Bulgaria

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 Bulgaria (Bulgaria) is a European Union (EU) country located in the eastern Balkans with a population of approximately 7.2 million people (as of 31 December 2015). 

The recent annual report of the Ministry of Health refers to 20,000–30,000 problem heroin users in the country. Heroin and methadone remain the main injected substances. At the same time, there is a growing use of amphetamines and highly addictive non-injecting drugs called ‘spices’.

In Bulgaria drug use itself is not prosecuted; however, drug posession is penalized by high fines and/or imprisonment, depending on the substance group.

Harm reduction programs in Bulgaria are highly dependent on international financial support currently provided through the Global Fund’s “Prevention and Control of HIV/AIDS” program. Even though the Global Fund’s financial support for NSP ends in July 2016, a solution for this crisis still has not been found.

Drug Use and Infectious Diseases

Although there is no information about the estimated number of people who inject drugs (PWID), the recent annual report of the Ministry of Health refers to 20,000–30,000 problem heroin users in the country. Heroin and methadone remain the main injected substances. At the same time, there is a growing use of amphetamines and highly addictive non-injecting drugs called ‘spices’.

Case-based statistics demonstrate a relatively small number of registered HIV cases since the beginning of the epidemic (see Table 1). HIV prevalence among PWID is also relatively low. In recent years, the proportion of HIV cases related to injecting drug use has been decreasing. For example, in 2014 this route of transmission accounted for 18.6% of all new HIV cases, whereas for the first 11 months of 2015 the figure stood at 11%. However, the high prevalence of hepatitis C shows that the epidemiological situation in the PWID community is far from perfect. 

Table 1. Epidemiological data 

Indicator

Data

Year of estimate

Total number of HIV cases registered in the country

 

2247

1986 – 25 November 2015

Cases of HIV transmission due to injecting drug use

474 out of 2077 (22.8%)

1986 – end of 2014

HIV prevalence among PWID

 

10.65%

2012

Hepatitis C prevalence among PWID

78.57%

2012

Hepatitis B prevalence among PWID

9.84%

2012

Policies

In Bulgaria drug use itself is not prosecuted; however, drug posession is penalized by high fines and/or imprisonment, depending on the substance group. The thresholds for substances are not defined in legislation, so they are left to the discretion of judges, who define them on a case-by-case basis. There is a legislative article about mandatory treatment, but it is not actively enforced. 

Bulgaria’s drug policy has not seen any major changes or progress in recent years, and NGOs report a general lack of interest in drug policy among decision-makers. A new National Strategy to Fight Drugs for 2014–2018, accompanied by an action plan and a financial plan, has been adopted. Mirroring the EU’s drug strategy, it seeks to reduce drug demand and supply, as well as improve coordination, legislation, information systems, research, evaluation, and international cooperation.  

The National Program for Prevention and Control of HIV/AIDS and STIs for 2016–2020 is still being drafted, and its finalization has been repeatedly postponed. NGOs expect that once it is approved by the Council of Ministers, it will provide them with better chances to advocate for more funding.

There are no PWID community initiative groups or PWID organizations in Bulgaria because of widespread stigma and discrimination. There are two active cannabis user groups that disassociate themselves from other drugs. Stigmatization and discrimination against PWID mean that non-governmental organizations (NGOs) working with PWID have little power or political influence.  

Programs

There have been no major changes or developments in harm reduction programs in Bulgaria over the last two years, since their budgets were nearly halved in 2012. There are currently eight needle and syringe programs (NSPs) financed by the Global Fund to Fight AIDS, tuberculosis and Malaria (the Global Fund) in Bulgaria that provide needle exchange and low-threshold services for PWID, with financial support available until July 2016. Two programs were already closed at the end of 2015 due to the lack of funding.

For now, NSPs provide health, social and psychological services, needle and syringe exchange, condoms and information materials at low-threshold centers for PWID, mobile medical consulting room services (five NGOs), and within outreach services. In 2013 the NSP services were provided at 33 locations in 28 towns in the country and at nearly 100 outreach sites. A total of 7,326 PWID were covered by NSP services in 2013, and 7,779 PWID in 2014. However, there were more individual NSP clients in 2012: 10,497 people. This drop in the number of NSP clients was directly linked to a budget cut for those services in 2012. The number of services remained the same, but their reach and coverage were reduced. The Global Fund financing for NSP finishes at the end of July 2016, and no other sources of funding to replace it had been identified as of March 2016. 

NSP Coverage*

In 2013 there were only 30 OST sites in 14 towns in Bulgaria, so coverage is insufficient and uneven. OST is conducted with methadone and morphine sulfate pentahydrate (Substitol). OST remains available only to those aged 18 and over. In 2013 there were 3,563 patients on OST, of which 138 were treated with Substitol. OST availability in Bulgaria is very limited, as the number of state-funded OST courses is only enough to meet the needs of one third of all current OST patients. Others have to pay a fee to use the service. Thus, patients tend to drop out of OST programs due to a lack of financial resources.  

OST Coverage*

Even though PWID make up 20% of the prison population in Bulgaria, there is no access to harm reduction or OST services within the penitentiary system. Only in one prison in Sofia do prisoners have access to paid methadone OST. NGOs distribute condoms in prisons as a part of the program financed by the Global Fund.

No specific programs for women and for young people under 18 have been developed in Bulgaria. Overdose prevention programs include training workshops and the dissemination of information. However, naloxone is available only in emergency health services. NSP services are not responsive to the needs of stimulants users, although the number of such clients is growing. NGOs use a range of syringes of different sizes to meet the needs of amphetamine and methadone injectors (beyond ‘traditional’ injectors of heroin). There is a lack of knowledge on how to monitor and tailor services to the recently emerged ‘spice’ users.

Even though harm reduction services are mentioned in some key policy and strategic documents and are the focus of coordinated advocacy efforts by civil society groups, they are not a top political priority in the country. This insufficient political will to support harm reduction is partly due to the low HIV prevalence in Bulgaria, which decision-makers use as an excuse for not prioritizing HIV prevention activities.

*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

Harm reduction programs in Bulgaria are highly dependent on international financial support currently provided through the Global Fund’s “Prevention and Control of HIV/AIDS” program. NSP services are almost exclusively funded by the Global Fund’s grant to the Ministry of Health.

In 2011, international donor support for harm reduction-related expenditures for PWID reached USD528,918, which represented 15.3% of the total HIV/AIDS prevention budget funded from international sources. However, funding from domestic sources was lacking. In 2012, Global Fund financial support nearly halved, leading to a significant decline in the coverage of PWID with NSP services: this indicates that access to NSP services in Bulgaria is to a large extent a financial issue. Even though the Global Fund’s financial support for NSP ends in July 2016, a solution for this crisis still has not been found.

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