Side event: Harm reduction in a changing global context

Louise Van Deth, AIDS Fonds. I’m proud to chair this all women panel. The Dutch elections were followed closely by the whole world, it stopped the trend of disasters in elections. Since we are also a small group, I’d also like to invite you, when you have questions and comments, to state your name and say where you are from. I will now introduce my colleagues. Monique has been part of the putting together of the Dutch approach. During the CND a lot of countries have shown to be opening up for the public health approach. Do they see the added value of harm reduction?

Monique middlehoff, Ministry of Foreign Affairs, Netherlands. Yes, I do see a lot more interest. The HIV resolution on financing showed that a lot of countries are very much in favour of a harm reduction agenda, but there is also resistance from other countries, and it’s disappointing that we still cannot include the wording ‘harm reduction’ at CND. It was very good that Dr. Chan from WHO mentioned it and she is a good advocate.

Louise. Can you name some examples of countries calling for this harm reduction approach?

Monique. Some countries in South East Asia have adopted frightening approaches. If you see people as criminals and can take their lives without any form of due process, this is a very frightening development and we cannot be happy with this.

Louise. What are the future challenges?

Monique. Engaging with those countries and showing that the harm reduction approach has mostly positive outcomes for people who use drugs and the prevention of HIV and hepatitis.

Louise. I am now turning to Janine Wildschut. It is about South Africa that I’d like you to give best practice examples where you work through Bridging the Gap.

Janine Wildschütz, AFEW International. I just want to give a short introduction of Bridging the Gap and will then explain the South Africa and Tajikistan examples. These are countries where we work and choose what is best according to the setting. Bridging the Gaps is an alliance of Dutch NGOs and international networks. We have a theory of change to strengthen civil society and hold governments into account, address human rights and deliver harm reduction services. We intervene in 16 countries and have a budget of EUR 50 million.

When it comes to South Africa, over the last two decades, South Africa has undergone a massive transformation, recognising human rights for all, with an economic boom. But poverty and inequality are very much present in the country and social, racial and economic lines are very present. The country is in the top 10 most unequal countries of the world. There are 7 million people living with HIV – one of the most burdened country in the world. Of course, all efforts were concentrated on the general population, but what we also saw was that there was a big risk that PWID could fuel the epidemic. This came together with a shift from smoking to injecting drugs. There are almost 70,000 PWUD and a dire need of service provision. But we have to realise that most people who use drugs are not problematic. There is a massive funding gap for harm reduction today. The Global Fund invests less than 1% of its total fund on PWUD. Investments are also moved to low income countries, so South Africa does not receive much funds for that issue. This is what we see in many other countries – if international funding is withdrawn, it does not mean that the government will take over funding.

There are also complicating factors: there is a big disparity between law, policy and practice with very repressive approaches, supply reduction and drug law enforcement to curb demand. Despite the harms related to this approach, there has been little advocacy from NGOs so far. There is physical aggression towards PWUDs, there is a push back from the community who see discarded needles, etc. We’ve been doing outreach with our partner TB/HIV Care Association. They work as peer educators, as paralegals. They work on being more responsible. But the peer educators get arrested for delivering clean water as this is seen as paraphernalia… We now have programmes in Pretoria, Durban and Cape Town. We offer NSPs, paralegal support on human rights violations. We contribute to showing effectiveness of harm reduction.

In the next phase of Bridging the Gap, we also bring the evidence to the policy environment. If you start a project like this, you can also impact on policy, making it more acceptable and easier to implement. And we will then try to ensure that the government can take over.

Another example is our work in Eastern Europe and Central Asia. It’s difficult to get some accurate figures. Russia is most affected by HIV and injecting drug use – this is a central theme in the region. But there is also a shift to sexual transmission, although more research is going on around this topic. A lot of women get infected, many of whom are labour migrants. AFEW in Tajikistan worked very closely with the government authorities – this is very different from South Africa. In many areas there were very few NGOs providing services, nothing was happening there. We decided that there was a gap in service delivery for women, both drug users and sexual partners of drug users. We extended this to a gender-specific client management, and we created a network of government institutions so that they could be better prepared to take over the responsibility. At the moment, however, we are working with NGOs and the community to get a coherent and single package through NGOs. We now reach 446 people in the project, 304 are women. By starting from the grassroots we can often be isolated, but we found a lot of support from the government and it worked with us, especially through the Ministry of Health.

Louise. I want to move more East to Ms. Trang, who coordinates SCDI and is also part of the PITCH programme, funded by the Dutch Ministry of Foreign Affairs. Vietnam has seen a lot of progress, could you share some of your experiences and advocacy work, and talk about what is needed for the future?

Ms. Trang, SCDI. The Vietnamese government has been known for progressive policies, with harm reduction adopted 20 years ago, and HIV programmes being well established. The police cannot arrest outreach workers. Drug use has been considered as a social evil for a long time, and this stays on, however. The rest of society still considers them as a social evil – making it difficult for the community to participate in the HIV programmes. There is funding from a lot of organisation, leading the Vietnamese government to change the approach towards drugs. I will focus here on policy.

PWUD in Vietnams benefit from an enabling legal environment – they can access harm reduction and treatment, but there are still some barriers. The most important one is stigma and discrimination. What we need to do is sensitise society on PWUD, and show what they look like in real life.

The government is quite progressive right now, not as progressive as the Dutch! Before 2013, we had compulsory drug detention centres – this was the only option for PWUD, and there was a lot of relapse after release. Heroin was a reward after two years of hardship in the centres. The international community got very concerned with the situation and tried to do something about it as it was a significant human rights violation. The change was made in 2013 with Decision 2596 known as the Renovation Plan on Drug Rehabilitation. Drug addiction is now considered as a treatable disease requiring comprehensive and long-term treatment. They also scaled up voluntary, community based treatment and gradually reduced compulsory centres, 94% reduction by 2020, only keeping 6 of these centres. This was a huge change in this policy.

Two years later, nobody was talking about this plan – nothing has been done because they don’t know what to do about it. The only reason they passed the decision was because of international pressure. The question of how to move from compulsory detention to community based treatment was difficult and challenging. SCDI has helped a lot on harm reduction and even for us treatment is new. That’s why international partners stepped in. This is how PITCH came in.

PITCH stands for Partnership to Inspire, Transform and Connect the HIV Response. It is a strategic partnership between AIDS Fonds, the Alliance and the Ministry of Foreign Affairs of the Netherlands. It focuses on HIV and a focus on key populations, including women. The entry point in Vietnam is the legal framework which is progressive. We work with the National Committee for AIDS, Drugs and Prostitution Prevention and Control within that project. In Vietnam, we focus on piloting and developing the voluntary treatment model, and we focus on policy with different agencies.

On the piloting of the treatment model, most patients come to us at community-based level with consultations and support points. We do capacity building at local level to make this possible, and we engage the community of PWUD to work with this on that. The next level is the methadone treatment. Then we have voluntary residential centres – we want people to recover in their environment, not being isolated like in compulsory centres, but some want to be alone and in another environment, so this is why we have those centres. And at the very top of the pyramid we have hospitals who are not reached in the community or centres. We apply this model in three communities.

On the policy advocacy, there are guidelines for compulsory treatment from the government. For voluntary treatment, there is no guideline so we are trying to develop those with the government. We have a draft of the circular on voluntary addiction treatment.

In terms of outcomes, we have three provinces for which we have financial support from PITCH, and six provinces where we provide technical support for designing and implementing services, with community involvement. Right now we use money from foreign sources, we hope that the government will be able to invest in the community centres. We showed the government at local level that we had solutions to implementing treatment programmes.

Louise. Thank you for this approach from the bottom up. Next year, we all be meeting in Amsterdam for the AIDS 2018 Conference. One of the focus areas for this conference will be Eastern Europe and Central Asia. Janine, could you tell us about the work of AFEW to activate and engage people on this issue? Later on Monique can tell us about the Conference.

Janine. The AIDS Conference is for everybody interested. We will pay attention to Eastern Europe and Central Asia as the need is so high. We will have a mentorship programme for civil society to do research and collate scientific evidence. We will also support organisations to write abstracts for the Conference. There is more evidence than ever on the effectiveness of harm reduction. We will have a programme to welcome everyone, have translations when needed, we will be able to help people prepare their presentations, etc. We are not choosing the programme, there will be a programme committee to select the abstracts. But we will do our best to help. It is important that Eastern Europe and Central Asia gets support from the world.

Louise. I am one of the co-chairs of the programme committee. One of the things we have talked about is that it’s important that the conference has a high political level. We are planning to pay a lot of attention to leadership. We do need some counter-balance on everything that is happening around the world. 2018 will be a pivotal moment.

Monique. Chris, Louise and me are all part of the conference preparations. Apart from AFEW’s work in building capacity, we also try to engage people more politically in the region, and we are trying to engage with Russia by having a dialogue on policies and being involved in the preparations for the Eastern Europe and Central Asia AIDS Conference in Moscow in 2018. We try to move away from what is good and bad, we must reach out to Russia since it is an important player in the region and is so heavily affected by HIV. We are also trying to reach out to the EU – their action plan ended in 2016. We are trying to push for a new EU Action Plan combined with HIV, TB and Hepatitis, or at least an update of the Dublin Declaration for both Europe and Central Asia. The negotiations are difficult processes, so it is good to start thinking now about these. We also need to start bottom-up. There will also be a scientific track. The team is already in place, there is a website for the conference. There are a lot of opportunities. Amsterdam is a lively city and a lot is possible there.

Olya, International HIV/AIDS Alliance. What I find inspiring in partnerships is how civil society is in country missions. Our colleague from Indonesia from Rumah Cemara is part of the government delegation, and this is an opportunity to develop good relations with their government.

Vera da Ros, REDUC. Brazil had harm reduction very soon, in the 1990s, and we showed all the good results from 1999. This comes and goes. Right now, Brazil has a lot of trouble to put harm reduction forward for non-injecting drug use. We have a lot of HIV issues with people using crack cocaine. So I would like to know what you think about helping Latin America where we don’t have injecting drug use problems.

Janine. On the Latin American experience, I am not the best person to speak, but this is a really important point. We see this in some areas of Asia and Indonesia. We have done several small scale pieces of research to see the connection with HIV infections. Here, when we’re talking about drug policies, we can’t only talk about HIV. HIV has brought a lot of money on the table and we should be grateful, but HIV reduction should not lead to a reduction in harm reduction – there are a lot of other issues such as TB, hepatitis and loads of social issues.

Ann Fordham, IDPC. Thank you for the event. We are veterans of the CND and the discussion around harm reduction more broadly is still challenging in this political environment and Vera’s point is important because here, harm reduction has been distilled into a set of interventions and specific interventions so far only focusing on injecting drug use and opiates. We should try and broaden this towards considering harm reduction as an approach. The Dutch government is one of the leaders for this. Last year at UNGASS there was an important event on drug checking. This is important for Latin America. We also think that it is important to also focus on mobilising people on the ground. We have developed the campaign Support. Don’t Punish, this will take place every 26th June, on UN Drugs Day, we have reclaimed that day to promote harm reduction and the health response. I want to thank the Dutch support for the campaign.

Louise. We do try to be at the forefront of the human rights grounded response. But we cannot do it alone. And I do find that we are calling from the desert. Having the conference in Amsterdam is important, come to us with your ideas for sessions.

Norway. Listening to the projects you’re implementing around the world, I wonder – how do you measure progress of your programmes? Is it in the number of people reached or do you have other ways of measuring progress?

Trang. The success is about people coming to our programmes, and spreading the word by PWUD. And it’s also about people who relapse, but still feel that the can come back to our programmes. The second indicator is local budget for our services. We want to show the government that this is an effective way of doing things. The third indicator is the evaluation of the quality of services by the clients. They give us feedback on how to improve our services.

Louise. We should finish the session now. Thank you!

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