UNGASS 2016” Conference of the
Commission on Narcotic Drugs, - 2016
By Dr. Fourkan Ali
Background The harm reduction
response to drug use has emerged as an evidence-based, highly effective and
cost-effective component of drug policies around the world over the last 30
years. It has been defined by Harm Reduction International as “policies,
programmes and practices that aim primarily to reduce the adverse health,
social and economic consequences of the use of legal and illegal psychoactive
drugs without necessarily reducing drug consumption”. In this respect, harm
reduction sits alongside, and is distinct from, other pillars of drug policy –
such as demand reduction and supply reduction. In the context of preparations
for the United Nations General Assembly Special Session (UNGASS) on the World
Drug Problem (19-21 April 2016, New York), the Deutsche Gesellschaft für
Internationale Zusammenarbeit (GIZ) GmbH on behalf of the Federal Ministry for
Economic Cooperation and Development (BMZ) of Germany, the Drug Commissioner of
the Federal Government of Germany, jointly with the International Drug Policy
Consortium (IDPC), hosted an Expert Group Meeting (EGM) on “New Approaches on
Harm Reduction” on 15-18 February 2016 in Berlin. The EGM attendees included
Government representatives from Brazil, Colombia, Germany, Ghana, India,
Indonesia, Mexico, Myanmar, Netherlands, Nigeria, Norway, Philippines,
Portugal, and United Kingdom. Additionally, civil society and academic
representatives attended the meeting, as well as representatives from the
United Nations Office on Drugs and Crime (UNODC) and the World Health
Organisation (WHO). The meeting included presentations of country experiences
from around the world, as well as thematic discussions about the current state
of harm reduction, gender issues and stimulant use, and the UNGASS
preparations. This Conference Room Paper seeks to sum up the key messages
stemming from inputs and debates in the course of the Expert Group Meeting.
However, the document does not necessarily reflect the particular position of
any of the organizing and participating parties. Harm reduction gained
prominence as a pragmatic response to HIV and hepatitis transmission among
people who inject drugs – a policy framework based on public health, human
rights, dignity and empowerment, and with people who use drugs at the forefront
of efforts to protect their peers. Germany was among the early pioneers of this
approach, domestically and internationally. The national drug policy comprises
four inter-connected pillars – prevention, harm reduction, treatment and
rehabilitation, and supply reduction – and includes innovations such as needle
and syringe vending machines and more than 20 drug consumption rooms. Yet
despite the available evidence, too many people who use drugs on a global level
still do not have access to harm reduction services. Because of this, around 13
per cent of people who inject drugs are living with HIV – a prevalence more
than 25 times that of the general population. Half of all people who inject
drugs are thought to be living with hepatitis C, and there are more than
180,000 drug-related deaths every year. In this context, the United Nations
General Assembly Special Session (UNGASS) on the World Drug Problem is a policy
milestone of great importance for the issue of harm reduction. Unless the
international community embraces and promotes the harm reduction response, and
significantly scales up the coverage and funding for this approach, theSustainable
Development Goals Target 3.3 to end the AIDS epidemic by 2030 will most
probably not be met, as participants warned during the meeting. II. Key Issues
and Recommendations – Priorities for UNGASS 2016 Political acceptance of harm
reduction At the last UNGASS on drugs in 1998 a harm reduction approach was not
included, despite the availability of nearly two decades of evidence and
experience from around the world. During the negotiations preceding the
adoption of the 2009 Political Declaration and Plan of Action, there was no
consensus between Member States to endorse the term harm reduction in the
documents. Instead, the term “related support services” was agreed upon.
Germany, on behalf of 25 other countries, on this occasion tabled a statement
to interpret this term as harm reduction. In 2014, the High Level Review of the
2009 Political Declaration again excluded a specific mention of harm reduction
– although the language edged forward to include “measures aimed at minimizing
the negative public health and social impacts of drug abuse that are outlined
in the WHO, UNODC, UNAIDS Technical Guide”. As was discussed during the EGM,
the concept of harm reduction remains contentious. In the preparation of the
negotiations of the UNGASS outcome document, the term harm reduction had been
included in the input papers of two regional groups, comprising 85 countries,
and additionally by eight individual countries. At the same time, the term harm
reduction has been endorsed by the UN General Assembly in both the 2001 and
2011 Political Declarations on HIV. Several participants stressed the
importance to draw upon agreed language from the UN General Assembly documents
in the course of the ongoing negotiations of the UNGASS Outcome Document. There
was also some discussion about whether it is important to have the term appear
explicitly or whether it is adequate to ensure references to the WHO, UNODC,
UNAIDS Technical Guide, as well as needle and syringe programmes, opioid
substitution treatment and naloxone to prevent drug-related deaths. It was
suggested that if the term ‘harm reduction’ cannot be reflected within the CND
framework in Vienna, then alternatives may be sought. For example, the recent
WHO Executive Board paper on the world drug problem used the language of
“prevention and management of the harms associated with drug use”. Broadening
out the concept of harm reduction Harm reduction is often associated with
interventions proven to reduce the acute health harms associated with injecting
drug use, especially the injection of opioids, as the emergence of
injecting-related HIV transmission has been a driving force behind the adoption
and promotion of this approach. However, as suggested by several participants,
harm reduction goes beyond this and should be conceived as a central tenet
behind drug policies – one defined by a set of principles rather than a list of
interventions. The harms that need to be reduced may be health harms (and not
just HIV), but they are just as likely to be social or economic harms such as
acquisitive crime, corruption, over-incarceration, violence, stigmatisation,
marginalisation or harassment, to name just a few. Participants discussed the
need to also apply these principles to supply reduction in order to reduce
social damage and violence. However, it was pointed out that the current lack
of concrete measures makes it hard to define and advance this important
concept. A number of participants expressed the concern that a broadening of
the concept of harm reduction towards a wider definition may imply the risk of
blurring or diluting the approach. 3 As stated on several occasions, the
traditional focus on opiates hasAs stated on several occasions, the traditional
focus on opiates has also resulted in a lack of attention for other types of
drugs and use – in particular non-injecting use and stimulant use. The existing
evidence base for stimulant harm reduction needs to be better collated and
communicated – a process that is currently being supported by UNODC and WHO.
Participants suggested raising awareness of the novel interventions being
implemented around the world, such as stimulant substitution therapies, pill
testing services, structural interventions, psychosocial support, and some of
the work being done around the use of cocaine paste (usually smokable) in Latin
America. Government representatives asked for better guidance for Member States
on how to tailor the harm reduction approach for people who use stimulants –
whether they inject, smoke or ingest drugs. Several presentations showed that
increased sexual risks among stimulant using populations also require tailored
interventions, male and female condom distribution, and accessible services for
sexually transmitted infections. Participants raised the point that, for people
who inject stimulants, the scale-up of interventions such as needle and syringe
programmes is needed due to the higher frequency of injection associated with
these drugs. Peer-based models may be an important mechanism to achieve this,
especially for ‘out of hours’ provision. Furthermore, experts underlined that
peer-supported route transition interventions should play a role in encouraging
people to move from injecting to other safer routes of administration, or to
embrace their identity as a non-injector. In terms of the UNGASS process,
several participants expressed a view that the traditional, cultural and
indigenous uses of mild plant-based stimulants (including coca, guarana, betel,
khat, kratom and ephedra) should be recognised, and that policies could be used
to manage the market towards less harmful plant-based substances. Harm
reduction in prisons: a global health emergency On a global scale, the level of
incarceration from drug-related offences is considered to be a major concern.
Widespread drug use in prisons creates high-risk environments for HIV,
hepatitis, tuberculosis and other drug-use related diseases. Some participants
stated that the coverage of proven harm reduction interventions in closed
settings is alarming. Even in countries that have community-based harm
reduction services, these often stop at the prison gates. As discussed during
the EGM, just seven countries are currently implementing needle and syringe
programmes in prisons, while only 43 countries provide prison-based opioid
substitution therapy, and only 28 countries provide condoms to prisoners.
Taking this into account, participants suggested to encourage the
implementation of the "Mandela Rules" on the treatment of prisoners.
This set of rules includes clear references to the provision of healthcare, HIV
prevention and treatment, and the need for collaboration between health
services in the community and in prison settings. Participants also discussed
the possibility of transferring prison health services – including harm
reduction – to Ministries of Health, rather than Ministries of Justice. Gender
responsive harm reduction interventions The EGM included a number of
presentations and discussions on the need for gender responsive harm reduction
and drug policy approaches. Participants warned that appropriate responses for
women who use drugs are hindered by the dearth of data on drug use and
drug-related harms among women. Presentations showed that, globally, only one
out of five people in drug treatment is a woman, even though one out of three
people who use drugs is a woman. According to recent data provided by
participants, women who use drugs often have higher rates of HIV, hepatitis C
and sexually transmitted infections than men who use drugs, and are often
subjected to heightened stigma and discrimination, domestic violence 4 and
gender-based violence. There was a widespread concern that manyexisting
responses feed on, and fuel, these harms and human rights abuses – including
campaigns offering women who use drugs money to be sterilised. UNODC has
published specific guidance and policy recommendations for women who use drugs,
building upon the WHO, UNODC, UNAIDS Technical Guide, and elaborating many of
the critical enablers, structural interventions and capacity building efforts
needed to address the specific and increased risks faced by this group.
Participants agreed that services should engage women who use drugs in their
design, implementation and evaluation. Furthermore, participants discussed that
drug policy responses should be based on the available evidence and on human
rights. Presentations during the EGM showcased that women drug offenders are
the fastest growing population in prisons around the world – especially in
Latin America and Asia. According to data provided by participants, a majority
of these women are low-level, nonviolent offenders, or women who use drugs. The
presented research showed that incarceration can have a devastating impact on
families and children, and exacerbates the harms facing women who use drugs –
including health harms, but also negative impacts on future employment, poverty
and social reintegration. Some participants suggested that greater efforts must
therefore be made to reduce the incarceration of women, including through more
proportionate drug sentencing that accounts for mitigating factors such as
coercion, caregiving status and motivations for offending, and through the
provision of gender-sensitive alternatives to incarceration. The policy and
legislative challenges for the implementation of harm reduction Throughout the
discussions, participants cited a number of policy and legislative barriers to
the adoption, scale-up and sustainability of harm reduction programmes around
the world. Some participants highlighted the need for an enabling policy
environment that is supportive for the implementation of harm reduction
interventions. Many participants noted that the application of criminal
sanctions for drug use creates a highrisk environment, which often impedes
access to health services, increases stigma and exacerbates drug problems.
There were several calls during the EGM for consideration to be given to
removing criminal sanctions for drug use, drug possession for personal use
and/or the possession of drug paraphernalia, in line with recommendations from
across the UN family – and specifically by the UN Secretary General, UNAIDS,
WHO, UN Women, OHCHR and UNDP. The role of networks of people who use drugs A
number of participants and speakers remarked on the role that networks of
people who use drugs have played in the global harm reduction response since
the 1970s – including in Germany. With international, regional and national
networks now flourishing around the world, the EGM participants discussed the
part that they should continue to play in advocating for and delivering lifesaving
harm reduction services. Furthermore, peersupported or peer-delivered harm
reduction and mutual support services were discussed as a way to achieve
greater levels of acceptance, uptake and coverage. For example, peerbased
needle and syringe programmes, or services that enable peer distribution (also
known as ‘secondary exchange’), were highlighted as particularly effective
interventions to reach individuals who are unable or unwilling to engage in
regular services. The global funding crisis for harm reduction Several
participants warned that despite the scale-up of harm reduction programmes in
some countries, the global coverage of these services remains woefully
inadequate to deliverthe public health, social and economic benefits that can
be gained. Some of the presented estimates suggest, that it will be 2026 until
some form of services are available in every country in need, if Member States
continue to adopt harm reduction measures at the current pace. Likewise, as was
stated in the course of the EGM, the Sustainable Development Goal of ending the
AIDS epidemic by 2030 will probably not be met. According to some participants,
there has been a visible fragility of harm reduction commitments in a number of
countries – both due to political changes and the withdrawal of essential
international funding, especially in middle income countries. Participants
widely agreed that a significant upscale in global harm reduction funding –
from international and domestic sources – will be essential to address the existing
coverage gaps. It was commented by some participants that such upscale could be
achieved by redirecting a small part the funding currently provided for drug
law enforcement efforts around the world.
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