000[220 000 – 270 000]

820 000[720 000 – 910 000]

57 000[50 000 – 64 000]

75 000[61 000 – 92 000]

82 000[48 000 – 140 000]

17 000[13 000 – 21 000]

31 000[23 000 – 40 000]

4500[3400 – 6000]


Adult & child deaths due to AIDS


260 000[230 000 – 300 000]

58 000[43 000 – 70 000]

76 000[60 000 – 95 000]

26 000[22 000 – 44 000]

24 000[20 000 – 27 000]

36 000[25 000 – 50 000]

12 000[8500 – 15 000]

8500[6800 – 19 000]

1400[<1000 – 2400]

0.8%[0.7% - 0.8%]

Adult prevalence (15‒49) [%]

5.0%[4.7% – 5.2%]

0.3%[0.3% – 0.3%]

0.5%[0.4% – 0.6%]

0.8%[0.7% – 0.9%]

0.5%[0.4% – 0.7%]

0.2%[0.2% – 0.3%]

0.1%[0.1% – 0.1%]

1.0%[0.9% – 1.1%]

0.2%[0.2% – 0.2%]

0.3%[0.2% – 0.3%]

12/06 e

Proportions of HIV infections in different population groups by region, 2005

IDU: Injecting Drug UsersMSM: Men having sex with menCSW: Commercial Sex Workers

Latin America

MSM 26%

IDU 19%

CSW 4%

All others 38%

South and South-East Asia*

CSW clients 13%

Eastern Europe and Central Asia

MSM 4%

IDU 67%

CSW 5%

All others 17%

CSW clients 7%

* India was omitted from this analysis because the scale of its HIV epidemic (which is largely heterosexual) masks the extent to which other at-risk populations feature in the region’s epidemics.

MSM 5%

IDU 22%

CSW 8%

All others 24%

CSW clients 41%

Figure 2

Estimated occurance of injecting drug use per 1000 inhabitants, in the 15-64 ys groups (EMCDDA, 2009)

Contact Cafe32

Risks: The silent epidemic

Sitting on a bomb…

Hepatitis C infections in the European Union, 1995-2005

(Rantala és van de Laar, 2008)

HCV prevalences among injecting drug users(regional and national data),

2006-2007 (EMCDDA, 2009)

*: data from Contact Cafe

Source: OEK, 2007, 2008, 2009

HIV, HCV testing – HIV: 0%

Centre 2006 2007 2008

person HCV +% person HCV+% person HCV+%

Drug Prevention Foundation

55 34,5 100 34,7 100 34

Blue Point 20 75 70 75 70 63,2

Nyírő Hospital,

Drug Outpatient Centre

50 34 80 18 65 23

Soroksar Methadone Centre

15 20 40 21,6 40 25

Baptist Charity

„Street Front”

20 25 30 21,4 30 21,4

MedlinePlusThe is no spontaneousrecovery, just onlybecause of treatment.

At-risk group Acute infection (100%)

Recovered (15-30%) Chronic,

carrying the virus

55-85%

70 persons: chronic hepatic illness5-20 persons: cirrhosis - 20-30 ys – no symptoms1-5 persons: death (cirrhosis, hepatocellular carcinoma)

The Hepatitis C epidemic(EMCDDA, 2007)

Why it is „silent”!

Treated HCV infected patients after HCV testing (Gazdag és Szabó, 2007)

2 IFNtreated

9 clients visitedthe outpatient

centre

60 HCV+ drug users

175 tested drug users

Cost of treatment of HCV infection:

Treatment (1 year): 3,5 - 4m HUF

Total life span: 3,5 - 7m HUF

Finger stick (qiuck) HCV testing

Data on needle exchange program

Data

•Clients•Visits (one client may have more visits)•Needle: delivered & taken back

January 09 January Febr March April May June July August Sept. Oct. Nov. Dec

Registered clients in 2010 (from January to December

2010.II.

félév

2010.I.

félév

2009.II.

félév

2009.I.

félév

2008.II.

félév

2008.I.

félév

2007.II.

félév

2007.I.

félév

2006.II.

félév

300

250

200

150

100

50

0

201221216221

233227205

276265

New clienst (per half a year)

2006 2nd halfyear

2010 2nd halfyear

N %

Active clients*

1047 50.7

Inactive clients

1019 49.3

sum 2066 100.0

Active and inactive clients

(total clients: 100%)

*visited the NEP at least once in 2010

Gender distribution in a certain year (%)

2010.

2009.

2008.

2007.

2006.

100%80%60%40%20%0%

28.0%

24.0%

27.6%

22.9%

18.6%

72.0%

76.0%

72.4%

77.1%

81.4%

Nõ

Férfi

N=2066

MaleFemale

Age of registered clients

<19 20-24 25-29 30-34 35-39 40+ys

malefemale

Total

Inactive clients

(%)

Active clients

(%)7th district 3.2% 4.7%

8th district 54.0% 55.5% 9th district 9.9% 10.5% 10th district 4.5% 6.2% „distant clients” 28.4% 23.1% Sum 100.0% 100.0%

2010.

2009.

2008.

2007.

2006.

100%80%60%40%20%0%

3%

2%

7%

4%

5%25%

42%

29%

30%

68%

62%

54%

66%

68%

30%

egyéb szer

absztinens,másnak visz

mefedron

heroin(ópiátok)

amfetamin

abstinentother

Drug use among registered clients

Place of residency

Place of residency

District N %

1. 2 ,2

2. 1 ,1

3. 15 1,4

4. 5 ,5

5. 7 ,7

6. 18 1,7

7. 41 3,9

8. 604 57,9

9. 113 10,8

10. 47 4,5

11. 22 2,1

12. 6 ,6

13. 53 5,1

14. 23 2,2

15. 9 ,9

16. 6 ,6

17. 3 ,3

18. 3 ,3

19. 14 1,3

20. 14 1,3

21. 5 ,5

22. 2 ,2

23. 4 ,4

Non Bp. 27 2,6

Sum 1044 100,0

} 7+ 8+ 9 district = 72,6%

Important for the local self-government

Clients’ visits per monthJanuary 2009 – July 2010

Febr. March

Delivered injectors in 2010

Injectors taken back in 2010

Clients’ visits per day

Febr. March

older clients return syringes in 45% of cases, while the proportion of returning the used syringes in case of new clients is only 22%

Typical client:

From the 8th district

Late 20s

Male

Amphetamine user

Socially excluded

Wrong employment position, criminality

Defined themselves as Roma

Main characteristics of the 8th district scene1.Many IDUs in a small territory: close community

2. Public injecting + shooting galleries (Type 1+2) + „drug litter”

3. High HCV infection prevalence, high risk behaviours prevalences1. injecting: common or shared injection equipment use2. sexual: without condoms, IDU sex partners, IDU sex workers

4. Difficult access to treatment visible!1. addiction treatment2. HCV treatment3. other (primary care, gyneacologist)

Local community affected

Fear from injecting drug users

Public nuisances

Discarded needles at playgrounds as well

Street drug dealing

Crime for drugs

Children as witness of injecting„Solutions”

Abstinence-oriented treatment

Methadone maintenance

Police presence

Needle exchangeLocal survey N=150

What does the needle exchange program do: some examples?

Safer injecting practices

More use – syringe deformities

Gyarmathy et al., 2009

Mean volume of fluid retained in two types of syringes

Needle exchange

Needle + paraphernalia exchange

Condoms and sexual counselling

Country Region Number syringes 2005

Number syringes 2006

Belgium Flemish community 390 522 538 783

Belgium French community 261 182 246 519

Bulgaria National (1) (6) 600 000 210 464

Czech Republic National (2) 3 274 000 3 868 880

Denmark National (3) 910 000

Germany National

Estonia National 867 600 1 615 270

Ireland National

Greece National 29 782 34 809

Spain National 3 184 845

France National

Italy National

Cyprus National 0 0

Latvia National 123 895

Lithuania National 258 650 196 952

Luxembourg National 406 451 332 347

Hungary National 85 127 142 433

Malta National 220 211 225 716

Netherlands Regional (9) 440 000 380 000

Austria Regional (7) 1 811 962 2 082 840

Poland National (10) 372 000 318 155

Portugal National (8) 2 845 031 2 591 150

Romania (4) 1 038 000 300 000

Slovakia Regional (13) 362 055 384 293

Finland National (11) 1 891 903 2 400 000

Sweden National 117 894

United Kingdom England and Wales 27.000.000 (2002)

United Kingdom Northern Ireland (12) 85 801 97 684

Croatia 135 981

Turkey 0 0

Norway National (5) 3 300 000

Needle exchange in the EU

Adequate syringe coverage: as many syringes from the SEP as their self reported injections in the last 30 days. SEPs were classified based on their syringe dispensation policy:

•unlimited needs-based distribution; •unlimited one-for-one exchange plus a few additional syringes; •per visit limited one-for-one plus a few additional syringes; Blue Point +5•unlimited one-for-one exchange; •per visit limited one-for-one exchange.

Findings:•unlimited needs-based distribution = 61%; •unlimited one-for-one plus = 50%; •limited one-for-one plus = 41%; •unlimited one-for-one = 42%; •limited one-for-one = 26%.

In multivariate analysis, adequate syringe coverage was significantly higher for all dispensation policies compared to per visit limited one-for-one exchange. Conclusion: Providing less restrictive syringe dispensation is associated with increased prevalence of adequate syringe coverage among clients.

Syringe dispensation policyBluthental et al., 2006

Drug use among needle exchange clients and their

friends (≠ clients)

Márványkövi, Melles, Légmán and Rácz, 2008

Drug use – last 30 days (%)

57,161,4

17,1

51,4

12,9

40,040,0

82,9

5,7

54,3

21,424,3

48,6

72,1

11,4

52,9

17,1

32,1

0

10

20

30

40

50

60

70

80

90

heroin amphetamine

non-presc. methadone

marijuana ecstasy sedatives

non roma drug user

roma drug user

total

Márványkövi, Melles, Légmán és Rácz, 2008

Injecting risk behaviours(≠ clients)

paraphernalialast 30 days

paraphernalialifetime

needleslast 30 days

needleslifetime

total 52% 75% 9% 56%

roma idu 60%* 80% 11,4%* 51,4%

non-roma idu 44%* 70% 7,1%* 60%

* p < 0,05

Mean N Sd

Outpatient 1,98 49 1,31Methadone maintenance 4,28 50 1,33

Daily clinic 1,50 28 1,04

Inpatient 2,39 49 1,50

Residential (TC) 3,03 39 1,50

1: easy access………………………5: very difficult access

Márványkövi, Melles, Légmán és Rácz, 2008Márványkövi, Melles és Rácz, 2006

Perceived access to different treatments

Public health measures(Gyarmathy and Rácz, 2010)

HCV as a HIV marker: at 30-35% HCV infection rate (Vickerman)1. Substitution (methadone, buprenorphine,

buprenorphine/naloxone=Suboxone)2. Access to sterile needles (needle exchange,

pharmacists)3. HIV, HCV testing + counselling4. Medically supervised injecting

Blue Point services

1. Substitutions: no funding2. Needle exchange: problem of long-term funding3. HIV, HCV testing + counselling: cooperation with the National

Centre for Epidemiology4. Supervised injection: against the law

From the literature:

Sydney Medically supervised

injecting facilities

München

Sydney

Entrance: Vancouver

Exit

Köln

Hannover

Frankfurt

Medically supervised injecting facilitiesHedrich, 2004 (EMCDDA)

Road to survival

• It needs local, city and national level consents• More advantages than disadvantages

• It is placed in a complex caring – treatment structure• It does not fulfil irreal expectations:

– Erases public injecting– Persuades injecting drug users to stop their drug use– In itself is not enough for decreasing morbidity and mortality rates– Solves problems with drug dealing and trafficking

Some experiences from a large scale Australian study on needle exchanges – 2000 - 2009

Estimated number of Australian IDUs

No. of syringes distributed in Australia)

≈150 injector/IDU

Injecting acts per injecting drug users (Australia Government Report, 2009)

Figure shows that injecting drug users are not able to decrease their drug use!

Injecting drug using visitors of the 8th district are about: 2.000 persons (1.500-2.500).

It means 800.000 injecting occasions per year, but here amphetamine users are the majority (who inject more frequently than heroin users), this number

maybe more than 1 million occasions per yearDistributed needles by the Contact Cafe are about 100.000/year, coverege of

injecting occasions are about 12,5% (10%).Similar coverege to Austratalia (150 injectors/person) – means about 300.000

injectors in a year.

Cost-effectiveness of Australian NSPs

Summary of investmentThe number of needles and syringes distributed in Australia increased during the past decade (from ~27 million to ~31 million).

Measures for NSPs to increase referrals to drug treatment and other services.• Over the last decade there has beeno Increases in funding for primary sites.o Increases in the number of secondary sites.o Increases (by 15%) in the numbers of units of equipment provided.o Stable spending on sterile injection equipment.O There were 85 primary sites, 737 secondary sites, 20 enhanced secondary sites, and 118 vending machines in 2010.

Effectiveness of NSPs

It was estimated that over the last decade (2000-2009) NSPs have directly averted:

• 32,050 new HIV infections;• 96,667 new HCV infections.

When secondary transmissions (sexual or mother-to-child transmission from infected IDUs) are considered, the epidemiological benefits are even greater.

Economic analysis of NSPs during 2000-2009

During 2000-2009, gross funding for NSP services was $243m. This investment yielded:• Healthcare costs saved of $1.28 billion.• Approximately 140,000 DALYs gained.• Net financial cost-saving of $1.03 billion.

It was estimated that:• For every one dollar invested in NSPs, more than four dollars were returnedin healthcare cost-savings in the short-term (ten years) if only direct costs are included; greater returns are expected over longer time horizons.• The majority of the cost savings were found to be associated with HCV-relatedoutcomes. However, when only HIV-related outcomes were considered in theanalysis, it cost $4,500 per DALY gained associated with HIV infection.• If patient/client costs and productivity gains and losses are included in the analysis,then the net present value of NSPs is $5.85bn; that is, for every one dollar invested inNSPs (2000-2009), $27 is returned in cost savings. This return increases considerably over a longer time horizon.• NSPs are very cost-effective compared to other common public health interventions.

DALY: disability-adjusted life year

The simulated number of annual (a) HIV and (b) HCV transmissionsamong IDUs in Australia versus the percentage of injections that are

shared and theaverage number of times each syringe is used before disposal.

The dashed lines refer to current levels of sharing and syringe use.

HIV HCV

Scatter plots of the simulated number of annual (a) HIV and (b) HCVtransmissions among IDUs in Australia versus the number of sterile

syringesdistributed in Australia are shown, assuming that syringe distribution

changes theaverage number of times each syringe is used before disposal.

The blue dots are results from 1000 simulations, the red curves represent the median parameter values, and the black dashed lines refer to current levels of syringe distribution.

Thank you for your attention!

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Public injecting, harm reduction services

Health & Medicine

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