Harm reduction refers to strategies that aim to reduce the harms associated with injecting drug use.1 The earliest forms of harm reduction promoted abstinence from drug use and put reducing its occurrence at the centre of substance use policy and interventions.2
The concept of harm reduction was re-invented in the early 1980s during the beginning of the HIV epidemic when healthcare workers started to provide clean syringes to people who inject drugs (PWID) rather than solely trying to achieve abstinence.2
Since then, there has been widespread support for harm reduction programmes as a component of the response to the HIV epidemic as well as other illicit drug use epidemics, with a wide range of initiatives implemented to date.3 2
However, of the 158 countries that report drug use, only 91 of them included forms of harm reduction in their national policies in 2013.4
The World Health Organisation (WHO), the United Nations Office on Drugs and Crime (UNODC) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) strongly recommend harm reduction as an approach to HIV prevention, treatment and care for PWID. Specifically, they advocate for a comprehensive package including:
- Needle and syringe programmes (NSPs)
- Opioid substitution therapy (OST) and other drug dependence treatment
- HIV testing and counselling (HTC)
- Antiretroviral treatment (ART)
- Prevention and treatment of sexually transmitted infections (STIs)
- Condom programmes for PWID and their sexual partners
- Targeted information, education and communication (IEC) for PWID and their sexual partners
- Vaccination, diagnosis and treatment of viral hepatitis
- Prevention, diagnosis and treatment of tuberculosis (TB).5
Types of harm reduction programmes
Needle and syringe programmes (NSPs)
Needle and syringe programmes (NSPs) allow PWID to obtain new, sterile needles and other drug paraphernalia at little or no cost to reduce HIV transmission. NSPs have the added bonus of preventing the transmission of other blood-borne viruses such as hepatitis B and C.6
NSPs can also serve as a crucial gateway to other HIV services. NSPs engage with their clients on a consistent basis presenting a number of opportunities to provide access to other forms of relevant healthcare such as opioid substitution therapy (OST), HIV testing and counselling (HTC), and treatment for HIV, tuberculosis (TB) and hepatitis.7
NSPs can be employed through a range of means including pharmacies, vending machines and outreach services.8 With high incarceration levels among PWID, access to sterile injecting equipment and NSP services are a vital component of healthcare in prisons.9
Opioid substitution therapy (OST)
Opioid substitution therapy (OST) - sometimes referred to as medically assisted treatment (MAT) - is the practice of replacing an illegal opiate (such as heroin) with a prescribed medicine such as methadone (MET) or buprenorphine (BUP) that are typically administered under medical supervision.10
In many places, OST has proved highly effective in reducing injecting drug use behaviours among opioid-dependent people, limiting their risk of HIV transmission.11 12 OST was available in 80 countries globally in 2014.4
These programmes have also been found to improve access and adherence to antiretroviral treatment, reduce instances of overdosing and associated mortality, lessen criminal activity and more generally, improve the physical and mental health of people who inject drugs (PWID).13 14 1516 OST has also been found to reduce the risk of HIV transmission from pregnant women dependent upon drugs to their infants.17
The benefits of OST have also been demonstrated in developing countries as well as developed ones. One study reported average treatment retention of 70% across Asia, Eastern Europe, the Middle East and Oceania. All countries also saw reductions in opioid use, HIV risk behaviour, criminal activity as well as improvements in general wellbeing.18
However, studies have found a difference in adherence between those on MET and those on BUP. For example, one randomised trial reported a 76% completion rate among those on MET compared to 46% among those taking BUP. It also found that sexual risk behaviours decreased equally among women on both treatment regimes but increased for men on BUP and decreased for men on MET.19
Despite evidence of the effectiveness of OST, 78 countries and territories that report injecting drug use did not have such programmes in place in 2014.4 Just 8% of PWID globally are receiving OST with access particularly low in developing countries. In 2010, 90% of PWID in the UK were receiving OST compared with just 3% in China and India.20
- Slow-release morphine
In some countries, including Switzerland, Austria and Slovenia, where methadone is deemed inappropriate due to individual's circumstances, patients are treated with slow-release morphine. Slow-release morphine has been found to be at least as effective as methadone in treating people dependent on opioids.21 22
Naloxone is an opiate antagonist that reverses the effects of an opioid overdose. Its use in drug consumption rooms is increasingly effective, as immediate administration of naloxone by supervisors reduces overdose deaths, and encourages future attendance at drug consumption rooms.4
One study in Sydney, Australia found that the opening of just one drug consumption room that offered supervised injections and naloxone for overdoses, significantly decreased the burden on the local ambulance service.23 By controlling the harm caused by injecting drugs in a safe environment, the risks of HIV transmission are lessened.
Other drug dependence treatment
Drug dependence treatment aims to improve or maintain someone's mental and physical health by reducing risk taking behaviours associated with drug use, reducing drug use or eliminating it altogether.24
It can reduce drug-related harms including the transmission of blood borne diseases such as HIV and hepatitis B and C, but the evidence is stronger and more supportive of interventions such as OST.25
However, these interventions are recommended where non-opioid drugs such as amphetamines, cocaine, sedatives and hypnotics are highly used and where OST remains unavailable. Drug dependence treatment helps prevent HIV transmission by reducing injecting drug use, the sharing of equipment and sexual risk behaviours as well as providing HIV education and other HIV-related healthcare.26
For example, cognitive behavioural interventions have been shown to decrease amphetamine use.27 Likewise, medically supervised drug withdrawal (detoxification) can assist with the withdrawal process as well as reduce the discomfort of withdrawal when used in conjunction with OST.28 29
Drug consumption rooms
Drug consumption rooms allow PWID to inject under medical supervision. They enable an immediate response to overdosing and decrease the transmission of blood borne diseases such as HIV through access to sterile injecting equipment and education on safe injection practices. They can also provide access to healthcare as well as HIV testing and counselling.30
To date, evidence regarding the effectiveness of drug consumption rooms as a method of reducing HIV transmission is limited. However, they are known to be effective in increasing uptake of detoxification and treatment services.31
As of 2014, there were 88 drug consumption rooms worldwide, although only two of these were outside of Europe (Canada and Australia).4
- Insite, Canada
In 2003, Insite in Vancouver became North America's first SIS. Since its inception, the facility has been a source of controversy between the government and public health researchers.32
In 2008, the facility was threatened with closure under drug trafficking and possession laws. However, the ruling said that Canada’s Controlled Drugs and Substances Act violated individual's 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." 33
In 2013, new legislation again threatened the existence of Insite and other proposed SIS for the country.32 By contrast, a 2012 report highlighted the need for a similar facility in Toronto based on positive results from Insite. Since its launch, uptake of methadone maintenance therapy has increased by 42% with the fatal overdose rate falling by 35%.34
Pharmacy sale of syringes
Many argue that pharmacies are an important but under-utilised resource in preventing the transmission of HIV and other blood borne infections among PWID. Pharmacists are one of the most accessible healthcare professionals and are in an ideal position to reach this group who are often socially marginalised and wish to remain anonymous.35
Pharmacists can fulfil a number of harm reduction roles including the sale of condoms, educating on safer sex practice, selling clean needles and syringes and dispensing oral methadone for opioid dependence.35
Research has shown how the sale of over-the-counter (OTC) syringes to PWID can reduce HIV prevalence among this group. One study of 96 metropolitan areas in the USA recorded an average HIV prevalence of 13.8% among PWID in areas with anti-OTC laws compared to 6.7% across those that didn't.36
A different study from Tallinn, Estonia, reported that PWID found pharmacies convenient for acquiring syringes due to their extended opening hours and local distribution. However, some reported stigma and discrimination from both pharmacists and customers. Overall, the idea of distributing free syringes to PWID was received negatively by pharmacists.37
Safer crack smoking resources
Smoking drugs can lead to open sores, burns or cuts on the lips and in the mouth. If a pipe is shared, this can increase someone's risk of HIV transmission and other blood borne viruses.38
As a result, some harm reduction agencies have distributed 'safe crack kits' to reduce the sharing of pipes and the use of broken ones. As per other harm reduction programmes, they enable drug users to access the appropriate healthcare and support.38
One study from Vancouver found that 12 months after kit distribution, 79% and 59% of recipients used supplied items such as mouthpieces and condoms respectively. However, while access to safer use items increased noticeably, their impact on safer use practice was limited.39
Amphetamine harm reduction initiatives
Amphetamines cause an elevated sex drive, and there has been an increase in unprotected sex among people taking the drug. This is most commonly reported among men who have sex with men (MSM), transgender populations, sex workers, and among attendees at ‘chem-sex’ parties predominately in European cities. As a result, the risk of HIV transmission from amphetamine-fuelled unprotected sex is rising.40
In the Czech Republic, the frequency of injecting amphetamines has been reduced by offering empty gelatine capsules so that people who normally inject drugs can place the drug inside and swallow them instead.41 However, research on this method is very limited.
Unlike opiates, there are currently no drug dependency treatments for amphetamines, although trials are on-going.40
Barriers to harm reduction for HIV prevention
Harm reduction has been demonstrated as both an effective and efficient way of preventing the transmission of HIV and other blood-borne viruses among drug users. However, a number of barriers prevent their implementation.
Legal and social barriers
A 'war on drugs' approach still prevails in many countries. Law enforcement authorities continue to criminalise the possession of needles and syringes and mount 'crackdowns' on PWID even when they are seeking treatment or visiting healthcare centres for clean needles and syringes or other services. Criminalisation drives PWID away from health and HIV services.42
Stigma and discrimination in healthcare centres also has the same effect. As well as having a detrimental impact upon people receiving treatment, stigma and discrimination later impacts upon those in the recovery process who may be drug-free but are still subject to prejudice in areas such as employment because of their history of drug use. Many advocate for stigma reduction initiatives as part of harm reduction programmes.43
Funding and economic barriers
One of the biggest barriers to harm reduction initiatives is a lack of sustainable funding, which forces programmes to downsize or run at a much reduced rate.44 4 At last estimate in 2010, international donors spent just $160 million on HIV prevention programmes for PWID - 7% of what is required.45
Approximately 75% of PWID live in middle-income countries, making them in the greatest need of harm reduction funding. However, international donor policies are changing, with funds increasingly directed towards low-income countries with bigger, more generalised HIV epidemics. This is regardless of the lack of commitment of national governments to harm reduction policy and funding in middle-income countries, such as the Middle East and North Africa.4
International donors provide the majority of financial resources for harm reduction programmes to prevent HIV - the Global Fund is the single largest funder in this area.46 However, many middle-income countries where the most PWID reside, do not qualify for Global Fund support.47 48
The harm reduction debate
Does harm reduction encourage drug use?
Some critics of harm reduction argue that by reducing the harms associated with drug use, people will be encouraged to consume them. The rationale behind this argument is that by assisting PWID to remain healthy they will regard drugs as safe and start using them or use them more frequently.49
However, a number of studies investigating the impact of harm reduction programmes on drug use have found no evidence that they lead to an increase in drug use. One study emphasises that:
"...people do often decide to participate in an activity more frequently when it is safer, but the increases are smaller, proportionately, than the reductions in harm, so total harm is generally reduced when an activity is made less harmful." 50
Does harm reduction send the wrong message?
Others argue that while harm reduction has proven effective in reducing the harms around drug use, these programmes communicate messages that encourage drug use. Indeed, their implementation implies that these practices are approved or at least, not strongly disapproved.51
A similar line of argument that sex education encourages premarital sex among teenagers has been shown to be inaccurate.52
Is harm reduction an effective form of treatment?
Some dispute harm reduction as an effective form of treatment because enabling drug use keeps PWID in a pattern of addiction.53
However, harm reduction programmes such as methadone maintenance treatment have been found to be particularly effective at retaining people in treatment and reducing heroin use. Moreover, it prevents HIV transmission, reduces mortality, is cost-effective and has population-wide benefits.54
Photo credit: Photo by Kaytee Riek/CC BY-NC-SA 2.0
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US Department of Health and Human Services (2009) 'Guiding Principles and Elements of Recovery-Oriented Systems of Care'
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