The urgent need for harm reduction funding: Scaling-up evidence-based interventions for people who use drugs

Organised by the United Nations Office on Drugs and Crime HIV/AIDS Section and the Strategic Advisory Group to the United Nations on HIV and Drug Use.

Anne Skjelmerud, Norway (Chair)

Norway is in between ambassadors at the moment, so I have been asked to Chair here today. I work for the Norwegian development agency, NORAD, and this is my 10th CND. My background is working in HIV, and this became a paradigm shift in social policies in Norway and in many parts of the world. It was acknowledged that people who use drugs faced challenges, and needed to be supported – and so the principle was of reducing harm, or harm reduction. This was due to concerns from public health but also concerns for individuals. This led to easy access to clean needles, information campaigns and, later, substitution therapies. Accepting the principle was a paradigm shift. Then the choice to be made was to implement programmes based on the idea of control, or to use empowerment strategies – and the latter was chosen. So our target groups are peers, involved in developing the responses. We know now that this was a good choice. Marginalised and stigmatised people are not in a position to consider risks, so we empower them to protect themselves and others. I am not saying we have mastered all challenges, but we have learned important lessons. Harm reduction works and it is the right approach. We are nowhere near the goal of ending HIV, nor ending drugs. But we have only had 7 or 8 cases of HIV amongst people who inject drugs – we do not have a drug-driven HIV epidemic. The people who inject drugs changed their behaviours, and today HIV is no longer the main reason why we support harm reduction. We know it works, it improves health and wellbeing, for individuals and society at large. It provided contact with people who use drugs, to provide them with other services too. This is not unique to Norway, but today we will focus on what lessons we have learned.

Ann Fordham, IDPC (and Chair of the Strategic Advisory Group to the UN on HIV and Drug Use)

The SAG used to focus on injecting drug use, but has broadened out. It is a forum of the key UN agencies, the leading international and regional civil society networks – including networks of people who use drugs – and donors. Our key role is to advice the UN and Global Fund on their approaches and work related to people who use drugs. This is important to improve inter-agency cooperation, and we are proud of the way that we are inclusive of different stakeholders. This is our first side event at CND.

Monica Beg, UNODC HIV/AIDS Section

I would like to begin by reminding us of the most recent and relevant global commitments as they relate to drug use and HIV. In the UNGASS 2016 Outcome Document, member states reconfirmed their commitment to end AIDS by 2030 – in line with the Sustainable Development Goals. CND resolution 60/8 from 2017 requested UNODC, as the convening agency for AIDS, drug use and prisoners, to show leadership and guidance on harm reduction. It also asked member states for more funding for this work. According to the latest estimates, there are around 12 million people who use drugs globally, 1.6 million are living with HIV and 6.1 million with HCV. People who use drugs account for 8% of all new HIV infections – 20% outside of Sub-Saharan Africa. Globally, new infections have declined – but have increased by 30% in Eastern Europe and Central Asia, driven by drug use. This is among the simplest modes of transmission to control – we know what works, and we know what should be implemented. So then why are we seeing rising transmission in the fourth decade of the epidemic?

The Lancet review published in 2017 found that needle and syringe programmes (NSP) operate in 93 of the 179 countries that have injecting drugs. But only 33 needles and syringes are provided per person who use drugs per year – the target should be 200. Opioid substitution therapy (OST) is provided in 86 countries, HIV testing for people who use drugs in 41 countries. Less than 1 percent of people who use drugs live in countries with a high coverage of NSP and OST. Finance is obviously an issue, and our core funding has decreased through UNAIDS since 2015. In 2017, the UNAIDS new funding model, each agency received $2 million per year – down from $5.5 million. There was additional funding provided for UNAIDS Fast Track Countries – but this list does not mirror those with epidemics driven by injecting drug use. $7 million is also provided for “other” countries. Of the country envelope funding, 13.9% was allocated for key populations, and 6% to UNODC. To put this into context, 44% of all new infections are among key populations. No funding was allocated in priority countries such as Afghanistan, Morocco, Moldova, Thailand.

UNODC is providing technical assistance, especially in 24 high priority countries, and also supporting legal and policy environment – such as in Myanmar, Vietnam and the Philippines. In Kenya, more than 1,500 people who use drugs are receiving OST through our programmes. In Vietnam, we are supporting the government’s expansion of OST in prisons, opened in 2015. We provide guidance and training tools – including on women who use drugs, an e-learning model for law enforcement, and a guide on HIV among people who use stimulants. We collaborate with a group of international and regional civil society groups – this year, we held our sixth meeting. This has been a useful forum and has enabled a series of small grants programmes. Each year, we come up with joint estimates on injecting drug use alongside the World Bank, UNAIDS, WHO and Harm Reduction International. In the plenary this week, there will be a statement from a HIV scientist.

Aljona Kurbatova, Estonia National Institute for Health Development

It is hard to share Estonia’s example, as there were so many problems – we are an example of how not to drive your response early on. Our HIV rate is unacceptably high still, and we have the highest number of opioid-related overdose deaths since around 2000, related to the synthetic opioids which have recently emerged as a global threat. Estonia had its policies in the 1990s – officially, we had harm reduction since 1997 but it really started later. We now have a harm reduction structure in the country – it was a push from the outside. We had to define for ourselves what we are doing, and why, for Estonian society. HIV is concentrated among people who inject drugs, but is now increasingly more sexually transmitted. The government have now picked up the funding for this approach, and we are one of the few countries who do this. There is strong evidence that it works. When we think back on what helped to secure the government funding, it was important not to create parallel structures for donors – it needed to be built in a way that was sustainable. Fentanyl is injecting more frequently than heroin, so the WHO target guidelines were not sufficient for people who may be injecting up to 10 times per day. The whole system is the responsibility for government – if the system has failed, a debt has to be paid. But also it was an acknowledgement of the costs of the harms – to individuals and society. We constantly counted the money, to allow us to increase funding year-by-year. In Estonia, the cost of harm reduction services is forty times cheaper than the costs of treatment and dealing with the harms. With a little money, you can do a lot of good. So it is not about competing with other sectors, it is actually about saving money for the government. At the national level, we do not talk about services although they are being implemented – but we are trying to push for people to have a safe space and support. This is a much better argument when trying to sell this to the public, as it is about a wider level of benefits. The human side is important, but you also have to be about numbers and keep your hand on the pulse. We hope that our experiences in Estonia will help other countries as well.

Valentin Simionov, INPUD

INPUD is a global peer-based organisation, based on the ‘nothing about us without us’ principle at all level – from policy making to monitoring and evaluation. The Vancouver Declaration of 2006 is our foundation document – and emphasises self-representation and empowerment. It is based on a model of regional networks of people who use drugs – both registered and informal – as well as a network of women who use drugs. These regional networks inform our advocacy and work. Paul Hunt, the former UN Special Rapporteur, once said that drug policy and human rights were “parallel universes”. We see in our community that violations continue today – including the extra-judicial killing and the death penalty. These are an insane repetition of a war on drugs. Mass incarceration disproportionately impact minorities, and very few people who inject drugs have access to harm reduction services. 100,000 people die from overdose every year, including in the USA where the government continue to respond ineffectively to this problem. Criminalisation has many impacts, such as marginalisation and discrimination. Networks of people who drugs have been formed to respond to these issues since the 1980s. In the 1990s, there was increased mobilisation to improve services under a patient engagement model. More recently, there has also been organisation within the psychedelics sector. Various drug user groups have mobilised – and two examples worth mentioning are AIVL in Australia and PKNI in Indonesia.

Fionnuala Murphy, Harm Reduction International

In 2014, £160 million was spent on harm reduction around the world – just 7 percent of the estimated resource needs. Since then, there has been no new total nor a new needs estimate. In 2016, UNAIDS released new data to show that – while countries pledged to halve new HIV infections among people who inject drugs – the numbers has actually increased by a third. Levels of NSP and OST coverage are insufficient to halt transmission. We also know that non-injecting stimulant is increasing around the world, and that overdose is increasing in many countries. The UNGASS Outcome Document specifically includes overdose prevention measures as well. To compound this, we have donors withdrawing from countries in need, and national governments are not stepping up to fill the gaps. HRI have assessed the funding situation in five Asian countries, showing the lack of domestic investments and the lack of sustainability. In a similar project in the EU, the funding crisis also remains – with serious concerns about sustainability and the inability of underfunded services to cope with new problems such as synthetic opioids. Yet there is always money for law enforcement, round-ups and imprisonment – this is not about the amount of money, it is about the choices and decisions that governments are making. In Hungary, the drug law enforcement budget is 2000 times greater than that for harm reduction. Governments should examine the cost-effectiveness of harm reduction – saving between $4-12 for every $1 that is invested. We call on governments to move funding from law enforcement into harm reduction. For those countries that do implement harm reduction services domestically, we urge them to speak about it here in Vienna as well – to communicate that this is a global approach. Donors must also provide emergency funds and mechanisms.

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