Injecting drug use IDU

The UNAIDS Key Populations Atlas is an online tool that provides a range of information about members of key populations—sex workers, gay men and other men who have sex with men, people who inject drugs, transgender people and prisoners—worldwide, together with information about people living with HIV.

Information about gay men and other men who have sex with men has been expanded with the inclusion of 11 new indicators from the EMIS and LAMIS projects. Under funding from the European Commission, EMIS-2017 collected data from gay men and other men who have sex with men in 50 countries between October 2017 and January 2018. LAMIS is the Latin American version of EMIS and finished data collection across 18 additional countries in May 2018.

The 11 new indicators shown in the Key Population Atlas—on syphilis, symptomatic syphilis, gonorrhoea, symptomatic gonorrhoea, chlamydia, symptomatic chlamydia, sexually transmitted infections testing, syphilis partner notification, gonorrhoea partner notification and hepatitis A and B vaccination—were chosen because of their high relevance to the communities.

Community-led and community-based infrastructure is essential for addressing the inequalities that drive pandemics such as the AIDS and COVID-19 pandemics, as well as for ensuring the continuity of health services and protecting the rights and livelihoods of the most vulnerable. The EMIS and LAMIS findings will be important for informing civil society organizations working on sexual health, HIV prevention and sexual minority rights and for policymakers, non-community prevention planners, epidemiologists and modellers.

“To leave no one behind, we need people-centred data collection that spotlights the inequalities that are hampering access to services. It is critical to understand who are the most affected and unable to access services. This will enable the European Commission, European Union Member States and civil society and community organization alike to address the specific needs of gay men and other men who have sex with men,” said Jantine Jacobi, the UNAIDS representative to the European Union.

Civil society and community-based organizations, especially those led by key populations, can complement traditional health systems’ pandemic responses, but this requires that they be treated as full partners—involved in governing, designing, planning and budgeting pandemic responses––with the technical and financial support to do so effectively.

The findings of the new indicators will help to increase the role of partnerships and communities across each country and will serve as the basis for decision-making and policy planning. For example, in Ireland, the EMIS-2017 National Report acknowledges that, “there has been an increase in HIV and STI testing compared to previous surveys and this is in some part due to the positive interventions carried out by stakeholders and the MSM [men who have sex with men] community in response to findings from previous surveys. Some of these positive interventions in relation to HIV testing can also be attributed to the increased availability of community testing.”

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.”

The neighbouring Baltic states of Estonia and Latvia offer starkly contrasting examples of how different public health approaches affect HIV epidemics among people who inject drugs. In the early 2000s, the two countries had among the highest rates of HIV diagnosis in Europe. As was the case for many European countries at that time, the sharing of non-sterile injecting equipment among drug users was fuelling their HIV epidemics.

The two epidemics began to diverge in the mid-2000s. According to the HERMETIC study, new HIV infections in Estonia declined by 61% countrywide and by 97% among men who inject drugs between 2007 and 2016.

Latvia’s HIV epidemic followed a different trajectory. The HERMETIC study highlights that, between 2007 and 2016, new HIV infections increased by 72% overall. By 2016, overall HIV incidence in Latvia was almost double that in Estonia (35 cases per 100 000 people versus 19 cases per 100 000).

Both epidemics centred largely on the sharing of injecting equipment by people who inject drugs, and probably on unprotected sex between people who inject drugs and their sexual partners. The HERMETIC study concludes that the main difference between the two epidemics lay in the availability of harm reduction services.

Needle–syringe programmes had been operating in Latvia since 1997, but on a very limited scale. As late as 2016, Latvia was distributing about 93 needle–syringes per drug user per year; neighbouring Estonia was distributing 230 per user per year. Both countries expanded access to opioid substitution therapy, which is proven to reduce drug injecting and HIV transmission, and improved HIV testing and antiretroviral therapy services for people who inject drugs. Although access to opioid substitution therapy remained limited in both countries, it was higher in Estonia than in Latvia.

The HERMETIC study’s results indicate that by 2016, about half the people who inject drugs in Estonia were taking HIV tests in a 12-month period—and three quarters of those who tested HIV-positive were on antiretroviral therapy. In Latvia, meanwhile, about 10% of people who inject drugs took an HIV test in any given year between 2007 and 2016, and only 27% of those living with HIV were on antiretroviral therapy. Slow adoption of international HIV treatment guidelines contributed to the low treatment coverage in Latvia.

GENEVA, 1 November 2021—On International Drug Users’ Day, UNAIDS is calling for urgent action against the criminalization of people who use drugs, for the redress of criminalization’s negative effects on HIV, viral hepatitis and other health issues, for the respect of human rights and for more funding for community-led harm reduction programmes.

“UNAIDS is committed to supporting countries in their journey towards the decriminalization of drug possession and to full-scale implementation of harm reduction programmes,” said UNAIDS Executive Director, Winnie Byanyima. “UNAIDS calls for the full involvement of communities of people who use drugs in achieving legal reform aimed at decriminalization and in the organization of harm reduction programmes at the country level. This will help us to end inequalities and end AIDS.”  

People who use and inject drugs are among the groups at highest risk of acquiring HIV but remain marginalized and often blocked from accessing health and social services. In 2020, 9% of all new HIV infections were among people who inject drugs. Outside of sub-Saharan Africa this rises to 20%. Although women represent less than 30% of the number of people who use drugs, women who use drugs are more likely to be living with HIV than their male counterparts.

Timely introduction and full-scale implementation of accessible harm reduction programmes can prevent HIV infections, as well as many cases of viral hepatitis B and C, tuberculosis and drug overdose. The United Nations system is united in promoting harm reduction services and decriminalization of personal possession of drugs, based on the evidence that harm reduction and decriminalization provide substantial public and personal health benefits and do not increase the number of people with drug dependency. Despite this position, reflected in the United Nations system common position supporting the implementation of the international drug control policy through effective inter-agency collaboration, in reality less than 1% of people who inject drugs live in countries with the United Nations-recommended levels of coverage of needles, syringes and opioid substitution therapy, and the funding gap for harm reduction in low- and middle-income countries sits at a dismal 95%.

Even where harm reduction services are available, they are not necessarily accessible. Punitive drug control laws, policies and law enforcement practices have been shown to be among the largest obstacles to health care in many countries. Criminalization of drug use and harsh punishments (such as incarceration, high fines or removal of children from their parents) discourage the uptake of HIV services, drive people underground and lead to unsafe injecting practices, and increase the risk of overdose. Women who use drugs face higher rates of conviction and incarceration than men who use drugs, contributing to the increased levels of stigma and discrimination they face in health-care settings. In effect, criminalization of drug use and possession for personal use significantly and negatively impact the realization of the right to health.

Earlier this year, United Nations Member States set bold global targets on decriminalization of drug possession for personal use and on elimination of stigma and discrimination against people who use drugs and other key populations. To reach these targets by 2025, strategic actions at the country level need to start today.

GLOBAL AIDS SOCIETAL ENABLER TARGETS 2025

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.

Since the West Africa Commission on Drugs launched a groundbreaking model drug law in 2018, civil society across the region and beyond has been engaging stakeholders on the need to use the model law as a blueprint for national reform.

The model drug law promotes, among other things, the availability of harm reduction services as well as the decriminalization of possession of drugs for personal use, which have long been called for by UNAIDS. 

As the model drug law is, by design, a long and technical document, UNAIDS supported the West Africa Drug Policy Network and the International Drug Policy Consortium to develop and disseminate two important new tools for civil society: a shorter and more accessible resource that summarizes the key points of the model drug law and a short guide for local nongovernmental organizations to explore how to use the model drug law in their work. In other words, the first advocacy explainer is about the key “ingredients” of the model drug law and the second contains a list of methods and strategies on how to use these ingredients to better integrate the law in their advocacy and to advance drug policy reform, based on experiences from the region.

The documents were launched on 27 September during a virtual webinar live on Facebook and can be found in English, French and Portuguese at https://www.wadpn.org/resources.

“These new tools will directly support and empower civil society advocacy for more health- and rights-based drug policies in western Africa and, in turn, strengthen the response to HIV among people who use drugs,” said Patrick Brenny, the Director of the UNAIDS Regional Support Team for West and Central Africa.

Adeolu Ogunrombi, a West Africa Commission on Drugs Commissioner, underlined that the needs and demands for drug dependence treatment and harm reduction are high, but service provision is low in the region, and specified that the law provides guidance on this. He also noted that criminalizing the possession of equipment and materials, such as needles, syringes and other paraphernalia, has been demon­strated to undermine harm reduction service provision and uptake and to have a damaging impact on public health.

A case study was presented by Chinwike Okereke, a civil society organization representative and focal point for the West Africa Commission on Drugs in Nigeria, on the use of the model drug law. In 2020, a coalition of civil society organizations made presentations on the model drug law to key policymakers, including the Federal Ministry of Justice, the Drug Law Reform Commission and the National Drug Law Enforcement Agency. “The model drug law presented an opportunity to have face-to-face discussions and drive a buzz on the reform that led to a drug law reform round table where all key federal, criminal justice and state actors and civil society made a case for the adoption of the law as a template for reform,” he said. Further engagement with the Drug Law Reform Commission then led to the setting-up of a working group that is actively working on reshaping drug laws in the country. He also encouraged civil society to use the new explainers and urged technical and funding partners to invest more funding for this effort across western Africa, as law reform takes some time to achieve.

On 29 June, one of the largest non-profit organizations based in Saint Petersburg, Russian Federation, is celebrating its twentieth anniversary. Humanitarian Action provides comprehensive medical and social assistance to people who use drugs, including services for the prevention of HIV, viral hepatitis and tuberculosis, following the principle of working with everyone, regardless of their lifestyle.

Humanitarian Action is the successor to Doctors of the World, which worked in the Russian Federation in the 1990s during an economic crisis that saw an increase in drug use and HIV and other infections.

Today, the main mission of Humanitarian Action is to improve the lives and health of people who use drugs, restore their dignity and raise public awareness about drug use. Its vision is, “A world in which people who use drugs do not die from an overdose, HIV, hepatitis, tuberculosis or suicide, have equal rights and opportunities, are not stigmatized and discriminated against and do not experience self-stigma.”

A converted tourist bus, known as the Blue Bus owing to its colour, and a converted minibus, the Little Bus, allow Humanitarian Action to work as close as possible to where people who use drugs live and congregate. A joint project with the Saint Petersburg AIDS centre provides home visits via mobile units to seriously ill people living with HIV, many of whom are former drug users who have been left behind by mainstream services. 

The organization offers personal protective equipment against bloodborne and sexually transmitted infections, including sterile syringes and needles, condoms, etc., and exchanges syringes. In its medical centre—a first of its kind in the Russian Federation, since it provides help through low-threshold programmes—doctors provide anonymous and free medical services in a range of specialities for people who use drugs, sex workers, homeless people and migrants.

People also can also get psychological services from Humanitarian Action. Legal advice on the restoration of documents, guardianship or problems with the law and medical and social support for HIV, hepatitis or tuberculosis diagnosis and treatment are also available.

“Not everyone is ready to change their life immediately. We help people learn to take responsibility for their health and change gradually, moving from one tiny victory to another,” said Alexey Lakhov, the Development Director of Humanitarian Action. “We are a kind of bridge between people who use drugs and various government and nongovernment services. It’s just that with us, it becomes easier to get such help thanks to partnerships with multiple social and medical services.”

The process of helping people who use drugs is based on the principle of taking small steps and is aimed at gradually introducing safer behaviours: do not start using drugs; if you have started, stop; if you use drugs, stop injecting them; if you do inject drugs, always use a sterile syringe; if it is not possible to use a sterile needle every time, at least never use someone else’s; if using someone else’s syringe, always disinfect it.

Some of Humanitarian Action’s employees are themselves former drug users, who share their stories with clients, helping those who wish to quit by referring them to appropriate services.

“We congratulate Humanitarian Action on its twentieth anniversary. We hope that by its thirtieth anniversary we will also be able to celebrate the end of AIDS and the elimination of all forms of stigma and discrimination against people affected by HIV,” said Alexander Goliusov, Director, a.i., of the UNAIDS Regional Support Team for Eastern Europe and Central Asia.

The drop-in centre of the Uganda Harm Reduction Network (UHRN) looks lonely from the deserted suburban pavement. It is a non-descript house, hidden behind an imposing solid pink steel gate, in an equally non-descript neighbourhood.

It looks like so many other drop-in centres in eastern Africa that serve key populations—anonymous and low-key. Necessary characteristics, perhaps, in a region that mostly criminalizes people who use drugs, gay men and other men who have sex with men, sex workers and transgender people.

Once through the gate, visitors are greeted with a hive of activity that belies the quiet exterior. Clients and staff are buzzing around, setting up chairs under the makeshift gazebo in the verdant garden. In a few minutes, a group of people who use drugs will take part in a harm reduction workshop run by one of the centre’s staff. There is also a consulting room at the front of the drop-in centre; and at the back, is the office of Wamala Twaibu.

Mr Twaibu is the founder and chairperson of the Eastern Africa Harm Reduction Network and UHRN. A self-styled “former drug user with roots in Uganda and the pioneer of the harm reduction movement in eastern Africa,” Mr Twaibu has a kind face and a penetrating gaze that tells a story of adversity, resilience and triumph.

In the consulting room, 25-year-old Kemigisa Sandriano, a heroin user and sex worker, is taking an HIV test conducted by the centre’s resident doctor, Mukiibi Grace Nickolas. The night before, Ms Sandriano was assaulted by a client after he took off the condom during sex. She protested, telling him to leave. Her swollen, bloodshot right eye attests to what happened after that. She is smiley and talkative, seemingly unbothered by yet another instance of violence at the hands of a client. She is happy that in his battle to get his money back, she won.

Ms Sandriano was introduced to heroin by her ex-husband, who she says “ruined” her life. Nevertheless, she is upbeat about her recovery.

“I have the hope that I can stop. I even went to rehab for three months. When I saw my days of rehab coming to an end, I saw no plan and I started again,” she says.

“I am ready to go to rehab again,” she continues. “But when I come out, I don’t want to be idle. When they take us out of rehab, we need a job. They can say to us, “Work in a supermarket, work in this shop, so you can stabilize.””

Employment aside, Mr Twaibu says medically assisted treatment for people with opioid dependence is critical for rehabilitation. And, since, December 2020, with advocacy from UHRN and financial support from the United States President’s Emergency Plan for AIDS Relief and the Centers for Disease Control and Prevention, the first medically assisted treatment services in Uganda have been available at the Butabika National Mental Referral Hospital in Kampala.

UHRN screens and provides initial preparation for eligible clients and refers and links them to the hospital and provides them with ongoing psychosocial support services. In December 2020, there were 81 people who use drugs enrolled in medically assisted treatment.

Besides medically assisted treatment, through its drop-in centre UHRN offers a comprehensive package of health services, including behaviour change communication, a needle–syringe programme, psychosocial support, overdose management, HIV testing and counselling and sexually transmitted infection screening.

The COVID-19 pandemic posed a major challenge to UHRN’s clients, who even under normal circumstances face high levels of stigma and discrimination, police abuse and harassment, alienation and limited access to health and social services.

Sex workers, transgender men and women, people who use drugs and gay men lost livelihoods and faced even more violence and detention under the guise of lockdown measures. Movement was severely limited as motor vehicles required a special permit to operate.

UHRN rose to the challenge. A team of 25 peer educators used bicycles, funded by Frontline AIDS, and motorcycles to reach their clients where they were, providing antiretroviral medicine refills and condoms to clients who could not reach health facilities.

The organization rolled out virtual counselling services on risk reduction and addiction management through phone calls and WhatsApp. As part of personal protective equipment procurement, UNAIDS, through the National Forum of People Living with HIV/AIDS Networks in Uganda, provided soap and bleach to prevent COVID-19 infection among the drop-in centre’s dedicated staff, who worked right through the pandemic.

Despite the constraints of the pandemic, UHRN’s needle–syringe programme reached 287 clients in 2020, providing more than 15 000 clean needles and syringes, tourniquets, cotton balls, swabs, water ampoules, condoms, lubricant and safe-injecting information notes.

“I’m proud that harm reduction issues are taking a centre stage in Uganda,” says Mr Twaibu. “Community-led means ownership. Usually when the community is at the centre, accountability and community needs are prioritized,” he says.

The Union for HIV Prevention and Harm Reduction is a nongovernmental organization located in Balti, in the Republic of Moldova. It provides integrated services to people who use drugs and other affected populations throughout the north of the country.

Each year, more than 3000 people benefit from its services, which including mobile testing for HIV, sexually transmitted infections and hepatitis, harm reduction services, including a needle–syringe programme, the distribution of condoms and psychological and social support. The organization’s outreach and medical workers work closely with state clinics and hospital departments that offer opioid substitution therapy to people who use drugs.

However, the organization has faced a long-time logistical problem with regard to the collection of used needles and syringes generated by the harm reduction programme. Medical waste disposal in the Republic of Moldova, especially in the north of the country, is problematic. Ala Iatco, the nongovernmental organization’s head, explained that destruction of used equipment was only possible by contracting medical institutions to do the work and that the union had to send boxes with contaminated waste to Chisinau, the capital of the country.

“For the approximately 20 years of the harm reduction programme in the country, this problem was always present and solved through burning needles and syringes or other non-environmentally-friendly ways. We had to find a solution to increase the effectiveness of the comprehensive package of services and enhance the safety and security of personnel and volunteers while operating the needle–syringe programme,” said Svetlana Plamadela, UNAIDS Country Manager for the Republic of Moldova.

The UNAIDS Country Office for the Republic of Moldova, together with the United Nations Office on Drugs and Crime and the union, came together and suggested a solution. In July 2017, specialized modern medical waste management equipment was procured from the Russian Federation and installed within a Union for HIV Prevention and Harm Reduction facility. The total cost of US$ 23 000 was funded with resources from the One UN Joint Action to Strengthen Human Rights in the Transnistrian Region of the Republic of Moldova project, financed with the support of the Swedish Embassy and co-funded by the Center for Health Policies and Studies (PAS Center), which is a Principal Recipient of the Global Fund to Fight AIDS, Tuberculosis and Malaria.

“The availability of the one-stop disposal system provided by the needle smelters and syringe cutters significantly reduces the risk of accidental exposure and contamination with bloodborne diseases by the volunteers and medical personnel,” added Ms Plamadela.

So far, three organizations—the Union for HIV Prevention and Harm Reduction, Young Women Cernoleuca and Adolescent!—have benefited from the needle–syringe destruction equipment. Partner organizations usually make monthly shipments of needles and syringes for destruction, which are collected by field workers in eco-boxes.

According to Ms Iatco, the equipment is easy to use and maintain. “The machine transforms the contaminated syringes and needles into biologically safe waste. We save almost 50% of the cost of destruction. And, most importantly, we face much fewer risks as we avoid transportation, storage and transfer of hazardous material. For our organization, located in a remote area where no such equipment is available in medical institutions, it’s a cost-effective and less risky solution,” she said.

The needle–syringe programme in the Republic of Moldova started in 1999. Its main goal is to prevent the transmission of HIV and other infections among people who inject drugs by avoiding the sharing of injecting equipment and ensuring enhanced access to health-care services and psychosocial support. The programme also aims to curb the sexual transmission of HIV among people who inject drugs and their sexual partners by promoting the use of condoms and raising awareness about the link between drug use and risky sexual behaviours.

Viral hepatitis infection is a major global public health problem causing approximately 1.4 million deaths per year—more than the annual number of AIDS-related deaths. Ninety-six per cent of these deaths are from cirrhosis and hepatocellular carcinoma due to hepatitis B and C viruses, which are transmitted via blood and body fluids.

People living with HIV and hepatitis B or hepatitis C coinfection have a more rapid progression to cirrhosis. Liver disease has emerged as an important cause of death among people living with HIV coinfected with either hepatitis B or hepatitis C.

Hepatitis C coinfection with HIV is reported across all key populations at higher risk of HIV, especially among people who inject drugs. This is due to the ease with which both viruses are spread through the sharing of non-sterile drug preparation and injecting equipment.