Harm reduction interventions for drug injectors or heroin users in Spain: expanding coverage as the storm abates (2012)

Aims - To show the utility of analysing time trends of need and coverage of needle-exchange programmes (NEPs) and opioid substitution treatment (OST) to assess harm reduction policies targeting drug injectors or heroin users.
Design - Multiple methods applied to secondary data.
Setting - Spain.
Participants - Thousands of drug injectors or heroin users included in administrative registers, surveys and published studies during 1987-2010.
Measurements - Coverage for the general population was calculated as the ratio between interventions provided (obtained directly from the sources) and interventions needed (estimated by multiple methods), and as the difference between the two. Timeliness was estimated by time elapsed between year of highest need and year in which coverage reached a reference level.
Findings - In 2010 NEPs provided 138 syringes per drug injector [95% confidence interval (CI) 100-223], covering 25.7% (95% CI 18.3-43.3) of their need. OST coverage was 60.3% (95% CI 44.3-94.2). Syringe and OST provision increased between 1991 and 2001 and then declined. Syringe and OST coverage also increased substantially during this period and then stabilized, due mainly to decreases in drug injection or heroin use. Medium-level coverage for both syringes and OST was not achieved until 2000, 8 years after the peak in need (1992).
Conclusions - In Spain, the expansion of harm reduction interventions was greatly delayed, although the concomitant decrease in heroin and injecting drug use led to reasonable coverage after 2000. A longitudinal measurement of need and coverage provides insight into the timeliness and potential population impact of interventions, enabling better assessment of their adequacy.