Side Event: Harm reduction and the UNGASS: Feedback from the Expert Group Meeting in Berlin

Side event organised by Germany, GIZ and the International Drug Policy Consortium

The Conference Room paper is available here.

Marlene Mortler MP, Drug Commissioner of the Federal Government of Germany. On behalf of the German delegation at CND, I am delighted to welcome all of you to this important event, and I would like to thank the co-hosts. In the Federal Government drug strategy, it is clearly stated that Germany will advocate internationally for harm reduction approaches and contribute with our own substantial and long-standing experiences. We promote harm reduction, especially in the context of HIV prevention. Why? Because, worldwide, millions of people are using psychoactive substances despite the high risk to health, especially if they are injecting. People use these drugs for different reasons – for recreational purposes, for anxiety, for pain relief, and for other reasons. But many have developed addiction and are no longer able to reduce consumption even if they wish to do so. Injecting drug users are in danger of infection from HIV. According to UNODC there are approximately 12.4 million people worldwide who inject drugs, and an estimated 1.8 million are living with HIV and 10 million have hepatitis C. Plus several thousand people die each year from overdoses.

Side event GIZ

In Germany, we are faced with these challenges and have had success in delivering the UN-recommended comprehensive harm reduction package. These interventions are practical, cost-effective and proven. Yet many countries still do not implement these services, and fewer provide them at sufficient levels of coverage and quality. The main barriers include a lack of political will, a lack of funding, and the prioritisation of law enforcement within a punitive, rather than rehabilitative, system. Germany has harm reduction as one pillar of its drug policy. We legalised needle and syringe programmes in 1992, and we now have the highest number of needle and syringe vending machines in the world. Worldwide, we have supported harm reduction. It is therefore no secret that we consider UNGASS 2016 as a key moment for the global promotion of harm reduction measures. Because of this, we held an Expert General Meeting in Berlin in February, and discussed new challenges in harm reduction with representatives from member states from Europe, Asia, Africa and Latin America, as well as civil society. The aim was to underline the efficiency and broad recognition of this approach. Germany also provides core and essential support to the Global Fund, which advocates for harm reduction programmes in its own work and grants too. We also fund harm reduction programmes in Central Asia. Overall, we can develop lessons learned from these bilateral programmes, especially in countries such as Nepal.

More efforts are needed to put the harm reduction approach onto the international agenda. It is a proven tool to prevent HIV and other infections. Without this, it is unlikely that we will achieve the targets set through the Sustainable Development Goals to end AIDS by 2030. The UNGASS is a great opportunity to push for the acceptance of harm reduction. In April, we should put the public health dimension of the world drug problem high on the agenda, as the key objective of the drug control system is the protection of the health and welfare of mankind. This is enshrined in the German drug strategy, and our evaluations show that harm reduction has helped to reduce the spread of infections. This is part of a comprehensive approach that is committed to the availability of evidence-based best practices. We intend to invest in measures that substantially reduce the number of drug-related deaths and infections. I hope that this meeting can give some needed impetus for the ongoing negotiations of the UNGASS outcome document.

Dr Ingo Michels, Head of Unit of the German Federal Drug Commissioner’s Office. In February, we met to discuss the future of harm reduction and new challenges, including for people who use stimulants and women who use drugs. The meeting included site visits to some of the innovative services that we have in Germany. Harm reduction is often associated with the injection of drugs, especially opiates. But the concept is much broader – and also applies to harms from non-injecting drug use, but also other harms such as social harms. On the global scale, the levels of incarceration of people who use drugs is a major concern, especially as drug use and drug harms continue inside of prisons. We also discussed the need for gender responsive harm reduction responses. One in three drug users is a woman, but only one in five people in drug treatment is a woman. Civil society must continue to play a role in advocating for, and delivering, lifesaving harm reduction services – including people who use drugs themselves. Engaging people who use drugs to deliver services is also a way to increase coverage. Yet the global coverage remains far too low to achieve the gains that can be achieved.

Patricia Kramarz, GIZ, Nepal. I will talk about how GIZ is supporting harm reduction in Nepal, where there are an estimated 91,000 people who use drugs, 57% (51,000) of whom are people who inject drugs. Between 6% and 17% of these people who inject drugs are living with HIV, depending on the region, and between 40% and 80% are living with hepatitis C. GIZ supports the national methadone programme, aligned with the work of other partners and especially the work funded by the Global Fund. Harm reduction should be embedded in a human rights based approach, be patient-focused, delivered alongside psychosocial support, linked to other programmes (including HIV and TB), well monitored, and sustainably financed. GIZ works to strengthen local capacity – through supporting new government guidelines, supporting the transfer of responsibility to the Ministry of Health, scaling-up from pilots to programmes, and supporting the decentralisation of provision from government settings to civil society groups. We are also helping to train staff and develop and institutionalise training curricula. There are currently 11 methadone sites, three delivered by NGOs, with 1,000 patients daily. There remain many challenges around sustainability (especially an over-dependence on the Global Fund), reaching more female patients, ownership of the government sites, and ensuring the demand for treatment. The future plans are to scale-up to nine government sites and 12 NGO sites, reaching 3,000 people daily. Even during the recent earthquake (and the 300 aftershocks), there was no disruption to the services. A more detailed case study from Nepal will be available later in 2016.

Zhannat Kosmukhamedova, UNODC HIV/AIDS Section. We don’t have good data on how many women inject drugs, but it is up to 30% of all injectors in some regions of the world. But we do know that there is higher HIV prevalence among women who inject drugs compared to men who use drugs. Key factors include: laws, policies and practices; stigma and discrimination; violence; and lack of community involvement. This is true for all people who inject drugs, but is even greater for women who use drugs. The criminalisation of drug use is a major problem, especially for those who inject drugs who also engage in sex work – this impacts the ability to access HIV services. In some countries, the removal of child custody due to drug use is also a major barrier, and in some settings there are even forced or coercive sterilisation and abortion campaigns for these individuals. Imprisoning someone who is responsible for children can lead to children being adopted, living with their mothers in prison, or homeless. Other factors include self-stigma, the use of compulsory detention, inequality, partner violence, gender norms and police abuses, and non-gender responsive services. Addressing this requires strong collaboration between different sectors – including alternatives to imprisonment, and work with law enforcement, and providing legal aid, anti-violence interventions and stigma reduction. To support this, UNODC have drafted a policy brief for harm reduction for women, outlining a package that addresses the specific needs of women. These papers bring to life what it is to be a woman who uses drugs, and challenges the way that we see this population – who can and should be an important part of the HIV response.

Dr Fábio Mesquita, Ministry of Health, Brazil. At this year’s CND, Brazil are here to reaffirm the principles that we believe, including health and human rights, stigma reduction, the end of the death penalty, and the inclusion of harm reduction for stimulant drug users. This is not just condoms and needles, but also innovations such as: peer-driven HIV testing to reach new people; the rapid provision of HIV treatment to everyone who is HIV positive, regardless of current drug use status (doubling the number of new people on HIV treatment over the past three years); providing hepatitis C treatment to all serious infections and those co-infected with HIV, again regardless of drug use status; plus offering services to treat drug dependence – including psychosocial clinics for crack cocaine users on a voluntary basis. The gold standard in Brazil today was the project “With Open Arms” (“De Bracos Abertos”) in Sao Paolo – a social intervention which includes treatment, but also offers housing and employment in a harm reduction context. The government is committed to invest in this programme, and expand to 91 key cities in the city as a more comprehensive strategy to help reintegrate people who use crack cocaine. We have a big challenge – both the UN and civil society – to stop only counting the success of harm reduction through the number of methadone clinics, as not all countries have opiate use needing these programmes.

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