This ERASMUS lecture is about a Hungarian public injection scene, about the local harm reduction services (run by Blue Point Drug Counselling and Outpatient Centre) and about connections of public injecting to other risks, including "police risks".

1. Public injecting drug use and the local harm reduction services József Rácz

2. Public injecting Blue Point Drug Counselling and Outpatient Centre: Contact Cafe 8th district of Budapest Injecting and sexual risk behaviours Local harm reduction services Risks of injecting: HIV, HCV Data on needle exchange Characteristics of the clientele Harm reduction methods Summary of a large scale study on needle exchange (Australia, 2009)

3. Public injecting scenes and shooting galleries

5. Blue Point Drug Counselling and Outpatient Centre

6. 8th district of Budapest with the placement of needle exchange program of Blue Point: the Contact Cafe

7. General background of 8th district

8. The VIII. district of Budapest faces a number of difficulties. This is an area where there are multiple social, health, livelihood, community, etc.. problems. The drug and social problems are much higher compared to other districts. The legal and illegal drugs and the presence of a large number of consumers in a very open drugscene requires various and several care providers at different levels to be present. In particular, there are many addicts living in the district who are suspicious of institutional care , which is a high-threshold care service. The legal and illegal drug use associated with poor living conditions and low social status seriously increases the risk of spreading diseases. The clients with health problems often do not turn to a doctor or do not ask for care and treatment. Cultrual diversity – including Roma culture - is one of the characteristics of the disctrict. There are large differences of inhabitants concerning ethnicity, nationality, education and housing, and social status and health. (The „Integrated Rehabilitation Strategy for Urban Development” of the capital places an emphasis on refurbishing the district, but this is impossible without dealing with social problems.) The well-defined part of the disctict’s inhabitants are living in poor conditions, bad housing, has poor health culture, poor mental status and is low skilled and unemployed. The socio-cultural background

9. Dezső Tamás’s photos Feeling of the 8th district

10. (Semi)Public injecting sites

11. social worker with visibility coat Drug litter

13. Shooting gallery Type 1

18. Shooting gallery Type 2 Csoki 36 ys old, heroin dependent. His wife, Zita 35 ys old, heroin dependent. Their son, Csabika 17 ys old, heroin dependent. „ At the deepnest of drug world ” Baptis Charity „Street Front”, Marcell Miletics, Miklós Barcs, Péter Borbély

19. Discarded needles, drug litter

24. Collecting dirty needles Most important for the local community & for the local self-government

26. „ User friendly milieu”

29. Roma culture on YouTube (videos watched by our clients)

30. Legal open scene Swiss „needle parks: 1980s-1990s: failure – re-designing of the Swiss drug policy Incidence of regular heroin users (Nordt és Stohler, 2006) Results: New heroin users referred to treatment in two ys. 4% yearly decrease in the number of problem heroin users. Needle Park in Zürich, 1992

31. Risks of (public) injecting

32. The ranges around the estimates in this table define the boundaries within which the actual numbers lie, based on the best available information. Regional HIV and AIDS statistics and features  2009 TOTAL 33.3 million [31.4 million – 35.3 million] 2.6 million [2.3 million – 2.8 million] Adults and children newly infected with HIV Adults and children living with HIV Sub-Saharan Africa Middle East and North Africa South and South-East Asia East Asia Central and South America Caribbean Eastern Europe and Central Asia Western and Central Europe North America Oceania 22.5 million [20.9 million – 24.2 million] 4.1 million [3.7 million – 4.6 million] 1.4 million [1.2 million – 1.6 million] 1.4 million [1.3 million – 1.6 million] 1.5 million [1.2 million – 2.0 million] 1.8 million [1.6 million – 2.0 million] 270 000 [240 000 – 320 000] 92 000 [70 000 – 120 000] 130 000 [110 000 – 160 000] 70 000 [44 000 – 130 000] 460 000 [400 000 – 530 000] 770 000 [560 000 – 1.0 million] 240 000 [220 000 – 270 000] 820 000 [720 000 – 910 000] 57 000 [50 000 – 64 000] 75 000 [61 000 – 92 000] 82 000 [48 000 – 140 000] 17 000 [13 000 – 21 000] 31 000 [23 000 – 40 000] 4500 [3400 – 6000] 1.8 million [1.6 million – 2.1 million] Adult & child deaths due to AIDS 1.3 million [1.1 million – 1.5 million] 260 000 [230 000 – 300 000] 58 000 [43 000 – 70 000] 76 000 [60 000 – 95 000] 26 000 [22 000 – 44 000] 24 000 [20 000 – 27 000] 36 000 [25 000 – 50 000] 12 000 [8500 – 15 000] 8500 [6800 – 19 000] 1400 [<1000 – 2400] 0.8% [0.7% - 0.8%] Adult prevalence (15‒49) [%] 5.0% [4.7% – 5.2%] 0.3% [0.3% – 0.3%] 0.5% [0.4% – 0.6%] 0.8% [0.7% – 0.9%] 0.5% [0.4% – 0.7%] 0.2% [0.2% – 0.3%] 0.1% [0.1% – 0.1%] 1.0% [0.9% – 1.1%] 0.2% [0.2% – 0.2%] 0.3% [0.2% – 0.3%]

33. 12/06 e Proportions of HIV infections in different population groups by region, 2005 IDU: Injecting Drug Users MSM: Men having sex with men CSW: Commercial Sex Workers Latin America MSM 26% IDU 19% CSW 4% All others 38% South and South-East Asia* CSW clients 13% Eastern Europe and Central Asia MSM 4% IDU 67% CSW 5% All others 17% CSW clients 7% * India was omitted from this analysis because the scale of its HIV epidemic (which is largely heterosexual) masks the extent to which other at-risk populations feature in the region’s epidemics. MSM 5% IDU 22% CSW 8% All others 24% CSW clients 41% Figure 2

34. Estimated occurance of injecting drug use per 1000 inhabitants, in the 15-64 ys groups (EMCDDA, 2009) Contact Cafe 32

35. Risks: The silent epidemic Sitting on a bomb…

36. Hepatitis C infections in the European Union, 1995-2005 (Rantala és van de Laar, 2008)

37. HCV prevalences among injecting drug users (regional and national data), 2006-2007 (EMCDDA, 2009) *: data from Contact Cafe

38. Source: OEK, 2007, 2008, 2009 HIV, HCV testing – HIV: 0%

40. Treated HCV infected patients after HCV testing (Gazdag és Szabó, 2007) Cost of treatment of HCV infection : Treatment (1 year): 3,5 - 4m HUF Total life span: 3,5 - 7m HUF

41. Finger stick (qiuck) HCV testing

42. Data on needle exchange program

44. January 09 January Febr March April May June July August Sept. Oct. Nov. Dec Registered clients in 2010 (from January to December

46. Gender distribution in a certain year (%) Male Female Age of registered clients <19 20-24 25-29 30-34 35-39 40+ys male female Total

47. abstinent other Drug use among registered clients Place of residency Inactive clients (%) Active clients (%) 7th district 3.2% 4.7% 8th district 54.0% 55.5% 9th district 9.9% 10.5% 10th district 4.5% 6.2% „ distant clients” 28.4% 23.1% Sum 100.0% 100.0%

48. Place of residency } 7+ 8+ 9 district = 72,6% Important for the local self-government District N % 1. 2 ,2 2. 1 ,1 3. 15 1,4 4. 5 ,5 5. 7 ,7 6. 18 1,7 7. 41 3,9 8. 604 57,9 9. 113 10,8 10. 47 4,5 11. 22 2,1 12. 6 ,6 13. 53 5,1 14. 23 2,2 15. 9 ,9 16. 6 ,6 17. 3 ,3 18. 3 ,3 19. 14 1,3 20. 14 1,3 21. 5 ,5 22. 2 ,2 23. 4 ,4 Non Bp. 27 2,6 Sum 1044 100,0

49. Clients’ visits per month January 2009 – July 2010 Febr. March

50. Delivered injectors in 2010 Injectors taken back in 2010 Clients’ visits per day Febr. March older clients return syringes in 45 % of cases, while the proportion of returning the used syringes in case of new clients is only 22 %

53. Local community affected Fear from injecting drug users Public nuisances Discarded needles at playgrounds as well Street drug dealing Crime for drugs Children as witness of injecting „ Solutions ” Abstinence-oriented treatment Methadone maintenance Police presence Needle exchang e Local survey N=150

54. What does the needle exchange program do: some examples?

55. Safer injecting practices

56. Safer injecting practices

57. Safer injecting practices

58. More use – syringe deformities Gyarmathy et al., 2009 Mean volume of fluid retained in two types of syringes

59. Needle exchange

60. Needle + paraphernalia exchange

61. Condoms and sexual counselling

62. Needle exchange in the EU Country Region Number syringes 2005 Number syringes 2006 Belgium Flemish community 390 522 538 783 Belgium French community 261 182 246 519 Bulgaria National (1) (6) 600 000 210 464 Czech Republic National (2) 3 274 000 3 868 880 Denmark National (3) 910 000 Germany National Estonia National 867 600 1 615 270 Ireland National Greece National 29 782 34 809 Spain National 3 184 845 France National Italy National Cyprus National 0 0 Latvia National 123 895 Lithuania National 258 650 196 952 Luxembourg National 406 451 332 347 Hungary National 85 127 142 433 Malta National 220 211 225 716 Netherlands Regional (9) 440 000 380 000 Austria Regional (7) 1 811 962 2 082 840 Poland National (10) 372 000 318 155 Portugal National (8) 2 845 031 2 591 150 Romania (4) 1 038 000 300 000 Slovakia Regional (13) 362 055 384 293 Finland National (11) 1 891 903 2 400 000 Sweden National 117 894 United Kingdom England and Wales 27.000.000 (2002) United Kingdom Northern Ireland (12) 85 801 97 684 Croatia 135 981 Turkey 0 0 Norway National (5) 3 300 000

64. Drug use among needle exchange clients and their friends (≠ clients) Márványkövi, Melles, Légmán and Rácz, 2008 Drug use – last 30 days (%) 57,1 61,4 17,1 51,4 12,9 40,0 40,0 82,9 5,7 54,3 21,4 24,3 48,6 72,1 11,4 52,9 17,1 32,1 0 10 20 30 40 50 60 70 80 90 heroin amphet amine non-presc. methadone marijuana ecstasy sedatives non roma drug user roma drug user total

65. Márványkövi, Melles, Légmán és Rácz, 2008 Injecting risk behaviours (≠ clients) * p < 0,05 paraphernalia last 30 days paraphernalia lifetime needles last 30 days needles lifetime total 52% 75% 9% 56% roma idu 60%* 80% 11,4%* 51,4% non-roma idu 44%* 70% 7,1%* 60%

66. 1: easy access………………………5: very difficult access Márványkövi, Melles, Légmán és Rácz, 2008 Márványkövi, Melles és Rácz, 2006 Perceived access to different treatments Mean N Sd Outpatient 1,98 49 1,31 Methadone maintenance 4,28 50 1,33 Daily clinic 1,50 28 1,04 Inpatient 2,39 49 1,50 Residential (TC) 3,03 39 1,50

68. Sydney Medically supervised injecting facilities

69. München

70. Sydney

71. Sydney

72. Entrance: Vancouver Exit Köln Hannover Frankfurt

74. Some experiences from a large scale Australian study on needle exchanges – 2000 - 2009

75. Estimated number of Australian IDUs No. of syringes distributed in Australia) ≈ 150 injector/IDU

76. Injecting acts per injecting drug users (Australia Government Report, 2009) Figure shows that injecting drug users are not able to decrease their drug use! Injecting drug using visitors of the 8th district are about: 2.000 persons (1.500-2.500). It means 800.000 injecting occasions per year, but here amphetamine users are the majority (who inject more frequently than heroin users) , this number maybe more than 1 million occasions per year Distributed needles by the Contact Cafe are about 100.000/year, coverege of injecting occasions are about 12,5% (10%). Similar coverege to Austratalia (150 injectors/person) – means about 300.000 injectors in a year.

77. Cost-effectiveness of Australian NSPs Summary of investment The number of needles and syringes distributed in Australia increased during the past decade (from ~27 million to ~31 million). Measures for NSPs to increase referrals to drug treatment and other services . • Over the last decade there has been o Increases in funding for primary sites. o Increases in the number of secondary sites. o Increases (by 15%) in the numbers of units of equipment provided. o Stable spending on sterile injection equipment. O T here were 85 primary sites, 737 secondary sites, 20 enhanced secondary sites, and 118 vending machines in 2010.

80. The simulated number of annual (a) HIV and (b) HCV transmissions among IDUs in Australia versus the percentage of injections that are shared and the average number of times each syringe is used before disposal. The dashed lines refer to current levels of sharing and syringe use. HIV HCV

81. Scatter plots of the simulated number of annual (a) HIV and (b) HCV transmissions among IDUs in Australia versus the number of sterile syringes distributed in Australia are shown, assuming that syringe distribution changes the average number of times each syringe is used before disposal. The blue dots are results from 1000 simulations, the red curves represent the median parameter values, and the black dashed lines refer to current levels of syringe distribution.

82. Thank you for your attention! [email_address]