HARM REDUCTION

Mainline's mission is to promote health and fulfil the human rights of people who use drugs without a primary focus on the reduction of drug use and with respect for the individual drug user's freedom of choice and capabilities.

INTERNATIONAL

Bridging the Gaps

Within the Bridging the Gaps - Health and Rights for Key Populations programme Mainline works to improve the health and rights of people who use drugs, sex workers, and lesbian, gay, bisexual and transgender people (LGBT).

Mainline is one of the leading organisations in this programme, especially with respect to the health and rights of people who use drugs. The programme is funded by the Dutch Ministry of Foreign Affairs.

In 2018, the Bridging the Gaps programme allowed Mainline to work in six countries around the world, namely Indonesia, Kenya, Nepal, Pakistan, Vietnam and South Africa. Highlights can be found throughout this report.

Speed limits

In 2018, Mainline completed its study of effective harm reduction interventions for stimulant users.
The study included a review of the supporting evidence for different harm reduction strategies and a detailed description of seven best practices from around the world. The resulting selection of strategies included drug-consumption rooms, housing-first projects, outreach interventions for people who use meth and support groups.

The study was supported by the Global Partnership on Drug Policies and Development (GPDPD), which was set up by the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH.

The study is set to contribute to our global understanding of harm reduction for people who use stimulants. It will do so via the dissemination of its findings in concrete terms that will allow relevant organisations to provide their clients with useful tools.

The findings support the understanding of harm reduction as more than just HIV prevention and healthcare, and emphasise the human rights and improved quality of life of those who use stimulants, regardless of how they do so.

We began the study in 2017 and concluded it in mid-2018 with a detailed and highly informative report of our findings. 

Research and innovation in Pakistan

Mainline and its partners in Pakistan conduct research on a fairly regular basis. We also work with them to set up innovative projects that make it easier to reach people who use drugs with effective harm reduction services.

Over the past seven years, Mainline’s main innovation partner, Nai Zindagi, has collected confidential data from over 40,000 harm reduction clients on the basis of 9,359,158 service occasions.

The nature and size of this database is unrivalled anywhere in the field of harm reduction. It includes national data on the country’s needle and syringe exchange programmes, condom distribution, wound care services, HIV testing, ART initiation and the adherence of HIV-positive clients to treatment. The database has allowed us to set out some ambitious research objectives, in collaboration with Nai Zindagi and the Kirby Institute of UNSW Australia.

In 2018, Nai Zindagi also researched HIV and hepatitis C prevalence and transmission risks among non-injecting heroin users. 

HIV prevalence was revealed to be much higher than expected. It ranged from 2% of heroin smokers in Rahim Yar Kahn to 7% in Rawilpindi and 10% in Multan. This was much higher than the national adult HIV prevalence in the general population, which hovers just above 0%. As a result, we aim to focus our local efforts in 2019 on adapting the harm reduction services for injecting heroin users to the needs of those who smoke the drug. We also aim to better understand risk-related behaviour among this group.

Another collaboration between ITPC, Nai Zindagi and APLHIV-Pakistan led to a study of the key barriers of access to HIV treatment at all stages of treatment for people who inject drugs. The study is part of the ITPC’s Missing the Target (MTT) report series. Barriers cited include lengthy travel to a physical clinic, stigma and discrimination towards people with HIV, limited expertise regarding HIV and AIDS, and the difficulty of adhering to treatment owing to an absence of methadone clinics.

Our efforts to scale up and improve harm reduction provisions in Pakistan will continue apace in 2019.



Mainline consultancy

30years

of harm reduction experience. Little gives us more satisfaction than sharing the knowledge and international experience we’ve acquired over three decades in the field of drug use and harm reduction. This is why we also offer our services as consultants. Among the many things we can help you with is assess the quality of your programmes and develop a harm reduction offering from scratch.

Women who use drugs in Kenya

390women

were provided with gender-sensitive harm reduction services by Mainlines partner MEWA in 2018. This represents a threefold increase on the years before.

1change story

describes how MEWA managed to attract more women to their services. MEWA attributes their success to the greater emphasis they began placing on looking for women who could benefit from their services, the constant refinement of these services in accordance with client feedback, and to their efforts in combating stigma and discrimination. Read more about MEWAs story of change.



Giant steps in South Africa

Mainline’s South African partner, OUT Wellbeing, was tireless in its efforts in Pretoria in 2018. Peer workers handed out an average of 10,113 syringes and needles a week, amounting to an annual total of 485,430. They also achieved notable success in their provision of HIV tests, tuberculosis and STI screening, and referrals to the recently launched methadone programme. 

The programme’s impact on HIV prevalence among people who inject drugs was demonstrated by the findings of a study by the University of California, San Francisco. The harm reduction programme will consequently be rolled out to two new locations in 2019.

Efforts in Durban suffered a setback following the municipality’s decision to shut down the city’s only needle exchange programme, after needles and syringes washed up on the beach. 

The effect was immediate and dramatic: clients had no choice but to begin sharing and reusing needles. The city’s network of people who use drugs has since been trying to distribute clean needles through peers.

TB HIV Care reported some welcoming developments. Methadone substitution is now in operation in Durban, Cape Town and Pretoria. And since the introduction of Cape Town’s needle exchange programme, the number of people sharing needles has been falling, from 37% in 2013 to 15% in 2017. In reflection of this trend, 81% of people who use drugs reported using a new needle the last time they injected. Finally, input from people who use drugs is at last to be included in the Department of Health’s National Drug Master Plan, its Hepatitis Action Plan and its National HIV PWID Plan.

The roadmap of the development of harm reduction in South Africa makes for interesting reading, and is available here.

Freedom in Georgia

Institutional placement for habitual offenders, resocialisation via volunteer work, halfway houses and electronic tags. These are just a few of the methods used to keep people out of prison in the Netherlands or ease them back into society.


Mainline is taking part in an EU project that aims to identify the success criteria for the rehabilitation of new offenders and recently released prisoners. In 2018, as part of the project, Mainline set about assembling a collection of Dutch case studies. These will provide an overview of successful resocialisation projects involving unbroken contact between offenders/ex-offenders and society. A booklet with 16 of these case studies will be published in 2019 and used by our Georgian partners to advocate for alternatives to imprisonment.

Ice in Vietnam

Mainline entered Vietnam in 2018. Meth-amphetamine is one of the country’s most popular drugs and we set out to understand the scale of its use. To this end, we joined forces with SOA AIDS Netherlands and local partner SCDI to conduct a pilot study in Ho Chi Minh City.


On the basis of the findings, we provided training to six local organisations and networks of people who use drugs, all of whom will now operate under the auspices of SCDI. We aim to work with them to set up harm reduction services in Ho Chi Minh City in the new year.

Harm reduction for meth users in Indonesia

In 2018, Mainlines Nick Veldwijk spent two months in Indonesia in order to work more closely with our local partners, Karisma and PKNM. To date, Karisma has reached more than 3,000 people who use crystal meth via its programme in Jakarta, and PKNM has reached around 750 in Makassar.


Our workshops in Jakarta also yielded great promise. The workshops involved 25 doctors and nurses from 12 of the city’s health centres, all of whom received training in providing mental healthcare, especially to people who use meth. Nick’s vlogs about Mainline’s activities in Indonesia are available for viewing here.

The development of the harm reduction programme for people who use meth in Indonesia has been a fascinating process that extends our strong track record in the country. 

Steroids: doping in recreational sports

Performance and image enhancing drugs (PIED) are now in use outside professional sports, such as in neighbourhood gyms. They are being taken by people who wish to lose weight and/or gain muscle mass faster.

Mainline, along with equivalent organisations in Finland, Greece, Lithuania and the United Kingdom, is participating in a new European project that aims to improve PIED prevention strategies within the EU.

One of Mainline’s undertakings within the project is to evaluate the suitability of Finland’s e-learning intervention tool for application in the Netherlands. The online modules have been translated into Dutch and are currently being “tested” by an assortment of healthcare professionals. Thus far, we have received 20 completed questionnaires from participants and interviewed 10 of them. The project is set to run until the end of 2019.

For further information, please visit the DELTS project.

Training trainers

Mainline launched its train-the-trainer (ToT) programme in 2017, with the objective of helping to develop the in-house training capacity of its local partners. Its operation not only allows our partners to train new members of staff, but also local health workers or even the police.

In 2018, a select group of successful participants from the first intake proceeded to the second level/year of the programme. In due course, Mainline hopes to deploy these trainers-in-training not just locally, but regionally; this will help keep long-haul flights to a minimum (and thereby reduce travel costs) and expand our partners’ capabilities.

The programme is already bearing fruit. Victor, one of our Indonesian participants, has run a training session in the Philippines.

A second intake of motivated participants from Indonesia, Kenya, Tanzania, Vietnam and South Africa will begin the programme in 2019.


Farewell to Nepal

It is with great pride that we wrap up 12 successful years with Youth Vision, our partner in Nepal. Youth Vision have achieved a string of notable successes during our time together and are now accomplished at delivering opioid substitution treatment and running needle and syringe exchange programmes.

Today, the organisation reaches more than 6,000 people who use drugs. Meanwhile, the country has seen HIV prevalence fall from 68% in 2002 to 8.8% in 2017, while incidence rates have stayed reassuringly low. The assumption of financial responsibility for ongoing programmes is scheduled to pass shortly to other donor agencies. As a memento of our partnership, Mainline and Youth Vision are producing a short video documentary of the highlights of our shared success. 




Nothing about us, without us!

In 2018, Mainline, INPUD, AFEW and researchers from King’s College London, UK, and three other countries began collaborating on a new research project. The project aims to examine the ways in which people who use drugs can be involved in the improvement of harm reduction services.

The project links local researchers to local communities of people who use drugs and is currently running in Indonesia, Kyrgyzstan and South Africa. Mainline expects top-line results in mid-2019.



NATIONAL

Fieldwork in 2018

In 2018, Mainline conducted a total of 334 fieldwork exercises. These activities consisted primarily of standard visits to support services and client hangouts. We also held countless online and telephone conversations with counsellors and people who use drugs.

These exercises allow Mainline to dispense useful information across the country to a variety of people who use drugs in whatever scene they may belong to. They also allow us to keep our finger on the pulse (and act as an alert system when necessary).

In Amsterdam, for instance, our outreach workers pay regular visits to 't Landje, an urban nomad settlement in the western part of the city. This began in 2018, and we’ve been supporting the community in concert with the JOT (Jellinek Outreach Team) and the Salvation Army’s soup kitchen on wheels.

Scratching beneath the surface

Things that come to our attention during field visits increasingly prompt further research efforts. These efforts sometimes take the form of in-depth interviews, which have been invaluable in improving our understanding of the everyday reality of people who use drugs. Here are three illustrations from 2018:

  • We learned via our annual survey of 50 people who use drugs that social contact and diverting activities are important factors for those trying to limit their consumption. We also learned that while the support services were deemed satisfactory, there was room for improvement regarding the way staff treat their clients.

  • We launched a syringe analysis programme, which involves analysing used syringes to find out what they had been used to inject.
  • We also made an inventory of drug consumption rooms in the Netherlands, in collaboration with the Trimbos Institute and the Correlation Network. It revealed a fall in the number of these rooms (we counted 24 in total, primarily for crack cocaine and heroin consumption, down from 37 in 2010). This decline is partly attributable to the fall in the number of people using these drugs and to the rise in the number of residential facilities for users. 








15,750

unique visitors to

https://sexntina.nl/en/  

1.948

repeat visitors

in 2018

1

candid informational website 

for men in the chemsex scene





Mainline magazine

We published four issues of Mainline — our magazine about drugs, health and the street — in 2018. The magazine puts a human face on drug use and allows us to discuss issues in the field. Its writers and editors visit users all over the country, both on the street and at home. Mainline includes personal accounts, practical harm reduction tips and our corrections of misconceptions within the scene, and commands a wide readership.

We received new confirmation of the breadth of readership in 2018 when Amsterdam’s political scene was given a good shake on account of one of our pieces. During a city council meeting, socialist party councillor Nicole Temmink tabled a question in response to a Mainline article about GGD Amsterdam’s decision to end night-time access to its heroin prescription programme. The decision had resulted in clients having to endure withdrawal symptoms and a rise in street noise, which upset the locals. The councillor was thus keen to know why the GGD had initiated early closing without permission from the Ministry of Health, Welfare and Sport.

One of the four issues we published was the Opioid Special, which not only addressed heroin and methadone use, but also the fivefold increase in the use of opioid painkillers in the Netherlands and its attendant consequences. We published the Alcohol Special in the middle of what turned out to be a baking hot summer, to coincide with the national spike in mainstream consumption. The facts and harm reduction tips regarding everyone’s favourite routine intoxicant certainly fostered a more responsible approach to drinking on the part of the magazine’s editor-in-chief and, we believe, on the part of readers too. The Sleep Special also attracted a lot of attention. A Facebook post asking people who use drugs to send us accounts of their sleep-related experiences prompted a deluge of responses. And the Crack Cocaine Special examined the consequences of this persistent drug, which typically include lung problems (COPD) and financial difficulties for hardcore users.

Mainline is distributed nationwide via homeless shelters, drug rehabilitation centres, assisted living facilities and red light districts. If you’d like an annual subscription or are interested in specific issues, please visit our online store

Soa Boa special

SOA

In 2018, we merged the newsletters C-zicht and Take-It, resulting in the newly designed SOA BOA Special, a bi-annual mini-magazine about drugs, STIs and infectious diseases. The first issue addressed men who have sex with men while using chems, a group marked by high rates of STIs and blood-borne infections. It explored topics such as condom use in gay saunas and how to notify sex buddies of infections.

BOA

The second issue addressed people who have contracted an infectious disease such as HIV or hepatitis C from using drugs. An illustrative article described the day-to-day life of a straight man with HIV and discussed the realities of maintaining a sex life post diagnosis.

Hepatitis C in Amsterdam

From 2017 to 2018, Mainline researched drop-in centre clients in Amsterdam, in collaboration with De Regenboog Groep and the GGD. Our purpose was to obtain a clearer picture of the prevalence of hepatitis C infection (HCV) among this audience and gauge the level of awareness regarding the infection. 


Among our many findings was the revelation that the majority of respondents had risked infection by:

  • injecting drugs (12%);
  • having unprotected sex with another man (20%);
  • getting a tattoo in an unlicensed tattoo parlour or in a country with a high prevalence of HCV (20%); and/or
  • sharing a crack cocaine pipe (29%),

Only a quarter of respondents had ever had themselves tested for HCV. You can read the full report here.

Recovery

Recovery entails participating in society and having one’s life under control. It's about being the person one would like to be, and the process of becoming this person usually means quitting drugs. However, it’s also possible to get one’s life back on track while using in a controlled way. 


In 2018, Mainline documented fifteen personal accounts of recovery and life goals. These testimonies formed the basis of a succinct report containing concrete answers to three key questions:

  1. What can people do to help themselves?
  2. What can those close to them do to help?
  3. What determines successful recovery?

Answers to the first question included thinking about how to better structure one’s day, forming meaningful relationships, finding meaningful ways to spend one’s time and practising self-acceptance.

Chemsex in 2018

Mainline's chemsex team reached new heights in 2018.

For the past two and a half years, Mainline has been monitoring a popular dating site for gay men, an international BDSM/fetish dating site and a dating site for slammers. In 2018, our efforts revealed a rise in the number of men who have experienced slamming. We also discovered that chemsex, far from being a purely metropolitan phenomenon, is happening in the provinces as well.

What are the most popular chemsex drugs? Mainline surveyed popular national dating sites for gay men and documented the responses of 100 men. The survey revealed that GHB and ecstasy still topped the list, followed by ketamine. Furthermore, one in three had experienced slamming, often involving crystal meth. 

Chemsex meetings

Since 2016, Mainline has been running bi-weekly drop-in meetings for gay men who use chems in a sexual setting and for those who have quit the scene. In 2018, a total of 86 men attended our “Sober is Sexy Too” meetings and 28 our “Let's talk about Chems” ones. These meetings provide a safe and secure setting for men to share their concerns and experiences, ask questions and learn from one another, and allow us to provide information and refer whoever needs support to the relevant care provider.

Chemsex Consultation Meetings

Mainline convened two Amsterdam Chemsex Consultation Meetings in 2018, with 18 other local organisations. Attendees revealed a common concern that the number of men approaching them with chemsex-related problems was merely the tip of the iceberg. On the basis of the Amsterdam meeting, Mainline established a South Holland chapter with regional stakeholders.

Quick Scan - Action!

In 2018, Mainline conducted a Quick Scan of two Dutch municipalities.

The municipality of Kampen invited Mainline to research substance use among teenagers and young adults. Our scan revealed that teenagers in Kampen considered drinking a normal part of their lives, and that the practice of getting together in shacks for the sole purpose of drinking was promoting excessive consumption. It also revealed major taboos around drug use. The most commonly used hard drugs were ecstasy, speed and coke. Laughing gas was also quite popular. 

Another municipality (which requested anonymity) sought our help because they were struggling to reach users of crack cocaine. We succeeded in making contact with this hidden group, and used semi-structured interviews to document the drug use within it, discover what support was needed and outline the drug prevention options available to the municipality. In conducting the research, Mainline worked with a local organisation with fieldwork experience, whose staff were happy to lend us their expertise and network. The respondents themselves were eager to assist us in any way they could, having reached the conclusion that users needed help.

The Quick Scan allowed us to produce a practicable working document with concrete recommendations, which the municipality used in developing its action plan. You can request a quickscan here.

Surveying the male body

360Dutch men

were interviewed about their bodies by Mainline and COC. We asked what they find important with regards to their looks and what they do to keep in shape. We also asked about their use of performance and image enhancing drugs (PIEDs), such as anabolic steroids. To be clear, none of the respondents were professional athletes.

1of 10

respondents replied that they used anabolic steroids or had used them in the past. 

TRAININGS

Training in the Netherlands

Our trainers are on hand to guide (health) practitioners into the everyday world of people who use drugs. We help you discover which drugs are popular in which scenes and show you how to establish contact and build trust with those who use drugs.

We also provide practical exercises that can help you to increase your understanding of drugs and healthcare and reduce the stigma that often creates a barrier between professionals and people who use drugs.

The overall objectives of our training service are to improve the quality of life of those who use drugs and make it easier for professionals to do their job. Every organisation we train has its own unique set of needs, which is why our programmes and workshops are tailored accordingly.

Interested? Check out our website and video and then write us at training@mainline.nl

FINANCE

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