The first outreach needle exchange program in Hungary
Judit Honti Peter Ban
Drug using habits in Hungary heretofore were different from those in Western Europe and the U.S.A. Substances generally used in these western countries except barbiturates -did not become common in Hungary. The closed political system, the lack of 'know-how' in the making of drugs, the high price of the drugs, and the severity of the laws restricted their spread. Because of legislation, other substances became easier to obtain and gained popularly in the 1970s. Berizodiazepines, trihexyphenidil (an anti-Parkinson drug), pills containing codeine derivatives and inhalants were used, mainly among teenagers. Users combined these substances with alcohol. Towards the end of the 1970s other forms of drug use became popular. The turning point occurred in the middle of the 1980s, when the technique of extracting opium from poppy heads was imported from Poland. The opium fluid is produced by cutting the green poppy head The white milk-like liquid which it contained was dried, boiled and acetilized. This home made opium Is used during the summer months. During the rest of' the year poppy tea, made from dried poppy heads is used. Because of the relatively low opiate content of poppy tea, 0.3 -0.7 g// I of' morphine, drug users combine poppy tea with gluthetimid, a sleeping pill. At the beginning of the 1990s, a method for making heroin out of opium came into the country, also from Poland. Marijuana is largely farmed in the region. Parallel with the political changes in Hungary at the beginning of' the 1990s and the Serbian war, the black market expanded. Dealers provided almost all kinds of internationally trafficked drugs. Nowadays, heroin and a huge amount of very cheap amphetamine are available for injecting drug users all the year, The use of cocaine has also become more prevalent over the past year.
2. The city and the region
Szeged is located on the southern border of Hungary, near the former Yugoslavia, in the middle of the Great Plains. The region is basically agricultural. The city has 200000 citizens and has traditionally been a university town . Around the city, private poppy plantations have been determining local drug using habits for years. Its location, near the border and at the European main route (E75). are also determining factors. During the Serbian war, the main drug traffic route between Turkey and Western-Europe, the Zagreb Beograd highway wits destroyed and the drug route shifted to Hungary, crossing Szeged, as the first big city in the country.
3. The drug scene and the youth drug center
The Youth Drug Center was established in 1987, as the first institutional reaction of' the government to the emerging drug problem. Its aim is to be a model institute for providing primary, school-based prevention, outpatient counseling and treatment and rehabilitation. Drug use during the 1970s mostly occurred in public places, i.e. yards, the river bank. However, the procedure of making extracts from poppies required kitchens, so since the 1980s drug users started to move into flats, staying hidden from the public. Drug use happened mainly in groups, and from the data of' a former survey of the Pompidou Group, we know that the prevalence of' needle sharing was very high. At the beginning of the 1990s, when the black market expanded, injecting use of' imported drugs increased, and fasted during the whole year. Injecting drug use started to appear in public places, like alternative pubs and university clubs. "Harm reduction" policies begin with the acknowledgement that some users cannot be persuaded to quit and then seek to reduce the likelihood that they will contract or spread diseases such as hepatitis and AIDS. "overdose" on drugs of' unknown purity and potency, or otherwise harm themselves or others (Nadelmann, 1993). Only four years after its establishment, the Drug Center recognized the philosophy of harm reduction. In 1991, as a response to the high prevalence of' needle sharing and an emerging epidemic in Poland, the Youth Drug Center started an in-house needle exchange program in 1991. The project began unofficially. The site of the needle exchange was in the building of' the basically abstinence oriented Youth Drug Center. The IDUs used the service only in summer. At the beginning, this involved up to 1500 syringes a year, but this number continuously decreased and drug users reported less willingness to go to that site for sterile syringes.
There are about 610 registered HIV positive cases in Hungary up to the present, 133 died of' AIDS (Statistical Yearbook of Hungary, 1996). There are only seven detected sero-positive cases in our county (the population is 450000) and two persons died from AIDS. The number of' registered drug users in the Youth Drug Center is 384 since 1987, 43% of them are IDUs; 31% of the IDUs have already shared syringes. In 1996, 69% of the clients Linder treatment were IDUs and 50'Y~, of them reported needle sharing. HIV and hepatitis B screening has been going on for sonic years at the Drug Center. No positive cases were detected until now. Hepatitis C screening started in 1992 in different institutions of the city. The first hepatitis C positive IDU case wits detected in 1994. They Found 12%, sero-positivity 2 years later, among the newly registered clients. Hepatitis C infections are not reported in the Statistical Yearbook of Hungary, 1995.
5. The Lindesmith center
After the political changes around 1990, Central and Eastern European countries experienced widespread use of illicit drugs and, in sonic of' them, an increasing prevalence of* HIV infection. Intravenous drug users are the largest group of' people living with HIV or AIDS in Poland -70 and 46'Y,,, respectively (Beniowski and Bozek, 1997). The main cause of HIV spread in the Ukraine is through the sharing of' injecting equipmcrit by injecting drug users (Andrushchak et al., 1997). However, in 1996 few harm reduction programs were going on in these regions. In 1995, the Drug Center applied for a grant to The Lindesmith Center of' the Open Society Institute to obtain funding for the establishment of a low threshold harm reduction program. From 1996, The Lindesmith Center of The Open Society Institute selected, and has been funding, 13 low threshold harm reduction services from Central and Eastern Europe as being model programs at the region. These programs have been partnered with well established service organizations from
Western Europe and the U.S.A., as mirror organizations. These organizations were to provide targeted pragmatic support and ongoing communication with the model projects. In March, 1996, the Lindesmith Center held a workshop in Budapest to bring together the professionals of the Model Project Program. Our project is partnered with The Integrative Drogenhilfe, Frankfurt. The formal assessment of our local situation, Current problem and probable needs happened during this workshop. Our colleagues at the Frankfurt institute made a short site visit to Szeged and then we started to develop a working plan of a low threshold outreach syringe exchange service.
6. Local conditions
The Drug Center has developed a narrow range of' contacts with the drug using population but we had little contact with the hidden drug scene. The need for using a sterile syringe was not an issue for drug users. Taking all this into consideration we developed the idea of a low threshold project of outreach work, needle exchange and peer education. Our anticipated interventions were making contact with the hidden group of drug users providing sterile syringe and collecting the used ones, providing condoms, providing written information about the services~ providing peer education oil safer way of drug use, sex and contagious diseases.
The legal regulations for harm reduction activities are not yet set in Hungary but we managed to negotiate with the local police and public health authorities to get special permission for the outreach needle exchange program.
8. The beginning
We started to build a staff Of Outreach workers, using current drug users and social worker students. They go out to the site on a daily basis to exchange syringes. The collected used syringes are forwarded to the near Children's Hospital's Burning Unit. The outreach workers stay on the site 2-4 hours a day. We have a weekly staff meeting where the outreach workers report on the last week's work and hand in the data sheets. They fill in a data sheet on a daily basis, collect data on the site of needle exchange, number of issued and collected needles, number of clients that they met, number of new clients, occurrence of' needle sharing, and the kinds of drugs used. We collect these raw data and we don't register the clients, even anonymously.
9. What did we do and learn?
The outreach workers make syringe exchanges in parks, pubs and apartments with an exchange rate of 64 83'Y,,. The most frequent sites are apartments. Before, we knew about a few apartments as drug using sites. During the first hall' year of the program, we have got to know 30 different apartments where IDUs are staying and shooting up. Between five and fifteen persons used to stay in one apartment. The outreach workers made regular contact with about 200 drug users. For comparison the number of newly registered users at the Drug Center in 1996 was 55. The outreach workers exchange 2-5 syringes per contact. The number of contacts was 78 704 per month (average: 299, S.D.: 215), totally: 2999. We issued 393 1264 syringes per month (average: 835, S.D. 284), totally: 8142. We collected syringes 251 - 1085 (average: 647, S.D.: 264), total: 6466.
We experienced a decrease in the number of needles exchanged until December, so we decided to increase our accessibility. We wrote a small leaflet on safer drug Use, safe sex, infectious diseases and the needle exchange service. We also started to use an easy call machine. The phone number of the easy call is also on the leaflet. Nowadays, we have ten to thirty calls a day to make appointments with the outreach workers.
10. Drugs used
The official data of' the Drug Center reports on the opiate epidemic. Our data at the needle exchange program shows opiate use during the summer season, when home made poppy extracts are available, and amphetamine and street heroin use in the autumn and winter. From the Outreach workers' weekly narrative reports we have also learned that the older users tend to use street heroin. The new ones, the weekend and recreational users tend to use amphetamine.
Our outreach needle exchange program is the very first in the country. We arc working in it Situation where any harm reduction activity is not legal in the country and in it climate of' public ignorance. The concept of' harm reduction has proved to be an important component of public health efforts to control the spread of 'HIV among IDUs ina number of developcd countries (Wodak et al., 1993). Considering the hidden IDU population and the local Situation with infectious diseases, the time is right to set up such a program.
However, the government may not consider that the intervention is important and our program could be implemented by foreign funding resource which could be a limit the sustainability of our program.
Andrushchak L, Kliod~tke~icii L IV~tSyLik V, Kohyslicha Y. Dewloping an Extensive Response to HIV Lpidemic in Injecting Ditig Users in Ukraine. Oral presentation at the 8th International Cont'erence on the Reduelion of' Drug Related Harm. Paris, France: 1997.
Benio,Aski M, Bozek E. From AIDS to Ilarin Reduction: Initiati\es in Poland (K~itok~,ice Distfict). Oral presentation at the 8th Intermitional Cont'erence on the Reduction of' Drug Related Ilann. Pari,, France: 1997.
Nadelinann F. Progressive legalizers. progressive prohibitioniStS ',111(1 OIC rC(-11[CtiOll 01'(11'Lig-I-Cl~itC(I1M1-111. In: I leather N, Woelak A, Nadelinann F, O'llare [1 (Eds.), Psychoactne Drugs and Haini Reduction: [.ioiii Vaith to Science. London: Whin.j., 1993.
Wo(lak A, Vischer R. Ciolls N. An exolving public ficalth crisis: HIV iiif'ccti,)ii aniong mjecting drui, users in dewlop ' ng countries. In: Ileathei N. Wodak A, Nadelmann F. O'llare 11 Psychoactive Drugs and Harin Reduction: Vrom Faith to Science. London: W1WIT, 1993.