Report Looks at Global State of Harm Reduction for People Who Inject Drugs

Harm Reduction International this month released the latest edition of its Global State of Harm Reduction report, mapping responses to drug-related HIV, hepatitis C, and tuberculosis epidemics around the world. The report looks at prevention interventions by region, including needle and syringe programs, opioid substitution therapy, harm reduction in prisons, overdose response, and access to antiretroviral therapy (ART) for people who inject drugs.

Below is an edited excerpt from a recent Harm Reduction International press release announcing the new report. The full Global State of Harm Reduction 2014 report is available free online.

International Launch of New Edition of the Global State of Harm Reduction Report

• Further HIV infections in sub-Saharan Africa driven by injecting drug use need to be tackled by a scale up in harm reduction
• Small-scale needle syringe programs now operating in Egypt and Jordan
• Globally only 4% of drug users living with HIV receive antiretroviral therapy
• Urgent scale-up of harm reduction needed globally if UNAIDS HIV/AIDS targets are to be met

February 17, 2015 -- London, UK -- New and emerging patterns of injecting drug use in sub-Saharan African countries such as Tanzania, Uganda, Senegal, Zanzibar, and Kenya will require a further scaling up of the provision of opioid substitution therapy (OST) such as methadone and buprenorphine, and needle and syringe programs (NSP) in order to effectively respond to the growing HIV/AIDS epidemic amongst people who inject drugs in the region, the newly released Global State of Harm Reduction report has revealed today.

Since the disbanding of the UN Reference Group on HIV and Injecting Drug Use, the Global State of Harm Reduction has become the only independent and civil society-led project collating global HIV and hepatitis C related harm reduction data.

The 2014 report, produced by UK-based NGO Harm Reduction International (HRI), says that the programmatic scale-up of harm reduction services in a few sub-Saharan countries has marginally improved since its last report in 2012, but it had not grown in proportion to the HIV epidemic among people who inject drugs.

The reported prevalence of HIV among people who inject drugs in Tanzania is an estimated 33.9%, 16.7% in Uganda, and 9.1% in Senegal. Moreover, because of the geographical location of countries such as Tanzania and Zanzibar along key transit points for the trafficking of heroin, cocaine, and other drugs, there is increased availability of these drugs in this part of the region.

"Further HIV infections in sub-Saharan Africa driven by drug use are as concerning as they are avoidable," said Rick Lines, Executive Director of Harm Reduction International.

"It is reassuring, then, to see the pioneering efforts of both Tanzania and Kenya, implementing programs on the ground reducing harm, but it is, at the same time, critically important that these interventions are scaled up and adopted across the region where similar patterns of drug use may be emerging."

Harm Reduction Takes Off in Sub-Saharan Africa

In 2012 the Kenyan government announced the initiation of NSPs within the country, resulting in 2014 in 10 newly operational sites. There has also been a scale-up of NSPs in Dar es Salaam, Tanzania, increasing from one site in 2012 to seven in 2014. The recent establishment and scale-up of community-based OST in Tanzania is a significant step forward, rising from one site to three in the city of Dar es Salaam. This makes the OST program in Tanzania the largest government-run program in the region, with over 1,200 people receiving methadone in 2013 and outreach workers making contact with around 20,000 people who use drugs.

In Senegal, a small-scale community-based needle and syringe program has been initiated, which is the only government-run harm reduction program in West Africa. In South Africa, there is presently only one NSP site focused on men who have sex with men who inject drugs.

New Injecting Drug Practices in Sub-Saharan Africa

The report points out that although services are generally lacking, the initiation
of research in the region will be vital in providing a basis for policy responses in the future. It also notes the concerns over the documentation of high-risk injecting practices, including that of flashblood occurring in Tanzania and Zanzibar and the marked increase in stimulant use that is evidenced in research into increased risk behaviors for sexual transmission of HIV. It cites as an example that in Western Cape Province, the proportion of admissions to drug treatment facilities for methamphetamine as the primary drug used increased from 0.8% in 2001 to 52% in 2011.

Drug User Access to Antiretroviral Therapy

In 2012 there were an estimated 6,991,492 adults receiving antiretroviral therapy in sub-Saharan Africa, representing 60% of those living with HIV. However, the data on numbers of people who inject drugs receiving ART within this region remain limited. In 2008, the Reference Group to the United Nations on HIV and Injecting Drug Use reported that just 38 people who inject drugs in Kenya and 138 people who inject drugs in Mauritius were receiving ART. These estimates represented less than 1% of HIV-positive people who inject drugs in Kenya and 1.1% of people who inject drugs in Mauritius receiving ART.

The low rates of access to ART in sub-Saharan Africa are echoed across the globe. Only 4% of people who inject drugs receive antiretroviral drugs. Despite an overall increase in the past two years in the number of countries providing opioid substitution therapy, such as methadone and buprenorphine, and needle syringe program to injecting drug users, the 2015 Millennium Development Goal target to reduce the HIV incidence among people who inject drugs by 50% only sits at 10%. Moreover, only an estimated 8% of the world's injecting drug users can actually access OST such as methadone and as a global average they are only able to access two clean needles per month.

Global Harm Reduction Funding

US $2.3 billion annually is estimated by UNAIDS to be required to fund HIV prevention among people who inject drugs in 2015. At the last estimate, only US $160 million was invested by international donors -- approximately 7% of what is required. International and national funding for essential services is disastrously short of need in low- and middle-income countries. More countries are becoming ineligible for international donor support due to their middle-income status, regardless of epidemiological need or the willingness of the national government to step in and cover the remaining funding gaps. This is despite the fact that the majority of people who inject drugs, approximately 75%, live in these countries.

"Too many people are being left behind and left out -- in the Americas, in Africa, in Asia, in Eastern Europe -- and there continues to be a dangerous shortfall in funding for harm reduction to reach the people who need help the most," said David Furnish, Chair of the Elton John AIDS Foundation and author of the report's foreword.

"As we look back on all of the important progress we've made in recent years, we must remember that 'Ending AIDS' must be much more than a slogan. It must be a realistic vision, grounded in science, and funded and implemented in a manner that will reach all who are in need. Because to truly end AIDS, we must make sure that no one gets left behind."

In contrast to the lack of funding for harm reduction, each year governments spend over $100 billion on arrest and imprisonment of people who use drugs, destruction of drug crops, and other drug control measures. HRI argues that if just a tenth of this money were redirected to harm reduction, it could fill the gap in HIV and hepatitis C prevention for people who use drugs twice over.  

In settings where comprehensive harm reduction has been implemented, HIV rates among people who inject drugs are low -- in some cases, almost negligible. This was the primary reason that HIV/AIDS epidemics amongst drug users in cities like London, Glasgow, New York, Sydney, Amsterdam, and Berlin were avoided when AIDS first surfaced in the early 1980s.

Malaysia a World Leader on Harm Reduction

It is also the reason that countries like Malaysia have been largely successful over the past seven years in turning around what was an injecting drug-led HIV/AIDS epidemic by introducing government-led harm reduction initiatives throughout the country.

The Global State of Harm Reduction 2014 report noted that Malaysia, along with Iran and Australia, had experienced the steepest increase in the number of NSP centers, from 297 sites in 2012 to 728 in 2014. In recognition of the Malaysian government's leadership on the issue, Harm Reduction International will host its biennial Conference in Kuala Lumpur in October 2015.

Other key highlights of the Global State of Harm Reduction 2014 include:

• In 2014, 90 countries and territories implement NSPs to varying degrees;
• In 2014, 68 countries or territories with reported injecting drug use do not provide NSP services;
• In 2014, 80 countries and territories implement OST (mainly methadone and buprenorphine); 
• The provision of NSP in prisons globally has declined since 2012, with only 43 countries providing OST in the prison setting;
• In 2014 there were 88 drug consumption rooms (DCRs) operating worldwide --outside of Europe, two DCRs are in operation, one in Australia and one in Canada. In Western Europe, Denmark saw the implementation of five DCRs, and both Spain and Switzerland, which had previous DCRs in operation increased their site provision by six each;
• The provision of overdose prevention medication (e.g., naloxone) has increased most markedly in North America. In the United States, as of June 2014, there are 30 states plus Washington, DC, that have at least one point of access for laypersons to obtain naloxone for people who use drugs, or friends and family;
• In the Middle East and Northern Africa region (MENA), one of only two regions in the world that continue to experience increases in HIV infection rates, harm reduction coverage is non-existent in many countries. However, small-scale implementation of NSPs now operate in Egypt and Jordan. Iran continues to be word leader both in and outside the region -- OST and NSP are widely available in the community as well as in prisons;
• The Eurasian region is home to an estimated 3.1 million people who inject drugs, with two of the largest populations living in Russia (1.8 million) and Ukraine (310,000). Eastern Europe and Central Asia is one of two regions globally where rates of HIV infection are continuing to rise. Approximately 1.3 million adults and children are living with HIV in the region (range 1,000,000-1,700,000). One in three new cases of HIV were reported to be attributed to a lack of access to sterile injecting equipment between 2006 and 2010. A recent systematic review suggested that one in two people who inject drugs are living with HIV in parts of Estonia, Russia, and Ukraine;
• Opioid substitution therapy is available in 26 countries of the region, with only three countries reporting evidence of injecting drug use not providing OST: Russia, Turkmenistan, and Uzbekistan. In Russia it is a criminal offense to promote or supply methadone;
• Some of the highest rates of multidrug-resistant TB (MDR-TB) in the world are reported in Kazakhstan, Uzbekistan, Tajikistan, and Kyrgyzstan;
• In Asia and the Pacific, more than two-thirds of people who inject drugs do not know their HIV status, and in 2013 only 18% of the total number of people living with HIV who were eligible for ART accessed treatment in the region;
• A systematic review in 2011 found that the region contained the largest number of people with viral hepatitis who inject drugs, with an estimated 300,000 having hepatitis B virus (range 100,000-700,000) and approximately 2.6 million having hepatitis C virus (HCV) (range 1.8-3.6 million). The limited data that is available suggest that 60-90% of people who use drugs who live with HIV in Asia and the Pacific also have HCV co-infection.

About Harm Reduction International (HRI)

Harm Reduction International is a leading non-governmental organization working to promote and expand support for harm reduction. With over 8,000 members worldwide, Harm Reduction International is the largest membership-based global harm reduction association. 

HRI works to reduce the negative health, social, and human rights impacts of drug use and drug policy -- such as the increased vulnerability to HIV and hepatitis infection among people who inject drugs -- by promoting evidence-based public health policies and practices, and human rights based approaches to drug policy. The organization is an NGO in Special Consultative Status with the Economic and Social Council of the United Nations.

2/24/15

Sources

Harm Reduction International. The Global State of Harm Reduction 2014. Released February 2015.

Harm Reduction International. International Launch of New Edition of the Global State of Harm Reduction Report. Press release. February 17, 2015.