The availability of needle and syringe programmes, opioid
substitution therapy and other harm reduction services for people who inject
drugs is getting even worse in many parts of the world, due to shifting
priorities among international donors and a refusal of many national
governments to adequately respond to the health needs of their citizens who use
drugs, according to delegates at the 24th International Harm
Reduction Conference, being held in Kuala Lumpur, Malaysia, this week.
UNAIDS
estimate that US$2.3 billion is needed each year for a core package of
HIV prevention, treatment and care for people who inject drugs – but
just 7% of this is provided.
To take the example of Thailand, as
support from international donors has dwindled and the Thai economy has
strengthened, the Thai government has become more
willing to pay for the HIV services made available to its citizens. But
not all
of them.
The Thai government has never supported harm reduction
policies for drug users and this remains the case. As financing has
‘transitioned’ from the Global Fund to Fight AIDS, Tuberculosis and Malaria to the Thai government, a programme which
previously reached half the country’s injecting drug users is withering away.
There is meant to be a ‘transition plan’ but Pascal Tanguay, an activist based
in Thailand, said that it appeared that things were being made up as they went
along. Without any agreement with the Thai government about how services for
people who inject drugs would be maintained, he said it was irresponsible of
the Global Fund to withdraw funding and imagine that the government would start
to fund harm reduction.
Some advocates and activists are reconsidering the focus of
their work. “Although we talked a lot about behaviour change interventions for
our communities and designed excellent interventions to reach out to hard to
reach populations such as drug users we never realised the challenge to reach
out to the governments and the almost impossible task of changing their
behaviours,” said Rajiv Kafle of the Global Network of People Living with HIV.
Many national governments that spend little on harm
reduction do spend considerable amounts of money policing drug use, imprisoning people who use
drugs and forcing people into involuntary treatment
programmes. “An estimated $100 billion is spent on punitive responses to drug
control, yet harm reduction investment amount to only $160 million a year,”
said Maria Phelan of Harm Reduction International. The organisation is
campaigning for 10% of the resources spent on punitive responses to be
redirected to harm reduction by 2020.
The funding difficulties
faced by many harm reduction
services has been partly caused by fundamental changes in the approach
taken by
the Global Fund to Fight AIDS, Tuberculosis and Malaria. Whereas it
previously supported programmes working with drug users, sex workers and
men
who have sex with men in many countries in Asia and Eastern Europe, they
now
make allocations on the basis of a country’s wealth and overall
prevalence of
HIV.
Rather than tackling concentrated epidemics in middle-income
countries, the priority is now poorer countries with generalised HIV epidemics.
However the majority of people who inject drugs live in lower middle-income
countries (such as Ukraine, Pakistan and Vietnam) or upper middle-income
countries (such as Brazil, Iran, Russia and South Africa).
“The idea that middle-income countries should take care of
their own is a theory of overseas development systems that seems to focus more
on gross national income than on inequality within countries,” said Daniel
Wolfe of Open Society Foundations. “People who inject drugs are often in richer
countries but still aren’t getting any services from their government.”
Marijke Wijnroks, Chief of Staff at the Global Fund defended
the organisation’s new approach, chosen in a context of rich countries
providing less money for the Global Fund to distribute. She said that it
remains the world’s largest donor for harm reduction, having spent a cumulative
total of $620 million in 58 countries. She argued that the Global Fund’s
adoption of human rights goals and requirements will mean that people who
inject drugs will continue to be served, including in some middle income
countries.
In many discussions, Malaysia – the country hosting the
conference – served as the poster boy for national governments and their
spending decisions. “Our commitment to ending AIDS is reflected in our domestic
AIDS spending,” the Minister of Health, Dr S. Subramaniam, told the conference.
“Last year 94% was contributed by domestic public funds.”
Harm reduction has been supported by the government since
2006, with opioid substitution therapy and needle exchange provided to around
80,000 people each. The annual total of HIV diagnoses has been cut in half since
a peak of almost 7,000 HIV diagnoses in 2002. Moreover the proportion due to
injecting drug use has plummeted from 74% in 2002 to 22% in 2014 – described as
“a phenomenal success” by the Minister.
While Malaysia supports both harm reduction and
antiretroviral therapy (ART), many other governments are investing in ART
alone. They are hoping that treatment’s prevention benefit will be enough to
bring HIV infections among drug users under control. “National governments have
shown scant regard for scaling up HIV prevention without external funding, but
those same governments are signing up to ‘test & treat’,” said Dave Burrows
of APMGlobal Health.
He argued that community organisations working with people
who inject drugs will need to shift focus if they want to survive. Funders will
be interested in their ability to engage with individuals who are undiagnosed,
to offer HIV testing and to use case management approaches which help drug users
adhere to HIV treatment, he said. Peer-led, community services will probably be
better at this than traditional health services but their outreach will likely
become focused on case finding rather than regularly providing sterile
equipment. Moreover opioid substitution therapy (which helps people adhere to
treatment) may more easily find its place than needle and syringe exchange.