Harm reduction programmes: ‘too few, too vulnerable and too underfunded’
People who inject drugs are increasingly left behind in the HIV response, with limited access to harm reduction services that secure their rights and their health.
Initiatives to reach people who use drugs with harm reduction services are "too few, too vulnerable and too underfunded", according to the new 2016 Global State of Harm Reduction Report.
The biennial report by Harm Reduction International shows an acute lack of services for people who use drugs, despite growing political support for harm reduction. Moreover, pledges from governments around the world to ‘end AIDS’ by 2030 will only be achieved by reaching key affected populations such as people who inject drugs.
However, global drug control continues to be carried out via criminalisation and prison sentences, fuelling poor health and human rights violations among people who use drugs across the world.
The provision of clean needles and syringes, and opioid substitution treatment and drug consumption rooms, are vital interventions for reducing transmission of blood-borne illnesses such as HIV and viral hepatitis. They also help link people who use drugs - often marginalised in society - with vital prevention, treatment and support services that they would not otherwise access.
Since the release of the last Global State of Harm Reduction Report, in 2014, there has been no change in the number of countries offering needle and syringe exchange programmes (NSP). Of the 158 countries reporting injecting drug use in 2016, 68 continue to have no NSP provision. While countries, such as Taiwan, Kenya and South Africa have scaled-up access to NSP, some 20 countries have reported less NSP provision than in 2014.
Only four countries have newly implemented opioid substitution therapy (OST) programmes, and only 80 now implement OST globally.
Just ten countries around the world operate drug consumption rooms. These types of facilities provide a safe place for people to inject drugs where they can access clean injecting equipment and health services, and minimise their risk of overdoes and mortality.
Targeting key groups
Even where the level of NSP provision is considered good, reaching certain groups such as migrants and people under 18 years old remains a significant challenge – despite explicit recommendations from the World Health Organization to provide needles to under 18s where necessary.
Prisoners also remain severely underserviced by harm reduction services, despite the fact that 90% of people who inject drugs are incarcerated at some point in their life. Only eight countries provide NSP in prisons, and it is completely unavailable in seven out of nine global regions where the data was collected. But the situation has improved for OST access in prison, with coverage increasing by 21% from 2014.
The report also identifies a rising trend in amphetamine-type stimulant (ATS) use in every region of the world, but highlights that there are few harm reduction services focusing on these substances and the people who use them.
While South East Asia accounts for the majority (60%) of all people who use ATS, other places, such as Europe and Australia, are seeing opioid use decline in favour of ATS. In the Czech Republic, for example, the number of people using methamphetamine has nearly doubled - from 20,000 in 2007 to more than 36,000 in 2014.
Globally, very few ATS users will use harm reduction services - mainly because they don't identify with opioid users, which the large majority of harm reduction services cater for. People using ATS will inject more frequently, so NSPs need to be aware of the increased volume of needles needed if injecting drug use is fuelled by this type of drug.
The report also highlights the alarming rise in deaths from overdose – along with AIDS, the leading causes of death from people who use drugs. The USA accounts for 25% of all global overdose deaths, with rates increasing by 137% since 2000. Increasing access to naloxone, a drug that can reverse the effects of a lethal opioid overdose, without policy restrictions is a vital harm reduction intervention to combat drug-related mortality.
Policy and funding
The report acknowledges the specific and largely positive commitments made this year at the United Nations General Assembly Special Session (UNGASS) on drugs in April, and the UN High Level Meeting on Ending AIDS in June, both of which spoke about delivering interventions for people who use drugs based on health and human rights – even if certain language was left out.
But increased political commitment and funding for harm reduction is gravely needed if any gains are going to be made on health-related global goals. Of particular concern are middle-income countries, now expected to fund their HIV response in light of decreasing international funding. It seems few of these countries have the will to prioritise HIV prevention for people who use drugs.
Katie Stone, the lead author of the report, said that the 2011 UN target to halve HIV among people who inject drugs by 2015 was missed by 80%. "Now people who inject drugs are being ever further left behind," she warned. "Emerging trends such as rising rates of amphetamine injection and overdose death are likely to see the challenges intensify. Without increased political and financial leadership we will not end AIDS or meet other global goals relating to people who use drugs."