Eleven of the 20 (55%) centres contacted returned the completed survey: the Basque Country (n=4), Catalonia (n=4), Madrid (n=2), and Valencia (n=1). All 11 centres provide NSP and two have a supervised injecting room. All centres offer mental health services by connecting users to established programmes, including other non-governmental organisations (NGOs) (n=3), referring them to established services in the public system (n=6), 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=11) 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.
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
|
✓
|
✓
|
✓
|
✓
|
✓
|
|
✓
|
|
✓
|
✓
|
✓
|
✓
|
Total
|
|
|
11
|
2
|
6
|
10
|
11
|
6
|
5
|
5
|
5
|
7
|
7
|
5
|
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=6) was 43.2 years (range: 40–47) and the average number of users in 10/11 centres in the same year was 1,130 (range: 15–8,748). All centres served more men (8,798 total, range: 13–6,735) than women (2,492 total, range: 2–2,013) and Spanish nationals (7,650 total, range: 11–5861) compared to those from other countries (3,645 total, range: 4–2,887).
Impact of the COVID-19 pandemic on harm reduction operating hours and service users
Ten out of eleven (90.9%) 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. The average weekly operating hours in 2019 for centres that reported these data (n=8) was 47.4 hours (range: 15–63) and in 2020 it was 43.1 hours (range: 25–66.5). Half of all centres (n=4) reduced their operating hours while others increased their operating hours.
The average number of service users between the months of January–June 2019 in the centres (n=10) was 219 (range: 11–956) in comparison to the same months in 2020, which was 171 (range: 10–600). The difference in the overall average number of service users reflects a decrease of 21.9%. There was great variability among centres (Figure 1).
Impact of the COVID-19 pandemic on needle and syringe programmes and distribution of materials
Nine of the 11 (81.8%) centres reported data on needle distribution for the months of March–June 2019 and 10/11 (90.1%) reported data for the same months in 2020. One centre did not have 2019 data available (Centre 9). June 2019 had the highest monthly average of needle distribution (3,471) among the 9 centres that reported these data and April 2020 had the least number of needles distributed on average (1,238). The total four-month average of distributed needles was 3,128. During the same months in 2020, the average number of needles distributed reduced by 40% (1,880) in all but one centre (Figure 2).
Impact of the COVID-19 pandemic on infectious disease testing
One centre did not provide data on testing practices. Four (40%) centres reported performing a Mantoux test for TB while five (50%) centres reported offering HBV and HIV testing. Six (60%) centres offered HCV testing. 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 2. Infectious disease (HBV, HCV, HIV, and TB) testing rate per 1,000 service users in March–June 2019 and March–June 2020
HBV TESTING RATES
|
|
Mar 2019
|
Mar 2020
|
Apr 2019
|
Apr 2020
|
May 2019
|
May 2020
|
Jun 2019
|
Jun 2020
|
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
|
HCV TESTING RATES
|
|
Mar 2019
|
Mar 2020
|
Apr 2019
|
Apr 2020
|
May 2019
|
May 2020
|
Jun 2019
|
Jun 2020
|
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
|
HIV TESTING RATES
|
|
Mar 2019
|
Mar 2020
|
Apr 2019
|
Apr 2020
|
May 2019
|
May 2020
|
Jun 2019
|
Jun 2020
|
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
|
TB TESTING RATES
|
|
Mar 2019
|
Mar 2020
|
Apr 2019
|
Apr 2020
|
May 2019
|
May 2020
|
Jun 2019
|
Jun 2020
|
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 (60%) out of ten centres reported providing methadone on-site, and five (50%) centres provided DAAs and 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 five centres that reported distributing DAA therapy, 26 clients received DAAs in 2019 during the same months compared to seven in 2020. This represents a 73% 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 11 (81.8%) centres responded that they did not see an increase in reported overdose deaths during the Spanish state of alarm, while one centre (9%) reported they did not know and another centre did not respond.
Two of the 11 (18.2%) centres responded that they saw an increase in reported overdose deaths immediately after the Spanish state of alarm ended. One centre (9%) did not know and the remaining did not report an increase in overdose deaths in their centres.
There were a total of 99 reported medical emergencies across all centres that responded (9/11) 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
Ten (91%) 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 10 (100%) people surveyed responding that it was “problematic” or “very problematic”. Nine (90%) 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 (8/10) (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=10), the majority of centres said that the responsible entity performed below average (n=4), followed by average (n=3). One centre responded that their responsible administration did an excellent job and two reported that their agencies did better than average.