The vast majority of countries, low-, middle-, and high-income, continue to pursue detrimental laws, policies, practices, and human rights violations whilst falling short in terms of service provision and harm reduction. Policies notably include incarceration, forced ‘treatment’, harassment, and violence in civil society and perpetuated by the police and state, policies which drive – and, in turn, are driven by – social exclusion, marginalisation, stigma, and discrimination.
Harm reduction is defined by the recognition that it is not possible to completely eradicate drug use and, rather than treating drug use solely through prisons and punishment, it is better to reduce the potential harms that can occur through the use of drugs. The World Health Organisation (WHO), the Joint United Nations Programme on AIDS (UNAIDS) and the United Nations Office on Drugs and Crime (UNODC) have described a ‘Comprehensive Package’ of harm reduction interventions in their Technical guide for countries to set targets for universal access to HIV prevention, treatment and care for injecting drug users. The nine interventions described in the Comprehensive Package are:
- Needle and syringe programs (NSPs);
- Opioid substitution therapy and other evidence-based drug dependence treatment;
- HIV testing and counselling;
- Antiretroviral therapy (ART);
- Prevention and treatment of sexually transmissible infections (STIs);
- Condom programmes for people who inject drugs and their sexual partners;
- Targeted information, education and communication (IEC) for people who inject drugs and their sexual partners;
- Prevention, vaccination, diagnosis and treatment for viral hepatitis; and
- Prevention, diagnosis and treatment of tuberculosis (TB).
Harm reduction programs are recognised throughout most of the world to be the most effective way to prevent HIV and hepatitis C transmissions, and to effectively respond to other health issues related to drug use. The way harm reduction is interpreted or provided differs significantly from place to place and program to program. For example, state funded NSP and OST, including heroin substitution treatment, are integral to responses to drug use in countries like Switzerland, Denmark and Germany whereas other countries respond punitively to injecting and will only provide either methadone, a form of buprenorphine, or both of these.
In Australia, the early response to HIV meant people who injected drugs were able to keep their rates of HIV extremely low in comparison to other countries. The unintended effect of this success has allowed Australian policy makers to refuse to progress in line with other developed nations in trying new and even more effective programs like NSP in prisons and heroin substitution programs. Despite many people’s promotion of Australia as being a world leader in harm reduction, very little has changed in Australia since the first introduction of harm reduction. The first peer naloxone programs have only recently started in some states and are still operating mainly as pilot programs.
The United States is an example of what can happen in developed countries when you don’t respond with evidence-based harm reduction programs. NSP is not funded federally in the United States and is always under threat and under resourced in the thirty-three states and 194 services that do provide it. This has resulted in HIV prevalence among people who inject drugs that is comparable to some of the poorest countries in the world. Conversely, the United States has been one of the leaders in providing naloxone to PUD to reverse overdose, a response that is not included in the United Nations ‘Comprehensive Package’ for injecting drug users.
In low and middle income countries it took many years and extremely high HIV prevalence in injecting drug user communities for harm reduction to even be considered. Many Asian countries, despite their high levels of injecting drug use and HIV, strongly opposed harm reduction twenty or even ten years ago. With financial support and expertise from countries like Australia, most have now implemented harm reduction programs in their HIV responses. However, the programs are often inadequate to meet the needs of the community of PUD. For example, there may only be one NSP in one or two major cities and none in rural areas. Additionally, the quality and amount of equipment PUD receive when they go to a NSP is often low. It may be one or two high dead space syringes and if they are lucky, a swab or a small bit of cotton. High dead space syringes, the kind where the needle tip is removable, have been shown to be extremely good transmitters of blood borne viruses as a large amount of blood is left in the tip after injecting. The lack of good quality injecting equipment means people are more likely to reuse equipment and share it with others.
Criminalisation of PUD is also extremely high, despite the implementation of NSP and other harm reduction services. Many PUD are afraid to access services as police often use these services to find people to arrest. When they do access services, they are afraid to carry equipment and may inject in a high risk environment near the NSP, then throw the equipment away or sometimes stash equipment in a public place the PUD community all know. These places are used by PUD when they need equipment but don’t want to access the NSP or can’t access new equipment. In some countries, NSP workers have responded to these challenges by leaving new injecting equipment in these areas for people to take when they can. This may address some of the need, but it is still extremely difficult to be able to provide enough supplies or to provide peer education to users in these circumstances.
Some low and middle income countries, on the other hand, have implemented ground breaking harm reduction programs over the last ten to fifteen years. This is in comparison to Australia where very little has changed since NSPs were introduced in the mid-1980s. For example, countries such as Iran have gone further than we have in Australia, allowing NSP to operate in prison. Many countries also now have drug user organisations representing PUD and advocating for change. In Vietnam, the number of drug user organisations providing small amounts of support to the PUD in their local communities is rapidly growing, despite barriers to their ability to legally register the organisations and the lack of resources that could fund some peer education and harm reduction services.
|A word of caution – ‘nothing about us without us’Though we welcome a call to increasingly focus on service provision, healthcare provision, and harm reduction as opposed to criminalisation, moves towards disempowering constructions of people who use drugs as pathological and inherently in need of ‘treatment’ and ‘rehabilitation’ are worrying. These understandings frame people who use drugs as sick, as lacking in agency and self-determination, and they feed into justifications for detention and compulsory ‘treatment’ (a phenomenon that the (Global Commission on Drug Policy calls to end), as well as feeding stigma and discrimination.INPUD response to Global Commission on Drug Policy report – ‘Taking Control: Pathways to drug policies that work’|
There are also still some countries that refuse to acknowledge the practicality and benefits of harm reduction and changes in drug using patterns throughout the world. Methadone is illegal in Russia, for example, and the few programs providing injecting equipment to the large injecting drug user population are at constant risk of closure. When Russia invaded the Crimea in early 2014, the existing methadone programs were suddenly closed leaving hundreds of people without the medication they relied on. Reports from organisations and people in the Ukraine have stated the serious consequences of these sudden closures. Many people who were on the methadone program have been imprisoned or forced into inhumane prisons and compulsory “treatment” facilities. Others have fled to the unoccupied area of the Ukraine where methadone programs still exist, often leaving their friends, families, jobs and lives behind. And several people are reported to have committed suicide. Anecdotal reports from people remaining in the area, those with a history of drug use and some who were on methadone, report several cases of their friends disappearing, and periods of unauthorised capture and beatings by military police and other Russian-led forces.
Africa has also recently experienced a period of significant change in relation to drugs. Some countries in Eastern Africa such as Tanzania and Kenya found themselves on the trade routes for heroin and other drugs where these drugs had previously been rare. As a result, large numbers of people in those countries had access to these drugs and, as has happened in other countries, began to use them. A few harm reduction programs have begun to operate in some of these countries, while others continue to deny there is any drug use in the country.
Asian countries have borne a large part of the HIV burden due to the historical, cultural and political nature of drug production and drug use. There are huge numbers of people using and injecting opiates and other drugs in Asia compared to much of the world. HIV epidemics appeared quickly in injecting communities in the 1990s and 2000s and continued to spread for many years while governments tried to crack down on drug users, and refused to try harm reduction responses. Eventually, almost every Asian country with significant numbers of PUD and HIV rates was convinced to implement some form of harm reduction using funding from international donors.
The period of funding for HIV programs, including harm reduction, has likely reached its peak. In 2010, the global estimate of international donor funding for harm reduction was approximately US$160 million and has not increased significantly since then. This amount of money is woefully inadequate. UNAIDS estimated that it would cost $2.3 billion a year to provide adequate harm reduction services for the people who need them in the first year, with these costs being reduced as the health and social consequences of providing enough services began to take effect.
Almost all of Asian countries who have used international funding for their harm reduction programs continue to rely on international donors. Very few governments in these settings have taken financial responsibility for all or any of these programs. As a consequence, NSP and OST is still too scarce to meet the needs of the PUD in these countries. Only seven percent of this funding is currently provided, in contrast to the approximately $100 billion US spent on law enforcement responses to drug use such as prisons, policing, probation and court costs. Out of all countries with reported injecting drug use, seventy-one do not provide any NSP and eighty-one do not provide OST.
A 2014 report, Funding crisis for harm reduction: Donor retreat, government neglect and the way forward (insert link from footnote), estimated that globally, on average, people who inject drugs were able to access two needle and syringe programs per month from harm reduction services in 2010. This is likely to be an over-estimate, and is particularly unlikely in low and middle income countries. The report also suggests governments and donors should change the way resources are allocated to respond to drug use. in particular, if ten percent of the funding that currently goes to law enforcement responses to drug use was instead put into harm reduction measures such as NSP and OST, people who use drugs would have enough services to adequately prevent HIV and hepatitis C transmissions. Preventing blood borne virus transmissions now would save significant amounts of money for governments in the future. Billions of dollars in health care costs would be saved, and countries would not lose large numbers of people from their workforce. It would also save millions of lives and improve the lives of millions more.
Unfortunately, in direct opposition to these recommendations, the funding available for harm reduction in developing and middle income countries, where the majority of people who inject drugs live, is decreasing and likely to decrease further in the next few years. Very few governments have committed to continue funding these necessary services as the international donors are leaving their countries.
The effects of these funding decreases have already been felt in countries which rely on international donors. For example, in Cambodia, the Australian Aid Program provided funding for the only methadone program in the entire country, a program run out of a hospital in Phnom Penh. Australian Aid also funded at least one of the three NSP programs in the country, also all in Phnom Penh. In 2014, the Australian program is ending and the methadone program and NSP previously funded by the program will end, leaving almost no services for people who inject drugs in the country. The Cambodian government has said it will not use any of its own money, nor will it direct other funding it receives to continue any of the programs, and other international donors have also not committed to keeping the programs going. NSP programs in other countries including Indonesia are also being shut down as donors reduce and stop funding them. Most of Indonesia’s harm reduction services have been funded by the Australian Aid Program and the Global Fund. The Australian Aid Program is also finishing the Indonesian program in mid-2015, and as Indonesia is being classed as a middle income country, it is no longer eligible for funding from the Global Fund. Although Indonesia has had one of the most successful harm reduction programs in Asia, the Indonesian government has not committed to continuing these programs and is instead already cutting back on them.
The removal of harm reduction services has recently been shown to be extremely harmful. The Global Financial Crisis, which had significant effects on some countries in Europe, meant scarce funds that had gone to services such as NSP were no longer available. There were two major results of this; people changed their drug using patterns because of changes in drug prices and availability, engaging in more risky behaviours, and people had less access to harm reduction services. It appears that already HIV and hepatitis C transmissions have increased significantly in many of these areas.
Indonesia is not the only country previously supported by international aid to have experienced changes in its economic status. In many cases, the change of classification for countries such as Indonesia, Malaysia and Thailand, from low income to middle income countries, is good news for some in the country. Unfortunately, it is disastrous for people who use drugs. Programs such as the Global Fund for AIDS, Tuberculosis and Malaria (Global Fund), the world’s largest provider of funding for HIV prevention and treatment services, does not support middle income countries. This means that, of the 58 countries previously eligible for Global Funding support, 24 are now ineligible. Fifteen countries are considered the highest priority for addressing HIV and injecting drug use, containing eighty-four percent of the world’s injecting drug users. Most of these countries are now classed as middle income, or in the case of some of them, Russia, Thailand and China, for example, refuse to provide harm reduction services with their own money if at all. The situation for PLHIV, and for people who inject drugs in particular, is likely to worsen rather than get better in the coming years.