Mapping the Response to Drug-Related HIV and Hepatitis C Epidemics
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Untitled-7 1 29/04/2008 12:11:46 Contents Acknowledgements p2 Foreword by Professor Paul Hunt p3 Introductory comments from Gerry Stimson p4 Introductory comments from International Network of People who Use Drugs (INPUD) p4 Introduction p7 Section 1: A global perspective p9 Section 2: Regional overviews Asia p21 Eurasia p33 Western Europe p47 Caribbean p57 Latin America p65 North America p75 Oceania p87 Middle East and North Africa p97 Sub-Saharan Africa p107 Section 3: Key issues The Human Right to Harm Reduction p119 Beyond injecting drug use – the overlap between HIV and non-injecting drug use p123 Civil Society Engagement: Connecting the local with the global p125 1 The Global State of Harm Reduction 2008 Mapping the response to drug-related HIV and hepatitis C epidemics Catherine Cook and Natalya Kanaef © 2008 International Harm Reduction Association ISBN 978-0-9557754-2-0 This report was produced by HR2, the Human Rights Monitoring and Policy Analysis Programme of the International Harm Reduction Association. Acknowledgements This report was made possible by the collaborative input of numerous harm reduction networks, drug user organisations and research institutes. IHRA would like to acknowledge the invaluable contribution of these individuals and organisations in gathering data for their specific countries or regions: Asia: Asian Harm Reduction Network, Thailand; Caribbean: Caribbean Harm Reduction Coalition, Saint Lucia; Eurasia: Eurasian Harm Reduction Network, Lithuania; Latin America: Intercambios Association Civil, Argentina; Middle East and North Africa: Iranian National Centre for Addiction Studies; North America: Harm Reduction Project and Harm Reduction Coalition (US), Canadian Harm Reduction Network (Canada); Oceania: Australian Injecting and Illicit Drug Users League (Australia), New Zealand Drug Foundation (New Zealand); Sub-Saharan Africa: South African Medical Research Council (Southern Africa), UYDEL, Uganda (East Africa), Student AID Liberia (Liberia), Professor A. Ouedraogo (West Africa); Western Europe: International Harm Reduction Association, ASUD/French National Association for the Safety of Drug Users (France), Brukarföreningen/Danish Drug Users Union (Denmark), Svenska Brukarföreningen/Swedish Drug Users Union (Sweden), National Treatment Agency for Substance Misuse (UK). Thanks also to the following people for reviewing sections of the report and for providing input and guidance: Rick Lines, Gerry Stimson, Damon Barrett, Jamie Bridge, Annie Kuch, Annette Verster, Joumana Hermez, Gabriele Riedner, Ying-Ru Lo, Danica Klempova, Lucas Wiessing, Dagmar Hedrich, Harry Shapiro, Richard Elliott, Sandra Ka Hon Chu, Sam Friedman, Alex Wodak, Kate Dolan, Dave Burrows, Paul Williams, Louisa Degenhardt, Stijn Goossens, Heino Stover, Luiz Paulo Guanabara, Irma Kirtadze, David Otiashvili, Matt Curtis and Catalina Iliuta. Section 3: The Human Right to Harm Reduction was written by Damon Barrett. Beyond Injecting Drug Use: The overlap between HIV and non-injecting drug use was written by Jamie Bridge, Marcus Day, Moupali Das-Douglas, Grant Colfax and Chris Beyrer. Civil Society Engagement: Connecting the local with the global was written by Damon Barrett, with substantial input from Pascal Tanguay. Designed by Mark Joyce Copy-edited by Jennifer Armstrong Printed in Spain by 7-23h Open Print Published by International Harm Reduction Association 40 Bermondsey Street, 2nd Floor London SE1 3UD United Kingdom Telephone: +44 (0)207 940 7525 E-mail: [email protected] Website: www.ihra.net 2 Foreword by Professor Paul Hunt Since the earliest days of the global HIV pandemic, people who inject drugs have been identified as one of the groups disproportionately affected by the virus. In the mid-1980s, harm reduction arose as a series of targeted, low-threshold interventions aimed at preventing the transmission of HIV through unsafe injecting practices. In the two decades since then, comprehensive harm reduction services have proven time and again to be remarkably effective responses to HIV. But the health benefits of harm reduction extend beyond HIV prevention to preventing the transmission of other blood-borne viruses and to protecting people who inject drugs, and their partners, from the wide range of other negative health consequences associated with injecting drug use. Today, despite endorsement by UNAIDS, WHO and UNODC, and the overwhelming evidence in favour of harm reduction as an effective HIV prevention strategy, the global state of harm reduction is poor. Less than 5% of those in need have access to harm reduction services. Up to 10% of new HIV infections worldwide are attributable to unsafe injecting. When sub-Saharan Africa is excluded, this figure rises to 30%. The figure is significantly higher still in some regions and specific countries, often the same places where access to harm reduction services is most limited. All over the world, people who use drugs remain marginalised, stigmatised and criminalised, with increasing vulnerability to HIV and decreasing access to essential health care services. In such environments, the full guarantee of the right to the highest attainable standard of health for people who use drugs is impossible. In seeking to reduce drug-related harm, without judgement, and with respect for the inherent dignity of every individual, regardless of lifestyle, harm reduction stands as a clear example of human rights in practice. What began as a health-based intervention in response to HIV must today be recognised as an essential component of the right to the highest attainable standard of health for people who inject drugs. Every state therefore has an obligation to implement, as a matter of priority, national comprehensive harm reduction services for people who use drugs. The Global State of Harm Reduction is a welcome and long overdue publication. As it develops, in print and online, it will, I hope, serve as a tool to assist not only in assessing the global state of harm reduction, but also the global state of the right to the highest attainable standard of health for people who use drugs. Professor Paul Hunt UN Special Rapporteur on the Right to the Highest Attainable Standard of Health 3 Introductory comments from Gerry Stimson It is over two decades since the first harm reduction projects started in Europe, Australia and North America – grass-roots services delivered by civil society and endorsed and (soon after) funded by some governments. Since the late 1980s, harm reduction has grown exponentially in terms of acceptance, coverage, popularity, implementation and scientific knowledge. Harm reduction programmes currently operate in a wide variety of cultural, religious and political contexts, and the approach is supported by international organisations such as UNAIDS, UNICEF, WHO, UNODC and the World Bank. This report aims to consolidate this growth by assessing and documenting the global state of harm reduction in 2008. In many ways, the scientific debate has been won and only ideological or moralistic criticisms remain. However, there are still numerous obstacles to the universal implementation of harm reduction, including resource shortages, re-emerging ‘War on Drugs’ approaches, legal restraints on substitution treatments, vociferous anti-harm reduction bodies and limitations on NGO operations in many developing and transitional countries. In order to overcome these barriers and move forward, harm reduction must become a truly global approach. The International Harm Reduction Association (IHRA) was formed in 1996 (as a result of the annual harm reduction conferences) and has since become a leading organisation promoting evidence-based harm reduction policies and practices on a global basis for all psychoactive substances. This report is a demonstration of IHRA’s commitment to the development of a conducive global environment for the promotion of harm reduction and the defence of the human rights of people who use drugs. Professor Gerry Stimson Executive Director International Harm Reduction Association Introductory comments from International Network of People who Use Drugs (INPUD) The global prohibition – imposed by the United Nations drug conventions – causes multiple damages to people who use drugs and the social environments in which we live. Under these circumstances, harm reduction is the only approach that really helps people who use drugs to survive. Harm reduction saves lives. Harm reduction and our community of people who use drugs have a symbiotic connection. Most important in this relationship is the acknowledgement that voices of drug user activists are fundamental for shaping the response to all problems related to illegal drug use. In this sense, drug user activism IS harm reduction. Drug user organising begins by addressing health-related issues. The drug user activists strive for political change. A recent online survey into the global state of drug user activism showed that 79% of responding organisations were engaged in advocacy, and 95% of them were purely peer-driven. Drug user activists are becoming increasingly involved in the global drug policy debate. In July 2007, the International Network of People who Use Drugs (INPUD), the first international drug user organisation, was registered, and since then it has been represented at international conferences and high-level meetings including the EU Civil Society Forum on Drugs, UNGASS Regional Consultations, UN Civil Society Task Force and the Commission on Narcotic Drugs. LUXEMBOURG Nevertheless, the life