Harm reduction, human rights and clinical services targeting people who use drugs
“Harm reduction for people who use drugs has reached the tipping point - we have solid scientific evidence that shows combination harm reduction prevents new infections. Combining oral substitution therapy [for people who inject opioids], HIV and tuberculosis (TB) treatment stabilizes the lives of the drug user, prevents illness and lowers community viral load. Reaching zero new HIV infections amongst drug users is not a dream, it is a reality — it is happening right now in countries with the full-scale programmes,” said Michel Sidibé, Executive Director of UNAIDS, at the keynote address of Harm Reduction 2010, the 21st annual conference of the International Harm Reduction Association held in Liverpool from April 25-29th. “But despite of the proof, the policy and the politics, we still have a long way to go.”
Indeed, reports released at the conference described how essential services for people who use drugs have very limited coverage, are dramatically under-funded, and that a number of countries particularly in the Asia Pacific region are detaining people who use drugs, purportedly for compulsory drug treatment, although they offer little other than cold-turkey detox, forced labour and inhumane living conditions.
With the World AIDS Conference being held in Vienna this year, ‘next-door’ to Eastern Europe (where some of the world’s fastest growing HIV epidemics are being driven through the use of contaminated drug injecting equipment), the prevention, treatment and care needs of people who use drugs have moved up the international HIV agenda.
Globally, around 3 million out of the estimated 15.9 million people who inject drugs are believed to be HIV infected, and along with HIV there are increased risks of hepatitis (B & C), TB and multi-drug resistant TB (especially among people who have been incarcerated).1 However, “in Eastern Europe, 57% of all new infections occur among injecting drug users,” said Sidibé. Over the last decade in Russia, the number of HIV infected people has increased tenfold from an estimated 100,000 to one million. In Bangladesh, 90% of new HIV cases are linked with injecting drug use. Meanwhile, drug injecting is becoming more common in new parts of globe, such as East Africa, where there is a risk it could fuel new concentrated epidemics.
However, many countries have been able to curb HIV transmission among people who use drugs through harm reduction —a public health strategy that focuses on reducing the harmful health, social and economic consequences of using drugs rather than on the prevention of drug use itself. Examples include adequately resourced clean syringe/needle exchange programmes which reduce the risk of transmitting blood borne infections, and oral opioid substitution therapy (OST), which gives people a much safer alternative to injecting.
Michael Bartos, also of UNAIDS, described some of the evidence documenting the effectiveness of harm reduction on the ground. “The most recent UNAIDS Global Report showed the Netherlands with only six new HIV infections amongst drug users. If you look at Australia’s national HIV surveillance, they found only three new HIV infections from a thousand drug users attending STI clinics. Portugal, with Western Europe’s most severe HIV epidemic amongst drug users, has seen new HIV infections halved since it introduced comprehensive health and harm reduction including needle exchange to its drug policies a decade ago,” he said.
UNAIDS, WHO and the United Nationals Office on Drugs and Crime (UNODC) have endorsed a package of interventions for drug users, with nine essential elements of a comprehensive response.2 These include: needle and syringe programmes (NSP); OST; antiretroviral therapy; HIV counselling and testing; prevention and treatment of sexually transmitted infections (STIs); condom programmes for drug users and their sexual partners; targeted information, education and communication (IEC); prevention, diagnosis and treatment of viral hepatitis and TB. Subsequently, WHO released a technical guide to help countries scale up these services at a level that might be expected to have a public health impact.3 Preliminary data suggest that a growing number (93) of countries and territories now support harm reduction.
“But still only a minority of countries are actually delivering these services to the scale that is required to reduce HIV transmission,” according to Dr Bradley Mathers of the Reference Group to the UN on HIV and Injecting Drug Use, and the University of New South Wales, who presented the findings of a global systematic review into how well countries are meeting the targets relating to the first three elements of the comprehensive package.4, 5
Overall, only 22 sterile needles are being distributed per drug user per year; for every 100 people who inject drugs around the world, only eight are receiving OST and for every 100 people who inject drugs living with HIV, only four are receiving ART.
“It is unacceptable that on average, each injecting drug user gets less than two clean needles per month or that so few drug users are on substitution treatment. It is unacceptable that only 4 percent of injecting drug users living with HIV are on HIV treatment, and that curable and preventable TB, remain a common killer of drug users,” said Sidibé.
“It is a pretty dismal result,” said the following speaker, Professor Gerry Stimson, outgoing executive Director of the International Harm Reduction Association. “We know there are many obstacles to implementing harm reduction, including ignorance by governments, antipathy to drug users, massive over-investment in criminal justice approaches to drugs, legal barriers to harm reduction interventions, for example in some countries where it is illegal to prescribe methadone; and the undervalued place people who use drugs hold in society, and by association, those who work with them. These obstacles go hand in hand with a lack of investment.”
In fact, the world’s investment in harm reduction and HIV prevention for people who inject drugs is less than 3 cents per day per injector, or US $13 per year, according to a new report from the International Harm Reduction Association (IHRA).6 This represents only one twentieth of the recommended $3.2 billion needed to implement comprehensive package of interventions.
In 2007 approximately $160 million was invested in HIV-related harm reduction in low and middle-income countries, about 90% of which came from international donors (most notably the Global Fund). “This figure is similar to the amount spent on President Obama’s inauguration,” said Professor Stimson, who also pointed out that private funders, such as the Gates Foundation, are contributing next to nothing to harm reduction.
“Not enough money is being spent on harm reduction. The goal of universal access to HIV prevention, treatment, care by 2010 is nowhere being met for people who use drugs and at the current rate of progress it will never be met,” he said.
Not only is it inequitable to neglect the prevention needs of drug users, it is also wasteful at a time when funding for treatment and care shows few signs of expanding. The IHRA report points out that prevention of HIV is much cheaper than treatment of HIV/AIDS. For example, in Asia it is estimated that the comprehensive package of HIV-related harm reduction interventions costs $39 per disability-adjusted life-year saved, whereas antiretroviral treatment costs approximately $2,000 per life-year saved.
The report makes seven key recommendations:
- More global resources are needed for harm reduction;
- Resources for harm reduction and HIV services for people who use drugs should be proportionate to need within countries;
- Donors should set targets for the proportion of global spending going to HIV related harm reduction, with 20% of global prevention funds going to harm reduction;
- Global expenditure on harm reduction must be properly monitored by UNAIDS and NGOs;
- Better estimates are required of the resources needed for HIV-related harm reduction;
- New ways of delivering harm reduction services may be needed;
- A global Community Fund for Harm Reduction should be established to advocate for increased resources for harm reduction.
Criminalisation and detention
Finally, there was a call to put an end to the ongoing arrest and detention of people who use drugs.
“The UN Reference Group on HIV and drug use has drawn attention to the scale of drug detention - in some countries there are more than ten times as many drug users detained in drug centers than receiving any form of treatment or prevention service. Yet many of these centres operate with no due legal process and no effective drug treatment, with the result that when users are released, they almost invariably return to drug use. Inhumane conditions, and the failure to respect the most basic of legal rights, cannot be excused,” said Bartos.
“The 'war on drugs' is a war on drug users and its fuelling the HIV epidemic, making public health responses much more difficult,” said Alvaro Bermejo, Executive Director of the International HIV/AIDS Alliance.
“Criminalising drugs and criminalising drug users causes considerable harms, serves as a barrier to public health objectives and has no discernible purpose other than to punish. A reassessment of the international drug control system is way, way overdue,” said Prof Stimson.
“Protective laws and policies for people living with HIV and people most at risk of infection are essential in promoting effective HIV prevention, treatment, care and support for people who inject drugs,” according to a Joint Position Statement on Detention Centres for “Drug Treatment” put out during the conference by the Global Network of People living with HIV (GNP+) and The International Network of People who Use Drugs (INPUD). “The human rights to due process, freedom from arbitrary detention, and medically and ethically acceptable health services on a voluntary basis are the most effective means of preventing HIV and other diseases.”
“Harm reduction is a much more effective approach to addressing HIV and drug use. It means drug users can prevent HIV transmission and live positively. It's time to move away from the detention centre system and to provide services for users in their communities and in government health clinics so they can see them as places where they can get help and not be badly treated,” said Bermejo.
“We must be prepared to speak out about human rights abuses wherever they occur. The crimes which are being committed today in the name of ‘Drug Detention’ must be renounced,” said Sidibé. “So I have made the call to decriminalise drug users as one of my main efforts as UNAIDS Executive Director.”
 Mathers B.M. et al. Global epidemiology of injecting drug use and HIV among people who inject drugs: a systematic review. The Lancet (online edition).
 WHO. Improving quality assurance in HIV prevention, WHO report to the UNAIDS Reference Group on Developing Minimum Quality Standards for HIV Prevention Interventions, Geneva, 2008..
 World Health Organization, WHO, UNODC, UNAIDS Technical Guide for Countries to set Targets for Universal Access to HIV Prevention, Treatment and Care for Injecting Drug Users. Geneva: World Health Organization, 2009.
 Mathers B et al. How successful have global efforts to expand HIV prevention for IDUs been. Results of a global systematic review. Harm Reduction 2010, Liverpool.
 Mathers BM et al. HIV prevention, treatment, and care services for people who inject drugs: a systematic review of global, regional, and national coverage. Lancet 375(9719):1014-28, 2010.
 Stimson G et al. Three Cents a day is not enough: Resourcing HIV-related Harm Reduction on a Global Basis. International Harm Reduction Association, 2010. http://www.idpc.net/sites/default/files/library/IHRA_3CentsReport.pdf