Organized by the UNODC HIV/AIDS Section with the support of Belgium, Brazil, Czechia, Mexico, the Netherlands, Norway, South Africa, Spain, Sweden, the World Health Organization and the International Network of People who Use Drugs
Monica Beg, UNODC HIV Branch: Welcome to the side event: people center public health and human rights bases for people who use drugs. This side event is a continuation of the consultation that we had one week ago, in preparation for the Commission on Narcotic Drugs. We saw that it will be a good idea to bring couple of presentations from this consultation to the larger audience of the CND. We also invited 2 countries, Egypt and Mexico, to share their experience. I don’t want to take long because we have a lot of interesting presentations. I will start now by inviting Christine Stegling the deputy executive director of UNAIDS, to give her opening remarks.
Christine Stegling, UNAIDS: Thank you and welcome everybody online. And in the room. I am absolutely delighted to be at the site event that focuses on people centered public health and human rights. HIV responses for and with people who use drugs for those of you who know me from the past know that I’ve working on HIV in human rights for about 25 years. So I’m happy to be here. The Universal Declaration on Human Rights recognizes all people as being equal in dignity, and guarantees, amongst others, the right to security, health, and medical care, and UNIADS has been advocating for people centered human rights and a public health approach to drug policy and in collaboration with co-sponsors is committed to supporting the implementation of the UN common position on drug related matters which provides a clear mandate to the whole UN system to promote harm reduction, human rights and the decriminalization of drug use and possession for personal use to ensure access, and the people-centered public health and human rights to the HIV response.
We must have in place, supportive and enabling legal and policy environments. We know that people use drugs are often among those who cannot access their rights due to stigma, limited resources and structural inequalities, while also bearing the brunt of punitive responses to drugs as undertaken by many countries the global aid strategy aims to reduce these inequalities that drive the AIDS epidemic and prioritize people who are not yet accessing life-saving HIV services.
The strategy sets out evidence-based priority actions and both targets to get every country and every community on track to end aids as a public health threat by 2030, I know all of you probably know these targets, but just to remind ourselves what the targets for this but most relevant for this conversation are less than 10% of countries, criminalized possession of small amounts of drugs by 2025 90% of people who inject drugs have access to comprehensive harm reduction services linked to Hepatitis, C, HIV and mental health services, and 80% of HIV prevention for key populations. In this case people use drugs is led by networks of key populations. Again, in this case, by people who use drugs.
Our data shows that the incidence of HIV infection among people who inject drugs, rose over the past decade and needle and syringe programs were operational in only 54 of 135 reporting countries and that opioid substitution therapy programs (OAT) were operational in only 80, 48 of a 130 of reporting countries. So we hope that the 30, 80, 60 targets bring priority and force to how we engage communities in service delivery meetings are the testing and treatment services prevention services and social enablers programs evidence-based harm reduction interventions, and program are essential for responding to HIV and drug use and ensuring people centered health and human rights.
HIV responses high quality, accessible and affordable harm reduction programs should be adequately resourced and scaled up, ensuring equitable access to HIV.
Viral hepatitis, tuberculosis and STI prevention, testing treatment and care and addressing other drug related harms specifically the management of drug dependence and overdose. It is time we commit ourselves wholeheartedly to addressing the needs of women, with particular attention to the vulnerabilities and female sex workers who use drugs. These members of our communities face high levels of poverty, intimate partner violence and unsafe work environments, while a heavy burden of stigma bars many from receiving needed medical and psycho social support however, and I know we are all painfully aware of the ongoing funding crisis for harm reduction in low and middle income countries, governments and donors have invested just 5% of the funds needed for investment response.
We need to scale up investment now with the focus on funding for community-led responses. And I think we can’t overemphasize that point if we want to get to our twenty-twenty-five and our 2030 targets, the join program must make more visible.
The value we bring in making the money work as we marshal the data evidence and partnerships that ensure that investments were as far as possible and have maximum benefit positive benefit for people whose drugs without continued access to HIV and harm reduction services we will not end AIDS among people who use drugs, and those who are incarcerated in prisons and other closed settings, and we will therefore not end aids for all.
We must value the dignity, health, and human rights of every person we use as drugs. I know many of us in this room know all of and agree with all of what I have said by the hopefully we will have an enlightenment discussion here with the presentations from your consultation.
Monica Beg, UNODC HIV Branch: Thank you. Very, thank you very much, Christine. I would invite now just to state it. Our host, to give his opening remarks.
Thank you very much, Monica. Colleagues on behalf of you and UNODC. It’s my pleasure to welcome you to this event, and thanks for taking time to join us I’d also like to thank the International AIDS Society and International Network of people who use Drugs (INPUD) UNAIDS, as well as Belgium, Brazil, Czechia, Mexico, Norway, South Africa, Spain, Sweden, and the Netherlands for sponsoring this event.
Last week we had an event, a consultation organized by a UNODC HIV Branch section, and the focus was on the structural inequalities. Also human rights barriers that’s significantly increase HIV risk and reduce access to services. Now, this side event is going to provide you a snapshot of the discussion which took place last week the deliberations of the consultations made it very clear the community based responses are proving to be a game changer in support and effective and resilient HIV responses among people who use drugs let’s look at a statistic. It is estimated that’s 11.2 million people inject drugs. This is a small percentage of that global population. And yet this particular group accounted for 10% of new HIV infections globally in 2021, the relative risk of acquiring HIV is 35 times higher.
Well, it’s the outcome document of the 2016 UNGASS on a world drug problem underline the need to fully respect the human rights and fundamental freedoms of people who use drugs. And it called on countries to consider alternatives to punishment and incarceration for drug offenses. Indeed, countries who are that have moved away from punitive laws and policies, and I’ve increased investment in harm reduction. Reduce new HIV infections and improved health outcomes. As Christine noted this year, marks the 75th anniversary of a universal Declaration on Human Rights. This recognizes that all people are born equal in dignity and guarantees, among others, the right to security, health, and medical care. People who use drugs are often among those who cannot access these rights due to stigma, limited resources, enact structural inequalities.
Even though this works with partner UN agencies, Member States, civil society, and the community to support the reform, development and implementation of effective legislation and policies that protect human rights and facilitate access to evidence informed and public health-base interventions for people who use drugs to people in prisons and other closed settings. To give you a few examples of our achievements from the past year.
After many years of continuous advocacy by UNODC with government agencies economic programs are now being implemented in Algeria and Pakistan, and recently, opioid therapy has been extended to prediction centers, ensuring its sustainability through all stages of the criminal justice program. Today we’ll hear from both Academia and the community about recent developments in the global epidemiology of injecting drug use, HIV, HIV and harm reduction coverage. This event also highlights the results of original assessment on the transition from compulsory facilities for people who use drugs to voluntary community based treatment, care and support services in Southeast Asia, efforts which, despite some progress, have a long way to ago.
Additionally, we will learn about experiences of Egypt and Mexico, in implementing and increasing access to harm reduction services. Let me conclude by thanking all of you in advance for your time and valuable inputs and I wish everyone, a very productive side event. Thank you.
Monica Beg, UNODC HIV Branch: Thank you very much, Justice. So, as you mentioned, we will hear about the most recent estimation of the extent of AIDS epidemic among people who use drugs, and their access to HIV prevention services and harm reduction services in general, so we will hear from Professor Louisa Degenhardt from the University of New South Wales (UNSW), a presentation on the recent data.
Professor Louisa Degenhardt, University of NSW (UNSW): Today I’m presenting today on a summary of some work that will be published within the next month. We’re hoping. This work is sort of has been a number of successive iterations of work. This was initially driven through the Secretariat for the Reference Group to the UN on HIV and Injecting Drug Use. So there’s been a long history of collaboration between a very large group of academics, and a very large group of people at different UN agencies, and many other agencies.
So this is a summary of in terms of the availability of information and of evidence around quantifying the extent of injecting an infectious disease.
We now have identified injecting drug use as being documented in 195 countries. So an increase by 11 countries since the the review, 5 years earlier. There has been a substantial increase in the number of countries that have made an estimate of how many people inject drugs in that country. Similarly, a small increase in terms of and number of countries that had estimated HIV, and of the number of countries and the coverage of population for people who countries that had an estimate of Hepatitis C antibody prevalence.
So I’ve role that has been increased spending increase in the amount of data that allows us to form a picture of what is happening within us countries. So this is just summarizing the prevalent system. The colors (on slide) indicate high prevalence, and globally we estimate that 14.8 million people might inject drugs who are aged 15–64 years. There’s wide uncertainty around those 10 to 21.7 million. The midpoint estimate of that is different from what is reported in the World Drug Report, but mostly the ranges for both sets of estimates are very, very overlapping.
What you can say is, there’s still a substantial number of countries where, in particular, in sub-saharan Africa, although there has been a real increase in the amount of evidence to define injecting but there’s still a lot of countries twhere injecting is occurring. But there is no estimate of how many people might be engaging in that behavior.
So this is looking at a comparison between the estimates that we made for the review that was published in 2017 versus the Review in 2022. What we’ve given on the right hand side (referencing slides) is an estimate of the the change in the midpoint estimated prevalence of injecting, and you can see that there has been some be increases and decreases across different jurisdictions overall and estimated slight decrease, although again the ranges for both the previous review and this review overlap substantially but it’s important to note that in the reasons for these estimated 2 changes vary across regions.
So, for example, in Latin America there was previously an estimate that had been reported. The new estimate is far lower than that earlier estimate.
By contrast, the estimated number of people injecting in North America; Canada and the United States thought to have increased.
It’s likely that that will reflect a true increase in the number of people who inject drugs but there’s a range of other things that will reflect changes in methodology.
Within regions and in countries that have an estimate where they didn’t have an estimate directly made in that country before. So it’s a bit of a complicated picture of why things are changing within countries and across regions. But that’s kind of the summary. In terms of some of the key characteristics. So we collected a lot a lot of the information.
Well, we looked for a lot of information. Unfortunately, what we found was for many things that we thought were really important to document and characterize this actually very sparse data globally. One of the clear things is that there is huge geographic variation in many of the characteristics that we’re looking at.
So what I’ve presented on this slide are the global estimates of portion of the people who took drugs and women proportion around 25 years, identifying as lesbian, gay, bisexual, transgender. These global estimates are very substantially across countries. So in some countries it’s less than 1%.
There are people who inject drugs where its one in 10 women, whereas you’ve got countries such as Australia, where it’s one in 3 women. Similarly, in many countries like Australia, there’s older populations of people who inject drugs, and in other countries with newer kinds of emerging injecting populations, but also younger age structures in their countries.
Anyway, the population is a lot younger, and what might not surprise anyone is that people who are willing to identify as they’re transgender very insubstantial across countries. But we felt it was important to start to really try and expand things from just a gender age kind of breakdown and really start to flesh out where possible, more information about people who inject drugs.
As I mentioned before, we looked at a range of different risks, risk exposures, exposure, to risk environments, but also a border range of mental and physical health problems that people who inject drugs might face again, these all very quite substantially overdose less so around one in 5. Globally, we are estimate, might have overdose within the past year, and that tended to be a little bit more.
But when you’re talking about things like being recently homeless or living in unstable housing about one in 4, we estimate globally, and that experience finding places like North America that level is far, far higher.
So it’s much closer to 60% similarly, the exposure to an incarceration varies really substantially, you’ll see that the global estimates of people who are living with HIV and people with active Hepatitis C infection.
So we’re not looking at ever trying to see antibody prevalence, but an estimate of active advertising fiction. Both of those decisions. Looking at it, they prevalence at a country level. You can see again, there’s really substantial country variation in levels of prevalence.
Again in sub-saharan Africa. Alright, there’s a lot that he’s not known yet about levels of HIV among people who inject drugs and this is the information for trying to say current hepatitis C prevalence.
Again, variation, as many of you will already be where the levels are higher, but there has been a substantial increase in the amount of data so moving on to the information around intervention. There has been not much change in terms of the number of countries where opioid diagnosis treatment is being provided, and needle and syringe programs provided over the past 5 years.
Having said that, and this is important to keep in mind when I show the estimated coverage estimates. Many more countries are now looking at, monitoring the extent to which they are providing those services. So it’s not just whether or not it’s in the country. But how many people are being reached with those interventions across that country. That’s really important. So you can see in the 2007 review those 61 countries that had that data went now to 82 countries. That matters, because the countries that have only more recently started counting and monitoring that are likely to be quite different in the maturity of their OAT programs, and and likely the coverage of their OAT programs compared to countries that have been monitoring that for many more years. You’ll see here we looked at evidence for the provision of supervised consumption facilities and drug checking services. They only remain available in only a minority of countries.
There’s very little information on coverage, but in many instances, again, many of you would be very aware of this, particularly, for supervised consumption, fertility, facilities and drug checking services. There’s often only one or a handful of those kinds of services in a whole country. So coverage is very, very low for those interventions.
This is the map showing estimated coverage of opioid agonist treatment per 100 people.What you can see is that there are large sections of the world where there is no OAT available at all. Particularly Africa, Latin America, and Eastern European countries, and sadly, not many countries that are providing it have high levels of coverage as denoted in the the joint UNAIDS target levels. This is just summarizing it at a regional level. We estimate that Australia, so Australia and New Zealand, South Asia, and Western Europe are the only regions that have high coverage. North America was estimated to have moderate levels of coverage, but everywhere everywhere else had low.
So this is evidence and coverage of needle syringe programs, sadly in Latin America things are very much gone backwards in terms of coverage levels, because there’s a number of countries that no longer provide NSP but they had previously. There are many countries to implement that intervention.You can see some countries where there does seem to be high level coverage of needle and syringes distributed, but on the whole, the default needs to, and this is reflected here.
When you look at the regional estimates where Australia and New Zealand, Australasia is the only region estimated to have high level, middle and range program coverage, moderate coverage in Central Asia and Western Europe and everywhere else is low coverage.
So this figure I know it’s a little bit busy, but this figure picks up on the thing that I highlighted before when I was talking about the availability of data. So the green, but is what proportion of the estimated number of people who inject drugs, who live in a country where there is high level coverage of for the top 2 roads, needle and syringe programs and the bottom 2 rows. The the yellow is moderate, and the rate is low. So what you can see is, there has been some improvements in orange.
When you look at the estimate number of people in living in a country where there is high level coverage compared to the rewiew 5 years earlier, but you can see an increase in these web, so it can at first glance, you might think of that very depressing and at one level. It is, but really, what it is reflecting is that the countries where we didn’t have information before, where we now have information, countries that don’t have a lot of those interventions being delivered. So is that level of low coverage would have been in existence previously but we just didn’t have any way, we didn’t have any data to estimate that level of coverage. Of course, the fact remains that by and large most people can detect drugs live in a country that doesn’t have alright high level coverage of either of these interventions.
This figure shows on the access. It’s the number of needles and so we use distributed per person who injects drugs annually, and on the x-axis. It’s a number of people receiving it. Per 100 people who inject drugs.
So really for, and the what you really want is for in an ideal world everyone to be concentrated up into the top right headquarters. Sadly, that’s clearly not the case. We’ve only got 5 countries that have high level coverage of both interventions.
So I guess a sobering thought given that there’s clearly a long way to go before there is the kinds of levels of coverage where you would expect to see not only individual benefits but also population level benefits in terms of cost.
The progress in the in the last year is quite modest. Moving from 1% of people who use drugs living in countries with high coverage of middle and syringe programs to 2%. It’s really, it’s really insignificant. The same with Methadone, moving from 5% coverage to 8% coverage sheets. Again, a very, very small progress.
Monica Beg, UNODC HIV Branch:I’m inviting Judy Chang, now the Executive Director of INPUD to give her perspective from the community on.
Judy Chang, Executive Director, INPUD: Thank you. Monica. I’m just checking the slides.
Thank you UNODC HIV Branch for leading on this side event. And really, you know, emphasizing the importance of people, in centering public health and human rights based responses for and with people who use drugs.
Of course, we all know these are very important and critical principles and goals, but I think, as we all know, anyone working in this build, and for people who use drugs ourselves, especially we know how far behind. We are indeed these principles so it’s a person who uses drugs, mainly when growing up in Australia.
I’ve been one of the privileged few to be in the countries where there is sufficient coverage, harm, reduction services. Unfortunately, this is not the case, for the millions of other peers around the world. INPUD is a global network working on harm reduction advocacy and human rights advocacy for people who use drugs.
You know, we see the political opposition and chronic underresourcing of harm reduction all around the world to the point where the majority of countries do not have harm reduction, as we are pointed out, do not have harm reduction programs. However, we have seen some movement and some progress.
For example, Pakistan Zimbabwe, Uganda, and Egypt, which is some positive, but, on the other hand, even conscious where we have seen progress as a last 2 years, many of them are still stuck in perpetual pilots stage of services, of course we also see regress you know we’ve seen countries that have usually had quite robust harm reduction services really have these programs gutted and funding cuts to the point where needle and syringe programs usually operate out of small mobile vans and really have like limited commodities that they are able to distribute people use drugs that need it. And yeah, unfortunately, we’re also seeing a lot of stock out and missing stock.
And we’re really seeing this. This literally does put thousands of lives at risk. Of course, you know the factors and the reasons for why we are in this situation are complex, but at the same time it really is rooted in stigma and discrimination.
For example, if you look at the low coverage of funding, it’s low, because governments and the public don’t think that people use drugs are deserving of basic health services and are willing to then thus fund them harm reduction at the end of the day is really about the belief that everyone no matter what we put in our bodies throughout our lives, has inherent right to tools and knowledge, to protect our health and lives of both ourselves, but also the communities around us.
So if you look at people centered services, you know, they really begin with understanding or wanting to understand and consult people who use drugs on our needs, perspectives, demands and accounts. INPUD members produced 3 research papers. These are community driven research papers. And we produce these because we strongly believe that this should be part of the research that informs decision-making. First we produced 3 documents versus the values and preferences document which which was commissioned by who in late 2020, to feed into the 2021 revision of the consolidation guidelines on key populations our second paper that we’re produced that will be published in later in 2023. It’s on harm reduction standards, and these are a compilation of best and worst practices. That document charts the experiences of people who use drugs as clients in services, and third, is a community-led research report on pandemic prevention, preparedness and response.
This will be launched on Friday, the 17th of March during our CND side event, and it really documents impact of Covid on people who use drugs in order to share lessons on these experiences and and develop and divide recommendations on how the board can be better prepared for future pandemic. So the next few slides that i’m going through are just some of the quotes and testimonials of people’s experiences in harm reduction programs.
So the first one is from the harm reduction standards, and really shows that our opinions as people use drugs is a rarely valued as we are not asked our opinion enough on commodities. In this case, on low-dead-space based syringes. And without, you know, really consulting and meaningfully consulting people who use drugs. It means that already scarce resources get wasted on inappropriate tools.
Our insights are really critical to the success of policies, regulations, and practices, and better understanding of values and preferences with more resources directed towards these values and preferences will mean successful alignment of services with what is needed and therefore, that will lead to better health outcomes.
Similarly respondents, peer respondents from the values and preferences on the WHO guidelines was frustrated with the lack of choice that they were presented with and harm reduction programs, and for being ignored when asked for, expanded choice additional points were made by the respondents on the need to increase the number of needles and syringes received by peers which is at the moment, in majority of countries far below the who recommendation.
Of course, there were also points made on implications, on breaches and privacy and confidentiality, as well as lack of access, points which speak to the need for scale up and different modalities of delivery to prioritize access to people who use drugs the needle syringe programs are not reaching people who need them. Most, or people are being deterred because of stigma. They will never have an impact at population, and therefore public health.
So these are a couple of quotes from Canada. Of course, as we all know, is experiencing an overdose epidemic because of the lack of safe supply of drugs, and the quotes point to, you know, the need to accelerate removal of regulatory barriers, immediately so the more countries can have it available and we can get into the hands of people most likely to witness an overdose and therefore safe lives.
The many quotes from respondents on the best modality best way of delivering services to people, and the values and preference study unequivocally showed that peers are the right people to reach people use drugs and recipients are more likely to listen since peers embody cultures of care for the community is really embedded in our daily lives.
Again, the next 2 quotes they talk about the value of specifically community LED organizations, and this is when organizations, when governance and management of organizations run run run by people from the community these quits really aligned to similar research that input is done in the past showing that key let organizations are more likely to go the extra mile, or able to build trust and empathy and meet a double stranger of needs.
Now looking at some of the ways that Methadone and Buprenorphine services are provided which, of course, are the gold standard. If we’re looking at methadone, and people are thinking, gold standards for treatment. But the problem lies currently and how they are delivered in many countries and across many programs.
In short, they’re too often experienced as a form of coercive control, with a focus based on abstinence only, which, of course, goes again the very principles of harm reduction.
Testimonials from 2 peers in the European region underline how little OAT programs are designed to be fit for purpose. They’re simply not reaching people outside of cities and also in prisons. And often these so high threshold as daetur people seeking services, that people pretty much forced to choose strict drugs over safe supply. This, of course, leaves them open to arrest and jail.
Time, the problem being criminalization next slide. And of course, criminalization is driving people away from the very services that were also invested in making available criminalization. Of course, intersects with stigma discrimination, and this creates a vicious cycle, which increases death, rates from overseas people, and especially women, are more likely to use alone, and also more likely to share injecting equipment. It’s impacts extension beyond health, destroying people’s chance of building a life post incarceration.
To access housing, and also impedes ability to earn an income next slide. 2 more slides, sorry and just to share just 2 recommended recommendations that came out of our a community-led research report on pandemic prevention, preparedness and response.
One really emphasized the need to learn from the innovations and partnerships that emerged during the COVID-19, and also pointed to the urgent need to fund sustainably.
Fund community-led programs which proved critical during the Covid pandemic and secondly, in line with the the Universal Health Coverage Central principle.
Research demonstrates that any health system, a response that works for the most marginalized, such as people use drugs will work better for all,
So just wanting to focus on 2 points, one, the importance of recognizing the critical role that communities play in research, and that without this research, you know very important voices, needs and experiences would be lost.
You know. We need the graph. We need the research from the grassroots and communities to be really impacting treaties, laws, policies and practices to make sure they more ground in reality. And lastly, just to emphasize human rights based approach drug use goes hand in hand with dismantling prohibition and just to finish on the last quote on the screen, prohibition is the reason we all have these harms.
We are overdosing and getting harmed and dying. This is the war on drug users. When we finally acknowledge front the cause of almost all the harm we will be much closer to finally putting an end to them until such a time harm reduction saves lives.
Monica Beg, UNODC HIV Branch: Thank you very much, Judy. Well, at this point we have to admit that we will run over time. It’s obviously that in the last 10 min that we have allocated for this side event we won’t be able to see 3 presentation. I would like to ask first the speakers to, and I would like to invite you to stay with us until we see all the presentations.
So now I will invite the Claudia Stoicescu who is Associate Professor at the Monash University in Indonesia to present their study on compulsory treatment centers in the Southeast Asia.
Associate Professor Claudia Stoicescu, Monash University, Indonesia: Thank you, Monica, and good evening. From Jakarta to everyone attending in Vienna and online. Thank you for this invitation to speak on compulsory treatment and its implications for public health and human rights centered responses for people who use drugs the arbitrary detention of people who use drugs or those who are suspected of using illicit drugs.
This, of course, not a new issue. There are many countries worldwide that implement different forms of compulsory detention and treatment.
My focus today is on countries in Asia that operate state-run, compulsory facilities where people who use drugs are typically detained and often with insufficient due process through criminal or administrative law for the purpose of enforcing abstinence from drug use.
The data that I will present today is based on the joint UN AIDS and UNODC report titled compulsory treatment and rehabilitation in east and Southeast Asia, which we published last year.
The report takes stock of the last decade of compulsory treatment implementation to assess where 9 key countries in the region are on achieving commitments to phase out compulsory facilities, commitments made at the 2,015 regional consultation on compulsory centers in Manila we gathered these data through a questionnaire, administer to health and drug control agencies, and in instances where data would not provide it or were missing. We filled in gaps. You published governments data sets provided through official channels such as the Aza and drug monitoring reports, one limitation I should mention is that these data at the moment only go up to 2018 we are currently in the process of collecting updated data and expect to publish a report by the end of this year.
This year, 2023 marks more than a decade since 12 UN organizations renewed a joint statement condemning the continued use of compulsory treatment and calling on States to release detainees and replace these centers of voluntary evidence based and human rights based services that statement highlighted the immense financial and human costs of compulsory centers, evidence of human rights, violations, and failure to produce sustained public health outcomes for the individuals detained in June 2,02013 UN organizations released a second joint statement citing concerns, related to covid transmission in these centers.
In the report we outline broad parameters based on the 2012 UN joint statement to provide a starting point for assessing what we mean when we refer to compulsory treatment, a drug treatment system may be considered to have compulsory elements if one or more of these conditions is present they include admitting people who use or dependent on drugs to treatment program against their will or not providing individuals with a choice to voluntarily consent or refuse treatment or not allow people the unconditional right to leave the program at any time without incurring penalties the next parameter refers to the process for ordering treatment and rehabilitation lacking adequate due process as established by international human rights treaties.
And finally, the conditions of treatment or rehabilitation violate UN international standards on human rights and I’d like to emphasize here that these are not intended as a rigid criteria because the conditions of detention look very different in each country but a key shared concern is that people don’t have a real choice to refuse or appeal a treatment order or to leave the treatment program at any time without incurring punishment or penalty of some sort, and I’ll now move on to summarize our findings.
All 9 countries that we looked at that in the report that China, Cambodia, Indonesia, Laos, Malaysia, Myanmar, Philippines, Thailand, and Vietnam, implement some form of compulsory treatment the number of compulsory facilities estimated at more than 800 in 7 countries with available data has not changed substantially since 2,012 in the majority of countries there was either an increase or no change in the number of compulsory centers, and only 2 countries registered a decrease and a similar picture emerges when we look at the number of people detained we found that approximately half a 1 million people were detained in a postal treatment.
Annually between 2012 and 2018 3 countries, China, Malaysia, and Vietnam reported a decline in the number of people in compulsory treatment, while 4 countries, Cambodia allows Philippines and Thailand saw an increase. People were held in compulsory facilities for various durations, ranging from 3 months to 2 years. In most countries methamphetamine was the most cited substance in relation to admissions, to compulsory treatment, accounting for 50 to 97% of admissions.
Perhaps unsurprisingly, we found the compulsory facilities were largely under the authority of the criminal justice system, and were disproportionately staffed by security personnel. The military or the police, which is more typical of a correctional facility rather than a health service.
For example, at least 50% of all staff, in compulsory facilities in Malaysia and Cambodia were custodial staff, while only a minority were medical, and substance use specialists the graphic on the right of the screen the data point to massive overcrowding in some countries where data were available with some centers operating at more than 400% capacity.
This is, of course, a serious public health concern, because we know that overcrowding in closed settings poses a serious risk for HIV, hepatitis, tuberculosis. And now covid-19 transmission.
I don’t have a slide on this, but I’ll note to say that data on interventions inside compulsory centers were very limited. Such interventions were limited to forced detoxification, monitored through mandatory urine drug testing, and we also saw non-evidence based interventions, including physical exercise, religious instruction, enforce slavery as therapy continued in several compulsory treatment systems detention and compulsory centres has also been associated with elevated risk of acquiring HIV, and not receiving antiretroviral therapy with repeat detainment in the center, associated with a greater risk of HIV infection, free condoms and sterile injecting equipment were not available inside compulsory facilities in all of the countries that we looked at.
The policy centers also entail numerous human rights violations that have been widely documented over the years, including fundamental rights, such as the right to life and freedom from torture or cruel and human degrading or degrading treatment, or punishment, as well as the right to health, including inadequate informed consent, of force. Detox, as I mentioned earlier, and in some cases violence, abuse, forced labor, and death.
More commonly these also involve the failure to provide evidence-based drug dependence, treatment and health harm, reduction and social support services inside. Although the data that we have for costs associated with compulsory treatment are also limited.
What we can see from what is available is that countries continue to spend vast amounts of debate, of domestic funding on these centers, despite their ineffectiveness with the reported cost per person in a compulsory facility per year ranging from for about $400 to about 4,000. This cost is much higher than the provision of harm reduction. One cost effectiveness study from Malaysia showed that it costs the country 2.5 more times to cover the annual cost of a person in compulsory treatment than the cost of that person accessing outpatient methadone.
Organizations and experts have developed international standards and global experts are in consensus that what’s needed instead of compulsory treatment is a comprehensive continuum of voluntary evidence-based options this has been referred to, as community- treatment and community-based treatment and is outlined in existing UNAIDS and UNODC guidelines.
Among other things, this comprises outpatient treatment and take home medication, assisted therapy. It also includes psychosocial and counseling support access to digital syringe programs, safer smoking kits and provision of naloxone are also crucial. Here is the inclusion of services that additional people’s welfare, economic housing and legal needs, those needs that go beyond just their drug use and HIV status.
The third booklet of the report, which I encourage you to download, is a discussion paper, I developed in consultation with a group of academic government and civil society experts from the region that formed the Asia Pacific expert advisory group on compulsory facilities established in 2020 this booklet documents promising alternatives to compulsory treatment from 8 countries.
A selection of these are pictured on the slides and they include peer-to-peer mental health support to people using crystal meth, and as well as case studies of partnership between the police government authorities and community based organizations to provide low threshold take home methadone in China and Malaysia. A common thread among these examples is the acknowledgement that many people may not be able to, nor desire to stop using drugs altogether, and this should not constitute a reason for punishing or denying that unfortunately, the availability of of these alternatives, and access to them is still, very insufficient. And many of these programs do not scale, do not get scaled up. In fact, several have been closed since we published a report due to lack of funding.
A key barrier to facing out compulsory treatment as has come up in previous presentations as well, is the continuation of punitive sanctions arising from the criminalization of drug use which pushed people further to the margins and away from existing HIV.
The way for is captured in the regional framework for action on transition, which this framework provides a roadmap for governments to accelerate a shift from compulsory treatment detention, and punishment toward health and rights based approaches across 3 areas of planning and management enabling policy environments and resourcing is strengthening health systems in the third. booklet, the expert advisory group makes updated recommendations to strengthen the framework’s 3 pillars of action on this slide I just highlighted. Those are recommendations which were added, since the initial set of recommendations in 2015, I will not read them out to time limitations, but I would like to emphasize one important action which is the removal of criminal penalties for the use of possession of scheduled drugs and other related offenses, an action that’s also promoted by that UN common position on drugs.
In closing. My hope is that all of you attending today’s event can interpret these data as a renewed call to action. Thank you.
Monica Beg, UNODC HIV Branch: Thank you very much. Claudia. Well, actually, in the consultation, we also had a presentation with the experience testimony of people who were in compulsory treatment, center, and you know it was it was a chilling reminder of the human suffering that can happen with this, so we will move now to the next presentation.
And actually, this is a good news is coming from Egypt, who just started operating in the last day. So I will invite Professor Mana Albu, who is the Secretary General in the Ministry of Health and Population in Egypt to give her presentation. And, Professor, I would like to remind you also to stay in time because we are already over a time thank you.
Professor Mana Albu, Secretary General in the Ministry of Health and Population, Egypt: Thank you very much. I have the pleasure and honor to meet you all, and I would like I would have the be more interested to join you alive.
But you know the circumstances I mean. Actually I respected the topic of the section. It’s about HIV and Aids, about the OAT. We will present our side event next Thursday with your respected conference, and today, let me tell you, in very few slides, how the virology clinic in the Justice Department of Mental Health and Addiction Treatment is working for more than 2 years now we started the implementation of the OAT policy to provide integrated treatment services. 2 years ago it was first hospital which implemented it was started in November 2020.
Now we are improving the service and increasing the centers, providing service. 21 hosts and centers in 14 of the Egyptian governance. Yes, these are our hospitals and sensors scattered all over Egypt and covering 5 governance in the Upper Egypt 8 governors in the Delta, and many, many of the greater Cairo regions.
The clinics provide the following services. It provides the examination, the advice consultation, and the treatment for hepatitis viruses. The testing, counseling, and treatment for HIV virus and the vaccination against hepatitis B virus. Then we got the opportunity to also involve the relatives and other patients, because our hospital provide the service for both the mental health and the treatment of addiction. So we also treated mental health patients which suffer from mental issues and these are the numbers, the confirmed cases were much less, especially as regard the HIV treatment received. The numbers are a little less, because patients are not very compliant for about the virus patients are are receiving mandatory vaccination.
Since 2005, so the numbers are naturally and about the appetite. As you can see, more than 14,000.
The persons received the first doors, and of course, those decreasing awareness and counseling service are also provided to patient suffering from addiction by conducting educational seminars about the ways of infection, especially with HIV, and the danger of using contaminated injection and sharing meetings. The service is provided by health care providers trained to provide a voice and examination with rapidly agents and modern treatment methods.
The good news is that just you just just said that 13 days ago, 13 days ago, March first, we started implementing the OAT program in Egypt and it’s our pleasure to start scattering it all over our medical services all through the country and his Excellency Professor Helen Dabba for the Minister of Health and population will be launching with, and we are very proud that after maybe more than 3 years preparation, we could establish this service in Egypt.
Thank you very much, and let me see you in our side event.
Monica Beg, UNODC HIV Branch: Thank you very much, Professor, and it’s my pleasure now to invite the last speaker.
Professor Alethse De La Torre Rosa, Director General of the National Center for the Prevention and Control of HIV /AIDS, Mexico: Thank you very much. It’s a pleasure to be here, and in the next 10 min I will give you a small summary of what we are doing for people who use drugs.
So we changed our approach. Previously. It was just HIV now we have the opportunity of having what its they community and key population at the center of our actions, including HIV, hepatitis and STI program.
We also have a strong area with the harm reduction and mental health and addiction, including the training of healthcare workers in Image Ga. So, of course, what we understand now is that people who use drugs also are people in other needs and we need to address those additional. A syndemics in order to be able to facilitate and also reduce the gaps that they have.
We also understand. Now that it’s essential for us as policymakers to have information, and that information needs to be in a standardized way. And we have developed an information registration system which allows us to follow up the outcomes of each person.
So we have an analysis in Mexico about this substance use, and HIV hepatitis and other epidemics, and as you can see in colors, and we have different districts with different needs.
So, of course, Mexico. It’s a huge country, but within that each of the United States have different needs and it’s essential for us to address that. It’s important for us to understand that. For instance, in Tijuana we will have HIV hepatitis, but also tuberculosis. Another actions that we need to have in order to reduce this and other a actions that we need to have in order to reduce these and issues. And, as you can see, across the country, it’s not just borders where we have an issue. We have an epidemic in drug use, and we need to address that. Otherwise it will become more difficult for us to achieve the international goals in terms of HIV.
We have some of our countries where over 30% of them, the new infections are associated with the drug use and this is important also to understand the outcomes of these people.
So about 80% of people who use drugs have virological control. And that’s less than 90% in other population. So of course, they will be having more difficulty in order to continue their treatment. And it’s important for us to create programs that address their particular needs.
So there are guides. It’s impossible to these barriers for them, but also when we understand what’s happening going on with hepatitis, it’s not just Iv drugs.
It’s also insane. So substances for instance, 14% of people have reported to use substances and of those 49% had hepatitis C. With China substances, that is about 30%.
And we Kim says as well, it’s about 45%. So it’s important for us also to make sure that we do not leave behind the rest of the drug use, because they will need also a different approach in order to reduce those gaps.
It’s also essential for us to to understand that having a primary healthcare approach and reducing the barriers for people, it’s important, for instance, these new era with the a HIV hepatitis coverage started in 2019 so of course, when we were launching the program, they, copied. Pandemic started, and we had 2 options to start to stop and wait until the pandemic was over, or to start and take that opportunity also to use what we have learned from HIV community-led services, and to increase the opportunity to use what we have learned from HIV community-led services and to increase the opportunity to increase the units. So we took the last option, and we had an expansion of coverage from less than 20 units.
So we took the last option, and we had 20 units to more than 140 units across the country, which has helped all their people as well. Also, we believe that community leaders are essential from policy making. So they are involved in the policy making, since the initial guidelines they were involved for them to participate in the a plan. For the next 4 years, but also in the national guidelines.
So, for instance, the HIV and Hepatitis guidelines, at least 20% of the participants are community leaders and that’s essential for us, because we have their voices, and we have their participants in the national guidelines as well as the online courses that we create including harm, reduction and treatment of capital. In our primary healthcare approach, which is compulsory for all healthcare workers.
In these clinics we also have elementary strategies. So we help community leaders with help clinicians to have the experts in mental health, drug use and other areas for them to be able to have specialized treatment in even remote areas.
We have also a prevention with the community approach where we have national campaigns, activations on rescue factors and the community leaders are part of these activities. We have community centers. And are these symbiosis between the government and the community leaders and we also pay for some peers to be able to reach communities that are otherwise impossible to the healthcare system. We also have actions focused on key populations, and their involvement is essential. So, for instance, here we have burden. We have regulates, we have legacy and other actions that are essential for us. They have more than some years of experience, and they are essential for the program, and the continuity of that. Of course, we need to address that. There are still barriers accessing the options, the treatment options, the main one is the statement, discrimination. So we cannot have a compulsory program if we do not fight stigma and discrimination, but also the time to travel to the center. So imagine if you have no job, no salary, and you need to travel more than 4 hours to reach that unit, and that will be of course, with the opening hours and the rest of the activities, impossible for you to have that access as well as that we are starting to create, a universal system. So we are now making sure that people are traveling less than 15 min to that center, that it’s closer to their home.
And what we, our need is to have a resilient system and it’s essential for us not to leave anyone behind. Of course, the pandemic has taught us that, but also like migration, other natural disasters, and we need to make sure that we have that population at this center corner. You have one that is, with harm reduction and that person he’s part of the harm reduction from predominance. He had hepatitis C, and he was so happy to be able to have access to treatment. Unfortunately, and he was the face of our initial campaign. He was murdered, due to gun violence.
So, of course, what we need to address is not just the health problem. We need to address also other issues that people face every single day.
Thank you so much for your attention.
Monica Beg, UNODC HIV Branch: Thank you very much. Thank you very much for your presentation.
Well, we run over time, as as we said, so there won’t be time for question and answers but thank you very much for staying online in such large numbers. Really, we appreciate everyone staying online for so much longer than what was actually planned. I really would like to thank our panelists and Christine for joining us in this session.
And also all the participants who really spent 2 days deliberating on this very important issues, addressing people-centered public health human rights based HIV response for people who who use drugs.
So it’s always really incredible discussion, very, very rich presentations, and we heard some of them. I just would like to really take this time to thank our partners. The International AIDS Society iINPUD, of course, who do the and all our INPUD colleagues who are always with us in whatever we do who colleagues, of course, and UNAIDS and all our Member States who have been supporting this whole process, Brazil’s Czechia, Mexico Norway, South Africa, Spain, Sweden, and the Netherlands, and of course it was wonderful to hear the experience and the good news from Egypt, that who are starting OAT, and also the excellent work that is already ongoing in Mexico, and how much you know the rich the discussion and what we what is going on there. So I thank you all very much, and I look forward to really continuing our partnership and I do to really make sure we have fully funded harm reduction programs that are led by the by the community where there is a need.
So thank you very much. Thank you.