I’m currently at the International Harm Reduction Association (IHRA) annual conference in Liverpool, UK, learning about the growing problem of injection drug use (IDU) and HIV/AIDS , and the incredibly complex interactions between the law, human rights issues, drug control policies and harm reduction. IDU is the main driver for the HIV epidemic in Eastern Europe Russia and parts of Asia: the number of new HIV cases linked with injecting drug use in Bangladesh is 90%, in Russia is 66% and in Indonesia is 50%. With more than 3 million people who inject drugs living with HIV the potential for harm reduction to mitigate the burden of HIV alone is huge. The main theme of this conference is assessing where we’re at with harm reduction and what comes next: an overriding thread running through talks has been that we have reached a ‘tipping point': the goal of achieving no new HIV infections among injecting drug users is clear, and in sight.
Harm reduction includes clean needle exchange programs and opioid substitution therapies, and as discussed by Bradley Mathers from the Reference Group to the UN on HIV and Injecting Drug Use here at the meeting and in a recent published systematic review, global coverage of harm reduction is poor: for instance, worldwide, just 2 needles per drug user per month are available.
One good question therefore is whether adequate resources are being devoted to harm reduction
A new report titled ‘Three cents a day is not enough: Resourcing HIV-related Harm Reduction on a Global Basis‘ was released by the IHRA at this meeting and discussed in a plenary session by one of the authors, Gerry Stimson. The report, which is based on a detailed review of funding levels for harm reduction from governments, NGOs and civil society groups, has exposed a massive funding gap which is frustrating efforts to prevent the spread of HIV by injecting drug users and contain some of the world’s fastest-growing HIV/AIDS epidemics in Eastern Europe and Asia.
Gerry reported some shocking facts in his talk: first, the biggest spenders on harm reduction worldwide are drug users, who foot most of the bill for harm reduction through out-of-pocket expenses. Second, it seems that few philanthropic funders stump up cash for harm reduction: as an example, only 0.001% of the total of Gates Foundation grants are for harm reduction.
The report estimates that in 2007 approximately $160 million was invested in HIV-related harm reduction in low and middle income countries, of which US$136 million (90 per cent) came from international donors. This spending equates to US$12.80 for each injector each year in low and middle income countries, or just three US cents per injector per day. UNAIDS estimated that the resources needed for harm reduction were US$2.13 billion in 2009 and US$3.2 billion in 2010. Rather than US $12.80 per injector per year, the needs estimated by UNAIDS averaged US$170 in 2009 and US $256 in 2010 per injector per year. These figures do not take into account the additional resources required for antiretroviral therapy, care and support.
“Three cents a day is a terrifying figure and equally terrifying are the HIV infection rates amongst injecting drug users in parts of Eastern Europe and Asia,” said report co-author Professor Gerry Stimson, who is also the outgoing Executive Director of IHRA and Chair of the Harm Reduction 2010 conference. “Current spending is clearly only a small proportion of that required and is nowhere near proportionate to need. More money is needed for harm reduction, and it is needed now.”
“We have known now for well over two decades that HIV is preventable – it is untenable that today in some 90 low and middle income countries nearly all people who inject drugs have no access to HIV prevention such as methadone and in some 70 countries they are without access to needle exchange services – especially when we also know that prevention measures such as these are significantly cheaper than treatment,” said Stimson. “Harm reduction is a low-cost, high-impact intervention. Its funding needs to be better monitored and 20 per cent of global HIV prevention funds should be dedicated to it.”
More than a 1000 participants from some 90 countries are attending this conference. The opening address from UNAIDS Executive Director Michel Sidibé was affected by the volcano — the speaker was stranded in Turkey — but a recorded speech revealed that Sidibé is encouraged by the evidence for the benefits of harm reduction, the agreement by many countries that harm reduction can help to curb the HIV epidemic, but cautioned that ‘we have to push outside the comfort zone of HIV and public health responses: we will not get to full scale unless drug control authorities are persuaded that harm reduction is more effective than punishment’ and concluded that ‘I have made the call to decriminalize drug users a centerpiece of my efforts as UNAIDS Executive Director’.