Picchio et al. Harm Reduct J (2020) 17:87 https://doi.org/10.1186/s12954-020-00432-w RESEARCH Open Access The impact of the COVID‑19 pandemic on harm reduction services in Spain Camila A. Picchio1, Jorge Valencia2, Jason Doran3, Tracy Swan4, Marta Pastor5, Elisa Martró6,7, Joan Colom8 and Jeffrey V. Lazarus1* Abstract Background: Containment policies and other restrictions introduced by the Spanish government in response to the COVID-19 pandemic present challenges for marginalised populations, such as people who use drugs. Harm reduction centres are often linked to social services, mental health services, and infectious disease testing, in addition to tools and services that help to reduce the harms associated with injecting drugs. This study aimed to explore the impact of the pandemic on these services in four autonomous communities in Spain. Methods: This is a cross-sectional study that employed a seven-section structured survey administered electronically to 20 centres in July 2020. Data from the most heavily affected months (March–June) in 2020 were compared to data from the same period in 2019. Averages were calculated with their ranges, rates, and absolute numbers. Results: All 11 responding centres reported having had to adapt or modify their services during the Spanish state of alarm (14 March–21 June 2020). One centre reported complete closure for 2 months and four reported increases in their operating hours. The average number of service users across all centres decreased by 22% in comparison to the same period in the previous year and the average needle distribution decreased by 40% in comparison to 2019. Most centres reported a decrease in infectious disease testing rates (hepatitis B and C viruses, human immunodefi- ciency virus, and tuberculosis) for March, April, and May in 2020 compared to the previous year. Reported deaths as a result of overdose did not increase during the state of alarm, but 2/11 (18%) centres reported an increase in overdose deaths immediately after finalisation of the state of alarm. Conclusion: Overall, Spanish harm reduction centres were able to continue operating and offering services by adjusting operating hours. The number of overall service users and needles distributed fell during the Spanish state of alarm lockdown period, suggesting that fewer clients accessed harm reduction services during this time, put- ting them at greater risk of reusing or sharing injecting equipment, overdosing, acquiring infectious diseases with decreased access to testing or discontinuing ongoing treatment such as methadone maintenance therapy, hepatitis C treatment, or antiretroviral therapy. Keywords: COVID-19, Harm reduction, Healthcare utilisation, Health systems, Spain Background On 31 December 2019, the first case of a novel coro- navirus, SARS-CoV-2, was reported in Wuhan, China. By 30 January 2020, the World Health Organization (WHO) had declared a Public Health Emergency of *Correspondence: Jeffrey.Lazarus@isglobal.org 1 Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University International Concern, and on 11 March, declared a pan- of Barcelona, Barcelona, Spain demic. COVID-19, the coronavirus disease caused by Full list of author information is available at the end of the article © The Author(s) 2020. 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The Creative Commons Public Domain Dedication waiver (http://creat​iveco​ mmons​.org/publi​cdoma​in/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Picchio et al. Harm Reduct J (2020) 17:87 Page 2 of 11 SARS-CoV-2, has spread to almost every country in the reusing syringes and other paraphernalia and injecting in world and infected over 20 million people globally [1]. groups. Common co-morbidities (HCV [10], and chronic The effects of COVID-19, and the measures taken to obstructive pulmonary disease (COPD) [11]) among contain it, have rippled across every aspect of society, PWUD are linked to adverse outcomes of COVID-19. In magnifying existing inequalities among marginalised addition, COVID-19 mortality is associated with older populations, such as people who use drugs (PWUD). age and smoking [12], both of which are common in PWUD face a range of legal, structural, and social barri- PWUD [13, 14]. ers and high rates of morbidity and premature mortality Across Europe, the containment policies that have been [2]. Recognising the challenges faced by PWUD, in 2012 put in place to mitigate the spread of COVID-19 include the United Nations proposed a comprehensive package strict physical distancing measures. Everyday services of evidence-based harm reduction measures [3], which for PWUD had to change their opening hours or were includes a number of services that aim to prevent the shut down until further notice, including some health adverse effects of using drugs (Table 1). and social services [15, 16]. Some PWUD have been left Harm reduction programmes often deliver or are without access to necessary services that allow them to linked with life-saving social programmes and medical protect themselves against, get tested, and seek treatment and mental health services. Nonetheless, infection with for bloodborne viruses (BBV) and TB; lower their risk of the human immunodeficiency virus (HIV), hepatitis C overdose; check the quality of the drugs they are using; virus (HCV) [4], and tuberculosis (TB) is prevalent and and obtain necessary medical and mental healthcare, continues to spread among PWUD, partially driven by including for emergencies. inadequate access to needle and syringe programmes In Spain, use of alcohol and drugs was one of the top (NSP) and opioid agonist therapy (OAT) [5], which, when five contributors to disability-adjusted life years (DALYs) combined, can lower the risk for HCV acquisition among in 2016 [17]. Cocaine (39%), cannabis (29%), and heroin PWUD by 74% [6] and also significantly lower HIV inci- (24%) were the primary drugs resulting in treatment dence [7, 8]. commencement in Spain and 58,749 clients received As a result of the COVID-19 containment measures, opioid substitution therapy (OST) in 2017 [18]. Of those PWUD living with HIV, HCV or TB may face disruptions who were admitted for addiction treatment in Spain in in access to antiretroviral therapy (ART), and direct-act- 2017, 14.3% began treatment for heroin use [19]. Spain ing antivirals (DAAs) for HCV and TB treatment, which has had a National Plan on Drugs [Plan Nacional Sobre could drive drug resistance and/or lead to treatment fail- Drogas (PNSD)] [20] since July 1985 and provides guid- ure. Similarly, in general, PWUD are at a greater risk of ance on policies on drug use and drug dependence. The acquiring these infections and, as a result of the contain- services offered to PWUD in Spain vary widely across the ment measures, may face disruptions in access to a timely country’s 17 autonomous communities [21]. In 2017, 137 diagnosis. facilities for drug dependency, financed through the pub- PWUD face an additional risk of infection with lic and private sectors, were reported in Spain [19]. While COVID-19 than people who do not use drugs [9], and harm reduction centres have been reported in 13 of the could suffer from associated poor health outcomes. 17 autonomous communities, often these centres have Drug use can involve close contact while sharing and/or insufficient data or resources for proper monitoring of Table 1 List of the United Nations-recommended services for people who use drugs United Nations-recommended services for people who use drugs Needle and syringe programmes Opioid substitution therapy HIV testing services Antiretroviral therapy for those living with HIV Prevention and treatment of sexually transmitted infections Condom programmes for people who inject drugs and their sexual partners Targeted information and education programmes Prevention, vaccination, diagnosis and treatment of viral hepatitis B and C Prevention, diagnosis and treatment of tuberculosis Community distribution of naloxone Sources: WHO, UNODC, UNAIDS technical guide for countries to set targets for universal access to HIV prevention, treatment and care for injecting drug users, 2012 revision. Geneva: World Health Organization; 2013. Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations, 2016 update. Geneva: World Health Organization; 2016 Picchio et al. Harm Reduct J (2020) 17:87 Page 3 of 11 outcomes, including the prevalence of infectious diseases National Plan on Addictions (2017–2024) [20], includes among their clients. all of the policies, strategies and programmes that ulti- In order to better understand the effect of the COVID- mately aim is to lessen the negative effects of substance 19 pandemic on harm reduction service provision in use (without necessarily aiming to achieve a reduction Spain, we report service utilisation, operating hours, and in their use) either at an individual level, or in families, provision of harm reduction services such as OST, DAAs, both in the area of treatment and prevention, and social and ART, infectious disease testing [hepatitis B and C incorporation. Harm reduction centres in Spain may be viruses (HBV, HCV), human immunodeficiency virus comprehensive or focus on specific aspects that reduce (HIV), and tuberculosis (TB)], and mental health services the harm associated with drug consumption. during the pandemic and for the same period one year Twenty harm reduction centres were contacted in earlier. four Spanish autonomous communities with the highest prevalence of PWUD: the Basque Country, Catalonia, Madrid, and Valencia. Methodology Study design We conducted a cross-sectional study that employed a Data analysis seven-section structured survey administered electroni- Standard descriptive statistics were used to examine the cally to one focal point per centre. The survey was fol- distribution of key outcomes variables. Means and ranges lowed up to confirm results and clarify any uncertainties. were calculated for continuous variables and percent- The survey consisted of questions regarding care pro- ages and numbers for categorical variables. These data vision, service user demographics, testing practices for were used to describe the study respondents and address infectious diseases (HBV, HCV, HIV and TB), reported the descriptive research question. To calculate testing prevalence of overdose, issues affecting PWUD during rates, the number of users in each centre was used as the the Spanish state of alarm, and the relevant government denominator. responses to the pandemic for PWUD. Four key variables were collected from March to June 2019 and the same Ethical considerations period in 2020 and included infectious disease testing No personal identifying information was collected and and number of positive results, number of methadone the IRB confirmed that no ethical approval was required. treatments distributed, number of needles and syringes In an introductory email sent individually to each harm distributed, and the number of people commencing DAA reduction centre focal point, information on the study treatment and ART. Data were also collected on the num- and its objectives were provided. All data were reported ber of service users for January–June 2019 and the same at the centre level and data were kept on a password-pro- period in 2020. One open-ended question was included tected Excel file. to allow for elaboration on these topics. All answers were dichotomous (yes/no) except for the Results questions on issues affecting PWUD during the Span- Thirteen of the 20 (65%) centres contacted returned the ish state of alarm (Not a problem, somewhat a problem, completed survey: the Basque Country (n = 4), Catalo- neutral, problematic, very problematic) and the govern- nia (n = 6), Madrid (n = 2), and Valencia (n = 1). All 13 ment response (excellent, above average, average, below centres provide NSP and four (30%) have a supervised average, bad), which were collected on a 5-point Likert injecting room. All centres offer mental health ser- scale. Prevalence of infectious diseases and the number vices by connecting users to established programmes, of tests performed, number of total users, sex and nation- including other non-governmental organisations ality distribution, and the number of needles and syringes (NGOs) (n = 4), referring them to established services distributed were collected as continuous variables. in the public system (n = 7), or providing the services that are integrated into their centre (n = 2). A sum- Population and sample mary of the main services offered by the 11 centres is Participants were harm reduction service providers who described in Table 2. All centres (n = 13) reported hav- have been providing services in Spain since at least Janu- ing had to adapt procedures in their centres by mak- ary 2019. ing mask-use mandatory, setting up socially distanced In 2017, 137 harm reduction centres were active in spaces, limiting capacity, and/or installing Plexiglas in Spain. A harm reduction centre, as defined by the Spanish order to guarantee the continuation of their activities Picchio et al. Harm Reduct J (2020) 17:87 Page 4 of 11 during the Spanish COVID-19 state of alarm. Of these, Impact of the COVID‑19 pandemic on infectious disease two centres shut down during this period. testing The average age of clients in 2019 in the centres that All centres reported testing for infectious diseases in situ. provided data (n = 7) was 43.7 years (range: 40–47) Six (46%) centres reported offering HBV testing and and the average number of users in 12/13 centres in Mantoux tests for TB while nine (69%) offered HCV and the same year was 1281 (range: 15–8748). All cen- HIV testing. Not all centres provided testing data despite tres that responded (12/13) served more men (12,400 reporting that they do provide them. Overall, most cen- total, range: 13–6735) than women (2969 total, range: tres reported a decrease in testing rates for March, 2–2013). Of the 11 centres that provided data, Span- April, and May in 2020 compared to the year before for ish nationals (9799 total, range: 11–5861) made up the all infectious diseases. In some centres, HIV and HCV majority of service users compared to those from other testing greatly increased in June 2020 in comparison to countries (5064 total, range: 4–2887). the year before and the month prior (May 2020). Testing rates for each centre for the months of March–June in 2019 and 2020 are described in Table 4. Impact of the COVID‑19 pandemic on harm reduction operating hours and service users Impact of the COVID‑19 pandemic on treatment Eleven out of thirteen (84.6%) centres reported that administration (methadone, DAAs, ART) they were able to keep their centres open and opera- Six (46%) out of 13 centres reported providing metha- tional during the Spanish state of alarm. One centre done on-site, and six (46%) centres provided DAAs and had to close in March and April 2020 but reopened on five (38%) provided ART, respectively. In the months of 27 May 2020 and the other closed from March until March–June 2019, 1163 clients in all centres received the end of the state of alarm (21 June 2020). The aver- methadone versus 1422 in the same months in 2020, age weekly operating hours in 2019 for centres that seeing a 22% increase in methadone distribution. In the reported these data (n = 9) was 52.4 h (range: 15–92) six centres that reported distributing DAA therapy, 88 and in 2020 it was 47.4 h (range: 25–82). Four centres clients received DAAs in 2019 during the same months reduced their operating hours while the remaining five compared to 16 in 2020. One centre did not report this others increased their operating hours (Table 3). data for 2019. This represents an 82% decrease. In the The average number of service users between the five centres that reported ART distribution, 10 clients months of January–June 2019 in the centres (n = 11) received ART in 2019 compared to 13 during the same was 292 (range: 11–1141) in comparison to the same months in 2020, showing a 30% increase. months in 2020, which was 215 (range: 0–819). The dif- ference in the overall average number of service users Impact of the COVID‑19 pandemic on overdose reflects a decrease of 26.4%. There was great variability and medical emergencies among centres (Fig. 1). Nine of the 13 (69%) centres responded that they did not see an increase in reported overdose deaths during the Impact of the COVID‑19 pandemic on needle and syringe Spanish state of alarm, while one centre (7.6%) reported programmes and distribution of materials they did see an increase, another (7.6%) did not know, Ten of the 13 (76.9%) centres reported data on needle dis- and two centres did not respond. tribution for the months of March–June 2019 and 11/13 Two of the 13 (15.4%) centres responded that they saw (84.6%) reported data for the same months in 2020. One an increase in reported overdose deaths immediately centre did not have 2019 data available (Centre 9). March after the Spanish state of alarm ended. One centre (7.6%) 2019 had the highest monthly average of needle distri- did not know if overdose deaths increased, the remaining bution (7393) among the 10 centres that reported these (61.5%) did not report an increase in overdose deaths in data and April 2020 had the least number of needles dis- their centres, and two (15.4%) did not respond. tributed on average (3555). The total 4-month average of There were a total of 99 reported medical emergencies distributed needles was 6831. During the same months in across all centres that responded (9/13) between March 2020, the average number of needles distributed reduced and June 2019 with a range of zero medical emergencies by 40% (4140). There was variability between each centre to 26 per month. During the months of March to June and some reported an increase in needle distribution in 2020, there were a total of 96 reported medical emergen- the 2020 months compared to 2019 (Fig. 2). cies among the same centres, ranging from zero medical emergencies to 25 per month. Table 2 Description of harm reduction services regularly provided by centres and number of users per centre (n = 11) during the first 6 months of the years Picchio et al. Harm Reduct J 2019 and 2020, Spain (n = 11) Centre n. users 2019 n. users 2020 NSP SIR Naloxone Education Mental OST HCV DAA HIV ART​ HBV testing HCV testing HIV testing TB testing (city name) (Jan–June) (Jan–June) distribution services health services Centre 1 (Badalona) 265 274 ✓ ✓ ✓ ✓ (2020) 17:87 Centre 2 (Bilbao) 923 721 ✓ ✓ ✓ ✓ ✓ ✓ Centre 3 4528 1945 ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ (Madrid) Centre 4 892 1090 ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ (Madrid) Centre 5 77 60 ✓ ✓ ✓ ✓ (Vitoria-Gasteiz) Centre 6 1267 1080 ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ (Bilbao) Centre 7 394 398 ✓ ✓ ✓ ✓ ✓ (Reus) Centre 8 764 687 ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ (Valencia) Centre 9 1365 679 ✓ ✓ ✓ (Bilbao) Centre 10 2652 3351 ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ (El Prat de Llobregat) Centre 11 N/A N/A ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ (Barcelona) Centre 12 N/A N/A ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ (Barcelona) Centre 13 6166 3912 ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ (Sant Adrià de Besos) Total 13 4 8 12 13 7 7 5 6 9 9 6 NSP Needle and syringe programme, SIR supervised injecting room, OST opioid substation therapy, DAA direct acting antivirals, HBV hepatitis B virus, HCV hepatitis C virus, HIV human immunodeficiency virus (HIV), TB tuberculosis, N/A not available Page 5 of 11 Picchio et al. Harm Reduct J (2020) 17:87 Page 6 of 11 Table 3 Operating hours and percentage change responded to the question (n = 12), the majority of cen- of centres with reported data (n = 9) pre-state of alarm tres said that the responsible entity performed average and during (n = 4) or below average (n = 4). One centre responded Centre Weekly Weekly % Change that their responsible administration did an excellent job (city name) operating operating and three (25%) reported that their agencies did better hours hours than average. (pre-state (during state of alarm) of alarm) Discussion Centre 1 15 25 + 67% Pandemics expose weaknesses in societies and bring (Badalona) to the fore a country’s ability to respond and protect its Centre 2 52.5 66.5 + 27% (Bilbao) most vulnerable people [22]. Measures to mitigate the Centre 3 63 28 − 56% effects of COVID-19 have had serious social and eco- (Madrid) nomic impacts; although they have affected everyone, Centre 4 63 49 − 22% the impact is largest among marginalised and vulnerable (Madrid) populations [23, 24]. This study set out to understand if, Centre 5 35 15 − 57% and to what extent, services for PWUD, an already vul- (Vitoria-Gasteiz) nerable population, were affected during Spain’s COVID- Centre 6 66 84 + 27% (Bilbao) 19 state of alarm—and the potential consequences of Centre 7 N/A N/A N/A pandemic-related disruptions. (Reus) Service closures and disruptions have been reported in Centre 8 N/A N/A N/A the United States, western and eastern Europe, sub-Saha- (Valencia) ran Africa, and Latin America and the Caribbean [22, Centre 9 N/A N/A N/A 25–28]. Our study found that all of the 13 participating (Bilbao) harm reduction centres reported having had to modify or Centre 10 29 42.5 + 47% (El Prat de Llobregat) adapt their services. Overall, the average weekly operat- Centre 11 56 35 − 37.5% ing hours across all centres decreased during Spain’s state (Barcelona) of alarm; however, four of the centres (13 responded) Centre 12 N/A N/A N/A actually increased their operating hours during this (Barcelona) period. Although Spain was one of the most heavily Centre 13 92 82 − 11% affected countries in the European Union, its network (Sant Adrià de Besos) of harm reduction centres showed resilience by adapt- ing policy changes and innovative strategies to deliver Challenges faced by PWUD during the COVID‑19 pandemic essential services to PWUD. Similarly, the only commu- state of alarm in Spain nity checkpoint offering services to men who have sex Twelve (92%) centres responded to the questions regard- with men in Barcelona reported a closure of services to ing challenges faced by PWUD during the COVID-19 the public from 13 April to 18 May 2020 (personal com- pandemic state of alarm. Those who responded to the munication). However, in an attempt to reduce the risks survey reported that limited access to social workers who associated with a cessation of essential services to this assist with social benefit processes was the most prob- population, only HIV and STI testing were interrupted lematic issue affecting PWUD, with all 12 (100%) people during this time while administration of ART and PrEP surveyed responding that it was “problematic” or “very continued with follow-up via telehealth. problematic”. Ten (83%) respondents also believed that Although these centres were largely able to stay open, difficulties with the police while on the street would be a they served a smaller number of people, and distributed “problematic” or “very problematic” issue for PWUD, in fewer needles in 2020 than in 2019. This decline in NSP addition to an increase in mental health issues (8/12) and coverage could lead to an increased risk for needle reuse limited access to drug-checking services (6/12) (Fig. 3). or sharing, and a corresponding increase in incidence of BBVs, though further research should investigate Government response to the COVID‑19 pandemic whether the decline corresponded to the reduction in the The types of regional agencies responsible for manag- drug supply. In addition, as a result of reduced operat- ing and coordinating the COVID-19 response in their ing hours or closures, testing for infectious diseases and autonomous communities for PWUD vary. Of those that linkages to health and social service programmes were Picchio et al. Harm Reduct J (2020) 17:87 Page 7 of 11 Fig. 1 Time trend graphs describing number of users per centre that reported data (n = 11) during the first 6 months of 2019 and 2020. Notes: Free Y-scale axis utilised to visualise the relative differences affected, with several centres operating at reduced hours (including street homelessness). This social isolation or deprioritising testing, given that the health system was increases the likelihood of overdose, which may be fur- overwhelmed with COVID-19 cases. Although it may be ther compounded by lack of regular access to OAT and/ too early to determine the impact of these reductions on or opioids due to COVID-19 prevention measures [26] the incidence of viral hepatitis, HIV or TB, this should be that restrict movement in some settings. While our study a priority for further research. did not report an overall increase in reported overdose Harm reduction programmes reach people at high risk deaths, we recognize that this can be a significant issue in for infectious diseases. People who inject drugs are 22 other settings [32]. times more likely to be living with HIV than the general Despite this study reporting data from the state of population [29], representing nearly 20% of the estimated alarm, which the Spanish government declared due to 15.6 million people who inject drugs globally. HCV is the ongoing COVID-19 pandemic, none of the surveyed highly prevalent, with approximately 50% of PWUD cur- centres offered COVID-19 testing during that time. Test- rently or previously infected [4]. Timely diagnoses of ing for the SARS-CoV-2 virus could be expanded into these diseases in centres that are regularly used by, and harm reduction services to include it through proper accessible to, PWUD is imperative for individual and referral or in parallel through community-based screen- public health. A breach in these people-centred models ing. As point-of-care diagnostic methods continue to of care [30] for PWUD could derail progress towards develop, testing in these settings should be considered. global goals and targets to eliminate viral hepatitis [31] Harm reduction centres that have GeneXpert platforms and AIDS as threats to public health. (Cepheid Inc.) for HCV and TB testing available in their Additionally, PWUD face risks to their survival, facilities or in community-based centres, should con- health, and well-being, since many are unstably housed sider using this or other similar platforms for COVID-19 Picchio et al. Harm Reduct J (2020) 17:87 Page 8 of 11 Fig. 2 Time trend graphs describing the number of distributed needles in each centre that reported data (n = 11) between the months of March and June in 2019 and 2020. Notes: Free Y-scale axis utilised to visualise the relative differences testing among their clients [33]. Early detection of However, such health system resilience should not be left COVID-19 could help mitigate possible complications to chance or to the goodwill of service providers. Spain caused by the virus among PWUD, who may have under- and other countries across Europe need to be prepared lying chronic medical conditions that increase their risk for the continuation of policies that may disrupt services of developing severe COVID-19 illness, such as COPD, during the current pandemic and/or future pandem- asthma, cardiovascular diseases, and viral hepatitis [9]. ics. In a recent study measuring the public’s perception PWUD are at risk for sepsis and endocarditis, and com- of government COVID-19 pandemic response efforts, monly have skin and soft tissue infections [34, 35] which, Spain was ranked low with 44 out of 100 points, indicat- when left untreated, can lead to hospitalisation and even ing that the Spanish government needs to improve its amputation, putting them at greater risk if infected with communication with all of its constituents, and according COVID-19. to the results of the study, in particular, in protecting the Drug treatment services and low-threshold harm welfare of vulnerable populations, which includes PWUD reduction services for PWUD are essential health [36]. Pandemic preparations and response should include services, which need to maintain operational under making the health system more people-centred through restricted conditions brought on by global crises, like improved engagement and communication with all key pandemics [15]. Our study showed that this was possible stakeholders [37, 38], not least the clients of harm reduc- in the Spanish context, where both government and non- tion services. governmental-run services adapted their opening hours. Picchio et al. Harm Reduct J (2020) 17:87 Page 9 of 11 Table 4 Infectious disease (HBV, HCV, HIV, and TB) testing rate per 1000 service users in March–June 2019 and March– June 2020 Mar 19’ Mar 20’ Apr 19’ Apr 20’ May 19’ May 20’ Jun 19’ Jun 20’ HIV testing rates Centre 3 50.2 23.8 35.3 29.0 52.6 72.5 49.2 97.2 Centre 4 40.5 38.5 211.9 0 112.6 4.9 27.6 0 Centre 6 58.5 30.5 36.7 0 41.9 46.9 65.8 193.7 Centre 8 63.5 52.2 85.3 0 90.2 19.2 14.8 67.8 Centre 10 2.8 1.8 0 0 0 0 0 0 Centre 13 7.6 14.1 9.5 0 39.6 13.2 35.9 23.1 HCV testing rates Centre 2 0 0 0 0 0 0 0 8.4 Centre 3 50.2 23.8 35.3 29.0 52.6 72.5 49.2 97.2 Centre 4 40.5 38.5 211.9 0 112.6 4.9 27.6 0 Centre 6 58.5 30.5 36.7 0 41.9 46.9 65.8 193.7 Centre 8 63.5 52.2 85.3 0 90.2 19.2 14.8 67.8 Centre 10 2.8 1.8 0 0 0 0 0 0 Centre 13 7.6 14.1 9.5 0 39.6 13.2 35.9 23.1 HBV testing rates Centre 3 29.3 20.4 21.4 0 26.3 0 28.1 71.6 Centre 4 20.3 11.0 19.9 0 0 0 0 0 Centre 6 0 5.1 0 0 0 5.2 0 20.9 Centre 8 39.7 26.1 54.3 0 22.6 0 7.4 0 Centre 10 2.8 1.8 0 0 0 0 0 0 TB testing rates Centre 2 0 0 0 0 0 8.8 0 16.8 Centre 3 8.4 13.6 2.5 0 5.5 0 7.0 25.6 Centre 4 40.5 27.5 72.8 0 38.7 0 20.7 10.0 Centre 8 7.9 8.7 38.8 11.2 22.6 0 22.2 0 Only centres that reported providing HBV, HCV, HIV, and TB testing are reflected in this table Conclusion diseases, in addition to decreased access to testing or Overall, consulted Spanish harm reduction centres were discontinuing ongoing treatment such as methadone able to continue running and offering services by adjust- maintenance therapy, hepatitis C treatment, or antiretro- ing operating hours; only two centres completely shut viral therapy. For centres that were able to remain open, down for a specific period of time. The number of over- and in some instances expand operating hours, lessons all service users and needles distributed fell during the learned should be shared with the centres that were una- Spanish lockdown period, suggesting that fewer clients ble to continue offering services so that harm reduction accessed harm reduction services during that time. This services remain operational during the COVID-19 pan- may have resulted in greater risk of reusing or sharing demic in the event of future pandemics. injecting equipment, overdosing or acquiring infectious Picchio et al. Harm Reduct J (2020) 17:87 Page 10 of 11 Responses (n=12) to the ques†on "In your opinion, which are the most important difficul†es that PWUD have had to experience during the COVID-19 state of alarm in Spain?" Limited access to social workers that assist with social benefit processes (i.e. monetary, immigra†on, etc.) An increase in mental health issues Social isola†ng and discrimina†on Difficul†es with neighbors Difficul†es with the police when on the streets Limited access to housing services or homeless shelters Limited access to BBV tes†ng Limited access to medical services Limited access to drug-checking services Limited access to safe injec†ng sites Limited access to OST Increase in drug prices Contaminated drugs or low-quality drugs Not being able to arrive to the centre (i.e. Due to there being no public transport, far distance, etc.) Limited access to drugs 0% 20% 40% 60% 80% 100% Not a problem Somewhat of a problem Neutral Problema†c Very problema†c No Response Fig. 3 Distribution of responses describing the most important difficulties that PWUD had to experience during the COVID-19 state of alarm in Spain, 2020 Acknowledgements Competing interests CAP and JVL acknowledge support to ISGlobal from the Spanish Ministry CAP, JD, TS, MP and JC have no competing interests to report. JV reports of Science, Innovation and Universities through the “Centro de Excelencia Research grants and honoraria for lectures from Gilead Sciences, grants and Severo Ochoa 2019–2023” Programme (CEX2018-000806-S), and support personal fees from ViiV, grants from Merck, and grants from Janssen, outside from the Government of Catalonia through the CERCA Programme. EM also the submitted work. EM reports grants and personal fees from Gilead, grants acknowledges support from the Government of Catalonia through the CERCA and personal fees from Cepheid, grants and personal fees from Abbott, and Programme to the Germans Trias i Pujol Research Institute (IGTP). The authors personal fees and a donation to IGTP from Abbvie, outside the submitted would like to thank the focal person from each of the eleven centres who work. JVL reports reports grants, personal fees and other from AbbVie, MSD took the time to complete and return the survey. From the Basque Country: and Gilead Sciences, and personal fees from CEPHEID, GSK, Intercept, and Blanca Bastida, Maria Cristina Marbella Merino, Marta Fernandez de Aguirre, Janssen, outside the submitted work. and Leticia Ituño. From Catalonia: Alicia Molina, Antoni Llort, Cristina Guijarro and Daniel Rodriguez, Lara Grau Lopez, Noemi González, and Claudio Castillo. Author details 1 From Madrid: Jorge Valencia and Jorge Álvarez Rodriguez. From Valencia: Alba Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University Moreno. The authors would like to thank Adam Palayew (University of Wash- of Barcelona, Barcelona, Spain. 2 Unidad Móvil de Reducción del Daño SMASD, ington, Department of Biostatistics and Epidemiology) for his contribution to Madrid, Spain. 3 Faculty of Public Health and Policy, London School of Hygiene creating the time trend figures. and Tropical Medicine, London, UK. 4 Barcelona, Spain. 5 Comisión Ciudadana Antisida de Bizkaia, Bilbao, Spain. 6 Microbiology Department, Laboratori Authors’ contributions Clínic Metropolitana Nord, Hospital Universitari Germans Trias I Pujol, Institut JVL is on the programme committee of the 5th European Harm Reduction D’Investigació en Ciències de La Salut Germans Trias I Pujol (IGTP), Badalona, Conference where this Harm Reduction Journal series will be launched in Spain. 7 Centro de Investigación Biomédica en Red en Epidemiología Y Salud November 2020. He conceived of the idea of the article. CAP developed the Pública (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain. 8 Programme concept note and the survey questions with JV, MP, and JVL. JV and MP pro- for Substance Abuse and for Prevention, Control and Treatment of HIV, STIs vided centre contact information. CAP contacted the centres, distributed the and Viral Hepatitis, Agency of Public Health of Catalonia, Barcelona, Spain. surveys and managed and analysed the data. CAP and JVL wrote the first draft of the manuscript. JD and TS contributed to the first draft of the manuscript. Received: 25 August 2020 Accepted: 15 October 2020 After revisions, JD, TS, EM, JC and JV contributed to the second manuscript draft. All authors read and approved the final manuscript. Funding No funding was received for this work. References Availability of data and materials 1. Worldometer. Coronavirus cases: COVID-19 coronavirus pandemic. 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