On the 13th & 14th of February, with 45 participants from more than 20 organisations, the first meeting of the BOOST Project took place in the Fondazione Villa Maraini in Rome.

The main aim of the BOOST project is to enhance the implementation of high-quality community-based & community-led communicable disease services as part of a comprehensive, people-centred and integrated harm reduction approach. To ahieve its goal, over the next three years, together with our partners we will focus on four key areas:

INFORM – providing a collection of up-to-date information and data on current practice and quality of community-based and community-led services.
IMPROVE – supporting the organisation of capacity building activities in the field of communicable diseases, indluding the use of digital tools.
SUPPORT – enhancing the scale-up of integrated community-based good practices building up existing models of good practice.
CONNECT & ACT – strenghtening and consolidating existing civil society networks and fostering advocacy interventions for the improved implementation comunity-based and community-led good practices oriented towards the needs of people who use drugs at European, national and local levels.

BOOST Project is founded by the EU4Health programme of the European Union, under the Action Grants to support the implementation of best practices in community-based services for HIV, AIDS, viral hepatitis and sexually transmitted infections. Partners include the Eurasian Harm Reduction Association, EuroNPUD, Free Clinic, Podane Ruce, LILA Milano, Asociacion Bienestar y Desarrolo, IGTP/ICO, ISGlobal, Foundazinone Villa Maraini. Supporting the projects work, the project with count with Scientific Advisory Board and the collaboration of organizations such as DPNSEE, ReGeneration, ARAS Foundation, AIDS Action Europe, among others.

Civil Society Monitoring of Harm Reduction in Europe

Webinar Announcement

Correlation – European Harm Reduction Network is hosting an online launch and discussion of the fourth annual report of its civil society-led monitoring of Harm Reduction in Europe. The webinar will take place on the 23rd of February, 2023, from 16:00h to 17:00h CET.

2022 was one of the most consequential in recent European history, witness to a series of overlapping crises: the aftermath of the COVID-19 pandemic, Russia’s invasion of Ukraine, fast-growing population displacements, the MPOX outbreak, shrinking civil society spaces and the deepening of socioeconomic inequalities, among others.

Within this context, C-EHRN’s monitoring activities have been embedded with increased urgency. Whilst the effects of these developments have been felt in nearly everyone’s life, people who use drugs, as well as other marginalised and underserved communities, have particularly and disproportionately experienced its negative consequences. Equally, harm reduction organizations in Europe have been put to the test.

In combination with advocacy, the application of civil society-led monitoring tools is crucial to hold governments accountable and to improve the care and support that people who use drugs receive and their environments.

Together with more than one hundred organizations and individuals from thirty-four European countries, C-EHRN set up for itself the task to provide an in-depth look at Harm Reduction in Europe. To this end, the annual 2022 Data Report focused on three main themes: harm reduction essential services, Hepatitis C, and new drug trends. In addition to the data collected, this year C-EHRN conducted in-depth interviews with all its Focal Points, allowing for a richer picture of the developments from last year.

During this webinar, C-EHRN will launch and discuss its annual 2022 Data Report, including key findings, results and opportunities for civil society advocacy, service provision and policy development.

The webinar is open to harm reduction activists and service providers, civil society representatives, researchers, policy-makers and the media. The event will be held in English.

Further information:

Roberto Perez Gayo
rpgayo@correlation-net.org

The event report and the Call to Action for the EU to lead on viral hepatitis elimination by 2030, are now available.

On 25 October 2022, the MEP Friends of the Liver Group hosted the event “The final push to eliminate viral hepatitis – how can the EU lead the successful achievement of this global public health priority?”, with support from the European Association for the Study of the Liver (EASL) as Secretariat of the Group, and the ACHIEVE Coalition.

The key takeaway from this panel discussion was the importance of different stakeholders speaking with one voice while working towards elimination. In keeping with the WHO 2030 Goal of Viral Hepatitis Elimination, panellists and audience members alike called for the explicit inclusion of this goal in the New EU Global Health Strategy.

Now, the event report has been published alongside the call to action. The Call was endorsed by the two Co-Chairs of the MEP Friends of the Liver Group, Cyrus Engerer MEP and Pietro Fiocchi MEP, as well as by the Group Members Dr. Cristian-Silviu Busoi MEP, Dr. Andrey Kovatchev, and Frances Fitzgerald MEP.

The goal is for the Call to be shared with the European Commission, selected Member States, as well as the interested public to shape future policy and funding initiatives.

This new publication discusses the need for scaling-up harm reduction services, and more information on our new BOOST project.

In 2023, C-EHRN will start to implement the European Union (EU) co-financed BOOST project, aiming to strengthen and support community-based and community-led harm organisations in providing high-quality communicable disease services to people who use drugs. These include the scaling-up of good practices in communicable disease awareness, prevention, screening/testing and linkage to care, delivered as an integrated part of people-centred harm reduction interventions. The project consortium includes, among others, the Eurasian Harm Reduction Association (EHRA) and the European Network of People Who Use Drugs (EuroNPUD).

The publication also contains information from the presentation by Roberto Perez Gayo (C-EHRN Policy Officer) on the BOOST project at INHSU 2022.

As well as this, Free Clinic in Belgium, Podane ruce in Czechia, Villa Maraini in Italy, and the A-Clinic Foundation in Finland are discussed as examples in harm reduction for an integrated HIV/HCV approach.

We are pleased to share the report from the INHSU 2022 conference.

Over three days in Glasgow, the INHSU 2022 conference took place; The 10th International Conference on Health and Hepatitis Care in Substance Users. The conference brought together professionals in the field to share the latest developments in the field.

We want to thank CEHRN Consultant Graham Shaw who collected the notes from the conference to create this report.

During the 3rd day of the INHSU 2022 conference, Roberto Perez Gayo, policy officer of C-EHRN, chaired a session on the need for scaling up community-based HCV prevention, treatment and linkage to care services for people who use drugs.

Free Clinic

Tessa Windelinckx of the Free Clinic in Belgium outlined their work and stressed that the clinical component of their programme was dependent upon their peer outreach workers and, therefore, collaboration between medical staff – including doctors and nurses – and peers was vital to reaching the most vulnerable people with viral hepatitis C (HCV) services and to link them with care. In addition, each part of the Free Clinic portfolio of services benefited from having staff with varying experiences working together, such as those running the needle-syringe programme (NSP).
As most vulnerable people are afraid of government services due to the stigma and discrimination that is often prevalent by such healthcare staff, peer-to-peer support by Free Clinic – called C-Buddies – acts as a bridge, or facilitation mechanism, between those in the community and the service providers at Free Clinic fixed sites. C-Buddies are usually people from the vulnerable community who use communication methods to build friendships with vulnerable people within a stable environment. Through building trust, vulnerable people are encouraged to access a range of services offered by Free Clinic, including HCV testing.

Spolecnost Podane Ruce

Lucie Maskova of the Spolecnost Podane Ruce non-governmental organisation (NGO) in the Czech Republic (Czechia) provided information on their services, noting that the country had an HCV elimination plan for people who inject drugs, but that treatment was only available through 22 specialised centres throughout the Czech Republic rather than through NGOs or other mechanisms. Rapid HCV testing through a finger-prick, or a sample of saliva, is facilitated through drop-in and mobile/outreach services as well as part of providing opioid agonist therapy (OAT) and drug treatment and includes counselling by non-medical staff. Approximately 2,000 people each year are tested for HCV. HCV testing is also provided for refugees from Ukraine with trained peers who speak Ukrainian and Russian.

Recently, an infectious disease specialist joined the NGO who will hopefully be able to prescribe direct acting antiviral (DAA) medication in the near future. Challenges facing the NGO include how to address comorbidities and the limited number of trained peers, together with funding as well as the relatively limited number of centres where DAA’s are available; the country also needs a national coordinator for the HCV elimination efforts.

Read the full presentation here.

Fondazione Villa Maraini

Examples of service provision in Italy were presented by Nadia Gasbarrini of the organisation Fondazione Villa Maraini which was founded in 1976 and delivers low threshold services including an emergency unit, drop-in centre, night shelter and services inside prison as well as outreach on the street. OAT, HIV and HCV services are also available, plus higher threshold interventions, including a therapeutic community and outpatient treatment.
On-site and street-based HIV and HCV testing and linkage to care also provide counselling, psychological support – including support to families – as well as peer-to-peer education and, more recently, COVID-19 testing and screening [see images 9 and 10]. In addition to people who use drugs, sex workers, the LGBTQI+ community, the homeless and migrants are also served. However, treatment of HCV involves referral of individuals to a hospital rather than provision of DAA’s through the organisation. To-date, in 2002 there were 536 people tested for HCV. Prior to the COVID-19 pandemic in 2019, the number of people tested was 1,310.

Read the full presentation here.

Group Discussion

Following the presentation, participants joined a group discussion. The key points include:

Important to include harm reduction as part of the medical training curriculum and to provide medical students with internships to work with organisations delivering harm reduction services as part of improving their practical skills in the delivery of client-centred harm reduction services;
Crucially, peer training of public-facing staff at healthcare facilities is important as receptionists and security guards are the first people with whom a vulnerable person will come into contact with.
Legislators/regulators should improve their understanding of how harm reduction services are delivered and be more flexible in the regulations and guidelines used by the medical profession in the provision of standard interventions for people who inject drugs and other vulnerable people. Likewise, harm reduction advocates need to facilitate awareness raising by legislators/regulators of the opportunities to make services more flexible and adaptable to the needs of vulnerable people;
Staff turnover is a challenge within organisations and there is a need to increase the number of peers trained in the delivery of an integrated approach to the provision of health, social and economic support interventions, including housing. It is also vital that trained peers are paid properly for the skills that they provide to service delivery agencies and are not discriminated against by being treated as volunteers due to their prior, or ongoing, lived experience;
The role of trained and trusted peers is vital as most vulnerable people are suspicious of healthcare workers. Therefore, outreach supports vulnerable people, such as providing evidence-based and clear information; answering questions; accompanying individuals, if needed, to healthcare facilities and acting as a bridge for both the client and healthcare staff to communicate and benefit from the available services; and to provide other pathways for a vulnerable person to voluntarily access social and economic services;
The time available for a doctor to spend with an individual client can be very limited due to the number of people seeking assistance and other competing priorities. Therefore, where practical, task shifting should be used to allow nurses and others to perform a range of tasks as this will free up time for a doctor to focus on those people who have more complex health and related needs;
There is a need to integrate services as the opportunities for the individual to return to a service provider could be extremely limited. Therefore, testing for common communicable diseases should be undertaken at the same and, ideally, for results to be available immediately that allows for treatment to begin without delay; this will reduce loss-to-follow-up and allow the client the most pragmatic approach to improving their health. However, at present, many providers –especially for OAT – have different regulations that they follow. Service providers need to show flexibility to improve access and adherence to treatment by vulnerable clients;
In running an effective harm reduction organisation, it is necessary to strike a balance between good levels of peer supervision and avoiding unnecessary meetings or paperwork. In addition, services must not try to micromanage vulnerable individuals as this will likely lead to them not returning again;
Good linkages with local law enforcement is important in facilitating access by vulnerable people to harm reduction services, either at fixed sites or through outreach. Examples from Tijuana, Mexico, were given during the Conference as to how this can be undertaken. Such linkages with police can be either formal or informal in nature but with the same objective of facilitating access to services by vulnerable people in the community. Small steps, such as peer education for police, can be the start of the process that eventually culminates in decriminalisation;
Different agencies of the same government structure can work against each other in reality, such as a health department supporting civil society partners to provide HCV testing in the community but the local laboratory being a barrier to PCR confirmatory testing; funding can also reflect the different priorities of government agencies;
Telehealth can increasingly link clinical providers with vulnerable people as a way of helping clients feel easier about accessing health services;
Stigma remains a major barrier to increasing access to, and full utilisation of, health services by vulnerable people.

Summary

In conclusion, participants stated that the most important issues for service providers to consider in establishing and scaling-up community-based HCV prevention, treatment and linkage to care services for people who inject drugs include:

Gaining the trust of people who inject drugs which can be achieved through trained peers who are paid at the same levels as those without such lived or living experience of drug use;
Ask people who inject drugs what they want; do not make assumptions on their behalf;
Ensure you have a baseline at the beginning of service delivery so that you can calculate changes and impact over time;
Learn from other organisations who have gone through similar processes and models of service delivery; this can include collaboration/partnerships with such agencies;
Ensure that medical practitioners are given the opportunity to learn about harm reduction from people who inject and otherwise use drugs in order to adopt more flexible and pragmatic approaches to service provision; this could include internships while studying at medical school, for example;
Provide access for people who inject drugs to education about the HCV continuum of care, including what medical practitioners require from those who undergo treatment, as well as barriers that clients may face in becoming free of HCV; and,
Provide web-based information to organisations who are considering establishing HCV services for vulnerable people, such as the materials available from C-EHRN.

We are excited to be attending the INHSU 2022 conference in Glasgow, and want to share some key reflections and images from day 1 (October 18th) as shared by Graham Shaw and Roberto Perez.

At the opening, the Scottish Government’s Minister for Public Health, Women’s Health and Sport, Maree Todd, stated that Scotland was close to halving viral hepatitis C (HCV) prevalence and by as much as 60-70% in some parts of the country. However, she also noted that HCV incidence remains high.

Jason Wallace of the Scottish Drugs Forum (SDF), speaking on behalf of the community of people with lived and living experience, outlined the main points from the statement developed by the community forum the previous day. Of particular note was that research must be controlled by the community, including the early involvement of the community in developing all aspects of a research proposal, as well as ownership of research data. He also stressed that poly drug use is the norm, not the exception. The community also demands a defined role of volunteers as well as to be paid equally for being employed in research work, as well as a clear pathway for peer workers to progress in drug-related programmes, together with proper supervision and support within such organisations.

In Andrew McAuley’s presentation, he spoke of the increasing global trend in drug-related deaths (DRD) which have roughly doubled over the past 30 years and exponentially increased since 2014 and that this trend has further climbed since the COVID-19 pandemic, with the USA and Scotland the stand-out leaders in the rate of DRD. Medically Assisted Therapy (MAT), also known as Opioid Agonist Therapy (OAT), Take-Home Naloxone (THN) were notable responses to opioid-related prevention of deaths and Direct Acting Antivirals (DAA) for the treatment of HCV. Drug Consumption Rooms (DCRs) and Drug Checking Services (DCS) are also key to the prevention of DRD but that there are gaps in evidence.

Niamh Eastwood of Release UK outlined the various aspects of how the war on drugs has failed and how non-white people were clearly being targeted by law enforcement agencies who use the war on drugs as an excuse to stop-and-search non-white people around nine times more often than they do with white individuals. However, advocacy continues to push for the decriminalisation of drug use and possession for personal use, including the cost savings arising from decriminalisation. A picture from the presentation is included below.

Impact of the Russian invasion on ART and OAT access by PWID in Ukraine

Jack Stone of the University of Bristol outlined the impact of disruptions to services for people who inject drugs due to the Russian invasion of Ukraine. Modelling shows that short-term closures of interventions could have a substantial impact on the increase in HIV infections even though OAT and ART access continued to increase outside of conflict areas but reduced in the areas invaded by Russia, partly a result of a drop-off of NGO service provision in such Russian-controlled areas of Ukraine. Images from the presentation are included below.

‘What the fresh hell is this?’

Presented by Garth Mullins, the producer of the Crackdown podcast based in the USA. The session discussed the ever developing emergence of new substances promoted through the consequences of prohibitionist policies, as seen originally in the early 20th century in the USA with alcohol. Particular focus was given to ‘benzo-dope’ and how naloxone responses to overdose only impact the ‘dope’ component and not the benzo’s, leaving people with severe memory loss from a few hours to several days. Contributors provided their own ‘benzo-dope’ overdose experiences, including Jason Wallace of the Scottish Drugs Forum who said that Benzos were implicated in an ever increasing number of drug-related deaths. Angela McBride of the South African Network of People who Use Drugs outlined the impact of alcohol and cigarette prohibition in South Africa during COVID-19 lockdowns but that such experience has been easily forgotten. Sione Crawford of Harm Reduction Victoria, Australia as well as Mat from the Canadian Association of People who Use Drugs (CAPUD) all noted the need for a safe supply to reduce overdose events and continued failure to provide a safe supply of substances will allow the black market to prevail and the resultant high levels of drug-related deaths.

HCV care models

Several different examples of HCV care models were presented from South Africa, Iran and Scotland. In all three countries, services were based within the community through building relationships and keeping each step as simple as possible; such an approach helps to reduce the level of stigma and discrimination experienced by people who inject drugs. In Dundee, Scotland, building such relationships helped move from confrontation to cooperation, such as in interactions with a local pharmacy, as well as the inclusion of other health interventions, such as wound care. In Rafsanjan, Iran, a local entrepreneur helped to fund a local response to provide HCV testing and treatment, with the local community identifying an unused bus that was repurposed and used as a mobile HCV unit. The local service was linked with the University of Medical Sciences and this model of micro-elimination of HCV is now being considered for implementation throughout the country. In South Africa, it was noted that advocacy can result in positive change in service provision and SANPUD capacitates fellow networks and organisations to pressure decision-makers for change to allow improved access to HCV testing and treatment services.

Individual choice

The choice of which opioid maintenance approach is appropriate for the individual was discussed within the context of Switzerland and Australia. A relatively wide range of options are available in Switzerland. The process of supporting an individual includes the person’s preferences as to which opioid agonist should be tried, with examples given for various substances available in Zurich and Arud. The future directions beyond medical treatment were also outlined within the context of the changing legislative environment. Key elements of effective OAT were presented together with approaches to the continued use of other substances by an individual.

In Australia, choice is often associated with not being chained to a pharmacy as well as the endemic stigmatisation of people who use drugs. In addition, there are social aspects to using substances and the medicalisation of treatment often negates this component and options also include the continued use of drugs. Also stressed during the discussion was the apparent fear held by prescribes of being held liable if an individual overdoses and the belittling view of people who use drugs held by legislators that results in unreasonable and excessively tight controls being in place for opioid maintenance.

The social sciences perspective of individual choice was reviewed and the key factors that influence individual preferences were outlined. Considerations that ‘professionals’ can make to facilitate choice by the individual were also provided.

Differentiated choice of the best suitable agonist were discussed. The first priority has to be the preference of the person in treatment; subjective experience and side effects are often overlooked and not addressed.

Long acting full agonsists include;

Methadone – frequent interactions, QTc, sedated
L-Polamidon – only in liquid form, less side effects
SROM (slow release oral morphine) – often better tolerated, no interactions, warmer and more lively

Long acting partial agonist;

Buprenorphin – sublingual, induction more complex, alert and less opioid feeling

Key elements of effective OAT;

Accessibility of treatment
adequate provision of information
Respect of autonomy of the person in treatment, no coercion, no sanctions
choice of best tolerated substance in sufficient dose, preferred route of administration
Take homes by default
Individualised goal setting, treatment tailored to the needs of the person in treatment
Diagnosis and treatment of comorbid disorders

On Top Use of other Substances;

Make sure OAT is optimised (substance, dose, route of administration)
No sanctions
Careful use of urine analyses – self report more informative
Address comorbid disorders (self-medication)
Consider agonist treatment of stimulant use disorders (also as stand alone treatment for people without opioid dependence).

“How can professionals enable choice in OPT decision making?”

To the extent possible;

Offer a range of non-stigmatizing treatment options
Provide accessible information in a range of formats to enable informed decision making
Listen to patients and answer questions
Share decision making
Review treatment and treatment decisions regularly and update

Key factors influencing patient preferences;

Personal dislike of particular OPT biodelivery systems
Desired feelings following OPT administration
Perceived effectiveness
Concerns about side effects
Ability to control the OPT
Impact on everyday life
Concerns about OPT-related stigma
Perceived need for adjacent psychosocial support
Personal treatment goals

On Tuesday, the ECDC hosted their webinar on testing and care of viral hepatitis among migrant populations in the EU/EEA; aiming to strengthen EU/EAA countries’ capacities and capabilities to prevent and control viral hepatitis among migrant populations.

Chronic HCV/HBV in European migrant populations

Milosz Parczewski [European AIDS Clinical Society – EACS] presented data on chronic HCV/HBV in European migrant populations. Milosz shared multiple figures on the data such as the one below.

Milosz emphasised the urgent need to collect current data from this target group, including updated vaccination data from the refugee population. He also highlighted the need for more outreach testing programmes as these numbers are still too small.

Novel model of care for testing HBV

Next, Camila Picchio presented a novel model of care for simplified testing of HBV in African communities during the COVID-19 pandemic in Spain. The model consists of two field visits; firstly, information regarding hepatitis b is provided by a community coordinator before the screening takes place with a blood extraction. During the second visit, the participants are given their blood results, offered their HBV vaccine, and those with past-resolved infection or prior vaccination are offered post-test counselling.

“This community-based HBV screening program provides an effective model for identifying and providing care to migrant populations at high risk of HBV infection, who may otherwise not engage in care”

Take away messages from the model were;

Identify barriers to linkage to care to increase the overall rate of linkage, particularly for those requiring vaccination
Additional research and focus is needed to increase linkage to care for females across the care cascade.
Tools to address vaccine hesitancy among this population are needed.

Testing and management of viral hepatitis for refugees from Ukraine

The final presentation was by Mojca Matičič, MD, PhD. A pre-war data set of the situation in Ukraine was presented, with data showing Ukraine was second largest HIV epidemic in the WHO EU Region, second highest prevalence of HIV/TB coinfection, and the fourth highest TB incidence rate among WHO EU region countries. HBV and HCV infections were identified as key public health issues in Ukraine.

“By October 11 2022, 4,350,995 refugees from Ukraine registered for temporary protection (or similar national protection schemes in Europe)”

Mojca reinforced the need for community healthcare providers to ensure access to services and continuation of vaccination programmes for Ukranian refugees, and highlighted the harm reduction services across Europe for refugees from the Ukraine which are described in the C-EHRN Ukranian snapshot.

The final push to eliminate viral hepatitis – how can the EU lead the successful achievement of this global public health priority?

This high-level conference is hosted by MEP Friends of the Liver Group with the support of EASL (European Association for the Study of the Liver) and ACHIEVE (Associations Collaborating on Hepatitis to Immunize and Eliminate the Viruses in Europe).

The conference will include a panel discussion including representatives from the European Commission’s DG SANTE, European Centre for Disease Prevention and Control (ECDC), European Cancer Organisation (ECO).

“In June 2022, WHO approved the Global Health Strategy Against Viral Hepatitis (2022-2030) which reaffirms the 2030 elimination target. However, progress in some Member States is lagging and mortality from hepatitis-related liver cancer is on the rise. The situation is even worse in some other World Regions.”

Kicked off by interventions by ACHIEVE and EASL, we would thus like to explore with our panelists and the audience:

What can the EU do to lead and achieve this global public health goal?
How can Europe’s Beating Cancer Plan support this aim?
Which are the funding needs from EU4Health for the years to come, and how can it be ensured that Member States and regions in greatest need will profit from this funding?
How can good practices be shared and picked up?

As part of our 2022 work plan, C-EHRN is working with different Expert Groups and will organize consultations addressing a variety of topics. With this open call, C-EHRN would like to invite all its members and partners to engage and participate in these Expert Groups and Consultations based on their interest and expertise in any of the following areas:

If you wish to participate, we invite you to express your interest and share a brief description of your area of expertise [max. 100 words] through the following email: administration@correlation-net.org before the 31st of July 2022.

BOOST

On the 13th & 14th of February, with 45 participants from more than 20 organisations, the first meeting of the BOOST Project took place in the Fondazione Villa Maraini in Rome.

Online Launch Data Report 2022

The Final Push to Eliminate Viral Hepatitis

The Lighthouse Concept

This new publication discusses the need for scaling-up harm reduction services, and more information on our new BOOST project.

INHSU 2022 Report