Harm reduction during the COVID-19 outbreak in Iran
Authors: Hamidreza Karimi-Sari, Heidar Sharafi, Mohammad Saeid Rezaee-Zavareh, Seyed Moayed Alavian
Journal: The Lancet Psychiatry (2020)

Similar to other countries,1Karamouzian M Johnson C Kerr T Public health messaging and harm reduction in the time of COVID-19.Lancet Psychiatry. 2020; 7: 390-391Summary Full Text Full Text PDF PubMed Scopus (37) Google Scholar Iran experienced unavoidable changes in the national harm reduction programme during the COVID-19 pandemic. These changes were made due to new policies from the Ministry of Health regarding physical distancing to stop the disease spreading. During the COVID-19 pandemic, drop-in centres were closed and no longer offered services such as HIV testing, catering, and bathing; however, they still delivered methadone behind closed doors. Moreover, shelters were working 24 h a day and providing methadone as an add-on activity. We assessed the advantages and disadvantages of the new policies by interviewing people who use drugs at an outdoor area near the Rah-Ahan district of Tehran, Iran. The interviews were done on April 21, 2020. Iranian drop-in centres provide opioid agonist treatments, primarily methadone maintenance therapy.2Bastani P Marshall BDL Rahimi-Movaghar A Noroozi A The risk environments of people who use drugs accessing two harm reduction centers in Tehran, Iran: a qualitative study.Int J of Drug Policy. 2019; 63: 90-96Crossref PubMed Scopus (13) Google Scholar During the COVID-19 outbreak, the closed drop-in centres continued to provide opioid agonist treatment to people who use drugs to maintain their main harm reduction activity. Individuals reported that methadone was as available as before the COVID-19 outbreak or even more available, because the centres were providing up to one week's dose at a time, compared with daily dispensing of methadone before the outbreak. Some individuals reported that they would have reverted to illegal drugs in the absence of the methadone provided at the drop-in centre. During the COVID-19 outbreak, as a temporary policy, clients could not enter, gather together, or sit inside drop-in centres. The centres are seen as safe places where individuals feel respected and are not tempted by seeing other people using drugs. Closure of the centres led to local hangouts for people who use drugs becoming more crowded, and individuals reported being tempted to use drugs when they saw others injecting drugs nearby. Before the COVID-19 outbreak, homeless shelters were available for clients overnight, until 0700 h.2Bastani P Marshall BDL Rahimi-Movaghar A Noroozi A The risk environments of people who use drugs accessing two harm reduction centers in Tehran, Iran: a qualitative study.Int J of Drug Policy. 2019; 63: 90-96Crossref PubMed Scopus (13) Google Scholar During the outbreak, shelters were open 24 h a day and some were providing methadone. It has been rumored among people who use drugs that using drugs is a protective factor against COVID-19 and one individual reported returning to drug injection in the belief that this would protect him against the virus. It is hypothesised that some people who use drugs could mistake the symptoms of COVID-19 for symptoms of opioid withdrawal, which could lead to the use of more opioid.3Dunlop A Lokuge B Masters D et al.Challenges in maintaining treatment services for people who use drugs during the COVID-19 pandemic.Harm Reduct J. 2020; 17: 26Crossref PubMed Scopus (190) Google Scholar One of the main concerns with the altered harm reduction during the COVID-19 outbreak is the increased risk for transmission of blood-borne infections, especially hepatitis C and HIV. Closure of the drop-in centres and other health-care facilities has disrupted initiatives for hepatitis C elimination among people who use drugs.4Karimi-Sari H Rezaee-Zavareh MS COVID-19 and viral hepatitis elimination programs: are we stepping backward?.Liver Int. 2020; (published online April 22.)DOI:10.1111/liv.14486Crossref PubMed Scopus (25) Google Scholar People undergoing treatment have not been able to attend appointments for evaluation of treatment response and re-infection. Our small project highlights the need to perform more comprehensive studies among people who use drugs, as a more susceptible population for both COVID-19 and blood-borne infections, to evaluate the effects of this pandemic on this group. Also, health policymakers should consider the current experience in preparing for future, similar pandemics. Finally, we think that services for safe injection, opioid antagonist treatments, necessary training and equipment (such as face masks) for prevention of COVID-19 transmission, and access to screening, testing, and treatment for COVID-19 should be provided for people who use drugs. Therefore, we recommend fully reopening the drop-in centres with implementation of physical distancing. We declare no competing interests.