Outi Karvonen in TB seminar 18-19.9.2017 St Petersburg - Nordic Russian Health Programme

1. Joint Action on HIV and co-infection
prevention and harm reduction
HA-REACT
Mika Salminen, Ph. D, Research Professor
Outi Karvonen, ProjectManager
19 September 2017, St. Petersburg
Principles and challenges of HA-REACT as
an example of multilateral and
multisectoral programme

2. > 5
3 to <5
1 to <3
< 1
Not included or
not reporting
Liechtenstein
Luxembourg
Malta
Non-visible countries
HIV diagnoses acquired through injecting drug
use, 2014, EU/EEA
Rate per 100 000 population
Source: ECDC/WHO (2015). HIV/AIDS Surveillance in Europe, 2014

3. 1240 new HIV diagnoses among PWID in 2015
5-10 cases in Denmark, Norway, Finland
<5 cases in Czech Republic, Slovakia, Croatia, Hungary, Cyprus, Netherlands, Slovenia, Iceland
Source: ECDC/WHO (Nov 2016)
Source: PRELIMINARY DATA ECDC/WHO (SoS2016)

4. TB among people who use drugs
• No statistical data easily available;
• WHO Global database: 13 from 31 EU/EEA countries reported 450
intravenous drug users (2%) among approx. 28 500 TB cases in the
respective countries in 2016;
• Link: drug use → HIV infection → co-infection HIV/TB;
• Experiences and guidance prepared by the TUBIDU project → used in
the HA-REACT Joint Action.
• Empowering the public health system and civil society to fight the
tuberculosis epidemic among vulnerable groups. Desk review;
• Handbook for community based organisations on tuberculosis
services for people who inject drugs;
• Training outline for trainings based on TUBIDU Handbook

5. TB among people who use drugs

7. Seven key recommended interventions
INJECTION EQUIPMENT: Provision of and legal
access to clean drug injection equipment, including
sufficient supply of sterile needles and syringes,
free of charge, as part of a combined multi-
component approach, implemented through harm-
reduction, counselling and treatment programmes
VACCINATION: hepatitis A and B, tetanus, influenza
vaccines, and, in particular for HIV-positive
individuals, pneumococcal vaccine
DRUG DEPENDENCE TREATMENT: Opioid
substitution treatment and other effective forms of
drug treatment
TESTING: Voluntary diagnostic testing with
informed consent for HIV, HCV, (HBV for
unvaccinated) and other infections including TB
should be routinely offered and linked to referral to
treatment
9
INFECTIOUS DISEASE TREATMENT: Antiviral
treatment based on clinical indications for those
who are HIV, HBV or HCV-infected. Anti-
tuberculosis treatment for active TB cases. TB
prophylactic therapy should be considered for
latent TB cases.
HEALTH PROMOTION: health promotion focused
on safer injecting behaviour; sexual health
including condom use; and disease prevention,
testing and treatment
TARGETED DELIVERY OF SERVICES: Services
should be combined and organised and delivered
according to user needs and local conditions; this
includes the provision of services through fixed
sites offering drug treatment, harm reduction,
counselling and testing, and referrals to general
primary health and specialist medical services.
COMBINE THESE KEY INTERVENTIONS TO ENHANCE PREVENTION
SYNERGY AND EFFECTIVENESS

8. Basic facts
The HA-REACT Joint action is based on:
• Communication from the Commission [COM(2009)569] on
“Combating HIV/AIDS in the European Union and neighbouring
countries, 2009 -2013”
• Commission [SWD(2014)106] Action plan on HIV/AIDS in the EU
and neighbouring countries 2014-2016

9. Basic facts (2)
HA-REACT
Budget: approx. 3,75 million EUR
co-funding by EC – 80%
Duration: October 2015 – September 2018
Coordination: National Institute for Health and
Welfare (THL), Finland
Partners: 22 partners from 18 countries

10. Geographical coverage of HA-REACT

11. Focusing the action: use of ECDC and EMCDDA objective selection
criteria
Mika Salminen/Outi Karvonen 9
Table1:IndicatorsofHIVtrend,transmissionriskandprevention coverage
AT BE BG HR CY CZ DK EE FI FR DE EL HU IS IE IT LV LT LU MT NL NO PL PT RO SK SI ES SE UK
HIVtrend
HIVcasereportsandprevalence
(15%weight;noincreaseincase
reportsorprevalence=0;
increaseinone=1;increasein
both=2;highwithoutan
increase=1)
0 0 2 0 0 0 0 1 0 0 0 1 0 0 0 0 2 1 0 0 0 0 0 0 2 0 0 0 0 0
Transmissionrisk
prevalenceofinjectingdruguse,
changesininjectingrisk
behaviour(HCVprevalenceand
trends)(10%weight;no
changes=0;moderateincrease in
onecriteria=1;increasein>1
criteria=2)
0 0 2 0 1 2 0 2 2 2 0 0 0 2 0 0 0 0
OSTcoverage
%estimatedproblemopiate
userpopulationreceivingOST
(cut-off30%)(25%weight;OST
coverage>30%=0;nodata=1;
OSTcoverage<30%=2)
0 1 1 0 0 0 1 1 1 0 0 0 2 1 0 0 2 2 0 0 0 0 2 1 1 2 0 0 1 0
NSPcoverage
Numberofsyringesgivenout
perPWIDperyear(cut-off100
syringes)(25%weight;NSP
coverage>100=0;nodata=1;
NSPcoverage<100=2)
1 2 1 0 2 0 1 0 0 1 1 2 2 1 1 1 2 1 0 1 1 0 1 1 2 2 1 0 1 1
TakingpartintheJointAction x x x x x x x x x x x x x x x x x x x x
Scores(maximum2)
0,
3
0,8 1 0 0,
6
0 0,
5
0,6 0,
3
0,
3
0,
3
0,9 1,2 0,
5
0,
3
0,
3
1,5 0,
9
0 0,
3
0,
3
0 0,8 0,5 1,
3
1 0,
3
0 0,
5
0,
3
Rankingofthoseparticipating in
theJA(1=greatest
need/opportunity toimprove
harmreductionsituation) 6 3 8 5 2 1 4 6
NOALERT–noevidenceforincreasein casereportsorHIV/HCVprevalenceand/ortransmission riskand/or lowintervention coverage
CONCERN-Subnational increasein HIV/HCVprevalenceand/ortransmission riskorconsistentbutnon-significantriseatnational level.
ALERT–evidenceforsignificantincreasein casereportsorHIV/HCVprevalenceand/orincreasein transmission riskand/or lowintervention coverage.
Informationunknown/notreportedto EMCDDA/ECDC.

12. Planning of the HA-REACT Joint Action
• Background concept paper from the European Commission
(commented by the EU HIV/AIDS Think Tank)
• Support from NDPHS Expert Group on HIV, TB and Associated
Infections
• Logical Framework Approach as a planning tool
• Based on the analysis of problems and development needs of the
beneficiaries
• Participatory approach – listening to professionals from Focus
countries: Latvia, Lithuania and Hungary (both government
organisations and NGOs)
• Aiming at sustainability
• To bring added value to the whole EU, not only Focus countries

13. Planning meetings
• Logical Framework Approach workshops during spring 2016:
– WP4 Testing and linkage to care, Budapest, 15-16 February
– WP8 Sustainability and long-term funding, Riga, 14-15 March
– WP5 Scaling up harm reduction, Vilnius, 16-17 March
– WP6 Harm reduction and continuity of care in prisons, Prague, 18-19 April
– WP7 Integrated care, Tallinn, 25-26 April

14. Objectives of HA-REACT
 Zero new HIV cases, reduced HCV and TB among PWID in the EU by
2020
 Improved prevention and treatment of blood-borne infections and
TB in priority regions and priority groups in the European Union
Purpose
Improved capacity to respond to HIV and co-infection risks and
provide harm reduction with specific focus on people who inject
drugs (PWID) in the EU
Direct beneficiaries: professionals working with PWID
Ultimate beneficiaries: people who inject drugs

15. Improved prevention and treatment of blood-borne infections and TB in
priority regions and priority groups in the European Union
Improved capacity to respond to HIV and co-infection risks and provide harm reduction
with specific focus on people who inject drugs (PWID) in EU
0. Admin and
management of
the Joint Action
5. National programmes
updated to overcome
barriers to respond to
HIV, TB and HCV-related
needs of PWID in the EU,
specifically in the focus
countries
Zero new HIV, reduced HCV and TB among PWID in the EU by 2020
1. Improved early
diagnosis of HIV,
viral hepatitis and
TB , as well as
improve d linkage
to care for PWID
2. Harm reduction
scaled up in EU
based on Latvian
and Lithuanian cases
3. Increased harm
reduction and
improved
continuity of care
for PWID in prison
settings
4. Improved
provision of
integrated HIV,
HCV, TB treatment
and harm reduction
for PWID
Structure and objectives of the Joint Action
0. Management Work Package 4 Work Package 5 Work Package 6 Work Package 7 Work Package 8

16. HA-REACT Work Packages and their leadership
 WP1. Coordination – THL, Finland
 WP2. Dissemination – CHIP, Denmark
 WP3. Evaluation – UKE – ZIS, Hamburg
 WP4. Testing and linkage to care – DAH, Berlin
 WP5. Scaling up harm reduction – CIBER (ISCIII), Spain
 WP6. Harm reduction and continuity of care in prisons – ISFF,
Frankfurt
 WP7. Integrated care – NIHD, Estonia
 WP8 Sustainability and long-term funding – CHIP, Denmark

17. Advisory Board
• CHAFEA
• DG SANTE
• DG HOME
• ECDC
• EMCDDA
• WHO/EURO
• Civil Society Forum on Drugs /Correlation network
• Civil Society Forum on HIV/AIDS
• European network of people who use drugs (EuroNPUD)
• Eurasian Harm Reduction Network(EHRN)
• European Association for the Study of the Liver(EASL)
• European Liver Patients Association(ELPA)
• NDPHS Expert Group on HIV, TB and Associated Infections
• UNODC
• European Forum for Primary Care(EFPC)

18. Activities so far
• 1st Steering Committee in Luxembourg, 8-9 December 2015
• Kick-off in Vilnius, 14 January 2016
• 2 Advisory Board meetings (Vilnius and Riga)
• 5Steering Committee meetings
• Partnership Forum in
Riga, November 2016
• CHAFEA Symposium in
Malta, January 2017

19. WP4 objectives
Testing and linkage to care
Improved early diagnosis of HIV, viral hepatitis and TB, as well as improved
linkage to care for PWID
1.Personnel working with PWID in Hungary and Latvia trained in low-threshold
testing of HIV, HCV
2.An interactive training manual and e-learning package on HIV and HCV testing in
low threshold settings for personnel who work with people who use drugs, with
special focus on women and peers, developed.
3.Awareness of clients of their infection status, of prevention and treatment of
HIV, HCV and TB, improved.
4. Access to treatment after positive test result is ensured.
5. Gender-specific approach in testing services focused on women who use
drugs developed and implemented.

20. WP4 activities so far
WP4 Testing and linkage to care
Improved early diagnosis of HIV, viral hepatitis and TB, as well as improved
linkage to care for PWID
• Training on HIV/HCV testing
– November 15-17, 2016, Latvia
– December 13-15, 2016, Hungary
– May 23-25, 2917, Latvia
• Leaflets and posters developed
to encourage PWID to take rapid HIV
and HCV tests (Lv, Hu, Eng, Ru)
• Training manual and e-learning tool
started.

21. Leaflets and posters to promote
HIV/HCV tests

22. WP5 objectives
Harm reduction
Harm reduction scaled up in EU based on Latvian and
Lithuanian cases
1.PWID epidemiology and harm reduction
interventions assessed in Latvia and Lithuania
2.Training package to care providers and policy makers
on HR interventions developed and implemented
3. Harm reduction interventions implemented in Latvia
and Lithuania

23. WP5 activities so far
Country mission implemented:
Regular meetings in Focus Countries (January, February, April and June) and by skype
to determine general situation in the countries, main barriers and necessities.
Jan 2015

24. WP5 activities so far (2)
WP5 Scaling up harm reduction
Harm reduction scaled up in EU based on Latvian and Lithuanian cases
• Seminars for Debate in Vilnius and Riga, April 2016
- Analysis of :
- successful experiences in other countries
- legal framework for the scale-up of HR: fully developed.
- Political will toward harm reduction,
- drug policy and HIV/AIDS
- Role of private sector:
- need to be involved (Lt)
• Study visits for participants from
Latvia (October 2016) and
Lithuania (September 2017), to
Madrid and Barcelona
• Study visit to Prague, 25-27 April, 2017

25. WP5 activities so far (3)
WP5 Scaling up harm reduction
• Mobile unit as a low-threshold service for drug users started in January
2017 in Riga
– Nurse, outreach worker,
social worker
– 23 hours per week
– Needle and syringe
exchange
-Testing on HIV, hep B,
hep C, and syphilis
- Condoms
- TB consulting
-Social and peer
counselling

26. WP6 objectives
Prison settings
Increased harm reduction and improved continuity of care for
PWID in prison settings
1.Situation analysis / mapping of needed support in the participating countries
implemented
2.Medical, social and other prison professionals trained to work with PWID and to
provide harm reduction services (incl. OST, NSP, condom provision and psychological
support)
3. IEC materials developed for PWID and staff in prisons
4. Practical toolkit for harm reduction in prisons made available
5. Condom provision and other harm reduction measures piloted in one prison
6. Policy brief developed based on experiences from the component

27. WP6 activities so far
WP6 Prison settings
Increased harm reduction and improved continuity of care for PWID in
prison settings
• E-learning modules developed for prison http://harmreduction.eu/
• Study tour for prison staff from Czech Republic
to Berlin (October 6-7, 2016)
•Pilot prison chosen in
Prague and distribution of
condoms started;
• International seminar
on harm reduction in
prisons, Warsaw,
March, 2017
– 80 participants

28. WP6 activities so far (3)
WP6 Prison settings
• “Needle exchange and other harm reduction measures in
prison settings” workshop in Luxembourg, 29-30 June, 2017
– Approx. 60 participants from 14 countries
– Visit to Schrassig prison

29. WP7 objectives
Integrated care
Improved provision of integrated HIV, HCV, TB treatment and
harm reduction for PWID
1.Capacity of health, social and civil society professionals in
providing better quality of care for PWID improved
2.Evidence- and practice- based tools and instructional
materials developed and provided for implementation of better
quality care for PWID

30. WP7 activities so far
WP7 Integrated care
Improved provision of integrated HIV, HCV, TB treatment and
harm reduction for people who inject drugs
• International workshop on building a platform for integrated care, 5 April,
2017, Vilnius (Lithuania)
– overview of different approaches to integrating care for people who inject drugs and
highlight how these necessitate new roles, responsibilities, skills and competencies
(Lithuania, United Kingdom)
– overview of good practices of integrated care from the countries already implementing
effective solutions (Spain, Portugal, Germany, United Kingdom (including Scotland)
– reflections on patients’ experiences, needs and expectations and how to involve patients
and community in developing services for PWID (Estonia, Portugal)
• Mapping report of existing guidelines on quality of care and different
models of care – under preparation.

31. WP8 objectives
Sustainability and long-term funding
National programmes updated to overcome barriers to respond to HIV, TB
and HCV-related needs of PWID in the EU, specifically in the focus countries
(WP8)
1.Strategies for national AIDS programmes for planning resource
mobilisation, allocation and financial sustainability for activities addressing
HIV-related needs of PWID suggested
2.Strategies for removing provider-dependant barriers in access to high-
quality HIV, co-infection and harm reduction services to PWID mapped,
analysed and proposed
3.Strategies for removing customer-dependant barriers in access to high-
quality HIV, co-infection and harm reduction services to PWID mapped,
analysed and proposed
4. Strategies for removing structural barriers in access to high-quality HIV,
hepatitis and TB services to PWID mapped, analysed and proposed

32. WP8 activities so far
WP8 Sustainability and long-term funding
National programmes updated to overcome barriers to respond
to HIV, TB and HCV-related needs of PWID in the EU,
specifically in the focus countries
• HA-REACT Sustainable Funding meeting in October 26, 2016, Budapest
(Hungary)
• Meeting on financing and sustainability of
harm reduction services on 6 April, 2017,
Vilnius (Lithuania)
• Literature review, policy review and survey
under preparation
• Guidance on funding mechanisms drafted.

33. Next activities
• National workshops on models of care to be organized in Lithuania (7
September), Czech Republic (16 October) and Estonia (30 August),
Hungary (to be confirmed);
• Training workshop on harm reduction interventions, Lithuania (October);
• Training on TB, gender-specific approach in testing and harm reduction
interventions for NGOs in December 2017 (Budapest, to be confirmed)
• “Harm reduction for people who inject drugs in Europe: findings from three
major European projects” session at the Addictions Conference in Lisbon, 25th
October
• Partnership Forum on 26-27 October in Lisbon
– Advisory Board on the 26th
– Steering Committee on the 26th
• Training of trainers workshop on harm reduction in prisons, Poland
(November).

34. Challenges
• 22 partner organisations;
• 18 countries – different languages and cultures;
• Different attitudes towards harm reduction and people who inject
drugs;
• Political changes;
• Merging of two partners into the Ministry of Human Capacities in
Hungary;
• Problems with rapid HIV and HCV testing in low-threshold settings
in Lithuania → new legal acts;
• Bureaucracy of the EU grant system;
• Inevitable amendments to the grant agreement;
• Guidance of partners who have not earlier participated in large EU
projects;
• Division of tasks, keeping timelines;
• Coordinating with other projects and programmes;
• Ensuring sustainability.

35. HA-REACT blog series
• Featured on the BioMed Central “On Health” blog and the
Hepatology, Medicine and Policy (HMAP) blog
• Structured as interviews
with Jeffrey Lazarus as WP2
lead & SC member
• Focuses on individual WPs
• Spotlights partners & their
work
• Promotes HA-REACT
• Ongoing (8 published to-
date)

36. More information available:
http://www.hareact.eu/en
#HAREACT
Project Manager Outi Karvonen, outi.karvonen@thl.fi
WP2 Dissemination and WP8 lead Jeffrey Lazarus, jeffrey.lazarus@regionh.dk

37. Website developed and hosted by AIDS Action
Europe
#HAREAC
T