HIV and drug addiction prevention in Estonia

Transcription

1 HIV and drug addiction prevention in Estonia May 2007 National prevention programmes What does the state do to protect my child? 1

2 What is a state? Narrow meaning: Central government organizations (government, Riigikogu (the parliament), ministries) and local authority vs. Broad meaning comprises all social levels: Central and local government organizations Private sector, nongovernmental organizations (ASBLs, LLCs, foundations) Research Institutions and academic organizations; religious organizations, etc. Community groups, family Who is responsible for the behaviour of state citizens? Central vs. shared responsibility National strategies Initiated by the central government but trying to involve as many different state levels as possible Unified goals, principles and a common activity framework Rely on evidence evidence-based approach in their choice of measures Are, in most cases, approved or adopted by the Government of the Republic; sometimes the Ministries have their own strategies Do not have the force of law but are rather agreements made at state level that are followed Regular reporting to the Government of the Republic on the efficiency of the implementation of strategies 2

3 Part I: National HIV and AIDS Strategy for the years All parties - state, county and local authority levels, the third sector, HIV positive persons, private sector, donors are involved in the creation of the Strategy. Help of foreign experts was used: WHO, UNAIDS Source documents: an epidemiological overview and the best practice from the world The following key elements of successful prevention and treatment will be tried to guarantee ( Three-in-one principle; WHO & UNAIDS): Central management and coordination A common activity framework A common monitoring and assessment system in the whole country See -> Public Health-> Drug Addiction and HIV/AIDS HIV strategy organisation Situation analysis Strategy activity spheres and management General policy and ethical principles in the field of HIV Spheres of activity: Prevention IDUs, youth, general population, people involved in prostitution, MSMs, the imprisoned, people with STD, people in hazard in their professional activity, preventing mother-to-child transmission of HIV Situation analysis Principles Strategic objective and its achievement indicators Sub-goals and their achievement indicators Task division Measures HIV testing and counselling Prevention, treatment and social care for people with HIV and AIDS Surveillance, monitoring and assessment Development of human and organisational resource Strategy implementation management Strategy management and coordination Strategy implementation and funding Strategy surveillance, monitoring and assessment Recital References 3

4 HIV strategy management Government of the Republic (GR) GR HIV and AIDS commission Ravi töörühm SMH töörühm Ennetuse töörühm SNide töörühm CCM Ministry of Social Affairs support entity RMB Ministry of Internal Affairs Ministry of Justice Ministry of education and research Ministry of Culture NEIF NIHD The State chancellery, 1 representative Commission structure Social Affairs Committee of the Riigikogu, 1 representative Thematic working groups of GR commission, 4 representatives Association of Estonian Cities, 1 representative GR HIV and AIDS commission, 23 members, Chairman - Deputy Secretary General of MSA HIV+ persons` network, 2 representative s Youth organisations` Association, 1 representative CCM, 2 representatives, incl. 1 by ASBLs and 1 by the state RMB MIA, 1 represen tative MJ, 1 represen tative MER, 1 represen tative MD, 1 represen tative OMPEA, 1 represen tative MSA, 2 esindajat, sotsiaal- ja tervishoid Teenindav üksus NEIF NIHD 4

5 HIV strategy implementation plan for the years Implementation plan covers all activities performed in the sphere of HIV at national level by a responsible Ministry Ministry of Social Affairs (MSA), Ministry of Education and Research (MER), Ministry of Internal Affairs (MIA), Ministry of Justice (MJ), Office of the Minister of Population and Ethnic Affairs (OMPEA), and Ministry of Defence (MD). In the implementation plan includes strategic goals, relevant measures described under each of the goals and definite activity indicators described under each of the measures. The majority of the activities fall within the administrative area of the Ministry of Social Affairs that also coordinates the implementation of the extensive foreign assistance projects including the Global Fund project the project UNODC project, the project EQUAL. HIV strategy funding Ministry of Social Affairs Incl. National Institute for Health Development (NIHD),Health Care Bard (HCB), Estonian Health Insurance Fund (EHIF) Ministry of Education and Research Ministry of Internal Affairs Ministry of Justice Global Fund (until the last quater of 2007) In the future UNODC Total costs: Year Total costs 56.4 mln mln mln mln 5

6 Prevention and treatment costs within the administrative area of Ministry of Social Affairs (MSA) in the years MSA prevention mln treatment 2.6 mln 11.6 mln 52.1 mln NIHD GFP prevention prevention treatment 11.3 mln 10.8 mln 8.4 mln 15.4 mln 24.1 mln 18 mln 27.7 mln 30 mln - EHIF prevention treatment 7.2 mln 7.3 mln 8.6 mln 14.8 mln 9 mln 32.5 mln HCB prevention 0.3 mln Total costs in ad. area of MSA: 40.4 mln 92.5 mln mln Incl. Prevention 22.1 mln 48.1 mln 67.2 mln Incl. treatment (ARV ) 18.3 mln (10 mln) 44.4 mln (29 mln) 84.6 mln (51 mln) Important activities performed in the framework of HIV strategy 1. Prevention among injecting drug users Harm reduction -> counselling, syringe exchange (26 syringe exchange points and three centres providing low-threshold services) and methadone treatment (nearly 600 clients). 2. Prevention among youth (15-29 years) Teaching life skills and promoting sexual health in the framework of national curriculum Youth-to-Youth trainings Schooling children and youth with special needs Co-operation with NEIF to increase the efficiency of prevention targeted at Russian speaking youth Internet-based prevention and counselling Youth Counselling Centres (19 centres) 3. Prevention among people involved in prostitution Counselling and testing, distributing condoms and lubricants; capacitating 6

7 Important activities performed in the framework of HIV strategy 4. Prevention among men having sex with men Consulting (incl. internet based), distributing condoms 5. Prevention among imprisoned Counselling and testing, distributing condoms and lubricants, support groups for imprisoned persons with HIV, training prison personnel 6. Prevention among general population Awareness campaigns; prevention at local level 8. Preventing mother-to-child transmission of HIV Counselling and information at syringe exchange points, low threshold centres, youth counselling centres and national health care system; case management of pregnant women with HIV; ARV-treatment of mothers with HIV and providing milk formula 9. Prevention among the persons jeopardized in their professional activities and donors Information and instructions, providing protective equipment to persons professionally challenged (incl. police, officials of the rescue service, etc.) Important activities carried out in the framework of HIV strategy 10. HIV testing and counselling Activity of anonymous AIDS cabinets (6) and their visits to risk groups (6); testing and counselling courses for health care workers 11. Psychosocial support and treatment for people with HIV Supporting self-help groups (nearly 175 members), providing health services to people without medical insurance, preventing HIV/TB transmission, providing antiretroviral treatment free of charge to everybody in need, case management 12. Monitoring and assessment Routine monitoring, studies on the population and risk behaviour of risk groups, prevention assessment, quality management 13. Development of qualified human and organisational resource (In-service) trainings and supervisions for specialists, development of vocational standards 7

8 Part II: National Strategy for Prevention of Drug Abuse up to the year 2012 Approved by the Government of the Republic in 2004; Today, the content is a little out of date but the strategy is going to be updated after the completion of the Public Health Development Plan. General objective: reduced supply and demand of drugs and effective treatment and rehabilitation system for drug addicts, which will all lead to the reduction of harm due to drug use. Includes the following chapters: 1. Primary prevention prevention 2. Treatment and rehabilitation quality and available treatment and rehabilitation system 3. Harm reduction field work/activity in the streets, syringe exchange, communicating information to risk groups 4. Drugs in prisons treatment and rehabilitation in prisons, drug free departments 5. Supply reduction police, customs, border guard 6. Surveillance and assessment situation monitoring and activity efficiency assessment See -> Public health -> drug addiction Managing the drug addiction prevention strategy The governing body is the Government commission for the prevention of drug addiction (Government regulation No. 17 of ) The members of the Commission include representatives of the Ministry of Social Affairs, Ministry of Internal Affairs, Ministry of Education and Research, Ministry of Justice, Ministry of Finance, Estonian Tax and Customs Board, National Institute for Health Development, Estonian Psychiatric Association, Association of Estonian Cities The Chairman of the Commission is Deputy Secretary General on Health with the Ministry of Social Affairs The task of the Commission is drawing up annual implementation plans and preparing reports (according to the administrative area). Estonian Drug Monitoring Centre (EDMC) of the National Institution for Health Development prepares an annual report on current situation in supply and demand in Estonia to be submitted to the Government of the Republic for approval. See: 8

9 National Strategy for Prevention of Drug Abuse for Main spheres: 1. Reducing demand Primary prevention of drug addiction among children and youth in Estonia in general Prevention among specially vulnerable groups, incl. children and youth with special needs and youth already experimenting with drugs Developing drug addiction treatment and rehabilitation system 2. Reducing supply Increasing the efficiency of control system for preventing drug abuse in custodial institutions Improving legal space Increasing the efficiency of the Financial Intelligence Unit Co-operation at national and international level to control drugrelated crime 3. Monitoring and assessment Drug monitoring Implementing a quality management system Main activities Curriculum-based prevention in schools(application of the critical life-skills conception); courses in the sphere of drug addiction for school personnel Development of support network (incl. Social workers, parents, teachers, child protection officials, etc.) for vulnerable children and youth and their families in cooperation with organisations and specialists providing psychological and crisis support to children and youth (incl. consulting parents with a view of creating positive role models to children and youth from problematic families). (activities related to the Development Plan for Reducing Crime Committed by Minors for the years (DPRCCM) and Child Rights Protection Strategy - CRPS) Integrating addiction prevention into the case management system of child`s problems early detection (cooperation with DPRCCM) Analysis of the Juvenile Sanctions Act with regard to drug addiction preventive measures and amendment of the Act based on the performed analysis Training programme on drug addiction prevention targeted at parents Prevention in orphanages and social welfare institutions; personnel training Drug addiction prevention among all population groups Prevention at local level via Health councils working at Local Governments Cooperation with Non-Estonian`s Integration Foundation to promote prevention among non-estonian youth Media campaigns Youth-to-youth trainings Prevention in schools for children requiring special treatment due to behavioural problems and among young prisoners 9

10 Main activities Developing drug addiction treatment: a) With adults: Out-patient substitution and replacement treatment based on opioid agonists (currently ca 700 treatment sites in total, including those funded by Local Governments) Institutional substitution treatment based on opioid agonists (ca 10 sites) Nonopiate institutional substitution treatment (14 treatment sites or 2 persons per year) Nonopiate out-patient substitution treatment (30 treatment sites or 36 persons per year) b) With minors: Nowadays only nonopiate treatment is provided (6 sites, 18 patients per year) Opiate treatment is planned to be provided Supervision of and training for service providers. Case management of pregnant drug users (it is planned to cover at least 35% in 2007) NB! The drug addiction treatment currently provided is funded from national or Local Government budget or the costs are covered by patients. National Drug Addiction Treatment database, launched in 2007, should give a better overview of the requirements. Main activities Rehabilitation: Rehabilitation is provided to those undergone treatment or not requiring treatment. Rehabilitation is divided into maximum-security rehabilitation (2 farms in Ida and Lääne-Viru county funded by the state. 54 places in 2007) and open rehabilitation (day centres, 60 places per centre in 2007). As of now, the only national rehabilitation centre is situated in Sillamäe. In 2008, a rehabilitation farm for women will be opened today women are not provided with rehabilitation services as the earlier experience has proved a big percentage of pregnancy occurring among women clients in mixed farms. Maximum-security centres (10 places per centre in 2007) and day centres (in 2008) for children will be opened. Developing programme for restoring the work habits of or gaining the first work habits by drug users (in the framework of ESF, in co-operation with Estonian Labour Market Board) Case management in cooperation with HIV strategy is planned; a support person for each client. Supervision of and training for service providers. 10

11 Important activities Monitoring and assessing: Launching collection of data on drug addiction treatment in 2007 Surveys (poll; ESPAD) Regular collection of monitoring data International co-operation in the framework of EMCDDA Creation of an internet database on prevention projects Development of a quality management system Service standards Funding Drug Addiction Prevention Strategy Costs of the Strategy Total Ministry of Social Affairs: Incl. National Institute for Health Development Inlc. EMCDDA Ministry of Internal Affairs Ministry of Finance Ministry of Justice Total:

12 Role division in the implementation of HIV and drug addiction prevention strategies Strategic planning Ministry of Social Affairs (MSA) Implementation of strategies and action plans in most cases the National Institution for Health Development (NIHD), the division of the Ministry of Social Affairs, together with its partners, Contracts with nongovernmental organisations Planning prevention proceeds from the evidence-based approach Part III: Planning evidence-based prevention: an example of drug addiction prevention Problem-behaviour theory (Jessor and Jessor) Participating in youth organisations; participating in the religious organisations; close relationships with parents; good relationships with adults, dedication to studies, ethnic identity 1 factor: Smoking; alcohol consumption; drug use; Antisocial behaviour (incl. thrashing, stealing, vandalising, school violence); early and unprotected sexual intercourses Conventional behaviour Unconventional behaviour 12

13 Risk factors vs. protective factors Constitutional Personal characteristics (incl. unsocial, impulsive, unreliable, hungry for experiences, hyperactive, uncontrollable) Genes Psychopathology (depression, ADHD, ODD/CD) Environmental factors Dysfunctional family (incl. abuse, parents`addiction problems, upbringing methods) Influence from people of the same age Life events Traumatic events, grief Sexual abuse Teenage pregnancy, etc. Health specific: personal attitude and wish to protect own health felt social support to health preserving behaviour (for example by close friends) Indirect factors: Personal characteristics perceived social environment PRECEDE model (Green and Keuter 2005) Factors proceeding from personality Behaviour of risk groups Exterior factors Health problem Quality of life Factors proceeding from personality Exterior factors Environmental factors (incl. behaviour of persons creating an environment) 13

14 Personal attitudes, awareness, beliefs, expectations towards outcomes of behaviour, self efficiency/skills; genes, psychopathology Personal life events (grief, unwanted pregnancy, severe illness, experienced sexual abuse) Attitudes, skills of family members, Attitudes, beliefs of Society members, attitudes, beliefs of Persons of the same age, Interest and competency of policy makers, journalists, prevention specialists, service providers Financial resources Risk behaviour incl. antisocial behaviour in childhood, experimenting with and using drugs (inability to fight group pressure; false expectations on consequences of activities, lack of knowledge; imitation) Environmental factors Interpersonal, organisational, community and society level family environment and role models Unfavourable group norms/lack of favourable group norms (society and persons of the same age); Inadequate information in media Easy access to drugs, insufficiency of legal regulations, Poor access to drug addiction treatment Health problems, incl. Psychological, physical and behavioural disturbances due to drug abuse, drug deaths, HIV, hepatitis, overdose Decrease in the quality of life, incl. Coping difficulties, low self esteem, lack of social support Risk behaviour changeable personal factors: 1. Awareness E: Youth can argue over the reasons for the harmful effect of drug addiction; its consequences on family and social life, health and society. 2. Attitudes and beliefs E: Youth admit the advantages of drug-free life as compared to drug use. Youth have reasoned/imagined the negative consequences of drug use on life (problems at home and at school, thoughtless action while being in the state of intoxication by drugs incl. HIV, becoming pregnant, embarrassing social situations health problems, etc.) Youth understand that drug addiction starts with experimenting with drugs and that even a single drug use may lead them to the path of drug addiction. Youth realize that drug-free life is more satisfying and offers them more opportunities than life with drugs. 3. Skills/self-efficiency E: Youth demonstrate their skills in fighting social pressure for using drugs. Youth demonstrate their self-confidence and ability to recognise and avoid situations in which they might be pressured to try and use drugs. 14

15 Risk behaviour changeable influence from external factors Personal life events (grief, unwanted pregnancy, severe illness, experienced sexual abuse) change of target group, need to target activities to the adults coming into contact with youth in crisis situation 1. Awareness E: People working with youth (youth workers, psychologists, school personnel) and parents can describe situations causing drug addiction risk and know how to recognise a youth using drugs. They can describe risks proceeding from drug use. 2. Attitudes and Beliefs E: People working with youth understand that supporting a youth in crisis situation prevents later more complicated consequences. They understand that drug addiction is an illness and do not have a pejorative attitude towards them. 3. Skills/self-efficiency E: People working with youth describe how/demonstrate their ability to recognise and help a youth in crisis situation. They can name places where they can refer a person in need of assistance Formation of environment is also influencing the persons forming the environment. Mapping intervention: Precede->Proceed 1.Assessment of needs, incl. Identification of changeable influence factors -> 2. Changing behaviour formulating objectives describing actions, for example Behaviour: Student informs a teacher of a drug dealer trading in school ; The teacher tells about the dealer to parents, social worker, police.-> 3. Formulating change describing objectives proceeding from the changeable influence factors (what exactly should target group be able to do, can do, know, think, etc.) these formulated objectives are also the criteria for assessment, for example Awareness: A student can argue over the reasons for the harmful effect of drug addiction ; Attitude: A student understands that implicating a dealer is not snitching but helping to prevent serious health damage ; Skills A student can name a teacher who can be addressed anonymously and told about drug problems in school ; A teacher can describe how he or she solves the situation and who he or she addresses -> 4. To study theories on changeable influence factors and select methods for achieving the changes according to objectives. 5. To plan measures proceeding from theory-based methods. For example: Changeable influence factor: Attitude; theory: regret theory; method: expected regret; measure: imagining regret following risk behaviour for example, composition, role play, etc. 15

16 Choice of Methods: example changing social standards - lacks; + low; ++ -average; +++ high Example: target group society as a whole Methods for changing standards Role model via mass media Education via entertainment Change behaviour journalism (behavioural journalism) of via Mobilisation of social networks Efficiency Feasibility Costliness Part IV: Employment opportunities in the field 1. Strategic planning Ministry of Social Affairs; Ministry of Education and Research, etc.; Tallinn Health Care Department at LG level 2. Planning Prevention programmes (incl. Youth-to-youth programmes vs. Programmes targeted at risk groups) National Institute for Health Development, Foundation of the Integration of Non-Estonians, nonprofit associations, etc. 3. Harm reduction ASBLs, LLCs, psychiatric hospitals 4. Social work, case management of people with HIV or/and injecting drug users Local Governments (LG), National Institute for Health Development 5. Drug addiction treatment and rehabilitation treatment centres and LLCs, LGs 6. Developing human resource; conducting (in-service) training universities, National Institute for Health Development, ASBLs, etc. 7. Evidence-based data; research Research Centre of the National Institute for Health Development, incl. Drug Monitoring Centre, universities Many opportunities for international partnership and implementation of projects; especially with an EU member state in the framework of different EU programmes and bilateral co-operation 16

17 Part V: Proposed study topics There is little data on specific groups, for example: How do female injecting drug users differ from male injecting drug users and which additional measures should be applied with and which additional services provided to those target groups? Which barriers exist affecting access to HIV and drug addiction prevention as to young men (young men are more difficult to be engaged in prevention activity); which would be the measures suitable for them? Which attitudes, beliefs and skills affect sexual behaviour of persons from different risk groups (persons involved in prostitution; homosexuals; injecting drug users; vulnerable youth; people with HIV); what are the main barriers for condom use and risk behaviour? Why do people aware of being infected with HIV behave in a way more risky than the drug users that are unaware of being infected with HIV? Proposed study topics Harm reduction: Preferences of injecting drug users in Estonia with respect to harm reduction services; Strengths and weaknesses of the Estonian system. How high is the actual demand for replacement treatment services in the opinion of the target group? Which model of replacement treatment service do they prefer (low-threshold service vs. high-threshold service)? Estonian population attitudes towards harm reduction services (incl. syringe exchange, replacement treatment, etc.). Comparative investigation Tallinn city/harju county vs. Ida-Viru county. People with HIV: Human rights of people with HIV in Estonia through the perspective of their own experience: attitude towards people with HIV at their job sites, in medical system, personal life. HIV testing: Survey among clients of anonymous AIDS counselling cabinets on the frequency of and reasons for retesting. 17

18 Thank You for Your attention! 18