The state of Harm Reduction

The 21st International Harm Reduction conference held the end of April in Liverpool, England, celebrated the progress of various countries over the past two years in applying harm reduction strategies for drug use.

The report nevertheless also cautioned that harm reduction strategies must be taken to those areas of the world where to it is taboo to discuss needle exchange, opium substitution and safe use rooms, among other harm reduction strategies.

Although harm reduction is a term that applies to minimizing damages caused by the use of all substances (one example being drinking and driving laws) the conference focused on the use of injecting drugs, currently used by 15.9 million people in 158 countries. One of the greatest damages associated to this type of drug use is HIV/AIDs contagion and Hepitits C, both spread by sharing syringes.

The Sociologist specialized in public health Gerry Stimson, current director of the International Harm Reduction Association (IHRA) spoke at the opening ceremony, stressing that one of the greatest challenges in the next few years will be to take harm reduction to those areas of the world that need them most urgently.

Solutions begin with correct diagnosis, as the IHRA report launched at the conference notes. The report, The Global State of Harm Reduction 2010 provides the data necessary to establish quality standards for the Reference Group to the United Nations on HIV/AIDs and Injecting Drug Use. The report notes there are many areas of the world where the information is lacking since quality data was unavailable.

There are today 93 countries and territories around the world that support harm reduction, according to the 2010 report (the previous one was issued in 2008) In other words, 11 more countries than in 2008. “When we spoke of countries that support harm reduction we want to say that they have already incorporated harm reduction into national drug policy guidelines,” said Catherine Cook, IHRA analyst and report editor. She cautions that even in those countries where harm reduction has gained political acceptance, harm reduction programs are still in their infancy.

Still taboo

From the point of view of international policy, the term harm reduction still meets with resistance. As we know, the 2009 Political Declaration issued by the United Nations Commission on Narcotic Drugs (CND) did not include the term harm reduction, although 26 countries signed a manifesto criticizing the exclusion of harm reduction. The term was also absent in the March 2010 Resolution for Universal Access to HIV Services.  

Some progress has been made however, with respect to Harm Reduction in the UN/AIDs resolution and in the Human Rights Resolution, supported by UN member states, including those who opposed themselves to its inclusion in the Political Declaration of the CND, among them Japan and Russia.

At a national level, despite the staunch position of the CND, many countries have made some progress in the topic. One of the most visible changes was made by the Barak Obama administration in the United States. The current administration has become much more flexible in its approach of the problem, adopting measures that include lifting a federal prohibition against financing syringe exchange programs and the public recognition that drug users must be treated like patients and not criminals. As for international politics, the biggest challenge remains Russia, whose government does not recognize the success of substitution therapies approved by public health researchers.

Syringe Exchange

According to the Global State of Harm Reduction, there are records of injecting drug users being contaminated with the HIV/AIDs virus in 120 countries around the world. The prevalence of the disease in this group rises above 40% in eight countries: Argentina, Brazil, Estonia, Indonesia, Kenya, Myanmar, Nepal and Thailand.

There are currently 82 countries that support some version of syringe and needle exchange, according to the report. Data show that there has been an increase in the number of services in various nations, including those in which AIDs is a significant disease among injecting drug users, such as the Ukraine, and Iran. On the other hand, syringe exchange programs were introduced into Mongolia, the Philippines, Kosovo and Tunisia.

In countries where there are syringe exchange programs, there is nevertheless great disparity in the degree of coverage granted by these programs. “There is, overall, greater coverage in developed nations, with countries in Western Europe and Australia reaching the desired quota of 200 yearly needles per injecting drugs user. In developing countries, coverage is much smaller, - in Latin America, the Caribbean, the Middle East and in Africa, less than one syringe per person is allotted per year, according to the report.

OST therapies

Opioid Substitution Therapy, OST, one of the great harm reduction strategies, is present in 70 countries. Methadone and buprenorphine are the medications most commonly used in most countries in treatment of opium and heroin users. In some cases small doses of morphine and codeine are used as well as assisted-heroin use.

Indicators show that a significant number of countries, among them China, India and Iran, have made considerable efforts to increase the numbers of OST centers over the past two years. OST therapy was introduced in Afghanistan, Armenia, Colombia, Kazakhstan, the Maldives and Senegal.

OST therapies are also much more prevalent in more developed countries. For every 100 injecting drugs users in Western Europe, there are 61 beneficiaries of OST, while the average of OST users for areas such as Latin America, Sub Saharan Africa and Central Asia, is of less than one beneficiary for every 100 injecting drugs users.

As for Drug Consumption Rooms, DCR, the report states that they are present in 60 countries around the world. Most of them are located in Eastern Europe, where there are, in total, 90 DCRs in the following countries: Holland, Germany, Luxemburg, Norway, Spain and Switzerland.

How Latin America stands

According to the Reference Group there are two million people using injecting drugs in Latin America, of which approximately one fourth (close to 500 thousand people) have AIDS. Brazil and Argentina have the highest levels of HIV positive people among injecting drugs users. “Government support for harm reduction has not increased significantly since 2008. Nevertheless one important step forward was Colombia’s adoption of OST and the open inclusion of harm reduction in its national policy,” states the report.

The report also stresses that there seem to be more programs of harm reduction that are born out of the communities that address injecting drug use, but that these initiatives are not well documented nor well disseminated. “The lack of official support and the reliance on international financial support continue to act as barriers for introducing and increasing harm reduction services in a number of countries,” states the report.

It is important to note that over the past few years there have been positive signs towards the decriminalizing drug use, as the report observes. This change has not however, been followed by an increase in harm reduction.

Despite the levels of injecting drug use noted by the report for the region in 2008, only five countries in Latin America implemented needle or syringe exchange programs. Brazil is the country with the largest numbers of injecting drugs users (as compared with countries that released their data) with 540 thousand people using injecting drugs, and also with highest number of syringe exchange programs. But they are still insufficient.

“It is estimated that the syringe exchange programs are very limited in scope and that where they are available, they offer low coverage. Injecting drugs users in Brazil are given what amounts to less than one syringe/needle per year. More research and more monitoring programs are needed in countries adopting these types of practices to determine the levels of coverage,” states the report.

As for OSTs, although the region has low rates of Opioid consumption, Colombia and Mexico have a significant number of heroin users. Both countries are implementing OST therapies.
Conference organizers and report authors believe nevertheless harm reduction has come a long way since the first syringe exchange program was begun in Liverpool, England, 20 years ago.
There is however, still plenty to do. “The next generation will see how harm reduction will take control, just as we have regulated all psychoactive substances. The massive investments of resources in combating drug use have not shown results,” said Gerry stemson, in the plenary session.

Cover photo and inside: International Harm Reduction Association, Global State of Harm Reduction.

This story includes information from the Global state of harm reduction 2010 report, and the IHRA bulletin, and Daily Update.

Read Further:

The complete report

IHRA

The 21st International Conference on Harm Reduction