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JANUARY 2016 Issue 5 [email protected] www.facebook.com/linkagesproject @LINKAGESproject DRUGS, DATA, DELIBERATIONS: PUTTING IT INTO PERSPECTIVE People who inject drugs continue to be disproportionately affected by HIV because of limited investment in — and access to — proven interventions. Even when effective services are available, severe stigma and punitive laws create barriers to their use, compounding people’s risk of acquiring HIV and hepatitis infection through unsterile injection equipment. Discrimination against drug users and criminalization of drug use also make it difficult to collect accurate data about people who inject drugs. Estimates of HIV prevalence among people who inject drugs; the size of drug-using populations; and their use of HIV prevention, care, and treatment services are incomplete, as is understanding of their needs and risk behaviors, because many people are unwilling to identify themselves as users of illicit drugs. All over the world, successful responses Photo Credit: © Malaysian AIDS Council / International HIV/AIDS Alliance to the HIV epidemic have been driven in large part by two key factors: Personal experiences inspired Amran Ismail to establish the first community- political commitment and agency of the based organization in Kuala on the east coast of Malaysia, CAKNA, which constituency group. For people who supports people who inject drugs. inject drugs, neither of these pillars has been given sufficient attention The Link, our guest authors write about of people who inject drugs are often and dedicated focus. In this issue of innovative efforts to strengthen both. gender-neutral or heavily skewed toward the men. Although women who IN THIS ISSUE On page 4, Judy Chang writes about inject drugs are even more hidden than Afghani women who use drugs—a 1 | DRUGS, DATA, DELIBERATIONS their male counterparts, they account 3 | HISTORIES OF COMMUNITY ACTION group who, traditionally, has had about for about one-third of all people who 4 | OUT OF THE SHADOWS as little agency as it’s possible to have. inject drugs.1 5 | DATA AND HUMAN RIGHTS Chang explains how gaps in the data 6 | WHAT WORKS FOR WHOM AND WHERE on these particular women—but also Estimates of those receiving evidence- 7 | IN FOCUS: LINKAGES IN INDIA for all women who inject drugs—are informed and rights-based HIV 8 | THE PEOPLE @ LINKAGES particularly pronounced. National and and harm reduction services are 9 | NEW RESOURCES international research and surveillance ARTICLE CONTINUED ON PAGE 2 DRUGS, DATA, DELIBERATIONS: PUTTING IT INTO PERSPECTIVE CoNtINued froM PAge 1 also problematic, but coverage is HIV. In addition to more comprehensive to guide the programs that serve undoubtedly poor. Fewer than eight data, he writes, we need a better them. Implementing Comprehensive in 100 people who inject drugs have understanding of how to promote HIV and STI Programmes with People access to opioid substitution therapy application of the data we have. Who Inject Drugs: Practical Guidance (OST), and only an average of two sterile for Collaborative Interventions, to be needles are distributed per month per However, a number of promising published in 2016, will be a welcome person who injects drugs.2 HIV-positive developments suggest a potential trend resource for improving programs. people who inject drugs appear to toward more evidence-based policies have lower rates of HIV treatment and and greater political commitment. In It’s true that more information is viral suppression compared to other April 2016, The UN General Assembly needed to better understand the most key populations, in part because many will hold a Special Session (UNGASS) effective way to provide services for people do not report their drug use on drugs. This Special Session will offer people who inject drugs and to retain when they seek these services.3 member states the opportunity to them in the HIV care cascade. But, put deliberate on the thorny issues related into perspective, data are just one part Estimating coverage may be to drug law reform. For over a year, of a bigger picture. In the absence of challenging, but the evidence base for organizations led by people who inject perfect data, governments must be comprehensive HIV and harm reduction drugs as well as other stakeholders determined to move from deliberation services for people who inject drugs have been participating in pre-UNGASS to action. The history of response to the AIDS epidemic was built through this combination of data and resolve and Fewer than eight in 100 people who inject drugs have based on the fundamental principles of access to opioid substitution therapy (OST), and only an people-centered approaches. average of two sterile needles are distributed per month 1. Degenhardt L, Whiteford HA, Ferrari AJ, et al. Global burden of disease attributable per person who injects drugs. to illicit drug use and dependence: find- ings from the Global Burden of Disease Study 2010. Lancet. 2013;382(9904):1564- is strong. Distributing free or low-cost consultations to share their practical 74. Available from: http://www.thelancet. com/journals/lancet/article/PIIS0140- sterile needles reduces HIV transmission expertise and experiences. 6736(13)61530-5/abstract. http://www. among people who inject drugs without thelancet.com/pdfs/journals/lancet/ increasing drug use, and it is most Most recently, the U.S. Congress PIIS0140-6736(13)61530-5.pdf. effectively lifted a decades-long ban on effective when combined with access to 2. UNAIDS. People who inject drugs. In: needle and syringe programs. Malaysia OST and HIV counseling and treatment. The gap report. Geneva, Switzerland: OST reduces high-risk injection has transformed eight compulsory UNAIDS; 2014. Available from: http:// behaviors and drug-related deaths while detention centers into voluntary care www.unaids.org/en/resources/cam- improving adherence to antiretroviral clinics and has expanded OST provision paigns/2014/2014gapreport/gapreport. regimens among HIV-positive people in prisons. Tanzania has established the 3. Pierce R, Hegle J, Sabin K, et al. Strategic who inject drugs.4 first community-based OST program in information is everyone’s business: per- East Africa. spectives from an international stake- holder meeting to enhance strategic Despite the strength of this evidence, information data along the HIV cascade Such community action has been most countries continue to emphasize for people who inject drugs. Harm Re- criminalization over harm reduction. instrumental in the development of duct J. 2015;12:41. Available from: http:// Drug use is illegal in all but a handful of harm reduction, writes Andy Guise on harmreductionjournal.biomedcentral. countries, and few offer harm reduction page 3. His call for research on how to com/articles/10.1186/s12954-015-0073-y. services in prisons. In many countries, support community action and a study 4. WHO, UNODC. UNAIDS technical guide people who inject drugs experience exploring how to support integrated for countries to set targets for universal involuntary drug testing and compulsory OST and HIV care in Kenya (see access to HIV prevention, treatment and care for injecting drug users – 2012 revi- page 6) are examples of a much-needed detention, or “rehabilitation,” which sion. Geneva, Switzerland: WHO; 2012. rarely includes OST. implementation science approach Available from: http://www.who.int/hiv/ to adapting proven interventions for pub/idu/targets_universal_access/en/. Lack of commitment is one cause of the people who inject drugs in different Photofailure Credit: to heed © evidence,Steve Lambert as Ralf Jürgens settings. notes in his article on page 5. This, rather than the scarcity or quality of data, is A central theme of this issue of The the main reason why people who inject Link is the importance of engaging drugs are left behind in the response to people who inject drugs in research 2 LEARNING FROM HISTORIES OF COMMUNITY ACTION In New York in the late 1970s and early research and development of biomedical Community action, and how to support it, 1980s, before the public health and med- methods of HIV prevention, and just 1% is then a key priority for global health re- ical authorities had recognized HIV and of that is oriented toward their social and search in the response to HIV for, and with, taken action, people who were injecting behavioral dimensions.5 New HIV research people who use drugs. Among the many drugs responded to the new challenge priorities from within the NIH’s Office of issues to learn about: facing them. Even hostile policing couldn’t AIDS Research also focus almost exclu- • The various roles people who use drugs 6 stop the emergence of a market in sterile sively on cure and treatment efforts. can play in facilitating access to care needles and syringes among the drug us- Biomedical interventions for people who within clinics ing community to replace the home-made use drugs are, of course, essential. PrEP, • How community action can foster new and frequently shared injecting equipment vaccines, and microbicides should all form norms that support preventive action that was being linked to HIV.1 part of a comprehensive HIV strategy, and that allow for the uptake of new This is just one vignette, from a specific alongside ART, opioid substitution thera- biomedical interventions time and place, but stories like this one pies, and needle and syringe programs. • How people who use drugs, and their have occurred many, many times around Community mobilization is in turn networks, are instrumental in altering the world. People who use drugs have been essential to ensure the relevance of these the structural environment and over- 7 central to the development of HIV and interventions and their accessibility. coming barriers, such as police brutality, harm reduction services, in settings from And yet, community mobilization, espe- that create vulnerability to HIV 1, 2 Africa and Asia to Europe and America.

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