Prevention: The Slovak Red Cross

Treatment: Spanish Red Cross - Centro de Encuentro y Acogida (CEA) - Meeting and Shelter Centre

Harm Reduction Example: French Red Cross

Harm Reduction Example: The Bulgarian Red Cross

Harm Reduction: Spanish Red Cross – Ourense branch

Harm Reduction: Macedonian Red Cross

Spanish Red Cross – Madrid Branch - Servicio De Mediación Sociolaboral (Employment and social mediation service)


Prevention: The Slovak Red Cross  (back to top)


The Slovak Red Cross Youth alcohol and drug prevention programme was developed in response to the rising numbers of young people in Slovakia who use marihuana and ecstasy, as well as an increase in the numbers of criminal acts carried out by young drug users.

The programme aims to:

• raise awareness among young people
• encourage discussion about the dangers of drug addiction
• offer alternative leisure activities to avoid involvement in drugs

The Rome Consensus Coordination team asked Barbara Nadasiova from the Slovak Red Cross about how they went about setting up the programme.

RC: Why was your drug programme developed?

BN: The programme was developed in response to the alarming trends of the drug situation in Slovakia in 2006. There was an increase in the number of cases of young people (aged 15-24) who were using marihuana, ecstasy, Pervitin (a cheap amphetamine with cocaine-like effects), or heroin. Production of Pervitin is now high in every part of Slovakia.

The highest levels of addiction were found in young people addicted to Pervitin (with an average age of 23). Following them, the second largest group was those addicted to heroin (with an average age 28) and the third group of young people was marihuana users, (with an average age of 20).

The highest levels of criminal activity were noted among the marihuana, Pervitin and heroin users.

We found that the group at highest risk are children and teenagers between the age of 10 to 16 because they are still developing psychologically and are in a rebellious stage where they do not like to accept authority.

RC: How did you go about setting up the programme?

Firstly we set up a working group in one local Red Cross branch. The working group analysed the situation in Slovakia, and following this, created the first proposal of activities and topics to be discussed in the youth workshops, also providing the research needed for workshop discussions. Following this, the group organised discussions based on peer-to-peer education in their local branch and in one designated secondary grammar school. One teacher from that school was a member of the working group. After 6 months they introduced the project to Youth Executive Board members. The Youth Board approved the project proposal and set up the national working group for expanding the project to a national level and developing training materials for future discussion leaders.

RC: Did you come across any obstacles?

BN: We still do not have the approval for the project from our National Society Executive Board. It is a long process to prepare the whole national project and to receive approval on all the educational materials. Also, preparation of the materials was a very big task.

RC: How did you overcome these obstacles?

BN: We are still working on receiving approval from the National Society Executive Board, but we hope to be successful given the importance of the project to young people in Slovakia.

RC: What do you hope to achieve with your programme?

We hope to raise awareness about drug abuse among young children because we think that this is a good way to avoid them becoming addicted to a substance. We also want to develop a discussion around the biggest problems that lead to drug addiction within young people.

RC: Are there any plans to expand the programme?

BN: The plan is to create the foundations for a national programme. This means training the first national discussion leaders and preparing the educational materials. We also have plans to monitor the process of implementation.



Treatment: Italian Red Cross Villa Maraini Therapeutic Community – a complex multi-service treatment facility

The Italian Red Cross has been active in the field of drug-related problems since 1976, when Dr Massimo Barra founded the Villa Maraini Therapeutic Community in Rome, Italy, with the support of the Italian Red Cross.

Since then Villa Maraini has increased its activities and services to become a leading organization in providing assistance to drug users and people living with HIV and AIDS, as well as in the fight against the related discrimination and stigma.

The experience gained and the results obtained by the Villa Maraini Foundation in Rome and the Italian Red Cross over the past 32 years demonstrate that it is not possible to force people to follow a therapeutic process in which they do not believe. The main focus of any treatment initiative must be towards building a trusting relationship with drug users; to help them in times of need or when they are ready to be helped. Villa Maraini firmly believes that no case is impossible to handle and even the hardest can improve his or her life and reintegrate into society if properly assisted and given the right conditions.

Villa Maraini has grown from being a small centre treating no more than five people per day in the mid 1970s, to the most comprehensive structure in Italy to help drug users. Today the Foundation provides a wide range of free therapies to approximately 800 drug users per day.

Even after 32 years, Villa Maraini is still striving to establish the most effective ways of tackling the drug issue.

How does the Centre work?

Teams of Villa Maraini social workers (approximately 30% of whom are former drug users trained under the programme), psychologists, Red Cross Volunteers and medical doctors, go out into local communities on a daily basis, interacting with drug users in the places where they use drugs: railway stations, deprived neighbourhoods, etc. These teams also liaise with the criminal justice system (courts, prisons, etc) to recommend and provide methadone drug therapy.

The Centre also works in close collaboration with the local police, who seek assistance from Villa Maraini when a drug user is arrested within Rome, to help deal with withdrawal symptoms or to assist in any kind of drug dependency crisis.

This close and regular contact with drug users both in the streets and at Villa Maraini has enabled the development of a strong bond and trust between the drug using community and the Foundation. This helps to bridge the gap between the social exclusion of drug use and wider society, working towards drug users’ reintegration.

Villa Maraini staff also provide social and legal counselling and self-help groups for drug users and people living with HIV and AIDS. Former drug users now make up one third of the staff at the Foundation, meaning peer-to-peer education is growing as an important part of the programme.

Services and Outreach provided by Villa Maraini:

Emergency Team Unit
The service has been running since 1994 and aims to provide support for those who are unable to request help directly from Villa Maraini or other structures.

It works in close collaboration with the “Unità di Strada” (the street unit), the local and State Police Forces in case of overdose, withdrawal symptoms, or drug related crises involving drug users under temporary arrest or awaiting trial.

The Emergency Team Unit consists of a medical doctor, a social worker (a former drug user), and an Italian Red Cross volunteer.

The Emergency Service provides pharmaceutical therapies or opiates (methadone) as well as assistance to families affected by drug addiction.

Street Units
The Villa Maraini Outreach service is called “Unità di Strada”, or Street Unit. Campervans equipped with medical supplies and medical staff are stationed in Rome at strategic points where drug use is known to occur. They aim to save the lives of those at risk of overdose - the hard-to-reach drug users who conduct high risk behaviour such as the use of heroin and cocaine.

The campers are paid for by donations and are part of the municipal emergency system and the Villa Maraini emergency service.

The basic team consists of a doctor, a psychologist, two social workers (former drug users) and two Italian Red Cross volunteers. The campers are present from 6 pm to 12pm at the Termini railway station site and from 10 am to 8 pm at the Tor Bella Monaca.

The Street Units provide:

• syringe and needle exchange and distilled water
• life-saving intervention in case of overdose
• prevention of overdose through naloxone distribution and information
• distribution of condoms
• on-site support talks (professional counselling to users from every part of the world even through targeted leaflets)
• referrals to public health centres and drop-in centres
• first aid facilities
• hot tea
• Advice on accommodation solutions for those who do not have a permanent residence

The main objectives of this type of harm reduction activities are:

• to reduce the number of deaths caused by drug-related overdose
• to approach and help drug users who have no contact with rehabilitation structures and who, at that time, do not want to change their behaviour
• to reduce the risks of transmission of the HIV virus and of other infectious diseases through intravenous drug use

The Night Shelter
Homeless drug users can use the Night Shelter service. The service provides 15 beds for both men and women and offers medical and psychological assistance from the shelter’s staff. The Night Shelter is open every evening and provides showers, clean clothes, dinner and breakfast in the Villa Maraini refectory. In order to maintain availability of beds, the period of stay is usually not longer than five nights. The shelters are informal and comfortable, with a conversation area where guests can have access to books, magazines, information on drug prevention, television, etc.

The Prison Project
In 1979, a group of social workers and Red Cross volunteers started counselling, support and orientation activities for detainees with problems of drug addiction in Rome’s Rebibbia and Regina Coeli prisons. The project is still running: therapeutic support and orientation are provided in order to help drug users to choose the most appropriate rehabilitation programme for them.

Telephone Helpline
This unit operates 24 hours a day throughout the year, offering counselling and information on drug addiction and HIV and AIDS. The staff is composed of psychologists, experts and former drug users, who answer questions on any of these concerns.

The Open Community Outpatient Service
In 1989 the psychotherapeutic programme “Open Community” was created. This service consists of a three year programme with weekly individual psychotherapy or group discussions which aim to reduce or stop drug use.

For the first year, opiate users are provided with Naltrexone, a medicine which prevents heroin from having an effect. The therapy consists of a week-long detoxification, followed by Naltrexone taken orally. The effects of Naltrexone are long lasting, and it does not create dependency. This particular protocol is recommended for individuals who have a strong motivation to stop taking drugs and who benefit from a solid social context.

The Training Centre
The Villa Maraini staff are kept up to date through periodic training, which they in turn provide for others. Since 2004 Villa Maraini Foundation, together with the Italian Red Cross and with support from the International Federation of Red Cross and Red Crescent Societies, has provided training on harm reduction and drug abuse treatment for representatives of Red Cross and Red Crescent National Societies. The training allows Villa Maraini staff to share the knowledge and experience they have gained and aims to facilitate implementation of drug abuse programmes in other countries through the National Societies.

These training sessions have enabled several National Societies to improve their skills and to set up programmes in support of drug addicts and people living with HIV and AIDS. They have also reinforced a network of civil society organizations with the same approach and methodology towards drug dependency treatment and prevention of infectious diseases.

Technical advice, including assessment and training, and programme support are provided during the training sessions. Delegates from 23 different National Societies have now been trained.

Repatriation of drug users
In partnership with the Dutch organization AMOC-DHV, other associations from Italy (Gruppo Abele) and many other European countries, Villa Maraini is part of the European Network “AC Company”, with the objective of repatriating drug users to their country of origin.

The In-House Detainees Community
In accordance with Italian Laws concerning drug use, it is possible for drug users who have been arrested to request for a full or semi residential therapeutic programme at Villa Maraini.

Through the Prison Project staff of Villa Maraini Foundation, detainees are involved in a series of psychological support and counselling while in jail before they are granted entrance to therapeutic community.

The Alcohol Service
The Alcohol service offers a prevention programme for alcohol dependence and abuse and counselling for alcohol related damages. This service focuses on the young population.

The semi residential Therapeutic Community
This structure - the first of its kind in Rome - was established in 1976. The therapeutic programme takes into consideration each patient’s individuality.

This programme involves a twenty-month full participation in group therapy, sports and cultural activities, including complete involvement in the daily life of each community programme.

This service provides:

• individual and group psychotherapy
• work therapy (gardening, cooking, cleaning and maintenance of the premises)
• support towards detoxification
• health and social assistance
• self- awareness and self-help groups held by users
• recreational activities (sports, society games)
• cultural activities (visits to museums and exhibitions, movies, library books, theatrical activities, English lessons)

Assistance is extended to patients’ families, who are involved in support and therapy groups.

There are 25 staff members, including psychologists, educators, social workers (former IVDUs) and volunteers.

HIV and AIDS Unit
The principal objectives of this unit are:

• to welcome and to offer persons living with HIV and AIDS the possibility of improving the quality of their life even though living with the infection
• to limit the risk of new infections from sexually transmitted diseases by providing information and counselling aimed at avoiding high-risk behavior

The services provided are:

• counselling before and after testing
• anti-HIV clinical and infectious counselling
• monitoring
• haematological and chemical analysis
• support talks
• psycho-social intervention
• support to families
• information and prevention on HIV and AIDS particularly for the younger generation

The Foundation was one of the first structures in Italy offering individuals the possibility of having the viral load test, a specific test evaluating the degree of HIV infection. This test is an indispensable tool which enables the administration of the tailored antiretroviral treatment.

The Clinic Service
The 24-hour Clinic Service offers free pharmaceutical assistance to anybody upon request, without distinction or discrimination. This therefore includes groups who are sometimes excluded from this type of service, such as illegal immigrants, the homeless, etc.

The Clinic Service provides a key support to all other sectors of Villa Maraini: it provides therapy in the case of withdrawal symptoms and supports patients (both in and out) with the most appropriate medication, including oral Methadone.

This service also offers Naltrexone therapy, combined with psychotherapeutic support, which can prevent a relapse back into heroin use in highly motivated and detoxified opiate users.

The Drop-in centre
The Drop-in Centre, “Unità Fissa”, provides a protected environment to those users who, although looking for an alternative to their current lifestyle have not yet taken the decision to start a therapeutic programme.

The activities of the Drop-in Centre are flexible, following the needs and requests of drug users in relation to their own condition.

The first aim is to “attract” active drug users by offering them the possibility of refreshing themselves off the streets: to take a shower, eat a hot meal, and sleep in a bed, whatever their intentions regarding substance consumption may be.

The second aim is to strengthen the relationship during the time of their stay. Active drug users, particularly those who are not sufficiently motivated to stop substance consumption may establish groundwork for future steps and begin to alter their behaviour and attitudes by adopting less risky and destructive lifestyle patterns. Alternatively, some are immediately attracted by a higher level of therapeutic provision.

The daily activities of the Drop-in Centre usually start with breakfast, followed by a general meeting to decide the day’s activities, such as general cleaning, maintenance of the premises, sport activities and recreation. Lunch, an afternoon snack and dinner are offered to the guests, who also have the opportunity to take a shower and get dressed if necessary.

The Orientation centre
The aim of this service is to support and provide assistance to drug users who intend to take advantage of the structured therapeutic programmes offered by the other services of the Foundation (such as the Semi Residential Therapeutic Community and the Open Community), or by other organizations offering residential programmes.

The first phase of intervention is designed to develop a detachment from using drugs and to recognize the psychological problems linked to drug dependency.

In the second phase, the person is assisted in defining internal and external resources with the objective of identifying a personal therapeutic and rehabilitation project.

The staff is composed of psychologists and social workers, who structure their work around weekly team meetings, psychological counselling, group meetings held twice a week, family counselling and ergo-therapeutic activities.

Patients may be supported by methadone or naltrexone treatment. Metabolic urinary analysis is carried out periodically to dissuade drug use and to determine attempts at drug consumption. The period of stay can vary according to the individual and the therapeutic program defined.

The Social Labour Cooperative
In 1981, Villa Maraini established a Social Labour Cooperative to enable former drug users to provide printing and gardening services to external contractors. The Cooperative enables drug users to move towards reintegration into society.

The Rome Consensus Coordination team asked Dr Massimo Barra, Founder of Villa Maraini, more about how the Centre was started:

RC: How did you first have the idea for Villa Maraini?

MB: In 1976 I went to France to see how drug users were treated there. In Paris I visited the Marmottan Hospital, of the famous psychiatric doctor, Oliverstein, and in Toulouse the Therapeutic Community run by Lucien Engelmeier, known as “le Patriarche”. Back in Italy, I wanted to do something in between the two French experiences.

RC: How did you go about setting it up?

MB: Once back from France, in August 1976, I wrote a note to the President of the Italian Red Cross, asking him for the possibility to use some abandoned rooms in order to host 5 drug users during 4 hours a day, having them working and paying them for their work. The President authorized this initiative that at that time was an unprecedented, revolutionary one, writing on his letter “Adelante, con juicio!”.

RC: Did you come across any obstacles?

MB: Obstacles have been and continue to be the leitmotiv of each activity run by Villa Maraini. In 1976, the sons of politicians and powerful men had not yet started to take drugs, so at that point there was no sensitivity towards the issue, which was considered to be marginal. The first budget I had for my activities was 500 Euro per month! A few months after, the Italian Red Cross decided to shut down the experiment. My staff not only opposed this decision, but extended the service to 24 hours/day, starting a powerful media campaign against the

National Headquarters of the Italian Red Cross, who refused to change their decision to close Villa Maraini. The campaign was successful, but the relationship between the Italian Red Cross and Villa Maraini has since remained tempestuous and the real budgetary needs of Villa Maraini remain uncovered.

RC: How did you overcome these obstacles?

MB: Despite strong internal debates, the group with whom I created Villa Maraini has always been very united. Thirty-two years after, apart from one person who has left, the seven founding team members are still working together.

RC: What is the most important achievement for you in the work of Villa Maraini?

MB: Having challenged the underground world of drug use with an aggressive strategy that does not limit itself to waiting for drug users, as most anti-drug centres do, but that looks for drug users in those places where their daily tragedy is enacted. That is why we can say that Villa Maraini knows all the drug users in Rome. We were the first ones in Italy and among the first ones in the world to put the principles of harm reduction into practice, many years before that terminology was even used.

RC: Are there any plans to expand the programme even further?

MB: We are ready to become the reference centre of the International Federation in this sector, and think that de facto we already are.

RC: Why is so important for the Red Cross-Red Crescent to tackle the issue of drug use?

MB: The International Movement of the Red Cross and Red Crescent enjoys the trust of both the Authorities and the marginalized. It is for this reason that it can cover the “grey zones” of extreme marginalization that governments have difficulties in accessing. It is in the interest of any government to have a Red Cross or Red Crescent National Society active, without prejudices or ideologies, in the field of substance abuse and assistance to drug users, basing their activities on evidence.



Treatment: Spanish Red Cross - Centro de Encuentro y Acogida (CEA) - Meeting and Shelter Centre  (back to top)


The Spanish Red Cross has set up treatment centres in Almeria in order to reduce the risks associated with drug taking. These treatment centres do not focus on rehabilitation, but rather they work to reduce the harm associated with drug taking, such as transmission of diseases, and to alleviate the conditions in which many people addicted to drugs live.

These treatment centres aim to:

• Minimise the risks associated with drug taking
• Improve the quality of life for drug users

The Rome Consensus Coordination team asked Rafael Aranda Giménez from the Almeria Branch of the Spanish Red Cross about how they went about setting up the programme.

RC: Why was your drug programme developed?

RAG: The meeting and support centres (Centros de Encuentro y Acogida) are spaces to treat people with problems of active drug addiction whether or not they are seeking rehabilitation, and to dignify the person addicted to drugs, offering them humanised treatment based on kindness and care. Services include provision of basic care and social, health and hygiene necessities, temporary respite and signposting to other resources.

RC: How did you overcome these obstacles?

RAG: In the end, the site for the Centre had to in the periphery of the city, but we are very close to the largest zone of Almeria, where there are people that look for and consume drugs. The outcome of the negotiations with the health services allowed methadone to be distributed from the centre. The campaigns to distribute are negotiated from one day to the next.

RC: What do you hope to achieve with your programme?

• To offer interventions aimed to improve the quality of life for people with problems of addiction who do not want to or cannot stop consuming drugs, reducing the negative consequences
• To design strategies that reduce the risk and harm for users
• To design strategies to encourage the general population to accept the philosophy of harm reduction

RC: Are there any plans to expand the programme?

RAG: Yes, since day one we have been including new projects, activities and services, such as: the distribution of methadone, an activities class, a cyber-class, employment services, etc. This year we are planning to open a project for homeless people addicted to drugs who have AIDS, covering basic needs with support for transport, housing, food, and so on.



Harm Reduction Example: French Red Cross  (back to top)


The French Red Cross (in cooperation with the Italian Red Cross) support a Joint Project on Harm Reduction in Ukraine. Ukraine has the most severe HIV and AIDS epidemic in Europe, with prevalence of 1.63% among the adult population, with 440,000 HIV positive people for a total population of 46.6 million. About 41% of new cases of HIV infection are related to the injection of drugs.
There are an estimated 400,000 Injecting Drug Users (IDUs) in Ukraine: To achieve a realistic impact on the HIV epidemic, about 30% of IDUs (120,000 patients) should have access to Substitution Treatment. Currently only about 2000 patients have access.

Ukraine does have a legal base for the implementation of harm reduction activities, but until now, no state budget has been allocated to cover the development of such activities. At present all major harm reduction activities in Ukraine are conducted only with the support of international funding.

Goals to achieve through Harm Reduction Activities:

• To build communication with IDUs community to promote:
  distribution of syringes, condoms, info materials
  syringe exchange
  change of dangerous behaviours
  medical and social counselling
  HIV testing
• To raise awareness on substitution treatment
• To provide home-based care support for HIV positive IDUs
• To build up the capacity of trained staff

Expected outcome of project activities:

Syringe Exchange Program

• To minimize sexually and blood transmitted diseases (HIV, Hepatitis, etc)
• To increase awareness on HIV/AIDS and risks related to drug use
• To build motivation for substitution therapy
• To strengthen the health consciences of IDUs
• To improve daily life by providing food parcels, clothes, etc

Home-Based Care

• To fill in the existing gap in health facilities for people with HIV/AIDS
• To fight the increasing rate of opportunistic diseases (OD)
• To improve the health and social conditions of patients

Substitution Therapy

• To decrease the number of injections and OD
• To improve the general health state, social and interpersonal life of the patients
• To cut down HIV transmission

Training

• To build the capacity of Red Cross Nurses in managing the support for HIV positive and IDUs

The programme works in partnership with:

Local NGOs: Kyiv Eney Club; Zapotizhzha Spodivannya; Chernivtsi New Family

National NGOs: All-Ukrainian Network of People Living with HIV/AIDS

State Partners: Ministry of Health of Ukraine; Regional AIDS Centers

International partners: GTZ (German Technical Cooperation); International Alliance on HIV/AIDS in Ukraine

To find out more about the programme, the Rome Consensus Coordination team spoke to Virginie Streit Guérinel, who is on charge of International Relations with the Movement for the French Red Cross.

RC: Why was the programme developed?

VSG: Ukraine is the country with the highest levels of HIV in Europe, with a prevalence of 1.63% within the adult population as of April 2008, according to figures from the United Nations Country Team. Drug injection is the principle means of transmission of the HIV virus in the region, which differs from most other countries, where it is mainly transmitted by the sexual route.

In 2007, nearly 199,000 people were living with HIV and AIDS in Ukraine, (number of people officially registered by the Ukrainian AIDS Centre, Ministry of Health). 60% of these people had been infected following intravenous drug use. We now think that 41% of new cases of HIV result from drug injection and we believe that there are about 400,000 injecting drug users in Ukraine now.

Although in Ukraine there is an awareness of this issue, the country does not have the financial capacity to deal with it, and at present relies solely on international funding.

RC: How was the programme set up?

The French Red Cross undertook a 3 month evaluation mission in 2006 in cooperation with local branches of the Ukrainian Red Cross.

The results showed that the most urgent issue in Ukraine was to halt the spread of HIV and AIDS. In response to this, the first action we took was to set up projects for clean needle distribution and the collection of used syringes. With the same objective in view, it was vital to establish a trusting relationship with injecting drug users. It was also indispensable to closely collaborate with local NGOs and other groups who were already in contact with the local population in order to establish a good image for the Red Cross so that we could become a trusted partner.

The programme was set up in cooperation with the Ukrainian Red Cross and the Italian Red Cross.

RC: Did you encounter any obstacles?

Apart from the obvious financial obstacles, we encountered six principle issues which were and still are problematic:

• The pervading stigmatisation of drug users and HIV positive people.
• Low levels of community groups and activity (associations of homosexuals, prisoners, etc). This made the target population difficult to reach.
• Police harassment: Ukrainian law rules that a person found with even a small amount of drugs in their possession is a dealer. The Ukrainian police use this ruling to bribe anyone found with a syringe, even a used one: money or prison. Used syringes are therefore disposed of indiscriminately (in letter boxes, gutters, bushes, etc).
• There is no official directive in Ukraine on the destruction of syringes: They are kept in completely unsecured places. Although the HIV virus dies rapidly on contact with the air, this is not the case for other viruses such as, for example, hepatitis.
• Due to frequent changes in the Ukrainian Government, it was difficult to establish relationships with individuals – we were obliged to start from scratch each time.
• It is extremely difficult to get treatment for HIV: HIV positive people can be unwelcome in the health system, and once they have contracted opportunistic diseases, they have to go to separate places to be treated (or are even refused treatment due to the fact that they are HIV Positive).

RC: How did you overcome these obstacles?

VSG: Unfortunately we have not been able to overcome these obstacles yet.

RC: What are your objectives?

VSG: To develop prevention strategies based on the health risks of HIV and AIDS in relation to drug use and to make drug users active players in preventing HIV transmission and in their own heath.

To develop a tailored and multidisciplinary assistance programme for drug users, and for drug users living with HIV and AIDS, and to improve the health of patients living with HIV and AIDS.

To inform the population of the risks of HIV and AIDS through drug use and to help to make progress in changing social attitudes (fighting the stigmatisation and discrimination of which vulnerable groups such as drug users are often the victims).

Challenge: In the context of the mutation of the epidemic and the risk of transmission to the general public, to protect drug users (a particularly vulnerable and stigmatised population) also means protecting the general public from the health, demographic and economic consequences of a generalised epidemic.

RC: Are there any plans to expand the project?

We are planning for the development of a specialised health centre which would enable the provision of a better level of assistance of patients. We are also developing assistance programmes for children because on our home visits we became aware of the high levels of poverty and squalor in which families live and children in particular suffer.



Harm Reduction Example: The Bulgarian Red Cross  (back to top)


The Bulgarian Red Cross Youth section is the largest and oldest youth NGO in Bulgaria. It was established in 1921 and is an integral part of the Bulgarian Red Cross and the International Red Cross Youth Movement. Young people of up to 35 years of age can be part of the youth section, which has 5,600 volunteers and 244 local youth clubs. < br>
The mission and goal of the Bulgarian Red Cross Youth drug initiative are to:

• Reduce the health and social vulnerability of children and young people
• Promote humanitarian values

The main activities of the programme are to transfer knowledge, skills and raise social awareness in the areas of:

• First Aid and Youth Emergency Teams
• Health Promotion – prevention of HIV and AIDS, sexually transmitted diseases and substance abuse, harm reduction among intravenous drug users, tobacco control, promotion of healthy and active living lifestyles
• Social Welfare – humanitarian aid, childcare reform and work with children from social care institutions, advocacy for children’s rights, international art competition for children with disabilities
• Promotion of international humanitarian law

The programme was set up to respond to Bulgaria’s considerable drug use problem. There are 25,000 problem drug users in the country, mostly heroin users. There are 19,800 Injecting Drug Users (IDUs) (aged 15-49), 7% of whom are HIV-positive. In Eastern Europe and Central Asia, injecting drug use is the major driving force behind the spread of HIV. In Bulgaria, 42% of the newly registered HIV-positive cases are IDUs.

In 2004 all drug use was criminalized, (previously ‘one dose’ had not been criminalised), forcing drug users underground and greatly hampering outreach activities. Presently, harm reduction programmes are implemented in 10 Bulgarian cities by different NGOs and are supported by the Ministry of Health.

Overview of the Bulgarian Red Cross Drug Activities

Advocacy:

In terms of advocacy, the Bulgarian Red Cross is an active member of the Rome Consensus for a Humanitarian Drug Policy.

Prevention:

• Training for peer educators on substance abuse prevention
• Peer educators’ training manual on substance abuse prevention
• Awareness-raising among youth in school and in out-of-school environments

Harm Reduction:

• Since 2004: harm reduction activities for IDUs in 2 Bulgarian cities - Rousse and Kyustendil as part of the framework of the Ministry of Health HIV and AIDS Prevention and Control Programme (funded by the Global Fund). Reaching out to the most vulnerable problem drug users. In Kyustendil 75 % of the IDUs served are from the Roma community.
• Between 2005–2006: implementation of harm reduction project in Stara Zagora, funded by IFRC and the Italian Red Cross.
• 2-year project: started in December 2008.
• Joint initiative of the Villa Maraini Foundation (coordinator), the Bulgarian, Italian, French, Portuguese and Latvian Red Cross (partners), Croatian and Macedonian Red Cross (associate partners).

Main Objectives:

• Preventing drug use, reducing drug-related harm and promoting substitution treatment
• Creating a multidisciplinary network of Red Cross National Societies, expanding the knowledge base and raising awareness of the social and health problems caused by substance abuse.

Forthcoming developments in the drugs programme:

• April 2009-5-day training in Bulgaria for local harm reduction programme coordinators and outreach workers, RC volunteers and staff, representatives of partner organizations and a delegation of the Macedonian Red Cross by Villa Maraini, Italian, French, Croatian Red Cross trainers. Keynote participation of Dr. Massimo Barra.
• Study visits and experience sharing meetings between partner National Societies.
• Publication and dissemination of materials on problem drug use and HIV/AIDS/STDs, supporting harm reduction programmes and anti-stigma campaigns promoting humanitarian drug policies and practices.

To find out more about the Bulgarian Youth activities, the Rome Consensus Coordination team interviewed Milena Panayotova, Health Promotion Expert from the Youth Department of the Bulgarian Red Cross:

RC: Why was your drug programme developed?

MP: The two harm reduction programmes that the Bulgarian Red Cross is presently running were developed as a continuation of the Bulgarian Red Cross Youth’s efforts in the field of substance abuse prevention among youth in schools and in an out-of–school environment. The programmes in the two Bulgarian cities of Kyustendil and Rousse were set up following a needs and capacity assessment commissioned by the Ministry of Health and have been running since 2004. They were developed jointly with the Ministry of Health as part of the HIV and AIDS Prevention and Control Programme funded by the Global Fund to meet the needs of problem drug users in the local communities. From 2005-2006 harm reduction activities were also implemented in the town of Stara Zagora in the framework of a project supported by the IFRC/RC and the Italian Red Cross.

RC: How did you go about setting up the programmes?

MP: The programmes were set up by the local Bulgarian Red Cross branches in the two Bulgarian cities with the guidance of the Ministry of Health and the Global Fund. Outreach teams consisting of a programme coordinator and outreach workers were formed and trained. The local BRC branches and the dedicated teams of outreach workers drew extensively on the expertise of partner organizations across the country, which had been working in the field since 1998.

RC: Did you come across any obstacles?

MP: One of the major obstacles facing outreach work in Bulgaria are the amendments to the Penal Code of 2004, which criminalized the “single dose” and drove drug users “underground” greatly hampering outreach activities. Another factor impeding harm reduction activities is the stigma and discrimination against intravenous drug users and the need for concerted and targeted advocacy efforts and campaigns.

RC: How did you overcome these?

MP: It goes without saying that the efforts to overcome obstacles are ongoing, that is why we value highly our dedicated outreach workers whose efforts to build confidence and trust in their outreach activities is no small feat , bearing in mind the fact that drug use in the country still incurs criminal liability.

RC: What do you hope to achieve with your programme?

MP: We are consistently trying to reach out to the most vulnerable problem drug users and the fact that in the town of Kyustendil specifically, the majority of clients come from the local Roma community is indicative enough. Even though our involvement with harm reduction projects has helped us develop our expertise in the field, we would like to step up our efforts in order to broaden the scope of our activities and widen their reach among vulnerable populations, so that we can live up to our image of always being there where we are needed most.

We also find it particularly important to attract more ex-drug users to our preventive and harm reduction campaigns, as this would have a two-fold impact. On the one hand, it would help enhance our credibility among both our target groups, and on the other, it would assist the process of reintegration of former drug users and reduce the prevailing social stigma and discrimination.

RC: Are there any plans to expand the programmes?

MP: We see the new EU funded project “Improving harm reduction strategies: a Red Cross approach in Europe”, which is coordinated by Villa Maraini in partnership with the Bulgarian, French, Italian, Portuguese and Latvian Red Cross as an opportunity to expand our existing activities as it would help build the capacity of our outreach workers, volunteers and partner organizations in the field of advocacy for humanitarian drug policies, harm reduction strategies and innovative outreach tools and techniques.



Harm Reduction: Spanish Red Cross – Ourense branch  (back to top)


The Ourense Red Cross programme provides aid to people with problems of drug addiction in the Pereiro de Aguiar Central Prison. It was developed in response to the high number of people in prison addicted to drugs, and the lack of sufficient resources within the prison directed to address the problem.
The programme aims to:

• Provide services within prisons that improve the quality of life of prisoners who consume drugs
• Minimise the risks associated with drug-taking in prisons
• Offer information to prisoners who consume drugs
• Offer treatment to help people in prisons stop taking drugs

The Rome Consensus Coordination team asked Pablo Villarino Torrado from the Ourense Red Cross branch of the Spanish Red Cross about how they went about setting up the programme.

RC: Why was your drug programme developed?

PVT: People with drug addiction constitute a high percentage of the prison population. Often the crime for which the person is in prison is related to drug addiction and, additionally, consumption has serious consequences for the person’s personal, health-related and social development. The programme is a response to this situation.

RC: How did you go about setting up the programme?

PVT: The programme began in 1997 with a grant from the Minister of Work and Social Affairs, which allowed the project to go ahead. The decision to implement the project was taken after evaluating studies conducted in the past by the Red Cross which indicated that people consuming drugs in prison were using numerous practices that exposed them to the risk of contracting HIV and other illnesses. The problem was not being addressed with the available resources.

RC: Did you come across any obstacles?

PVT: The main obstacles have been associated with the reduction in funding, the increased pressure on the service and coordination with Central Prison staff. Over the years, the situation has been changing as much in the prison – the introduction of a needle exchange programme, for example – as it has in society – such as the changing profile of people with drug addiction problems. This has meant that the programme has had to adapt itself constantly to the situation.

RC: What do you hope to achieve with your programme?

PVT: The objectives of the programme are:

• To improve the quality of life of people with problems of drug addiction who actively consume (through the reduction of harm and risks)
• To offer therapeutic treatment to people with problems of drug addiction that wish to reduce or stop consumption

RC: Are there any plans to expand the programme?

PVY: Recently the Central Prison has expressed a desire to expand the programme, and so we are currently looking for funding that allows us to contract more staff and therefore, ensure that the programme reaches a greater number of people.

RC: Could you outline the basic elements of the programme?

PVT: The programme is based on the understanding of drug dependency as a symptom of a lack of wellbeing and takes into account the history of the person and the wider context.

We work to change the identity of the subject from a drug addict or drug consumer, ideally to arrive at a point where the person constructs a new, alternative, identity, in which a life without drug consumption is possible. This implies working not only with aspects related directly to drug consumption, but also with family relationships, the existence of a purpose in life, the adoption of a different perspective towards themselves and towards others, etc.



Harm Reduction: Macedonian Red Cross  (back to top)


Macedonia is a country with, for the moment, a low prevalence of HIV. The majority of the registered cases (total 112 in 2008) were through heterosexual transmission, and only 9 of them are intravenous drug users. This is the fairly “bright picture” represented by the official numbers, but the reality is more disturbing and revealing, given the magnitude of the HIV problem in Eastern Europe where a large percentage of the registered infections have been officially attributed to injecting drug use, and the progressive number of new drug users in the country there was no time to spare on initiating harm reduction activities.

Macedonia has a relatively well developed network of NGOs that provide harm reduction services (11 harm reduction programs in the bigger cities, 3 of which are run by the Macedonian Red Cross) but the major challenge in the country is the unavailability of centres for substitution treatment (only 10% of the target population is in the substitution programme), which reduces the total impact of the harm reduction programs.

Goals of the Macedonian harm reduction programme:

Main goal

To reduce the harm inflicted to individuals and the community by drug use.

Specific goals

• To increase the availability of clean injecting equipment and condoms among injecting drug users
• To establish contact with a greater number of injecting drug users and provide them with information about health protection, HIV, STI prevention and treatment opportunities.
• To increase the accessibility of injecting drug users to health care, social and legal services
• To perform advocacy for public health approaches towards injecting drug users and to reduce stigma and discrimination associated with drug use.

Services and activities in the Macedonian Red Cross harm reduction program:

Drop-in centres with needle exchange and condom distribution programmes

The Drop-in centre premises in the three Red Cross branches (Prilep, Veles and Kicevo) are open on a regular basis five days per week, four working hours. The hours are adjusted to the request from the clients. The clients are provided with sterile injecting equipment, condoms and educational materials.

Counselling and education of drug users about the consequences of high-risk behaviour and overdose prevention

All team members are trained and educated for counselling of the clients on high-risk behaviour (needle sharing, reuse of equipment, unprotected sex etc), safer injecting and overdose prevention.

Voluntary counselling for HIV, blood borne diseases and STI and referral and assistance

Education and counselling on HIV, blood borne disease and Sexually Transmitted Diseases are also provided for the clients, emphasising the importance of taking precautionary measures and regular testing. Information, referral and assistance in obtaining the tests in the local health institutions is provided. Since 2008, in collaboration with the Ministry of Health and other NGOs, Red Cross volunteers have been trained in motivating and mobilizing target groups in order to engage them in the new field testing services.

Publishing of drug-related informational and educational material

An essential first step is providing information on the services offered in our centres, safer injecting techniques, effect of various drugs, HIV, Hepatitis C and B information. A Macedonian Red Cross harm reduction manual will be published by the end of March 2009

Basic medical services for drug users

The drop-in centers offer basic medical services for mainly skin and vein conditions related to long-term and improper injecting techniques.

Psychological support for drug users and their families

Psychological support is regularly provided in the drop-in centres and it not confined to the clients, but also the clients’ next of kin.

Assistance in obtaining social or health insurance

The majority of our clients do not know the health and social rights and are not aware of the benefits offered by the relevant institutions. The social worker from the Harm Reduction teams informs them and helps them prepare the necessary documentation. When necessary they are accompanied in the process of obtaining social or health insurance.

Legal counselling

Legal counselling is also provided once a week for the clients, informing them on their human rights and the legal procedures in the country.

Outreach activities

The outreach activities represent the true “proactive” approach to offering services to our clients. Three times per week the outreach workers go to the clients, give them sterile injecting equipment, condoms and informational material. The key success in the outreach activities is the engagement of former stable drug users as a bridge to the target population.

Collection of non-sterile drug injecting equipment from public places

The unsafe disposal of injecting equipment poses a health hazard to the community. Parallel to the education of the clients on safe disposal of their equipment and returning of used needles and syringes to the harm reduction centres, cleaning of the places were clients frequently inject is another activity of the local teams.

How the programme works in the community:

Collaborating with local partners and facilitating local capacity building for drug prevention and harm reduction programmes. In order to ensure the success of the harm reduction programme, intensive contact and collaboration with various institutions and organizations were pursued:

• The Red Cross branches contacted the emergency departments in local hospitals and visited the general practitioners to discuss the acceptance of this kind of patient and their drug therapy as well as referral to secondary or tertiary treatment.
• Visits to local pharmacies, in particular to those that distribute methadone, and distribution of educational and informational material about the available services through the harm reduction programme.
• Regular contact with local police authorities was made in order to ensure support for harm reduction activities.
• Regular contact with local NGOs was made to develop joint action in harm reduction activities. In collaboration with Roma NGOs, distribution of educational material and informational sessions are held in Roma settlements.

The Rome Consensus Coordination team asked Elena Eftimovska, MD more about the project:

RC: Why was your harm reduction programme set up?

EE: Traditionally, the Macedonian Red Cross was undertaking drug preventive educational activities, mainly with the youth and mainly during the traditional Week for fight against alcohol, drugs and smoking. This was insufficient to address the drug problem in the country and especially the needs of the vulnerable people who use drugs. This was primarily the reason for starting harm reduction programs parallel to the drug prevention activities aimed at youth population.

RC: How was your harm reduction programme set up?

EE: In 2005, supported by the IFRC and the Italian RC, the Macedonian Red Cross started to introduce harm reduction activities into the National Society’s activities. Representatives from the local Red Cross branches all around the country were trained and the IFRC guidelines on harm reduction, Spreading the light of science, relating to injecting drug use was translated. After this introduction period, several local Red Cross branches analyzed the situation in their local communities and presented projects for Needle Exchange Programme (NEP) development. Training from the Croatian Red Cross and the local NGO HOPS was provided in 2006 and since then three Red Cross branches Veles, Prilep and Kicevo have developed and maintained harm reduction activities. The local harm reduction teams are composed of:

• local coordinator
• social worker
• medical person
• outreach worker
• legal consultant

RC: Did you come across any obstacles?

EE: The main obstacle was developing trust and confidentiality. It really was a major challenge to develop trust between the Harm Reduction team and drug users.

Another obstacle we encountered was acceptance of the program among the general population and local institutions.

A third obstacle we came up against was the unavailability of centres for substitution treatment in Prilep, Kicevo and Veles. Because of this, clients are referred to neighboring towns, which poses a financial burden on them.

RC: How did you overcome these?

EE: In the beginning of the project establishing trust among clients was difficult. The remedy for this problem was patience, time and engagement of the representatives of the target group as team members.

The Macedonian Red Cross continuously advocates for the harm reduction rationale and we work on the sensitizing the local environment for this. The Red Cross branches implementing the project organize workshops with local stakeholders, decision makers and relevant local governmental and non-governmental organizations in order broaden the support for the harm reduction programme and to facilitate the process of making local action plans for drug prevention that take into consideration the opinion of the target group.

The Red Cross Branches discussed the issue of transport to neighbouring towns for substitution treatment with the local social welfare centres and now they have provided financial aid for the clients’ travel expenses. This is only a temporary solution of the problem until centres for substitution treatment are opened in Prilep, Kicevo and Veles. The Red Cross has been lobbying for this for almost two years.

RC: Are there any plans to expand the programme?

According to the current situation and needs assessment, we plan to expand the harm reduction programme in the following ways:

• Training stabilized former drug users as peer educators
• Self-support groups
• Re-socialization activities - creative workshops, non-formal education, etc.
• Monitoring of behavioural changes among clients

Mainstreaming Drug Related Outreach into Existing Red Cross-Red Crescent Programmes  (back to top)


It is also possible for National Societies to incorporate drug related activities into their existing programmes. For example, a condom distribution/HIV prevention programme could be extended to include information on the risks involved in drug use (especially injecting drugs); or peer-to-peer youth projects could be developed to include information on the risks associated with drugs for youth populations.



Spanish Red Cross – Madrid Branch - Servicio De Mediación Sociolaboral (Employment and social mediation service)  (back to top)


The Madrid Red Cross has developed a programme to implement actions to facilitate and foster access to the labour market for vulnerable populations.

The programme aims to increase their employability through orientation and training, establishing work habits and assisting them in the process of finding a job. It also aims to facilitate access to the employment market with the support of actors from the private sector. At the same time, the programme is working towards sensitizing the local business community to the difficulties of these vulnerable populations and the opportunities that they can also present it terms of work force.

The target population is:

• Immigrants
• Refugees
• Marginalized youth
• Women in difficult social circumstances
• Drug addicts and former drug addicts
• Marginalized populations
• Handicapped
• Long term unemployed people
• Homeless

Specifically for drug addicts or former drug addicts, the following actions are taken to help people regain employment:

• Reinforce cooperation between employment services and drug treatment centres
• Introduce a mediator within the drug treatment centres to build capacity to reach out to difficult profiles
• Increase motivation and follow up on job applications
• Create trusting relationships between mediators and individuals in the programme by encouraging them to find their own solutions, without imposing fixed ideas
• Use work as a type of therapy
• Focus interventions on “unemployable” individuals
• Take advantage of the possibilities of contact within the centres – waiting rooms, etc.
• Actively seek to involve the most reluctant populations in the programme

The Rome Consensus Coordination team asked Antonio Díaz-Rubín Suárez-Pazos from the Spanish Red Cross in Madrid about how they went about setting up the programme.

RC: Why was your drug programme developed?

A D-R S-P: We developed the programme to respond to the employment needs of drug users in our treatment centres. Finding a job presents a significant hurdle to them.

RC: How did you go about setting up the programme?

A D-R S-P: We set up a pilot programme in one of the centres, from which we developed a set of guidelines. These guidelines were the result of a close collaboration between the Red Cross drug programmes and employment programmes.

RC: Did you come across any obstacles?

A D-R S-P: The main problem we encountered was the lack of specialised training of the technicians. We overcame this by providing training for them.

RC: What do you hope to achieve with your programme?

A D-R S-P: We hope to help people to reintegrate into society by providing them with the necessary social skills and access to job opportunities.

RC: Are there any plans to expand the programme?

A D-R S-P: Ideally, we would like to expand our project to all the Spanish Red Cross local branches.

RC: How did you go about setting up the programme?

RAG: The Second Andaluz Plan on Drug and Addiction (el II Plan Andaluz sobre Drogas y Adicciones), within the scope of socio-health care intended to address the needs associated with drug consumption and other addictions. It is based on a model of integrated care, coordinated with the health and social services, and adapted to individual needs. It provided services for those addicted to drugs that do not want to or cannot stop consuming drugs, reducing the negative consequences through different support programmes (meeting and support centres, mobile units, needle exchange programmes, and hygienic consumption rooms).

The Centre was established by the Spanish Red Cross in Almeria and is recognised by the Social Affairs Council (Consejería de Asuntos Sociales) as a Centre of Treatment and Prevention for drug addiction and other addictive disorders. It has an interdisciplinary team of staff that, working from a psychosocial perspective based on harm reduction, guarantee continued treatment over the year.

RC: Did you come across any obstacles?

RAG: Yes, before embarking on the initiative we had to find a site, which wasn’t easy given the pressure from the neighbourhood. Then we had problems locating a space to dispense methadone. The institutions do not give us the facilities we need to conduct distribution and awareness-raising.