Clinical & Policy Updates:
SMMGP Policy Update May 2009
Note: All the papers included in this Update were tabled at the IHRA conference - Bangkok April 2009.
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Despite the proven efficacy of harm reduction interventions and endorsement by the UN bodies uptake of these strategies, simply put, is thoroughly inadequate ...national responses to injecting drug-related HIV epidemics have been poor in many parts of the world and there still remain seventy-six states with evidence of injecting drug use in which no harm reduction interventions are present.
- Anand Grover, UN Special Rapporteur on the Right to Health
It is estimated that 15.9 million people inject drugs in 158 countries around the world. Up to 30% of worldwide HIV infections occur through injecting drug use (IDU) outside of Sub-Saharan Africa. Despite the overwhelming evidence in favour of harm reduction (HR) as an effective HIV prevention strategy and support from global government agencies, the world-wide state of harm reduction is poor, particularly in countries who need it most (low and middle-income countries).
Harm reduction policies or programmes have been adopted in more than half of the 158 countries where IDU is reported (March 2009):
- 84 Support harm reduction in policy or practice.
- 74 Have explicit reference to harm reduction in national policy documents.
- 77 Have needle and syringe exchanges (NX).
- 10 Have needle and syringe exchange in prisons.
- 65 Have opioid substitution therapy (OST).
- 37 Have opioid substation therapy in prisons.
- 08 Have drug consumption rooms (DCR).
Asia: Despite recent significant developments in HR policy and practice in parts of Asia, it is still only between 2-5% in many areas of Asia and not sufficient to have an impact on HIV epidemics. Barriers to uptake include strong criminalisation of drug use (several Asian countries retain the death penalty for drug offences). No Asian prisons have needle and syringe programmes (NSP), but India, Indonesia and Malaysia provide limited oral substitute therapy (OST) to prisoners. Bizarrely, India makes methadone and sells it to other countries but it is not allowed to be prescribed there and only buprenorphine is used.
Central and Eastern Europe and Central Asia: This region has witnessed the fastest growing HIV epidemics in the world (following a rapid increase in IDU during the 90s) rising to 1.5 million in 2007; almost 90% of those infected live in either the Russian Federation (69%) or Ukraine (29%). Of the new HIV cases reported in this region in 2006 where information is available on the mode of transmission, about 62% were attributed to IDU, the rest mainly sex workers and their various partners. In the Russian Federation, HIV prevalence among injecting drug users ranges from 3% in Volgograd to more than 70% in Biysk. Prevalence is also high among injecting drug users in Ukraine; among surveyed injecting drug users in national diagnostic studies prevalence increased from 11% in 2001 to 17% in 2006; also, local HIV prevalence as high as 63% has been found. High infection levels have been detected among injecting drug users in Tashkent, Uzbekistan (30%, 2003-2004); in Zlobin, Belarus (52%); and in Kazakhstan. In response, all states now some have NSP but most with poor coverage and the majority prescribe some OST for drug dependence. But - large numbers do not have access to HR e.g. in the Russian Federation the use of OST is prohibited and coverage of needle exchange (NX) is poor.
Western Europe: HIV epidemics amongst IDUs in the Netherlands and the UK during the 80s prompted the development of NSP, and now almost every country in this region has a range of HR interventions in place, averting HIV epidemics in several of them. However, barriers do exist - stigma and discrimination, and limited funding. Several countries have innovative HR measures including establishing drug consumption rooms (DCRs), but attempts to introduce in the UK have so far failed. In prisons OST is available but access to sterile injecting equipment is limited.
Caribbean: HIV is predominantly sexually transmitted in this region and IDU is rare - research has highlighted a link between crack cocaine smoking and HIV transmission. National drug and HIV policies remain largely unconnected.
Latin America: IDU is associated with HIV in several countries. The majority of the NSP sites are in Brazil and Argentina. Mexico is the only state that prescribes OST but coverage is low; prisoners in this region have no access to NSP or OST. Barriers to access include severe stigma and fear of arrest.
North America: Canada and the US both have HR programmes supported by some aspects of national policy. However, service provision is inconsistent and many states favour repressive drug law enforcement and abstinence-only approaches. The US has publicly expressed support for NSP at the 2009 UN Commission on Narcotic Drugs meeting. In Canada the Conservative government has shifted towards an enforcement oriented drug policy. Neither of these countries has NSP in prisons and whilst OST is available in most Canadian prisons, it remains rarely accessible for prisoners in the US.
Oceania: The early implementation of HR strategies in both Australia and New Zealand has resulted in lower levels of HIV amongst IDU. Australia has good NSP but barriers to access do exist (cultural inappropriateness, lack of coverage in rural areas and stigma). In prisons OST is available in both countries, but neither provides access to sterile injecting equipment. HR services are not available in the Pacific islands and more research is needed to determine the levels of drug use.
Middle East and North Africa: IDU is fuelling HIV epidemics in Iran and Libya. A small number of governments have begun to embrace an HR approach, with Iran leading the way in terms of scale. Barriers include severe stigma and low awareness of risks. There are severe penalties for drug offences, leading to large prison population numbers who have used or do use drugs. Only Iran offers HR services to prisoners.
Sub-Saharan Africa: The effect of drug use on HIV epidemics is becomingly increasingly evident in many countries and injecting has been reported in the majority of states in this region. Sharing practices are common. Mauritius is the only country where NSP is operating and OST is prescribed to a limited extent and also in South Africa. There is no HR in prisons in the region.
- IDU identified in at least 148 countries, with an estimated 15.9M IDUs worldwide.
- Prevalence high in many countries, particularly Central Asia and Eastern Europe. Emerging use in other countries including Sub-Saharan Africa is a cause for concern.
- Prevalence of HIV among IDU varies considerably around the world. It is estimated that there may be 3 million IDU who are HIV positive.
- IDU is responsible for an increasing proportion of HIV infections in Eastern Europe, South America and East and SE Asia.
- Data on the extent of IDU are absent in many countries; more recent and scientifically rigorous data are needed for many countries where estimates currently exist.
- Methamphetamine use is widespread and injection of this drug is established or emerging in a significant number of countries (especially Asia).
- Limited treatment options are available for methamphetamine or cocaine dependence and HIV prevention programmes do not serve the needs of injectors of these drugs.
- Injection of diverted pharmaceutical opioids occurs around the world. Supervised OST results in minimal diversion.
At least 84 countries around the world support or allow the operation of HR programmes.
Despite all the evidence that harm reduction is a valid, evidence-based approach to the treatment of drug use, in March 2009 at a High Level meeting of the UN Commission of Narcotic Drugs (CND) held in Vienna to finalise the text of a new political declaration on drugs, it became apparent during negotiations that a number of countries (including US, Russia, Japan, Italy and Sweden) would block support for harm reduction approaches to appear in CND resolutions and have blocked any reference to HR in the declaration. This is despite up to 10% of all global HIV infections occurring through unsafe IDU and evidence suggesting that up to 3 million people who inject drugs are living with HIV.
This feels like a large blow to human rights and the fight for harm reduction - not only is CND out of step with those of us who are fighting for improved HR services for people who use drugs, but with the UN as a whole.
We may have reasonably good drug services in England, but we need to continue fighting for improvement and become involved in the national and international drug policy debate.
We note here that we disagree with the conclusion of the recent report entitled "The Phoney War on Drugs" by Kathy Gyngell of the Centre for Policy Studies, that harm reduction has no place in government policy and that it has failed in the UK. (Kathy Gyngell is the Chair of the Social Justice Policy Review for the Conservative Party).
For more comment on the report see the article entitled "The Phoney Argument for a New Drug War" by Axel Klein, Lecturer in the Study of Addictive Behaviour, Centre for Health Service Studies, University of Kent on the Transform website.
There are national and international HR networks and knowledge hubs around the world (and in regions) who all follow a broadly similar approach. It is an inexpensive and accessible way to empower civil society and advocates for HR. The Network of Networks is an informal coalition enabling individual networks to work together where required. For more information visit the websites listed below:
- International Harm Reduction Association
- International Network of People who Use Drugs
- International Nursing Harm Reduction Network
STOP PRESS: STOP PRESS: STOP PRESS:
At the 20th IHRA Conference recently in Bangkok early discussions took place to develop an International Doctors HR Network to try and bridge the gap between policy and practice and to promote the sharing of good practice. Watch this space for developments!
Even in countries with progressive policies HR young people are largely ignored, often criminalised for their drug use and not involved in the development of programmes for them and policy. The UN Convention on the Rights of the Child, which is the most widely ratified of all human rights documents, should help change this by providing a framework. The convention includes non-discrimination, the right to life, survival and development and the right to be heard.
In 2008 Youth RISE (Youth Resource, Information, Support, Education) asked young researchers about drugs in their countries as well as youth-specific drug, HR and HIV policies. Whilst it is easy to generalise, and being aware that the countries from which reports were received were diverse, patterns do emerge, and issues that were common to all of the countries were identified:
- Young people are using drugs! - prevention campaigns have not worked.
- A lack of disaggregated data exists - who uses drugs, why those drugs, how?
- There are few youth-specific policies and programmes - period.
- Youth are criminalised for drug use by most countries - mandatory treatment, rehabilitation, youth detention centres or even jail awaits them.
- Youth are not involved in policy and programme design - they are seen only as recipients of services.
It seems we have a long way to go to achieve the aims of the UN Convention on the Rights of the Child. There is a widespread lack of young people's services in this country and the postcode lottery seems to operate. A joint College/NTA initiative is currently under way to set up a network of GPs who work with adolescents with substance misuse problems - for more information or if you are interested in taking part see the RCGP website or contact Jo Betterton on email@example.com