Thirteen of the 20 (65%) centres contacted returned the completed survey: the Basque Country (n=4), Catalonia (n=6), Madrid (n=2), and Valencia (n=1). All 13 centres provide NSP and four (30%) have a supervised injecting room. All centres offer mental health services by connecting users to established programmes, including other non-governmental organisations (NGOs) (n=4), referring them to established services in the public system (n=7), or providing the services that are integrated into their centre (n=2). A summary of the main services offered by the 11 centres is described in Table 1. All centres (n=13) reported having had to adapt procedures in their centres by making mask-use mandatory, setting up socially distanced spaces, limiting capacity, and/or installing Plexiglas in order to guarantee the continuation of their activities during the Spanish COVID-19 state of alarm. Of these, two centres shut down during this period.
Table 1. Description of harm reduction services regularly provided by centres and number of users per centre (n=11) during the first six months of the years 2019 and 2020, Spain (n=11)
Centre
(City name)
|
n. users 2019
(Jan-June)
|
n. users 2020
(Jan- June)
|
NSP
|
SIR
|
Naloxone distribution
|
Education services
|
Mental health services
|
OST
|
HCV DAA
|
HIV ART
|
HBV testing
|
HCV testing
|
HIV testing
|
TB testing
|
Centre 1 (Badalona)
|
265
|
274
|
✓
|
|
✓
|
✓
|
✓
|
|
|
|
|
|
|
|
Centre 2 (Bilbao)
|
923
|
721
|
✓
|
✓
|
|
✓
|
✓
|
|
|
|
|
✓
|
|
✓
|
Centre 3
(Madrid)
|
4528
|
1945
|
✓
|
|
✓
|
✓
|
✓
|
✓
|
✓
|
✓
|
✓
|
✓
|
✓
|
✓
|
Centre 4
(Madrid)
|
892
|
1090
|
✓
|
|
✓
|
✓
|
✓
|
✓
|
✓
|
✓
|
✓
|
✓
|
✓
|
✓
|
Centre 5
(Vitoria-Gasteiz)
|
77
|
60
|
✓
|
|
|
|
✓
|
✓
|
|
|
|
|
✓
|
|
Centre 6
(Bilbao)
|
1267
|
1080
|
✓
|
|
|
✓
|
✓
|
|
✓
|
✓
|
✓
|
✓
|
✓
|
|
Centre 7
(Reus)
|
394
|
398
|
✓
|
|
✓
|
✓
|
✓
|
✓
|
|
|
|
|
|
|
Centre 8
(Valencia)
|
764
|
687
|
✓
|
|
|
✓
|
✓
|
✓
|
✓
|
✓
|
✓
|
✓
|
✓
|
✓
|
Centre 9
(Bilbao)
|
1365
|
679
|
✓
|
|
|
✓
|
✓
|
|
|
|
|
|
|
|
Centre 10
(El Prat de Llobregat)
|
2652
|
3351
|
✓
|
|
✓
|
✓
|
✓
|
✓
|
|
✓
|
|
✓
|
✓
|
|
Centre 11
(Barcelona)
|
N/A
|
N/A
|
✓
|
✓
|
✓
|
✓
|
✓
|
|
✓
|
|
✓
|
✓
|
✓
|
✓
|
Centre 12
(Barcelona)
|
N/A
|
N/A
|
✓
|
✓
|
✓
|
✓
|
✓
|
✓
|
✓
|
|
✓
|
✓
|
✓
|
✓
|
Centre 13
(Sant Adrià de Besos)
|
6166
|
3912
|
✓
|
✓
|
✓
|
✓
|
✓
|
|
✓
|
|
|
✓
|
✓
|
|
Total
|
|
|
13
|
4
|
8
|
12
|
13
|
7
|
7
|
5
|
6
|
9
|
9
|
6
|
Abbreviations: Needle and syringe programme (NSP); supervised injecting room (SIR); opioid substation therapy (OST); direct acting antivirals (DAA); hepatitis B virus (HBV); hepatitis C virus (HCV); human immunodeficiency virus (HIV); tuberculosis (TB); not available (N/A)
The average age of clients in 2019 in the centres that provided data (n=7) was 43.7 years (range: 40–47) and the average number of users in 12/13 centres in the same year was 1,281 (range: 15–8,748). All centres that responded (12/13) served more men (12,400 total, range: 13–6,735) than women (2,969 total, range: 2–2,013). Of the 11 centres that provided data, Spanish nationals (9,799 total, range: 11–5861) made up the majority of service users compared to those from other countries(5,064 total, range: 4–2,887).
Impact of the COVID-19 pandemic on harm reduction operating hours and service users
Eleven out of thirteen (84.6%) centres reported that they were able to keep their centres open and operational during the Spanish state of alarm. One centre had to close in March and April 2020 but reopened on 27 May 2020 and the other closed from March until the end of the state of alarm (21 June 2020). The average weekly operating hours in 2019 for centres that reported these data (n=9) was 52.4 hours (range: 15–92) and in 2020 it was 47.4 hours (range: 25–82). Four centres reduced their operating hours while the remaining five others increased their operating hours (Table 2).
Table 2. Operating hours and percentage change of centres with reported data (n=9) pre-state of alarm and during
Centre
(City name)
|
Weekly operating hours
(Pre-state of alarm)
|
Weekly operating hours
(During state of alarm)
|
% Change
|
Centre 1
(Badalona)
|
15
|
25
|
+67%
|
Centre 2
(Bilbao)
|
52.5
|
66.5
|
+27%
|
Centre 3
(Madrid)
|
63
|
28
|
-56%
|
Centre 4
(Madrid)
|
63
|
49
|
-22%
|
Centre 5
(Vitoria-Gasteiz)
|
35
|
15
|
-57%
|
Centre 6
(Bilbao)
|
66
|
84
|
+27%
|
Centre 7
(Reus)
|
N/A
|
N/A
|
N/A
|
Centre 8
(Valencia)
|
N/A
|
N/A
|
N/A
|
Centre 9
(Bilbao)
|
N/A
|
N/A
|
N/A
|
Centre 10
(El Prat de Llobregat)
|
29
|
42.5
|
+47%
|
Centre 11
(Barcelona)
|
56
|
35
|
-37.5%
|
Centre 12
(Barcelona)
|
N/A
|
N/A
|
N/A
|
Centre 13
(Sant Adrià de Besos)
|
92
|
82
|
-11%
|
The average number of service users between the months of January–June 2019 in the centres (n=11) was 292 (range: 11–1141) in comparison to the same months in 2020, which was 215 (range: 0–819). The difference in the overall average number of service users reflects a decrease of 26.4%. There was great variability among centres (Figure 1).
Impact of the COVID-19 pandemic on needle and syringe programmes and distribution of materials
Ten of the 13 (76.9%) centres reported data on needle distribution for the months of March–June 2019 and 11/13 (84.6%) reported data for the same months in 2020. One centre did not have 2019 data available (Centre 9). March 2019 had the highest monthly average of needle distribution (7,393) among the 10 centres that reported these data and April 2020 had the least number of needles distributed on average (3,555). The total four-month average of distributed needles was 6,831. During the same months in 2020, the average number of needles distributed reduced by 40% (4,140). There was variability between each centre and some reported an increase in needle distribution in the 2020 months compared to 2019 (Figure 2).
Impact of the COVID-19 pandemic on infectious disease testing
All centres reported testing for infectious diseases in situ. Six (46%) centres reported offering HBV testing and Mantoux tests for TB while nine (69%) offered HCV and HIV testing. Not all centres provided testing data despite reporting that they do provide them. Overall, most centres reported a decrease in testing rates for March, April, and May in 2020 compared to the year before for all infectious diseases. In some centres, HIV and HCV testing greatly increased in June 2020 in comparison to the year before and the month prior (May 2020). Testing rates for each centre for the months of March–June in 2019 and 2020 are described in Table 2.
Table 3. Infectious disease (HBV, HCV, HIV, and TB) testing rate per 1,000 service users in March–June 2019 and March–June 2020
HIV TESTING RATES
|
|
Mar 19´
|
Mar 20´
|
Apr 19´
|
Apr 20´
|
May 19´
|
May 20´
|
Jun 19´
|
Jun 20´
|
Centre 3
|
50.2
|
23.8
|
35.3
|
29.0
|
52.6
|
72.5
|
49.2
|
97.2
|
Centre 4
|
40.5
|
38.5
|
211.9
|
0
|
112.6
|
4.9
|
27.6
|
0
|
Centre 6
|
58.5
|
30.5
|
36.7
|
0
|
41.9
|
46.9
|
65.8
|
193.7
|
Centre 8
|
63.5
|
52.2
|
85.3
|
0
|
90.2
|
19.2
|
14.8
|
67.8
|
Centre 10
|
2.8
|
1.8
|
0
|
0
|
0
|
0
|
0
|
0
|
Centre 13
|
7.6
|
14.1
|
9.5
|
0
|
39.6
|
13.2
|
35.9
|
23.1
|
HCV TESTING RATES
|
|
Mar 19´
|
Mar 20´
|
Apr 19´
|
Apr 20´
|
May 19´
|
May 20´
|
Jun 19´
|
Jun 20´
|
Centre 2
|
0
|
0
|
0
|
0
|
0
|
0
|
0
|
8.4
|
Centre 3
|
50.2
|
23.8
|
35.3
|
29.0
|
52.6
|
72.5
|
49.2
|
97.2
|
Centre 4
|
40.5
|
38.5
|
211.9
|
0
|
112.6
|
4.9
|
27.6
|
0
|
Centre 6
|
58.5
|
30.5
|
36.7
|
0
|
41.9
|
46.9
|
65.8
|
193.7
|
Centre 8
|
63.5
|
52.2
|
85.3
|
0
|
90.2
|
19.2
|
14.8
|
67.8
|
Centre 10
|
2.8
|
1.8
|
0
|
0
|
0
|
0
|
0
|
0
|
Centre 13
|
7.6
|
14.1
|
9.5
|
0
|
39.6
|
13.2
|
35.9
|
23.1
|
HBV TESTING RATES
|
|
Mar 19´
|
Mar 20´
|
Apr 19´
|
Apr 20´
|
May 19´
|
May 20´
|
Jun 19´
|
Jun 20´
|
Centre 3
|
29.3
|
20.4
|
21.4
|
0
|
26.3
|
0
|
28.1
|
71.6
|
Centre 4
|
20.3
|
11.0
|
19.9
|
0
|
0
|
0
|
0
|
0
|
Centre 6
|
0
|
5.1
|
0
|
0
|
0
|
5.2
|
0
|
20.9
|
Centre 8
|
39.7
|
26.1
|
54.3
|
0
|
22.6
|
0
|
7.4
|
0
|
Centre 10
|
2.8
|
1.8
|
0
|
0
|
0
|
0
|
0
|
0
|
TB TESTING RATES
|
|
Mar 19´
|
Mar 20´
|
Apr 19´
|
Apr 20´
|
May 19´
|
May 20´
|
Jun 19´
|
Jun 20´
|
Centre 2
|
0
|
0
|
0
|
0
|
0
|
8.8
|
0
|
16.8
|
Centre 3
|
8.4
|
13.6
|
2.5
|
0
|
5.5
|
0
|
7.0
|
25.6
|
Centre 4
|
40.5
|
27.5
|
72.8
|
0
|
38.7
|
0
|
20.7
|
10.0
|
Centre 8
|
7.9
|
8.7
|
38.8
|
11.2
|
22.6
|
0
|
22.2
|
0
|
|
Note:Only centres that reported providing HBV, HCV, HIV, and TB testing are reflected in this table.
Impact of the COVID-19 pandemic on treatment administration (methadone, DAAs, ART)
Six (46%) out of 13 centres reported providing methadone on-site, and six (46%) centres provided DAAs and five (38%) provided ART, respectively. In the months of March–June 2019, 1,163 clients in all centres received methadone versus 1,422 in the same months in 2020, seeing a 22% increase in methadone distribution. In the six centres that reported distributing DAA therapy, 88 clients received DAAs in 2019 during the same months compared to 16 in 2020. One centre did not report this data for 2019. This represents an 82% decrease. In the five centres that reported ART distribution, 10 clients received ART in 2019 compared to 13 during the same months in 2020, showing a 30% increase.
Impact of the COVID-19 pandemic on overdose and medical emergencies
Nine of the 13 (69%) centres responded that they did not see an increase in reported overdose deaths during the Spanish state of alarm, while one centre (7.6%) reported they did see an increase, another (7.6%) did not know, and two centres did not respond.
Two of the 13 (15.4%) centres responded that they saw an increase in reported overdose deaths immediately after the Spanish state of alarm ended. One centre (7.6%) did not know if overdose deaths increased, the remaining (61.5%) did not report an increase in overdose deaths in their centres, and two (15.4%) did not respond.
There were a total of 99 reported medical emergencies across all centres that responded (9/13) between March and June 2019 with a range of zero medical emergencies to 26 per month. During the months of March to June 2020, there were a total of 96 reported medical emergencies among the same centres, ranging from zero medical emergencies to 25 per month.
Challenges faced by PWUD during the COVID-19 pandemic state of alarm in Spain
Twelve (92%) centres responded to the questions regarding challenges faced by PWUD during the COVID-19 pandemic state of alarm. Those who responded to the survey reported that limited access to social workers who assist with social benefit processes was the most problematic issue affecting PWUD, with all 12 (100%) people surveyed responding that it was “problematic” or “very problematic”. Ten (83%) respondents also believed that difficulties with the police while on the street would be a “problematic” or “very problematic” issue for PWUD, in addition to an increase in mental health issues (8/12) and limited access to drug-checking services (6/12) (Figure 3).
Government response to the COVID-19 pandemic
The types of regional agencies responsible for managing and coordinating the COVID-19 response in their autonomous communities for PWUD vary. Of those that responded to the question (n=12), the majority of centres said that the responsible entity performed average (n=4) or below average (n=4). One centre responded that their responsible administration did an excellent job and three (25%) reported that their agencies did better than average.