Harm reduction progress: Slow. Uneven. Stagnated

13 December 2018

Harm reduction for the 15.6 million people who inject drugs remains a critical cornerstone to respond to the global epidemics of HIV and hepatitis C – but progress has stagnated.

People who inject heroin relax in their ward at the government-run Jangalak rehabilitation centre in Kabul, Afghanistan.

This week (10 December) Harm Reduction International released their landmark biennial report, The Global State of Harm Reduction 2018, one decade on from when it was first published. In these ten years, getting vital health services to marginalised populations of people who use drugs has been slow, uneven, and now, stagnated.

Harm reduction refers to the provision of an evidence-based public health response for people who inject drugs that traditionally includes needle and syringe programmes (NSP) and opioid substitution therapy (OST), and access to testing and treatment of HIV, tuberculosis (TB) and viral hepatitis B and C. Increasingly, it now also focuses on access to naloxone (a medicine to reverse opioid overdose); drug checking programmes for amphetamine-type stimulants (ATS) and cocaine in nightlife settings; and access to other vital health and wellbeing services sensitive to the needs of these diverse vulnerable populations. These initiatives are also critical to reducing new HIV infections.

In reflection of a changing dynamic of global drug use, this year’s report also chronicles for the first time programming of amphetamine-type stimulants. It is estimated that there are around 35 million ATS users worldwide – and this number is increasing in all regions and requires unique harm reductions responses.

Injecting drug use is present in 179 countries, but just 86 countries provide NSPs – a number which has declined from the last report in 2016. Bulgaria, Laos and the Philippines have all cut these types of programmes and moved towards a punitive approach to drug policy.

Alarmingly, a zero-tolerance rhetoric is spreading and particularly in Asia where an estimated 46% of the global population of people who inject drugs live. Mass arrests, extra-judiciary killings are now an increasing reality for people who use drugs here. “Compounded with diminishing funding for harm reduction in the region, these punitive environments risk us backsliding from the progress we have worked so hard for,” said Ma. Inez Feria, from local Philippine NGO, NoBox Transitions.

The other countries that report stopping their NSP programmes include Argentina and Brazil – mainly because there are not enough people who inject drugs here to warrant their activity. In fact, Latin America has the world’s highest levels of smokable cocaine use, as well as new psychoactive substances (NPS). Here innovative harm reduction interventions are being implemented to tackle these issues, including drug checking at nightclubs and festivals and small-scale projects which provide intensive shelters for long-term support of drug users – successful but oversubscribed.

Global OST coverage has increased slightly from 80 to 86 countries, and the number providing drug consumption rooms has increased from 90 to 117. The lack of OST is perhaps most notable in Russia, where its provision is prohibited by law. Here NSPs are also severely limited, despite 100,000 people becoming newly infected with HIV here each year – a number largely attributed to unsafe injecting practices.

The Russian response is unanimously condemned by international agencies, the Committee on Economic, Social and Cultural Rights (CESCR) noting, “Drug users tend to refrain from seeking medical treatment under the policy of criminalisation, which contributes to increased incarceration of drug users”.

We know that globally prisons are a bedrock for injecting drug use but still, just 10 countries provide NSP and 54 provide OST – despite them being a high-risk environment for blood-borne infections including HIV.

In the Middle East and North Africa (MENA), a lack of progress in harm reduction is threatening the HIV response – between one and four needles are distributed per individual per year in the region and only a few provide OST. Yet it is one of two regions globally where AIDS-related deaths are increasing and over half (57%) of all new HIV infections in the region are among this group. Regional instability and mass migration are fuelling drug consumption and hampering the provision of services here.

Women make up a third of all people who inject drugs globally, but their experiences and vulnerabilities are unique and they require gender-specific harm reduction services which most countries do not cater for.

In Iran, which is a beacon for harm reduction in the MENA region, successful projects such as Khaneh Khorshid are looking holistically at the needs of women providing gender-sensitive ancillary services including referrals to employment agencies and educational institutions.

In Kenya, sub-Saharan Africa's harm reduction leader, women who use drugs are a hidden population along the predominantly Muslim coastal region. Here investment into their broader needs, including providing expert harm reduction training to female drug users for peer-to-peer support, is hoped to be implemented now at the national level.

For the rest of the continent, the picture is decidedly bleak. The large majority of people who use drugs have no access to services, as countries are politically resistant to harm reduction despite endemic HIV in many contexts. Although 10 countries now explicitly support harm reduction in national policy on the continent - an additional three from 2016. New NSPs have also been established in Uganda, Mozambique and Mali.

The US now has the fastest annual percentage rise of drug-related fatal overdose ever recorded, with an increase of 21.4% between 2015 and 2016 alone. Providing naloxone can help this – but getting it into the hands of peer networks where it is actually needed, and out of the hospital, is a continuing challenge.

Katie Stone, Harm Reduction International’s Public Health and Social Policy lead, said: “The lack of progress in implementing harm reduction measures is a major concern and stunting progress in global health. Harm reduction is cost-effective and proven to promote healthier societies. It is disgraceful that governments continue to ignore the evidence in favour of demonising people who use drugs. This is a crisis in need of urgent response.”

Written by Caitlin Mahon

Content Specialist - HIV & Sexual Health