International harm reduction indicators are still not reached: results from a repeated cross-sectional study on drug paraphernalia distribution in Germany, 2021.

BACKGROUND: To prevent the transmission of blood-borne infections and reach the elimination of viral hepatitis by 2030, the World Health Organization (WHO) has set the goal to distribute 300 sterile needles and syringes each year per person who injects drugs (PWID). We aimed to assess drug paraphernalia distribution in Germany in 2021, including the WHO indicator, and to analyse changes to the distribution measured in 2018. METHODS: We conducted a repeated cross-sectional study of low-threshold drug services in Germany. We assessed type and quantity of distributed drug paraphernalia and the number of supplied PWID in 2021 using an online and paper-based questionnaire. We conducted a descriptive statistical analysis of data from 2021, assessed fulfillment of the WHO indicator and changes in services that participated 2021 and in the previous study 2018. RESULTS: Five hundred and eighty-nine of 1760 distributed questionnaires were returned in 2021. 204 drug services from 15 out of 16 federal states confirmed drug paraphernalia distribution, covering 20% of Germany's rural and 51% of urban counties. 108 services had also participated in 2018. The most frequently distributed paraphernalia for injecting drug use in 2021 were syringes (97% of services), needles (96%) and vitamin C (90%). Pre-cut aluminium foil (79% of services) and pipes (28%) for inhaling, and sniff tubes (43%) for nasal use were distributed less frequently. We found a median reduction in distributed syringes by 18% and by 12% for needles compared to 2018. Of 15 states, two reached the 2030 WHO-target for needles and one for syringes. CONCLUSIONS: The current national estimates and changes from 2018 to 2021 for drug paraphernalia distribution seem far from meeting the WHO target. Reasons could include a change in drug consumption behaviour towards less injecting use and more inhaling, and effects of the COVID-19 pandemic (supply difficulties, social distancing, lockdown, reduced opening hours of services). We observed pronounced regional differences in drug paraphernalia distribution. To close existing gaps, Germany should expand its drug paraphernalia distribution programmes and other harm reduction services, such as drug consumption rooms. Further investigation of determinants for adequate distribution is essential to reduce blood-borne infections in this key population.

[Take-home naloxone: a building block of drug emergency prophylaxis in Germany]. / Take-Home Naloxon: Ein Baustein der Drogennotfallprophylaxe auch in Deutschland.

Naloxone is an opioid antagonist that reverses the (respiratory-paralyzing) effects of opioids in the body within minutes. Naloxone can therefore reduce opioid overdose deaths. Take-home naloxone (THN) is an intervention recommended by the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) and the World Health Organization (WHO). It involves training opioid users and their relatives or friends in the use of naloxone and providing them with the drug in case of emergency.So far, THN has been implemented in Germany mainly by individual addiction support facilities. In order to fully exploit the potential of THN, it is necessary to establish the measure nationwide. In particular, THN can be included in the services offered in (low-threshold) addiction support facilities, in psychiatric facilities, in the context of opioid substitution treatment, and in the correctional system.This discussion article reviews the development of THN in Germany since 1998, highlights the difficulties and obstacles to its widespread implementation, and outlines how THN can succeed as an effective public health intervention in Germany. This is particularly relevant in view of the increasing number of drug-related deaths over the past 10 years.

[HIV/HCV Among Drug Users in Germany: Elimination Targets in the Mirror of Practice]. / HIV/HCV unter Drogengebrauchenden in Deutschland: Die Eliminierungsziele im Spiegel der Praxis.

BACKGROUND: In 2016, the World Health Organization presented the first strategy for the elimination of viral hepatitis by 2030, following the goals of the Agenda 2030. Ending Acquired Immune Deficiency Syndrome (AIDS) by 2030 was also formulated as one of the Sustainable Development Goals and subsequently included and elaborated in the Joint United Nations Programme on HIV/AIDS (UNAIDS) strategy. People who inject drugs (PWID) are among the most vulnerable groups in terms of human immunodeficiency virus (HIV) and hepatitis C virus (HCV) infection. Following the objectives of the WHO and the UN, the German Federal Ministry of Health (BMG) has presented the first integrated overall strategy for HIV and Hepatitis C (as well as Hepatitis B and other sexually transmitted infections). OBJECTIVES AND METHODS: Six years after the adoption of the German government's BIS 2030 strategy this article discusses the role of PWID in Germany in relation to the elimination targets on HIV and HCV based on currently available data and in light of recent responses and efforts from the field. RESULTS: Although there are multiple positive practice approaches, the WHO elimination targets have not yet been achieved with regard to HCV and HIV in PWID. CONCLUSION: In order not to fail the elimination targets 2030, Germany will have to substantially improve the situation of PWID as a key group and in particular advance the implementation of diagnostics and treatment as well as evidence-based harm reduction measures.

A multicentre sero-behavioural survey for hepatitis B and C, HIV and HTLV among people who inject drugs in Germany using respondent driven sampling.

BACKGROUND: People who inject drugs are at high risk for hepatitis B, hepatitis C and HIV. HTLV was reported by neighboring countries to be prevalent in this population, but the situation for Germany is unclear. To generate seroprevalence and related behavioural data and to enhance prevention efforts against these infections for drug users in Germany, a multicentre sero- and behavioural survey was initiated. People who inject drugs are not well reached by services for testing and counselling for blood-borne infections in Germany. An interventional part of the study is intended to prove feasibility and acceptance of testing and counselling in low-threshold drop-in settings. METHODS/DESIGN: Between May 2011 and March 2015, eligible participants (persons having injected drugs within the last 12 months, aged 16 years+, and living in the study city) are recruited by respondent driven sampling, using low-threshold drop-in facilities as study-sites in eight German cities with large drug scenes. Calculated sample size is 2,033 participants. Capillary blood samples collected as dried blood spots are anonymously tested for serological and molecular markers of hepatitis B and C, HIV, and HTLV I and II. A detailed face-to-face-interview about hepatitis- and HIV-related knowledge, former testing, imprisonment, sexual and injecting risk behaviour is conducted with participants. Staff is trained to offer pre- and post-test-counselling of blood-borne infections and HIV rapid testing to participants. DISCUSSION: We chose respondent driven sampling for recruitment of participants to improve representativeness of results. Persons, who are not reached by the facility where the study is conducted, are aimed to be included by recruitment through their personal social network of injecting drug users. To reduce differential biases in the questions on knowledge of transmission and prevention of infections, we present true statements on hepatitis B, C and HIV, their possible routes of transmission and measures of prevention to participants. Participants are told that the statements are true and are asked to answer if they knew this fact already or if it is new to them. In case of knowledge gaps they are offered free targeted counselling as well as free HIV rapid testing and post-test counselling of HIV and hepatitis test results.

SMOKE IT! Promoting a change of opiate consumption pattern - from injecting to inhaling.

BACKGROUND: Intravenous drug use has been predominantly practised since illegal heroin use became known in Germany in the early 1970s. The available data suggest that the risk of accidental overdose when smoking heroin is substantially reduced compared to injecting a substance of unknown purity and quality. Moreover, the risk of transmitting HIV, Hepatitis B or C via blood contact is considerably reduced when smoking heroin rather than when injecting it intravenously. In spite of the significant strain on the lungs and the respiratory tract caused by smoking, it can be concluded that inhalative use - measured by the indicators 'overdose' and 'viral infections' is considerably less dangerous than intravenous use. Despite these harm-reducing effects of inhalative use, there is only very limited scientific survey on this subject. The project 'SMOKE IT!' studied to what extent a change of the consumption method can be supported by making new equipment for drug use available. METHOD: 'SMOKE IT!' was carried out as a multi-centre survey in drug consumption rooms (DCRs) in five German cities. Participants received 'SMOKE-IT!' packs that contained new heroin smoking foils, as well as information about inhalative drug use. The quantitative data collection was aided by a written questionnaire filled out at three different stages in 2012. RESULTS: The vast majority of the 165 respondents favoured using the foils from the 'SMOKE-IT!' packs (82.5%). The survey shows that two-thirds of the sample used the SMOKE-IT foils for inhaling instead of injecting. Almost six out of ten said that smoking was healthier than injecting. Thirty-five percent of the participants named the reduced risk of a hepatitis or HIV infection as a particularly important factor. A third of the respondents used the smoking foils to avoid the danger of an overdose. CONCLUSIONS: Targeted media and personal intervention in association with the dispensation of attractive drug use equipment can motivate opiate users to change their method of drug use. The main reason for inhalative use is that it is significantly less dangerous, measured by the indicators 'overdose' and 'viral infections'. All drop-in centres should expand their syringe-exchange services to include the dispensation of smoking foils.