1. HIV Prevention, treatment and care among people who inject drugs Fabienne Hariga, MD, MPH Senior HIV Adviser, UNODC Vienna

2. Co-sponsor HIV among People who Use Drugs HIV in Prison Settings CONVENING AGENCY

3. Prevalence of HIV among people who inject drugs 12.7 million PWID (0.27 % ) 1.7 million PWID living with HIV (13.1% of PWID) 52% with hepatitis C Source: World Drug report 2014

4. HIV AND PEOPLE WHO INJECT DRUGS IN PRISONS

5. JOINT UN RECOMMENDED INTERVENTIONS Comprehensive Package of interventions for HIV prevention, treatment and care among people who inject drugs 1.Needle and syringe programmes (NSPs) 2.Opioid substitution therapy (OST) and other evidence-based drug dependence treatment 3.HIV testing and counselling (HTC) 4.Antiretroviral therapy (ART) 5.Prevention and treatment of sexually transmitted infections (STIs) 6.Condom programmes for people who inject drugs and their sexual partners 7.Targeted information, education and communication (IEC) for people who inject drugs and their sexual partners 8.Prevention, vaccination, diagnosis and treatment for viral hepatitis 9.Prevention, diagnosis and treatment of tuberculosis (TB).

6. Effectiveness of NSP  Reduction in the rate of HIV transmission (and HCV)  Frequency of unsafe injection (risk HIV and HCV)  No initiation of injecting among people who have not injected previously  No increase in the duration or frequency of illicit drug use or drug injection  Allow for IEC  Allow for referral to OST, HTC or ARV and TB  Reduce number of used syringes discarded in public areas  Bleach is not an effective alternative especially for Hepatitis C HIV (and hepatitis C or B) is transmitted among people who inject drugs through sharing injection equipment

7.  Opioid use  Frequency of injection & unsafe injection (risk HIV and HCV)  Risk of overdoses  Risk of abortion/miscarriage of pregnant opiate dependent women  Increase retention in drug dependence treatment  Adherence to treatment (ARV, TB, Hepatitis C)  Improve health status and wellbeing  Social functioning  Work and productivity and economic status  Criminal behaviour  Recidivism  Violence, drug seeking in prison Reduction in the rate of HIV transmission (and HCV) Effectiveness of OST

8. Why a comprehensive approach? Source: Sarkar et al, 2008

9. Universal Access Physically accessible – geographically distributed – Hard to reach location Affordable – patients should not have to pay for their treatment Equitable and non-discriminatory – no exclusion criteria except medical ones, e.g. – OST should not be limited to only those IDUs who are HIV infected or who have failed on other drug dependence treatment – No compulsory treatment Non-rationed – supply should be determined by need: – e.g. needle and syringe programmes with strict limits on the number of syringes provided to each client are less successful than those that do not impose such restrictions

10. HIV incidence Incidence du VIH à Maurice (2000-oct 2013) NSPNSP

11. PRINCIPLES  Prison health is public health  Linkages with public health and community programmes  Human rights based and gender sensitive  Principle of equivalence  Medical ethics  No segregation of PLWH;  Criminal justice reforms to reduce the prison population  Alternatives to imprisonment  Reduce pre-trial incarceration  End compulsory detention of drug users and sex workers for “rehabilitation”  Prison reforms  Ensure safe prison conditions  Prevent violence  Proper classification  Conjugal visiting rooms

12. 12 Harm reduction in prisons

13. Bottlenecks

14. Critical enablers Supportive legal and policy framework Supportive law enforcement practices Empowerment of people who use drugs Alternatives to imprisonment including decriminalisation of drug use Appropriate funding

15. New publications: Police, HIV and PWID: a training manual Policy brief on HIV and women who inject drugs Handbook on needle and syringe programmes in prisons

16. …Unfortunately, many national drug control systems rely on sanctions and imprisonment, rather than evidence-based health care in full compliance with human rights standards … … These are major barriers to HIV and to harm reduction services, including in prisons and other closed settings… UNAIDS Programme Coordinating Board,1 July 2014

17. Thank you! Fabienne.Hariga@unodc.org www.unodc.org