The global state of harm reduction

Published in May, the Global State of Harm Reduction 2008 report provides a region-by-region assessment on drug-related HIV and hepatitis C epidemics, as well as the extent of policy and programmatic responses from multilateral agencies, government and civil society. Catherine Cook.

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The evidence base for interventions that aim to reduce harms associated with drug use is extensive and unequivocal. United Nations agencies have long endorsed harm reduction and international best practice guidelines to promote access to harm reduction services as both a human right and a public health imperative.

At a national level, government policy and strategy increasingly includes harm reduction, which, in many countries, now forms an integral part of the response to drug use. Leadership and innovation in the harm reduction field has traditionally hailed from civil society. Non-governmental and community-based organisations, including peer-led initiatives, continue to provide essential services, with or without government support and often in difficult circumstances.

Despite this, HIV, hepatitis C and numerous other health, social and economic harms affect people who use drugs – particularly those who inject – to staggering extents in much of the world. Globally, the vast majority of people who inject drugs have no access to life-saving harm reduction services. The recently released United Nations Secretary General’s report revealed that only 34 percent of countries with an HIV epidemic concentrated among key populations have programmes in place to reduce the risk of HIV transmission among people who inject drugs.

Throughout 2007, the International Harm Reduction Association (IHRA) worked with harm reduction networks, researchers and organisations of people who use drugs around the world to piece together a global snapshot of the harm reduction response. This ambitious project involved gathering the most reliable data to reflect the situation in over 200 countries and territories worldwide.

In New Zealand, where both harm reduction and research in this area is long established, IHRA collaborated with the New Zealand Drug Foundation. In some countries, research on this issue was plentiful, whereas in others, for example, the Pacific Island countries and territories, there was a severe drought of information. The Global State of Harm Reduction 2008 has, for the first time, enabled us to view the harm reduction picture worldwide and examine how far harm reduction has developed, but also to identify the gaps and to determine how much more work there is to be done.

Injecting drug use, HIV and hepatitis C

Injecting drug use is now a global phenomenon reported in 158 countries and territories across all regions of the world. IHRA cautiously estimates the number of people injecting drugs worldwide is 11.6 million, with the vast majority living in developing and transitional countries. The most commonly injected drugs are heroin, cocaine and amphetamine-type stimulants. People who inject drugs are predominantly male, ranging from approximately 70 to 75 percent in Europe and North America to over 90 percent in many Asian countries.

The regions with the highest numbers of people who inject drugs are Asia and Eastern Europe, with the largest numbers residing in Russia, China and India. In New Zealand, it is estimated that 31,000 people inject drugs. Opioids are the most commonly injected substances here and, to a lesser extent, amphetamine-type substances, including methamphetamine.

Many health, economic and social issues are faced by injecting drug users, who continue to be among the most marginalised in societies across the globe. The Global State of Harm Reduction research focused on the often overlapping epidemics of HIV and hepatitis C affecting increasing numbers of people who inject drugs in all continents around the world.

It is estimated that up to 10 percent of all HIV infections occur through injecting drug use. Therefore, using the United Nations Joint Programme on HIV/AIDS (UNAIDS) latest estimates,there may be up to 3.3 million people who inject drugs and live with HIV. In much of Western Europe as well as Australia and New Zealand, where harm reduction initiatives are long established, HIV prevalence among people who inject drugs remains below 5 percent.

At the other extreme, in countries such as China, Estonia, India, Kenya, Myanmar, Nepal, Thailand and Vietnam, HIV prevalence has reached 50 percent or higher among people who inject. While these figures illustrate the national prevalence rates among people who inject drugs, where it is available, data on populations such as prisoners often reveal even higher prevalence rates.

Hepatitis C (HCV) is the most common infectious disease among people who inject drugs. Most HCV infections around the world occur through unsafe injecting drug use. Due to the lack of symptoms, many people remain unaware they have the virus and, therefore, are less likely to seek treatment. This outcome is even more pronounced among populations who have poor access to general healthcare services.

In some areas, HCV prevalence rates among people who inject drugs are as high as 95 percent. Worldwide, it is reported to be over 50 percent in 49 countries or territories. The vast majority of people who inject drugs in countries as far ranging as Indonesia, Thailand, Pakistan, Mauritius, Estonia, Lithuania, Russia, Ukraine, Luxembourg and Switzerland are living with HCV. In New Zealand, this figure remains very high at 70 percent, despite very low HCV prevalence within the national population.

The global harm reduction response

Established in response to growing epidemics of HIV and other blood-borne infections, harm reduction has grown in acceptance, popularity, scientific support, advocacy methods and evidence base since the late 1980s. The harm reduction approach is currently endorsed by the majority of EU countries, Australia, New Zealand and a growing number of more recent converts including Indonesia, Malaysia, Taiwan,China, Iran and Morocco. Harm reduction programmes currently operate in a wide variety of cultural, religious and political contexts. They have been adapted to suit most settings, resource restrictions and populations. Harm reduction is a mainstay of United Nations policies and is supported by UNAIDS, UNICEF, UNESCO, UNODC and the WHO.

Presently, at least 77 countries and territories have some form of syringe distribution programme, and approximately 63 have some type of methadone or buprenorphine substitution treatment. Seventy-one countries or territories explicitly support harm reduction in their national HIV and/or drug-related national policies.

While these numbers have been steadily increasing since the late 1980s when the first harm reduction projects began in the Netherlands and the UK, many countries have small pilot projects, or very limited services in place, which do not reach all who could benefit. In New Zealand, needle and syringe exchange, opioid substitution therapy and wider HIV and HCV prevention, treatment and care services are available for people who inject drugs, but to a much lesser extent for those in prisons.

‘Universal access’ to HIV prevention, treatment and care, including harm reduction services, is far from a reality for the majority of the people who inject drugs. Barriers to accessing harm reduction services are very similar from region to region, but, in general, are experienced much more severely in transitional and developing countries. These include poor coverage and quality of services, costs associated with service access, police harassment or arrest, stigma and discrimination. Scale-up of quality harm reduction services is often impeded by repressive legislation (for example, criminalising needle and syringe services or prohibiting prescription of opiate substitution therapies), lack of funding and/or support from government and limited capacity for service delivery.

Civil society, including groups of people who use drugs, has a key role to play in advocating to governments, donors and multi- and bi-lateral organisations for the rights of people who use drugs to access life-saving harm reduction services. The Global State of Harm Reduction 2008 is intended to serve as a useful reference and advocacy tool for all key stakeholders. It is also proving useful in informing strategic planning for harm reduction advocacy campaigns and project implementation, using a process of identifying priority countries according to the data gathered.

To read the report and to find out more about the International Harm Reduction Association, please visit www.ihra.net. Later this year (2008), the IHRA website will host a web-based Global State of Harm Reduction resource, which will be updated periodically.

• Catherine Cook is the research analyst for HR2, the International Harm Reduction Association’s Harm Reduction and Human Rights Monitoring and Policy Analysis Programme.

• Matters of Substance, guest editorial, August 2008