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International Journal of Drug Policy 26 (2015) S1–S4

Contents lists available at ScienceDirect

International Journal of Drug Policy

j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / d r u g p o

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tate of the art science addressing injecting drug use, HIV and harm eduction

Unsafe injecting drug use continues to drive the HIV epidemics n many countries around the world. The United Nations Office on rugs and Crime (UNODC), Joint United Nations Programme on IDS (UNAIDS), World Health Organization (WHO) and the World ank estimate that there are 12.7 million (range: 8.9–22.4 mil-

ion) people who inject drugs (PWID), globally. Among them, 13.1 er cent or 1.7 million people (range: 0.9–4.8 million) are living ith HIV, with wide variations between regions and countries.

he HIV situation is of particular concern in South-West Asia and n Eastern and South-Eastern Europe and Central Asia, where the revalence of HIV among PWID is estimated to be between 23 nd 29 percent, respectively. While HIV in sub-Saharan Africa is ransmitted mainly via unprotected sexual intercourse, HIV trans-

ission through unsafe injecting drug use has now also emerged s a significant concern in East Africa, and has also been reported n several countries in other parts of Africa (UNODC, 2014). In ddition, high risk sexual practices linked to the use of stimu- ant drugs (e.g. amphetamine-type stimulants, cocaine) among key opulations – for example, men having sex with men – are also ontributing to the spread of HIV in certain parts of the world.

To respond to HIV and associated epidemics among people who nject drugs, WHO, UNODC and UNAIDS have jointly recommended

package of nine interventions, commonly referred to as a ‘harm eduction’ approach to injecting drug use (WHO, UNODC & UNAIDS 012), aimed at reducing the risk of acquiring and improving treat- ent and care of HIV, hepatitis and TB in PWID. The first four

nterventions: needle-syringe programmes (NSP), opioid substitu- ion therapy (OST), testing and counseling for HIV and provision f antiretroviral therapy (ART) are the most critical. There is com- elling evidence that NSP and OST are effective in reducing the haring of injecting equipment and averting HIV infections. In com- ination with ART, these interventions reduce HIV transmission, ecrease mortality, reduce drug dependency, and improve quality f life.

In March 2014, UNODC organized, in the context of the High- evel Review of the 57th session of CND, a one-day Scientific onsultation in Vienna, entitled “Science addressing drugs and HIV: tate of the Art”, where it brought together leading scientists to dis- uss the latest developments in prevention and treatment of HIV

nd AIDS as it relates to drug use. The presentations and discussions t the Scientific Consultation revolved around six thematic top- cs, pre-identified by UNODC, in consultation with its civil society artners. These were: The cost effectiveness of harm reduction; HIV,

ttp://dx.doi.org/10.1016/j.drugpo.2014.11.008 955-3959/© 2015 The Authors. Published by Elsevier B.V. This is an open access article un

drugs and the legal environment; Women and drugs; Harm reduction in prisons; Compulsory detention as drug treatment and the impact on HIV outcomes; and Prevention, treatment and care of hepatitis C among people who inject drugs. The scientists were encouraged to reach out to a broader group of the relevant scientific com- munity and gather its inputs as they were to prepare for their individual thematic paper and related presentation at the Scientific Consultation.In their commentary, Wilson, Braedon, Shattock, and Fraser-Hurt (2015) demonstrate the cost-effectiveness of key harm reduction interventions for people who inject drugs, from both gov- ernment and societal perspectives, in terms of HIV outcomes and drug dependency. The commentary also provides a brief overview of current implementation levels of the various interventions by region. Access to comprehensive harm reduction services for PWID remains disproportionately low. As of 2010, globally, fewer than 8 in 100 PWID have access to OST, only 2 sterile needles are dis- tributed per month per PWID and only 4 in every 100 eligible people who inject drugs are receiving ART (Mathers et al., 2010). HIV services are typically not responsive to the specific needs of particularly vulnerable groups of PWID, in particular women, young people, and those living in prisons and other closed settings. In the commentary by Azim, Bontell, and Strathdee (2015) the authors discuss the reasons why women who use drugs are particularly vul- nerable to HIV infection, suggesting that interventions to optimize HIV prevention and care need to be sensitive to the needs of women and often, their children.A growing body of evidence indicates that the main factors behind the disproportionately low access to harm reduction services among PWID include: the lack of supporting drug policies and legislation in many countries; over-reliance of many national drug control systems on sanctions and over-use of incarceration of people who use drugs; compulsory detention for drug use and punitive practices in a number of countries in the name of treatment for drug dependence; and stigma and dis- crimination. In their commentary, Strathdee, Beletsky, and Kerr (2015) show how the legal environment, such as policing prac- tices, are directly or indirectly responsible for elevated HIV risks among PWID. They also present examples where police educa- tion programs and supportive policing practices can enhance harm reduction programs rather than undermining them. The commen-

tary by Kamarulzaman and Mc Brayer (2015) provide an overview on the increased international attention and the evolving response to the human rights abuses and the denial of medical care that often exist within the compulsory drug detention centres. It also high-

der the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

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ights an increased risk of HIV transmission within these centres, roviding further evidence calling for their closure.

The commentary by Dolan et al. (2015) reports that PWID re over-represented among prison populations, among whom IV prevalence is elevated (Dolan et al., 2015). Since HIV pre- ention, including NSP and OST is provided very rarely in these ettings, advocacy is needed to shift the focus of prison policies owards implementation of harm reduction programs, including rug dependence treatment, to protect the health of inmates and he general public.

Beyond HIV, Hepatitis C and TB epidemics are also tightly inter- inked with injecting drug use and significant proportions of PWID re co-infected with two or three of these infections. The commen- ary by Bruggmann and Grebely (2015) reports that despite the fact hat two-thirds of PWID are estimated to be living with hepatitis C irus (HCV), awareness of HCV is generally low, even among health roviders, and access to HCV testing and treatment is very poor.

Based on the six thematic papers and the follow up discuss- ons among the lead authors during the Scientific Consultation,

Scientific Statement was produced which was presented at the lenary of the High-level Review of the CND. The text of this cientific Statement follows this editorial. The individual scien- ific contributions to the pre-CND consultation have now been e-drafted, peer-reviewed and are assembled, together with the cientific Statement in this special issue of the International Jour- al of Drug Policy. We are grateful to the authors and to the ditors of the Journal for making this special issue of the IJDP ossible.

onflict of interest statement

The authors have confirmed that they have no potential conflicts f interest.

References

Azim, T., Bontell, I., & Strathdee, S. A. (2015). Women, drugs and HIV. International Journal of Drug Policy, 26, S16–S21.

Bruggmann, P., & Grebely, J. (2015). Prevention, treatment and care of hepatitis C virus infection among people who inject drugs. International Journal of Drug Policy, 26, S22–S26.

Dolan, K., Moazen, B., Noori, A., Rahimzadeh, S., Farzadfar, F., & Hariga, F. (2015). People who inject drugs in prison: HIV prevalence, transmission and prevention. International Journal of Drug Policy, 26, S12–S15.

Kamarulzaman, A., & Mc Brayer, J. L. (2015). Compulsory drug detention centers in East and Southeast Asia. International Journal of Drug Policy, 26, S33–S37.

Mathers, B. M., Degenhardt, L., Ali, H., Wiessing, L., Hickman, M., Mattick, R. P., et al. (2010). HIV prevention, treatment, and care services for people who inject drugs: a systematic review of global, regional, and national coverage. Lancet, 375(9719), 1014–1028.

Strathdee, S. A., Beletsky, L., & Kerr, T. (2015). HIV, drugs and the legal environment. International Journal of Drug Policy, 26, S27–S32.

UNODC. (2014). World drug report. Vienna, Austria: United Nations Office on Drugs and Crime.

WHO, UNODC & UNAIDS. (2012). Technical guide for countries to set targets for univer- sal access to HIV Prevention, Treatment and care for injecting drug users. Geneva: World Health Organization (revision 2012).

Wilson, D. P., Braedon, D., Shattock, A., & Fraser-Hurt, N. (2015). The cost- effectiveness of harm reduction. International Journal of Drug Policy, 26, S5–S11.

Monica Beg∗

HIV/AIDS Section, Drug Prevention and Health Branch, Division for Operations, United Nations Office

on Drugs and Crime (UNODC), Vienna, Austria

Steffanie A. Strathdee Division of Global Public Health, University of

California San Diego School of Medicine, United States

Michel Kazatchkine United Nations, Geneva, Switzerland

∗ Corresponding author. E-mail address: [email protected] (M. Beg)

NODC Scientific Consultation Science addressing drugs and HIV: State of the Art of harm reduction”

scientific statement

ontext

As the Commission on Narcotic Drugs (CND) conducts its high- evel review of the implementation of the Political Declaration and lan of Action, there remains a significant discrepancy between hat science has shown actually works, and what in reality is being

mplemented in countries most affected by HIV and hepatitis C epi- emics driven by unsafe injecting drug use.

It is estimated that, of the estimated 13 (9–22) million eople who inject drugs worldwide, 13% are living with HIV nd more than 60% live with the hepatitis C virus with large egional variation. As long as effective measures to reduce rug consumption and unsafe injection are not implemented, IV and hepatitis C virus will continue to spread among peo- le who inject drugs and ultimately to their partners and to

in Eastern Europe and central Asia and throughout the rest of the Asian region.

In its resolution 56/6 in 2013, the Commission on Narcotic Drugs requested United Nations Office on Drugs and Crime (UNODC) to implement, as appropriate, the joint WHO, UNODC and UNAIDS- recommended comprehensive package of services for people who inject drugs, also known as harm reduction services, which includes: (a) Needle and syringe programs (NSP) that provide people who inject drugs with sterile injecting equipment and remove contaminated injection material from circulation; (b) Opi- oid substitution therapy (OST), and other evidence-based drug dependence treatment. Opioid substitution therapy is the best researched and most effective form of treatment of opioid depend- ence; it is also highly effective to prevent HIV among people who inject drugs; (c) HIV testing and counseling; (d) Antiretro-

ociety in general. The HIV/AIDS and hepatitis C epidemics as hese relate to injecting drug use are of particular concern

viral therapy (ART). Antiretroviral therapy is effective for people who inject drugs as for other patients when associated with

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ppropriate support; (e) Prevention and treatment of sexually ransmitted infections; (f) Condom programs for people who inject rugs and their sexual partners; (g) Targeted information, edu- ation and communication for people who inject drugs and their exual partners; (h) Prevention, vaccination, diagnosis and treat- ent for viral hepatitis; (i) Prevention, diagnosis and treatment of

uberculosis. Recent studies indicate that that the combination of opioid sub-

titution therapy and needle and syringe programs can significantly educe injecting risk behavior, HIV and, to a lower degree, hepati- is C incidence. Needle and syringe programs, opioid substitution herapy and antiretroviral therapy have a synergistic impact on the eduction of HIV incidence at a population level.

The absence of an enabling legal and policy environment and upporting regulatory framework, continues to hamper effective mplementation of these programs. In many countries of the world, he provision of these evidence-based UN-recommended HIV inter- entions for people who inject drugs remains very limited or even bsent.

According to the Harm Reduction International’s Global State f Harm Reduction latest report, 97 countries and territories cur- ently support a harm reduction approach, this support being xplicit either in national policy documents in eighty-three ountries, and/or through the implementation or tolerance of arm reduction interventions such as needle and syringe pro- rams in eighty-six countries, or opioid substitution therapy in eventy-seven countries. Expansion of harm reduction programs as been slow and many of the new programs remain small- cale pilots. Based on the same report, opioid substitution therapy n prisons was available in only forty-one countries and nee- le and syringe programs in prisons in only ten countries. In ost low- and middle-income countries coverage of harm reduc-

ion services remains by far insufficient to stabilize and reverse IV and viral hepatitis epidemics among people who inject rugs.

cientific statement

The following statement represents the current scientific evi- ence on prevention and treatment of HIV and hepatitis as it relates o injecting drug use.

. There is unambiguous and compelling evidence that shar- ing of injecting equipment is strongly associated with the risk of acquiring HIV and hepatitis C and its ongoing spread. Criminalization of drug use, restrictive drug policies and aggressive law enforcement practices are key drivers of HIV and hepatitis C epidemics among people who inject drugs. Drug policies should fully integrate and prioritize both public and individual health in order to implement strategic and effective responses to improve health among people who inject drugs, their communities and the general population.

. There is compelling evidence that needle and syringe programs (NSP) and opioid substitution therapy (OST) are effective in reducing sharing of injecting equipment and averting HIV infec- tions. Together with antiretroviral therapy (ART), which is also highly likely to reduce HIV transmission among people who inject drugs, needle and syringe programs and opioid substi- tution therapy improve quality of life, decrease mortality and

reduce drug dependency. There is also evidence that these harm reduction interventions reduce crime and public disor- der, improve social functioning and provide a bridge to drug dependence treatment.

rug Policy 26 (2015) S1–S4 S3

Harm reduction interventions are good value for money. There is compelling evidence of cost-effectiveness for each of the three interventions across all regions of the world, with average costs per HIV infection averted ranging from $100 to $1000.

The coverage of harm reduction programs is currently too low across almost all regions to have impact on spread of new HIV and hepatitis C infections. Scaling up harm reduction programs is a worthwhile investment; not only do the community benefits of harm reduction programs exceed treatment costs, but they also have the potential to provide significant returns on investments for governments.

The large number of people who inject drugs who are incarcer- ated and the high HIV and hepatitis C prevalence among them, together with the absence of effective harm reduction services in prisons, hamper efforts to reduce HIV prevalence among people who inject drugs and in the community. We need to stop incar- ceration of people who use drugs for minor drug related offenses, including by referral to HIV and drug services in the community.

Laws and policies should be implemented to ensure that the rights of people in prisons and pre-trial detention, including people who inject drugs, to access equivalent health care are respected.

Compulsory centers for drug users (CCDUs) currently oper- ate in many countries. These centres are not only ineffective in reducing drug use but often times represent acts of abuse and torture. HIV prevention and treatment is not provided in these centers where a high proportion of the detainees is either HIV positive or are at very high risk for infection. The United Nations has repeatedly called for the closure of these centres.

Women who inject drugs often have higher rates of HIV than their male counterparts. Women who use drugs and sell sex are even more vulnerable to HIV. Harm reduction should be included in all interventions for sex workers and safer sex messages should be part of all harm reduction programs for women who inject drugs. Reproductive health services should be integrated with harm reduction services. Women who are sex partners of men who inject drugs but do not inject drugs themselves are vul- nerable to HIV infection because of low condom use and intimate partner violence.

3. Laws and policies that undermine access to harm reduction are key drivers of HIV and hepatitis C risks among people who inject drugs. Laws that criminalize drug use and possession result in stigma and policy displacement, which in turn undermine sup- port for harm reduction. In addition, law enforcement practices and especially unauthorized policing practices are a pervasive barrier to the implementation and effectiveness of harm reduc- tion programs.

Laws facilitating needle and syringe programs and opioid substitution therapy are effective “structural” interventions to curb HIV and hepatitis C virus spread among people who inject drugs. There is an urgent need to re-align harm reduction and law enforcement approaches to support prevention and treatment of HIV and hepatitis C among people who inject drugs.

4. Hepatitis C is a rising cause of severe liver disease and pre- mature death among people who inject drugs, and represents a growing public health, social and economic burden. Aware- ness of the hepatitis C infection among people who inject drugs is low although the infection is highly prevalent in this population. Hepatitis C virus testing is rarely available to people who inject drugs worldwide, and even less have

access to treatment, despite the evidence that the infection is curable. Successful hepatitis C prevention strategies com- bine high coverage of harm reduction measures with hepatitis C treatment.

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There is an urgent need to integrate hepatitis C treat- ment services into harm reduction services to enhance treatment uptake and cure rates. Novel, well-tolerated, and

efficacious hepatitis C treatment regimens now offer the oppor- tunity to treat the majority of infected people who inject drugs.

This scientific statement was produced in the context of a scientific consultation entitled “Science addressing drugs and Health: State of the Art” organized by the United Nations Office

Adeeba Kamarulzaman, Philip Bruggmann, and their respective co-authors, under the overall guidance of the Co-Chair of the sci- entific consultation Michel Kazatchkine, United Nations Secretary

on Drugs and Crime (UNODC) on 11 March 2014, preceding the high-level segment of the 57th session of the Commission on Narcotic Drugs (CND) based on thematic papers developed by David Wilson, Steffanie Strathdee, Tasnim Azim, Kate Dolan,

General’s Special Envoy on HIV/AIDS for Eastern Europe and Cen- tral Asia and Monica Beg, Riku Lehtovuori and Fabienne Hariga of UNODC.