Side event: Harm reduction as a public health policy

Ambassador Pilar Saborio, Costa Rica. This side event is organised by Costa Rica, ACEID and IDPC. Thank you because you are the ones that know what is going on on the ground. We welcome the role of civil society even though some would like to diminish the role of civil society. Here we would like to discuss how harm reduction is grounded in human rights and public health. Harm reduction is recognised in the UNGASS Outcome Document. And in this case partnerships between NGOs and governments is essential. We are lucky to have four speakers here who come from very different parts of the world: Costa Rica, India, South Africa and Uruguay. Each will have 8 minutes to present their general views in highlighting evidence based practices. Your experiences provide valuable information.

Charanjit Sharma, India HIV AIDS Alliance. We have HIV programmes run by about 250 NGOs and funded by the government and by the Global Fund. We have about 8 components of the standard UNODC/WHO harm reduction services. At the moment what is missing is addressing hepatitis C in our country. There are programmes being implemented by PWUD, by community-based organisations. And these are the effective ones. There are still people who do not understand the concept of harm reduction so it is hard for them to work with PWUD.

At the CND one of the main highlights was about stigma, which is a big public health issue. We need new estimates of how many PWUD there are, and there is still a fear from them about accessing services. We also want to make sure that clean needles are available in drop-in centres but also other public health centres. We also ask that naloxone be available in hospitals but also in drop-in centres and in the community. We are also demanding that TB programmes be incorporated in HIV programmes. There are a lot of communities involved in designing and implementing the programme and the government needs to listen to activism. I had a presentation here and I decided not to give it because I heard a delegate say that drugs kill and drug users die. I presented myself to him and told him I was from a drug user background – this is something I want to pass on here. This is just a thought that came to me as I was preparing for today.

CND should be extended for half a day on Saturday so that those officials who do not believe in drug treatment can be given orientation on the issue. This is a big event but apart from the plenary, we should request UNODC for an orientation so that people can understand what harm reduction is all about. People are talking about arresting drug users and putting them in compulsory detention – this is not harm reduction. It’s not about arresting people and putting them in prison or compulsory detention. They won’t stop using and they will be at greater risk of HIV and hepatitis C. There are better ways.

Ernesto Cortes, ACEID, Costa Rica. Thanks to the Costa Rican government and IDPC for organising this event. I want to discuss the harm reduction model in Costa Rica and some key points on how it was developed, and challenges ahead of us. Costa Rica has decriminalised drug use, it has never been criminal and since Law 8204, there is an article promoting voluntary and free treatment. Persecutions of PWUD dropped significantly by 2012. There are still some arrests, but people do not go to jail at all. The government then started doing some work on this issue. We have two national public policies, one on treatment, one of drugs. Our Vice President was at the UNGASS. We were part of the national delegation as civil society. The Costa Rican government has been very vocal. We are grateful for this side event this year.

This is our harm reduction model. We have many institutions involved: the National Drug Institute, the National Treatment Institute, those working on poverty, homelessness, health, social insurance and us, ACEID. This was a network created to make this policy. The network was always inclusive of civil society. We had trainings and meetings, the model was implemented in partnership with users, sex workers, homeless people and the government tried to be as open as possible.

Around 2017, the government approved the model and started working with it. The model defines harm reduction as a set of policies and comprehensive interventions aimed at reducing risks and adverse consequences of use, with a focus on human rights and how to improve life quality of different population groups according to their realities and needs. This is a broad approach. These basic principles recognising youth and gender specificities, and recognising the vulnerabilities of people is harm reduction. It is about not putting them in jail or harassing them, it is about supporting them. We want to facilitate access to healthcare services.

The model was also focused on improving interventions already on the ground, especially for homeless people. For example there is a big shelter for people in San Jose, a place for people to get food, to get people to listen to them. There are a lot of organisations doing that already but were not recognised by the government. There are also mobile units for people to have a shower, etc. The National Institute on Alcohol and Drug Dependence has never recognised these programmes or offered funding. Now they are recognised, although we are still looking for funding. This has changed how we are working with drug users in Costa Rica.

In terms of challenges, we need more education, training on harm reduction, treatment. There is only one master’s degree on treatment in Costa Rica, very few are doing research, there is no estimate of PWUD in Costa Rica. We just know there isn’t much injection. This has also led us to not having funding for harm reduction. The Global Fund has a big project on transgender and MSM but nothing on harm reduction – we need to expand what we consider as harm reduction, it’s not just needle exchange. We also have to go further and how we can get more support for HIV and hepatitis C, TB. The biggest thing is the participation of drug users on drug policies and on the ground. There is still no drug user group in Costa Rica and there is still a lot of stigma. Coming to CND at UNGASS and sharing with Charan and Shaun has led us to understand that drug users have to be part of the whole process.

View the full PowerPoint presentation here.

Martin Rodriguez, Cannabis Regulation Institute of Uruguay. I would like to explain the harm reduction strategy in Uruguay, without talking about specific services, because this encompasses every educational and care services we have. I will focus on cannabis regulation in Uruguay and non-medical use. This will be a brief summary and then we can chat a bit more in detail.

In December 2013 the Uruguay Parliament regulating cannabis by the state. All this was promoted with a focus on a public health approach, harm reduction and human rights. It also seeks to reduce the risks associated with organised crime, trafficking and the illicit trade. It created the Cannabis Regulation and Control Institute (IRCCA), my organisation. It includes the ministries of health, social development and lifestock. Now, the possession of minimal amounts of cannabis is possible. However, the stigma remains. Not even now that cannabis is completely regulated.

The reform was not a result of popular vote. Although the changes in views evolved over time. We developed a registry of cannabis members and social clubs. We focused on the most controversial aspects of the policy: non-medical use and access. The perception and public opinion can change quickly. Before starting pharmacy sales for non-medical purposes in 2017, the opinion polls showed 3/4 were against. Reject fell by half in 6 months. This shows that concerns from the population failed to materialise. Being a cannabis user does not mean being a criminal, not having a job, or school dropouts. In fact, most people registered are older than 40 years old. We have now 22,000 people registered to buy in pharmacies currently. There have been no episodes of violence between users or in surroundings of sale points, no robberies in pharmacies, the number of people registered grew 400% in six months. Personal information is protected.

The entire production and distribution chain has a closed traceability system, from the plant to the user. The product has to comply with strict quality standards, the price is fixed to about USD 7 per 5 grams. Our communication campaigns focuses on ‘Regulating is to be responsible’. There are detailed guidelines for users on harm reduction and we distribute the guidelines to every person buying cannabis in pharmacies. I will show you the cannabis package designed by our institute. Every message here is a warning, law, and conditions, as well as recommendations from the perspective of harm reduction. In pharmacies, people can get 4 kinds of cannabis, two indicas, two sativas. The package also has an expiry date and badges to know where each of those comes from. To conclude, I invite you to see one spot of the campaign.

Shaun Shelly, TB/HIV Care Association, South Africa. I come from South Africa. If it was an individual, it would have a multiple personality disorder on harm reduction. The response is carried out because we were able to introduce the first harm reduction programmes as civil society with support from the public health ministry. Although we were arrested for distributing sterile water which requires a pharmacist to distribute it. This os obviously problematic. Although we have seen a move from public health to support us, with a new action plan which supports it, policy is not enough. One example of a programme to change this has maximised the benefits of harm reduction.

In South Africa, we need to change public attention as well as government attention. It’s good to have a conversation, but also to just do, and apologise later. But you also have to do a lot of research and collect data. We started with low-threshold methadone programmes with take home doses. We proved that this worked. We have an 80% retention rate. We don’t expert anybody to do anything, it’s a low-threshold programme. We don’t do drug testing, it’s only self-report. And data is interesting. We were able to create data on prevalence of hepatitis C, which is at 40% of PWUD. This creates a strong motivation for the government to address the issue.

Pretoria has taken a bold step. The approach of the local government has been the development of a drug programme. We are seeing the uncomfortable of a harm reduction approach with a traditional war on drugs approach. We see a low-threshold approach, with people on subsidised methadone programmes, which is free. Somebody in the city still decided to take 700 people to rehab, without any OST whatsoever and only enough accommodation for 300 people. So you can imagine that this strategy did not last for very long. We have this dual situation going on.

What the city has now done is that the government has a mandate to implement the programme. We tried to move away from a war on drugs approach and wording. We established 10 sites and will establish 10 more in the communities in the public health system. Every household is asked the question: does anybody use drugs? Do you consider it a problem? There is no coercion, no forced treatment, but if somebody injects we will make sure they get sterile equipment. We make sure we don’t send them to forced rehab, we don’t support criminal activity but this is a health approach. Because it’s a public health response, we develop parallel responses, especially on HIV. We are laying our approach on top of the health system, in the community. The pilot programme was developed, staffed and implemented 100% by people who use drugs. This comes from working with peers. I am working to show the impact, positive or negative, with working with peers.

As recommendations, we need to do first, then they’ll follow, collect data, make governments comfortable (highlight discrepancies in approach). Finally, if you want to see harm reduction as a public health response, WHO documents and other guidelines have to include harm reduction. Otherwise, no nation will take it seriously.

Questions and answers:

Vera, REDUC, Brazil. Our minister has just announced that the new drug policy should abolish harm reduction. ‘Harm reduction is trying to dry out ice and does not work’. This is a plea for help, we don’t know what to do, we need information on how to answer to people who think like this.

Shaun. Brazil is one of the key policies focusing on a development oriented model in the community without calling it harm reduction, because these are focused on the key principles of health and medical ethics. You don’t have to call this harm reduction, but good medical ethical practice. My mentor is on the public health policy in South Africa. He always asks: what did you know, and what did you do? I went to the South Africa drug policy conference and highlighted the challenges before the policies and evidence and best practice examples (some US states, Mauritius). These examples have to be presented, with tangible data. Always go back to what you know, and what you’re going to do. Data doesn’t change hearts, but it may change minds. We need to bring in people from the ground – we need to focus on popular votes and the media.

Charan. Our advocacy with the government includes working with spouses and partners of PWUD. Earlier, when we worked with several programmes in India there was strong opposition from them who saw this as encouragement to use drugs. We communicated with them about how this was focusing on reducing harms. We provide medication such as buprenorphine, TB, HIV programmes, testing of spouses as well. The advocacy is no longer from PWUD but from families and community as well. Another way of engaging is to have a learning programme which countries where policies are successfully implemented and supported by the government. We are doing this now as an exchange between India and Nepal. That way, there is more communication and this could be another option.

Sofia, GIZ, Germany. Thank you very much, this was interesting. Harm reduction goes well beyond services, it’s about a comprehensive health and social approach. We are very interested in these concepts. Last year we had a meeting on stimulant harm reduction and we produced a conference room paper which is presented here, and we hope we can continue the discussions here in Vienna. We commissioned a study on best practice examples on harm reduction for stimulant use with Mainline and this will come out this summer.

Iran. We have one of the largest harm reduction projects in the world. About 450,000 people receive OST in the country and about 50% are prisoners. We are not only focusing on the health consequences of drug use. About 10 years ago, 80% HIV cases were through injecting drug use. Now it is only half. Overdoses have also dropped after the introduction of harm reduction services. The social and cultural consequences of drug use were also reduced thanks to the expansion of harm reduction. We have a comprehensive package of harm reduction services in the community and prisons. We are ready to welcome your Minister from Brazil to show him that harm reduction works.

Ernesto. We are out of time, but thank you very much for being here.

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