Side event – Harm Reduction Works

Harm Reduction Works.  Examples from Around the World

Invest,             Kazakhstan
Engage           Tanzania
Implement     Malaysia

Funded by UNAIDS, technical support agencies – PWUD.
Speaker from Crimea not able to be here for obvious reasons

Tanzania Case Study .  Often focusing on the problems, etc.  May need more development, scaling up, etc.  But look at what works, what is happening, etc.

General overview of Tanzania, epidemiological data.  Very different epidemic in Zanzibar.
Tanzania.  PWID 50K.  Huge lack of population data.  42% general population — PLWHIV 55-68%.
Number of PWID living with HCV 75.6%.
Domestic funding for HR.  HIV/AIDS consumes substantial amount of government budget Amount contributed by government is only 5% of total expenditures of HIV/AIDS.
Overview.
Mature generalized HIV epidemic.
HIV prevalence rates 5.75 among adults 15-149 year old adults.
Pretty well managed with overall HIV rates leveling off and even decreasing.
Prevalence among PWID had reached 42%  (2003/2007) particularly sex workers and MSM.

Drug policy challenged
Very severe penalties for drug taking.
Growing HIV epidemic among PWID has concentrated minds and resulted in a pragmatic public health response.
Tanzania national drug control commission DCC based in PMs office, led development of national strategic HIV/AIS framework for 2010-2014.
Except for criminal justice move to create more enabling environment.
Drug scene significantly based around camps or maskani – PWUD come with limited resources to buy sell and use drugs and also to live.  2nd wave of epidemic.  Many AIDS orphans.  Predominantly men.  Women quite vulnerable in some of these camps.  Outreach helps people engage methadone services.  Big change…Peer respondent.
Tanzania.
Breadth of harm reduction services.  Voluntary HIV testing and counseling, NSP, OST, ART, Drop in centers, outreach, community mobilization with PWUD.
Very evolved political system.  Possible to work with local government.  National development agency coming in.  Services have really developed and evolved.  Working with women to stop them injecting if only smoking.

Challenges.  Scale up.  70% funding in 2013 dependent on external donors
Declining pool of funding with world crisis
AIDS trust fund, vehicle for domestic investment in HIV response.  ATF will contribute 36% of total HIV AIDS response.
Applications to the Global Fund for key population work have not to date been successful.

Women, much higher levels of stigmatization. Hidden.  85% of women who inject drugs traded sex
Positive experience of MdM women.  Drop in session and access to OST for women who smoke heroin.

Stigma.  Barrier to people engaging in services and forces PWUD onto margins
Impact of marginalization on health is well illustrated by situation of women who inject drugs.
Manage extra-vulnerability of women…?

Way forward.
Continue positive start made with police sensitization training
Develop better population data
Invest in drug user organizations – sustainable funding needed if community mobilization is to achieve full potential.
Peer naloxone delivery training and supplies – useful extension to spectrum of harm reduction services.  (legally allowed)
Most outreach is volunteer.  Needs investment.  Can’t expect people to work for free.

Still a pilot response.  But network response to growing pattern of HIV among PWID with combined response from NGOs and health service.
Organizations now a technical resource that can support the scale up and sharing of skills.

Urgent need to scale up response that has been so well modeled in pilot phase
Requires mix of external donor funding and greater domestic investment
Early evidence of positive impacts of responses – strong platform.

Gloria Lai.  Malaysia.
Key data.
170K according to PWID
8.7% prevalence of total PLHIV among PWID – 55, 891.
Domestic funding for HR, largely domestic with supplement from GF and CAHR through international HIV/AIDS alliance.
OST – 2012, 52080 in 2012 across 674 sites.  Total number of OST.
Laws on drugs contradict OST.  Caning, incarceration and death penalty.
ART – 2500 people in receipt.
HCV 67.1%…costs a barrier.  Very high.
HIV epidemic concentrated among PWID, sex workers and transgender communities.
70-80% associated with unsafe injecting.
Harm reduction – now sexual transmission primary.
Malaysia policy context.
Drug use is public enemy number one.  Harm reduction has changed public perception on drug use as health rather than criminal issue.  Ministry of health rather than law enforcement.  Drug treatment coordinated by MoH.
Significant investment in Harm reduction for PWID.
Why Malaysia decided to scale up OST in 2005.  Progress report based on MDG.  Malaysia would not be likely to achieve goals.  International external pressure.  Malaysian government responded by scaling up harm reduction services.  S
14,695 HIV infections averted by harm reduction services
Providing training to police and prison services.
Drug treatment services.
Drug treatment used to be compulsory treatment – for up to two years.  By 2010 recognized costly effects of that.  More costly to detain than offer OST.  Also a deterrent to harm reduction services.  Key policy shift made in 2010.  Became voluntary treatment centers.
Supported by UNAIDS when they did an evaluation of pilot centers.  Tried to encourage other countries to shift to community based voluntary treatment.  Most significant indicator of government willingness to deal with drug use as a health issue.  Major obstacle to Harm Reduction are laws making drug use a criminal offense.   Malaysia provides first line ART at no cost for eligible PLHA and as of 2009 ART available for prisoners as well as drug rehab centers.
By end of 2006 an estimated 25 % of people receiving ART were drug users, an increase from 7%.
Only 5% of PWID are receiving ART.
Challenge – policy, lack of policy harmonization between harm reduction and drug policy. Capacity – lack of staff skilled in harm reduction
Meaningful involvement of PWID.

Improving access to ART for PWUD.  Challenges of living patterns and compliance with ART.  Concerns about resistance.  Access to HCV still expensive.

Kazakhstan.  About to become primary funder of harm reduction services.  Funded by the government.  Success model in Eastern Europe and Central Asia Region.

Showing film about Tanzania Network of People Who Use Drugs.

Questions – IDU in Tanzania mostly heroin, although crack cocaine coming in.
Diversion of medical opioids not an issue – not enough for medical use to be an issue.

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