Challenges of providing COVID-19 prevention services to homeless people who use drugs in Iran

Iran was among the first countries struck by the COVID-19 pandemic and is currently among the highest infection prevalence and mortality in the world (World Health Organization, 2020a). People who use drugs (PWUD) and specifically those without homes have potentially higher probability of contracting and transmitting COVID-19 due to limited access to personal hygiene facilities and medical care, and suffering from underlying diseases (United Nations Office on Drugs and Crime, 2020; Volkow, 2020). This article focuses its attention on people who have often experienced several years of homelessness, injecting and high sexual risk behavior while residing in so-called ‘spots’ [Patogh] located in streets and the margins of highways, parks, deserted buildings and temporary shelters (Amin-Esmaeili, Rahimi-Movaghar, Gholamrezaei, & Razaghi, 2016). So it is important to ensure adequate access of low-threshold and COVID-19 services for people residing at ‘spots’.

To respond and manage the COVID-19 crisis among PWUD, responsible government organizations planned strategies including stopping admissions in voluntary mid-term residential addiction treatment centres (Drug Control Headquarter, 2020) and providing longer take-home doses for people on opioid agonist therapy. To slow the spread of coronavirus, compulsory treatment programme through arresting and transferring people to residential treatment centres stopped and discharges were postponed. Recently, following pressure from the Social Services Organization of Tehran Municipality and the mass media on the presence of the homeless people in the public places, it was decided to re-implement compulsory addiction treatment programmes based on a special protocol which is being drafted by the National Committee on Combatting Coronavirus. Additionally, to maintain social distancing, the Judiciary released a large number of prisoners (TasnimNewsAgency, 2020). These measures probably increased the number of homeless people in ‘spots’ and clients in harm reduction centres.

Non-governmental organizations (NGOs) in Iran are key partners in implementing harm reduction programmes, operating as an expansive network of community-based drop-in centres, shelters, outreach teams and mobile centres. To protect the homeless PWUD from COVID-19, Iranian NGOs and harm reduction staff have faced the following challenges in conducting appropriate interventions.

Drug ‘spots’: Sharing drug consumption paraphernalia, living communally, lack of proper nutrition, and making money through waste collection are common among people residing at ‘spots’. For those located in the margins of highways and deserted areas where there is no access to water and sanitation, provision of hand washing liquids or bars of soap is not practical. Instead, distribution of alcohol pads and disinfectants is more useful and helpful. For the ‘spots’ located near or in parks, with reference to the social distancing restrictions in public places, access to water and sanitation has been limited, resulted in increased risk of contracting and transmitting the infection.

Isolation and care: If a homeless person is diagnosed with COVID-19, the main barrier for isolation is the absence of a safe place in which to meet their basic needs. In addition, even though opioid users may be treated by opioid maintenance medications in quarantine, stimulant users remain a big problem because they are not allowed to use drugs and receive the infection treatment services simultaneously.

Education: People living at ‘spots’ rarely have access to cell phone or the Internet, hence it is not possible for them to receive online training or information. It is very difficult to maintain a safe distance during face-to-face education, so increases the risk of infection and transmission. It has been helpful to make educational podcasts and play them with a loudspeaker on a mobile van, although it is not feasible in some spots which are close to residential neighbourhoods.

Drop-in centres and shelters: The large number of clients has led to crowds causing higher risks of infection and transmission. For this reason, the time spent by clients in the centres has been reduced and they are not allowed to be too close together. In addition, the capacity of shelters has been reduced because the distance between the beds must be maintained. There are not enough centres to provide services, so a significant number of homeless PWUD has been deprived of harm reduction services, especially shelter. This may affect the spread of other diseases, such as HIV/AIDS and viral hepatitis.

Peer-support workers: The majority of individuals providing harm reduction services are peers. Many of them are in older age groups. According to the strict COVID-19 care recommendations for personnel, the use of these human resources should be carried out with caution. In addition, participation in the provision of services in this setting is subject to informed consent and volunteering. The number of active staff has declined and the probability of their burnout has increased (World Health Organization, 2020b).

Supply shortage: Lack and/or shortage of disinfectants and medical equipment are a public concern. Furthermore, the common bureaucracy of government agencies to send essential medical supplies and equipment does not have capacity for the current situation. This has not only slowed down the provision of services but also has affected the spirit of service providers; for instance, their motivation and enthusiasm. However, the advocacy and use of public networks, NGOs, donors and professionals have been somewhat helpful.

Social stigma: People who are homeless and use drugs face stigma and discrimination (Rafiey, Alipour, Moghanibashi-Mansourieh, & Mardani, 2019).With the emergence of COVID-19, a discriminatory public impression was formed in the country that homeless PWUD are “coronavirus moving bombs”. The impression was - intentionally or unintentionally - provoked by some organizations and social activists who are in favor of arrest and compulsory addiction treatment programmes. So part of the energy of other activists and NGOs is now devoted to advocacy and demands for effective and humane interventions.

Monitoring and follow up: Transient and marginalized community receives limited social support. If they contract COVID-19 or even die, the health care system will not have accurate information about their status. For this reason, they people who are homeless and use drugs are usually missed in the data, which makes it very difficult to assess and respond to the issue.

Availability of drugs: Due to intra and inter city traffic and travel restrictions, and the drug dealers’ fears of contracting COVID-19, drug distribution network may be disrupted, leading to a lack of access. Stockpiling of drugs by consumers may increase the probability of high-risk consumption methods, such as injection and overdose.

It seems that successful control of COVID-19 prevalence cannot be achieved without attention, design and implementation of targeted interventions for vulnerable groups, especially homeless PWUD. Therefore, to prevent undoing the effects of the necessary measures that have been taken throughout Iran, essential support actions should be conducted immediately by international organizations such as United Nations Office on Drugs and Crime (UNODC), World Health Organization (WHO) and national responsible government agencies which meet the needs of people who are homeless, who use drugs, and who are living at ‘spots’.

Declaration of Competing Interests

The authors declare that there is no conflict of interest on the publication of this manuscript.