HEALTH, RIGHTS AND DRUGS - HARM REDUCTION, DECRIMINALIZATION AND ZERO DISCRIMINATION FOR PEOPLE WHO USE DRUGS - UNAIDS
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UNAIDS I 2019 HEALTH, RIGHTS AND DRUGS HARM REDUCTION, DECRIMINALIZATION AND ZERO DISCRIMINATION FOR PEOPLE WHO USE DRUGS
CONTENTS Foreword 1 Introduction 2 Recommendations 6 1. People who use drugs: a population under attack 8 2. Harm reduction: linking human rights and public health 16 3. Overcoming the human rights barriers to health, dignity 32 and well-being 4. The role of communities 40 Conclusion 45 Annex 1 46 Annex 2 47 Annex 3 48 Annex 4 49 Annex 5 52 References 53
FOREWORD
In 2016, UNAIDS published a landmark report on HIV and drugs. That report—
Do no harm: health, human rights and people who use drugs—showed how the
world was failing to protect the health and human rights of people who use drugs,
and it provided a road map for countries to reduce the harms that are associated
with drug use, and to turn around their drug-related HIV epidemics.
Three years later, this report, Health, rights and drugs: harm reduction,
decriminalization and zero discrimination for people who use drugs, shows that
people who use drugs are still being left behind. New HIV infections among
adults worldwide declined by 14% between 2011 and 2017, but there has been no
decrease in the annual number of new HIV infections among people who inject
drugs. This is unacceptable: people who use drugs have rights, and too often these
rights are being denied.
In 2016, I wrote that “Business as usual is clearly getting us nowhere” and called
for countries to learn lessons from those that had reversed their HIV epidemics
among people who inject drugs. Despite this, too many countries are failing
to learn those lessons and carrying on with business as usual. As a result of
the current global approach, persistently high rates of HIV, viral hepatitis and
tuberculosis continue among people who inject drugs.
We know what works. There is compelling and comprehensive evidence that
harm reduction—including opioid substitution therapy and needle–syringe
programmes—improves the health of people who inject drugs. It is safe and cost-
effective. Additionally, when people who use drugs have access to harm reduction
services, they are more likely to take an HIV test, and if found to be living with
HIV, enrol in and adhere to HIV treatment.
Decriminalization of drug use and possession for personal use reduces the stigma
and discrimination that hampers access to health care, harm reduction and legal
services. People who use drugs need support, not incarceration.
I’ve seen what works: an opioid substitution programme in Minsk, Belarus,
that helps people dependent on opioids live with dignity; and a health centre
in Saskatoon, Canada, that provides sterile injecting equipment so that people
who inject drugs can prevent the spread of HIV, viral hepatitis and other blood-
borne infections. Such enlightened and effective programmes should be available
wherever and whenever there is a need. Sadly, they are the exceptions, and policies
that criminalize and marginalize people who use drugs are too often the rule.
The time is overdue to revisit and refocus the global approach to drug policy,
putting public health and human rights at the centre. I’ve said it before and I will
say it again: if we are to end AIDS by 2030, we can’t leave anyone behind. And that
includes people who use drugs.
Michel Sidibé
UNAIDS Executive Director
1
INTRODUCTION
“AT THE UNITED NATIONS GENERAL ASSEMBLY SPECIAL SESSION ON THE
WORLD DRUG PROBLEM . . . GOVERNMENTS CAME TOGETHER TO CHART A
NEW PATH FORWARD THAT IS MORE EFFECTIVE AND HUMANE, AND LEAVES
NO ONE BEHIND . . .
“IT IS VITAL THAT WE EXAMINE THE EFFECTIVENESS OF THE WAR-ON-DRUGS
APPROACH AND ITS CONSEQUENCES FOR HUMAN RIGHTS. DESPITE THE
RISKS AND CHALLENGES INHERENT IN TACKLING THIS GLOBAL PROBLEM,
I HOPE AND BELIEVE WE ARE ON THE RIGHT PATH, AND THAT, TOGETHER,
WE CAN IMPLEMENT A COORDINATED, BALANCED AND COMPREHENSIVE
APPROACH THAT LEADS TO SUSTAINABLE SOLUTIONS.”
UNITED NATIONS SECRETARY-GENERAL António Guterres 26 June 2017
People who use drugs have been the inject drugs and their sexual partners B and C—reduce the incidence of
biggest casualties of the global war account for roughly one quarter of blood-borne infections, problem
on drugs. Vilified and criminalized all people newly infected with HIV. drug use, overdose deaths and
for decades, they have been pushed In two regions of the world—eastern other harms. Countries that have
to the margins of society, harassed, Europe and central Asia, and the successfully scaled up harm reduction
imprisoned, tortured, denied services, Middle East and North Africa— have experienced steep declines in
and in some countries, summarily people who inject drugs accounted HIV infections among people who
executed. Billions of dollars spent, a for more than one third of new inject drugs.
considerable amount of blood spilt infections in 2017. Viral hepatitis
and the imprisonment of millions of and tuberculosis rates among people Armed with this overwhelming
people have failed to reduce either the who use drugs also are high in many evidence, grass-roots organizations
size of the drug trade or the number parts of the world. These preventable of people who use drugs,
of people who use psychoactive and treatable diseases, combined harm reduction and human
substances (1). with overdose deaths that are equally rights advocates, and allied
preventable, are claiming hundreds of nongovernmental organizations
Amid the widespread stigma and thousands of lives each year. have played a leading advocacy role
discrimination, violence and poor on harm reduction. Civil society
health faced by people who use This is a problem that has a clear organizations also are instrumental
drugs, people who inject drugs are solution: harm reduction. Study in the delivery of harm reduction
beset by persistently high rates of after study has demonstrated that services, often through trusted peer
HIV. While the incidence of HIV comprehensive harm reduction outreach workers.
infection globally (all ages) declined services—including needle–syringe
by 25% between 2010 and 2017, HIV programmes, drug dependence In 2016, the United Nations (UN)
infections among people who inject treatment, overdose prevention with General Assembly held a Special
drugs are rising (Figure 1). Outside naloxone, and testing and treatment Session on the World Drug Problem.
of sub-Saharan Africa, people who for HIV, tuberculosis, and hepatitis Amid growing calls for a people-
2
Figure 1. Comparison of incidence of HIV, people who inject drugs and total population (all ages),
global, 2011–2017
People who inject drugs Total population
1.8 0.050
1.6 0.044
1.4 0.038
1.2 0.033
HIV incidence (%)
HIV incidence (%)
1.0 0.027
0.8 0.022
0.6 0.016
0.4 0.011
0.2 0.005
0.0 0.000
2011 2012 2013 2014 2015 2016 2017 2011 2012 2013 2014 2015 2016 2017
― Estimate (people who inject drugs) Lower and upper bound ― Estimate (total population) Lower and upper bound
Note: The scales of the vertical axes in each graph are different. HIV incidence is considerably higher among people who inject drugs compared to
the general population. Plausibility bounds for incidence among people who inject drugs are adopted from the new infections’ calculated bounds
rather than directly estimated.
Source: UNAIDS 2018 estimates.
centred, public health and human of HIV infection who face stigma therapy coverage remain low in most
rights-based approach to drug use, and discrimination and restrictive of the 51 countries that have reported
UN Member States agreed to an laws that hamper their access to data to UNAIDS in recent years.
outcome document that took an HIV services (4). The 2016 Political Just three high-income countries
important step forward: it called Declaration on Ending AIDS contains —Austria, Luxembourg and
for effective public health measures a commitment to “saturating areas Norway—reported that they had
to improve health outcomes for with high HIV incidence with a achieved UN-recommended levels
people who use drugs, including combination of tailored prevention of coverage for these programmes
programmes that reduce the impact interventions,” including harm (Figure 2). Those three countries
of the harms sometimes associated reduction, and it encourages UN are home to less than 1% of the
with drug use. The outcome Member States to reach 90% of those global population of people who
document also underlined the need at risk of HIV infection with these inject drugs. A recent systematic
to fully respect the human rights services (4). review of published harm reduction
and fundamental freedoms of people programme and survey data similarly
who use drugs, and it called on In 2017, the International Narcotics found that less than 1% of people who
countries to consider alternatives to Control Board (INCB) also called inject drugs globally live in countries
punishment for drug offences (3). for the abolition of the death penalty with sufficient access to these critical
for drug-related offenses, stressing harm reduction services (7).
A few months after the 2016 Special the importance of human rights
Session, the UN General Assembly and public health principles in drug This low coverage is perpetuated by
convened a high-level meeting on the control (5, 6). low investment. Only a handful of
global HIV epidemic. The meeting low- and middle-income countries
concluded with the 2016 Political However, change within countries have reported expenditures to
Declaration on Ending AIDS that has been slow. Three years after the UNAIDS that are sufficient to meet
acknowledged people who inject 2016 Special Session, needle–syringe the needs of people who inject drugs.
drugs as a key population at high risk distribution and opioid substitution Domestic financing is particularly
3
“MANY POLICY-MAKERS CONTINUE TO THINK THAT HARM REDUCTION
ENCOURAGES DRUG USE, AND [THAT] OPIOID SUBSTITUTION
TREATMENT IS ABOUT REPLACING ONE DRUG WITH ANOTHER.
IT MEANS THAT MORE ADVOCACY WORK SHOULD BE DONE. AS CIVIL
SOCIETY, WE SEE IT AS OUR PREROGATIVE TO WORK WITH THE
GOVERNMENTS AND CONVINCE THEM THAT HARM REDUCTION WORKS.”
Elie Aaraj, Middle East and North Asia Harm Reduction Network (2)
Figure 2. Coverage of needle–syringe programmes and opioid substitution therapy, by country,
last year available (2013–2017)
100
90
Malaysia Norway
80 France
People who inject drugs receiving opioid substitution therapy (%)
70
Malta
Luxembourg
60 Portugal Ireland
Cyprus Greece Austria
Spain
50
40
40
Mauritius
30 Italy Finland
Morocco
Belgium
Serbia Bulgaria
Lithuania Viet Nam
20
North Macedonia India
Czechia
Georgia Slovenia
Romania Myanmar
Kenya Estonia Cambodia
Albania Iran (Islamic
Republic of) Bosnia and Herzegovina
10 Latvia
Dominican Republic
Seychelles
United Republic Armenia Kyrgyzstan
of Tanzania Nepal Ukraine
Bangladesh Tajikistan
Thailand Afghanistan
0 Indonesia Azerbaijan Republic of Kazakhstan
Belarus Moldova
0 50 100 150 200
200 250 300 350 400 450 500
Needles–syringes distributed per year per person who injects drugs
Source: UNAIDS Global AIDS Monitoring, 2013–2017.
4
low: in 31 countries that reported services. Czechia, the Netherlands, use—that are proven to have
expenditure data to UNAIDS, 71% Portugal and Switzerland are negative health outcomes and that
of the spending for HIV services for among a handful of countries that counter established public health
people who use drugs was financed have decriminalized drug use and evidence (21).
by external donors (8–10). possession for personal use and that
have also financially invested in harm The Declaration and Plan of Action
Even when services are available, reduction. The number of new HIV on International Cooperation
criminalization of drug use and harsh diagnoses among people who inject towards an Integrated and Balanced
punishments discourage their uptake. drugs in these countries is low (14). Strategy to Counter the World
Punishments can include lengthy Drug Problem, adopted at the
prison sentences, heavy fines and, in Multiple UN and regional human 2009 high-level segment of the
some cases, even the death penalty. rights mechanisms—including the Commission on Narcotic Drugs,
An estimated one in five persons in UN Special Rapporteur on the right set targets for countries to achieve
prison globally are incarcerated for to the highest attainable standard by 2019, including a target to
drug-related offenses; approximately of health, the UN Committee on “eliminate or reduce significantly and
80% of these cases are related to Economic, Social and Cultural measurably” the supply and demand
possession alone (11, 12). People in Rights, the African Commission on for these drugs (22). As this deadline
detention often have less access to Human and Peoples’ Rights, and approaches, data from the United
harm reduction services and face the Office of the United Nations Nations Office on Drugs and Crime
greater risk of HIV, tuberculosis and High Commissioner for Human (UNODC) show that the global war
viral hepatitis transmission, as well as Rights (OHCHR)—have found that on drugs—and the punitive response
other health risks. Intersecting forms criminalization of activities related to drug use—has failed to achieve
of discrimination and vulnerability to personal drug use can negatively these targets (1). Recognition of
related to gender, age and race have affect a person’s health and well- this failure is growing, and more
different impacts on people who being, and they have recommended communities, cities and countries
use drugs. decriminalization of activities related that are grappling with the realities
to personal drug use (15–19). In of drug use are embracing harm
Thirty-five countries retain the death advance of the 2016 UN General reduction. Meanwhile, much of the
penalty for drug-related offences, and Assembly Special Session on the world continues to wage a war on
the Philippines has seen thousands World Drug Problem, four UN drugs and to turn its back on people
of extrajudicial executions of people Special Rapporteurs joined the Chair who use drugs, slowing progress on
who use drugs since a national of the Committee on the Rights the pledges they made at the UN
crackdown began in 2016 (11, 13). of the Child to issue a statement General Assembly in 2016.
Some countries have removed describing the current international
criminal laws on drug possession drug control regime as “excessively As a new chapter begins in the
and use, but they instead use punitive” and calling for human response to the world drug problem,
administrative laws to detain people rights obligations to be better UNAIDS calls on countries to end
who inject drugs in compulsory drug integrated into the international drug the divide on drug use. Stronger
detention centres that have been control regime (20).1 and more specifics commitments
linked to torture, forced labour and for a human rights-based, people-
other abuses (11). In 2017, 12 UN entities issued centred and public health approach
a joint statement on stigma and to drug use are needed, and those
In sharp contrast, decriminalization discrimination within health-care commitments need to be rapidly
of drug use and possession for settings that called on countries to transformed into national and local
personal use has been shown to review and repeal punitive laws— laws, policies, services and support
facilitate the provision, access and including the criminalization of that allow people who use drugs to
uptake of health and harm reduction drug use and possession for personal live healthy and dignified lives.
1. The four Special Rapporteurs were Mr Juan E Méndez (Special Rapporteur on torture and other cruel, inhuman or degrading treatment or punishment), Mr Christof
Heyns (Special Rapporteur on extrajudicial, summary or arbitrary executions), Mr Seong-Phil Hong (Chair-Rapporteur of the UN Working Group on Arbitrary
Detention), and Mr Dainius Pûras (Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health).
They joined Benyam Dawit Mezmur, Chair of the UN Committee on the Rights of the Child.
5
RECOMMENDATIONS The overarching purpose of drug control should be first and foremost to ensure the health, well-being and security of individuals, while also respecting their agency and human rights at all times. As UN Member States reflect on what has occurred in the 10 years since the 2009 Political Declaration and Plan of Action on International Cooperation towards an Integrated and Balanced Strategy to Counter the World Drug Problem, UNAIDS reiterates its call for a public health and human rights approach to drug use, calling on countries to adopt the following recommendations. Implement harm reduction services Fully implement comprehensive harm reduction and HIV services— including needle–syringe programmes, opioid substitution therapy, naloxone and safe consumption rooms—on a scale that can be easily, voluntarily and confidentially accessed by all people who use drugs, including within prisons and other closed settings. Ensure that all people who are drug dependent have access to noncoercive and evidence-informed drug dependence treatment that is consistent with international human rights standards. All forms of compulsory drug and HIV testing and compulsory drug treatment should be replaced with voluntary schemes. The use of compulsory detention centres for people who use drugs should cease, and existing centres should be closed. Ensure widespread availability of naloxone, including injectable and noninjectable (nasal) forms, through community-based distribution of this life-saving public health measure. All people likely to witness an overdose—such as health workers, first responders, prison staff, enforcement officials, family members and peers—should have access to naloxone to enable timely and effective prevention of deaths from opioid overdose among people who use drugs. Access to health-care services Ensure that all people who use drugs have access to prevention, testing and life-saving treatment for HIV, tuberculosis, viral hepatitis and sexually transmitted infections (STIs). Ensure adequate availability of and appropriate access to opioids for medical use to reduce pain and suffering. Facilitate access for people who use drugs to HIV, sexual and reproductive health, and other health services through an integrated, people-centred approach that is gender-responsive and youth-friendly. 6
Ensure that universal health coverage systems are structured in a way
that makes services accessible and acceptable to people who use drugs,
including both integrated and stand-alone services, as needed.
Human rights, dignity and the rule of law
Protect and promote the human rights of people who use drugs
by treating them with dignity, providing equal access to health and
social services, and by decriminalizing drug use/consumption and the
possession, purchase and cultivation of drugs for personal use.
Where drugs remain illegal, adapt and reform laws to ensure that people
who use drugs have access to justice (including legal services) and do
not face punitive or coercive sanctions for personal use, and that policing
measures encourage people to access harm reduction and health
services voluntarily. Ensure the principle of proportionality is applied for
drug-related crimes, and put in place public health-based alternatives to
incarceration, administrative penalties and other forms of corrective action.
Ending stigma and discrimination
Take action to eliminate the multiple intersecting forms of stigma and
discrimination experienced by people who use drugs, including while
accessing health, legal, education, employment and social protection
services, or when interacting with law enforcement.
People-centred approach
Include, support, fund and empower communities and civil society
organizations—including organizations and networks of people who use
drugs—in all aspects of the design, implementation, and monitoring and
evaluation of drug policies and programmes, as well as in the design and
delivery of HIV, health and social protection services.
Ensure an enabling legal environment for civil society organizations of and
for people who use drugs so they can operate without fear of intimidation,
threat, harassment or reprisal.
Ensure use of social contracting modalities for engaging allied
nongovernmental organizations for the delivery of community-led and
community-based harm reduction services.
Investment
Undertake a rebalancing of investments in drug control to ensure
sufficient funding for human rights programmes and health services,
including the comprehensive package of harm reduction and HIV services,
community-led responses and social enablers.
7PEOPLE WHO USE DRUGS: A POPULATION UNDER ATTACK 1
PEOPLE
WHO USE
DRUGS: A
POPULATION
UNDER
ATTACK
Activists for people who use drugs and sex workers at their office in Kyiv, Ukraine.
Credit: Global Fund/Efrem Lukatsky.
One in 18 adults use drugs (Figure 4). Similarly, western and
An estimated 275 million people central Europe and North America
worldwide—5.6% of the adult had a greater share of people who
population—used drugs at least once inject drugs than their share of the
in 2016 (1). Cannabis is the most global population (2–4).
widely used recreational drug.2 An
estimated 19.4 million people used Almost half of all people who injected
opioids, many of whom injected their drugs worldwide in 2016 lived in just
drugs (Figure 3). Some non-opioid three countries: China, the Russian
drugs—such as amphetamines, Federation and the United States
barbiturates, cocaine and of America. Although these three
methamphetamines—are sometimes countries together account for just
consumed via injection. 27% of the global population (aged
15–64 years), they are home to 45% of
Injecting drugs carries a high risk of the world’s people who inject drugs—
HIV and viral hepatitis transmission an estimated 4.8 million people (1, 2).
if sterile injecting equipment is
not easily accessible and injecting Drug control efforts have little
equipment is shared among users. In impact
2016, more than half of people who The billions of dollars spent each year
inject drugs were living with hepatitis on efforts to reduce the supply of
C, and one in eight were living and demand for illicit drugs have not
with HIV. resulted in a reduction of the overall
number of people who use drugs.
The prevalence of injecting drug use
varies by region and country. For The United Nations Office on Drugs
example, the eastern Europe and and Crime (UNODC) estimates
central Asia region was home to suggest that the number of people
21% of the world’s people who inject who use drugs each year may have
drugs (aged 15–64 years) in 2016, risen between 2006 and 2016, largely
despite having only 4% of the global due to increased use of cannabis
population within that age range (Figure 5). However, this increase
2. Not including alcohol and tobacco, which are not included in the estimate.
9Figure 3. Population size of people who use drugs, global, 2016
Among the 275 million
people globally who used
drugs at least once in 2016
19.4 million used opioids and
10.6 million injected
drugs, among whom
HIV+ 1.26 million were living with HIV.
Source: World drug report 2018. Vienna: UNODC; 2019.
Figure 4. Number of people who inject drugs (aged 15–64 years), by region, 2016
Asia and the Pacific
Western and central Europe and North America
Eastern Europe and central Asia
Russian China
Federation Latin America and the Caribbean
Middle East and North Africa
Eastern and southern Africa
Western and Central Africa
United States
Source: World drug report 2018. Vienna: UNODC; 2019.
10Figure 5. Global trends in estimated number of people who use drugs (aged 15–64 years),
2006–2016
400
350
Number of people who use drugs (millions)
300
250
200
150
100
50
0
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Number of people who use drugs Number of people with drug use disorders
Source: World drug report 2018. Vienna: UNODC; 2019.
falls within the uncertainty bounds ages) between 2010 and 2017.4 The infection. Globally, an estimated
of the estimates and cannot be decreasing size of the population 51.9% of people who inject drugs had
considered conclusive. Meanwhile, of people who inject drugs and the hepatitis C infection in 2016; among
the number of people with drug use increasing incidence of HIV within the 71 million people with hepatitis
disorders has stayed roughly the same that population have contributed C globally in 2016, an estimated 8%
over the decade.3 to an increase in the percentage of were people who inject drugs (7, 8).
people who inject drugs who are
UNODC and UNAIDS estimates living with HIV (up from 11.4% in An estimated 7% of people living with
suggest that the global number of 2011 to 12.5% in 2016) (1, 5). HIV who inject drugs have hepatitis
people who inject drugs may be B (8). As more and more people
slowly declining, but this trend also Hepatitis B and C and living with HIV access antiretroviral
lies within the uncertainty bounds of tuberculosis are also therapy and thus live longer,
the estimates. widespread coinfection with chronic hepatitis B
Hepatitis C virus is more resilient is associated with accelerated
HIV is on the rise among than HIV, and it is capable of progression of cirrhosis and higher
people who inject drugs surviving on drug preparation and rates of liver-related mortality (8).
The incidence of HIV infection injecting equipment for several
among people who inject drugs days to weeks (6). Hepatitis C virus People who use drugs tend to
appears to have risen over the past is thus easier to transmit when have higher rates of tuberculosis
decade, from 1.2% [1.0–1.3%] in injecting equipment is shared, and and higher prevalence of latent
2011 to 1.4% [1.2–1.5%] in 2017. when people who inject drugs do tuberculosis infection than others
This is in contrast to the overall not have access to needle–syringe (9). This is in part due to high
trend worldwide, which shows a programmes, hepatitis C infection incarceration rates of people who use
25% decline in HIV incidence (all is often more common than HIV drugs: the risk of tuberculosis disease
3. UNODC defines people with drug use disorders as a subset of people who use drugs. People with drug use disorders need treatment, health and social care, and
rehabilitation. Under the UNODC definition, the harmful use of substances and dependence are features of drug use disorders.
4. UNAIDS does not calculate estimates of HIV prevalence and incidence among noninjecting drug users. Data are not routinely collected for this population in the Global
AIDS Monitoring system or the HIV estimates process.
11in prisons is on average 23 times Although few countries report condemnation of the UN Committee
higher than the risk in the general sex-disaggregated data to UNAIDS on the Elimination of Discrimination
population (10). Among people living on people who inject drugs, the against Women (CEDAW) (13, 14).
with HIV, those who inject drugs majority of publicly available data CEDAW, along with the UN Working
have a twofold to sixfold greater risk suggest that women who inject drugs Group on Arbitrary Detention, has
of developing tuberculosis than those have a greater vulnerability than noted with concern the increasing
who do not (10). men to HIV, hepatitis C and other number of women incarcerated
blood-borne infections (1). In 16 of for drug-related crimes, as well
Prevalence of multidrug resistant the 21 countries that reported such as the disproportionate rates of
tuberculosis is also high among data since 2013, women who inject incarceration of poor and otherwise
people living with HIV who use drugs were more likely to be living marginalized women. Those who
drugs (9). In eastern Europe, access with HIV than their male peers. In are incarcerated often lack access to
to treatment for multidrug resistant Germany, Uganda and Uzbekistan, gender-sensitive health and harm
tuberculosis is low; as a result, HIV prevalence among women who reduction services (15, 16).
mortality is high (11, 12). inject drugs was almost twice as high
as among their male peers (Figure 6). Young people
Women Drug use among young people is
Drug use is more common among Women also appear to be generally more common than among
men, with women accounting for just disproportionately affected by the older people, with substance use
one in three people who use drugs criminalization of drugs, with higher often peaking at 18 to 25 years (1).
and one in five people who inject rates of convictions and incarceration Early life adversity is associated with
drugs (1). However, women who use for drug-related offences than men. an increased risk of substance use
drugs face special health risks. This has drawn the attention and and dependence (18). For example,
Figure 6. HIV prevalence among people who inject drugs by sex, last year available (2013–2017)
60
50
40
HIV prevalence (%)
30
20
10
0
it
y
m
ia
o
y
n
na
n
e
nd
ia
an
n
ia
al
ne
da
s
us
a
ne
ar
an
ni
ta
ta
ec
ta
wa
ic
l
d
tv
g
do
ar
ra
i
st
i
an
la
ng
ex
Ch
to
ra
In
rtu
kis
s
zs
m
pi
La
re
Ku
kh
iki
l
st
er
ng
Be
Uk
Ug
Es
y
M
er
ilip
G
Hu
be
Po
Au
rg
j
tz
za
Ta
Ki
G
i
Ky
Uz
Ph
Ka
Sw
d
ite
Un
Male Female
Source: UNAIDS Global AIDS Monitoring, 2013–2017.
12CASE STUDY:
MEETING THE NEEDS
OF WOMEN IN CONFLICT
SETTINGS
Women who use drugs in conflict and emergency settings face complex transgender and intersex (LGBTI)
challenges. people and sex workers who use
drugs all face additional vulnerability
The armed conflict in eastern Ukraine, which started in 2014, has to police harassment and misconduct
had a significant negative impact on people who use drugs. The and to violence in detention (19, 20).
nongovernmental organization Svitanok Club has conducted special Stigma and discrimination, abuse or
surveys to understand the needs of this highly stigmatized population. violence linked to sexual orientation,
Many women who use drugs migrated to other parts of Ukraine to avoid gender identity and sex work are
the conflict, but they returned when they were unable to find housing or also widely reported in health-care
employment, a challenge made worse by stigma and discrimination. settings (21). These multiple risks
are likely to lead to higher HIV
“They now live in extreme poverty, and simply have no money to pay for prevalence than among those who
rent,” says Svetlana Moroz of Svitanok Club. The women that Moroz has have only one type of risk (22–26).
interviewed are often homeless. “They returned back to their homeland,
but many still lost their homes.” Many rely on other family members, Sex workers who use drugs face
leaving them vulnerable to intimate partner violence. multiple forms of violence,
violations of privacy, and stigma
Moroz says that the women she studied—many of whom are survivors of and discrimination (27). Chemsex—
abuse, including kidnappings and beatings—need specialized services. intentional sex under the influence of
“They need psychological and psychotherapeutic support, and none of various psychoactive drugs—is on the
this is available. No one works with them on their traumatic experience rise among gay men and other men
of torture or other violence” (17). who have sex with men (28, 29). The
drugs used in chemsex are reported
to reduce inhibitions and intensify
pleasure, and chemsex may involve
unprotected sexual activity with
the risk of methamphetamine use compared to older people who multiple partners. For these reasons,
is higher among young people inject drugs is likely a factor in this it is associated with increased rates of
who grow up in an unstable family difference. STIs, including HIV and hepatitis C
environment, and many studies have (30–32).
observed high levels of substance Key populations
use—including injecting drug use— As well as people who inject drugs, Violence
among street children (1). key populations at high risk of HIV People who use drugs face an elevated
infection include sex workers, gay risk of many forms of violence. For
Only a handful of countries men and other men who have sex example, more than half of people
have reported to UNAIDS with men, transgender women and who inject drugs surveyed in Pakistan
age-disaggregated estimates of HIV prisoners. reported that they had experienced
prevalence among people who inject physical violence in the previous
drugs. These data generally show Many people within these key 12 months (33). In the Philippines,
that HIV prevalence is lower among populations face multiple risks. a national campaign to crack down
younger people who inject drugs Because same-sex sexual behaviour, on the drug trade has resulted in
(under 25 years of age). Fewer years sex work, and in some cases, diverse thousands of extrajudicial killings
spent at higher risk of HIV infection gender identities, are criminalized in (34, 35).
(e.g., sharing injecting equipment) many countries, lesbian, gay, bisexual,
13Figure 7. Age-adjusted drug overdose death rates, United States, 1999–2017
30
25
Deaths per 100 000 standard population
20
15
10
5
0
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
― Male ― Female ― Total
Notes: Deaths are classified using the International Classification of Diseases, 10th Revision. Drug poisoning (overdose) deaths are
identified using underlying cause of death codes X40–X44, X60–X64, X85, and Y10–Y14.
Sources: NCHS, National Vital Statistics System, Mortality. Data Brief 329. Drug overdose deaths in the United States, 1999–2017.
Data table for Figure 7. Age-adjusted drug overdose death rates: United States, 1999–2017 (https://www.cdc.gov/nchs/data/
databriefs/db329_tables-508.pdf, accessed 25 February 2019).
Women who use drugs report and other blood-borne infections and deaths have recently skyrocketed in
particularly high rates of both STIs, and it can negatively affect the the United States, climbing by 16%
gender-based violence and police ability of women to negotiate safer annually since 2014, reaching 70 237
abuse (36). A 2016 study in sex and safer drug use (38). deaths in 2017 (Figure 7) (40). In
Kyrgyzstan found that 60% of the 2017, the lifetime odds of dying from
women who use drugs surveyed in Mortality an accidental opioid overdose in the
the study reported surviving physical Stigma and discrimination, violence United States exceeded for the first
or sexual violence in the past year and low access to health and harm time the lifetime risk of dying in a
(36). Similarly, a study in Indonesia reduction services together drive motor vehicle crash (Figure 8).
found that more than 50% of women higher rates of mortality among
who use drugs reported physical people who use drugs. Globally, Canada is also experiencing an
or sexual violence from their male there were 450 000 deaths directly or ongoing public health crisis of opioid
partners in the previous year (37). indirectly related to drug use in 2015 overdoses. There were more than
Sixty per cent of women in the same (1). The majority of these deaths were 9000 opioid-related deaths between
study who reported contact with law caused by overdose or were related January 2016 and June 2018, and 72%
enforcement also reported verbal to infections of HIV and hepatitis C. of accidental overdose deaths in 2017
abuse by police, while 27% reported These were deaths that could have involved either fentanyl or fentanyl
physical abuse and 5% reported been prevented by harm reduction. analogues (41). In the European
sexual abuse. Violence perpetrated by Union, Norway and Turkey, opioid
police tends to be underreported due Opioid-related deaths are on the overdose deaths increased 34% in five
to the risk of retaliation. rise in many parts of the world. In years, from 6800 in 2012 to 9100 in
the United States, deaths related 2016 (Figure 9) (42).
Violence of all kinds exacerbates the to drug use increased sixfold from
existing risk of transmission of HIV 1980 to 2014 (39). Drug overdose
14Figure 8. Lifetime odds of dying due to injury, selected causes, United States, 2017
Opioid drugs Falls Suicide
1 in 96 1 in 114 1 in 88
Motor vehicle accidents
1 in 103
Pedestrian Motorcyclist Drowning
incident
1 in 858 1 in 1117
1 in 556
Gun assault
1 in 285
Fire or smoke Food
choking
1 in 1474 1 in 2696
Unintentional injuries Intentional self-harm Assault
Source: National Center for Health Statistics. Mortality data for 2017 are compiled from data provided by the 57 vital statistics jurisdictions through
the Vital Statistics Cooperative Program. Deaths are classified on the basis of the 10th Revision of The international classification of diseases (ICD-10),
which became effective in 1999. See: https://injuryfacts.nsc.org/all-injuries/preventable-death-overview/odds-of-dying/data-details/.
Figure 9. Drug-induced mortality, European Union member states, Norway and Turkey,
2009–2016
10 000
8000
Drug-induced mortality
6000
Rest of EU
Poland
Italy
4000
Norway
France
Spain
2000 Sweden
Turkey
Germany
0 United Kingdom
2009 2010 2011 2012 2013 2014 2015 2016
Source: Statistical bulletin 2018–overdose deaths. In: European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) [website]. Lisbon: EEMCDDA
(http://www.emcdda.europa.eu/data/stats2018/drd).
15HARM REDUCTION: LINKING HUMAN RIGHTS AND PUBLIC HEALTH 2
HARM
REDUCTION:
LINKING
HUMAN RIGHTS
AND PUBLIC
HEALTH
The provision of harm reduction A comprehensive approach
services has consistently reduced The World Health Organization
morbidity and mortality among (WHO),United Nations Office on
people who use drugs. Drugs and Crime (UNODC) and
UNAIDS recommend delivering a
The foundation of a rights-based comprehensive set of harm reduction
public health approach to drug use, services to people who inject drugs,
harm reduction is a set of principles including the following:
and an evidence-informed package
of services and policies that seeks Needle–syringe programmes.
to reduce the health, social and
Drug dependence treatment,
economic harms of drug use.
including opioid substitution
Harm reduction is grounded in the
therapy.
recognition that not all persons who
use drugs are able or willing to stop HIV testing and counselling.
using drugs. The principles of harm
Antiretroviral therapy.
reduction include trust, inclusivity,
non-judgmental attitudes, flexibility Prevention and treatment of
to adapt to the needs of clients, sexually transmitted infections
and the active participation of the (STIs).
community of people who use drugs
Condom programmes for people
in planning, implementation and
who inject drugs and their sexual
evaluation. Harm reduction services
partners.
should also respect such fundamental
rights as privacy, bodily integrity, Targeted information, education
dignity, due process and freedom and communication for people
from arbitrary detention. who inject drugs and their sexual
partners.
Diagnosis, treatment and
vaccination for viral hepatitis.
Prevention, diagnosis and
“PEOPLE WHO INJECT DRUGS CAN BE treatment of tuberculosis (1).
FOUND IN ALL SEGMENTS OF THE SOCIETY.
WHO has also recommended
THEY ARE A PRIORITY TARGET OF SENEGAL’S opioid overdose management with
NEW HIV/AIDS STRATEGY.” community distribution of naloxone
for overdose prevention. Pre-exposure
Safiatou Thiam, Executive Secretary of the Senegal National Council for the prophylaxis (PrEP) is not explicitly
Fight against AIDS (9) recommended for people who inject
17Figure 10. A comprehensive approach to HIV and other harms associated with
drug use
Information, HIV testing Prevention, Anti-
education and and counseling diagnosis and retroviral
communication treatment for therapy
tuberculosis
Needle– Drug Diagnosis,
syringe Condom dependence treatment, Prevention and
programmes programmes treatment and vacci-
incl. opioid treatment of
nation
substitution STIs
for viral
therapy hepatitis
Opioid overdose Pre-exposure
management prophylaxis
with naloxone (PrEP)
g
endence
atment,
luding opioid
stitution
rapy (OST) Source: Technical guide for countries to set targets for universal access to HIV prevention, treatment and care for injecting drug users.
Geneva: WHO, UNODC, UNAIDS; 2012; and Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations.
2016 update. Geneva: WHO; 2016.
drugs but should be available on of 68 countries that have reported among people who inject drugs
demand to them (2). Evidence also programme data to UNAIDS since who continue to share injecting
suggests that safe consumption sites 2013, only 14 have distributed the equipment (7). However, if the
offer many benefits (3). recommended amount. Global injecting equipment provided does
programme coverage has remained not fit local preferences, uptake may
Needle–syringe programmes largely static for the past seven years be low. WHO recommends offering a
Evidence (see Annex 1). range of needle–syringe types to meet
Needle–syringe programmes reduce diverse needs (1, 8).
the probability of transmission of Maximizing impact
HIV and other blood-borne diseases Well-designed needle–syringe Drug dependence treatment,
by lowering the rates of sharing of programmes help clients access a including opioid substitution
injecting equipment among people range of related services, including therapy
who inject drugs (4, 5). drug dependence treatment, health Evidence
care, and legal and social services. Evidence-informed forms of drug
Coverage Programme managers should also dependence treatment, such as
To prevent HIV transmission, WHO understand the types of drugs that opioid substitution therapy using
recommends distributing 200 needles are injected, how they are injected methadone or buprenorphine, curb
and syringes per person who injects and the type of injecting equipment the use of opioid drugs. They greatly
drugs each year. In 2018, 86 countries that is preferred. Providing low reduce the risk of HIV and hepatitis
had at least one operational needle– dead-space syringes helps decrease C acquisition and reduce the risk of
syringe programme (6). However, the risk of transmission of HIV overdose (10–13). Opioid substitution
18Figure 11. Age-adjusted rates of overdose-related mortality, observed and modelled,
Croatia, 2001–2015
40
35
Opioid substitution therapy
Age-specific mortality per 1 million population
introduced in 2007
30
25
20
15
10
5
0
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
― Modeled age-adjusted rate Observed age-adjusted rate
Source: Handanagic S, Bozicevic I, Sekerija M, Rutherford GW, Begovac J. Overdose mortality rates in Croatia and factors associated with
self-reported drug overdose among persons who inject drugs in three Croatian cities. Int J Drug Policy. 2019;64:95–102.
therapy has also been shown to be effective for pharmaceutical substitution therapy programmes
substantially increase HIV treatment opioid dependence (16). Effective in 86 countries (6). A number
enrollment, treatment adherence and substitution treatment for dependence of countries are scaling up these
viral suppression among people living on stimulants, including cocaine, is services: of the 23 countries that
with HIV who inject drugs (14). in the pipeline; treatment trials using reported coverage data to UNAIDS
psychostimulants appear promising in the last three years, 12 showed
Following the rapid escalation of and deserve further study (17). significant increases in the number
overdose-related deaths in three cities of people enrolled. Afghanistan and
in Croatia between 2001 and 2007, Coverage Georgia reported large percentage
the introduction and scale-up of United Nations (UN) guidelines increases, albeit from very low levels
opioid substitution therapy coincided recommend 40% coverage of opioid of coverage. Malaysia added more
with a reduction in overdose substitution therapy (10). While than 58 000 patients over a three-year
mortality rates by an average of 8% there is uncertainty in the estimates period.
annually between 2007 and 2015 of opioid users in many countries,
(Figure 11) (15). in most countries that have reported Maximizing impact
data to UNAIDS, the coverage of Only one in nine people who use
There is also demand for effective opioid substitution therapy among drugs develop drug use disorders
treatment and support for people who inject drugs is lower such as drug dependence (83).
dependence on noninjecting than desirable (see Annex 2). Regardless, many people who use
drugs and nonopioid drugs. Harm Reduction International has drugs are forced to enter compulsory
Opioid substitution therapy may documented the existence of opioid drug dependence programmes,
19PRISONS
Despite the universally-recognized principle that prisoners should enjoy Maximizing impact
the same standards of health care that are available in the community— It is essential to routinely offer
and the explicit recognition by governments that health services in voluntary, confidential HIV testing to
prisons should ensure continuity of treatment and care, including for drug people who use drugs, such as when
dependence and HIV, tuberculosis and other infectious diseases—harm individuals access needle–syringe
reduction coverage in prisons remains low (23–26). services and drug dependence
treatment.
In 2017, only seven countries reported to UNAIDS that they had needle–
syringe programmes in prisons, and just 18 reported prison programmes Innovative approaches to reaching key
for opioid substitution therapy. The actual number may be higher: these populations have also been shown to
did not include European Union member states, some of which also offer deliver results, although some bring
harm reduction in prisons (27). risks that must be carefully addressed.
These innovative approaches include
community-based testing, self-testing
and diverse forms of index testing.
including in cases where treatment HIV testing and treatment
is not clinically indicated. This is a Evidence All HIV testing should be undertaken
violation of their rights, and WHO UN Member States have committed only with informed consent (28).
and UNODC have stressed that drug to achieving the 90–90–90 testing and
dependence treatment should not be treatment targets: to ensure by 2020 Community-based testing, linked to
coerced (18). that 90% of people living with HIV prevention, care and treatment, has
know their HIV status, 90% of people the potential to reach greater number
Additionally, relapse into drug use who know their HIV-positive status of people than clinic-based HIV
should not be grounds for expelling are accessing treatment and 90% of testing and counselling—particularly
individuals from drug dependence people on treatment have suppressed those unlikely to go to a facility for
treatment. Drug dependence is a viral loads. Antiretroviral therapy testing, including people who inject
chronic health condition that often protects people living with HIV from drugs (2, 29).
requires long-term and continued AIDS-related illnesses and greatly
treatment. Those affected may remain lowers the risk that they will transmit HIV self-testing is a form of testing
vulnerable to relapse for a lifetime. the virus to others. where individuals gather their own
Patients who relapse need continued specimens (oral fluid or blood) to
medical attention and support. Coverage perform an HIV test and interpret the
Global progress towards these targets results in private (30, 31).
User fees for dispensing opioid has been strong in recent years, but
substitution therapy may create people who inject drugs and other With index testing, a person with
barriers to accessing and maintaining key populations are often being left a confirmed diagnosis refers other
therapy, and governments should behind. Among the 13 countries that untested individuals for HIV testing
consider sponsorship of fees, recently reported data to UNAIDS and counselling services. Two forms
reducing fees or eliminating them on treatment coverage among people of index testing are assisted partner
altogether (19–21). The Georgian living with HIV who inject drugs, notification services and risk network
Network of People who use Drugs has eight stated that treatment coverage tracing. Each comes with benefits and
reported that eliminating user fees was lower among people who inject risks:
resulted in a sevenfold increase in drugs than it was among the wider
drug dependence treatment coverage population of adults living with HIV Assisted partner notification is
in just two years (22). (Figure 12). increasingly used among couples
20Figure 12. Treatment coverage among all adults living with HIV and among people who inject
drugs in particular, last year available (2014–2017)
100
80
Treatment coverage (%)
60
40
20
0
7) 7) 6) 7) 7) 7) 7) 7) 7) 7) 7) 6) 4)
01 01 01 01 01 01 01 01 01 01 01 01 01
(2 (2 (2 (2 (2 (2 (2 (2 (2 (2 (2 (2 (2
ta
n ar ni
a
di
a
es
h sia in
e
ta
n
am ny
a
ur
g
tri
a
nc
e
kis nm a bo ad ay ra iki
s N Ke bo
s a
Pa ya hu gl al Uk j et Au Fr
M Lit Ca
m n M Ta Vi xem
Ba Lu
Antiretroviral therapy coverage among people who inject drugs Antiretroviral coverage among adults (aged 15 years and older) living with HIV
Source: UNAIDS Global AIDS Monitoring, 2014–2017; and UNAIDS 2018 estimates.
in high-prevalence settings. It of discrimination, violence and to people living with HIV who
has proven highly effective at arrest, HIV testing programmes inject drugs significantly improved
finding new cases (32). Health- working with key populations initiation of (and adherence to)
care workers should plan for should consult with communities antiretroviral therapy: this approach
and address the risk of intimate representing those populations had a 45% better chance of patients
partner violence or social harm before adopting risk network achieving viral suppression (37).
that may result following partner approaches to testing, and they
notification (33). should take measures to keep Combination prevention
the personal data of individuals of HIV and STIs
Risk network approaches, confidential. Evidence
sometimes also referred to as People who use drugs have multiple
“contact tracing,” are widely WHO recommends that countries intersecting needs. Combined
used to reach key populations in implement high impact interventions provision of condoms and lubricants,
concentrated epidemics. Using to prevent and respond to HIV drug behavioural interventions, and sexual
such an approach, health-care resistance (36). Integrating harm and reproductive health information
workers ask recently diagnosed reduction and treatment can help and services (including contraception
individuals to refer others in their to improve treatment adherence and STI testing and treatment)
social networks for HIV testing. for people who use drugs, ensuring have been shown to lower the risk
In Tajikistan and Ukraine, this individuals are speedily referred for of sexual transmission of HIV and
approach has helped to efficiently second-line treatment when needed. STIs. Staff of harm reduction services
find undiagnosed people living A recent systematic review found that should be trained and supported
with HIV (34, 35). Given the risks providing opioid substitution therapy to provide counselling for people
21Opioid substitution therapy patient takes methadone at the District Heath Centre of South Tu Liem, Hanoi, Viet Nam. Credit: UNAIDS.
who use drugs on family planning antiretroviral medicines. WHO Malaysia, Philippines and Serbia (see
and contraception, and they should recommends that PrEP be offered Annex 3).
understand the full range of the as an additional prevention choice
sexual and reproductive health needs for all people at substantial risk of There have been limited efforts to
and rights of both people who use HIV infection (2). However, the provide PrEP to people who use
drugs and their partners (38). Tools introduction of PrEP should not drugs. Community attitudes toward
such as the new United Nations come at the expense of other proven it vary (40–42). Concerns about
Population Fund (UNFPA) and low-cost interventions that reduce adherence, cost-effectiveness and
International Planned Parenthood the health and social consequences of the potential for coercive use—
Federation Health, rights and well- drug use. and insufficient engagement of
being: a practical tool for HIV and communities in the development of
sexual and reproductive health and Coverage pilot efforts—have all been raised by
rights programmes for young key Condom programmes and behaviour community groups and researchers
populations in eastern Europe and change interventions designed (41, 43–45). Civil society groups
central Asia provides guidance on for the general population are not have also expressed concerns that
how to provide combined services adequately reaching people who the introduction of PrEP could
in a manner that meets the needs of use drugs. Among the 30 countries be used as a substitute for other
different populations (39). that have reported relevant data to harm reduction strategies and
UNAIDS since 2011, condom use that a strong focus on PrEP could
PrEP is one option that enables at last sex among people who inject indicate a re-medicalization of HIV
individuals to reduce their HIV drugs was generally low, and fewer (44). Any decision about whether
risk by taking regular doses of than one third did so in Hungary, to include PrEP in harm reduction
22CASE STUDY:
YOUNG WAVE
Young Wave is youth-led group in Lithuania that provides harm reduction who use drugs, and governments are
services at music festivals and night clubs. Young Wave volunteers join reluctant to prioritize investment in
public gatherings of young people to share information about safe drug the treatment (54, 55). Despite this,
use, condoms, water (to prevent dehydration and overheating), straws recent price reduction strategies,
for snorting drugs (to prevent transmission of viral hepatitis) and drug including the use of generics,
checking. Young Wave also provides psychedelic peer support (PsyHelp), have made direct-acting antivirals
an approach that aims to transform challenging psychedelic experiences more affordable in a wide range of
into learning opportunities, and to reduce hospitalizations and other countries.
harms. The group also engages in policy advocacy, and it provides harm
reduction training to police (88). In some countries, people who use
drugs are often refused hepatitis C
treatment, whether pre-emptively or
through bureaucratic requirements
programmes should be made only and C (49, 50). Direct‐acting (56). In some cases, individual
with the active consultation and antivirals are recommended for the providers and hospitals deny direct-
engagement of the community of treatment of all people with chronic acting antiviral treatment to people
people who use drugs, and it should hepatitis C infection (51). They have who use drugs, in contravention
take their preferences into account. cure rates of around 95% and are far of national policies (57, 58). This
Some national programmes have less toxic and better tolerated than is despite evidence showing that
developed specific guidance to assess interferon-based treatments (which treatment outcomes for people who
the suitability of PrEP for people who are no longer recommended); they inject drugs, including those actively
inject drugs (46, 47). also can be provided to all persons using drugs, have been as good as
with chronic hepatitis C infection. with other patients (59).
Prevention and management Several new direct-acting antiviral
of viral hepatitis and medicines have been approved by Maximizing impact
tuberculosis at one least stringent regulatory Newly-published guidance on
Evidence authority since 2013 (52). implementing comprehensive HIV
People who use drugs face and hepatitis C programmes for
increased risk of tuberculosis Prevention strategies for hepatitis people who inject drugs recommends
infection, including a high risk of B infection among people who a set of practical approaches that
multidrug-resistant tuberculosis. use drugs focus on vaccination are grounded in community
WHO recommends a package of and ensuring that sterile injection empowerment (60). Wherever
collaborative tuberculosis/HIV equipment is available. Hepatitis B possible, health services for people
activities. Key services include infection is a chronic disease, and who use drugs should be integrated.
tuberculosis preventive treatment, most people require ongoing antiviral In countries with high tuberculosis
such as isoniazid preventive therapy, treatment (53). incidence, harm reduction
regular screening for early diagnosis programmes should consider
of tuberculosis, and timely initiation Coverage including the provision of 12-week
of anti-tuberculosis therapy and Direct-acting antiviral therapies are tuberculosis prevention for people
antiretroviral therapy for people living not yet widely accessible. In many who use drugs when tuberculosis
with HIV who use drugs (2, 48). countries, the high price of direct- screening is negative. According
acting antiviral therapies or collateral to WHO, countries with low
People who inject drugs face fees charged for diagnosis makes tuberculosis incidence may consider
additional vulnerability to hepatitis B access to them challenging for people systematic testing for (and treatment
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