Monitoring quality and coverage of harm reduction services for people who use drugs: a consensus study

Abstract

Background and aimsDespite advances in our knowledge of effective services for people who use drugs over the last decades globally, coverage remains poor in most countries, while quality is often unknown. This paper aims to discuss the historical development of successful epidemiological indicators and to present a framework for extending them with additional indicators of coverage and quality of harm reduction services, for monitoring and evaluation at international, national or subnational levels. The ultimate aim is to improve these services in order to reduce health and social problems among people who use drugs, such as human immunodeficiency virus (HIV) and hepatitis C virus (HCV) infection, crime and legal problems, overdose (death) and other morbidity and mortality.Methods and resultsThe framework was developed collaboratively using consensus methods involving nominal group meetings, review of existing quality standards, repeated email commenting rounds and qualitative analysis of opinions/experiences from a broad range of professionals/experts, including members of civil society and organisations representing people who use drugs. Twelve priority candidate indicators are proposed for opioid agonist therapy (OAT), needle and syringe programmes (NSP) and generic cross-cutting aspects of harm reduction (and potentially other drug) services. Under the specific OAT indicators, priority indicators included ‘coverage’, ‘waiting list time’, ‘dosage’ and ‘availability in prisons’. For the specific NSP indicators, the priority indicators included ‘coverage’, ‘number of needles/syringes distributed/collected’, ‘provision of other drug use paraphernalia’ and ‘availability in prisons’. Among the generic or cross-cutting indicators the priority indicators were ‘infectious diseases counselling and care’, ‘take away naloxone’, ‘information on safe use/sex’ and ‘condoms’. We discuss conditions for the successful development of the suggested indicators and constraints (e.g. funding, ideology). We propose conducting a pilot study to test the feasibility and applicability of the proposed indicators before their scaling up and routine implementation, to evaluate their effectiveness in comparing service coverage and quality across countries.ConclusionsThe establishment of an improved set of validated and internationally agreed upon best practice indicators for monitoring harm reduction service will provide a structural basis for public health and epidemiological studies and support evidence and human rights-based health policies, services and interventions.

Long-Term Opioid Agonist Treatment Participation after First Treatment Entry is Similar across 4 European Regions but Lower in Non-Nationals

“…The longitudinal analysis of annual treatment participation has a close relationship with the recently proposed cross-sectional "coverage" indicator for OAT, that is, the number of patients in OAT divided by the estimated prevalence of high-risk opioid use [28]. As the coverage denominator also includes high-risk opioid users who have never entered OAT, the adjusted treatment participation multiplied with the proportion of high-risk opioid users having ever been in OAT will correspond with coverage.…”

“…In addition, if an adjusted treatment participation of 50% and a 45% OAT coverage are known for a specific region and year, the proportion of high-risk opioid users who have never been in OAT can be estimated. Thus, the combination of adjusted treatment participation and coverage estimates may lead to profound insights as to how the OAT coverage could be improved in a "harm reduction cascade model" as successfully established for other chronic health conditions [28].…”

We know DAAs work, so now what? Simplifying models of care to enhance the hepatitis C cascade

“…A second study made comparable projections for other European countries, but also found that some countries would need to scale‐up opioid substitution therapy (OST) and needle and syringe exchange programmes (NSP) interventions to reduce chronic HCV prevalence . Yet in most countries of the world, particularly low‐ and middle‐income countries, access to DAAs and harm reduction services remains extremely limited , and achieving the WHO targets will require major expansion of both forms of access . That is because besides DAA therapy, which enables a sustained virologic response (SVR), the most effective form of HCV prevention for PWID is harm reduction, including OST, NSPs, and supervised injecting centres.…”

Desafios Às Práticas De Redução De Danos Na Atenção Primária À Saúde

“…As experiências internacionais têm demonstrado que onde as políticas de redução de danos estão em vigor, as economias dos custos em saúdecomo, por exemplo, na redução das infecções virais de pessoas com HIV e hepatite Ce a melhoria da qualidade de vida das pessoas que usam drogas, estão sendo percebidas e comprovadas pelas práticas de intervenção, tal como prover drogas de forma sistemática e monitorada para usuários dependentes. Intervenções mais amplas, abarcando legislações e políticas públicas de provisão, como algumas verificadas em países da Europa, estão possibilitando a redução dos crimes e prisões vinculadas ao uso de drogas e a redução da mortalidade por overdose (Wiessing et al, 2017).…”

“…Todavia, na maioria dos países, as ações de redução de danos continuam centradas nos indivíduos e não em políticas mais amplas que incluem aspectos estruturais e mudanças nas legislações (Menéndez, 2012). Sem enfrentamento desta situação também se torna difícil monitorar a eficácia dos serviços de redução de danos, pois estes produzem melhores resultados quando combinadas as várias estratégias de intervenções (Wiessing et al, 2017).…”