 Thank you Peter for inviting me. Hello everybody. It's nice to be here in Budapest again. I am Marianela Kloka, I'm an Advocacy Officer of Praxis NGO, a non-governmental organization. I'm not here to tell you what to do. I'm here just to tell you what we have done. And maybe if you think that something of this is inspiring or it's interesting to implement it here, it would be important then you can copy it freely. Okay, so a few words about Praxis. Just in order to understand how an NGO can be involved in this kind of harm reduction interventions, Praxis is an independent non-governmental organization. Main goal is a design, application and implementation of humanitarian program and medical interventions. We have started as one of, let's say, little organizations coming from medicine of the world. So, these are our basic services. I will not read them all. You can see here. Psychological support, social support. It's the holistic approach. When we see someone that is out of the health system, we try to find the ways to reintegrate him in the society and not only cure him or give him a medicine or whatever. All services are provided for free. It's important to see who are the beneficiaries of our work because you have to take under consideration that Greece is in a very difficult situation since 2009 and on at least, if not even before also. So, the beneficiaries of Praxis are homeless people, uninsured economic migrants, undocumented migrants, asylum seekers and refugees, unaccompanied children, trafficking victims, sex workers, state children, people who use drugs, Roma, people living with HIV and AIDS, men have a sex with men, Greek families heavily affected by the economic crisis and what we could state in general, every person experiencing social or end economic exclusion and is deprived of basic goods. So, the range is huge and we are working the best that we can. So, what happened in Greece? Since 2011, the Greek Organization Against Drugs called OKANA and the Hellenic Center for Diseases and Control have observed the rise of positive HIV diagnosis among IDUs in the center of Athens. You can see the blue line here. It's very quiet, sleepy from 1980 and on, 19, etc. Something here is not worth to mention and you see that in 2010, we have a big rise of new HIV diagnosis among people who inject drugs. Of course, there was a mess because I don't know exactly why I am investigating on that. People can use drugs and have hepatitis C for a long time. When HIV interferes, there is a red alarm, which is important because maybe it can help us also treat hepatitis C. So, the Ministry of Health, alarming, called immediately for support the European expert bodies. Like Ms. Fabian, for example. We had the NCTC, the WHO Europe and the NCTDA in a joint mission in Athens for two times within three months. So, they have observed what is happening in Athens. They have talked with people, with NGOs, with drug users, with everybody, with stakeholders. And they have came up with seven key interventions that they told us as a suggestion that we have to implement in order to see things going down again. These are the seven proposals, most of them coming from the comprehensive packets that Ms. Fabian said before. So, you could see that the first thing that they told us that we should do is needle and syringes distribution. Very important because since 2009, we had not the program for distribution in the center of Athens. Maybe we can say that scarcely we could distribute some syringes and needles. Okay, so the first thing that they told us is that you should go on the streets and try to distribute needle and syringes. The second one they told us is that we have to vaccinate for hepatitis A and B and make a special care among HIV positive people concerning flu and tetanus. I don't know exactly how it's called in, okay, hope it's the same. The third thing was OST, the second important issue that Ms. Fabian told us before. So, substitution therapy till 2009 in Athens was seven years waiting list. I mean, I don't know if you can understand, I am a drug user, I inject drugs, I am a person that doesn't have so many good relationships with the family due to this use and I have to wait seven years going around on the streets waiting for an OST program. So, OST and other treatment options should be provided to all those who decided to follow them. Medical examination for TB, access to antiretroviral therapy and hepatitis treatment independently of the regular or not irregular status or health insurance status. Because one of the proportion of new HIV infected drug users in the center of Athens were undocumented migrants. Not the biggest one, but one around 25 to 30%. And from 2009 till today we calculate that the one third of Greek nationals have lost their health insurance status. So it was very clear that we have to provide antiretroviral therapy to all. Health education targeted to the key affected populations. Targeted services according to the needs of the IDUs, for example, provide people with food, water, shelter, supervised consumption rooms, OST, art, etc. That was the seven proposals that the international European bodies came up to the Greek government. So what Okana did? Okana has formed a network with people that they were working in Okana and NGOs. We have provided this hygienic kit that you can see there and we have organized a common outreach work in order to distribute those packages under the idea of reaching 200 surgeries per user. PAXIS, the organization that I represent, joined the network at the very first moment. Offering volunteers and intervention to the hospitals in the cases of newly infected undocumented migrants that the system couldn't understand how to treat them. Because there was no mediator, there was no provision for people that they don't have insurance, health insurance, or they don't have papers. And finally we have the Aristoteles project. The Aristoteles project was one more intervention. If you see here that we have seven, there was not included here an intervention concerning rapid tests for HIV and hepatitis C in large scale. So Aristoteles project what did was to try to find, test, and link IDUs from the center of Athens with the clinics that treat HIV. Aristoteles project has tested more than 3000 IDUs with a snowball effect. I am a drug user. I come, I test myself, and I have three, five, or four more people here that I bring, friends of mine, friends that I share a needle or I shoot with them in the street of Athens. And so that means that we have entered in the circle of the people that they use drugs, the injected drugs in the center of Athens. So what I am presenting you is a model where non-governmental sectors and governmental sectors work together in order to combat an epidemic. What are the benefits of the governmental sector? Obdain funding by the Ministry of Health. Okana is easier to get funding than Praxis or another NGO. Easier access to the structural EU funds. The drug consumption room in Athens, for example, was covered, fully covered by EU structural funds for a year as a pilot project. Know how of the harm reduction interventions because those people that were working in Okana in a good way, in a very organized way, in a bad organized way, it doesn't matter. They had the experience of working in the streets with IDUs. Close cooperation with the European expert body on harm reduction, the MCDDA. Years of experience in outreach work with IDUs as I told you before. Psychological support for the street workers because they also try to give them the opportunity to enter in the OSD project. And sense of being secure working on the streets at least as I was one of the state workers. This is what I felt going out with people that were working in Okana. Which are the benefits of non-governmental sector like Praxis, for example. A tract of IDUs in the rest of health services provision Praxis has mobile units. We could offer free testing for HIV, for hepatitis B and C. Motivation and vision to change things for better. Flexibility in action, less bureaucratic procedures. We know, at least in Greece, I don't know if it's the same thing here, probably it would be. The bureaucratic procedure of the state, it's amazing. So we have the possibility of doing things good in a good way and in a quick way. Obdain financial support for the programs by other donors such as institution, private sector, etc. For example, the state cannot be in a position to receive funds from a foundation. Praxis can do that. Volunteer work, which is another very big issue because everybody in the state has to be paid for even an hour on the street. We provide volunteers. Constant proposals in order to improve the cooperation. Our critical point of view was always present and is always present. We don't just implement a project. We are part of the project, we are out of the street and constantly making a criticism, a very constructive criticism, in order to make things better and better all the time. So the results till now. We had a major contribution to the national objective, 200 series per active user, which we have obtained in 60% during 2012 and 2013. The creation of an innovative model of governmental and non-governmental organizations in order to be applied in many other challenges and not only in this epidemic that we were facing. Influence of the national policy concerning the need for more collaboration. Creation of a permanent, official national commission, permanent national official commission based on both sectors. With a five years mandate, it's now legal. Four subgroups are in a monthly coordination concerning key areas such as street work, testing for HIV and hepatitis C, health intervention to the community and one thing that is very important, linkage to care. And I'll tell you why. This is the results. 2010, we had 15 IDUs HIV positive. 2011, the red alarm, 213. In 2012, the alarm was even more red, 514. In 2013, things are decreasing. 239 new HIV cases among IDUs. In 2014, 84, till November 2014 that we have the data. So this is something that we have done, we have achieved working together and not putting anything else but following instructions of the international and European bodies. Challenges for the future because nothing is over. The OSD waiting list in Athens needs to be raised because OKANA did a very nice work and from seven years has reduced it to two years and a half. Still, one IDU has to wait for two years and a half on the streets. Drug consumption rooms legal status to be assured because we have funding from the European Union. We have started the pilot project of the drug consumption room but it was not legally assured. So since August 1st, it is closed. Address hepatitis B and C and TB co-infections because I told you before HIV is very important but hepatitis C is something that it's crawling in IDUs for a long time and nobody gives a damn. The feeling of irregular status or health insurance issues from access to treatment and care. Yesterday, I was part of a meeting where we have seen that more than 50% of the European countries they don't provide art to undocumented migrants. Access to all necessary harm reduction interventions to prisons, as Fabian also said, very many important things I will not repeat them. Part of the campaign support don't punish. It's very important when you have someone in prison to give them the same rights that he has or she has out of prison. Scale up the condoms distribution as sexual transmission can be the upcoming transmission way among IDUs and their sexual partners because let's say that we distribute needles and syringes and everybody and we have the drug consumption room so everybody goes there and shoots, everything is okay but we have people that they also have sexual partners. So condoms are very important and according to our opinion what is the most important is that if you test and find people, you test them and you find them HIV positive, you have to link them to antiretroviral treatment. Special Infection Units keep asking for special ed staff in order to retain IDUs. Today data shows that one third of the found tested linked remain linked in the Special Infection Unit. The two thirds are lost. At the same direction goes the one stop shop proposal that we have. It's one space where an IDU can come and all the basic needs can be covered. Additionally the OST and the antiretroviral treatment. Thank you for your attention. You mentioned that there was a drug consumption room in Athens. It was opened and then it was shut down. So can you explain the situation now like why it happened, why it was opened first time and why it was shut down and is it a possibility that it will be reopened? Well as you have seen the consumption room was not in the list of the seven proposals made by the international bodies. Although if you read carefully materials that have been published by the MCDDA and other international bodies you will see that the intervention of drug consumption rooms generally speaking is very important because first of all if you take it from the public health point of view you have not crawling the epidemic on the streets. If you take it from the public order point of view you don't have people shooting in the center of Athens and people complaining about it. Fabian said before about syringes on the streets. So this is another way not to enter in these problems let's say finding syringes, used syringes all around the streets because it's consumption room, people go there, inject and everything is well protected. If you take it from a personal health point of view you can avoid overdoses. For example in Athens we had more than 500 cases of people that monthly were visiting the drug consumption room. 500 different people monthly. And at the beginning from October 2013 that has started as a pilot intervention till June 2014 that almost ended there although the official end was first of August we had 30 people that have avoided overdoses. So I don't know if numbers concerning possible deaths mean anything to anybody. I hope that they mean something. It's also very important. So you see that there is a very interesting area of intervention that the drug consumption room can help, can assist. Of course drug use and drug consumption room is a little bit difficult to be well understand by people and also by families and also by politicians. This is really difficult because using it's not legal. So providing tools for someone to use in a let's say effective way it's legal but it's also in a grey legal zone. Street work that we said before concerning needles and syringes for example is also in a grey legal zone. I mean any time if the legal system of a country is not well prepared and well set we as street workers can be arrested. So combating HIV, hepatitis C and other issues needs also a different approach concerning drug use itself. I don't know if politicians are ready to take this risk. For example in my country from since 2009 since today we have changed the Ministry of Health, the Ministers of Health more than six times. I don't know if you can understand how totally unstable it's the political situation in Greece right now and nobody takes care and takes responsibility for projects that are not very well receptive or they're not very well advertised for example. So it's a combination between people that they understand and they drive from one part for several interventions for the public health and the personal health of the people and promoting human rights and public safety and avoiding deaths and another part where we have people mostly politicians that they don't understand exactly these issues or if I may say they're not interested. So this is something that we have to gap, it's a very big gap that we have to make bridges and understand it and give responses in a different way. Finally at the bottom of everything Peter I think that it's important to realize are inside of our concern people, human rights and public health safety. If not then everything comprehensive packages, consumption rooms etc. are useless. Greece if what types of drugs are injected in your countries? So new psychotic substances are in Greece or it's mainly heroin that are injected by drug to Greece? I'm sorry. I understand well you ask me about new substances. Yes so synthetic ketinones are injected in your country? Yes. What drugs are injected mainly by the users? Okay we have traditional use, we have heroin, heroin users and recently from 2009 and on we had the intervention of CISA. CISA is a crystal methamphetamine. It's a very cheap drug, it's called the homeless people drug and of course in 80% it was smoked. In 20% it was injected five or six times per day. But till now I have to say that no scientific report can make a liaison between the HIV outbreak and the use of CISA. All the moment nothing has proved that it was risk the cause and not for example the lack of intervention activities of harm reduction. May I have a question to Maria Nella? My first question was actually related to your comment you just made how do you explain the brutal increase of the number of HIV cases until you sort of responded because you understand well it's not related to the decrease of funding, it's related to the quality of services basically. So it was not related to the financial crisis or maybe to another pattern of use. What is the place of the people who use drugs in your program? What is their role and what is their place? Well I may say that when the epidemic has started there was no drug union, drug users union sorry. It was not formed yet, there were just people hanging around some of them of course very sensitive concerning what is happening but there was no union. The drug users union in Athens has started in 2012. So we were already on the streets working in this project. What we have tried to do is to bring them in a way on the tables with the government and in the commissions that I mentioned before that they are official by law they are included there. So they have a voice, they have a meaningful engagement up to the position that they can or that they want and now praxis is starting to incorporate them in the street work too because this is another myth, another thing that it's a little bit not well understood let's say. Do drug users have the right and they are suitable in a way to do street work with us? So we try to incorporate them in our street work too. But concerning also the first question I think that now it's very critical not to leave aside all these interventions due to budget cuts because we are keep telling all the time that these numbers reduced will remain reduced only if those interventions keep on. If they don't keep on when EMCDDA and PCDC came for the first time talked about an epidemic that will concern us for the next decade. So it's very important to keep on if not scaling up at least keep on the same numbers. And of course the waiting list that we have two years and a half we keep on having the waiting list for two years and a half it has to be reduced to a month at maximum. How much does it cost to intervene in the Hepatitis C drug users in Russia and Romania? For Romania you have to stop using drugs but this is not an official requirement and the official information is that we don't have the money to treat people who use drugs. And it starts being true for people who inject drugs for HIV as well. Normally, you just have to go to the an infectionist to get an assessment. Normally, the procedure is an ELISA test, a second confirmation ELISA test, a Western blood, CD4 counts, and then treatment. But in the case of an unknown number of drug users, the procedure stops at the CD4 levels. And apparently, there are people who are told by doctors that they are in good health and they don't require treatment. Otherwise, if you're not right people and you have the necessary money, I guess it's very easy for you to get into the treatment. On the other hand, it's not that drug users do not access treatment at all. Infectious diseases, I am hospitalized in Bucharest, treat a lot of people who inject drugs now. And they complain of the fact that they don't know how to deal with them, how to talk with them and to manage the violence and the crashing from the part of people who inject drugs, who steal the goods of other patients, smoke their cigarettes or get violent with them. And it's a real security challenge in infectious disease words in Bucharest. As far as I know, universal access is no longer the case. You have to be insured. And I would say that would be the official requirement. Well, increased people, IDQs that were HIV positive, were privatized in the waiting list for anti-revolution treatment. So that was the interesting thing. When we have reached the top number of HIV infections that were around 1,000, we have seen that 35% of those 1,000 people were homeless. So their health insurance status is very bad. That created a problem because the IDQ is not a person that can very easily go and come back and go again and come back to the special infection units. You have to be able, when QC approaches the special infection unit, to be able to treat and give the best possible support in order to have him or her again coming. That's why we talked about nonstop shops. Well, food, shelter and other things that their needs are different. They don't want anti-revolution treatment as it basically, they understand and have to take it. But their needs of water, clothing, other basic needs. The grip state had brought several objections to keep on giving anti-revolution treatment to these 35% that they have lost health insurance status. But as on the other hand we were able to demonstrate what in a long term will be the payment concerning the public health expenditures, hospitalizing people, etc. They understood that okay, we have to do something and in a way support with antiretroviral therapy this 35%. What we have as a big problem now is the two thirds of the HIV positive news that they are not linked, that they have disappeared. This is our big challenge.