 So good morning everybody. I'm really pleased to welcome you all to the official scientific press conference for the 27th Harm Reduction International Conference. My name is Naomi Berkshine. I'm the Executive Director of Harm Reduction International and we're really pleased to be the convener of this event, bringing together a thousand people from close to 80 countries around the world. I think I speak for everyone here and I say there's been incredible energy around the conference centre over the past few days. It's been so exciting to be reunited post-COVID. At the same time, we have a really exciting kind of body of evidence and research being presented. Kind of broadly adding to our renewed optimism in the field. Perhaps cautious optimism, but renewed optimism. We see some great policy progress around the world, whether it's developments in places like Thailand and Malaysia, a harm reduction services implementation in a number of countries, eastern and southern Africa. Yesterday we were really excited to have been part of the first ever media tour of Melbourne's medically supervised injection room. We're accompanied by Commissioner Helen Clark, Chair of the Global Commission on Drug Policy, and had this incredible chance to really kind of take the client's journey through the centre, interacting with the clinical staff but also the peer experts that are there to support people when they use the service. Commissioner Clark said on site yesterday, we need more of these rooms in Melbourne, Australia and across the Tasman. The medical supervised injection room has been granted permanency by the Victorian state government, and the basis for that is largely due to the public health benefits of the centre, the evidence base. So today we're going to hear about some other spectacular new evidence and research being presented this week at the conference. And this data we think is critical to informed decision makers going forward. On that note, let's get started. Let me just quickly run through some housekeeping. This press conference is live in person as you can tell because you're here. We're going to, thanks to Ishwana, we're going to grab it and put it online immediately afterwards, and people will be able to see it on the HRI YouTube channel and on the Drug Reporter page. Today we'll be hearing brief remarks from all our speakers, talking about the research they're presenting here this week, and then I'll open the room for questions. When you do ask a question, please indicate the media outlet you're representing and who you'd like to direct your question to. Okay, with that, let us begin. Our first speaker, I'm delighted to introduce you to Bezad Hajari Zada, an associate professor at the University of New South Wales in Sydney. Bezad's work is under review in the Lancet Global Health, and here he'll recap for us some of the global data around people living with hepatitis and their access to a range of health services. Bezad's data is linked to the research project recently presented and published by Degenhart, the systematic review in Lancet Global Health. Please take it away. Thank you very much Naomi, and good morning everyone, and thank you very much for the invitation. I would also like to start with acknowledging the traditional historians of the land that we are gathering today and pay more respects to elders past and present. As Naomi said, this is actually a part of the larger project which is led by Luisa Degenhart and Jason Grebley, with many people involved, and I think I'm just lucky enough to present the data for you on behalf of all my co-authors. This is based on a systematic review that we conducted, looking to evaluate the coverage of testing and treatment for hepatitis C and HIV among people who inject drugs. We collected data from peer-reviewed literature, just great literature, which is non-peer-reviewed data resources and also contacting with many experts and stakeholders around the world and then putting together all the available data to develop some estimation. In terms of the HIV testing, the proportion of people who inject drugs who were tested for HIV antibody in the past 12 months, we had the data available from 67 countries and the global estimation was 49%, which means that 49% of the global population who inject drugs were tested for HIV antibody in the past 12 months, then less than half of them actually got tested. With a very wide range across the countries with less than 1% up to more than 80% in some other countries. In terms of the HIV treatment, the data was less available, only 18 countries they had the data of the HIV treatment, then because of the insufficient data we could not develop any kind of global estimation of the treatment uptake, but the range was very wide from 3% to 82% across the countries, that was the proportion of the people living with HIV who received treatment. In terms of the HIV antibody testing, we had the data from 49 countries and the global estimate was 47%, which means that 47% of the global population who inject drugs, they have ever tested for HIV antibody, again less than half the population, again with very wide range across the countries. But for HIV, there is an important point to mention, there is a difference between HIV testing and HIV testing. In HIV, HIV antibody testing is more or less equal to HIV infection, and the people with HIV antibody testing, that's the person who is infected with HIV, but for HIV antibody testing that only shows the HIV exposure, then a person with HIV antibody positive has to do another test which is called HCV RNA, which shows the active infection. And that's actually where the very limited data, the HCV RNA testing, we had only data from 3 countries across the world, they are very, very limited data in that aspect. And in terms of the HCV treatments, again very limited data, the data was from 23 countries only available, again not enough to have a kind of global estimate, but the range was very wide again between 2% to 89% across countries. The overall message is that definitely there is a gap, a real gap in terms of the data of the treatment and testing for HCV and HIV, particularly for HCV RNA testing and also for the treatments, then even in the countries with available data, there are really suboptimal coverage in the majority of the countries. Then firstly there are more investment effort is needed for development of the quality data in terms of the treatment and testing, and also more strategic interventions to improve the linkage of the people who inject drugs to hepatitis C and HIV care to improve their testing and treatment object. Thank you very much. Thank you, Bazad. Just to really emphasise what a significant academic endeavour it is, these systematic reviews come out once every 5, 6, 7 years. So it's really very exciting for us to have Bazad and his colleagues presenting the latest research at our conference. Our second speaker today, really excited to introduce you to Karen Timmermans. Karen is a technical manager at Unitade, which is a global health agency, and today we'll be making an important funding announcement in relation to hepatitis C. Thank you very much, Naomi and Home Reduction International for inviting Unitade to speak here today. We know, and we have heard it in the conference before in the past few days, that people who inject drugs are profoundly and disproportionately infected and affected by hepatitis C. It is estimated that about 4 out of every 10 people who inject drugs have active hepatitis C infection, which is frankly enormous. And we've also just heard that the coverage of these people with testing, their access to treatment in as far as there is data, is really problematic, it's way too low. I have also been very impressed in this conference in the past few days with what I have heard and seen about the leadership and the engagement that Australia is taking in this area, and I feel that there are many lessons that we and perhaps the whole world can learn from Australia's pioneering role in harm reduction. But I also note that many of the tools and approaches that are helping to achieve a very welcome change here are not available to people in low and middle income countries, where some 80% of the hepatitis C infections occur. So that is why I'm really pleased to be here today and to be able to announce on behalf of the Global Health Agency Unitade that a new investment of 31 million US dollars that will be focused on preventing and treating hepatitis C among people who inject drugs in low and middle income countries. The funding will support efforts in 10 countries to do three main things. We will pilot the introduction of long-acting buprenorphine. We will boost or try to boost the use of low death space syringes and both these products are really promising products that can really help to prevent block-borne infections such as hepatitis C but also HIV when injecting drugs. And then the third important thing thinking back of your data that we will do is we will also aim to make sure that really highly effective hepatitis C medicines that can cure hepatitis C will reach people who inject drugs in these countries and we aim to do that by integrating testing and treatment in harm reduction settings and in other spaces and places where people who inject drugs feel safe to go learning from what we see here in Australia. The first product that I mentioned long-acting buprenorphine is a new extended release formulation as we call it in technical language. It's a medicine so buprenorphine is a medicine that is used in opioid substitution therapy and it reduces cravings and it reduces withdrawal symptoms for people. The long-acting formulation is an injectable formulation that can last one month as opposed to the normal buprenorphine which is an oral product that you have to take every day. This new product is already being rolled out in high-income countries including here in Australia but so far people in low- and middle-income countries do not have access to that product with the exception of some people in Ukraine. The second product is low death space syringes. These are safer syringes, safer injection products. Normal or traditional syringes I don't know if you've ever paid attention that they have like a small reservoir like in the tip where liquid or blood can remain even if you press the plunger down completely. Low death space syringes are slightly different because the reservoir is much smaller so the quantity of blood that can remain there is much less and therefore it reduces the risk of transmitting blood-borne diseases when needles and syringes are being shared. Early research in high-income countries has shown that these products can reduce hepatitis C transmission by about 76% and we think in Unitate that this is also possible that these products will also be effective in resource-limited settings if they can be rolled out there effectively. So the work that we will support will try to do those things but it is also really important for us that the support will really put the voices and the preference of communities of people who are injecting drugs at the center and we will really be guided by their needs and by what they want and what will work for them. The work will be implemented through three complementary projects led by Frontine 8, Medicine Du Monde and PART and it will take place in 10 countries. These countries are Ukraine, Vietnam, India, South Africa, Tanzania, Nigeria, Egypt, Kyrgyzstan, Armenia and Georgia. And through these efforts, we really aim to address the different factors that restrict access to and use of these products in low and middle-income countries and our ultimate aim really is to kick-start efforts that enable scaling up of these products in low and middle-income countries to benefit people who inject drugs in those countries. Thank you. Amazing news. Thank you, Karen. Really, really exciting. Our next speaker is Marie-Jopée Roustide. Marie is a researcher at the Institut Nationale de la Santé at a little research medical in France. Marie is presenting some really exciting new data, a controlled study of drug consumption rooms in France, significant in its very first of its kind. And she'll also give us some insights into some social science data unpublished at this point. Thank you, Naomi, and thank you, Harm Addiction International, for inviting me today. I will present some data on behalf of my co-authors and this afternoon I will be able to list all the names of people who have been involved in these works. I will begin with some elements of context. So drug consumption rooms have been implemented worldwide in Europe, Australia, and North America. And the first drug consumption rooms opened in 1986 in Switzerland, in Bern. And since this first drug consumption room has been implemented, we have a lot of data that shows the efficiency on public health and public safety outcomes. But despite this evidence-based extensive literature, drug consumption rooms are still difficult to implement in several settings. That's the case in Australia, because they are facing difficulties to implement some new drug consumption rooms. But that's also the case in my country, France. So in my country, France, in 2016, the French government decided to implement two drug consumption rooms, one in Paris and another in Strasbourg. And it was 30 years after Switzerland. And the French government decided to implement only two rooms and for an experiment for five years. At the same time, the government requested my research institution to evaluate, again, the effectiveness of drug consumption rooms and their social acceptability in the French context. So we did several surveys. So we did a court survey called COSINUS that I would present this afternoon. That was a 12-month prospective court of people who inject drugs. We recruited 664 people who inject drugs in four cities. And the methodology was original because it was the first time that we were able to compare two groups, a group of people who benefit from the services from the drug consumption room in Paris and Strasbourg and a control group in Marseille and Bordeaux who was not able to attend a drug consumption room. So the result of our court survey confirmed that drug consumption rooms are inefficient harm reduction measures that achieved to reduce overdose events, to reduce syringe and paraphernalia sharing, to reduce injections in public space, to reduce emergency department visits, to reduce abscesses linked to injection and also to reduce criminality reported by people who inject drugs who attend drug consumption rooms. And this court was also completed by different social science survey that I will present briefly now. So we did an ecological survey before and after the implementation of the Parisian Drug Consumption Room and with this survey we showed a large decrease of discarded syringes in public space in the area where the Parisian Drug Consumption Room is implemented. The number of discarded syringes was divided by three. We achieved this result with a ethnography study combined with a modeling study and data have not been already published. We also analyzed policy administrative data combined with semi-structural interviews with police officers and all these data highlighted that the Parisian area where the disease has been implemented is not any more considered as a problematic place in regards to public order, criminality, and safety issues since the drug consumption rooms have been implemented. So we also conducted semi-structural interviews with people who inject drugs who attend drug consumption rooms and they reported that they considered drug consumption rooms as a protective refuge and also as a place where they felt being respected as citizens. And finally we did a media analysis on drug consumption rooms controversy in France. We reviewed 2,000 press articles from 1990 to 2018 and we found that the voice of the French people who inject drugs were 30 times less represented compared to politicians and 10 times less represented compared to residents. Our semi-structural interviews and ethnographic data also showed that the implementation of drug consumption rooms in France is framed in a welfare state philosophy. The French state considers that it is its responsibility to manage public safety for residents and also to improve the health for people who inject drugs but unfortunately to a lesser extent. The French state imposes at the same time a prohibitionist drug policy regime and as a consequence a focus on punishment, surveillance and a moral approach of drug use. And that's why drug consumption rooms implementation is still controversial in France and since 2016 we have no new drug consumption rooms that has been able to be implemented despite the willingness of local actors. So for the future to conclude for securing the dissemination of drug consumption rooms in France and abroad we need to change our drug policy model. We need to integrate drug consumption rooms in a more comprehensive approach with access to stable housing for people who inject drugs, social inclusion, treatment of mental health and trauma and empowerment of people. We need to reinforce mediation actions with local residents in order to decrease drug consumption rooms social acceptability and finally we also need to stop the demonization of people who inject drugs imposed by prohibitionist drug policy regime and we also need to listen to their voices and to their experience of drug consumption rooms. If we want to improve the effectiveness of drug consumption rooms we also need to act on structural levels by reducing precarity and stigma of people and we also need to produce new indicators of drug consumption rooms. With evaluation that will take into account social support, mental health and we also need research more embedded in community-based approaches and during this year I will lead a research program with the European monitoring centre of drugs and drug addiction to produce new models of drug consumption rooms evaluation with a collaboration of harm reduction providers and people who inject drugs representative in Europe. Thank you. Thank you so much. Really exciting to have such a significant contribution to the evidence base that drug consumption rooms are working for both the clients that they serve and the communities around them. New York City opened its first drug consumption room at the end of last year. Really exciting move to the United States and they will be presenting the results of some similar research later this year. So it's worth watching out for that one too. Really pleased to introduce our next speaker, Nilawan Pitak Panawang. Nilawan is a member of the Thai Drug Users Network and is also representing Development of Quality for Life Lahu Association. Today she will describe an extraordinary program delivering methadone to hard to reach villages and isolated places in Thailand. Thank you, Nilawan. I would like to say thank you Naomi and Michael and Asia 23 Committee to invite me to here and today I would like to talk about mobile telephone, mobile methadone therapy for drug users within ethnic groups in Phang District, Chiang Mai, Thailand. Yes, the northern region of Thailand bordering with Myanmar is known for several ethnic populations like Lahu people, Korean people, Aka people and Padong people and more. Yes, you can come to visit our Thailand and especially Chiang Mai province. Ethnic groups have been using OPM for treating illnesses such as stop nausea, diarrhea or as a pain killer and to ease work fatigue. You begin to use drugs following their friends while others resort to drugs to solve personal problems. Several drug users want to take up methadone therapy but methadone therapy requires continuous treatment which is a challenge for interested users. The distance between the ethnic groups village in the hills and the gold mentor methadone service. Most drug users are poor without vehicles so regular long distance travel is a hard obstacle. Transportation can be closely and public transportation is not readable or viable. The leads to the treatment discontinuation. Double-check Thai drug users network covering 6 districts of Chiang Mai. Outreach workers are ex- or current drug users. Drug users are identified, educated about harm reduction, safe drug use and drug harm towards oneself and family. HLV, STI and HPC, clean equipment is offered to them too. Mobile methadone therapy service brings methadone to drug users at the village. Health service visit the communities and provide the service with our civil society staff. This reduce continuous treatment and help people who cannot travel to receive the treatment result in 2022, 118 clients receive the methadone therapy from government health service and 80% of whom were from ethnic groups. Some work on their farms while others are earning money to spend on their families. Some users reduce heroin injections from 5 per day to 2 or 1 per day. As a result, they had more money to spend on other things. Their health improved and they had better family lives. Once drug users in the community began to have a better life, other drug users became motivated to receive treatment too. Thank you. Thank you. Next up we have Courtney McKnight. Courtney is a clinical assistant professor of epidemiology at New York University. Courtney will present some new and complex data on fentanyl trends. The data is under consideration with the international drug policy. Thank you Naomi. Good morning everyone. Tomorrow I'm going to be presenting findings from an ongoing study that we are doing with people who inject drugs in New York City examining fentanyl use. Fentanyl as you may know is a highly potent synthetic opioid that has been added to the list of drugs supply in New York City and North America largely since for about 10 years. Since its surface it has caused precipitous increases in drug overdose mortality. As you may know in 2021 over 107,000 people died from drug overdose deaths in the United States. In New York City where this research took place, while we have had a steep increase in mortality since 2015, drug overdose deaths have increased by 80% additionally since the COVID-19 pandemic began. Fentanyl is now involved in 80% of all overdose deaths in New York City. So in 2016 we started to investigate, as Fentanyl sort of appeared on the scene, we started to investigate with people who use drugs whether or not they were aware of fentanyl and sort of their opinions of it. But given the fact that overdose has increased so much since that time we decided to sort of revisit and see how people are feeling about fentanyl what they knew about it and also examine their exposure to it through urine toxicology testing and potential changes to in preference for fentanyl. So in this study we conducted urine toxicology testing, we also did in-depth interviews as well as surveys. And what we found was 99% of our sample reported recent use of heroin but only 40% tested positive for it. In contrast 83% of people tested positive for fentanyl but only 18% of people reported that they had intentionally used it. Meaning that 78% of people in our study were not intentionally using fentanyl. When we examined differences between people who had intentionally used fentanyl versus those that hadn't, we found that people using fentanyl intentionally were more likely to be young, white, have overdosed at least once in the last six months, reported injecting more frequently and self-reported fentanyl as their main drug. So given the ubiquity of fentanyl in the drug supply in New York you can imagine that people are very concerned about overdose. 95% of people reported that they were using at least one harm reduction strategy to try and prevent an overdose event but most people were reporting using multiple strategies at once. The most common strategies people were using were keeping the loxone nearby, using a smaller amount of drugs to try and gauge the potency of their drugs, using a trusted supplier to try and ensure consistency in the drug supply and then using drugs with or near others so that in the event of an overdose they could be resuscitated. Our in-depth interviews that we conducted found that for many people who were using fentanyl intentionally the ubiquity of it has really led to an increased tolerance of heroin alone or potentially heroin mixed with fentanyl may not be satisfying. So I just want to share with you one quote that really exemplifies this shift. So in the in-depth interviews we were asking people whether or not they prefer fentanyl and one of our participants answered, now I do. Yeah, if I see something too dark I'm like I don't want it and by too dark they're referring to heroin which is sort of has a brown tint to it as opposed to fentanyl which is much more white. She says I want the fentanyl because I get sick like I could do dope and still get the sweats. When I first got sick I'm like why am I getting sick and I'm still doing it and then my friends like I think that's fentanyl. This quote came from a woman whose preference for fentanyl was developed by repeated unknown exposure to it which increased her tolerance and made heroin and potentially heroin mixed with fentanyl an undesirable option. She reported that she just wants to use straight fentanyl now and that she's able to get straight fentanyl. Our findings demonstrate that fentanyl use was widespread in New York City yet most people reported preferring and using heroin. Our findings also found that unsuspected fentanyl use and the persistent volatility in the drug supply is putting people at significant risk for overdose as evidenced by our mortality data. In 2021 over 2,600 people in New York City died of a drug overdose and preliminary data indicate that this number is going to increase for 2022. So what do we recommend? We need access to safe and our regulated drug supply particularly for people whose tolerance continues to increase due to fentanyl but also for people that are very concerned about overdose which is the majority of folks that we're talking to. We also need to increase access to naloxone as well as methadone and buprenorphine and lastly as Naomi mentioned you may be aware that two overdose prevention centers the first two sanction overdose prevention centers in the United States opened in New York City in late 2021 but these programs are operating with private funding only. So we are urging our government both federal especially federal but as well state governments to provide support for implementation as well as expansion of overdose prevention centers in the United States. Thank you. Thank you Courtney such important work. Our final speaker today is Chris Goff. Chris is the CEO of the Canberra Alliance for Harm Minimization and Advocacy also known as CUMHA. Last Friday HRI took a group of local and Southeast Asian journalists to visit CUMHA's offices and the CanTest pill testing facility. CUMTest are one of the partners helping the operation to fulfill its mission. I know the journalists were blown away by the site visit and today Chris will give us a brief overview of the center as well as provide an update on the latest drug checking numbers produced by CanTest this week. Thanks. Thank you very much for having me. I'd like to acknowledge the traditional custodians of the land on which we are meeting and pay respect to elders past and present. I'm going to start by just giving a brief run down on CUMHA as a service and what we've kind of done in the ACT and then I'll move on to CanTest and the figures that have just come out. So CUMHA is an integrated harm reduction service so very much a one stop shop kind of a model. We are a member of the Australian Injecting and Elicit Drug Users League and so there's a peer based organization in almost every jurisdiction in Australia and Canberra is represented by CUMHA. We run a community drop in sensor where people can come have a cup of tea or coffee, a meal and that's all we ask of them so there's no, you don't need to change it's what we call the low threshold drop in center and so the idea is to start to build trust within our community and to grow everything we do at CUMHA is about community development. So we also do a lot of drug treatment support and case management as well as an eloxone program. We have a doctor and a nurse who in reach to us every week from directions health services who are the organization that runs CanTest in partnership with other organizations and we have a point of care testing machine which just turned up and we're part of a number of different research projects in Australia looking at the health and well-being of people who use drugs. Canberra probably sees about feeds about four to five hundred people every month at barbecues across the ACT and that's where we actually go out to people where they are and we do that in partnership with directions so we provide peer treatment support workers who provide a community barbeque and then next door to us or in the same space as us is a clinical van which has a doctor and a nurse and a mental health clinician and so they're able to do vaccinations, method and buprenorphine treatment hepatitis C treatment and send people pretty much wherever they need to in the primary health care system. And so part of the idea of that is that we are out there vouching for this wonderful service a doctor and a nurse Lord of our community has had fairly appalling experiences with health care services it has to be said over the last kind of 30 years but slowly as things change and as society starts to accept people who use drugs you know we've been able to kind of move it along and some of the policy we work we've done at Karma's we're very proud of and so that includes advocating to make cannabis properly decriminalised and you're allowed to have 50 grams of cannabis now and drop to two plants in the ACT which has been fantastic. There's also no police discretion so it's simply part of the law that people can possess up to 50 grams of cannabis which has had a significant impact on the stigma and discrimination that's felt by the community and a significant impact on the number of people who are coming forward to seek treatment if they believe that their cannabis use has become problematic for them. So we really are a strong believer in partnership and that brings me to wonderful CanTest. CanTest is Australia's first fixed site drug checking service and again it's a low threshold harm reduction service so don't expect you to change. We just want to come say hello, give you a great experience and educate and inform you about what is in your drug sample. CanTest is run by directions. The peer workers are provided by Karma. Pill testing Australia really did the heavy lifting in terms of the advocacy for the service and continue to engage with governments around Australia about increasing the profile of drug checking in Australia and the ANU who provide the analytical chemistry side of things which is pretty complicated. So over the last month at CanTest we've just released our eight month overview of what happened at the service in March this year. There were 91 samples taken through CanTest in March bringing our total up to 789 so an average of almost 100 about 98 samples every month. Eight of those samples were discarded which is great and one community notice was released and that was a red community notice we found four fluoroamphetamine and 25C n-bomb. In a sample it was purported to be 2Cb so it's quite a dangerous mixture those two. And in 2017 in Victoria they were responsible for a cluster of four deaths. They were associated I should say and associated with four deaths in the ACT. One of the things that's been great with CanTest is to actually give people an understanding of what they actually have. And we found that some drugs are more, the supply is more stable than others so for example methamphetamine supply is quite stable in the ACT but our ketamine supply certainly isn't and so if you look at the statistics from last month there were 19 samples of ketamine centene and only 10 contained ketamine. The other nine samples contained a plethora of different chemicals. Procane, teletamine, MDMA but also a range of different substances so very important function of CanTest is actually letting people know what they really have and then giving harm reduction advice to people to make sure that they can use it safely. In particular people are looking for how long is this drug going to take before it comes on in my system? How long is the experience going to last and what is it going to feel like? And so these are fairly simple things but they make the difference in a lot of cases between somebody knowing that they have to wait 40 minutes for their experience to come on and they make the difference between that and somebody becoming anxious because they're not feeling anything after 20 minutes and then re-dosing and re-dosing with the potential to overdose. The other thing that's been fantastic about CanTest has been the uptake from the community the way the community members describe the experience as being very non-judgmental and the way that they go out and talk to their friends about the experience it's forming this really beautiful thing in the community where people are going out to festivals with their friends and they're going to have the right information and resourcing to keep their mates safe and some of those and it's also I think having a profound effect on the way that people are viewing their own drug use having that knowledge and centering the knowledge within the person has been an amazing experience to see happen. So thank you very much for your time. Fantastic, thank you for being with us Chris I'm really happy to open for questions now really happy to open for questions now can you take us from the floor? Please, may I go first? Thank you. Yeah My name is Sanucha Jirenpo I'm coming from Thailand the Bangkok Post newspaper it is only language, English newspaper in Thailand just like we are the newspaper that looks like the middle of the world when you go to Thailand I have a question to Mr. Nila Wan Yes As you know that the drug use and drug problems remain the serious problem in Thailand and if you are in Thailand we will receive news about the heavy crackdown suppression of police authorities in Thailand every day and would like to know in terms of cooperation from the state I'm very impressed with your mobile methadone therapy given to the remote drug user in Thailand because as you know that in the north of Thailand there are very high remote areas and it's quite insensible to travel to meet those people in the remote areas and how much cooperation from the state that you help is that state officers are facilitating your project I mean mobile methadone therapy during you start the project and how it's about the local community participation they help you to run this kind of project or not Thank you Thank you for question In our project before we like we do the project we have like the meeting or seminar with the local organization and the governmental organization in the local too so the sector that come to join our project is like a hospital hospital in the local hospital and the local governmental like he come to join us too and for this about the sector of police he come to help us too because when our patients go to the hospital the police they have like a Korean or whatever sorry I asked her we have like the police sector our clients need to pass the sector so we should tell him that today our clients go to the hospital don't erect him or don't paste anything in his blood like that so the police can help us too so I think for yes so for our methadone therapy we have many sector in many organization in the areas help together not just civil society governmental organization in the local very helpful for us so I think this is the corporate between the government and civil society organization yes yes thank you fantastic any other questions thank you hi I'm Sulin from Code Blue Malaysia so I have a few questions for Marie by your study so my first question is the health benefits that you cited in your study is it narrowly defined to overdoses or reduction in emergency room visits that's one did your study measure for example compare the frequency of heroin injections or the number of people going on opioid therapy or also their general health HIV, HCV status or mental health was there analysis of that and comparison between both groups and I guess finally it seems like the main success of the DCRs in the French cities is it really public order rather than personal health because it seems like the main benefits is fewer like you said less disposal of syringes everywhere in the city and fewer people injecting publicly that's it thank you thank you for your question I have no time to detail the public health result and I will do it this afternoon so the benefits of drug consumption were both in the both area so we had a lot of benefits in the health measures but also a lot of benefits in the public order measure so regarding your question on health measures we unfortunately in this survey we were not able to have a lot of mental health indicators because we need to do the survey in a short period of time and we will implement this year a new court survey that I will present this afternoon called the bebop survey and this survey will be focused on mental health but the first one was a request from our government and they were interested by overdoses infectious disease transmission and public order indicators so regarding the public health indicators we have very very good impact on reducing overdoses and also reducing the transmission of HIV and HCV by a measure that is paraphernalia and injecting paraphernalia sharing we were not able to collect biological data so that's why all the measures of HIV and HCV that we have in this study are declarative status we have other studies that are ongoing now with biological data will help us to continue to evaluate our consumption rooms there is a result that was not able to present now but I will present it this afternoon on opioid substitutive therapy and in France we have a specificity we have a paradox because we have a very prohibitive regime but we have also a very high access to health and contrary to New York City or contrary to the United States all the harm reduction services and all the drug treatment services are public funded and it's not funded by private sector and that's why it is sustainable and for opioid substitutive treatment we are not able to show an increase in the access to opioid substitutive treatment because the level of access is very high we have 85% of people in France who attend harm reduction services so the group control who are under opioid substitutive treatment so the level is so high that it's difficult to have a higher access even for people who attend drug consumption rooms but regarding even if we have only one year of follow-up we were very happy with the result on overdoses, emergency visits, abscesses and also with public order measures that were expected from our government Very useful insight, thank you Marie I think we don't even have time for last question but if there is one we can come in Thank you, please Kompas Thank you, I'm Evie I'm from Kompas Daily Newspaper from Indonesia just one question about we know that many studies that give proof about how effective the harm reduction to reduce to prevent overdose and also the other all the transmission many infection diseases like as IVA and hepatitis C maybe but how the data used for the researcher and the civil society to push maybe the policymaker to put the harm reduction in the drug policy because in some countries it's not success to push the policymaker to maybe there is harm reduction program but not in the massive in the all area for example in Indonesia many is just concentrate in maybe just pilot project in one or two city, thank you Maybe for Karen Yes I'm getting the hard one Thank you for the question I do think it's a difficult question and a question that many people are struggling with I think what we are trying to do in Unitate is first of all make sure that you have the data because I hear you say that data is available but many of the data is from high income countries and our experience at Unitate at least has been that if you then present that data to a government in a low or middle income country and you try to use that data to encourage them to act the policies that we would like to see they are going to say yeah but that's in France but that's in Australia they have resources that we don't have so it's easy for them to at least put the data in question or saying the data is valid but not in my country so that is why excuse me that is why this is why the data that is why we think it is important to do work in low or middle income countries to get data from there so at least it is more likely that the policy makers will believe it and they'll take it serious but I do agree with you it's not sufficient necessarily to have the data so you also need to demonstrate the solution so that is the other part that we are going to try to do not just show the problem but show the solution show the solution is working and is working in your country or if not in your country at least in maybe a neighbouring country a country that is quite similar and then I think the third element is also that we need to complement that also with the stories of the people themselves who have experienced the problems and hopefully who have experienced the solution so I didn't really highlight it in that way but there is a lot of reasons why we believe that in our work but I think many of the other speakers here said the same thing why it is so important to involve the community it is partly of course to make sure that the services are matching what they want and what they need and I think the other part of it is also that the community can then be empowered also to talk to the government either directly or through you people like through the journalist like listening to the community and also bringing out their stories and helping to reach the government so I think that is a bit of a complex answer but I think the situation is complex but I also think it can be done there are examples and we've mentioned them in high income countries where the governments are starting to listen or are already listening for some time but there are also examples in low and middle income countries like I think a country like Ukraine a country like Vietnam they already have harm reduction programs and of course they can be improved also in my country it can be improved everything can be improved anywhere but we have examples of countries that are low and middle income countries that already have good harm reduction programs and also and this is the last thing I will say what I understand is that there are also slowly by little more and more low and middle income countries that at least are starting to think about creating a harm reduction program and in the countries where Unitate will work we intentionally have a mix of some countries where there is already a pretty good harm reduction program although maybe they have not done so much on hepatitis C they have maybe more focused on other issues that are important and on HIV but we also intentionally have some countries in there where the harm reduction program is only about to start because we think in those countries maybe we can work with them to make the program comprehensive from the start and yeah hopefully in I don't know the next harm reduction international conference or at least the one after that hopefully we will be able to share you very good results but for now as I mentioned this new so we are just putting everything in place and we are getting going but we are very happy about that and yeah hopefully all the people as well thank you Thank you Karen, really useful so please join me in thanking all our excellent panelists today huge huge amount of work goes into each and every one of these presentations so I really encourage you to connect with the speakers you all know our media consultant Michael Kessler our communications analyst Chitra Rajagopalan so please reach out to them if you need any further contact thank you