Injecting drug use IDU

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.

A new report by UNAIDS demonstrates the critical role communities play, and how underfunding and harmful barriers are holding back their lifesaving work and obstructing the end of AIDS.

LONDON/GENEVA, 28 November 2023—As World AIDS Day (1 December) approaches, UNAIDS is urging governments across the world to unleash the power of grassroots communities across the world to lead the fight to end AIDS. A new report launched today by UNAIDS, Let Communities Lead, shows that AIDS can be ended as a public health threat by 2030, but only if communities on the frontlines get the full support they need from governments and donors.

“Communities across the world have shown that they are ready, willing and able to lead the way. But they need the barriers obstructing their work to be pulled down, and they need to be properly resourced,” said Winnie Byanyima, Executive Director of UNAIDS. “Too often, communities are treated by decision-makers as problems to be managed, instead of being recognised and supported as leaders. Communities are not in the way, they light the way to the end of AIDS.”

The report, launched in London during a World AIDS Day event organized by the civil society organization STOPAIDS, shows how communities have been the driving force for progress.

Community advocacy from the streets to the courtrooms to parliaments has secured groundbreaking changes in policy. Communities’ campaigning helped open up access to generic HIV medicines, leading to sharp, sustained reductions in the cost of treatment from US$ 25 000 per person per year in 1995 to less than US$ 70 in many countries most affected by HIV today.

Let Communities Lead shows that investing in community-led HIV programmes delivers transformational benefits. It sets out how programmes delivered by community-based organizations in Nigeria were associated with a 64% increase in access to HIV treatment, a doubling of the likelihood of HIV prevention service utilization, and a four-fold increase in consistent condom use among people at risk of HIV. It also notes how, among sex workers reached by a package of peer-based services in the United Republic of Tanzania, the HIV incidence rate was reduced to below half (5% vs 10.4%).

“We are the vehicle for change that can end systematic injustices that continue to fuel HIV transmission. We have seen groundbreaking developments with U=U, improved access to medicines, and have made great strides in decriminalisation," said Robbie Lawlor, Co-Founder of Access to Medicines Ireland. “Yet, we are expected to move mountains without being financially supported. We are supposed to fight for a more equitable world and are tasked with dismantling stigma yet are side-lined in crucial discussions. We are at a tipping point. Communities can no longer be relegated to the periphery. The time for leadership is now.”

The report highlights how communities are at the forefront of innovation. In Windhoek, Namibia, a self-funded project by the youth Empowerment Group is using e-bikes to deliver HIV medicines, food and adherence support to young people who often cannot attend clinics due to their schooling hours. In China, community organizations developed smartphone apps that link people to self-testing which contributed to a more than four-fold increase in HIV tests across the country from 2009 to 2020.

The report reveals how communities are also holding service providers to account. In South Africa five community networks of people living with HIV inspected 400 sites across 29 districts and conducted more than 33 000 interviews with people living with HIV. In the Free State province, these findings led provincial health officials to implement new appointment protocols to reduce clinic wait times and three- and six-month dispensing of antiretroviral medicines.

“I am extremely concerned about the exclusion from health services of key populations like the LGBT+ community,” said Andrew Mitchell, Minister of State for Development and Africa. “The UK champions the rights of such communities, and we will continue to protect them, working closely with our partners in civil society. I thank UNAIDS for keeping us focused on the inequities driving the pandemic and I look forward to working with our partners to champion the voice of people living with HIV and end AIDS as a public health threat by 2030.”

Despite the clear evidence of community-led impact, community-led responses are unrecognized, under-resourced and in some places even under attack. Crackdowns on civil society and on the human rights of marginalized communities are obstructing communities from providing HIV prevention and treatment services. Underfunding of community-led initiatives is leaving them struggling to continue operating and holding them back from expansion. If these obstacles are removed, community-led organizations can add even greater impetus to end AIDS.

In the 2021 Political Declaration on ending AIDS, United Nations member states recognized the critical role communities play in HIV service delivery, particularly to people most at risk of HIV. However, whereas in 2012, when over 31% of HIV funding was channelled through civil society organizations, ten years later, in 2021, only 20% of funding for HIV was available—an unprecedented backsliding in commitments which has cost and is continuing to cost lives.

“At this time, community-led action is the most important countermeasure in the AIDS response,” said Solange Baptiste, Executive Director of the International Treatment Preparedness Coalition. “Yet, shockingly, it isn’t a cornerstone of global plans, agendas, strategies, or financing mechanisms for improving pandemic preparedness and health for all. It is time to change that.”

Every minute, a life is lost to AIDS. Every week, 4000 girls and young women become infected with HIV, and out of the 39 million people living with HIV, 9.2 million do not have access to lifesaving treatment. There is a Path that Ends AIDS and AIDS can be ended by 2030, but only if communities lead.

UNAIDS is calling for: Communities’ leadership roles to be made core in all HIV plans and programmes; Communities’ leadership roles to be fully and reliably funded; And for barriers to communities’ leadership roles to be removed.

The report features nine guest essays from community leaders, in which they share their experience on the achievements they have secured, the barriers they face, and what the world needs to end AIDS as a public health threat.

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.

“Drugs were a way to escape from reality. But because of it, I have faced a lot of discrimination,” said Yukusna Kurumbang. “After a while I had no one around me. No friends I could contact. I have my family but they do not trust me. I am trying to improve.” 

There aren’t many resources at Ms. Kurumbang’s disposal. She’s fashioned her own path to recovery including volunteering with YKP Lead Nepal—a youth-led organisation. 

“I’m investing in myself and others to escape drugs,” she explained. “I’m trying to control my mind.” 

The organisation’s President, Rojal Maharajan, recalls the feeling of isolation he too faced while using: “It’s very humiliating—the gossiping and negative comments. My family also got sick and tired of me. Eventually I had no one to tell about my problems and my mental health status.” 

He started his advocacy eight years ago after a successful rehabilitation stint.  

“I wanted to do this work to make sure young people who use drugs are treated as human beings. They deserve to have a good life and better opportunities,” he said. 

These deeply personal perspectives help YKP Lead Nepal respond to the addiction challenge facing Nepal’s youth. And it’s a complex challenge.  

There was a 2021 review of the human rights situation of people who use drugs in Nepal by the International Drug Policy Consortium, Recovering Nepal, YKP LEAD Nepal and Youth Rise International. It notes that the Narcotic Drugs Act criminalises not only drug possession, but addiction itself. According to a 2019 survey of people who use drugs, almost half had been arrested for drug use or a related offence. Among people who injected drugs the arrest rate shot up to 63%.  

Treatment for drug dependence is privatised and inaccessible to most, including residents of border towns where services are most scarce. Among those who have had access to drug treatment, one in ten reports having experienced ill-treatment, violence and even torture.

The Government of Nepal has made progress around the provision of harm reduction services including needle and syringe programmes and opiate agonist therapy (OAT). However there are allegations that police frequently harass and detain people visiting these facilities.  

“Punitive drug policies across the region have created a culture of violence and impunity by law enforcement,” said Ikka Noviyanti, Regional Coordinator of Youth LEAD, the Asia and the Pacific young key population network. “This makes it more difficult for people to reach the range of prevention and treatment services they need to stay safe. The situation is even more dire for youths.” 

A 2019 Ministry of Home Affairs survey determined that over three-quarters of people who use drugs in Nepal are under age 30. Another study found that one-third of young people who use drugs started before age 15, with almost half commencing drug use between 15 and 19. The advocates say that in lieu of heroin which is expensive, there’s a growing trend of young people mixing and injecting tranquilizers like Diagepam, Nitrazepam and Dormin. 

Injecting drug use increases the risk of abscesses as well as illnesses including HIV, Hepatitis B and C. HIV prevalence for injecting drug users is 3% for males and 2% for females. By comparison, Nepal’s adult general population HIV prevalence is 0.1%.  YKP Lead Nepal is advocating for disaggregated data so they can better grasp the scale of the HIV burden carried by young people.  

The organisation shares safety information with clients along with clean needles and syringes. During the Covid-19 lockdowns, for example, they home delivered both food and harm reduction packages. Their outreach includes homeless young people.  

But the advocates say that even when clients are aware of the risks, there are barriers to staying safe.  

“Most of them don’t want to go to the service sites,” Mr Maharajan explained. “Many of the young women have told us they are harassed at the OAT clinics. Others have a concern that the people running the needle exchange programmes are from rehabs. They don’t want to be forced to go (to rehab) because they are fearful of torture.”  

UNAIDS Country Director for Nepal, Masauso Nzima, says that the Government of Nepal has made a move in the right direction with its investment in harm reduction services. However, more needs to be done to ensure a people-centred approach to drug policies “if we are to make a sustained difference in the lives of young people”. 

“A critical step is the adoption of laws that treat drug dependence as a health condition rather than a crime. Action is also needed to outlaw torture and ill treatment, holding violators accountable and providing increased oversight for rehabilitation centres. Finally, we are advocating for expanded access to drug treatment and harm reduction programmes, without discrimination,” Mr Nzima said. “That means young people, women and people living in all parts of the country should have equitable access.” 

YKP Lead Nepal goes a step further, calling for designated days for young women to access harm reduction services and for young people to be among the service providers.  

With support from UNAIDS Asia Pacific, Youth LEAD is now piloting a “Regional Healthcare Worker Training Manual: Friendly HIV and SRHR services for young key populations in Asia Pacific”. The approach is meant to address the multiple barriers to young key populations accessing services including concerns about privacy and confidentiality, stigma and discrimination among healthcare providers, inconvenient opening hours and service packages that do not speak to their specific needs. 

“Young people account for one of four new HIV infections in Asia and the Pacific,” Ms. Noviyanti said. “We are failing young people. But with targeted investments for youth-led responses and action we can turn the tide.”

At his previous factory job, Tom Wang (not his real name) says coworkers gossiped about his sexuality and made fun of him. When he visited a public health facility for an HIV test, the nurse peppered him with questions like “Why do you need it? Have you been sleeping with many partners?”

Thailand is a country famed for its tolerance. It is among the world’s top locations for gender affirming care. Same-sex sexual activity hasn’t been criminalised since 1956. And the policy tide is turning on other key population issues. A 2021 Drug Law allows for harm reduction as opposed to automatic imprisonment, while a bill is in the pipeline to affirm the rights of sex workers. Yet stigma and discrimination persist. In homes, communities, schools, workplaces and—critically—healthcare settings, discriminatory attitudes can take their toll.

“Microaggressions—intentional or unconscious verbal or behavioural slights toward stigmatised groups—can drive people away from HIV prevention and treatment,” noted UNAIDS Regional Human Rights and Law Adviser, Quinten Lataire. “There are evidence-based approaches for measuring and lowering both overt and subtle stigma and discrimination in healthcare settings.”

It was this need for stigma-free services that led to the establishment of the Rainbow Sky Association of Thailand (RSAT). RSAT offers sexual healthcare for men who have sex with men, migrants, people who use drugs, sex workers and transgender people. It also advocates for the full rights and equity of lesbian, gay, bisexual and transgender (LGBT) communities. Tom Wang is amongst the clients who have benefited from their support.

This work is critical if HIV programmes are to reach and retain key population communities. In Thailand, as in the rest of Asia, these groups carry the heaviest HIV burden. Nationally HIV prevalence is 1% for sex workers, 8% for people who use drugs, 11% for transgender women and 12% for men who have sex with men.

A one stop shop for sexual health services

RSAT’s approach demonstrates how programmes can improve outcomes by implementing strategies to affirm and empower clients. They are jointly supported by PEPFAR, USAID, EpiC, the National Health Security Office (NHSO) and Thailand’s Institute of HIV Research and Innovation (IHRI).

There are no depressing charts or drab walls at their five key population clinics. At the Bangkok site the rainbow motif appears on the floors and walls. There are swarms of cut-out butterflies. Signs are either upbeat and multi-coloured or a soothing blue.

Most of the staff are themselves members of key population groups. All staff receive anti-stigma and discrimination training which even addresses the fine point of body language. Nothing about staff’s interactions should make a client feel judged or uncomfortable. The entire team is retrained annually. There is an internal complaint mechanism that allows clients to confidentially flag issues, as well quality assurance staff to ensure Standard Operating Procedures are followed. Every team member signs a confidentiality agreement.

RSAT’s service package includes on-site testing for HIV and other sexually transmitted infections, Hepatitis C, Tuberculosis and Covid-19. For transgender clients they offer hormone level monitoring. Mental health screenings which evaluate for depression, anxiety and stress have been integrated into the HIV service package. Where required, clients are referred for additional mental healthcare.

“Many of our clients engage in chem sex (recreational drug-use during intercourse). Some clients inject meth so we need to provide more than condoms. They also need clean syringes and needles which are part of our harm reduction package,” said Deputy Director, Kao Kierati Panpet.

Pre- and post-test counselling are critical. All counsellors are certified and accredited by the Ministry of Public Health according to Counsellor Supervisor, Sasiprapha Khamthi. Even before receiving HIV test results, clients know that treatment is available. Following a positive test, the counsellors reassure clients that with treatment they can live a normal life, explained Niphon Raina, Care and Counselling Supervisor.

“We also ask what their concerns are and give basic information about how HIV is and is not transmitted, using a picture book so they are clear on the facts,” Care and Counseling Officer, Bussarin Poonvisitkun added.

RSAT keeps a stock of antiretroviral therapy drugs onsite and can initiate new clients’ treatment on the day of diagnosis by giving them one month’s supply. Although HIV care is provided at the Ratchaphiphat Hospital, RSAT is able to dispense right away in accordance with instructions from a hospital doctor, delivered via telemedicine. Clients living with HIV receive help from the care and support team to navigate their next steps, including attending hospital visits.

RSAT also provides pre-exposure prophylaxis or PrEP services with hospital supervision. Mr. Tom Wang explains how this has protected his health: “I decided to get on PrEP because I am changing partners. To me PrEP is another means of protection in case you are intoxicated or the condom breaks. It’s a way to ensure I stay HIV-free.”

A redress mechanism for rights violations

The organisation advocates for structural changes to eliminate stigma and discrimination. For example, they are currently making recommendations for the Gender Recognition Draft Bill.

“But the reality is that policy and legal changes take a lot of time,” said RSAT Director, Tanachai Chaisalee.

While this longer-term work proceeds, a redress mechanism helps clients address current concerns. RSAT is tapped into the Crisis Response System (CRS) initiated by the Ministry of Public Health in collaboration with the Office of the Attorney General, Ministry of Justice. People with complaints about prejudice or rights violations in any sphere can scan a QR code and report their experience. Reports may also be sent via Facebook, email or LINE, Thailand’s answer to WhatsApp. A multi-disciplinary team conducts investigations and works with the client and other stakeholders to help.

The lion’s share of reports made via RSAT come from transwomen (78%) while gay men have lodged 17% of reports. The most common challenges relate to requirements for gender confirming attire, social exclusion (particularly during job application processes) and HIV status.

RSAT’s Human Rights Manger, Watcharawit Waraphattharanon, shares that they have been able to resolve some cases very quickly. For instance, if a person living with HIV is being forced to take an HIV test as a requirement for work, the Attorney General’s office does an emergency intervention.

“We can close these cases within one week,” he said.

“The work of key population-led, community-based organisations like RSAT is critical to reach those who most need HIV services,” UNAIDS Country Director, Patchara Benjarattanaporn stressed. “The Government’s progress in funding Community-led Health Services and building partnerships between these organisations and the public health system puts us on the path to end AIDS.”

A group of journalists visited the Ozone Foundation as part of the UNAIDS, UNDP, APN Plus and USAID/PEPFAR Southeast Asia Regional Workshop on HIV-related Stigma and Discrimination in Bangkok, Thailand on June 8, 2023. Learn more about this novel training