The Joint Action proposal on “HIV and Co-infection Prevention and Harm Reduction” (HA-REACT) addresses existing gaps in the prevention of HIV and other co-infections (especially tuberculosis and hepatitis) in priority areas of the EU. Despite huge advances in treatment and care and successful implementation of evidence-based preventive interventions in many EU member states, these infections are still not controlled among certain population groups and regions. The HA-REACT Joint action (JA) directly addresses the Communication from the Commission [COM(2009)569] on “Combating HIV/AIDS in the European Union and neighbouring countries, 2009 -2013” and relevant actions laid out in the associated [SWD(2014)106] action plan extension 2014-2016. The project takes a practical rather than a theoretical or purely guiding approach. It will implement concerted, multi-country, and multi-actor actions, strengthening evidence-based practices in the focus countries, where the situation and needs are particularly challenging. Focused action for greater impact is the leading principle of this proposal. The HA-REACT will focus on pragmatic actions targeting the most vulnerable populations, i.e. people who inject drugs (PWID). The focus countries for the JA were selected according to an objective and transparent selection criteria, developed by the ECDC and the EMCDDA in which the countries were ranked according to their epidemic situation and coverage of preventive measures. In addition to work packages of Coordination, Dissemination and Evaluation, HA-REACT actions are organized into five core work packages: Testing and linkage to care, Scaling up harm reduction, Harm reduction and continuity of care in prisons, Integrated care, Sustainability and long-term funding.
Despite huge advances in treatment and care and successful implementation of evidence-based preventive interventions in many EU member states, these infections are still not controlled among certain population groups and regions. The Joint Action (JA) on “HIV and Co-infection Prevention and Harm Reduction” (HA-REACT) addresses existing gaps in the prevention of HIV and other co-infections (especially tuberculosis and hepatitis) in priority areas of the EU. The JA directly addresses the Communication from the Commission [COM(2009)569] on “Combating HIV/AIDS in the European Union and neighbouring countries, 2009 -2013” and relevant actions laid out in the associated [SWD(2014)106] action plan extension 2014-2016. The HA-REACT JA focuses on pragmatic actions targeting the most vulnerable populations, i.e. people who inject drugs (PWID). Focus countries (Hungary, Latvia and Lithuania) were selected according to their interest and objective and transparent selection criteria, developed by the ECDC and the EMCDDA by which the countries were ranked according to their epidemic situation and coverage of preventive measures. HA-REACT actions are organized into five core work packages: Testing and linkage to care, Scaling up harm reduction, Harm reduction and continuity of care in prisons, Integrated care, Sustainability and long-term funding. The project is expected to contribute to the overall objective of zero new HIV infections, reduced HCV and TB among PWID in the EU by 2020, and its purpose is to improve capacity to respond to HIV and co-infection risks and provide harm reduction with specific focus on people who inject drugs in the EU.
The partnership will apply as set of pragmatic measures including components of harm reduction services, low threshold health and social services, integrated care models and interventions applied in incarcerated settings. During the project lifetime, focus country needs will be reviewed through a series of needs and gap assessments, followed by design and scale up of targeted interventions and health service models. These are applied in selected regions and partner countries in the greatest need of dissemination of harm reduction measures. Activities include training of social and health professionals as well as peer educators. In some regions specific studies and support of initial/pilot scaling up of services have and will be applied to kick-start services. A dialogue with policy makers and a specific line of work aiming at finding innovative ways for sustainable funding is included in the project. A series of methods, including the logical framework analysis approach, interactive trainings and site visits will be used in different phases or throughout the project.
The project was launched with the 1st Steering Committee meeting in Luxembourg on 8-9 December 2015. The Consumers, Health, Agriculture and Food Executive Agency (CHAFEA) hosted the meeting, and representatives of DG SANTE and DG Migration and Home Affairs were also present. The Kick-off meeting was organized in collaboration with the Centre for Communicable Diseases and AIDS (CCDA) on 14 January in Vilnius, Lithuania. Altogether 59 participants attended the meeting. Administrative and financial issues were first discussed among associated partners and then the work package plans were reviewed by a wider audience including collaborating partners, advisors, Lithuanian representatives from the Ministry of Health and NGOs. The session also reviewed the latest ECDC and EMCDDA information on epidemiology and responses to infectious diseases among PWID in Europe. The Advisory Board had its first meeting after the Kick-off. It is co-chaired by ECDC, EMCDDA and the Civil Society Forum on Drugs. In addition, members of the Board include representatives of Chafea, DG Santé, DG Home, WHO/EURO, 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 and the European Forum for Primary Care. To finalise work plans, a series of Logical Framework Approach workshops were implemented – one for each core work package. Detailed work plans and some indicators for the work packages were produced. The Partnership Forum was organised in November 2016 in Riga, and 50 partners from 19 countries gathered to discuss the results of the first year of activities, as well as future plans. Several international organizations and networks such as ECDC, Civil Society Forum on HIV/AIDS, European Forum for Primary Care and AFEW International were represented at the meeting. The Forum was followed by Steering Committee and Advisory Board meetings.
WP 4 –Testing and linkage to care started with more detailed country situation reviews to assess current situation, practice of testing for HIV, HCV and TB, referral for treatment and care and training needs in focus countries. A leaflet and a poster for PWID to promote rapid HIV and HCV tests in low threshold facilities in Latvia and Hungary were also prepared in cooperation with a drug user organisation. The materials are available in English, Hungarian, Latvian and Russian. The first draft of the training manual on HIV and HCV testing in low threshold settings has been prepared. The first three-day trainings on testing of HIV and HCV for personnel working with PWID in low-threshold facilities in Hungary and Latvia were implemented in the end of 2016. The second three-day training on testing of HIV and HCV, gender issues, TB and harm reduction for personnel working with PWID in low-threshold facilities was conducted in Latvia in 23-25 May, 2017.
WP5 Scaling up harm reduction organized two seminars for debate: 11-12 April in Vilnius and 14-15 April in Riga in order to identify stakeholders, share experiences, and start the assessment of needs/barriers to scale-up harm reduction interventions and improvement of epidemiological information availability. Country missions in Focus Countries to interview key persons have been implemented in order to identify gaps and barriers for HRI not detected during the deskwork and to adjust the specific project activities. Preparatory steps were taken for a study to updating estimates on PWID prevalence in Lithuania: sources of information have been identified and permission from the State Data Protection Inspection requested. In May 2017, terms of reference were finalised and a tender was opened on updating estimates on PWID. Preliminary work for a manual to overcome HRI professionals’ reluctance was also started; along with an agreement on the
During the 2nd year of the joint action, activities have been implemented with increasing speed. Latvian and Hungarian low-threshold service providers have been trained in rapid testing of HIV and HCV; and harm reduction measures tailored in women-friendly way as well as tuberculosis control have been the topics of the second training. Training manual on these issues including linkage to care has been drafted.
Several study visits have been organised for Latvian and Lithuanian professionals to get acquainted with harm reduction measures in Spain and Czech Republic. A mobile unit providing rapid testing, needle and syringe exchange, condoms and counselling has started to work in Riga. A study protocol on estimation of amount of people who use drugs in Lithuania has been prepared, and a manual on overcoming professionals’ reluctance towards harm reduction has been drafted.
Major training seminars have been organised for prison personnel in order to provide evidence and examples of harm reduction measures in prisons. A prison in Prague has started piloting of condom distribution. Educational and informational materials as well as e-learning modules have been produced. International workshops have been organised on integration of care for people who inject drugs, as well as on funding mechanisms for harm reduction. A survey among harm reduction service providers has been completed.
With regard to objective 1 (‘Improved early diagnosis of HIV, viral hepatitis and TB, as well as improved linkage to care for PWID’), some delays occurred due to restructuring of partner organisations in Hungary. This influenced continuation of training in Hungary, as well as procurement of test supplies to Hungarian service providers. The activities implemented cover: first training workshop in Hungary and two workshops in Latvia have been held; first draft of training manual has been prepared, and e-learning package has been outlined; Italian NGO LILA Milano was selected to develop gender-specific testing approach for women who use drugs.
With regard to objective 2 (‘Harm reduction scaled up in EU based on Latvian and Lithuanian cases’), all planned milestones have been completed totally or partially: country missions to Latvia and Lithuania have taken place; training package on key HRI has been developed; two seminars for debate have been organised in Riga and Vilnius; study visit for Latvian professionals was organised to Madrid and Barcelona; another Study visit took place in Czech Republic for Latvian and Lithuanian professionals; the third study visit was organised for Lithuanian professionals to Spain. NGO DIA-LOGS was chosen to implement a mobile harm reduction unit which has started its activities. “Manual to Overcome Harm Reduction Reluctance” and “Educational material to PWID” are now being developed based on identified key problems in relationship with Harm Reduction concept and drug-user necessities, respectively. Study protocol for estimation of number of people who use drugs has been developed. The beginning of the work in the 1st year was challenging as several partners realised during the logical framework workshop that they do not have enough human resources to fulfill the tasks they had taken. The workshop was followed by a transfer of several tasks to other partners. The second year has been full of activities, even though an important expert of the WP lead was unexpectedly and tragically deceased.
With regard to objective 3 (‘Increased harm reduction and improved continuity of care for PWID in prison settings’), most planned milestones have been completed totally or partially: country analyses have been started, but are delayed due to restructuring in Hungary; first training has been held to prison professionals; study visits for prison staff were organised to Berlin and Luxembourg; international training seminar on OST has been organised in Warsaw; meeting on NSP and harm reduction has been organised in Luxembourg; e-learning modules for PWID and prison staff has been produced; pilot prison has been chosen to implement HRIs and it has started condom distribution.
With regard to objective 4 (‘Improved provision of integrated HIV, HCV, TB treatment and harm reduction for PWID’),implementation of the milestones has been started: first international workshop has been organised, two national workshops have been held - in Estonia and Lithuania; material development for better quality care for PWID and mapping of existing guidelines has been started.
With regard to objective 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’), all planned milestones have been completed partially: preparatory work for strategy work has been started; policy reviews on prevention and treatment access barriers have been drafted; a survey has been implemented and literature review is finalised. Some delays have occurred due to different views of partners on how the tasks should be implemented.
A stakeholder analysis was performed and dissemination strategy planned in December 2015. The A-REACT website (www.hareact.eu/en) was launched in February 2016. A blog series on Biomed Central provides more detailed info about the project, its partners and activities: http://blogs.biomedcentral.com/on-health/tag/ha-react/; and already 11 blogs have been published. The project is very active on social media (in particular LinkedIn and Twitter); and the pan-European network AIDS Action Europe monthly newsletter features HA-REACT events, publications and news. A project leaflet was prepared, printed and published at the HA-REACT web page and distributed at events. It was updated again in May 2017.
Through WP3 reporting forms for workshops, study visits and trainings (evaluation sheet, mission report template, pre-post testing template) were developed. An evaluation framework was drafted, revised by appropriate parties and finalized. A live survey database was set up to collect data from four groups -associated partners, collaborating partners, advisory board, and national focal points to EMCDDA. The tools were extensively tested and piloted. The database was made functional in September, 2016; and two internal evaluations have been carried out.