Harm reduction

VIENNA/GENEVA, 22 March 2024— UNAIDS welcomes the adoption of a key resolution today at the 67th session of the United Nations Commission on Narcotic Drugs (CND), recognizing harm reduction for the first time as an important part of an effective public health response. The resolution encourages member states to develop and implement harm reduction measures to minimize the adverse public health and social consequences of the non-medical use of illicit drugs. UNAIDS congratulates the CND and the CND Chair for this historic milestone.

The resolution represents a landmark in political commitment to a rebalancing of drug policy towards a public health approach. Such a shift is critical to meeting the targets in the 2021-2026 Global AIDS Strategy.

Harm reduction is a “a comprehensive package of evidence-based interventions, based on public health and human rights, including needle syringe programmes (NSPs), opioid agonist maintenance therapy (OAMT) and naloxone for overdose management. Harm reduction also refers to policies and strategies that aim to prevent major public and individual health harms, including HIV, viral hepatitis and overdose, without necessarily stopping drug use.” (World Health Organization, 2022).

Since 2018 only five countries have reported achieving the target of providing 200 sterile needles and syringes per person who inject drugs. In that same timeframe only three countries reported achieving the target of 50% coverage of opioid agonist maintenance therapy among people who inject drugs.

The criminalization of drug use and possession for personal use in at least 145 countries, along with stigma, discrimination and violence, continues to restrict both the provision of and access to life-saving harm reduction services.

A failure to invest in harm reduction services or remove the structures that inhibit access, including those relating to gender, have led to a situation where HIV prevalence among people who inject drugs is 7 times that of the rest of the population, and people who inject drugs have the highest incidence globally of any key or vulnerable population. In countries with data, median HIV prevalence among women who inject drugs is almost twice that of men who use drugs.

Under the UN Common Position on Drugs, UNAIDS collaborates with other UN agencies and partners with governments, community-led organizations and donors to increase the provision of harm reduction services and remove harmful laws and policies which create barriers to accessing such services, such as the criminalization of possession of drugs for personal use. UNAIDS works to ensure all efforts relating to drug policy are in conformity with international human rights, as outlined in the international guidelines on human rights and drug policy.

UNAIDS

The Joint United Nations Programme on HIV/AIDS (UNAIDS) leads and inspires the world to achieve its shared vision of zero new HIV infections, zero discrimination and zero AIDS-related deaths. UNAIDS unites the efforts of 11 UN organizations—UNHCR, UNICEF, WFP, UNDP, UNFPA, UNODC, UN Women, ILO, UNESCO, WHO and the World Bank—and works closely with global and national partners towards ending the AIDS epidemic by 2030 as part of the Sustainable Development Goals. Learn more at unaids.org and connect with us on Facebook, Twitter, Instagram and YouTube.

VIENNA/GENEVA,14 March 2024—At the 67th meeting of the United Nations Commission on Narcotic Drugs taking place in Vienna, UNAIDS has called for the urgent scaling up of services to prevent new HIV and viral hepatitis infections among people who use drugs. Addressing delegates in her video message, UNAIDS Executive Director, Winnie Byanyima, commended some countries for making progress in implementing evidence-based programmes but called for bolder action.

“Gathered here are leaders whose decisions can save and transform lives, tackle social exclusion, and protect public health for everyone. As leaders you can deliver on the shared pledge to end AIDS as a public health threat by 2030 – if all people can secure the HIV prevention, testing, treatment and care services they need. To end AIDS we need to ensure that no one is excluded,” said Ms Byanyima.

Since the 2019 Ministerial Declaration of the United Nations Commission on Narcotic Drugs (CND) there has been some progress in a rebalancing of drug policy towards public health. Several countries have moved towards a more public health-based approach to drug use, with some, such as Ghana, decriminalizing all personal drug use. UNAIDS is supporting Brazil in engaging transgender women in harm reduction programming.

The context of the COVID-19 response led some countries to increase the availability of take-home doses of opioid agonist maintenance therapy, such as in Vietnam. Communities have been central to progress in programmes and policy reforms; in Kenya, Tanzania and Uganda peer groups have been instrumental in delivering harm reduction interventions, law enforcement training sessions and awareness-raising initiatives, including women-centred harm reduction services in Kenya.

But progress remains piecemeal. Services such as needle-syringe programmes, and opioid agonist maintenance therapy, crucial for reducing HIV and other health risks among people who inject drugs, only exist in around 50% of countries. In 2019, UNAIDS reported that only 1% of people who inject drugs had access to recommended harm reduction services, and since then no additional country has reported achieving recommended levels of coverage.

Too often, laws and policies continue to exacerbate exclusion, and people who use drugs are today seven times more likely to be living with HIV than other adults. Drug possession for personal use is still criminalized in 145 countries – with 34 countries retaining the death penalty. The stigma, and outright fear, that this exacerbates is driving people away from vital health services.

Attending the meeting in Vienna, UNAIDS Deputy Executive Director, Christine Stegling said:

“We know that drug prohibition has failed. Punitive drug laws and law enforcement practices create significant barriers for people who inject drugs to access a range of services, increasing their risk of acquiring HIV and reducing their access to services. To protect public health, we need to decriminalize possession of drugs for personal use, we need to significantly scale up harm reduction service provision, and we need to make sure that communities of people who use drugs are adequately resourced and in the lead in the response.” 

UNAIDS

The Joint United Nations Programme on HIV/AIDS (UNAIDS) leads and inspires the world to achieve its shared vision of zero new HIV infections, zero discrimination and zero AIDS-related deaths. UNAIDS unites the efforts of 11 UN organizations—UNHCR, UNICEF, WFP, UNDP, UNFPA, UNODC, UN Women, ILO, UNESCO, WHO and the World Bank—and works closely with global and national partners towards ending the AIDS epidemic by 2030 as part of the Sustainable Development Goals. Learn more at unaids.org and connect with us on Facebook, Twitter, Instagram and YouTube.

Alexander Godin moves through a number of locked doors escorted by a guard to prison 16’s pharmacy. This is part of his daily routine. He comes to get his medicine – a syrup-like dose of methadone. Methadone is an opioid agonist therapy (OAT) to help people overcome withdrawal symptoms, decrease heroin dependence and prevent HIV infection from infected needles.

Since 2000, a few prisons in Moldova offered such harm reduction services.

Now all do.

“I have been on methadone substitution treatment for 10 years,” said Mr Godin. His family urged him to take advantage of such services so he could get healthy again.

“For years I used drugs and opioids and for this, money was needed so problems began among my family,” he said.  Since he has been on the programme, he feels much better.

Any new prisoner to the country’s 17 penitentiaries sees a psychiatrist, a doctor and if needed is offered to join a treatment programme. Comprehensive harm reduction services not only include drug dependence treatment but also needle syringe exchange and HIV testing and treatment. HIV prevalence is 11% among people who inject drugs in Moldova vs 0.36% among the general population.

They are one of the most affected groups in the country. 

For Maria Potrîmba Head of Infectious Diseases at prison 16 (Pruncul) helping prisoners stave off drugs has positive knock-on effects.

“If a patient is on this substitution treatment the person is more aware of consequences and will more likely adhere to their other treatment,” she said.

The prisons also make sure to provide clean syringes with a regular pick-up every two days carried out by volunteer prisoners.

The head of medical unit at prison 13 (Chisinau) believes harm reduction services are important for both inmates and prison employees.

“The volunteers are all prisoners and the vast majority of them are also people who have been treated for communicable diseases like HIV or hepatitis or tuberculosis,” Oleg Costru said.

Moldova has committed more resources to the prison programme over the years. “In the beginning, when these services were developed, they were actually financed from external sources,” said Irina Barbîroș, head of the medical department at the national prison administration. “Over the years, the state assumed its commitment and took over the financing of these services from the state budget.”

UNAIDS, UNODC and WHO have been long-time supporters of expanding these services to all prisons. Currently, according to Harm Reduction International, only 59 countries globally provide OAT in prisons.

This, even though harm reduction has been proven to not increase the number of people with drug dependency but rather provide personal and public health benefits.

Svetlana Plamadeala, UNAIDS Moldova country director, has seen the pilot projects gain traction in the country and is quite proud of the success of the nationwide coverage.

“It is really about putting people in front and people at center as well as taking on a solid public health approach,” she said. For her, to end AIDS, protecting the health and human rights of people who use drugs is key. “It is about equalizing.”

Harm reduction policies and practices help people who are using drugs to stay alive and protect them from HIV and Hepatitis C

Released ahead of International Harm Reduction Day - 7 May 2023

GENEVA, 5 May 2023—Many prison systems are struggling to cope, with overcrowding, inadequate resources, limited access to healthcare and other support services, violence and drug use. In 2021, the estimated numbers of people in prisons increased by 24% since the previous year to an estimated 10.8 million people, increasing the strain on already overstretched prison systems.   

Drug use is prevalent in prisons. UNAIDS Cosponsor, the United Nations Office on Drugs and Crime (UNODC), estimates that in some countries up to 50% of people in prisons use or inject drugs. Unsafe drug injecting practices are a major risk factor for the transmission of HIV and hepatitis C due to limited access to harm reduction services, including condoms, clean needles and syringes, and a lack of comprehensive drug treatment programs, particularly opioid agonist therapy.

People in prison are 7.2 times more likely to be living with HIV than adults in the general population. UNAIDS reports that HIV prevalence among people in prisons increased by 13% since 2017, reaching 4.3% in 2021. Although data are limited, it is thought that around one in four of the total prison population has hepatitis C.

“Access to healthcare, including harm reduction services, is a fundamental human right, and no one should be denied that right because they are incarcerated,” said Eamonn Murphy, UNAIDS Regional Director for Asia Pacific and Eastern Europe and Central Asia. “Prisons are too often ignored in countries' efforts to respond to HIV. A multisectoral, multifaceted approach is urgently needed to save lives, which includes access to clean needles and syringes, effective treatment for dependence on opioid drugs and reducing stigma and discrimination.”

Both drug use and HIV infection are more prevalent among women in prison than among imprisoned men. In particular, women who use drugs and sex workers are overrepresented in prisons. Highlighting the urgent need to scale up the implementation of community-led harm reduction services for women who use drugs and women in prison. 

Ms Ghada Waly, Executive Director of UNODC, said, “It is time to put compassion at the heart of our responses. To take a more serious look at de-penalization and alternatives to incarceration for minor drug offenses, focusing instead on treating and rehabilitating. To use a gender-sensitive lens when looking at women and girls who use drugs, and to ensure that they have equal access to treatment. To reach out to young people, who are using drugs more than ever before, understand their vulnerabilities to substance abuse, and help them be part of the solution. To stand with marginalized and vulnerable people, including people in prisons who are underserved by treatment programmes, and people who inject drugs, who are far more likely to be living with HIV, yet far less likely to access life-saving services”.

Among the countries reporting on prisons to UNAIDS in 2019, just 6 of 104 countries had needle and syringe programmes in at least one prison; only 20 of 102 countries had opioid substitution therapy programmes in at least one prison, 37 of 99 countries had condoms and lubricants in some prisons.

UNAIDS, UNODC, and WHO have long supported expanding harm reduction services to all prisons. However, according to Harm Reduction International, only 59 countries globally provide opioid agonist therapy in prisons.

Some countries have made huge progress in recent years. Despite the challenges faced by the influx of refugees and the repercussions of the war in Ukraine, Moldova, (which has an HIV prevalence of 3.2% in its prisons, compared to 0.4% among the general population) has committed significantly more resources into its prison systems.

In the early 2000’s few of its prisons provided harm reduction services. Today all of the country’s 17 penitentiaries provide harm reduction services including, methadone (an opioid agonist therapy), access to psychiatrists, doctors and treatment programmes, needle and syringe exchange and HIV prevention, testing, treatment and care.

Svetlana Plamadeala, UNAIDS Country Director in Moldova said, “It’s about putting people front and center, treating them as equals and taking on a solid, public health approach, grounded in human rights and evidence.”

UNAIDS, UNODC, UNFPA, WHO, ILO and UNDP recommend 15 comprehensive and essential interventions to save lives and ensure effective HIV programming in prisons. These include HIV prevention, testing and treatment, condoms, lubricant, opioid agonist therapy and post-exposure prophylaxis. However, this is only part of the solution. UNAIDS also recommends that countries amend their laws to decriminalize the possession of drugs for personal use.

UNAIDS has set ambitious targets for 2025 which include: 95% of people in prisons and other closed settings who know their HIV status, 95% who know their status are on treatment; and 95% on treatment are virally suppressed; 90% of prisoners used condoms at last sexual activity with a non-regular partner; 90% of prisoners who inject drugs used sterile needles and syringes at last injection; and that 100% of prisoners have regular access to appropriate health system or community-led services.

UNAIDS advocates that communities take an active role in planning, providing and monitoring HIV services. However, this is not always facilitated in prison settings. Without community engagement it will be impossible to reach the global AIDS targets.

For more information on Moldova’s work on HIV in prisons please read Moldova expands harm reduction services to all prisons and watch https://youtu.be/JQYtnsiJKs0

Fact sheet: UNAIDS Human rights fact sheet on HIV in prisons

UNAIDS

The Joint United Nations Programme on HIV/AIDS (UNAIDS) leads and inspires the world to achieve its shared vision of zero new HIV infections, zero discrimination and zero AIDS-related deaths. UNAIDS unites the efforts of 11 UN organizations—UNHCR, UNICEF, WFP, UNDP, UNFPA, UNODC, UN Women, ILO, UNESCO, WHO and the World Bank—and works closely with global and national partners towards ending the AIDS epidemic by 2030 as part of the Sustainable Development Goals. Learn more at unaids.org and connect with us on Facebook, Twitter, Instagram and YouTube.

Introduction

Thank you Ambassador Ghislain D'hoop and Belgium as the Chair of the 65^th Commission on Narcotic Drugs, distinguished members of the Commission, Member States, Civil Society and networks of people who use drugs, UN agencies and all colleagues.

I thank very much my sister Ghada Waly for your strong leadership of United Nations Office on Drugs and Crime (UNODC) and your unequivocal support for the United Nations common position on drug policy.

I’d like to begin by expressing my solidarity for the people of Ukraine, who have suffered so much violence and injustice. For the last 15 years, Ukraine has had one of the largest and most successful HIV responses in Europe.

Now the entire HIV response is collapsing, and the lives of hundreds of thousands of Ukrainians living with HIV and the key groups are hanging by a thread.

I call on all partners to work to restore essential services for people living with and affected by HIV in Ukraine. 

Last June, Member States adopted the 2021 Political Declaration on Ending AIDS.  The resolution contains bold commitments, including new targets for 2025 to bring the response back on track to end AIDS by 2030.

Last year UNAIDS worked with all countries and partners to develop and adopt the Global AIDS Strategy. The golden thread of the strategy is on ending inequalities in an epidemic where 65% of all new infections are within particular groups – and these include people who use drugs and prison inmates.

We know that if we continue as we are, if we do not close the inequalities in the HIV response - the world could see 7.7 million AIDS deaths over the next ten years.

The global HIV response, which was already off track before COVID-19, is now under even greater strain as the COVID-19 crisis continues.

And people who use drugs and prisoners continue being among the most affected!

Globally, harm reduction services are not available at the level and scale that is required to end AIDS. And that’s true in the community and in prisons. In too many countries, they are not available at all.

Without continued access to HIV and harm reduction services, we will not end AIDS among people who use drugs and prison inmates, and we will therefore not end AIDS at ALL.

Key barriers to access to HIV and harm reduction services for people who use drugs and prisoners are criminalisation, stigma and discrimination.

We will not end inequalities and end AIDS without addressing these barriers and removing punitive laws and policies.  

In particular, women who use drugs face legal, policy and social barriers to accessing life-saving HIV and harm reduction services; we need to invest in non-judgmental harm reduction services tailored to the needs of women.

We have an ongoing funding crisis for harm reduction in low-and middle-income countries. Government and donors have invested just 5% of the funds needed for an effective response. We need to scale up investment now, with a focus on funding for community-led responses. They are the most effective.

CONCLUSION

Members of the Commission, I believe in your leadership.

We must value the health and human rights of every person who uses drugs and the dignity of every prisoner.

We must implement our commitments to create enabling legal environments. We must promote and scale-up harm reduction as a safe and effective approach essential to end AIDS.

We must remove punitive and discriminatory laws and policies. This includes laws that criminalize drug use and possession as set out in our new Global AIDS Strategy.

Our work to end the inequalities that drive AIDS must be based on science, evidence and human rights.

I urge you Commissioners to uphold these principles to get us back on track to end AIDS by 2030.

I thank you all for your attention.

Winnie Byanyima
UNAIDS Executive Director
Vienna, 14 March 2022
 

"Without continued access to HIV & harm reduction services, we will not end AIDS among people who use drugs & prison inmates, and we will therefore not end AIDS at ALL."

Watch @Winnie_Byanyima's opening remarks at #CND65 @UNODC @CND_tweetshttps://t.co/c7McJbOv1A pic.twitter.com/LZWDdf6gWJ

— UNAIDS (@UNAIDS) March 14, 2022

The hardships caused by the COVID-19 pandemic have magnified the challenges that people who use drugs face. 

In Uganda, during the COVID-19 lockdowns there was limited access to HIV treatment and other health services, including access to medically assisted therapy, which provides daily doses of methadone to people who use drugs. Access to support systems, such as drop-in centres, was also affected. 

“During the COVID-19 lockdown, access to medically assisted therapy for a daily dose was really hard for me, since movement was restricted and we required permission from the area local council. However, getting permission for a travel permit from the local council was very hard and took time, so it became challenging to sustain without access to these crucial services,” said Nsereko Joshua (not his real name), who is currently undergoing medically assisted therapy.

An analysis conducted by the Uganda Harm Reduction Network (UHRN) in July 2020 on the effects of the COVID-19 pandemic showed a decline in access to condoms, pre-exposure prophylaxis, counselling, psychosocial support, HIV testing, sexual and reproductive health services and legal aid services. It also highlighted a 25% increase in human rights violations reported among people who inject drugs during the COVID-19 lockdown. Issues included an increase in arrests and detentions, gender-based violence and eviction from their houses by the police at night.

When the UNAIDS Solidarity Fund for key populations was announced in December 2020, Wamala Twaibu, the founder and Chairperson of the Eastern Africa Harm Reduction Network and UHRN, saw an opportunity to empower people who inject drugs. He envisioned a transformed community that could support one another when in need, managing their own income sources.

“I was an injecting drug user for more than seven years, and I know what a drug user goes through daily. My aspiration is to improve the health, human rights and socioeconomic well-being of people who use drugs,” he said.

Mr Twaibu noted that injecting drug use and drug dependence often have long-term impacts on a person’s socioeconomic status and health outcomes. The lack of work skills, past criminal histories, stigma and discrimination and the criminalization of drug use are some of the main issues that people who inject drugs face regularly.

UHRN applied for the UNAIDS Solidarity Fund grant to kickstart the Empowered PWID Initiative for Transformation (EPIT) project, which was awarded in 2021. Through the EPIT project, community members currently on medically assisted therapy will be equipped with skills in craft-making for a sustained livelihood. Mr Twaibu noted that knowledge and skills in small-scale business management for people who inject drugs will form the core of the project. 

About 80 people who inject drugs on medically assisted therapy will be engaged in the EPIT project, clustered in 16 cohorts with five members in each cohort and with at least six women-led cohorts across the five divisions of Kampala. 

To ensure the sustainability of the initiative, a “Save, take and return” approach will be used. This strategy encourages beneficiaries to save some of the profits of the social enterprises every day, which they can get back after a few months. 

“This fund looks at the socioeconomic empowerment of key populations, led by the affected community. That is the catch. Community ownership of the initiative is important because nothing for us without us,” said Mr Twaibu. “Change is possible when we support each other without discrimination and stigma. I wish to see a transformed and empowered people who inject drugs community that can support one another when in need,” he added. 

Thinking about the effects of the COVID-19 pandemic so far, Mr Twaibu worries that the next wave of COVID-19 might affect the programme. However, he envisions a fully established and functional craft-making programme in the five divisions of Kampala and a scale-up in other regions where UHRN works. 

Now that he is a part of the EPIT project, Mr Joshua expresses hope for a brighter future. “I yearn to have a complete recovery from drug addiction, and I believe that medically assisted therapy will do this for me,” he said. “And I believe the EPIT programme will give me an opportunity to develop and demonstrate my readiness for my recovery with the ability to earn something for my survival and for transport to seek my treatment. I think even after this programme, the skills will help me to sustain my family and myself as well.”