PEER EDUCATION AT THE FREE CLINIC OF ANTWERP
Sven Todts, Free Clinic, Antwerp, Belgium
This is a version of a paper presented at the VIth International Conference on the Reduction of Drug Related Harm in Florence, March 1995.
Free Clinic was established in 1973 as a low-threshold centre aiming to deliver affordable integrated medical, social and psychological care to young people Drug problems are an important but not exclusive part of our work. HIV prevention in IDUs started in 1988. Needle exchange was illegal, ambulatory treatment practica11y nonexistent, funding and personnel unavailable . Looking for cheap solutions, we decided to seek the cooperation of the IDUs themselves: with some funding from the City Health Board we engaged and trained a first batch of five active IDUs to deliver HIV prevention to their peers. They distributed prevention kits containing an informative comic, syringes, condoms, bleach and stabs. The 'Cool' project succeeded in reaching hundreds of IDUs in a short period for a price of about US$8 per contact. Since then, the project is funded for the Flemish region. This article will deal with training issues, effects on behaviour and on government drug policies .
Since 1989, the Free Clinic of Antwerp has run at HIV prevention programme that involves drug user as counsellors on a street level. This article will consider the work in this held, as well as the social and political environment in which it was performed.
Free Clinic is a small, non-governmental institute that was founded in 1973. It has its roots in the countercultural movement of the late 1960s and early 1970s. From the beginning, its aim was to provide integrated medical and psychosocial help to young people, and to provide these services free of charge More specifically, it was the intention to provide services that were necessary but not provided by main stream health organisations.
In 1973 this meant, among other things, the provision of contraceptives to minors, assisting women with unwanted pregnancies to get abortion and psychosocial support for people with alternative lifestyles including drug use. The clinic was succesful because from the start our patients perceived us as being 'on their side' against a conservative establishment. They knew that mentioning drug use would not mean that they would be refused treatment, as was so often the case elsewhere. This has not changed all that much since then: the goals are still the same, although next to individual help, Free Clinic has broadened its horizons and is now also active in the fields of research and in establishing education and prevention programmes.
What has changed are our patients: drug use, from the start a part of the lifestyle of many of our patients,
has become more problematic. In 1975 we treated
our first heroin addict with a short one month methadone programme. Since then drug problems take more and more of our time. In 1994, drug users accounted for more than 50% of the 5000 patient contacts registered by the medical staff. The Antwerp drug scene, probably something like 5000 drug users, has 1500-2000 injecting users. Free Clinic is in contact with more than 500 of them. Despite legal problems and a lack of financial means, we have established a methadone maintenance treatment programme for 100 people, with priority for the most marginalised. In the rest of our patient load, we are experiencing a shift towards lower social strata youth from disadvantaged neighbourhoods, often presenting the same array of social and psychological problems. They are the brothers, sisters, children and neighbours of the drug users. it gives us new opportunities to detect early problematic drug use or to pre vent drug problems in risk populations.
THE 'COOL' PREVENTION PROJECT.
When we first thought about HIV prevention in injecting drug users ( IDUs) in 1988, HIV prevalence in this group was 1 or 2 % (it had not been investigated yet), and at least in the Flemish region nobody seemed to care particularly about it. There were not too many options anyway. Methadone maintenance was illegal and in fact considered criminal by the courts as well as by the Belgian Medical Association. Syringe exchange was illegal: it was considered to be 'maintaining an addiction'. Technically syringes were also considered to be medication, so deliver) was only possible by a pharmacist. There was absolutely no clarity about who was politically responsible for HIV prevention in IDUs. In 1988 there was still no state funding for HIV prevention in general mainly because of this problem. Belgium was, and to an extent still is, going through a radical change from a centralised to a federal state. If I mention the fact that for a population of approximately 10 million people, we have six ministers of Health, you will start to grasp our problem.
In fact, the only active political interest in drug users at that time came from extreme right wing parties. They were succesful by focusing on 'the decay of civilisation', meaning immigration and drugs. Their success seemed to paralyse the other parties. This would soon change. In the drug scene itself, AIDS was not yet an item of concern. Our first aim was therefore to put AIDS on the agenda of IDUs, to break the silence around it. In that context, we decided on an outreach information campaign with the following message:
• If you do drugs, do not inject
• If you inject, use your own works
• If you share, clean your works
• Always have safe sex.
The bleach method for cleaning works was introduced. This message was to be brought to IDUs through person to-person talks with IDU co workers who would be trained by us. The organisation of the project consisted mainly of recruitment and training, production and testing of prevention material, and establishing the cooperation of the authorities. In the first year we recruited almost exclusively from our own methadone programme. In later years we would attract others by using posters ( in our waiting room) and snowballing.
Training was split up into four sessions:
- An introduction: the global aims were explained and some practical items such as payment, safety conditions, etc. were tackled.
2. Attitudes and beliefs about drugs, AIDS and the project itself.
3. HIV and AIDS knowledge: we made sure that all co-workers got the right information and were able to communicate the correct knowledge.
4. The method of streetwork itself.
We produced a prevention package that could be used to support our co-workers in their streetwork. It consisted of a plastic bag containing two sterile syringes, condoms, a comic strip on safe sex/safer use and alcohol swabs. The syringes were of course only a symbolic gesture. Nevertheless, in a repressive environment these syringes created enormous sympathy and attention from the drug scene.
The story line of the comic strip was developed with the help of IDUs and the result was tested before it went into print. Nevertheless, we encountered some problems: our first artist used a lot of 'avant garde' techniques such as bird eye views and zoom effects. Soon it became clear that this made the story incomprehensible for unsophisticated readers, and in later editions we left out these effects to turn back to more basic illustrations. Also, some of the drawings on safe sex were very explicit. Partly this was of course inherent to the subject, partly it was 'overdone' because we had found out that 'sex comics' were quite popular in the target population. Although no IDU made any complaint about the drawings, some of them were not appreciated by the authorities we had to deal with. As a lot of energy was lost in those discussions we decided to censor ourselves in later editions. In these later editions, we also tackled other problems like, for example, sexually transmitted diseases.
In later years, other items were included in the package. At the request of our co-workers we produced a small booklet ( it fits in a wallet) containing telephone numbers of treatment centres, addresses of where to get free meals, etc. In 1992, when the project focused on male sex workers, extra-safe condoms were added and last year female condoms were added to the packages used in the female sex worker scene. Our co-workers report every week to the project leader. These reports were instrumental in improving the quality of the intervention as well as in learning a lot about the Antwerp drug scene. As a result of the amount of information that became available, we added an ethnographer to the project in 1992.
What results can we present with this basic methodology? In a 4-month period, five co-workers had 316 meetings, contacting 462 IDUs. More than 1300 packages were distributed: partly some people came back for a second or third package, partly the drug scene was enthusiastic about and took it upon itself to organise secondary distribution. The total price of the project per contact individual in the first period was $US8.
In the next years we trained more than 30 co workers. The method has been used in different drug scenes in different cities, always with the result that a considerable part of the scene can be reached with little effort. Ninety-three per cent of the contacts evaluate the project as positive. By selecting coworkers it is possible to target specific sub populations. In Antwerp, we made special efforts to target known male and female sex workers and Turkish IDUs.
Independent research has furthermore shown that there seems to be an important shift from injecting to non-injecting use. This was found in an analysis of new entries into treatment facilities. Also, before the first actions in 1989, bleach use was unknown. Some months after the first actions,20% of sharers claimed to use bleach all the time. In 1992 this percentage was up to 48%. It was shown by a knowledge questionnaire, used in a 1993 research project, that knowledge on safer use was significantly better if respondents came from the Antwerp drug scene.
Our experience has shown, first, that even a small organisation with hardly any financial means and in a repressive context, can make a difference and achieve significant preventive results. It can, how ever, succeed only if this organisation is trusted by the drug scene. Second, by 'stretching' the law, for example, by distributing syringes or by introducing methadone maintenance as we did in 1990, and thereby forcing the authorities to accept responsibility, we reactivated the debate on syringe exchange, on harm reduction and on drug policies in general.
Together with parallel (and often more succesful) efforts in the Walloon region and together with the struggle for the legalisation of methadone, a battle that was largely won in October 1994, our efforts culminated in a new 'Action programme on drugs' that was presented by the federal government in 1995. In a 10-point programme it states among other things:
- Syringe exchange (or rather syringe distribution) outside pharmacies is important, legal changes as well as funding to make this possible are under way.
- Methadone maintenance is good medical practice and programmes should be incorporated into general practice where possible.
- In nine inner cities low threshold service unit will be established with the aim to care for drug users and to give social and medical support. Th emphasis will be on harm reduction, including syringe exchange and low-threshold methadon programmes rather than detoxification.
This is the 'Free Clinic' model that has finally been recognised. Enough money will be made available: the nine new facilities, for example, will have a yearly budget of more than half a million dollars each. With this plan, Belgian drug treatment has entered a new era and can now start to introduce more professional harm reduction interventions.
Sven Todts, Free Clinic, General Lemanstraat 36, B2600 Antwerp, Belgium.