Implications of loss of new funding opportunities for Harm Reduction programs in Albania
Country overview
Albania is situated in Balkan Peninsula in southeastern Europe. By land it is bordered by Greece, Montenegro, Macedonia and Kosovo, while shares the Adriatic Sea with Italy and Ionian one with Greece as well. It has has an area of 28,748 square kilometers and its relieve is predominantly mountainous. The capital city of Albania is Tirana (with around ½ million inhabitants) located in the west central part of the country.
Population
The population of Albania in 2011 was estimated at ~ 3.500.000 inhabitants (including the number of Albanian migrants who live and work abroad). The age structure of Albania is considered still young in comparison with many European countries.
According to CIA Word Fact Book, 21% of Albanians belong to the 0-14 years old group and vast majority belong to 15-64 years old. Recently, Albania is becoming an urban population, as now 52% of population lives in urban areas.
Health care
Two decades after the transition of the socialist system from a centralized to a free-market policy and economy have resulted in dynamic socio-economic and political developments in Albania. Intensive migration, urbanization, uncontrolled demographic movements, bureaucracy, corruption, unemployment rates have played a considerable role in changing Albanian demography and socio-economic situation.
In the past decades Albanian health care system has experienced significant structural changes. However, despite many reforms to diversify financing and increase decentralization, yet this sector remains underfunded and its standards are relatively low.
HIV/AIDS
In comparison with other European countries, due to deep isolation and strict movement policies Albania remained “immune” to HIV/AIDS until early 1990, when the socialist regime fell and Albanians were no longer restricted to freely travel within and outside of Albania. As expected, this free movement had the other “side of the coin”, as Albanians now were exposed to many sexual and behavioral risk factors for HIV/AIDS, including substance abuse.
The first case of HIV was detected in 1993, and since then the number of HIV infected people is increased considerably over the years. As of December 2011, 485 cases of HIV have been identified and more than 90 % of these infections are concentrated mainly to heterosexual transmission, including man who have sex with man (MSM) activity. The most affected age group is people between the ages of 25 and 44 years. Based on national reported prevalence of HIV and cases of HIV/AIDS, Albania is considered a low prevalence country; however the trend of HIV incidence and prevalence is going up, and different estimations show a higher number of undiagnosed cases. Moreover, the results from the three bio-behavioral surveillance studies (2005, 2008, and 2011) continuously have shown that high risk behaviors are still present and increasing progressively among most-at-risk populations, such as Injecting Drug Users (IDU) and MSM.
Since 2004 and on, ARVs is provided free of charge to people living with HIV/AIDS and this treatment is provided either in inpatient or as outpatient settings at Tirana University Hospital Center (TUHC) and Infectious Disease Service. With Global Fund support, at the end of 2007 was opened an Outpatient Clinic for persons with HIV/AIDS.
There is a guideline on applying ARV therapy, which has approved by the Infective Disease Department and Service and the Albanian Infective Diseases Association.
Drug abuse
The drug use began to appear in Albania after ‘90s, especially among small groups of youth, particularly those who returned from migration. Soon, this country became an easy transit and production spot for illicit drugs destined for other European Countries. In a little while, it became a consumption country and number of drug users increased significantly over the years, providing government authorities with a hard to deal new challenge.
Until now, no survey about drug use among general population has been carried out and data on number of drug users in Albania are extracted from experts’ opinions. Nevertheless, according to EMCDDA country report the number of drug users in Albania is increasing significantly, from 5.000 in 1995 up to 60.000 drug users by the end of 2010. The common drugs used by drug users are marijuana, heroin, cocaine, ecstasy and other synthetic drugs, while heroin remain the drug of choice for injecting drug users (IDU). Based on the above mentioned estimations, the numbers of IDUs are thought to be from 8.000 up to 10.000 where majority of them lives in capital city or its suburban areas.
Treatment and harm reduction responses
The Service of Clinical Toxicology of TUHC is the only public clinic that offers treatments (detoxification and overdose) for drug users, either as inpatient or outpatient unit. This center has been located at Military Hospital which is governed by Ministry of Defense. Early this year (March 2012), this service was removed at TUHC. This service is named “Center for Care and Treatment of Addiction”, which in fact is the first specialized center in Albania and established under a joint program of UNODC (United Nations Office on Drugs and Crime) and WHO (World Health Organization) and Ministry of Health (MoH). If fund permits, it is planned that this service will be scaling up in other six other regions in Albania.
Harm reduction and needle exchange services were introduced since 2000, mainly supported by OSFA or sporadically by other donors. From 2007 to March 2012, the Global Fund under the terms of Round 5 grant had strongly supported the sub-populations in Albania considered most vulnerable to HIV/AIDS, that is, injecting drug users (IDU), sex workers and men who have sex with men (MSM). While in terms of Needle Exchange Programs (NEP), only four NGOs in Tirana were supported to provide such services. The total amount of grant dedicated to NEP was estimated to be around 10% of the Round 5 grant.
Treatment coverage for drug users is fairly limited and mainly focused on detoxification and opioid substitution therapy. Methadone Maintenance Program was introduced in 2005 in Albania, and provided as outpatient settings by Aksion + NGO. Initially this program was based in Tirana and later through the GF support scaled up in other 6 regions. Buprenorphine and naloxone programs are not yet introduced in the country.
Although many important steps have been taken to improving the treatment responses for drug, drug treatment and rehabilitation remains a low priority and are not yet receiving the adequate attention from government and other donor agencies. In addition, majority of health providers are not familiar and have lack of knowledge and experience with substance abuse problems, overdose prevention and early diagnosis and treatments.
Policies Related to Drug Use and Needle Exchange Programs
Over the years, Albania has adapted in the country laws regarding possessing, trafficking and using illicit substance. The Penal Code has undergone many improvements placing more severe sanctions for production, selling, distribution and possession of drugs. According to Penal Code/article 283, the “possession of small quantities of drugs for personal use” is no longer considered as punishable. Although it is not considered as a crime, often this law is not applied as such. The deficiency of specifying the exact amount for personal use, frequently is misused (and why not intentionally abused) in influencing the court deciding the length of punishment for the offence.
In terms of Needle Exchange Programs, the law (Penal Code) neither specifies restriction nor facilitates the provision of sterile syringes to injection-drug users in an effort to reduce the spread of blood-borne diseases. However, the police officers justify the NEP restriction by interpreting that needle distribution is considered as “Facilitation of the drugs intake and use”.
Up to now, NEP activities in Albania have been operated under mutual agreement and permanent permissions between NGOs that run such programs and Police Force Department. Nonetheless, cases when NEP staffs (socio-health and outreach workers) have been stopped or shortly incarcerated by police forces have been common.
Risky behaviors and drug-related infectious diseases among IDUs
Mounting of evidences tell us that injection drug use is a major risk factor for HIV infection and other blood borne diseases throughout the world. Different risky behaviors that facilitate HIV transmission include shared use of needles and syringes or drug injection equipment and unprotected sex (without condom) with multiple sexual partners are common among people who inject drugs.
As their mates throughout the world, IDUs in Albania are not an exemption. Data from three repeated Bio-BSS (2005, 2008, and 2011) show that vast majority of injecting drug users have been involved in high risky behaviors, where sharing used drug injection equipments, poor techniques or measures in cleaning these equipments were commonly reported by them. On the other hand, having unprotected sex with unknown or multiple partners under the drug influence or selling sex to by drugs are frequently risky behaviors reported IDUs.
Until 2010, the IDU population account for only 1 % of HIV infection and the first two Bio- BSS studies (2005 -2008) did not show any HIV cases among IDUs. The last Bio-BSS study showed that only one of the IDU respondents tested positive for HIV (surprisingly HIV1 and 2).
Even though, these figures rank Albania as a low prevalence country in regards to HIV infection among injecting drug users, yet there are many limitations with the epidemiological data available on drug use and HIV drug-related infection rates in Albania. Mainly, information on HIV prevalence among IDUs is gathered on HIV testing in very specific environments/cities and specific drug using population, such as NEP or Methadone attendees. Therefore, knowing the limitation of data gathering and techniques, the low HIV prevalence among IDUs rarely provides a national-level picture of this problem. Hence, the above figure should be taken with caution due to the paucity of data.
While in respect to Hepatitis Viral C (HVC) among IDUs, data from the above mentioned studies, laboratories and NGOs working in the field show that HVC prevalence has increased over the years, ranging from 12% in 2005 up to 30% in 2011. Reports from STOP AIDS NGO show that number of HVC among their clients is closed to 40%, based on Rapid Test techniques (As of October 2012).
Implications of loss of new funding opportunities for Harm Reduction programs in Albania
Funds for NEP
Since end of March 2012, the four NGOs providing needle exchange services for injecting drug users are no longer receiving funds to run this activity. Under the Continuity of Services of Round 5 Grant Agreement, Albania was eligible to receive a two-year extension (1 April 2012 to March 31, 2014) for the following services:
a) Continuation of Methadone Maintenance Therapy to 474 patients; and
b) Continuation of Provision of second line ARV Treatment to 50 patients.
Up to now, the four NGOs have shut down their NSPs and have lost part of their experienced staff. NSP are surviving through volunteer work of few outreach workers who provide a small scale and segmented intervention (mainly leftover syringes from previous programs) to a few numbers of street IDUs or sex workers in very specific injecting areas .
Nowadays, the vast majority of IDUs are left without new and sterile drug injecting equipments and due to lack of financial means they are not able to buy new needles/syringes or other drug equipments for each injection.
Anecdotal reports from nurses at Emergency Care Unit at public hospitals show that number of IDU who go to these services seeking sterile syringes is increasing considerably lately. One of them said: it reminds me of the time in early 90s, when groups of drugged people were brutally and nervously asking for single used syringes in hospitals. On the other hand, some pharmacists report that the number of IDU clients who wants to by “diabetic syringes” for drug use purposes is also increasing.
Conversely, even for those who can afford buying sterile needles in pharmacies it hard to find as pharmacists do not want to sell any product to drug users due to fear of theft/violation during the night, or mainly due to fact that it is hard to find 1ml syringes, as now diabetics are using multiuse pen syringes.
This situation implies that even though they might be aware about the risk of sharing drug injecting equipments, IDUs are imposed to use used syringes and share with their injecting partners. Moreover, they are more exposed to HIV and Hepatitis and posing a major risk for getting these infections and transmitting to their injecting and sexual partners.
Furthermore, while injecting drug use has been predominantly an urban phenomenon, different reports from printed media in Albania show that now problematic drug users and injecting as well is recently becoming visibly a semi-urban phenomenon.
It is widely known, and Albania represents a successful example for NEPs in reducing HIV and Hepatitis, and cost-effective intervention as well, as the cost per HIV infection averted is far below the lifetime cost of treating an HIV-infected person.
Although NEPs are a great tool in fighting HIV/AIDS and yielding a significant cost savings, seven months after NEPs collapsed in Albania, this problem is receiving lesser and lesser attention and financial sources either from Albanian government or other donor bodies. Much of HIV intervention funding comes from international agencies, such as UNICEF, UNFPA, OSFA, etc, in forms of prevention and human rights approach programs for most at risk groups. The EU and USAID programs are mostly focused on corruption, local governance and justice system, and harm reduction and particularly NEP are not part of their assistance scheme or agenda. National AIDS Program and Country Coordination Mechanism (CCM) are closely working together to identify gaps and formulate appropriate needs in this regard and submit to the GF .
The only donor agency run by Albanian government is the Agency for the Support of Civil Society (ASHMC) established in 2009. This agency provides short and long term grants for civil society up to $ 100.000.00 for a period over 12 months. But as with many agencies, the mission of ASHMC does not provide support for harm reduction or NEP . Other than this agency, there is no other national body or agency that provides support for civil society organization.
The situation seems to be more dramatic knowing that even for the 2013 fiscal year the above mentioned agencies or aren’t planning to support NSP programs in Albania .
HIV/AIDS progress
No studies or evaluations have been undertaken to measure the implication cost of loss of new funding opportunities for harm reduction and NEPs in Albania. HIV prevalence remains to be low among injecting drug users, but the number of Hepatitis Viral C among this group of population is increasing considerably. The HIV situation might not be real due to lack of testing among IDUs particularly in other cities than Tirana; or the HIV infection has not reached the saturation point among this population and will later on do so if not adequate precaution measures are taken.
However, as of November 2012 the numbers of new HIV infection are progressing: from 485 cases in 2011 to 550 in 2012, counting for 70 new cases (10% more than in 2011). This figure (new cases) is the highest since the HIV history in Albania. Among 70 new cases, one case belongs to IDU community having the HIV1 and2 virus. HIV continues to run in family as well, with 4 new children infected in 2012 (28 infected children in total) . Furthermore, among the general population, HIV testing coverage is low; in 2010 only 2,896 people were tested for HIV (0.1%) and 2% of Albanian health facilities offered HIV testing services .
Up to now, Albania remains a low HIV prevalence country with prevalence less than 1% in general population (less than 1 per 1,000 of the 15-49 year old population in Albania). It is estimated that the total number of Albanians in the 15-49 year age group is about 1.5 million and a prevalence rate of 0.1% (1 per 1,000) would mean a total of about 1,500 HIV infections . Another scenario foreseen by James Chin (2002) estimates that in case of lack of effective interventions especially among groups at risk, the number of HIV infected people could be up to 7.000 in 2015 (up to 15.000 HIV cases in worst scenario) .
At present, the estimation of the actual prevalent number HIV infected people in Albania cannot be accurate due to limitation of data. Although there is mixed evidence to project a rapid spread or explosion of HIV infection among IDUs in Albania, the possible risk factors that may contribute in a HIV epidemic outbreak cannot totally be ignored in near future. There are enough ingredients of concern to the public health experts that the number of HIV infections among IDUs may be increased in the future. The increased number of Hepatitis Viral C, the risk of overlapping with heterosexual transmission (MSM included) and sex work, free movement and epidemic outbreak and spread in neighboring regions are factors that should not be neglected.
Is Albania getting to zero HIV infections among IDU?
The 2011-2015 UNAIDS strategy calls for global commitments to achieve universal access to HIV prevention, treatment, care and support. Under the Vision slogan: To get to Zero New Infections, one of the Millennium Development Goals for 2015 is: All new HIV infections prevented among people who use drugs . As many countries, Albania embraced this strategy and last year was highly promoted that the 2015 would be the end of HIV epidemic and the country has all infrastructure and means to halt and reverse the spread of HIV in Albania. Theoretically it is known that the risk of HIV spread through sharing contaminated drug injecting equipments can be reduced whether fewer people use and inject drugs and less frequently share injection equipments.
But the question remains: is Albania ready to getting to zero and prevent the new infections among people who use and inject drugs? It is hard to give a response without deep analysis and epidemiological researchers, but facts reveal that not only this millennium goal cannot be achieved, but the situation can be worsening if HIV/AIDS among IDUs continues to remain a neglected issue.
The 30 years history of HIV/AIDS has shown that this epidemic among IDUs has its own cycle and curb, with many ups and downs. It differs and varies from region to region, where in some have been halted, while in others the prevalence of HIV is rising and in some others exploding. The non uniform curb of HIV among IDUs in different regions shows that yet we do not have adequate understanding on the dynamic of this infection among IDUs, and it also shows that we- public health advocates- have not been able to influence policy makers and donors to apply the lesson learnt and best practices.
We have lost too many people from HIV/AIDS, far too many. There is no time to experiment with new financing schemes or bodies. We have learnt a lot during these 30 years, from science, experience and mistakes. We don’t need to follow again the same wrong approach: once the HIV epidemic explodes somewhere, it takes the attention of everybody.
Positive and negative experience and time has shown that if we are reluctant to invest today in prevention services, tomorrow we will spend more and more for treatments and palliative care services. With a few investments today, we could change the trajectory of the global HIV epidemic.
Albania must be a country where mistakes and lesson learnt gained from the past in other countries could be prevented.
