Evidence and arguments for implementing the UNGASS commitments to harm reduction

Organised jointly by the Permanent Mission of the Netherlands, the Permanent Mission of Czech Republic, the Permanent Mission of Canada and the Permanent Mission of Switzerland, together with the UNODC HIV/AIDS Section and Harm Reduction International, and in collaboration with the IDPC, AFEW International, AIDS Fonds and the International HIV/AIDS Alliance.

Welcome from Marco Hennis (Netherlands Ambassador): Fifty years ago, harm reduction didn’t have this easy-going connection and connotation that it has now. We focus on four interventions here: medically-assisted therapy, injecting equipment provision, antiretroviral therapy, and naloxone. Blood-borne virus prevalence in Netherlands has been low for many years, and the health situation of people who inject drugs is generally good. Overdose deaths are also relatively low. We rely heavily on injection equipment programmes, on the drug consumption room we have introduced, etc. I also acknowledge John-Peter Kools, who is here in the audience today, and who played a key role in starting these programmes. All of these interventions contribute to the right to health, and to the broader public health agenda. Our four speakers will describe their national experiences, but first I give the floor to my co-host.

Welcome from Fionnuala Murphy (HRI): Thank you to the governments who have cosponsored this event – your leadership on harm reduction is much needed at this moment as countries begin to implement the UNGASS Outcome Document. Paragraph 1 commits to tackle the health-related harms of drug use. It specifies injecting equipment provision, medically assisted therapy, antiretroviral therapy and naloxone – this is a historic first for a UN document on drugs, and represents important progress. We need to see this recognition at the country level. UNAIDS data shows that new HIV infections among people who inject drugs have increased by a third. The Global State of Harm Reduction reports show that, since 2014, no new countries have started needle and syringe programmes. More than half of the countries with injecting drug use still do not provide opioid substitution therapy, and a third do not have needle and syringe programmes. People who inject drugs continue to be left behind. Now is the time to implement harm reduction.

Police Col. Ta Duc Ninh (Head of National Drug Control Unit, Vietnam): Introduction to Vietnam, with a population of around 94 million people, and divided into 63 provincial units. At end of 2016, there were 210,000 “drug addicts”, around half of whom use heroin. The use of amphetamine-type stimulants is on the increase. There are 227,225 people living with HIV, with a decreasing trend – especially for infections through drug injection. We realised that just using supply reduction was not enough, so in 2008 we adopted a new approach – harm reduction. We started with methadone maintenance therapy and needle and syringe programmes, and are proud to be the first country in the region to legalise these interventions in our law. Services exist in most provinces in Vietnam, covering more than 50,663 heroin users compared to a target of 80,000 (this includes in drug detention centres). Buprenorphine pilots have started too. The needle and syringe programme reaches 106,000 people per year. Positive impacts of methadone provision include reduced frequency of drug use and needle sharing, improved health and mental benefits, and a reduction in crime from 40.8% down to 1.34% after 24 months of treatment. This success comes from leadership from the very top, and support from members of society. The HIV law has a whole chapter on harm reduction, and the drug law was quickly amended to avoid any conflicts. Support from international donors has also been crucial – thank you to Australia, Netherlands, the Global Fund, etc. This was all backed by training courses for law enforcement officers, as they need to be engaged and supportive – encouraging people to attend harm reduction services. Challenges remain – including the need to scale-up and reach people in more remote areas, high drop-out rates in some areas, and the need to keep training a new generation of law enforcement officers.

Tomas Sadilek (Czech Republic): Harm reduction is not just a small part of our response, it is a pillar of how we approach the drugs issue. The drug free world is not an idea that we can follow. A white paper in 1995 defined harm reduction as part of the national budget, and harm reduction has been a core element ever since. We have more than 70 centres around the Czech Republic that provide these services. We opened the first low-threshold services, for people to use without identification or anything to access social workers and harm reduction interventions. At that time, hepatitis C prevalence was 60% among people who inject drugs. After twenty years we have HIV prevalence under 1% and hepatitis C under 20% among this population. The drug using population is now getting older in the country. It was hard work to keep fighting for the budget and services over the past 20 years, and coordination was key to making the services established, stable and sustainable. The debate continues every few years, with the usual questions, but we have the data that shows that if you invest in harm reduction the savings are multiple times what you investment.

Thomas Cai (AIDS Care China): In China, harm reduction came along in response to HIV/AIDS. In 2004, we started providing methadone, and then needle and syringe programmes as well. China’s government initiated a free antiretroviral therapy programme in 2004, but due to the stigma against people who use drugs, their access to HIV treatment has been a challenge. Doctors believed that people who use drugs would not adhere to treatment, and these people were also anxious about walking into a hospital to access treatment. Harm reduction helps with adherence and confidence. The viral suppression rate for people who inject drugs is very high (93%) and comparable to other populations, and remains high over time. When given treatment, people who use drugs are playing an important role in the objective to end AIDS in China. More than 60% of those in need are in treatment now, and the HIV rate has fallen by 88% among this group. This means that the Government have adopted harm reduction as a strategy after the Global Fund’s support ended. Funding has actually increased since the Global Fund withdrew. On the border with Myanmar, where migrant issues have become an issue, harm reduction is now provided and the first HIV treatment policy and programme for foreigners is now in place.

In 2013 a media conference was held to promote the positive impact of a pilot naloxone programme, and in 2015 a national programme was launched. The model is simple – a short training, the provision of training, case reporting – and many lives saved. Methadone treatment has played an important role in stabilising the lives of people who use drugs, and supporting their reintegration into society. Since 2014, take home dose provision was also piloted, with positive impacts recorded, and a national scale-up is planned. Law enforcement can change their role from punishing to supporting. Thanks to the Dutch government for supporting these efforts, to help develop new and ambitious new models depending on the country context.

Benjamin Phillips (Harm Reduction Coalition, USA): The USA is in the middle of an overdose crisis, with a five-fold increase in deaths since 1990. 52,000 deaths in 2015 – roughly 144 people every day. In 2015, more people died from overdose than from motor vehicle deaths. It is showing no signs of slowing – especially among opioids. The research tells us that the risk of overdose increases after periods of abstinence, especially in prisons, but that effective overdose prevention can be effectively taught in less than 10 minutes. The Harm Reduction Coalition worked with the New York State Government to train all soon-to-be-released prisoners, regardless of previous drug use history, and then provided them with intranasal naloxone if they wanted it upon release. In New York alone, 22,000 people are released from prison each year, and more than 4,000 naloxone kits have been distributed since 2015. The nurses in the prisons are also now equipped with naloxone to use in emergencies. It was instrumental to find an advocate inside the system who can facilitate this kind of programme and help to navigate complex systems. We trained staff first, and then used volunteers (such as prison guards) to deliver the training to the people in need. This was a successful collaboration between civil society and government. We are able to tell people on their release that they can save someone’s life. There are also around 100 buses in New York with naloxone adverts on the side too – another collaboration effort. [Benjamin then played a short video showing examples of harm reduction in the criminal justice system].

Monica Beg (UNODC HIV/AIDS Section): UNGASS OD is a unique opportunity to promote evidence-based interventions based on public health and human rights. Member states reiterated their commitment to end AIDS, including among people who use drugs, by 2030.  This means that the world needs to achieve a 90% reduction in new HIV infections by this time – which requires a 75% reduction by 2020. Yet new infections have actually increased, and the previous target (a 50% reduction by 2015) was missed. We will miss all the other targets if we do not change the way we respond to this epidemic. In order to achieve the Sustainable Development Goals Target 3.3, the world must embark on a fast-track response. There are 36 “Fast-Track Countries” for drugs and HIV, and the UNODC have chosen 25 high-priority countries to work in, and have technical assistance programmes existing in around 17. UNODC have developed a comprehensive package for injecting drug users, and for harm reduction in prisons, as well as various other tools and guidance. Their efforts focus on alternatives to incarceration for people who use drugs – including in their work in Myanmar (which has drafted a revised drug law that ends registration of drug users, inclusion of harm reduction, etc). In Kenya, it took more than five years of intense advocacy efforts to finally launch an opioid substitution therapy programme, and to develop a real-time monitoring system to improve services and linkages. UNODC also collaborate with civil society and the scientific community. We have made significant strides, but still a lot more needs to be done by all of us if the UNGASS targets are to be met.

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