Albania

Unless otherwise referenced, data included in the following overview has been taken from EHRN country profiles and case studies, all of which are available from the Knowledge hub

Overview

The Republic of Albania (Albania) is a non-European Union State located in Southern Europe. According to national statistics, the total population of the country was 2,886,026 people in January 2016. 

According to the latest available estimates, there are 3,710 people who inject drugs (PWID) in Albania.

The legislative and policy environment in Albania appears relatively comprehensive. Drug use itself is not illegal. Possessing a ‘daily dose’ of drugs for personal use is not punished either. However, the country is lacking implementation and enforcement, which has a negative effect on PWID in terms of their human rights and access to harm reduction services.  

NSP services are not currently supported by the government. Only OST medication for limited number of patients is provided from domestic sources. Since the end of the Global Fund Round 5 grant in 2012, the Albanian government has failed to support the cost-effective functioning of the HIV and TB programs in the country, resulting in a deterioration of services over recent years. The fledgling harm reduction program nearly collapsed due to the absence of funding. Consequently, access to both NSPs and OST in Albania is poor.

There is no information about active PWID community initiative groups or organizations in Albania.

Drug Use and Infectious Diseases

The number of people who inject drugs (PWID) in Albania is estimated to be between 4,000 and 8,600; a slightly more recent study (2014–2015) estimated there to be 6,182 problematic drug users (with a range of 3,626–8,737), with more than 60% reporting injecting drug use (more than 3,710 PWID). The most common age of starting drug use is around 18 years, with 62% having first used drugs in their teenage years. Heroin is the most popular illicit drug for injection. According to the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Albania is a transit country for heroin trafficking. Increasingly, some of the heroin is remaining in Albania for local consumers. Albania remains a country of origin for cannabis and its derivatives. Synthetic drugs are less of an issue in Albanian drug markets, in terms of both supply and demand. 

Albania has a low HIV prevalence, which might be significantly underestimated. The total number of HIV cases registered in the country up until 2014 was 780 (see Table 1). Around 60% of all HIV cases in Albania are reported at a late stage of the infection, suggesting that most new infections may be among people who lack knowledge about HIV transmission and their HIV-positive status.

A report by the European Centre for Disease Prevention and Control (ECDC) indicates just five registered cases of HIV transmission due to injecting drug use between 2005 and 2014. PWID comprised 0.6% of all HIV infections in 2015, resulting in only one or two PWID living with HIV. These figures may, however, be greatly underestimated due to difficulties in reaching most PWID nationwide and the generally suboptimal system of HIV testing and counseling (the HIV testing rate among PWID is 41%). Hepatitis C prevalence is relatively higher, which indirectly indicates that risky behaviour among PWID (e.g. sharing injecting equipment) is common.  

Table 1. Epidemiological data 

Indicator

Data

Year of estimate

Total number of HIV cases registered in the country

780

2.7 per 100,000 population

1993–2014

HIV prevalence among adults (15–49 years old)

<0.1%

2014

Cases of HIV transmission due to injecting drug use

5

2005–2014

HIV prevalence among PWID

0.6%

2015

Hepatitis C prevalence among PWID

28.8%

2011

Hepatitis B prevalence among PWID

11.5%

2010

Policies

The legislative and policy environment in Albania appears relatively comprehensive. However, the country is lacking implementation and enforcement, which has a negative effect on PWID in terms of their human rights and access to harm reduction services.

National legislation on illicit drugs is summarized in the Albanian Penal Code. Drug use itself is not illegal. Possessing a ‘daily dose’ of drugs for personal use is not punished either. However, thresholds for substances are not clearly defined. At the same time, possession of larger quantities of drugs than a so-called ‘daily dose’ and other legal offences for drug possession are punished by five to ten years of imprisonment. Only offences associated with ‘cravings for use’ are prosecuted in the same manner as other ordinary offences. It is up to the court to decide whether and how to consider the offender’s addiction when determining the penalty.

Although opioid substitution therapy (OST) services in Albania are being implemented without restriction, the distribution of sterile needles and syringes remains illegal. However, in practice, needle and syringe programs (NSPs) are provided through community-based memoranda entered into by local non-governmental organizations (NGOs) implementing harm reduction programs and local police and authorities. Effective collaboration between NGOs and the police at the community level has proven successful.

There are several political documents in Albania that define a framework for the implementation of harm reduction activities. The National Strategy Against Drugs 2012–2016 was approved by the Council of Ministers in June 2012. It emphasizes four main issues: strategic coordination; drug supply reduction; drug demand reduction; and harm reduction. Although OST is included in the drug strategy, there is no legislative or strategic provision for NSP. The National Strategy for the Prevention and Control of HIV/AIDS in Albania, 2015–2019 has been costed and includes harm reduction and other support for PWID. It has been used as the guidance document for writing the approved Concept Note to the Global Fund to Fight AIDS, Tuberculosis and Malaria for further funding of HIV-related interventions. However, it is unclear to what extent the government plans to support it financially. For now it seems that the government is willing to support only the purchase of methadone medication. Unfortunately, it is possible to conclude that in reality well-developed and comprehensive strategic documents in Albania lack financial support for their implementation from either domestic or external sources. 

There is no information about active PWID community initiative groups or organizations in Albania. There is no direct representation of PWID in the Country Coordination Mechanism, so the PWID community relies on NGOs to speak on its behalf.

Programs

Since the end of the Global Fund Round 5 grant in 2012, the Albanian government has failed to support the cost-effective functioning of the HIV and TB programs in the country, resulting in a deterioration of services over recent years. The fledgling harm reduction program nearly collapsed due to the absence of funding. Consequently, access to both NSPs and OST in Albania is poor.

The number of NGOs implementing services for PWID fell from four to two as soon as Global Fund financial support ended in 2012. As of spring 2016, only a small number of sterile needles and syringes are being distributed by two NGOs, and only in the capital city, Tirana (NGOs Aksion Plus and Stop AIDS). In 2016 only 80–150 PWID are receiving NSP services, compared to over 4,142 when the Global Fund grant ended in 2012. 

Harm reduction responses in Albania used to be focused on needle and syringe exchange, peer education, information and counseling, basic medical support and psychosocial support, and distribution of information and education materials. Condom distribution programs for PWID functioned until the end of 2012, but there is no data available about their current status. NSP services are rather static and usually implemented in NGO facilities. The NGO Stop AIDS operates a mobile outreach team in Tirana only.  

NSP Coverage*

NSP services are not available in prisons, although inmates can receive OST and antiretroviral therapy (ART). Condoms are distributed in prisons as well. 

OST was introduced in Albania in 2005 and run by the NGO Aksion Plus. Currently there are five OST sites in the country. Methadone and buprenorphine can be used for OST. In March 2016 there were 578 OST clients, including 61 clients in prisons. All of them were receiving methadone. OST coverage nationwide is rather low at just 9.17%. The OST program reaches only a limited number of PWID and largely relies on external financial support. OST services were badly affected by the end of the Global Fund grant. Recently OST services have been supported through the use of remaining stocks of methadone medication purchased with the Global Fund continuation of services (COS) grant between 2012 and 2014 and the use of UN funding to cover staff salaries, such as medical and psychosocial support, and administrative personnel costs.

OST Coverage*

Another problem for OST programs in Albania is that the current average dose of methadone is well below the World Health Organization (WHO) recommended dose. Thus, there is a high risk that clients may continue to inject drugs because of the low OST doses. The availability of other treatment for drug dependence is fairly limited in Albania.  

*In order to reverse an HIV epidemic, WHO/UNODC/UNAIDS (2014) guidance recommends that 60% of all PWID should be reached regularly by NSP, while 40% of all opiate users should be enrolled in OST.

Funding

Fundamentally, the reliability of funding is the major obstacle to the implementation and scale-up of the harm reduction program in Albania, rather than a lack of an enabling environment or technical skills.  

NSP services are not currently supported by the government. Only OST medication for 100 patients is provided from domestic sources (Ministry of Health, Institute of Public Health via the Global Fund Secretariat). OST programmes in Albania are now supported by the UN office, to ensure service continuity. The amount of this support is about USD38,600.  

The total estimated cost of the national HIV/AIDS strategy in Albania between 2015 and 2019 is USD33.2 million, of which approximately USD6.6 million — or 19.9% — is for harm reduction interventions. Unfortunately, the projected domestic investments in the sector for the three years are less than one third of the costs estimated in the strategy. Based on the national strategy, the funding needed for harm reduction for the period 2017–2019 (three years) totals USD4 million. The Global Fund has committed to cover 21.6% of what is needed, with the resulting financial gap for harm reduction services slightly less than the entire government indicative funding commitment to the whole HIV/AIDS sector over the same time-frame. Therefore, other external donors will be required to fill at least some of this gap, unless the government can be persuaded to allocate substantially more financial resources to support its own national HIV/AIDS strategy.

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readiness to sustain harm reduction interventions