Access and coverage of needle and syringe programmes (NSP) in Central and Eastern Europe and Central Asia*

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1 RESEARCH REPORT doi: /j x Access and coverage of needle and syringe programmes (NSP) in Central and Eastern Europe and Central Asia* Carmen Aceijas 1, Matthew Hickman 1,5, Martin C. Donoghoe 2, Dave Burrows 3 & Raminta Stuikyte 4 Centre for Research on Drugs and Health Behaviour (CRDHB), London School of Hygiene and Tropical Medicine (LSHTM), Department of Public Health and Policy, London, UK, 1 WHO Regional Office for Europe, Copenhagen, Denmark, 2 AIDS Projects Management Group, Sydney, Australia, 3 Central and Eastern European Harm Reduction Network (CEEHRN),Vilnius, Lithuania 4 and Department of Social Medicine, University of Bristol, Bristol, UK 5 ABSTRACT Objective To estimate access, activity and coverage of needle and syringe programmes (NSP) in Central and Eastern Europe and Central Asia. Methods Two data sets ( regional and high-coverage sites ) were used to estimate NSP provision (availability/number of sites), NSP utilization (syringes distributed/year), needle and syringe distribution (needles/syringes distributed/idu/year), IDU reached (number/percentage of IDU contacted/year), regular reach (five or more contacts/month) and syringe coverage (percentage of injections/idu/year administrable with new injecting equipment). Results Regional data set: results from 213 sites in 25 countries suggested that Czech Republic, Poland, Russia and Ukraine had > 10 NSP during 2001/2. Czech Republic, Kazakhstan, Latvia, Russia, Slovakia and Ukraine had IDU in contact with NSP. Ten countries reached 10% of the estimated IDU population. The 25 countries distributed ~ 17 million syringes/needles. Eight countries distributed > 0.5 million syringes/year. Syringe coverage (assuming 400 injections/idu/year) was < 5% in 19 countries, 5 15% in five and > 15% in Macedonia. Overall syringe coverage was 1.2% and when assuming 700 injections/idu/year it decreased to 0.7%. Syringe coverage for the IDU population in contact with NSP was 15% in 10 countries, 15 60% in 11 and > 60% in Croatia, Macedonia, Moldova and Tajikistan. Overall syringe coverage for the population in contact with NSP was 9.8%. High-coverage data set: Soligorsk, Pskov and Sumy s NSP reached 92.3%, 92.2% and 73.3% of their estimated IDU population, respectively (regular reach: 0.2%, 1.8% and 22.7%). The distribution levels were 47.2, 51.7 and 94.2 syringes/idu/year, respectively. Conclusion The evidence suggests suboptimal levels of NSP implementation, programme activity and coverage. This paper provides a baseline for development of indicators that could be used to monitor NSP. Strategies to increase coverage that may go beyond NSP are urgently required, as is research into understanding how NSP can contribute to better syringe coverage among IDU. Keywords Central Asia, Europe, IDU, NSP, syringe coverage. Correspondence to: Carmen Aceijas, Centre for Research on Drugs and Health Behaviour, London School of Hygiene and Tropical Medicine, Department of Public Health and Policy, Keppel Street, London WC1E 7HT, UK. carmen.aceijas@lshtm.ac.uk Submitted 23 March 2006; initial review completed 23 June 2006; final version accepted 7 March 2007 INTRODUCTION The sharing of needles and syringes among injecting drug users (IDU) is a significant route of transmission of human immunodeficiency virus (HIV) [1] and hepatitis C virus (HCV) [2] globally (5 10% of all HIV new cases are linked to unsafe injecting practices [3]), and a major vector in the transmission of HIV in seven of 10 world regions [4]. Injecting drug use is propelling epidemics in numerous countries, including North-East India, *The contents of this paper, including data, analysis, interpretation and presentation are the responsibility of the authors and not of the United Nations. On behalf of the Reference Group on HIV/AIDS Prevention and Care among IDU in Developing and Transitional Countries.

2 2 Carmen Aceijas et al. Indonesia, Iran, Libya, Pakistan, Spain, Ukraine, Uruguay and Vietnam [4]. We have estimated ~13 million IDU world-wide [5]. Strong evidence of needle and syringe programmes (NSP) in reducing HIV infection among IDU does exist [6]. Distribution of sterile needles/syringes to IDU through needle and syringe programmes (NSP) is effective in reducing syringe sharing [7,8], preventing HIV epidemics among IDU [9 11] and reducing HIV prevalence among IDU [12], with little evidence of adverse consequences [13]. United Nations (UN) agencies have requested countries to monitor and increase the coverage of HIV prevention interventions [UNGASS] [14]. Factors influencing the effectiveness of NSP include duration and sustainability [15], gender differences [16], law enforcement [17], location of the programme [18], dispensation policy [19], prison setting [20] and drug consumed [21]. Overall, we estimate that ~ 65 of 130 (50%) countries with evidence of IDU populations report at least one NSP [22]. Among countries reporting HIV among IDU (n = 78) the level is 83%. However, the mere presence of an NSP does not mean that a sufficient number of IDU are reached with sterile needles and syringes. Some western European countries introduced syringe exchanges in the mid-1980s. By 1988, Switzerland, Denmark, Netherlands, Sweden, the United Kingdom, Norway, Malta and Spain had officially adopted them as a public health measure. In the 1990s the number of countries supporting needle exchange continued to increase [23]. However, in Eastern Europe and the former Soviet Union, few NSP began operating before the mid- 1990s. The number of countries in this region reporting at least one NSP has grown dramatically since 1996, but still 70 90% of all HIV infections in the region are attributed to injecting drug use [24]. In this paper we examine available data on NSP availability, activity and coverage for Central and Eastern Europe and Central Asia. METHODS We assessed the access, activity and syringe coverage of NSP in Central and Eastern Europe and Central Asia using two data sets ( regional data set and highcoverage sites data set ). First, regional data set (Table 1): data on NSP were obtained from the Central and Eastern European Harm Reduction Network (CEEHRN) survey among harm reduction (HR) programmes [25]. NSP were defined as any distinct syringe provision point where syringes were distributed to injectors. Each point was treated as an independent unit of analysis and referred to here as NSP. The survey was launched at the end of 2002, targeting all known HR programmes in the countries of Central and Eastern Europe and the Newly Independent States (CEE/NIS). Two hundred and twenty-eight programmes were sent a questionnaire that collected information on the programme location, contact details, target populations and services provided, and the annual number of syringes and needles distributed, annual syringe and needle exchange rate and number of IDU reached. Nonresponders were contacted on several occasions until Spring 2003 to boost the response rate. Data from the survey [25], along with available estimates of IDU populations [26], were used to calculate: (a) NSP provision (availability and number of sites [27]); (b) NSP utilization (level of use of the services measured by the number of syringes distributed in a given period [28]); (c) needle and syringe distribution (number of needles and syringes distributed/idu/given period [29]); (d) IDU reached (number and percentage of IDU contacted by any site in a given period [28]); and (e) syringe coverage (percentage of injections per year with new injecting equipment), assuming an average 400 [30] and 700 [29] injections per IDU per year. The latter assumptions represent approximate rates of one and two injections per day, respectively, and were selected on the advice of regional experts. Syringe coverage was calculated both for the estimated IDU population and the population in contact with the NSP. Data from 2001 and 2002 were combined to estimate the average annual number of IDU in contact and syringes distributed. Missing or incomplete data were imputed based on values for other sites within a country, and are specified in the footnote to Table 1. Secondly, the high-coverage sites data set (Table 2) collected data from three NSP within the region identified as high-coverage : Soligorsk (Belarus), Pskov (Russian Federation) and Sumy (Ukraine). Estimates of IDU populations were obtained from a rapid assessment exercise conducted in 2001 which assembled a set of multipliers for all oblasts (regions) of Belarus and used them to estimate the IDU populations [31]). These data were combined to estimate (a) IDU reached; (b) regular reach [28] defined as those attending the site 5 times/month; (c) NSP utilization; and (d) needle and syringe distribution. Due to the diversity of monitoring methods employed, comparisons between sites were not attempted. RESULTS For the regional data set, all programmes targeted (228) answered the survey (100% response rate). A total of 213 provided the number of IDU reached and syringes distributed. Table 1 presents the findings. Analysis of NSP provision showed that six countries reported one to three NSP (Albania, Azerbaijan, Bosnia and Herzegovina, Estonia, Slovenia and Turkmenistan); 15 had four to 10 NSP (Belarus, Bulgaria, Croatia,

3 Access and coverage of NSP 3 Table 1 NSP Provision, reached IDU population, NSP utilization, needle and syringe distribution level and syringe coverage in Central and Eastern Europe and Central Asia (regional data set). Syringe coverage Country NSP provision 1 Estimated 2 (1000s) IDU reached (1000s) IDU reached 3 (%) NSP utilization 4 (1000s) NSP distribution 5 For For IDU pop. in contact For in contact 400 injections/year 700 injections/year For in contact Albania Azerbaijan Belarus Bosnia and Herzegovina Bulgaria Croatia Czech Republic Estonia Georgia Hungary Kazakhstan Kyrgyzstan Latvia Lithuania Macedonia Moldova Poland Romania Russia Slovakia Slovenia Tajikistan Turkmenistan Ukraine Uzbekistan Totals Missing or incomplete values for parameter IDU in contact in 31 of 211 sites (12 were sites in Russia and 11 in Ukraine). Missing or incomplete values for the parameter syringes distributed in 19 sites (seven were in sites in Russia and seven in Ukraine). Figures rounded up to one decimal. Source: self-production from CEEHRN s survey [25]; 1 NSP provision = no. of sites; 2 midpoint of available estimates of IDU [5,22]; 3 percentage of the estimated IDU population in contact with NSP; 4 syringes distributed; 5 needles/syringes distributed/idu/given period.

4 4 Carmen Aceijas et al. Table 2 Analysis of three high-coverage sites: Soligorst, Pskov and Sumy (high-coverage sites data set). Sites Estimated IDU population IDU reached Regular reach 1 NSP utilization Range Midpoint n % n % n Year Needle and syringe distribution 2 Soligorsk Pskov / Sumy Attended HR or drug treatment services at least five times/month; 2 no. of syringes/idu/year. The denominator is the midpoint of the estimated number of IDU (3rd column); 3 34 months of programme activity; 4 52 months of programme activity; 5 31 months of programme activity; 6 derived using a set of multipliers from the results of several surveys for all oblasts in Belarus; 7 derived from a five-city study in Eastern Europe in plus a further situation assessment study in 2000; 8 derived from a multiplier/benchmark study of five Ukrainian cities and triangulated with estimates from IDU (interviewed by NSP staff) and from local journalists. Georgia, Hungary, Kazakhstan, Kyrgyzstan, Latvia, Lithuania, Macedonia, Moldova, Romania, Slovakia, Tajikistan and Uzbekistan); and four had > 10 NSP (Czech Republic, Poland, Russia and Ukraine had > 10). Only six countries had IDU in contact with NSP: Czech Republic, Kazakhstan, Latvia, Russia, Slovakia and Ukraine. Ten reached 10% of the estimated IDU population: Bulgaria, Czech Republic, Estonia, Georgia, Hungary, Latvia, Lithuania, Macedonia, Slovakia and Slovenia. In one country, Latvia, the estimated percentage of IDU reached was > 100%, with the total IDU population in contact with five sites in Riga (n = ), surpassing the estimated national IDU population (n = ). The number of IDU reached annually by the 213 programmes in the 25 countries was The total NSP utilization level was estimated at , with considerable regional variation. Countries distributing < syringes/year were Albania, Azerbaijan, Bosnia and Herzegovina, Estonia, Georgia, Hungary, Latvia and Turkmenistan. Countries distributing > 0.5 million syringes/year were: Bulgaria, Czech Republic, Kazakhstan, Kyrgyzstan, Moldova, Poland, Russia and Ukraine. Macedonia and Lithuania were estimated to provide the highest number of needle and syringes per IDU (distribution level) at 72.1 and 40.5 syringes/idu/year, respectively. Considering only the IDU population in contact with NSP, 13 countries distributed < 100; seven distributed ; and three distributed > 300 syringes per IDU in contact per year. Syringe coverage (assuming 400 injections/idu/year) for the estimated IDU population was < 5% in 19 countries, 5 15% in five and > 15% in one country only (Macedonia). Syringe coverage was estimated to 1.2% across all the 25 countries. Syringe coverage for the IDU population in contact with a NSP was higher: 17% overall; and < 15% in 10 countries, 15 60% in 11 countries and > 60% in Croatia, Macedonia, Moldova and Tajikistan. Estimated syringe coverage for the estimated IDU population, assuming 700 injections per IDU per year, was < 5% in all but two countries (Lithuania and Macedonia at 5.8% and 10.3%, respectively), and was 0.7% across the region. Syringe coverage for the IDU population in contact with an NSP was < 5% in eight countries, 5 15% in five, 15 60% in 10 and > 60% in Macedonia and Moldova. Regionally, we estimated syringe coverage at 10%. In order to reach 50% syringe coverage among the 25 countries for the estimated IDU population, either the average frequency of injection would have to have been 9.6 times/idu/year or the number of syringes distributed would need to be > 40-fold. Similarly, for current syringe coverage to reach 50% among IDU in contact with NSP within the 25 countries either the average frequency of injection would need to be 137 times/idu/year or syringe distribution would need to increase by 2.5-fold. Table 2 presents the results from the three high-coverage sites. In Soligorsk, the estimated number of IDU, (midpoint: 1300), was derived using a set of multipliers for all oblasts in Belarus. These were based on number and estimated proportion of IDU registered by drug treatment services, attended emergency room for overdose and arrested for drug-related crimes. The NSP in Soligorsk began in February By December 2002 it had reached 1200 (92.3% of the estimated IDU population). However, client statistics provided for 5 months (August December 2002) showed that only two clients (0.2%) attended the site more than once per month. The number of needles and syringes distributed was (47.2 needles/syringes/idu) in In Pskov, the estimated number of IDU, IDU (midpoint: 1250), derived from a five-city study of NSP (including Pskov) in ; a further situation assessment study was undertaken in 2000, contacting IDU who accessed the NSP the previous year. The NSP in Pskov began in August By December 2002 it had reached 1153 IDU (92.2% of estimated IDU population). Client statistics for 2002 showed that 22 clients (1.8%) attended the service more than once per month. The number of needles and syringes distributed was

5 Access and coverage of NSP 5 (51.7 needles/syringes/idu/year) from June 2001 to May In Sumy, the estimated number of IDU was ~ 1500 IDU, derived from a multiplier/benchmark study of five Ukrainian cities, and triangulated with estimates from IDU and local journalists. The NSP in Sumy began in May By December 2002 it had reached 1100 (73.3% of estimated IDU population). Client statistics (provided for 2 months in 2002) showed that 341 clients (22.7%) attended the service NSP more than once per month. Sumy s NSP distributed needles and syringes in 2002 (94.2 per IDU/year). DISCUSSION Our general finding is that NSP had suboptimal levels of implementation, activity and coverage. Only the Czech Republic, Poland, Russia and Ukraine had > 10 NSP. The number of sites was not directly proportional to the size of the IDU population, e.g. the Czech Republic had an estimated IDU population of almost and 13 NSP, while Kyrgyzstan, with an estimated IDU population of > , had five. Only the Czech Republic, Latvia and Slovakia reached 50% of the estimated IDU population. In contrast, the three high-coverage sites reached > 70%, but a substantially lower proportion regularly. Regarding NSP utilization, Kazakhstan, Russia and Ukraine distributed > 1 million syringes per year. The two countries providing most syringes per IDU, Macedonia and Lithuania, also had small IDU populations. Syringe coverage was generally low, even if we estimated it using only those IDU in contact with NSP. Only Croatia, Macedonia and Moldova were estimated to provide 300 syringes per IDU per year; and the three high-coverage sites distributed less than 100 syringes per IDU per year. The two data sets are subject to several potential biases and limitations. We collected data from multiple sources but were unable to test the reliability of the evidence on the number of NSP, or the service activity data. Also the reliability of the estimated size of the IDU population, although obtained from multiple sources, was not tested, which means that some estimates of NSP coverage need to be interpreted cautiously. For example, Latvia was estimated to have reached over 100% of the IDU population, which suggests either inaccurate estimates of IDU prevalence or NSP activity. Moreover, any of the five available estimates of IDU in Latvia (9450, , , and ) [26] would have produced > 100% syringe coverage. The last three estimates came from state police statistics, the AIDS prevention centre (calculated indirectly from some HIV prevalence studies and HR programmes) and the drug abuse agency (also indirectly calculated from registered drug-dependent people), respectively. Clearly, it is important to measure and monitor coverage and NSP activity with reliable estimates. We acknowledge other potential limitations. NSP provision is a rough indicator of geographic accessibility that should be assessed with reference to the size of the country, as well as the IDU population size and concentration. NSP are often clustered in some locations and not available in others. For example, a review of NSP in the UK in 1997 reported that despite an estimated 27 million syringes distributed, the number distributed in Scotland was three to four times less than for England and Wales [32]. The number of IDU ever reached is a cumulative figure increasing for as long as the service exists and may exceed 100%, and therefore is less informative than the proportion of IDU in regular reach, which provides a more accurate measure of the population in contact. Syringe coverage, although it is a more comprehensive indicator than NSP activity alone, may be misleading if information on the denominator (number of IDU and injections/given period) is inaccurate [29]. Also, our assumptions on the number of injections per IDU fail to capture individual differences, which may be important in protecting or increasing the risk of transmission of HIV and other blood-borne viruses. Injection frequency is related to factors such as levels of tolerance and compulsion, as well as patterns and scale of polydrug use; in particular, cocaine plus opiates (speedball) has been associated with increases in the frequency of injection [33]. Increases in the frequency of injection are also associated with the number and type of drugs injected [34 37]. The problems associated with polydrug use have become more important in most of the European Union (EU) countries, although the treated population remain dominated by opiate users. In the EU cocaine use is frequent among opiate users [23], but 60% of the total treatment requests made are still known to be for opiate treatment. In many countries, opiates remain the principal drug for which clients seek treatment (e.g. in Lithuania, Slovenia and Bulgaria they make > 70% of the demands for treatment) [23]. The largest cocaine market world-wide is the United States [38]. Cocaine use among the new EU member states is substantially lower ( %). The prevalence rate of cocaine use in East- and South-East Europe is ~ 0.1% [38], and only ~ 5% of new cocaine clients report injecting it [23]. The abuse of synthetic drugs, particularly of amphetamine-type stimulants (ATS), is globally widespread and increasing: ~ 30 million abuse ATS [39] but ~ 15 million (> 60% of the world s ATS users) live in Asia, most of them in East and South-East Asia [39]. The main route of administration of ATS in the EU is oral (58.2%). Methamphetamine use in CEE/NIS continues to be limited to the Czech Republic, Slovakia, Estonia and

6 6 Carmen Aceijas et al. Latvia [38] (~ 15% of ATS users are IDU, > 60% in the Czech Republic) [23]. Given the potential increase in injecting frequency because of changes in type and number of drugs injected, it is important that we establish whether 400 or 700 is the better denominator estimate of number of injections per year. Although given that few countries achieve even moderate coverage levels, this is a minor issue. Assessing the quality of services was beyond the scope of our assessment. Some valuable clues on qualitative indicators have been given; for example, the three S as defined by Des Jarlais & Braine [40]: (1) size, (2) smiles and (3) services [40]. Bastos & Strathdee also identified some qualitative aspects, such as opposition by police, community and laws regarding possession and exchanging of injecting paraphernalia [29]. Nor could our crude data address NSP policies such as exchanging one-forone, one-for-one plus or distribution [19], or encouraging secondary distribution for its impact on coverage. Our results do not challenge evidence on the effectiveness of NSP in reducing HIV [6]. Analysing the impact of NSP on HIV levels was beyond the scope of this study. However, given the suboptimal levels of activity found across countries and the often very high prevalence of HIV among IDU makes it critical that further analyses inform local and national policy makers on how many HIV infections may have been prevented, even with low coverage, and how many more could be prevented given appropriate NSP scale-up within a comprehensive programme. There, the odds that the activity of these NSP was impacting on the regional HIV levels among IDU were marginal. Further research should focus on the comprehensive evaluation of NSP that would include trends in HIV and HCV and programme indicators (quantitative and qualitative) and take into account the ecology of the programmes (substitution and antiretroviral treatments included) that would provide information on whether they are part of a comprehensive strategy to confront the HIV and HCV epidemics, or isolated efforts with little opportunity to make a difference. This paper provides a framework for the development of indicators to monitor NSP. Collaborations between researchers and policy makers to develop standardized instruments and methods to assess the functioning of resources distributing injecting equipment to IDU are needed (such as the biannual survey among NSP in the United States [41]). Finally, it is also critical that we measure coverage achieved through pharmacy sales which, in many developed countries, is the prime source. 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