While famous for its pristine beaches and azure oceans, Greece is also renowned for its nimble harm reduction movement, led by a dedicated group of clinicians, advocates, community members and policymakers. In just a few short years, the country has established a hostel, drug consumption room, and the ability to distribute naloxone.
Greece is a nation steeped in a rich history that straddles the continents of Europe and Asia. Today, Greece is a popular holiday destination, owing to its picturesque Mediterranean islands and abundance of UNESCO sites.
However, beyond the obvious beauty and history, there is a great deal more complexity to Greek society, including an economy that has faltered several times since joining the European Union, as well as significant migrant and refugee populations that reside in the country. The deeply vulnerable communities of undocumented migrants contribute complexity to the provision of health care and harm reduction services in Greece.
HIV outbreak leads to expanded interventions
Between 2011-2013, Greece experienced a massive HIV outbreak among the injecting drug user community. At the time, the HIV infection rate amongst injecting drug users was unseen in Europe. Associate Professor Dr Vana Sypsa, from the University of Athens, was one of the researchers who began undertaking testing and research with the injecting drug user community.
We already knew that the prevalence of HCV infection was high, but the HIV outbreak was something that really made us try to respond and expand interventions, set up new interventions and so on. So in 2011, we recorded many HIV cases among people who inject drugs. We set up a program called Aristotle, aiming at reaching the population who were most at risk – people who inject drugs, who are actively injecting and are not linked to other services.
The HIV outbreak in 2011 showed researchers like Dr Sypsa that there was an evident lack of services and linkage to care for injecting drug users with hepatitis C and HIV.
The introduction of DAAs
In 2014, the new Direct Acting Antiviral (DAA) medications for hepatitis C were being introduced across Europe, but it wasn’t until 2017 that they were available in Greece. Access to the treatment initially was similar to other countries, where treatment was provided mainly in hospital settings and initially to those with more severe liver disease.
However, in the years since the introduction of DAAs, there has been a significant increase in the harm reduction services offered in Greece and pathways for treatment for people who inject drugs.
OKANA is a state-funded organisation that provides services for people who use drugs. These services include in-patient rehabilitation, Opioid Agonist Treatment (OAT) and harm reduction services.
OKANA operates an extensive network of OAT centres across the country, and it has also been activated for hep C testing and treatment. In recent years, OKANA has built on top of its OAT service provision to increase harm reduction services for those actively using drugs.
This growth has created new opportunities for OKANA to connect with the more marginalised street-based community, especially in the major cities of Athens and Thessaloniki.
The first Drug Consumption Room in South West Europe
In 2022, OKANA established a Drug Consumption Room (DCR) in downtown Athens. This was the first DCR, or Supervised Consumption Site (SCS), based in South-West Europe and was a giant leap forward for harm reduction in Greece. OKANA’s DCR was launched alongside a range of wrap-around services, including primary health care, psychosocial services, and a drop-in centre.
For Savvas, a Greek man in his 40s who is experiencing homelessness in Placca, a busy tourist neighbourhood, the DCR has dramatically improved his daily life.
In the morning, I go to the DCR, to the drug consumption room, and sometimes I use (of drugs) there or just for coffee, something to eat and speak to people. I have my therapist also there. Once a week, we speak and talk about how I’m feeling and what I’m going to do.
In addition to the range of psychosocial services and support provided to their clients, OKANA also offers hepatitis C and HIV point-of-care tests. OKANA can now quickly prescribe the medications through the OKANA pharmacy, and the medicines can be dispensed at an OKANA OAT service or the Drug Consumption Room.
Savvas completed his hepatitis C treatment through OKANA and picked up his medications daily from the DCR. Savvas reflects on completing treatment “After three months, I went back to the doctor, and she made me a blood test. She told me, you are okay. I then feel free to kiss my child. I thought yes, let’s live free again.”
Hepatitis treatment and care in the prison environment
While Greece is a relatively small European country, it has a prison population of approximately 10,000 inmates, half of whom cycle back into society yearly.
We wanted to implement public health initiatives to reach these populations and provide them with treatment, and we thought that an excellent environment would be the prison setting. Since it’s a closed environment, we believed we could eventually achieve the first micro-elimination of hepatitis C in the country. But, unfortunately, we realised from the first interventions that the barriers in prison settings are even more, and that we need to overcome many more barriers to achieve a micro elimination project.
George Kalamatis and the ‘Prometheus’ team have continued to provide access to support the health teams of doctors and nurses who work in Greek prisons; this support has included accessing diagnostics and DAAs and delivering them directly to the prison.
In addition to their direct support in the jails, George Kalamatis and others have also worked hard to advocate to the government. In 2022, they successfully supported the Greek government in changing a law that would provide a medical ID number for undocumented migrant prisoners.
This seemingly small shift is a significant step. It will ensure all prisoners can access hepatitis C Direct-Acting Antiviral medications while in prison and thus move one step closer towards micro-elimination in Greek prisons.
Community-based testing initiatives
Over the past decade, Dr Vana Sypsa has undertaken several research projects researching linkage to care for people who inject drugs. The most recent is the Alexandros Project which established a community-based space where community members could quickly and easily be tested for hepatitis C and HIV in Greece’s second-largest city Thessaloniki.
The site had a small team, including project coordinator Despina Trafali and peer Zafiris. The team partnered with OKANA clinician Dr Tsirogianni and Prof. Goulis, working in the main hospital in Thessaloniki. This partnership ensured that people who needed treatment, like community member Mike, could do so in a way that wasn’t intimidating or overwhelming.
Well, it was very nice. The vibes, the people in there with you, were very nice. I also have problems in my veins from using, but they was cautious how they touched the needles on me and everything. And it was a nice experience because I don’t like to be in the hospitals but it had different vibes in this place.
The Alexandros project has made significant steps in demonstrating how a community-based seek-test-treat program to enhance diagnosis and linkage to care for HCV/HIV/HBV among people who inject drugs can work in Greece.
Unfortunately, funding continues to be a significant factor in limiting the scale up of Alexandros and other earlier projects.
These three programs have shown the importance of research. Not only by providing services to the population but also by collecting data. Otherwise, some needs are not identified. I think through these programs, we have seen the profile of the population who inject drugs. We have seen their needs and major gaps in those needs. Sometimes there were misconceptions even for people working with the population collecting data. I think it’s the first step to see what is needed and advocate to get what is really needed for the population.
A housing-first harm reduction project in the heart of Athens
A decade ago, Fotini Leobilla was a research assistant on one of Dr Vana Sypsa’s early research projects testing people who inject drugs in Athens for HIV. Now Fotini is spearheading the first housing-first services in Greece called MyAthens.
MyAthens has grown out of Fotini’s relationship with the Mayor of Athens, Kostas Bakoyannis. Fotini was a candidate in the municipal elections, which is where they met. The mayor told Fontini during the elections that whatever happened, he wanted to work together to help people who use drugs in Greece.
He (the mayor of Greece) was someone who had a lot of empathy, and he really cared about this situation. I said to him, ‘Mayor, the answer is harm reduction for cities like Athens. We are not here to (re)invent the wheel, but try to replicate the good examples of other countries or cities.
The first priority was hostels, then Drug Consumption Rooms and the third was a daily drop-in centre.
While the COVID-19 pandemic wreaked havoc around the world, one minor upshot was that Greece’s first hostel for the most vulnerable street-based drug users was fast-tracked and opened within a matter of months. Since opening in April 2020, MyAthens has the capacity to house up to 70 residents at any one time. In addition, MyAthens residents receive three meals a day and access to personal hygiene supplies, clothing, primary health care, psychosocial care, referral to addiction treatment programs, and connection with social services.
Meropi is one person who has benefitted from the service, having been left homeless and sleeping on the streets of Athens when living with a violent partner was no longer safe.
Meropi was linked to MyAthens and was able to move into a vacant room and has happily called the residence home since. Meropi accesses a range of health services through MyAthens. She also receives her daily methadone dose from an OKANA service not too far away. After a life of great difficulty, MyAthens means a lot to Meropi today.
First of all I’m calm. I have quietened down, and I’ve taken a lot of positive things from all the people here, from all the nurses here. I’ve received love and hospitality; I’ve taken a lot of things which I never had. Before, I was constantly in fear, terror, these things. But now, these things do not exist, anymore. I sleep well now.
While a small nation with limited resources compared to much of Western European, the Greek harm reduction movement has made incredible gains quickly. Establishing a hostel, a drug consumption room, and the ability to distribute naloxone are all examples of increased services for the most marginalised community of people who use drugs.
However, while there are notable examples of progress in Greece, there remains a significant absence of long-term committed funding to models of care for hepatitis C testing and treatment, resulting in many projects receiving limited research-based budgets.