Harm reduction in social and medical care for people who use drugs in the new environment Michel Kazatchkine UN Secretary General’s Special Envoy on HIV/AIDS in Eastern Europe and Central Asia

People who use drugs: illicit drugs People who inject drugs Non-problematic use; problematic use; dependence Life-long; intermittent; current use and/or injection Variety of substances: depressants, stimulants, hallucinogens Drugs are procured through criminal markets

People who use drugs: licit drugs Most « drugs » are « drugs » ! Opioids for treatment of pain Benzodiazepines for treatment of anxiety Stimulants for alertness Cannabinoids for treatment of spastic diseases Drugs are procured on legal regulated markets

Harm reduction Interventions, policies and messages that aim at reducing harm without requiring that harmful behaviors be eliminated Nicotine patches, light beer, seat belts, helmets for cycling or skiing

Harm reduction “Addiction is a primary, chronic disease… characterized by an inability to consistently abstain… Like other chronic diseases, addiction can involve cycles of relapse and remission”. American Society of Addiction Medicine

Harm reduction interventions Compelling evidence of effectiveness In combination with antiretroviral treatment (ART), NSP and OST: Reduce HIV transmission Reduce HCV transmission Decrease mortality Promote initiation of and compliance with ART Reduce drug-dependency Reduce crime and public disorder Highly cost-effective

Harm reduction interventions Needle and syringe distribution Opioid substitutive therapies Supervised injection sites Safer injection education Medical heroin prescription Naloxone distribution Adapt interventions to evolving context of drug use

Environment in EECA, 2017 Repressive legislation and policies on drugs across the region Repressive law enforcement and over-incarceration. Fear of violence from police is associated with lower capacity for risk reduction High levels of stigma and discrimination, including in healthcare settings Major treatment gaps for addiction, HIV infection, hepatitis Low coverage of harm reduction Fast growing HIV, HCV epidemics primarily driven by unsafe injection drug use Clash of evidence and ideologies Use of health (harm reduction) as a political tool Significant issues around financial sustainability of programs

Health is politics Drug policies heavily relying on prohibition law enforcement hamper access to OST and NSP. Methadone is illegal in the Russian Federation and Turkmenistan; it is not available in Uzbekistan. High rates of incarceration for drug related offences in most countries in the region. Low / very low proportion of national HIV budgets devoted to prevention and to vulnerable groups. Discontinuation of OST in Crimea following annexation. Discontinuation of OST in the Donbas associated with ongoing conflict and government restrictions on the delivery of humanitarian aid in the conflict areas.

« Drugs have harmed many people, but wrong government policies have harmed many more » Kofi Annan, 2015

Harm reduction policies Policies to fight stigma, including in health care settings. Means more advocacy and more empowerment of people by civil society and community organizations Re-define drugs as a health and social issue Close the treatment gap*: Expand capacity, reduce barriers to entry and retention, increase flexibility, integrate services * less than 1/10 patients suffering from dependences - all dependencies - have access to care worldwide

Planning treatment of dependence A continuum: screening-brief intervention-diagnosis-treatment-rehabilitation-relapse prevention-harm reduction Close to where people need it, e.g. primary care Abstinence cannot be the only objective of treatment

Harm reduction policies Integrate medical, social and community harm reduction services Does not mean having all services in one place; aim at medical and social hubs Integrate harm reduction into health reforms: harm reduction as a fundamental approach to healthcare for all vulnerable populations

A model to reduce HIV prevalence/incidence by half over 10 years in St Petersburg To halve incidence: 79% on high coverage NSP 30-40% on paired interventions 20% on all three interventions* To halve prevalence: Not possible for just NSP Twice coverage needed to halve incidence *coverage just amongst HIV+ PWID Vickerman P, Platt L, Jolley E, Kazatchkine MD, Rhodes T, Int J Drug Policy. 2014 Nov;25(6):1163-73. Int J Drug Policy. 2014 Nov;25(6):1163-73. Controlling HIV among people who inject drugs in Eastern Europe and Central Asia: insights from modeling. Vickerman P1, Platt L, Jolley E, Rhodes T, Kazatchkine MD, Latypov A.

Prisons: a high risk environment in EECA The Russian Federation and many countries in the region have some of the world’s highest incarceration rates Many prisoners wait for months in pre-trial detention Overcrowding; poor physical conditions; poorly trained and often corrupt prison staff Unsafe injection drug use and unsafe sex; High prevalence of TB and MDR-TB No access to harm reduction in detention settings, with a few exceptions (Moldova, Kyrgyzstan) No integration of services in the penitentiary sector and services in the community

Harm reduction policies Stop incarcerations of minor drug-offenders Decriminalize drug use and possession Move towards government-regulated drug markets

2016 recommendations on decriminalization Abolish death penalty for all drug-related offences End all penalties - both criminal and administrative – for drug possession for personal use. To criminalize people who use drugs is ineffective and harmful, and undermines the principle of human dignity and the rule of law Implement alternatives to punishment for low level non-violent actors in the drug trade UN member states to remove the penalization of drugs as a treaty obligation under the international drug control system States to explore regulatory models for all illicit drugs and acknowledge this to be the next logical step in drug policy reform following decriminalization

Opioid substitution therapy program in Dnipropetrovsk, Ukraine (Natalia Kravchenk / Alliance 2013)

Outreach in Moscow, run by activists. 2013