1. Bridging the Gap between Needs and Services Towards Evidence-based Drug Policy In Poland Issue: Matching Needs and Services in Environments of Rapid Change Experience has shown that drug use patterns can change rapidly, leading to equally dramatic increases in the spread of bloodborne diseases like HIV, HBV and HCV. The provision of drug abuse prevention, harm reduction and treatment services should be based on evidence of the current patterns and geographical distribution of risk. In the course of a Rapid Policy Assessment and Response Intervention in the city of Szczecin and surrounding rural areas, we uncovered evidence that Poland’s programs to prevent and reduce drug-related harm may not be responsive to rapidly changing current conditions Methods: Rapid Policy Assessment and Response (RPAR) RPAR is an intervention that mobilizes local knowledge and capacity to fight HIV/AIDS among sex workers, injection drug users, and members of other marginalized populations at the city level. In RPAR, a research team from a site city works with a Community Action Board (CAB) to collect three kinds of data: laws and written policies relevant to health risks in the target populations; existing data on the epidemiological situation and the operation of the criminal justice system; and qualitative interviews with police, judges, prosecutors, drug users, sex workers and others who can describe how the laws are put into practice. The data collection and interpretation are guided by the CAB, which develops an action plan and final report. The Szczecin RPAR was begun in January, 2005; research was completed in September and a final report was released in March, 2006. The CAB included representatives of law enforcement (the police, judiciary, prisons), both public and private drug treatment providers, health care (physicians, nurses) and social welfare agencies (Family Support office). Existing laws and formal policies in ten domains relevant to drug policy and health (including harm reduction, drug treatment and prevention) were collected. To determine how these laws were being put into practice, three focus groups were conducted, and the team interviewed 24 people in law enforcement, health care and social services, as well as 14 IDUs. Implications and Recommendations The Community Action Board and research team discussed the findings in light of their existing knowledge and experiences in addressing drug use in the region. Drug policy is oriented to large cities; the needs in rural areas need to be urgently assessed and addressed in terms of both mandates and resources. Patterns of drug use in rural areas are not properly diagnosed; most policies are based on information from larger cities where outreach workers collect necessary data. NGOs, the primary providers of outreach services, have traditionally been city-based and city-focused – they are not geared to providing services in rural areas and will require funding assistance to do so. The Polish National Office for Counteracting Drug Addiction needs to support and be guided by more frequent and rapid research; work with the criminal justice system to promote better coordination of available treatment services with court processes and to educate judges and prosecutors about the benefits and availability of treatment. The Szczecin city and regional administrations and NGOs should work together to further delineate the risk to rural populations and to institute needed services. Poland has a low rate of HIV infection among IDUs, which is mostly due to the swift introduction of prevention, harm reduction and treatment programs for opiate use in early 90s. An equally timely response is required now. Infectious Diseases Prevention Association for Western Pomerania Region Department of Infectious Diseases& Hepatology Pomeranian Medical University, Szczecin Incidence of HBV and HCV (Poland) HIV Diagnoses (Poland) This research was supported by NIDA/NIH Grant # 5 R01 DA17002-02 PI: LAZZARINI, ZITA. The findings and conclusions expressed are those of the authors and not necessarily of NIH, NIDA, or the US government. Sobeyko J (1), Leszczyszyn-Pynka M (2), Duklas T (7), Parczewski M (2), Bejnarowicz P (1), Chintalova-Dallas R (4), Lazzarini Z (4)(6), Case P (5), Burris S (3)(6). (1) Infectious Disease Prevention Association of Western Pomerania, (2) Department of Infectious Diseases & Hepatology, Pomeranian Medical University, Szczecin, (3) Temple University Beasley School of Law, (4) University of Connecticut Health Center, (5) Fenway Community Health Center, (6) Center for Law and the Public’s Health at Georgetown and Johns Hopkins Universities, (7) Association for Health Promotion and Social Risks Prevention “TADA” The limitations of our methodology Our findings are based on interviews from purposively selected informants and by the information provided by our CAB, supported where possible by epidemiological statistics and secondary sources. The data must be viewed with appropriate caution. Given the experience of rural amphetamine use in other areas, however, and the potentially rapid spread of bloodborne disease among injectors, they should be taken seriously and followed up with more sustained research and intervention work. Findings: Changing Patterns of Injection Drug Use Injecting drug use, once a “city” problem involving opiates, has moved out into the countryside and now centers on amphetamine. “ Everybody uses drugs in pubs in Szczecin, but they don’t inject …” -- Regular drug user, occasional injector “Young people in [small town near Szczecin] inject amphetamine using shared equipment. They are not afraid of being infected with HIV or Hepatitis because they are convinced that risk of infection is related to the type of drug – home made heroin -- not to the way of its administration.” – Injection drug user, using for 8 years Findings: There’s a Poor Match Between Needs and Services Prevention, harm reduction and treatment services needed for an injection-based amphetamine epidemic are unavailable in the countryside. Syringe Access “Young people in small towns are not able to exchange equipment. There are no syringe exchange programs. They have problems to buy the in pharmacies as well.” – Injection drug user, addicted for 18 years “ [Young people] don’t want to go to pharmacy because they are afraid to be perceived as drug addicts. Though their parents and neighbors are all addicted to alcohol.” – Injection drug user, small town. Some pharmacists are reluctant to sell equipment to drug users. Two IDU informants reported that pharmacists will claim to be out of small-bore needles. “It’s not a problem for old drug users to inject with a big needle, but it’s still a problem for young kids” – Rural IDU, 26 years old. Meanwhile, the syringe exchange in the city of Szczecin has seen a decrease in clients based on ease of access to and low cost of syringes, as well as a decline in injecting drug use. “There is no point in going to the syringe exchange because we can buy syringes in any pharmacy.” Occasional IDU, Szczecin. Syringes cost about $0.10 in a pharmacy. Drug Treatment There are no programs designed for drug addiction in small towns. “We have relevant therapy offer for drug addicts – they are treated together with alcohol addicts but they are counseled individually twice a month.” – Therapist from a small town. This reflects health policy: “The national health service does not pay for treatment of drug users here. We need to treat them together with alcoholics, in the same group, and try to get our money back. We like people with multiple dependencies because they are easier to get paid for.” The law also plays a role: A “Sobriety Law” from the Communist Era requires municipalities to provide alcohol treatment. While the Law on Counteracting Drug Addiction requires local programs to combat drug abuse (Ch. 4), there is no mandate to offer treatment. HIV Testing Few people in the rural areas are getting tested for HIV. IDU_4 said that “these young people do not test as they are sure HIV is not their problem”. She also said it seemed strange for her as “they believe nobody is infected but how can they know it if nobody has ever been tested for HIV” A physician who works at the HIV testing center in Szczecin confirmed that clients are asked about their place of residence and the vast majority are from the city. There are no testing sites in the rural areas. Findings: The Rise in Rural Amphetamine Injection Poses a Threat to Health that Should Not Be Treated Lightly We know from other countries that amphetamine epidemics can cause serious health and social problems. There is a risk for rapid spread of bloodborne disease if HIV or Hepatitis gets into a network of young injectors underserved by prevention, treatment and harm reduction services. HIV and Hepatitis do exist in the population. HIV in the West Pomeranian Voyvodeship has been stable since 2000 at 4/100 000 (stable since 2000)/ There were 600 diagnosed HIV infections between 1985 and 31.04.2005. 51% were attributed to IDU. 52% of HIV+ people are co- infected with HCV and 8% with HBV. Findings: The Gap is Unfolding Below the Radar Policy-makers have not been fully aware of the shift, which is not surprising given the lack of any “early warning” mechanism. Interviews with service providers indicate that drug abuse prevention and treatment agencies are unaware of the potentially serious threat and unprepared to address it effectively. “There is a drug use in our town but people do not inject.” – Therapist from a small town In Szczecin, the major focus of drug policy is party or club drugs; injected amphetamine in the surrounding area is not a worry.