Importance of Harm Reduction Program

I   Introduction

Thirty percent of new global HIV infections now occur outside sub-Saharan Africa (which alone is home to almost 64% of all HIV infections), and of these, 30% now involve People Who Inject Drugs (PWID). This means that the sharing of injection equipment currently accounts for approximately one in every 10 new HIV infections in the world. HIV spreading among PWID has led to generalized epidemics in at least half a dozen countries. In some countries, HIV epidemics appear to have started with PWID sharing injecting equipment in prison. There are now an estimated 13 million PWID worldwide. Many spend several years of their period as PWID in prison. Injection drug use has been reported in 144 countries worldwide, among which 128 have detected HIV among PWID.

Most HIV transmission among PWID involves the shared use of needles and syringes although other forms of injecting equipment, such as spoons and tourniquets, also make a contribution. As HIV prevalence in this population begins to increase, sexual transmission becomes more important. There are generally more male than female PWID. In developing countries, the proportion of male PWID is usually much higher. This means that most male PWID have female sex partners who do not inject drugs. Inevitably, sexual transmission to these women will later result in transmission to other, possibly non-drug using, men. In many countries, there is considerable overlap between PWID and female sex workers, providing a readily available bridge for HIV to reach the general population. Lack of enthusiasm to prevent HIV spread among PWID is common, but most are prepared to take this problem quite seriously when the magnitude of the risks to the general population are considered. 

   

What is Harm Reduction?

Harm Reduction refers to strategies that aim to reduce the harms associated with injecting drug use. The earliest forms of harm reduction promoted abstinence from drug use and put reducing its occurrence at the center of substance use policy and interventions.

The concept of harm reduction was re-invented in the early 1980s at the beginning of the HIV epidemic when healthcare workers started to provide clean syringes to PWID rather than solely trying to achieve abstinence. Since then, there has been slow but steady progress in support for harm reduction programs as a component of the response to the HIV epidemic as well as other illicit drug use epidemics, with a wide range of initiatives implemented to date.

Of the 158 countries that report drug use, only 88 of them explicitly reference harm reduction in their national policies (56%).

History of HIV prevention programs for PWID

HIV prevention programs for PWID are interventions that aim to halt the transmission of HIV. They are implemented to either protect an individual and their community, or are rolled out as public health policies.

Initially, HIV prevention programs focused primarily on preventing the sexual transmission of HIV through behavior change. For a number of years, the ABC approach - "Abstinence, Be faithful, Use a Condom" - was used in response to the growing epidemic.

However, by the mid-2000s, it became evident that effective HIV prevention needs to take into account underlying socio-cultural, economic, political, legal and other contextual factors. As the complex nature of the global HIV epidemic has become clear, forms of 'combination prevention' have largely replaced ABC-type approaches.

     Combination prevention

Combination prevention is a package of coordinated biomedical, behavioral and structural HIV prevention interventions. 

Combination prevention advocates for a holistic approach whereby HIV prevention is not a single intervention (such as condom distribution) but the simultaneous use of complementary behavioral, biomedical and structural prevention strategies.

Combination prevention programs consider factors specific to each setting, such as levels of infrastructure, local culture and traditions as well as populations most affected by HIV. They can be implemented at the individual, community and population levels.

UNAIDS has called for combined approaches to HIV prevention to be scaled-up, to reinvigorate the global response and make a sustained impact on global HIV incidence rates.

(http://www.unaids.org/sites/default/files/en/media/unaids/contentassets/documents/unaidspublication/2011/20111110_JC2007_Combination_Prevention_paper_en.pdf)

Behavioral interventions

Behavioral interventions seek to reduce the risk of HIV transmission by addressing risky behaviors. A behavioral intervention may aim to reduce the number of sexual partners individuals have; improve treatment adherence among people living with HIV; increase the use of clean needles among PWID; or increase the consistent and correct use of condoms. To date, these types of interventions have proved the most successful.

Examples of behavioral interventions include:

1. information provision (such as sex education)
2.  counselling and other forms of psycho-social support
3.  safe injecting practices
4. education on proper condom use
5. stigma and discrimination reduction program

Biomedical interventions

Biomedical interventions use a mix of clinical and medical approaches to reduce HIV transmission. In order to be effective, biomedical interventions are rarely implemented independently and are often used in conjunction with behavioral interventions.

Examples of biomedical interventions include:

1. male and female condoms
2.  sex and reproductive health services
3. HIV testing and counselling
4. testing and treatment of sexually transmitted infections
5. needle and syringe programs
6. opioid substitution therapy
7. blood screening 

Structural interventions

Structural interventions seek to address underlying factors that make individuals or groups vulnerable to HIV infection. These can be social, economic, political or environmental.

"For many people, the simple fact that 90% of the world's HIV infections occur in developing countries is evidence that social, economic and political structures drive risk behaviors and shape vulnerability." Structural interventions are much more difficult to implement because they attempt to deal with deep-rooted socio-economic issues such as poverty, gender inequality and social marginalization. They can also be reliant on the cooperation of governments to achieve law or policy reforms.

Examples of structural interventions include:

1.  interventions addressing gender, economic and social inequality
2. decriminalizing sex work, homosexuality, drug use and the use of harm reduction services
3. interventions to protect individuals from police harassment and violence
4. laws protecting the rights of people living with HIV

A public health approach to combination prevention

More recently, some people have advocated for a public health approach to combination prevention. This involves using a combination of biomedical, behavioral and structural strategies to target currently available resources at high prevalence regions or 'hot spots' and high-risk groups.

For example, a combination of needle and syringe programs, antiretroviral treatment, HIV testing and opioid substitution therapy in Tallinn, Estonia, was found to reduce HIV prevalence among people who inject drugs from 20.7% to 7.5% between 2005 and 2011.

It is thought that targeting combination prevention initiatives at high-risk groups together with a scale-up in antiretroviral treatment has the potential to reduce HIV prevalence from pandemic levels to low-endemic levels.

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2813%2962230-8/abstract

The World Health Organization (WHO), the United Nations Office on Drugs and Crime (UNODC) and the Joint United Nations Program on HIV/AIDS (UNAIDS) strongly recommend harm reduction as an approach to HIV prevention, treatment and care for PWID. Specifically, they advocate for a comprehensive package including:

1.  needle and syringe programs (NSPs)
2. opioid substitution therapy (OST) and other drug dependence treatment
3. HIV testing and counselling (HTC)
4. antiretroviral treatment (ART)
5. prevention and treatment of sexually transmitted infections (STIs)
6. condom programs for PWID and their sexual partners
7. targeted information, education and communication for PWID and their sexual partners
8. vaccination, diagnosis and treatment of viral hepatitis
9. prevention, diagnosis and treatment of tuberculosis (TB)

Needle and syringe exchange programs

Needle and syringe exchange programs are a type of harm reduction initiative that provide clean needles and syringes to PWID. The World Health Organization (WHO) recommends providing 2-3 sterile needles and syringes per drug injector per day, in order to effectively tackle HIV transmission via this route.

Programs aim primarily to reduce the transmission of HIV and other blood-borne viruses caused by the sharing of injecting equipment. Many also work to reduce other harms associated with injecting drug use by providing:

1. advice on safer injecting practices
2.  advice on minimizing the harm done by drugs
3. advice on how to avoid and manage an overdose
4. information on the safe handling and disposal of injecting equipment
5. referrals to HIV testing and treatment services
6. help to stop injecting drugs, including access to drug treatment (such as opioid substitution therapy) and encouragement to switch to safer drug taking practices and
7. other health and welfare services (including condom provision)

6.1.         How are needle and syringe programs delivered?

1. Fixed sites

   fixed sites are typically located where the drugs are bought and sold openly. They are normally Drop-In Centers (DICs) and have a reception area for clients where they receive new syringe, and return the used one. At fixed sites, it is easier to offer additional services such as healthcare alongside testing and counselling for HIV and other blood-borne viruses. 

1. Mobile programs

Mobile programs operate from a van or bus with needles and syringes distributed
through a door or window. Some large mobile programs act like fixed sites with
testing and other healthcare services also available. Others run in conjunction with
fixed sites. In these instances, the fixed site is typically located in an area with high
numbers of people who inject drugs with the mobile unit focusing on harder to reach
or smaller populations. Mobile programs can be more accessible than fixed sites and
often face less opposition than fixed sites.

1. Outreach programs

Outreach programs take many forms including mobile units (such as a van or bus),
backpacking services on the street or even home deliveries. They typically operate
where there is a shortage of funding for needle and syringe programs. Some outreach
programs exist to complement fixed or mobile units where injecting drug users are
not engaging with established services. Outreach workers are tasked with
encouraging people who inject drugs to use existing fixed or mobile sites.

  Barriers to harm reduction for HIV prevention

Harm reduction has been demonstrated as both an effective and efficient way of preventing the transmission of HIV and other blood-borne viruses among drug users. However, a number of barriers prevent their implementation.

1. Stigma, discrimination and the war on drugs

A'war on drugs' approach still prevails in many countries. Law enforcement authorities continue to criminalize the possession of needles and syringes and mount 'crackdowns' on PWID even when they are seeking treatment or visiting healthcare centers for clean needles and syringes or other services. Criminalization drives PWID away from health and HIV prevention services. In 2014, the UN Committee on Economic, Social and Cultural Rights raised concerns with Ukraine about “the punitive approach taken in the State party towards persons who use drugs, which results in high numbers of such persons being imprisoned”.

Criminalization drives PWID away from health and HIV services.

    The harm reduction funding crisis
One of the biggest barriers to harm reduction initiatives is a lack of sustainable funding, which forces programs to downsize or run at a much reduced rate. International donors provide the majority of financial resources for harm reduction programs to prevent HIV. At last estimate in 2010, international donors
spent just $160 million on HIV prevention programs for PWID - 7% of what is required. 

          Barriers faced by young people who inject drugs

1.  Although data for people who inject drugs is available, it is unknown how many young people inject drugs, or what the HIV prevalence among this group is. One report has suggested that 3% of young people who inject drugs are living with HIV worldwide. Many drug users start injecting when they are very young, with high proportions of teenage drug users in Eastern Europe and Asia especially. 
2.   Young people are also likely to show more high-risk behavior such as sharing needles or getting needles from unofficial places. HIV prevention programs typically overlook young people at risk of injecting drug use; few reach out to vulnerable youth to prevent them from starting to inject or help them to end their addiction if they have already started. 
3.   Moreover, prevention programs do not specifically address the issues that vulnerable young people face, such as peer pressure, unstable family homes or exclusion from school. Some HIV prevention initiatives like OST may even deter young people because they require registration, parental consent or impose age restrictions.

       Effectiveness of Needle Exchange Programs (NEPs)

NEPs have been associated with a number of positive health outcomes. In 1988, Buning and colleagues in Amsterdam reported declines in needle sharing and injection frequency associated with NEP participation (1). Other studies subsequently reported reductions in incidence of HIV, HBV, and HCV infections (2), decreased needle sharing among HIV-negative and HIV-positive persons (3), decreases in syringe reuse (4), and increased rates of entry into drug treatment programs (5). In the United Kingdom and Australia, where NEPs were introduced early and vigorously within the context of a comprehensive prevention program including expanded methadone maintenance programs, HIV epidemics among PWID have been essentially averted (6). Despite variations between programs, a recent international comparison showed that in 29 cities with established NEPs, HIV prevalence decreased on average by 5.8% per year, but it increased on average by 5.9% per year in 51 cities without NEPs (7). In New York City, NEPs have been associated with a dramatic decline in HIV incidence, which represents an HIV epidemic among PWID that has essentially been reversed (8). Although the overwhelming majority of studies have found NEPs to be associated with beneficial health outcomes, some studies have been equivocal in their findings. In 1997, one of the authors reported an HIV outbreak among PWID that occurred in the presence of a high-volume NEP that had been introduced early (9). More recently, Hagan and colleagues (10) reported no benefit of NEP attendance upon incidence rates of HBV and HCV among PWID in Seattle, Washington. On the other hand, Bruneau and colleagues reported a higher HIV incidence among NEP attendees compared to non-attenders in Montreal (11). These findings have generated controversy surrounding the evidence of NEP effectiveness among policy-makers, the lay community, and even scientists (12). Among the scientific community, discussion has centered on possible explanations for higher observed incidence of HIV among NEP attendees relative to nonattendees in some settings (13). One of the most obvious explanations is that of selection bias, because NEPs tend to attract higher risk PWID who engage in riskier behaviors compared to IDUs who tend to obtain syringes from other sources (14). Vancouver researchers demonstrated that selection bias could have entirely accounted for the higher HIV incidence rates observed among frequent versus infrequent NEP attendees (15). In San Francisco, PWID who later began attending an NEP had higher HIV incidence rates than those who had never attended (16). Others have pointed out that the discrepant findings have tended to occur in settings where PWID can legally purchase syringes in pharmacies (17). This would only serve to intensify the difference in risks between NEP attendees and nonattendees, because PWID who can afford to buy syringes at pharmacies are likely to represent higher socioeconomic strata that are consistent with lower HIV risk propensities. To date, there appears to be no published evidence that NEPs cause negative societal effects. For example, there is no evidence that NEPs cause increases in drug use (18) or crime (19). Studies have failed to support the notion that NEPs indirectly contribute to the formation of high-risk needle sharing networks (20). There have been isolated, infrequent accounts of needle-stick injuries occurring in cities where NEPs exist. However, Doherty and colleagues (21) have demonstrated that there has been a significant decrease in the number of discarded needles on the street following the introduction of an NEP in Baltimore, which supports earlier studies (22). Although some contend that the evidence on NEP effectiveness remains open to interpretation, there is widespread agreement among scientists that NEPs do not cause social harms.

Conclusions

1. The high-risk practice of sharing syringes and other injection equipment is common among PWID.

 HIV can be transmitted by sharing needles, syringes, or other injection equipment (e.g., cookers, rinse water, cotton) that were used by a person living with HIV. According to a study of cities with high levels of HIV, approximately one-third of PWID reported sharing syringes and more than half reported sharing other injection equipment in the past 12 months.

1. Use of injection drugs can reduce inhibitions and increase risk behaviors. 

These include not using a condom or taking preventive medicines (such as pre exposure prophylaxis, or PrEP) as directed. In the study of cities with high levels of HIV, 72% of females who inject drugs reported having sex without a condom in the last year. People who inject drugs may also take part in risky sexual behaviors to get drugs or while under coercion.

Young people (aged 15-30 years) who inject drugs have many of the same risk
factors for HIV found in older PWID, including a significant risk of sexual HIV 
transmission among MSM who inject drugs and among PWID who exchanged sex
for money or drugs. These findings suggest HIV prevention interventions for PWID
should include sexual risk reduction as well as injection risk reduction.

Injection drug use is often viewed as a criminal activity rather than a medical 
issue that requires counseling and rehabilitation. Stigma related to drug use may
prevent PWID from seeking HIV testing, care, and treatment. Studies have shown
that people treated for substance abuse are more likely to start and remain in HIV
medical care, adopt safer behaviors, and take their HIV medications correctly than
those not receiving such treatment.

     Social and economic factors affect access to HIV treatment. 

PWID are at especially high risk for getting and spreading HIV, but often have trouble getting medical treatment for HIV because of social issues.  Almost two thirds (65%) of PWID with HIV reported being homeless, 61% reported being incarcerated, and 44% reported having no health facilities in the last 12 months. Because of these issues, some providers may hesitate to prescribe HIV medications to PWID because they believe PWID will not take them correctly. Needle exchange programs are most beneficial when preventing the spread of disease and illnesses. A needle exchange program gives people a place to dispose of dirty needles and to get clean needles in their places. PWID who have to reuse needles are more likely to become ill or to spread disease by sharing needles, so preventing the need for sharing or reusing needles is vital. 

Needle exchange programs are also used to help PWID learn about how to prevent and minimize the risk of overdose, how to properly and safely dispose of needles and injection equipment, and how to inject safely. The needle exchange programs hope
to inform drug users about how they can minimize the harm of drugs on their bodies, too. 

    Harm-reduction strategies are key in these programs. Harm reduction, which is defined as reducing the negative consequences associated with drug use, focuses on abstinence, but it supports the health and care of anyone who wants to minimize the risks to themselves, even when participating in a high-risk behavior.

Although NEPs have achieved global expansion since the first was introduced 17 years ago, NEPs exist in less than half of the countries reporting HIV infection among PWID. Coverage of NEPs in most developed and developing countries is low and varies considerably within and between countries, states, and cities. If we are to truly achieve optimal syringe coverage both quantitatively and qualitatively, we must have diverse syringe sources. Our review of the above syringe sources underscores the need to offer a range of venues where sterile syringes are available to PWID to achieve maximal syringe coverage. Examples of alternative or supplemental approaches to enhancing sterile syringe access include pharmacies, physician prescription, and vending machines. Additional research is needed to determine what types of programs and which combinations are necessary to reach specific subgroups of PWID and prevent or reverse epidemics of HIV and viral hepatitis. In both developed and developing countries, the collective experience indicates that there have been both intentional and unintentional barriers to the provision of sterile syringes to PWID communities. Although these barriers are often specific to local settings, there are often common structural, legal, and ideological barriers that can be identified, which is the first step to overcoming them. 

     

       

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