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Coordination, cooperation, and creativity within harm reduction networks in Iran: COVID-19 prevention and control among people who use drugs

An unprecedented public health crisis confronts the world. Iran is among the hardest-hit countries, where effects of the COVID-19 pandemic are stretched across society and felt by the most marginalised people. Among people who use drugs, a comprehensive response to the crisis calls for broad collaboration, coordination, and creativity involving multiple government and non-government organisations. This commentary provides early insights into an unfolding experience, demonstrating the operational and policy impact of an initiative, bringing together a diverse array of harm reduction stakeholders to address the pandemic. In the context of lived experiences of social and economic marginalization, this initiative intends to lead efforts in developing an equitable response to the COVID-19 pandemic.


Introduction
In Iran, the first two cases of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) were confirmed on February 19, 2020. By April 19, Iran had the ninth and seventh-highest numbers of infections and deaths in the world, respectively ( Johns Hopkins University, 2020 ). Among people who use drugs (PWUD), numbers of SARS-CoV-2 infections and deaths are unknown; however, the scale of the pandemic and vulnerability of PWUD underscore the need for relevant and timely action, if the threat is to be controlled among this population.
Drug use is a significant public health issue in Iran. In 2013, an estimated 1.6 million people had used drugs in the previous year ( Nikfarjam et al., 2016 ). Since the 1979 revolution, Iran has gradually shifted from zero-tolerance policies towards drug use to adopting harm reduction initiatives in the late 1990s and drug law reforms in 2010s ( Alam-mehrjerdi, Abdollahi, Higgs, & Dolan, 2015 ;Ekhtiari et al., 2019 ). By 2014, opioid agonist therapy and needle exchange pro-grams were available in more than 5000 clinics and nearly 500 centres, respectively ( National AIDS Committee Secretariat, 2015 ). The non-government sector has played a significant role in this trajectory, in promoting a sharper focus on harm reduction vs punitive/criminal justice approaches, and in providing access to care among the most marginalised PWUD ( Ghiabi, 2020b ). In recent years, the harm reduction infrastructure has been utilised to scale-up therapeutic interventions among PWUD ( Alavi et al., 2019 ;Mirzazadeh et al., 2019 ), and is well-positioned for provision of COVID-19 control measures too, given appropriate public health leadership in policy development and allocation of resources. The government has a limited capacity for leading efforts in identifying and corresponding to the specific needs of PWUD during a pandemic ( Farhoudian et al., 2020 ). Years of unilateral economic sanctions imposed by the United States, the rise of socially austere policies within a weakened economy, and ongoing restrictions on humanitarian trade transactions have contributed to significant shifts in priorities and reduced the potential for a comprehensive COVID-19 https://doi.org/10.1016/j.drugpo.2020.102908 0955-3959/© 2020 Elsevier B.V. All rights reserved.  public health strategy ( Ameli, 2020 ;Kokabisaghi, 2018 ;Murphy, Abdi, Harirchi, McKee, & Ahmadnezhad, 2020 ;Takian, Raoofi, & Kazempour-Ardebili, 2020 ).
The necessity to act against the pandemic and gaps in COVID-19 public health policy prompted a major non-government organization (NGO) to initiate administrative action and develop the COVID-19 prevention and control Working Group, bringing together a diverse range of representatives from private and public sectors. This Working Group aims to enable greater collaboration between government and nongovernment sectors and develop an equitable COVID-19 response among PWUD.

Impact of COVID-19 policies on people who use drugs
Since early March, the government has implemented several physical distancing policies; these strategies are primarily in line with recommendations on continuity of care among PWUD, including increases in take-home doses of opioid agonist therapy ( Farhoudian et al., 2020 ; United Nations Office on Drugs & Crime, 2020b ). Decisions to close public parks and temporarily release more than 100,000 people from prisons, were made to reduce community and in-custody transmission ( Kinner et al., 2020 ), although without significant oversight. Many individuals from the lower socioeconomic background were not linked to adequate financial, harm reduction, and housing support post-release from prison; and among many people without stable housing, closure of parks limited access to water and sanitation facilities. Subsequently, on April 2, Tehran Municipality Welfare, Services & Social Participation Organization published images of PWUD and homeless people on Twitter (@swsctehran), gathering in large groups in Shoosh neighbourhood of South Tehran ( Fig. 1 ). Magnified on various media platforms, these photographs and similar video footage, instigated social panic and presumption of heightened transmission among this transient and marginalised community. These images and broader societal reaction reflected on the need for proactive and robust civil society response, enabling the development of public health policies within the context of underlying social and economic disadvantages of PWUD.

COVID-19 prevention and control working group
Development of the Working Group was primarily a spontaneous response to an unprecedented challenge. This initiative was inspired by the principles of asset-based community development ( Mathie & Cunningham, 2003 ;McKnight & Russell, 2018 ); Rebirth Charity Society ( Rebirth Charity Society, 2020 ), a well-known local organization, mobilised the existing networks among harm reduction stakeholders, to create a collective vision for equitable COVID-19 response among PWUD, garner broad support, and activate institutional resources.
The Working Group was established using popular messaging applications. These platforms provided an accessible space to discuss critical issues, including COVID-19 policy updates, scientific information and education, and service provision among peer-support workers and people attending community-based drop-in centres, homeless shelters, and mobile and outreach services. The leading group comprise 50 members, including 37 NGO representatives (23 peer-support workers and 14 management and coordination staff), three clinicians, three social workers, psychologist, sociologist, academic researcher, journalist, two members of an intergovernmental organization, and a representative from the State Welfare Organization. All members work in addiction care and PWUD health, or associated fields; the majority (56%) have a history of drug use. Several methods are used to mobilise members around the common goal. All members, particularly peer-support workers, are encouraged to collect and share stories of community success, including reports, video, and photographs of daily activities across the country. These stories are crucial in positioning and discussing supply shortages and priority actions. Given the scarcity of resources, actions that solve existing issues within the community are ideal. Disagreement about priority areas and solutions are not uncommon and are mostly resolved through open discussion (text, voice messages, or calls) on the Working Group messaging application. Face-to-face meetings are rare, considering physical distancing guidelines. Tasks are assigned to smaller groups, including fundraising, purchases, media releases, development of educational material, and publication of findings, reports, and recommendations. Allocation of tasks is mainly volunteer-based. In all steps, from sharing of community stories to implementation of actions, inclusive participation of all members is profoundly meaningful. Historically, peer-support workers are directly engaged in service delivery and play a limited role in the process of decision making. To address this issue, members who occupy leadership positions or those with perceived importance (e.g. highly educated individuals) ensure contributions of everyone, particularly peer-support workers, are valued. These efforts are reflected in highlighting community achievements, inviting peer-support workers to express their views and thoughts on specific needs of the community, and encouraging them to share their skills, passions, and social and associational networks with all members. Where needed, knowledge, activities, resources, and investments from outside the group are sought. Emerging as an immediate response to a health crisis, the Working Group has not developed a Terms of Reference for members; however, as the COVID-19 pandemic unfolds in Iran, members aspire to focus on experiences and successes of the past and continue to promote change that would improve health outcomes among PWUD.

Working Group operational response to COVID-19
Direct care services for people who use drugs Between March 15 and April 13, the Working Group coordinated distribution of COVID-19 prevention equipment and education booklets, personal items, food, and water among 2577 people attending 20 community-based drop-in centres, 18 homeless shelters, and eight mobile and 27 outreach services (visiting 87 street-based drug markets) in four provinces. On average, each person received 11 face masks, two litres of hand sanitiser, five litres of surface disinfectant, five education booklets, 15 meals and snacks, and three small bottles of water (excluding people in Fars province) ( Table 1 ).
The Working Group collaborated with the United Nations Office on Drugs and Crime Country Office and state Drug Control Headquarters to develop content for three COVID-19 prevention education podcasts and a booklet. Podcasts were prepared professionally, presented by a well-known Iranian producer ( United Nations Office on Drugs & Crime, 2020a ). Among people attending community-based drop-in centres, shelters, and mobile and outreach services, trained peer-support workers held face-to-face education sessions. They played the podcasts on speakers while displaying prevention measures, including hand washing. These sessions were held recurrently, and booklets were distributed among attending individuals.
Among people attending community-based drop-in centres, shelters, and mobile and outreach services, peer-support workers have carried out routine checks to identify people with common symptoms of SARS-CoV-2 infection, including fever, cough, and shortness of birth. Thus far, five people were referred to hospitals, who did not test positive for infection.

Support and care services for peer-support workers
In addition to services directly to people in need, the Working Group actioned necessary support for peer-support workers. Between March 15 and April 13, the Working Group coordinated the distribution of COVID-19 prevention equipment among 212 peer-support workers in four provinces. On average, each person received 20 facial masks, 19 pairs of gloves, and 3 litres of hand sanitiser ( Table 2 ).

Systems improvement
Many PWUD and homeless people access clean water through shelters and community-based drop-in centres ( Bastani, Marshall, Rahimi-Movaghar, & Noroozi, 2019 ). However, among those with limited engagement with these services, interrupted access to water deepens the experience of stigma and social marginalization. The recent closure of public parks, as a physical distancing measure, further stressed the need to resolve this issue. Through a successful fundraising campaign, the Working Group has received 15 water tanks, 500-liter capacity each, as well as commitment for ongoing free refills. Peer-support workers and project coordinators were appointed to locate high-priority areas, organize logistics of transportation and installation of tanks, and educate people on the maintenance of their water source.

Working group policy advocacy
Violation of physical distancing by PWUD and homeless people in Tehran in early April marked the beginning of a campaign by several government organisations, led by factions within the state Drug Control Headquarters, proposing swift capture and hold of these individuals in designated shelters for the duration of the pandemic. Working Group members noted several limitations within this proposal, including shortcomings in contextual relevance, and issues directly related to COVID-19, namely lack of separate quarantine facilities for people with and without COVID-19 symptoms on arrival, suboptimal infrastructure for COVID-19 prevention and treatment, and potential interruptions in access to opioid agonist therapy. The Working Group took several subsequent steps to 1) initiate mainstream and social media debates on principles of equity, respect, and diversity in public health strategies; and 2) participate in proposal revisions and development of COVID-19 policies that are adjusted to the needs of marginalised people. The Working Group partnered with the State Welfare Organization, to develop a joint report of current COVID-19 prevention activities and put forward a set of recommendations on an appropriate response to the pandemic among Table 2 COVID-19 prevention items distributed among peer-support workers in community-based drop-in centres, homeless shelters, and mobile and outreach services in four provinces in Iran, March 15-April 13, n = 212. Items, n All, n = 212 Tehran, n = 151 Fars, n = 39 Markazi, n = 11 Alborz, n = 11   Face mask  4250  2500  1100  300  350  Pair of gloves  3880  2500  650  450  280  Gown  515  350  100  25  40  Face shield  104  70  20  7  7  Hand sanitiser (liter)  555  400  85  30  40  Electronic thermometer gun  21  12  4  2  3 PWUD and homeless people. As public discussion swirled on various media platforms ( Deilamizade, 2020 ;Moghanibashi-Mansourieh, 2020 ;Mohammadi, 2020 ;Nouri, 2020 ;Radfar, 2020 ), State Welfare Organization participated in several meetings with other government organisations, including the office of the presidency, to present the joint report and discuss concerns raised by the Working Group. In late April, the state Drug Control Headquarters withdrew the initial proposal. They published the finalised protocol for the accommodation of PWUD and homeless people, endorsing the recommendations of the Working Group on transportation, housing, medical, and harm reduction needs of these populations. Several concerns remain about adequate implementation of this policy over the coming months, supporting the need for continued monitoring of health outcomes among people in government facilities and ongoing collaborations between the Working Group and government organisations, to inform future policies.

Lessons learned
In the past several months, many examples of civil society response to the COVID-19 pandemic have been recorded in Iran. The experience of the Working Group is among numerous grassroots initiatives that have enabled communities to organize, manage common problems, and develop a new understanding of government responsibilities and capacities ( Ghiabi, 2020a ). Among Working Group members, thus far the successful experience of COVID-19 response provided muchneeded space to develop an innovative model of cooperation within the harm reduction network and explore new ways of engagement with broader government organisations. Grounded in values of equity and inclusion, members were able to share their expertise in identifying specific needs of vulnerable populations and participate in developing immediate and long-term solutions. The experience of collaboration within a non-judgemental and inclusive environment was new to many members, given the common hierarchical culture of organisations in Iran. Use of messaging applications was an inexpensive method to increase the accessibility of information for all, enable faster communication about field and policy updates, reduce delays in decision making and implementation, and promote a platform for all members to contribute different types of knowledge and skills. Inspired to share this experience with other members of the harm reduction community, Working Group is developing digital communication platforms to promote people-centred education and advocacy material for people in regional and rural areas. Currently, the capacity of the Working Group in gathering member opinions and concerns and facilitating an active interaction with policymakers is built upon decades of working relationships among senior harm reduction stakeholders. Key connections with government organisations are pivoted around influential individuals, particularly those within the State Welfare Organization who have longstanding ties within the community and non-profit sector. Ongoing contribution to creating more effective governance systems would require the Working Group to maintain these connections while investing on developing a balanced organisational structure, involving components for a broader member base and policymakers who join the harm reduction network ( Albareda, 2018 ).

Conclusion
In the unprecedented times of a pandemic, Iran finds itself in a difficult position to respond to a significant public health crisis and provide adequate care and support for its large population of vulnerable people. In most middle-income countries, including Iran, control of the pandemic requires resolving significant financial and technical challenges ( Bedford et al., 2020 ;Hopman, Allegranzi, & Mehtar, 2020 ); however, the experience of this Working Group reflects on how greater collaboration among stakeholders and between government and non-government sectors could bring individual and population health benefits at the operational and policy levels. In support of equitable public health interventions among marginalised populations, particularly in settings with limited resources, the function of this Working Group highlights the need for empowerment of civil society, enhanced use of existing community assets, and meaningful collaboration in decision making.

Ethics
This manuscript is a commentary, reflecting on the experience of civil society responding to the COVID-19 pandemic in Iran. Ethics approval was not necessary.

Declarations of Interest
Authors have no commercial relationships that might pose a conflict of interest in connection with this manuscript.