1. Drug Consumption Rooms in Catalonia:
Major impact on HIV-HCV risk behaviors and engagement in care
Folch C1, Lorente N1, Major X2, Parés O3, Roca X2, Brugal T3, Roux P4, Carrieri PM4, Colom J2, Casabona J1, REDAN study group
1 CEEISCAT (Public Health Agency of Catalonia); 2 Subdirecció General de Drogodependències (Public Health Agency of Catalonia); 3 Public Health Agency of Barcelona; 4National Institute of Health and Medical Research of France
Lisbon October, 2017
The authors declare no conflict of interest  

2. Drug consumption rooms
Professionally supervised healthcare facilities where drug users can consume drugs in safer and more hygienic conditions.
Objectives:
to establish contact with hard-to-reach populations
to provide a safe and hygienic environment for drug consumption
to reduce mortality and morbidity associated with drug use, as a result of overdose, transmission of HIV, hepatitis and bacterial infections
to promote access to other social, health and drug treatment services
to reduce public drug use and associated nuisance.
Let’s start with a brief introduction of the topic.
As you may know, DCR are professionally These facilities aim to......They also seek to contribute to reduce public drug use.....

3. 90 Drug Consumption Rooms in Europe
DCR have been operating in Europe for the last three decades. The first DCR was operated in Switzerland in 1986….There are currently 90 DCR in Europe, 13 of them in Catalonia (Spain)
13 of them in Catalonia, Spain
Source: EMCDDA, 2017

4. Mobile Units: 6 (3 with Drug Consumption Room)
HIV and HCV prevalence among PWID recruited in Harm Reduction Centers. Catalonia
HARM REDUCTION Centres & Programmes Drop in centres: 16 (10 Drug Consumption Room)
Mobile Units: 6 (3 with Drug Consumption Room)
Street work: 11
Although HIV and HCV prevalences show a decreasing trend during among PWID recruited in HRC, prevalences remain high

5. The Structure of the Catalan Drug Dependency Care Network
HARM REDUCTION Centres & Programmes Drop in centres: 16 (10 Drug Consumption Room)
Mobile Units: 6 (3 with Drug Consumption Room)
Street work: 11
13 DCR
Therapeutic C. Units: 20
Places: 596
Drug treatment centres 61
Detox units: 11
Beds: 65
As part of the CATALAN DRUG DEP. CARE NETWORK, DCR have been establish in Catalonia since These facilities are mainly located in Open Drug Scenes where specially marginalized PWID buy and use drugs (2 of them provide an inhaled CR) erating
All DCRs in Spain receive public funds from different public administrations. The first DCR in Spain opened in 2000 in Madrid. For political and financial reasons, the DCR ‘Dave’, located in Madrid and the first DCR which opened in Spain in 2000, closed at t
he end of Facilities have multidisciplinary staff (including at least one nurse) on-hand to supervise and counsel clients during all stages of drug consumption.
National estimates of last year prevalence of high-risk opioid use: 2.1 Rate per population
Social rehabilitation centres:
12 day centres and 21 social rehabilitation schemes
140 Places on rehabilitation apartments
Dual Diagnosis Units: 5
Crisis Units: 1

6. Objectives
To describe the socio-demographic and behavioral characteristics of people who inject drugs (PWID) attending DCR in Catalonia
To describe patterns of utilization of DCR and to identify factors associated with frequent attendance.
The objectives of this presentation are

7. PWID, Harm reduction centers: REDAN Project PWID, street recruitment
Methods
Integrated Bio-Behavioral Surveys among Key Populations (Catalonia, )
Youth, online
PWID, Harm reduction centers: REDAN Project
PWID, street recruitment 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15
MSM, gay venues
MSM,
SIALON I
MSM, EMIS
MSM, SIALON II
As part of the Integrated HIV/STI Surveillance System (SIVES),18 biennial bio-behavioural surveillance surveys among IDU were implemented in Catalonia since 2008 in the network of harm reduction centres.
Female Sex Workers

8. REDAN study (2014-15) Cross-sectional survey (n=730)
Harm Reduction Centres:
Needle exchange programs
Outreach programs
Drug consumption rooms
Inclusion criteria:
Injection in the last 6 months
Older than 18
Informed consent
Anonymous questionnaires (face-to-face interviews)
Oral fluid samples (HIV/HCV prevalence)
This presentation is based on the cross-sectional study conducted in
PWID were recruited in HRC such as.....
Inclusion criteria was having injected in the previous six months, being older that 18 and signed the informed consent document.
Face-to face interviews were conducted by trained interviewers and oral fluid samples were collected anonymously to estimate HIV and HCV prevalence
After collecting data on the number and characteristics of clients contacted by harm reduction centres in the previous year, a convenience stratified sample was selected according to the type of centre and country of origin using proportional allocation. Incentives: 12€
Anti-HIV antibodies were detected in oral fluid using Genscreen HIV1-2 v.2.0 from BIORAD according to the manufacturer's instructions (sensitivity=98.5%; specificity=100%)
Anti-HCV antibodies were detected using HCV 3.0 SAVe ELISA (sensitivity=86.7%; specificity=100%).
anonymous numerical code

9. DCR attendance
To measure attendance, we asked participants about the frequency of visits during the last 6 months.
“Frequent attendance”
having used the DCR every day that they injected
“Medium attendance”
having used the DCR >half the days that they injected
“Low attendance”
having used the DCR half the days that they injected or less
Multivariate logistic regression was used to determine factors independently associated with frequent attendance.
To measure attendance, we asked participants about the frequency of visits during the last 6 months. “Frequent attendance” was defined as having used the DCR every day that they injected, “Medium attendance” as having used the DCR more than half the days they injected, and “Low attendance” as half the days that they injected or less.

10. Results 29 (5,2%) had never used them
N=730 interviewed
539 (73,8%) reported available DCR in their places of living, injecting and/or drug purchasing
510 (94,8%) had ever used them
29 (5,2%) had never used them
Among all the participants in the REDAN study, 539 reported there were available DCR in their places of living, injecting and/or drug purchasing, and almost all (94.8%) had ever used these safe injecting facilities. For this particular analysis, data from the 510 clients of the DCR in the last 6 months were included.
Among users, 21.2% reported FREQUENT ATTENDANCE, 45.7% MEDIUM AND 33.1% LOW ATTENDANCE.
n=108
n=233
n=169

11. Socio-demographic characteristics by DCR attendance
Frequent
(n=108) %
Medium (n=233)
Low
(n=169) p
18-29 years old
7,4
17,2
23,1
0,003
Born outside Spain
38,0
51,9
52,1
0,035
Female 13
13,7
27,8
<0,0001
Currently in treatment
52,8
47,2
41,4
0,257
Education: Less than primary
58,5
51,7
52,7
0,529
Illegal source of income*
50,9
58,8
59,5
0,033
Homeless
41,1
27,9
16,6
Ever in prison
75,9
72,5
74,6
0,781
Here you can see the comparison of the main socio-demographic characteristics by DCR attendance:
-The proportion of users younger than 30 years old was lower among FA, as well as the proportion of migrants.
-The majority of participants were men, being the proportion of women higher among the group of “low attendance”.
-An illegal source of income was reported less frequently by FA, although in this group a higher proportion reported to be homeless (living in the street).
* last 6 months

12. Drug use patterns by DCR attendance
Frequent
(n=108) %
Medium (n=233)
Low
(n=169) p
Mean years of injection
18,8
15,0
14,9
0,005
Main drug injected: cocaine
34,3
20,0
27,4
0,008
Daily injection
44,4
55,2
58,6
0,015
Place of injection*
<0,0001
Houses
0,9
11,4
61,6
Outdoors (street, cars….)
8,3
10,9
31,7
DCR
90,7
77,7
6,7
Needle return: always sterile places
75,0
36,1
30,2
In relation to the drug use patterns, mean years of injection was higher among FA, as well as the proportion who reported “cocaine” as the main injected drug.
On the other hand, Daily injection was highly reported by both medium and low A.
With regard to more frequent place of injection, DCR is the main place of injection for most of Frequent and Medium A. Contrarly, private houses and outdoors settings were highly reported by LA.
Finally, A higher proportion of FA reported always return their used needles in sterile places.
* More frequent, last 6 months

13. Prevalence of risk behaviours by DCR attendance
This figure shows the prevalence of NEEDLES or injection equipment sharing by DCR attendance. For both risk practices, the prevalence was clearly lower among FA
* p<0,001

14. Access to services*, treatment, and overdoses by DCR attendance
Frequent
(n=108) %
Medium (n=233)
Low
(n=169) p
Access to Primary Health Centres
53,7
45,9
34,9
0,06
Access to hospital
35,2
31,3
26,8
0,320
Access to CAS
81,5
66,1
55,4
<0,0001
In antiretroviral treatment1
77,1
76,6
0,032
Ever HCV treatment1
15,5
20,7
10,4
0,089
Overdose (last year)
17,6
19,3
21,9
0,660
The proportion who reported having accessed PHC and Centrers for......was higher among FA.
Among those who self-reported being HIV positive, the proportion in ARV treatment was lower among LA.
The prevalence of overdose in the previous year did not differ by attendance pattern
Future studies should explore the impact of DCR not only in the incidence of overdoses, if not in their severity –fatal or nonfatal overdoses or overdose mortality. We asked among those who reported overdoses in the last year if at lest in one occasion they had been attended by medical staff and the proportion among FA was slightly higher (not significant): 77.8 – 61-8 – 50
Previous studies in Vancouver confirmed that overdose events were not uncommon at the safer injection facility; None of the overdose events occurring at the SIF resulted in a fatality.
1among those HIV and HCV Ab positive, respectively; CAS: Centers for people with addiction problems

15. HIV and HCV prevalence by DCR attendance
No significant differences were found in the HIV and HCV prevalence by attendance patterns (overall HIV prevalence: 27.4%; HCV prevalence: 67.5%).
* p<0,001

16. Factors associated with frequent attendance
At multivariate level, FACTORS ASSOCIATED WITH FA WERE: being homeless, neither sharing needles/syringes nor other injection equipment, and having accessed social and health centers for drug addiction in the last 6 months. The model was also adjusted by ……
*adjusted on age, sex, origin, injection frequency, HIV/HCV status, years of injection

17. Limitations
Information bias: underestimation of self-reported behaviours.
Comparison were not possible with non-attenders
The cross-sectional structured behavioral survey does not allow for inferences about temporal associations and causal pathways between measured factors.
There are several limitations in the study that need to be highlighted.
Firstly, the prevalence of some risk behaviors may have been underestimated, even though data collectors attempted to create an anonymous atmosphere for the interviews and used simple and understandable language
On the other hand, comparison with the group of “not attenders” were not possible….the sample was collected in HRC and almost all have ever been in contact with DCR
Finally, the cross-sectional…..

18. Conclusions
20% of PWID using/attending DCR in Catalonia were frequent attenders.
Frequent attenders were mainly men, older than 30 years, Spanish-born, and most of them infected by HIV and/or HCV.
Frequent attenders reported fewer public injections and less unsafe needle disposal than medium/lower attenders.
Homelessness, which is commonly a factor in public injection drug use, was associated with frequent use of DCR.
Frequent attendance of the DCR has a positive effect on high risk injecting behaviours, and was positively associated with higher levels of access to care.
To conclude,

19. Recommendations
There is a need to maintain current DCR and promote their opening in countries where they are not yet present, in conjunction with other harm reduction strategies
Further (longitudinal) analysis would be needed in Catalonia to confirm the benefits of the DCR as demonstrated elsewhere
For the DCR to be able to fully exert an influence on the health and well-being of PWID, it seems necessary to promote frequent contact with them
I would like to finish my presentation with some recommendations….

20. Acknowledgements THANK YOU!
I want to thank all interviewers, participants and the centres who have collaborated in this study
Other members of the REDAN Group:
Victoria Gonzalez (Servei Microbiologia HUGTiP);
Albert Espelt (Agència de Salut Pública de Barcelona);
Mercè Meroño, Anna Altabas (Àmbit Prevenció).
All of the co-authors:
Nicolas Lorente; Xavier Major; Oleguer Parés; Xavier Roca; Teresa Brugal, Perrine Roux; Patrizia Carrieri; Joan Colom and Jordi Casabona
THANK YOU!