1. #AIDS2016 | @AIDS_conference DRUG USE, HIV AND HARM REDUCTION IN AFRICA Isidore S. Obot Professor, Department of Psychology, University of Uyo & Director, Centre for Research and Information on Substance Abuse (CRISA) Uyo, NIGERIA 21 st International AIDS Conference, 18-22 July 2016, Durban, South Africa

2. #AIDS2016 | @AIDS_conference Outline Drug use and drug policy in Africa IDU and HIV Responses to HIV among PWID What is harm reduction? The value of harm reduction Support for HR and challenges to adoption and implementation HR in post-UNGASS 2016 Africa Conclusion

3. #AIDS2016 | @AIDS_conference Drug policy in Africa Focus of drug control policy is on law enforcement – In many countries drug control bodies are under the supervision of Ministry of Justice not Health – Success is measured in terms of arrests and seizures – Laws are severely punitive; the “war on drugs” fuels the HIV epidemic in various ways Policies are not guided by evidence of effectiveness There is inadequate availability of drug dependence treatment and harm reduction services. Data on drug use and related problems are generally lacking; reported estimates are largely unreliable.

4. #AIDS2016 | @AIDS_conference Drug use Cannabis and alcohol are the most consumed drugs in Africa. Use of cannabis is much higher (12.4%) in West and Central Africa than rest of Africa (7.6%) and globally (3.9%). Cannabis is primary drug of abuse among people in treatment for drug use disorders. Less than 0.5% of adult Africans (15-64 years of age) had used cocaine or heroin in the 2014 (WDR 2016). Use of amphetamine type stimulants (ATS) is growing (especially injection of methamphetamine). Increasing use of opioid analgesics reported in West Africa (especially tramadol, Pentazocine, and codeine containing cough syrups).

5. #AIDS2016 | @AIDS_conference Annual prevalence of illicit drug use (2014) in African Regions RegionCannabisCocaineOpiatesOpioidsATS East4.2-0.150.17- North4.4-0.25 0.57 South5.10.70.340.400.71 West & Central 12.40.70.430.44- Total7.60.40.310.33 Source: WDR 2016

6. #AIDS2016 | @AIDS_conference Injecting drug use Globally 12 million drug users have injected (WDR 2016) More than 1 million people in Africa report injecting drugs; Prevalence of injection: 0.16% (global – 0.26%) First assessment of IDU in Nigeria in 2000 (1 city), with studies in 2003 (3 cities), and 2006 (5 cities). – 23% of 546 drug users in five cities had injected at least once; significant increase over previous years. – Drugs injected were heroin, pentazocine, cocaine. – Profile of injector: male (90%), mean age of 31 years, single (60%), self-employed, less than secondary school education (54%), 30% had been in jail. – No strong association of IDU with HIV then (and now). Injecting reported in many other African countries with significant populations of PWID in South Africa, Mauritius, Kenya, Tanzania, Senegal, Mozambique

7. #AIDS2016 | @AIDS_conference Estimates of People who inject drugs in African Countries CountryNo. PWID Seychelles Senegal Mauritius Nigeria Kenya Tanzania South Africa 345 1324 10,000 11,692 18,327 30000 67000

8. #AIDS2016 | @AIDS_conference HIV among PWID Globally 12 million people injected a drug in 2014. “Among people who inject drugs, one in seven [14%] is living with HIV and one in two [50%] is living with hepatitis C” (WDR 2016) An estimated “140,000 … people who inject drugs were newly infected with HIV globally in 2014” (UNAIDS 2016) Number of HIV cases among PWID in Africa: 112,000 Prevalence: 11.2% Women who inject drugs are much more likely than men to be HIV+.

9. #AIDS2016 | @AIDS_conference Prevalence of HIV among PWID in Africa CountryNo. PWIDHIV% Seychelles Senegal Mauritius Nigeria Kenya Tanzania South Africa 345 1324 10,000 11,692 18,327 30000 67000 5.8 9.1 44.3 4.2 * 18 33.9 19.4

10. #AIDS2016 | @AIDS_conference Incidence of HIV infection among PWID and population size estimate (2014) RegionIncidence per year (%) Population size estimate Eastern and southern Africa 2.9333,000 Middle East and North Africa 1.2462,000 Western and central Africa 1.4155,000 Source: UNAIDS, 2016

11. #AIDS2016 | @AIDS_conference Harm Reduction Response to HIV Among PWID

12. #AIDS2016 | @AIDS_conference What is Harm Reduction? "Policies and programs which attempt primarily to reduce the adverse health, social and economic consequences of mood altering substances to individual drug users, their families and communities, without requiring decrease in drug use." (IHRA)

13. #AIDS2016 | @AIDS_conference Harm Reduction Interventions In HR, the focus is not on eliminating drug use but on reducing the health and social harms caused by drug use. HR interventions include the following: Opioid substitution therapy (as in methadone maintenance therapy), Use of other substitute medications, e.g., buprenorphine Needle and syringe programmes (community based and in prisons), Bleach distribution Medical prescription of heroin Provision of safe injection sites/drug consumption rooms Overdose prevention (with naloxone)

14. #AIDS2016 | @AIDS_conference Comprehensive package of services, endorsed by WHO, UNODC, UNAIDS Needle and syringe programmes Opioid substitution therapy and other evidence-based drug dependence treatment HIV testing and counselling Antiretroviral therapy (for HIV) Prevention and treatment of sexually transmitted infections Condom programmes Targeted information, education and communication Prevention, vaccination, diagnosis and treatment for viral hepatitis Prevention, diagnosis and treatment of tuberculosis

15. #AIDS2016 | @AIDS_conference Availability of NSP and OST globally in 2014

16. #AIDS2016 | @AIDS_conference Number of countries with NSP and OST, globally and in Africa, 2008-2014 YearNSP, globalOST, globalNSP, AfricaOST, Africa 2008 2010 2012 2014 77 82 85 78 63 70 78 80 11351135 24552455 Source: HRI, 2014

17. #AIDS2016 | @AIDS_conference Number of PWID, prevalence of HIV and availability of Harm Reduction interventions in African countries CountryNo. PWIDHIV%NSP avail. No. of NSP Sites OST avail. No. of OST sites Seychelles Senegal Mauritius Nigeria Kenya Tanzania South Africa 345 1324 10,000 11,692 18,327 30000 67000 5.8 9.1 44.3 4.2 * 18 33.9 19.4 -YY-YYY-YY-YYY - 1 52 - 10 7 1 YYYYYYYYYY - 16 - 3 -

18. #AIDS2016 | @AIDS_conference “Harm reduction works” “I feel better and look better than I did a few months before coming here” -- Client at CEPIAD, Dakar, Senegal “I’m alive today because of harm reduction” -- NGO representative at UNGASS

19. #AIDS2016 | @AIDS_conference The truth about substitution therapy Participation in MM is associated with a large number of desirable outcomes. Reduction in HIV risk behaviours, e.g, exposure to infections Reduction in the use of heroin Longer stay in treatment Reduction by up to one-third in death rate compared to people not in treatment, Higher employment rates and better income, Reduction in criminal activities of up to 50% after only one year in treatment. HR services serve as an entry points to treatment. There is clear evidence it is effective and cost-effective and no evidence it promotes drug use.

20. #AIDS2016 | @AIDS_conference WHO speaks “There is overwhelming evidence that increasing the availability and utilisation of sterile injecting equipment to injecting drug users contributes substantially to reductions in HIV transmission, and that there is no convincing evidence of major unintended negative consequences of such programs”-- WHO, 2004.

21. #AIDS2016 | @AIDS_conference Ribbon Cutting at Official Launch of the Tanzanian MAT Programme, Feb. 2011

22. #AIDS2016 | @AIDS_conference Support for HR is growing Recent reports: Global Commission on Drug Policy, West Africa Commission on Drugs, Lancet/JHU Commission Globally, growing number of countries support harm reduction Endorsement of focus on health in addressing drug problems – Action Plans: ECOWAS and African Union – National Master-plans (e.g., Nigeria NDCMP 2105-2019) – UNGASS Common African Position Support from development partners and international NGOs (e.g., IDPC) More interest in the role of drug use among HIV/AIDS professionals Active role of CSOs and networks of NGOs

23. #AIDS2016 | @AIDS_conference Role of civil society One of the early efforts to introduce harm reduction to African health professionals was in 1991 with the formation of a group in Nigeria. In October 2007 the IHRA helped launch the Sub- Saharan Africa Harm Reduction Network (SAHRN) in Nairobi to promote HR in SSA; 10 countries were represented. Today several coalitions, networks and youth groups are active in harm reduction work (informational, outreach) and policy advocacy. However, CSO capacity is generally weak; strengthening these organizations is an essential post- UNGASS 2016 activity.

24. #AIDS2016 | @AIDS_conference Hope for the Future: HR in Africa post-UNGASS 2016 Greater acceptance of a public health perspective on drug control in African countries With more knowledge about HR fear will begin dissipate. Need for HR will grow with growing recognition of link of drug use with HIV/AIDS, tuberculosis, hepatitis and other blood borne infections. More overdose deaths and risky behaviours like “flashblood” will lead to search for pragmatic solutions. The language of evidence is growing and might influence acceptability of harm reduction services. More attention to the human rights of PWUD

25. #AIDS2016 | @AIDS_conference Many challenges remain Legal barriers to adoption and implementation of HR and lack of policy frameworks that recognize HR as part of a comprehensive package of care Cultural and moral attitudes which affect social acceptability of treatment for drug problems and see HR as “encouraging” drug use Stigma and discrimination which inhibit help seeking behaviour and provision of care Continued denial that there is a drug problem or that the problem is one that responds to natural interventions Doubts about the “effectiveness” of HR in Africa. General lack of manpower and opportunities to access treatment and other types of intervention The disruptive role of law enforcement

26. #AIDS2016 | @AIDS_conference Conclusion Drug use will not be eliminated, but the harms associated with use can be substantially reduced. Dependence is a biological condition influenced by psychological and social factors; it is not “a failure of will or strength of character” (WHO, 2006, p. 248). The harm caused by psychoactive substances are dependent on how, where and how much the substance is taken. Social response to each substance of abuse should take into consideration the level of harm imposed on individuals and society by that drug. Drug use and dependence are a public health problem. A public health approach calls for support of harm reduction methods and discourages “rigid, judgmental attitudes based on the concept of morality” (Goldstein, 2001). Drug policy should focus more on demand reduction as a strategy for controlling the spread of drug problems in society. In selecting and implementing demand reduction strategies, emphasis should be placed on those strategies that have been tested and shown to be effective and not those that are merely attractive and easy to implement. Several harm reduction services have been tested and found to be effective and cost effective; there is no justification for not making these services available to people who will benefit from them.

27. #AIDS2016 | @AIDS_conference Thank you obotis@gmail.com www.crisaafrica.org