Perspective: Why we need harm reducation to reach universal access goals

Address by Michel Sidibe, Executive Director of UNAIDS
Donor Conference on Harm Reducation, Amsterdam, Netherlands, 28/01/2009

I am deeply honored and privileged to join you for this important meeting for three reasons:

First, we are witnessing a revolution in practice – a revolution which brings altogether users and ex-users, human rights advocates, public health practitioners and of course those who have the financial resources to make a difference – to address a pressing problem for which there are straight-forward evidence-informed solutions.

Second, I am genuinely pleased to be here in the Netherlands – which has not only taken the initiative to convene this conference on harm reduction – but has of course been a pioneer in proving that it can work and must work.


Third, being here provides me an opportunity to publicly acknowledge the work of our Cosponsors. Please allow me to congratulate the UNODC [United Nations Office on Drugs and Crime] for the initiatives they have been taking in bringing together national programmes for HIV, drug control and prisons – programmes which deal centrally with drug injection, but all too often in the national setting do not work closely together. They are also working with WHO [World Health Organization] and UNAIDS in developing integrated ТВ, HIV and injecting drug user services.

Tonight I want to speak to you about four inter-related themes:
1. Harm reduction as part of the renewed push for universal access to HIV prevention, treatment, care and support
2. Laws which prevent drugs users from access to harm reduction measures are counterproductive to the AIDS response.
3. Backing human rights approaches to harm reduction
4. Bringing the harm reduction community into a renewed global movement for HIV prevention

Only universal access to harm reduction can deliver the results we need.

The global commitments to universal access to HIV treatment, prevention, care and support must be made a reality for all – including the most marginalized and cast out by society. Drug users, often invisible to society, fall squarely into this category.

Universal access means all the elements of harm reduction must reach all injecting drug users.

The Netherlands has so successfully demonstrated the power of universal access to harm reduction, As you know, harm reduction programmes started here in Amsterdam by the union of injecting drug users in 1984 and were progressively taken up by municipal and national authorities. By 2006 the estimate is that there were no more than six new HIV infections through injecting drug use in this country. That is a remarkable figure. Similar success has been seen in a variety of other countries including, for example, Australia, Switzerland and more recently Malaysia and Bangladesh have made significant progress.

These achievements would not have been possible without determined efforts with law reform which deals effectively with stigma and discrimination and ensure universal access to harm reduction services.

I am pleased that the Netherlands has also been able to export its success – for example needle and syringe programmes in Slovenia were set up with drug-user representatives from the Netherlands.

There is overwhelming evidence that harm reduction initiatives work. But let me remind you that harm reduction has also been shown to be very cost effective.
– In the Ukraine needle and syringe exchange is estimated to cost less than $100 per HIV infection averted.
– In Australia the return on investment of a decade of needle and syringe programmes was estimated at one and a half billion US dollars.

In other words, harm reduction provides an excellent return on public investment.

Services remain inappropriate and inadequate

However, the level of coverage of HIV services for injecting drug users remain far short of universal access.

The 2008 Report on the global AIDS epidemic highlighted that only an estimated 47% of users world ¬wide were reached by information or needle exchange services.

In Eastern Europe drug injectors represent 83% of HIV cases but only 24% of those on HIV treatment.

In ten countries with some of the world’s largest drug-driven HIV epidemics, some 70,000 drug users are on opioid therapy, while 3.7 million miss out.

It is unacceptable that in some countries that drug users are forced to choose between ТВ treatment, drug substitution therapy and HIV treatment because services are not integrated.
And the newly emerging drug use hotspots of both eastern and western Africa, where drug use has followed changes in drug trafficking routes, harm reduction programmes are still largely lacking.

Unacceptable human rights abuses of injecting drug users

Paul Hunt, the UN Special Rapporteur on the right to the highest attainable standard of health addressed the conference of the International Harm Reduction Association last year and presented a shocking litany of human rights abuses of drug users from every region on the world.

We know from study after study across the world that police crackdowns on drug users have massive negative health consequences:
– overdose deaths rise because uses are reluctant to call for medical assistance,
– drug users who fear arrest are more likely to share needles,
– there is a direct impact on access to harm reduction services.

In contrast, partnerships between law enforcement and public health officials are very successful – for example in Britain and Australia where drug action teams police focus on the crime fighting and successfully refer drug users to health and welfare services.

It is unacceptable when drug testing or HIV testing is used an instrument of police harassment. It is unacceptable when drug users are locked up and forgotten in the name of drug treatment. All of these violations of human rights impede our public health goals.

I was shocked to read of the study from Pakistan where injecting drug users felt so completely powerless that in order to avoid arrest ‘Sometimes they [IDUs] would cut themselves with some blade … near their neck. This scares the policemen that they might get into trouble because of him so they let him go.’

Equally disturbing are the abuses that happen in the name of drug rehabilitation. Abuses documented by organizations such as the Open Society Institute and human rights organizations-countless cases of injecting drug users being tortured, beaten up, chained, imprisoned, or left for dead.

So what can we do about it?

So what do we need to do to address these challenges?

First we need to disseminate widely the evidence of what works.

Second, we need all the international institutions to speak out loudly and clearly in favour of harm reduction.
I hope and expect we will see further advances when the Commission on Narcotic Drugs meets in Vienna in March.
– One – in Vienna we need a clear recognition of what has been learnt over the past decade of harm reduction efforts
– Two – we need to develop an effective programme of action which unites our efforts in relation to HIV, health, and human rights.
– Third, we need a clear programme of legal reform and human rights protection which have the health of injecting drug users as their primary goal.

I have already said, we must clearly and unequivocally break the conspiracy of silence-clearly the evidence shows harm reduction works. It should not be a crime to get clean syringes. It should not be a crime to get methadone treatment. The human rights of every single person need be respected.
One of the most significant steps forward we can make to universal access to HIV prevention, treatment, care and support is to stop criminalizing use of needle exchange, methadone treatment and other substitution therapies.

We must stop criminalization of drug users.

Addiction is an illness which needs treatment, not a crime in need of punishment.

Whatever the challenges in dealing with the social impacts of drug use, it is never the appropriate response to make the lives of the most vulnerable even more miserable.

Fourth, we need to focus in on the most important gaps in HIV programmes for drug users.

And last, we need to deliver programmes for injecting drug users at full scale, not as pilot or experimental projects. For my part, I will use my office to engage, country by country as required, in proactive prevention diplomacy to ensure universal access for all to harm reduction services.
I am deeply committed to this agenda as universal access is the only path I see to ensure that the next generation is free of HIV.

Winds of change

It is extremely heartening that countries with huge populations like Indonesia and China are seriously embracing the harm reduction challenge, at the full scale.
Indonesia for example is aiming to ensure that needle and syringe exchange covers 70% of injecting drug users by 2010, up from the baseline of only 10%, and that methadone treatment reaches 30% of users.

And China had only 50 needle and syringe programmes in 2004, but this rose 10-fold by 2006 and is planned to double again by 2010, along with methadone clinics which aim to reach 70% of heroin users.

We know that programmes work best when the communities most affected are involved in shaping those programmes. Today I want to salute the courage of those advocates who have been willing to come forward as people who use drugs, often at considerable personal risk.

Working with, not against, drug users is how we can make universal access a reality. The challenges are real, but the progress we have seen over the past decade is considerable.
Let me finish with four inter-linked imperatives: universal access, human rights, a revitalized HIV prevention movement and the full inclusion of drug users in the AIDS response.

Let’s join hands to make real progress on all four. I know it is possible.

Thank you

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