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Harm Reduction and HIV Prevention
Introduction to harm reduction
Harm reduction programmes aim to reduce the negative consequences of drug use, by reducing the harm self-inflicted by the user through unsafe practices and the subsequent harm inflicted upon society. 1 The provision of other harm reduction measures, just like with needle exchanges, is generally poor, and opposition to them is impairing the fight against HIV.
Like needle exchanges, other harm reduction measures exist to minimise the harmful consequences associated with drug use. The provision of these programmes is often hindered by laws which prohibit carrying drug paraphernalia and the fear of discrimination brought by the association with such programmes. 2
Maintenance therapy / opioid substitution treatment
Maintenance therapy, or opioid substitution treatment, involves the provision of drugs such as methadone or buprenorphine, in pill or liquid form, to drug users as a way of minimising risks associated with injecting. These programmes aim to curb needle sharing, the use of contaminated street drugs, overdoses, and crimes associated with funding drug addiction. Methadone or buprenorphine substitution therapy exists in over 77 countries worldwide. 3
USA researchers from the University of Philadelphia monitored 152 injecting users receiving methadone maintenance treatment and 103 injecting users on no treatment over a period of 18 months, all of whom were HIV negative at the beginning of the study. The results showed that over the 18 months, only 3.5 percent of those receiving methadone became infected with HIV, in contrast to 22 percent not on treatment. 6
A report by WHO in March 2005 reviewed many global studies and concluded that substitution treatment is a ‘critical component’ of HIV prevention policy, significantly reducing opioid dependency and HIV infection rates. 7 In addition, studies have also found a decline in crime rates and commercial sex work when PWID no longer have to find ways to fund their expensive addictions. 8 9
Several studies have shown that prescribing injectable opiates – including heroin – can help heroin addicts who have failed on traditional maintenance therapy. The Randomised Injectable Opioid Treatment Trial (RIOTT), which took place in three UK cities, targeted the 5 percent of addicts who were not benefiting from existing treatments and were continuing to inject street heroin despite receiving oral methadone. Individuals in all three groups – those receiving injectable heroin, injectable methadone, or oral methadone – decreased their consumption of street heroin, with the biggest decrease among those receiving injectable heroin. Programmes such as these would be beneficial for HIV prevention among ‘problem’ drug users as reducing their use of street heroin also reduces the likelihood of using contaminated needles. This was in addition to a substantial reduction in crime. 10
The risk of HIV infection through the use of methamphetamine ('crystal meth') is high, yet substitution treatment for meth addiction does not currently exist. As well as the HIV risk associated with injecting meth, one effect of the drug is a high sex drive, which can lead to an increase in sexual partners and riskier sexual behaviour. In the United States of America the use of meth by men who have sex with men (MSM) is 20 times higher than in the general population and is believed to be a major cause of new HIV infections among MSM. 11 If substitution treatment was made available to meth users the risks associated with this drug could be substantially reduced. 12
Some differences between the results of methadone and buprenorphine treatment have been highlighted. One study (2014) has found that more people adhered to, and completed their course of methadone (74 percent of participants), compared to those on buprenorphine (46 percent). Males on methadone also had lowered sexual-risk behaviour by the end of the study, whereas men on buprenorphine had elevated sexual-risk behaviours. 13 However, a healthcare professional will decide which substitution medicine is best based on a number of factors such as which drug was being injected, the length of the injecting period and what withdrawal symptoms a person experiences. 14
Despite evidence of the effectiveness and need for opioid substitution therapy, 81 countries and territories which report injecting drug use do not have opioid substitution therapy in place. 15
Safer injection facilities (SIFs)
These provide an environment where drug users can inject in a safer manner and under medical supervision. Like needle exchange programmes they may offer drug education and referral for treatment. They also aim to reduce public disorder issues and risks associated with injecting drug use such as large congregations of injectors in public places and litter, particularly syringes. Such facilities exist in only eight countries including Germany, Switzerland, the Netherlands, Spain, Australia and Canada. 16
After Frankfurt introduced SIFs in the early 1990s, cases of HIV among PWID declined, as did overdose cases in the city which dropped dramatically from 147 in 1991 to 22 in 1997. 17 18 This decline can be attributed to the city’s overall harm reduction approach, though overdose cases dropped steeply in the year following the introduction of SIFs. 19 Furthermore, PWID who overdose in safer injection facilities are 10 times less likely to require hospitalisation. 20 Research of Vancouver's Insite, North America’s first SIF, found that there was no association between the facility and the rate of drug trafficking or other crimes linked to drug use. 21 22
The Insite facility had faced pressure by Canada’s Conservative government, and was threatened with closure under drug trafficking and possession laws. However, a 2008 ruling allowed it to remain open. 23 In the judge’s opinion, Canada’s Controlled Drugs and Substances Act violated individuals' constitutional rights:
“It denies the addict access to a health care facility where the risk of morbidity associated with infectious disease is diminished, if not eliminated… While there is nothing to be said in favour of the injection of controlled substances that leads to addiction, there is much to be said against denying addicts health care services that will ameliorate the effects of their condition.” 24
However, in 2013, new legislation again threatened Insite and other proposed new SIFs in the country. 25 This is despite a 2012 report (from the Centre for Research on Inner City Health in Toronto), concluding that Toronto could hugely benefit from the creation of three safer injection facilities. This was based on the reported health benefits of Insite in Vancouver:
- Between 1996 and 2011 hepatitis C and HIV transmission in Vancouver declined rapidly.
- Methadone maintenance therapy amongst drug users has increased by 41.6 percent since it opened. 26
- In the two year period following the opening of Insite, the fatal overdose rate declined by 35 percent in the surrounding area. 27
In spite of this, the views of the Canadian Conservative government and those of public health researchers continue to clash over the issue. 28
Safer crack smoking resources
Like needle exchange programmes they distribute clean crack-smoking implements in order to curb the risks associated with sharing of equipment.
These have not been implemented on as wide a scale as needle exchange programmes but have shown to be effective in cutting behaviours associated with HIV transmission. An Ottowan needle exchange that also began providing sterile crack-smoking equipment, such as glass stems and rubber mouthpieces, found the proportion of participants sharing implements every time decreased from 37 percent six months prior to implementation, to 12 percent 6 months after. 29
Pharmacy sale of syringes
Non-prescription over-the-counter sale of syringes is another way to allow drug users access to sterile needles. In the US, some states have amended drug paraphernalia laws to exclude syringes. Pharmacies that provide clean injecting equipment may also offer similar secondary services as needle exchanges such as providing information and referrals. In Australia, pharmacy-based needle and syringe programmes account for 15% of all syringes used for injecting drugs. 30
An examination of the 96 largest metropolitan areas in the United States of America found both the proportion of PWID living with, and becoming infected with, HIV, was lower in the 60 areas that permitted the purchase of syringes without prescription compared to the 36 metropolitan areas that did not allow this. 31
Supplying tin foil to deter injecting
One method of helping habitual drug users avoid the harms of injecting is supplying tin foil to encourage smoking of drugs instead. Heroin can be boiled on a piece of foil and then its vapours inhaled. Some countries such as Holland and Spain supply foil through their needle exchanges. In England, however, it is illegal to do so, though it is believed that around 100 of the known 1300 needle exchanges break the law and supply foil. 32 An Early Day Motion in the British Parliament aims to overturn section 9A of the Misuse of Drugs Act which restricts the supply of tin foil. 33 34
Again, while no one would claim that smoking heroin is a healthy activity, for people who are addicted to the drug and normally inject, smoking can be a preferable option:
"Smoking drugs is by no means safe, but is a great deal safer than injecting drugs – which is particularly associated with overdose, blood-borne viruses, drug-related litter, greater dependency, abscesses and vein damage." - Jamie Bridge, International Harm Reduction Association 35
Safe needle disposal
Various disposal methods exist so contaminated needles are unable to injure another person. These include, drop-off points located in buildings such as police departments, clinics, community organisations or medical waste facilities; mail-back programmes where used needles are sent in a special container to a collection site; residential pick-up services; and in-home disposal services that safely destroy the needle. 36 Programmes that offer safer syringe disposal may well be part of a general needle exchange service.
Community-based outreach programmesThese work with people who inject drugs to distribute clean equipment, promote condom use and provide information about prevention and rehabilitation. Injecting communities are often secretive and distrustful of authorities. Outreach programmes focus on accessing these hidden groups, opening an important route to providing support. In some cases, former PWID are recruited and trained as peer-outreach workers. Some PWID are likely to be involved in sex work to fund their expensive addiction, so provision of sexual health information and condom promotion play key roles in preventing HIV transmission through other routes. Involving communities in the development of harm reduction programmes can help to ensure that policies around harm reduction are suitable for local context and meet the needs of PWID. 37
A report from the WHO reviewed data from over 40 studies on outreach prevention methods and concluded that these significantly reduce high-risk behaviour in PWID and are successful in directing them to rehabilitation services. 38
In 2006, UNAIDS published a report that reviewed several ‘high coverage’ prevention programmes (50 percent of local PWID population accessing more than one prevention initiative) in transitional and developing countries. The inclusion of harm reduction measures was one of the key factors in achieving high coverage. 39
A case study: Harm reduction in Russia
Given that the Russian AIDS epidemic is being driven by injecting drug use, harm reduction measures like needle exchanges and substitution therapy are crucial. However, HIV prevention for drug users is largely inaccessible with opioid substitution therapy being illegal and needle exchange coverage hugely inadequate. 40 It is estimated that in 2008 just 7 percent of Russian people who inject drugs were accessing needle exchanges. 41 This is reflected across the wider Eastern Europe and Central Asia region, which Russia dominates, and it is no coincidence that this is the only large part of the world where HIV prevalence is increasing.
Russia’s leading figures in psychiatry and addiction have rejected opioid substitution as an effective way of dealing with the harms of drug use. In an official memorandum they wrote:
“The effective way to solve the problem of drug addiction treatment is an intensive search for and introduction of new methods and means that focus on complete cessation of drugs use by patients with addiction, their socialization into a new life style free from drugs, but not on exchanging from one drug to another.” 42
In 2009, Global Fund prevention programmes were almost cut after the organisation, under its strict guidelines, deemed the country too wealthy to continue to receive funding. The Russian government chose not to step in, instead saying it would focus on broader health promotion. Given Russia's stance, the Global Fund felt it had no option but to extend funding for prevention efforts directed at vulnerable groups until 2011. 43 An editorial in The Lancet outlined the difficulties of providing prevention services for drug users and stressed the need for harm reduction initiatives in the country:
“In Russia, the opposition to harm reduction programmes has meant that needle exchange is mostly run by non-governmental organizations (NGOs). The government has repeatedly refused to allow methadone substitution to be offered to people who inject drug, despite many international calls to support this evidence-based intervention…We urge the Russian Government to continue to fund effective and science-driven harm reduction programmes, in addition to its general health promotion efforts.” 44
Read more about drug use and HIV prevention in Russia.
The controversy of harm reduction
Harm reduction measures are supported and implemented by NGOs, health authorities, governments and multilateral organisations worldwide. However, such methods for dealing with the harms of drugs have been surrounded by controversy since the mid 1980s when needle exchanges and substitution treatments were first introduced in Western Europe. Drugs policy is often discussed in a very moralistic way, with many politicians adopting stances that do not take into account scientific evidence. Because of the impact of drug abuse on society, and perhaps the mind-altering nature of drugs, legislators want to show they are "tough on drugs", even if their policies contribute to the damage they claim to be against.
Some countries have strategies that involve forcing drug users to abstain or have treatment. Currently there are up to several hundred thousand people who use drugs who are detained in order to undergo treatment, of whom very few have access to maintenance therapy. 45 The WHO maintains that drug detention centres are not effective at preventing drug use and that they can undermine effective harm reduction programmes and increase HIV risk. 46
Advocates of needle exchanges and other harm reduction measures point to the evidence that such programmes reduce the incidence of HIV infection and do not encourage drug use. 47 Furthermore, they say having abstinence as the only goal worth pursuing is unrealistic, and as long as people continue to take drugs, they should be encouraged to do so in the least harmful way possible. It is argued that the benefits of harm reduction transcend beyond the drug user into society, not only by reducing death, crime and HIV infection but through supporting education. 48 49 This is recognised by the England and Wales National Institute for Health and Clinical Excellence who state that "While NSPs (needle and syringe programmes) can help reduce the harm caused to people who inject drugs, the consequent reduction in the prevalence of blood-borne viruses benefits wider society". 50 Moreover, studies show that harm reduction measures can also result in financial savings, for example for every $1 spent on methadone treatment, at least $5 is saved through alleviating public spending in sectors such as healthcare or prisons. 51 52
"Harm reduction recognises that containment and reduction of drug-related harms is a more feasible option than efforts to eliminate drug use entirely… [it] does not focus on abstinence: although harm reduction supports those who seek to moderate or reduce their drug use, it neither excludes nor presumes a treatment goal of abstinence.”UK Harm Reduction Alliance. 53
The arguments against harm reduction range from moderate to extreme. Some believe that needle exchange services are a waste of money and only promote injecting drug use, when the message should be abstinence from drugs. 54 Opioid substitution treatment is a difficult concept for many to accept; critics argue that this prolongs drug addiction or provides users with drugs to sell on the street to fund further drug use. Although outreach work is the most accepted form of harm reduction, some believe its activities, such as teaching safer injecting methods, is a waste of resources. There is also strong opposition to safe injection rooms and heroin prescription for problem PWID, often the most contentious forms of harm reduction.
In 2004, Republican Congressman, Mark Souder, then chairman of the US Subcommittee on Criminal Justice, Drug Policy and Human Resources, criticised harm reduction supporters:
"Advocates of this position hold that dangerous behaviors, such as drug abuse, should be accepted by society and those who choose such lifestyles - or become trapped in them - should be enabled to continue these behaviors in a less harmful manner." 55
In response the president of the International Harm Reduction Association summarised the debate over needle exchange programmes and other harm reduction measures as one which “divides participants into those who base their judgements on data from those who base their judgements on other considerations than data”. 56
The controversy surrounding harm reduction exists at the highest levels of global decision making. Harm reduction is supported by many United Nations bodies including the General Assembly, UNAIDS, the UN Office on Drugs and Crime, and the World Health Organization. However, the 2009 Political Declaration of the UN Commission on Narcotics Drugs, which outlines international cooperation on drug strategy for the next ten years, does not refer to it at all. 57 This omission was encouraged by several states including the United States of America and Russia as well as Sweden, Italy and Japan. Even the Vatican weighed into the debate, criticising harm reduction, to which one group in favour responded:
“By making a statement against harm reduction, the Vatican has indicated that its moral objection to drug use is more important than its commitment to the sanctity of life.” 58
- 1. Harm Reduction Coalition (Accessed 2010, 16th April) 'Principles of Harm Reduction'
- 2. UNAIDS (2009, 20th April) 'International Harm Reduction conference opens in Bangkok'
- 3. IHRA (2012) ‘ Global State of Harm Reduction 2012’
- 4. Keen J., et al (2003, June), ‘Does methadone maintenance treatment based on the new national guidelines work in a primary care setting?’, British Journal of General Practice 53(491)
- 5. European Monitoring Centre for Drugs and Drug Addiction (2010) ' Trends in injecting drug use in Europe'
- 6. Metzger D.S., et al (1993, 6th September), ‘HIV seroconversion among intravenous drug users in and out-of-treatment: an 18-month prospective follow up’, Journal of Acquired Immune Deficiency Syndromes 6(9)
- 7. World Health Organization (2005, March), ‘Effectiveness of drug dependence treatment in preventing HIV among injecting drug users’
- 8. Rothbard A., et al (1999, June), ‘Revisiting the effectiveness of methadone treatment on crime reductions in the 1990s’, Journal of Substance Abuse Treatment 16(4)
- 9. Gossop M., et al (2005, 1st September), ‘Reductions in criminal convictions after addiction treatment: 5-year follow up’, Drug and Alcohol Dependence 79(3)
- 10. Action Against Addiction (2009, September), ‘ Untreatable or just hard to treat?
- 11. Das M et al (2010, 24th April) ' Feasibility and acceptability of a phase II randomized pharmacologic intervention for methamphetamine dependence in high-risk men who have sex with men', AIDS 24:7
- 12. Das M et al (2010, 24th April) ' Feasibility and acceptability of a phase II randomized pharmacologic intervention for methamphetamine dependence in high-risk men who have sex with men', AIDS 24:7
- 13. George Woody et al (2014) ' HIV Risk Reduction With Buprenorphine-Naloxone or Methadone: Findings From A Randomized Trial' JAIDS
- 14. NHS (accessed 2014) ‘ Opioid substitution therapy’
- 15. IHRA (2012) ‘ Global State of Harm Reduction 2012’
- 16. IHRA (2010) ‘ Global State of Harm Reduction 2010’
- 17. Marion Nickolai (1997, 12th August), ‘Evolution of Frankfurt’s approach to the drug problem’, Euro-Methwork Newsletter 12
- 18. Thomas Kerr, (2000, November), ‘Safe Injection Facilities Proposal for a Vancouver Pilot Project’, Harm Reduction Action Society
- 19. Thomas Kerr, (2000, November), ‘Safe Injection Facilities Proposal for a Vancouver Pilot Project’, Harm Reduction Action Society
- 20. Böllinger L., Stöver H and Fietzek L, ‘Injection rooms: Places where intravenous drug use is tolerated’, cited in Broadhead R.S. et al (2002), ‘Safer injection facilities in North America: Their place in public policy and health initiatives’ [PDF]
- 21. Wood et al (2006, 8th May), ‘Impact of a medically supervised safer injecting facility on drug dealing and other drug-related crime’, Substance Abuse Treatment, Prevention, and Policy, 1(13)
- 22. The New York Times (2011, 7th February) ' An H.I.V Strategy Invites Addicts In'
- 23. Vancouver Sun (2008, 27th May), ‘Insite can remain open: Judge’
- 24. The Honourable Mr. Justice Pitfield (2008), ‘Reasons for Judgement’
- 25. The Globe and Mail (30th September 2011) ‘ Supreme Court ruling opens doors to drug injection clinics across Canada’
- 26. The Lancet (2nd November, 2013) ‘ Canada proposes new legal hurdles for supervised injection’
- 27. Marshall, Brandon D L. (2011, April) ' Reduction in overdose mortality after the opening of North America's first medically supervised safer injecting facility: a retrospective population-based study' The Lancet 377(9775)
- 28. The Lancet (2nd November, 2013) ‘ Canada proposes new legal hurdles for supervised injection’
- 29. Leonard L.E, et al (2006), ' I inject less as I have easier access to pipes: frequency of injecting declines, frequency of sharing crack-smoking materials declines as needle exchange distributes safer crack-smoking tools' XVI International AIDS Conference.
- 30. Australian Government Department of Health and Ageing (2009), 'Return on investment 2: evaluating the cost-effectiveness of needle and syringe programs in Australia 2009'
- 31. Dr Friedman S. (2004, 12th May), letter to Elias A Zerhouni, MD, Director, National Institutes of Health
- 32. The Observer (2009, 20th September), 'UK addicts may be given free foil for "safer" heroin smoking'
- 33. Release website, 'Drug paraphernalia', accessed 6th November, 2009
- 34. Advisory Council on the Misuse of Drugs (2010, 10th November) ' Consideration of the use of foil, as an intervention, to reduce the harms of injecting heroin'
- 35. The Observer (2009, 20th September), 'UK addicts may be given free foil for "safer" heroin smoking'
- 36. Coalition for Safe Community Needle Disposal, ' Types of sharps disposal program' Accessed 05/2011
- 37. WHO/UNAIDS/UNICEF (2011) ‚' Global HIV/AIDS Response: Epidemic update and health sector progress towards Universal Access 2011'
- 38. World Health Organisation (2004), ‘Effectiveness of Community-Based Outreach in Preventing HIV/AIDS among Injecting Drug Users’
- 39. UNAIDS (2006), ‘High Coverage Sites: HIV prevention among Injecting Drug Users in Transitional and Developing Countries’ [PDF]
- 40. Human Rights Watch (2012, February) ' Russia: Government Shuts HIV-Prevention Group’s Website'
- 41. Mathers, B et al. (2010, 1st March) ' HIV prevention, treatment and care services for people who inject drugs: a systematic review of global, regional, and national coverage'
- 42. In Elovich R. and Drucker E. (2008), ‘On drug treatment and social control: Russian narcology's great leap backwards’, Harm Reduction Journal 2008, 5:23
- 43. The Global Fund to Fight AIDS, Tuberculosis and Malaria (2009, 13th November), 'Global Fund to provide $24 million of new funding to fight HIV/AIDS in Russia'
- 44. The Lancet (2009, 10th October), ‘The future of harm reduction programmes in Russia’, 374(9697)
- 45. WHO/UNAIDS/UNICEF (2011) ‚' Global HIV/AIDS Response: Epidemic update and health sector progress towards Universal Access 2011'
- 46. WHO/UNAIDS/UNICEF (2011) ‚' Global HIV/AIDS Response: Epidemic update and health sector progress towards Universal Access 2011'
- 47. UNAIDS (2010, 10th March) ' Pragmatism vs. Punishment: The case for harm reduction'
- 48. BBC NEWS (2004, 8th April) ' I get my heroin on the NHS'
- 49. The Scotsman (2010, 6th April) ' Methadone is key to effective drug treatment'
- 50. National Institute for Health and Clinical Excellence (2009, February), ‘Needle and syringe programmes: Guidance'
- 51. Drug Policy Alliance (2010) ' Methadone Maintenance Treatment' Accessed 2010, 27th April
- 52. The Scotsman (2010, 6th April) ' Methadone is key to effective drug treatment'
- 53. UK Harm Reduction Alliance website, 'Harm reduction defined', accessed 22nd September 2008
- 54. The Times (2010, 6th April) ' Drug experts back methadone treatment'
- 55. Souder, Mark E (2004, 27th April), letter to Elias A Zerhouni, MD, Director, National Institutes of Health
- 56. Dr Wodak, Alex (2004, April 28th), letter to Elias A Zerhouni, MD, Director, National Institutes of Health
- 57. United Nations, ‘Political Declaration’
- 58. The Guardian (2009, 27th February), ‘Vatican’s stance on UN drugs policy “risks lives”’