“Integrated interventions are dead. Long live sustainable integrated interventions!” — Austerity Challenges the Continuation of Effective Interventions in the Field of Drug Use-Related Harm Reduction

December 2013 saw the end of “Aristotle” - a “seek, test, treat and retain” intervention. “Aristotle” was co-funded by the European Social Fund and national resources, and was implemented by the Department of Hygiene, Epidemiology and Medical Statistics of Athens University Medical School and the Organisation against Drugs as a response (along with other responses) to an HIV outbreak in Athens (Sypsa et al., 2015). In 2011, the number of newly diagnosed HIV infections among people who inject drugs was 16 times higher than in 2010 (Nikolopoulos et al., 2015; Paraskevis et al., 2013). “Aristotle” contributed significantly to the containment of the outbreak (Sypsa et al., July 20–25 2014), worked jointly with other multidisciplinary interventions in the area, e.g. Transmission Reduction Intervention Project (TRIP; see Friedman et al., 2014), and gained European and international recognition (“Reacting to an outbreak,” n.d.). In early 2015, the epidemic has substantially receded even though the number of new HIV diagnoses has not decreased to the pre-outbreak levels yet. Although “Aristotle” was a successful, integrated intervention which effectively reduced drug use-related harm, the odds that the programme will continue are very low given the lack of ongoing funding. A number of critical questions need to be explored:

• Is it enough to put efforts only (or mainly) on designing effective integrated interventions and running them once?

• Should we try for something more than that?

• What are the conditions, from micro to macro levels, which are necessary to enable ongoing, effective intervention planning, implementations and assessments (process as well as outcomes) to operate, or not to operate being aware that uncertainties, unpredictability and lack of total control is an ongoing reality?

We believe that effective interventions in the field of drug use prevention, treatment and harm reduction are effective only if they can be sustainable over long periods of time. But is sustainability certain?

In the European region, the number of countries that have included prevention, treatment and harm reduction in their national drug intervention policies and strategies has increased (MacGregor & Whiting, 2010). Following international recommendations (e.g., Joint United Nations Programme on HIV/AIDS [UNAIDS], European Centre for Disease Control and Prevention [ECDC] and the European Monitoring Centre for Drugs and Drug Addiction [EMCDDA]), an increasing number of countries have joined their forces to improve surveillance and monitoring systems collecting epidemiologic and coverage data about high-risk drug use and their related harms (Hope et al., 2010). However, funding for these operations should not be taken for granted. Austerity and budgetary cuts in many European countries risk the size, quality and sustainability of these operations (Harm Reduction International, 2012). In many parts of the world, programmes face widespread challenges in the context of economic and donor uncertainty (e.g. Global Fund in Romania; see ECDC, 2013a, 2013b; Harm Reduction International, 2012). Climate changes and their ecologic and economic consequences are likely to exacerbate these challenges (Friedman & Rossi, in press).

The Greek response to the outbreak showed the importance of engaging all key players in combination approaches. At the national level, the role of public agencies and institutions has been central in detecting and understanding the epidemic, in identifying risk factors¹ and assessing needs for immediate response.² Both governmental and non-governmental agencies in the field of specialised treatment and harm reduction, including drug-user groups, offered essential services to HIV-infected people who use drugs and raised awareness among the non-infected. At the international level, European institutions (notably the ECDC and the EMCDDA) and other key experts from all over the world have also contributed substantially with their expertise and policy advocacy. Synergy of key players (persons and institutions) and the combined implementation of evidence-based interventions³ are prerequisites of best practice (Degenhardt et al., 2010). Yet, institutions and best practice depend on ongoing, time-appropriate, political and financial support. And, in countries like Greece, where economic crisis and austerity affect policy decisions, the sustainability of both institutions and programs is at stake.

Integrated and synergistic interventions are very useful and correctly advocated as models of best practice. Yet, intervention “business” remains unfinished if and when successful interventions are discontinued. Obviously, the suggestion here is not to refrain from undertaking integrated interventions with time-limited resources. Instead, we believe that the drug use(r)-related intervention community - individuals as well as systemic stakeholders for health and wellbeing - should not relax on its temporal successes of a well-designed approach. The struggle for political and economic support to anchor effective interventions within financially sustainable and temporally-sensitive systems remains as a critical challenge to relevant stakeholders as well as to local and global communities.

Biographies

Georgios Nikolopoulos, PhD, GR., has received a post-doctoral research fellowship from the International AIDS Society and the National Institute on Drug Abuse and is now leading the Transmission Reduction Intervention Project (Principal Investigator: Dr Samuel Friedman) in Athens, Greece. He earned a PhD in the epidemiology of infectious diseases at the School of Medicine of the Athens University in Greece and has served at the Greek public health agency, focusing on HIV surveillance. Dr. Nikolopoulos also has expertise in the conduct of systematic reviews and meta-analyses with useful contributions to the evolving domain of genetic epidemiology.

Anastasios Fotiou, PhD, GR, is the head of the Epidemiology Unit of the Greek Reitox focal point of the EMCDDA at the University Mental Health Research Institute (UMHRI), Athens, Greece. He is also a researcher in the Drug Epidemiology Research and Prevention section at UMHRI. He has worked on epidemiological studies of substance use and related harm in the general and special populations in Greece. His research interests are in tobacco, alcohol and other substance use, high-risk drug use and related harm, psychosocial factors, prevention and responses. Anastasios Fotiou has received B.A. degree in sociology from the University of Crete (Greece), an M.A. degree in sociology from for the Essex University (U.K.) and a Ph.D. degree in psychiatry from the medical school of the National and Kapodistrian University of Athens. He has also received the State Scholarships Foundation award in 1992.