[IN-Mouraria/GAT LOGO]Harm reduction and HIV/HCV responses for several populations: the challenge of integrating responses

Ricardo Fuertes, Adriana Curado, Diana Silva, João Santa Maria, Marta Luz, Magda Ferreira, Rosa Freitas, Luís MendãoGAT – GRUPO DE ATIVISTAS EM TRATAMENTOS

in.mouraria@gatportugal.org

IN-Mouraria case example

IN-Mouraria is a harm reduction centre, started in 2012 by GAT, an organization of people living with HIV/CV. The center is located in an urban quarter of Lisbon where migration, drug use, sex work, and homelessness coexist. The project goals include increasing awareness, activism and participation of people who use drugs and performing harm reduction interventions and HIV/HCV rapid testing. Services are provided to clients without an appointment, free of charge, and without the need for personal identification. Trained health professionals, lay workers and peer counsellors perform the tests and provide information. Active referrals to hospitals are offered to all clients newly or previously diagnosed HIV/HCV positive, regardless of migrant’s legal status. Those who request, can be escorted by peers to medical appointments.

Testing and other services (condom/gel distribution, information) are also available for general population. IN-Mouraria was included as a case example in the World Health Organization´s Consolidated guidelines on HIV testing services (3) published in July 2015.

During the first 3 years of activity, 500 different people registered as regular clients, mainly people who have drug and/or alcohol problems and - in a lower number - clients with other vulnerabilities (homeless people, sex workers, socially vulnerable migrants).

HIV/HCV integrated services in harm reduction – towards a new model?

Working with different key populations - addressing multiple vulnerability HIV/HCV factors (and opening some services to general population).

Combining interventions in a single setting - harm reduction + HIV/HCV testing & treatment + social support + peer education + advocacy

References:(1) . Departamento de Doenças Infeciosas do INSA and Programa Nacional para a Infeção VIH/SIDA. Infeção VIH/SIDA: a situação em Portugal a 31 de dezembro de

2013. Instituto Nacional de Saúde Doutor Ricardo Jorge, Lisboa; 2014(2) Marques J, Queiroz J, Santos A, Maia S et al. European professional profile of the outreach worker in harm reduction. APDES; 2013(3) World Health Organization. Consolidated guidelines on HIV testing services. WHO, Geneva; 2015

Offering case management services (including escort services) – referrals to prevention, treatment and care services (linkage to different levels of care).

Providing services in a community-based setting. Task sharing and the involvement of lay workers and peers can help to address the needs of key populations reluctant or unable to access conventional services.

Integration in local policies – clear strategy and long-term action plans, re-allocation of resources and responsibilities, greater community support, sustainability of harm reduction services.

What are the challenges in Portugal?

Stigma associated with drug use is a barrier to place integration of services in the political agenda.

Different approaches and concepts between conventional healthcare services and harm reduction services.

To increase access to care and treatment, social structural barriers should be addressed – e.g. unstable housing and other basic needs. That is specially challenging in a resource-constrained setting.

Inadequate model of harm reduction services and funding, focused on fragmented interventions (syringe exchange, methadone treatment, outreach work).

Economic and administrative barriers to access specialized care or to perform interventions outside the NHS – e.g. hepatitis C treatment

Peer work is rare and not recognized. Very often is performed in a voluntary basis.

No professional recognition of harm reduction workers. Harm reduction training is absent from university curricula. Low wages, job insecurity and lack of career prospects are the norm (2).

Prevention should not be based only on syringe exchange and information. Drug consumption rooms and harm reduction in prison settings are needed. Tailored HCV prevention for other most at risk populations also needs to be developed (e.g. HIV positive MSM, MSM performing fisting or other risk sex practices).

[LOGOS] Support: CML, JFSMM, Abbvie, BMS e ViiV] Partner: AHF

HCV infection is hyper-endemic among people who use drugs, especially those injecting. Injection drug use-related HIV infection also accounts for a substantial proportion of the total cases of HIV in Portugal (1). In this country HIV and HCV treatment and care responses are based hospitals. However people who use drugs are in many occasions reluctant to use traditional healthcare services and are more comfortable to request health support in harm reduction services, opioid substitution treatment or addiction services. For that reason reallocating or co-locating HIV/HCV treatment and care services in harm reduction settings could have benefits in access and adherence.On the other hand some services that are already available in harm reduction services - such as rapid testing - could also be extended to other populations exposed to sexual or drug-related risk (sex workers, MSM, some communities of migrants) and general population, creating access to those services without duplicating responses and costs.

Introduction

No guidelines and specific criteria for HCV testing. HCV treatment guidelines are not clearly targeting active drug users