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The following are extracts of key statements from UN bodies on HIV and IDUs
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18.1 TECHNICAL BACKGROUND NOTE on the DRAFT DECLARATION OF COMMITMENT (Submitted by the UNAIDS Secretariat at the request of the UNGASS facilitators) 09/05/2001: NATIONS GENERAL ASSEMBLY SPECIAL SESSION ON HIV/AIDS 25 - 27 JUNE 2001 New York.
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Definition of "harm reduction”
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Harm reduction refers to policies and programmes aimed at reducing the adverse health, social and economic consequences of mood altering drugs. Harm reduction can include: (i) abstinence or reduction in consumption of drugs; (ii) prevention of transmission of HIV and other diseases among injecting drug users; and (iii) use of less harmful drugs in place of the more damaging ones. Based on evidence from many countries around the world, harm reduction programmes have proven to be effective in preventing HIV infection among injecting drug users. Effective harm reduction programmes are not limited to the provision of sterile injecting equipment but must also include other components such as AIDS awareness raising and education among drug users and their sex partners, provision of barrier methods to prevent sexual transmission, drug dependence treatment and rehabilitation, treatment of sexually transmitted diseases and other health services; and access to voluntary and confidential counselling and testing. Moreover, local communities, including the drug-user community itself, must be mobilized and participate fully for such package of measures to work. No single element of this package will be fully effective if practised on its own. Harm reduction programmes do not promote drug use and can be implemented in countries alongside programmes on primary prevention of drug use and demand reduction.
Emphasis added
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18.2 Special Session of the General Assembly on HIV/AIDS Roundtable 1: Prevention and care 15th June 2001: NATIONS GENERAL ASSEMBLY SPECIAL SESSION ON HIV/AIDS 25 - 27 JUNE 2001 New York.
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HIV/AIDS is preventable
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There is no cure for HIV/AIDS and, as yet, no vaccine. Therefore, prevention must be central to the response. Given vocal and innovative leadership and strong community involvement, well-targeted, low-cost prevention strategies have been effective in promoting behaviours such as delayed onset of sexual activity, reduction in sexual partners, abstinence and safer sexual practices (including use of condoms). Ensuring the safety of blood and blood products, encouraging evidence-based demand reduction and harm reduction for injecting drug users and managing sexually transmitted infections can also be effective in preventing transmission. It is increasingly possible to prevent transmission of infection from mother to infant. Unfortunately, such approaches have not been implemented on a scale sufficient to halt the pandemic.
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Targeted prevention works
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Targeting prevention efforts towards those particularly vulnerable to HIV infection is most effective. Targeted HIV education and condom promotion among sex workers and their clients in Thailand increased condom use, changed risky behaviour and resulted in rapidly reduced HIV spread. The lessons are being applied with similar success in Cambodia. Comprehensive prevention strategies, including peer outreach, HIV risk reduction counselling and information, needle and syringe programmes and drug dependency treatment, have been shown to be effective in preventing or reducing HIV spread among injecting drug users in many settings. This experience has not yet been applied on a large scale, as the rapid spread of HIV among injecting drug users in the Russian Federation, the newly independent States and Eastern Europe as well as in parts of Asia shows.
(Emphasis added)
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18.3 International Narcotics Control Board (2004) Report of the International Narcotics Control Board for 2003. Vienna: International Narcotics Control Board.
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p 36 The Board maintains the position expressed by it already in 1987 that Governments need to adopt measures that may decrease the sharing of hypodermic needles among injecting drug abusers in order to limit the spread of HIV/AIDS.
p 36 Many Governments have opted in favour of drug substitution and maintenance treatment as one of the forms of medical treatment of drug addicts, whereby a drug with similar action to the drug of dependence, but with a lower degree of risks, is prescribed by a medical doctor for a specific treatment aim. Although results are dependent on many factors, its implementation does not constitute any breach of treaty provisions, whatever substance may be used for such treatment in line with established national sound medical practice.
Article 14 of the 1988 Convention requires parties to adopt appropriate measures aimed at eliminating or reducing illicit demand for narcotic drugs and psychotropic substances, with a view to reducing human suffering. The ultimate aim of the conventions is to reduce harm’
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18.4 Dr. Gro Harlem Brundtland Director-General World Health Organization Moscow, 2 November 2000 Address to the Russian Academy of Medical Science .
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So far, infections have spread predominantly among the rapidly growing group of intravenous drug users. But at the infections rates we are now experiencing and with the close link that exists between drug use and commercial sex, there is an imminent danger of the virus spreading more widely. This, I need not tell you, is a public health emergency.
We know about it. We can see it coming. We can prevent it. But to do so will mean making a series of difficult decisions, many of which lie outside the area of health.
The key to limiting the spread of HIV lies in harm reduction among intravenous drug users. In other words, efforts to stem the spread of drug use must contain an acceptance of the need to provide needles and condoms to those who already are addicted to these drugs.
Research has shown that in order for such programmes to be effective, at least 60% of the high-risk groups must be covered. There is already important experience gained from several pilot projects, but the projects which work well need to be taken to scale.
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18.5 ODCCP Studies in Drugs and Crime Monographs UNAIDS Best Practice Collection UNAIDS Drug Abuse and HIV/AIDS: Lessons learned Case Studies Booklet Central and Eastern Europe and the Central Asian States Vienna and Geneva, April 2001.
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The term “harm reduction” is used in some of the case studies included in the present publication. From the point of view of the United Nations International Drug Control Programme, the term is meant to cover activities aimed at reducing the health and social consequences of drug abuse, an integral part of the comprehensive approach to drug demand reduction, as recognized in the Declaration on the Guiding Principles of Drug Demand Reduction1 adopted by the General Assembly of the United Nations at its twentieth special session, to counter the world drug problem together, convened in 1998. In the present document, the following three principles are referred to as “harm reduction principles”:
(a) Reaching out to injecting drug users;
(b) Discouraging the sharing of contaminated injecting equipment by providing sterile injecting equipment and disinfectant materials;
(c) Providing substitution treatment.
These principles, which are part of the principles for preventing HIV infection among drug users compiled by the World Health Organization (WHO) in cooperation with the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the Council of Europe in 1998,2 should not be viewed in isolation from overall national drug strategies or national acquired immune deficiency syndrome (AIDS) programmes. They are, however, valuable in guiding national policies and programmes as regards the specific goal of reducing human immunodeficiency virus (HIV) transmission among injecting drug users.
Notes
1 General Assembly resolution S-20/3, annex.
2 WHO, Principles for Preventing HIV Infection among Drug Users (WHO Regional Office for Europe, Copenhagen, 1998).
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UNDCP and UNAIDS are aware that so-called “low-threshold” and “harm reduction” interventions are controversial in many environments. They also consider that the term “harm reduction” has been used as a flag for a variety of causes and, as such, has been given disproportionate attention. In the present booklet, an attempt is made to steer clear of political interpretations of the term and instead to build upon an empirical basis and describe practical experiences aimed at improving the wellbeing of drug users, reducing individual and public health risks and, in particular, preventing the transmission of HIV/AIDS among drug users.
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The ability to halt the epidemic involves a three-part strategy: (a) prevention of drug abuse, especially among young people; (b) provision and facilitation of access to drug abuse treatment; and (c) establishment of effective outreach to engage drug users in HIV preventive strategies that protect them and their partners and families from exposure to the virus and encourage the uptake of substance abuse treatment and medical care. A comprehensive strategy to reduce drug abuse and the spread of HIV would offer a broad range of measures, including comprehensive programmes for youth and primary prevention of drug abuse.
Experience around the world indicates that a comprehensive package of measures must be used to prevent the spread of HIV among injectors. There is a need to link such measures with existing health and social services and raise awareness among, and educate, injectors and their sexual partners about HIV risks and safe practices; provide sterile injecting equipment; make available drug treatment programmes; provide HIV infected injectors with access to counselling, care and support and to information about sexually transmitted infection; and provide condoms. Moreover, local communities, including the drug-user community, must be mobilized and participate fully for such a package of measures to work.
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Experience from around the world indicates that a comprehensive package of measures must be used to prevent the spread of HIV among injectors. Such measures must be linked with existing health and social services and include raising awareness among and educating injectors and their sexual partners about HIV risks and safe practices; providing sterile injecting equipment; making available drug treatment programmes; providing access to counselling, and care and support, for HIV-infected injectors and with regard to sexually transmitted infection (STI); and providing condoms. Moreover, local communities— and the drug-user community itself—must be mobilized and participate fully in order for such a package of measures to work. No single element of this package will be effective if practised on its own.
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Box 3. Principles for preventing HIV infection among drug users
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The basic principles* for effective preventive work among injecting drug users at the national and
local levels are:
_ Information, communication and education;
_ Providing easy access to health and social services;
_ Reaching out to injecting drug users;
_ Providing sterile injecting equipment and disinfectant materials;
_ Providing substitution treatment.
These principles should not be seen in isolation from overall national drug strategies or national AIDS programmes. They are, however, valuable in guiding these national policies and programmes with regard to the specific goal of reducing HIV transmission among injecting drug users.
*In this instance, the latter three principles in particular are referred to as “harm reduction” principles.
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Harm reduction principles. In the present document, the following three principles are referred to as “harm reduction principles”:
(a) Reaching out to injecting drug users;
(b) Discouraging the sharing of contaminated injecting equipment by providing sterile injecting equipment and disinfectant materials;
(c) Providing substitution treatment.
These principles are part of the principles for preventing HIV infection among drug users compiled by WHO in cooperation with UNAIDS and the Council of Europe in 1998. Another two principles concern information, communication and education; and provision of easy access to health and social services. The above-mentioned principles should not be viewed in isolation from overall national drug strategies or national AIDS programmes. They are, however, valuable in guiding national policies and programmes as regards the specific goal of reducing HIV transmission among injecting drug users.
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Low-threshold services. Services for drug users are known as low-threshold services when they are easily accessible by clients, and when abstinence is not a prerequisite for service provision. Often, such services work with clients on an anonymous basis. They are designed to attract future clients by offering, besides drug-related services, other services that respond to the immediate needs of clients, such as free or cheap food, clothing or shelter.
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18.6 UN Twenty-sixth special session Resolution adopted by the General Assembly S-26/2. Declaration of Commitment on HIV/AIDS UNITED NATIONS GENERAL ASSEMBLY SPECIAL SESSION ON HIV/AIDS 25 - 27 JUNE 2001 New York.
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By 2005, ensure: that a wide range of prevention programmes which take account of local circumstances, ethics and cultural values, is available in all countries, particularly the most affected countries, including information, education and communication, in languages most understood by communities and respectful of cultures, aimed at reducing risk – taking behaviour and encouraging responsible sexual behaviour, including abstinence and fidelity; expanded access to essential commodities, including male and female condoms and sterile injecting equipment; harm-reduction efforts related to drug use; expanded access to voluntary and confidential counselling and testing; safe blood supplies; and early and effective treatment of sexually transmittable infections.
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18.7 Annex to the Report of 8th Session of ACC Subcommittee on Drug Control 28-29 September 2000 PREVENTING THE TRANSMISSION OF HIV AMONG DRUG ABUSERS A position paper of the United Nations System.
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The aim of this paper is to present a United Nations (UN) system wide position on policy and strategies to prevent the transmission of HIV among drug abusers. Drug abuse and HIV/AIDS issues cut across much of the work of the United Nations family. Both are directly and indirectly associated with many complex public health and social problems. They affect the workplace, undermine social and economic development, and affect the lives and well being of children.
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Deciding on the implementation of the intervention strategies to prevent HIV in injecting drug abusers is one of the most urgent questions facing policy makers. Studies have demonstrated that HIV transmission among injecting drug abusers can be prevented and that the epidemic already has been slowed and even reversed in some cases. HIV prevention activities which have shown impact on HIV prevalence and risk behaviour include AIDS education, access to condoms and clean injecting equipment, counselling and drug abuse treatment.
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Drug abuse treatment is one approach that may have an impact on preventing HIV infection.
Many large-magnitude studies have shown that patients participating in drug substitution treatment such as methadone maintenance, therapeutic communities, and outpatient drug-free programmes decrease their drug consumption significantly. Several longitudinal studies examining changes in HIV risk behaviours for patients currently in treatment have found that longer retention in treatment, as well as completion of treatment, are correlated with reduction in HIV risk behaviours or an increase in protective behaviours. However, studies have found more effectiveness for changing illicit drug use than changing sexual risk behaviour.
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Several reviews of the effectiveness of syringe and needle exchange programmes have shown reductions in needle risk behaviours and HIV transmission and no evidence of increase into injecting drug use or other public health dangers in the communities served. Furthermore, such programmes have shown to serve as points of contact between drug abusers and service providers, including drug abuse treatment programmes. The benefits of such programmes increase considerably, if they go beyond syringe exchange alone to include AIDS education, counselling and referral to a variety of treatment options.
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In 1998, the UN General Assembly adopted the Declaration on the Guiding Principles of Drug Demand Reduction, the first international instrument to deal exclusively with the problem of drug abuse. The Declaration emphasises that demand reduction programmes should cover all areas of prevention, from discouraging initial use to reducing the negative health and social consequences of drug abuse for the individual and society as a whole.
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The Ottawa Charter on Health Promotion (1986) outlines five areas for action: building public health policy, creating supportive environments, strengthening community action, developing personal skills, and reorienting health services. These areas are all relevant to drug abuse issues and HIV/AIDS.
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Drug abuse problems cannot be solved simply by criminal justice initiatives. A punitive approach may drive people most in need of prevention and care services underground. Where appropriate, drug abuse treatment should be offered, either as an alternative or in addition to punishment. HIV prevention and drug abuse treatment programmes within criminal justice institutions are also important components in preventing the transmission of HIV.
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The ability to halt the epidemic requires a three part strategy: (i) preventing drug abuse; (ii) facilitating entry into drug abuse treatment; and (iii) establishing effective outreach to engage drug abusers in HIV prevention strategies that protect them and their partners and families from exposure to HIV, and encourage the uptake of substance abuse treatment and medical care.
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Treatment services need to be readily available and flexible. Treatment applicants can be lost if treatment is not immediately available or readily accessible. Treatment systems need to offer a range of treatment alternatives, including substitution treatment, to respond to the different needs of drug abusers. They also need to provide ongoing assessments of patient’s needs, which may change during the course of treatment. Longer retention in treatment, as well as completion of treatment, are correlated with reduction in HIV risk behaviours or an increase in protective behaviours.
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A comprehensive package of interventions for HIV prevention among drug abusers could include: AIDS education, life skills training, condom distribution, voluntary and confidential counselling and HIV testing, access to clean needles and syringes, bleach materials, and referral to a variety of treatment options. This complete package should be implemented along with drug abuse prevention, especially among young people.
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18.8 Drug Use and HIV Vulnerability Policy Research Study in Asia Task Force on Drug Use and HIV Vulnerability October, 2000 UNAIDS Asia Pacific Intercountry Team Bangkok, Thailand.
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The results of the study, which are documented in this monograph, indicate that in many countries serious legal and political barriers exist, which impede the implementation of effective preventive interventions for the spread of HIV infection among injecting drug users. Such interventions include needle and syringe exchange or distribution and drug treatment as part of comprehensive package of interventions.
Peter Piot
Executive Director
Joint United Nations Programme on HIV/AIDS
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18.9 Drug use and HIV/AIDS UNAIDS statement presented at the United Nations General Assembly Special Session on Drugs Committee of the Whole New York, Tuesday 9 June 1998 UNAIDS Best Practice Collection Key Material Geneva, UNAIDS, 1999.
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Effective Interventions
What specific interventions providing sterile needle injecting equipment have proved effective? One that has proved successful is a needle exchange programme, operated in conjunction with other components of the package. In these programmes, a clean needle and syringe are given out in exchange for a used set. The exchange can be effected by a person, or by a dispensing machine. Countries where needle exchange programmes have been successful as part of an integrated HIV prevention programme for drug injectors include Australia and the United Kingdom --- and, on a smaller scale, Brazil, Nepal and the Russian Federation. There are also many other needle exchange projects now around the world, and a few of them operate in prisons, where there is often a particularly acute problem of drug injecting.
Many studies have now established that needle exchange programmes, if properly run, reduce the number of new cases of HIV infection --- and at the same time do not increase drug use. And we should of course also recognize that strategies for preventing HIV infection in injecting drug users may well also reduce other health risks, including overdoses and the transmission of other bloodborne infections, such as hepatitis B, hepatitis C, syphilis and malaria.
Supportive environment
Beyond these specific essential components, there is still another important requirement. This requirement is to ensure a supportive environment. This means reducing poverty and creating opportunities for education and employment --- the lack of which often leads people, out of sheer despair, to inject drugs. And laws and government policies on drugs are important too. We know that in most places drug use is illegal. Without proper policy and legislative support from above --- whether at national level or local level --- and all the necessary resources, there will be little hope of launching, or of successfully sustaining, comprehensive HIV prevention programmes. And creating a supportive environment also means continuing to do everything possible to educate and inform people ---especially young people --- about drugs, and about their implications for health and social well-being, in language that can readily be understood.
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Reduction of demand
Along with reducing the harm caused, an important parallel strategy is to reduce the demand for drugs. Our goal must be to stop young people from starting to take drugs in the first place ---as well as encouraging existing users of all ages to stop, by participating in treatment programmes.
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18.10 The Warsaw Declaration: A Framework for Effective Action on HIV/AIDS and Injecting Drug Use Warsaw, Poland November 12 – 14, 2003 The Policy Dialogue.
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Two decades after the AIDS epidemic was first recognized, the spread of HIV infection through injecting drug use is an increasingly serious public health problem in many countries and regions of the world. Abundant, high-quality evidence of effective, safe and cost-effective harm reduction strategies exists, yet in many countries, the implementation of such strategies is still “too little and too late.”
The HIV/AIDS pandemic constitutes an unprecedented global crisis, and HIV continues to spread worldwide. At the United Nations General Assembly Special Session (UNGASS) on HIV/AIDS in 2001, all member states of the United Nations adopted a Declaration of Commitment that sets goals and targets for an expanded response to the epidemic. Included are commitments related to reducing HIV transmission among identifiable groups at highest risk (such as injecting drug users) through the provision of a wide range of programmes, including information, education and communication aimed at reducing risk-taking behaviour; expanded access to essential commodities including male and female condoms and sterile injecting equipment; and harm reduction efforts related to drug use a The Declaration also calls on countries to enact, strengthen or enforce laws and regulations that protect against discrimination of people living with HIV/AIDS and members of vulnerable groups.
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All of the prevention strategies needed to reduce the HIV infection rate among injecting drug users are entirely consistent with the international drug treaties b,c have been endorsed by the UN General Assembly, the World Health Assembly, and several high-level UN Commissions, and are included in the operational plans of the World Health Organization (WHO) and the UN Office on Drugs and Crime (UNODC).
The following guiding principles and policy objectives are intended as the foundation for such policy action. They flow from and build upon the UNGASS Declaration of Commitment, the UNAIDS Global Strategy Framework on HIV/AIDS, the WHO Global Health Sector Strategy on HIV/AIDS, and the global priorities outlined in the UNAIDS Report from the XIV International AIDS Conference, Barcelona 2002. They are also informed by specially commissioned papers reviewing the evidence on reducing the risks, harms and costs of HIV/AIDS and injecting drug use and proposing policy approaches.
Reduce HIV transmission among those who inject drugs through strategies which decrease the use of contaminated injecting equipment and increase the adoption of safer injecting practices; and are delivered through sustained high-coverage programmes of information, education and communication aimed at reducing risk-taking behaviour; expanded access to sterile injecting equipment; and increased availability of a range of drug dependence treatment services, including substitution treatment and rehabilitation programmes.
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The principles of ‘harm reduction’ as defined in documents published by the UN Office of Drugs and Crime, the World Health Organization, and the Joint United Nations Programme on HIV/AIDS refer to activities aimed at reducing the health and social consequences of injecting drug use: reaching out to injecting drug users, discouraging the sharing of contaminated injecting equipment by providing sterile injecting equipment and disinfectant materials, and providing a range of drug dependence treatment including substitution treatment. These principles, which are part of the principles for preventing HIV infection among drug users compiled by the World Health Organization in cooperation with UNAIDS and the Council of Europe in 1998, should not be viewed in isolation from overall national drug strategies or national AIDS programmes. They are, however, valuable in guiding national policies and programmes as regards the specific goal of reducing HIV transmission among injecting drug users.
These treaties are: The 1961 Single Convention on Narcotic Drugs; the 1971 Convention on Psychotropic Substances; and the 1988 Convention against Illicit Traffic in Narcotic Drugs and Psychotropic Substances.
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18.11 Joint WHO/UNODC/UNAIDS statement on substitution maintenance therapy World Health Organization, United Nations Office on Drugs and Crime, Joint United Nations Programme on HIV/AIDS, 2004 Geneva 27, Switzerland.
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Substitution maintenance treatment is an effective, safe and cost effective modality for the management of opioid dependence. Repeated rigorous evaluation has demonstrated that such treatment is a valuable and critical component of the effective management of opioid dependence and the prevention of HIV among IDUs.
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Provision of substitution maintenance therapy of opioid dependence is an effective HIV/AIDS prevention strategy that should be considered for implementation – as soon as possible – for IDUs with opioid dependence in communities at risk of HIV/AIDS epidemics. Once HIV has been introduced into a local community of IDUs, there is the possibility of extremely rapid spread. Provision of substitution maintenance therapy should be integrated with other HIV preventive interventions and services, as well as with those for treatment and care of people living with HIV/AID
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18.13 Intensifying HIV prevention, UNAIDS policy position paper. Programme Coordinating Board, Seventeenth meeting, Geneva, Switzerland, 27-29 June 2005.
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Preventing transmission of HIV through injecting drug use- by developing a comprehensive, integrated and effective system of measures that consists of the full range of treatment options, (notably drug substitution treatment) and the implementation of harm reduction measures (through, among others, peer outreach to injecting drug users, and sterile needle and syringe programmes), voluntary confidential HIV counselling and testing, prevention of sexual transmission of HIV among drug users (including condoms and prevention and treatment for sexually transmitted infections), access to primary healthcare, and access to antiretroviral therapy. Such an approach must be based on promoting, protecting and respecting the human rights of drug users.
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