Injecting drug use increases worldwide, but no increases in needle and syringe programmes

Despite reports of expanding rates of injecting drug use in a new list of countries around the world, no new countries have established needle and syringe programmes in the last three years.

This is one of the headline findings of an exhaustive review of the state of harm reduction services around the world conducted by international NGO Harm Reduction International, presented at the 25th International Harm Reduction Conference (HR17) in Montréal last week.

The absence of any increase in the number of countries that report starting needle and syringe programming is significant. Katie Stone, Research Analyst with Harm Reduction International describes this problem:

“This is the first time that there has been no increase since we started monitoring coverage of harm reduction services in 2008. Access to one of the most important HIV prevention and harm reduction services is stagnating, while rates of injecting drug use are increasing.” 

Of the 90 countries that report provision of needle and syringe programmes only 17 countries are expanding these services, whilst 20 countries report a decrease of needle and syringe programmes.

This is in a time when the need for harm reduction services for people who use drugs continues to grow. A UN target to halve HIV transmission among people who inject drugs by 2015 was not only missed, but HIV rates among people who inject drugs increased by a third between 2011 and 2015 according to UNAIDS.

Needle and syringe programmes are one of the most effective HIV prevention interventions available for people who inject drugs. Access to needle and syringe programmes is attributed to substantial reductions in the sharing of injecting equipment – a high-risk practice that drives HIV and hepatitis C transmission across the world. Needle and syringe programmes are the first intervention on the World Health Organization’s list of essential services for HIV and hepatitis C prevention and care for people who inject drugs.

The evidence for the effectiveness of needle and syringe programming is very strong. It is one of the most effective HIV prevention interventions available to HIV programmers, though it is often fraught with controversy. The distribution of clean injecting equipment often causes controversy because policy makers, neighbours, local officials and other stakeholders fear that it will lead to increases in drug use.

The World Health Organization reports that there is no evidence that distributing clean injecting equipment encourages drug use.

Needle and syringe programmes are often successful beyond their immediate HIV/hepatitis C virus (HCV) prevention objective in that they can be important interventions to bring drug users closer to health services. Needle and syringe programmes are often outreach-based, and delivered by peers, people who are or were previously drug users, and who are trusted by drug users. When outreach workers reach drug users with clean injecting equipment, they also educate drug users about safe injecting, preventing overdose, the benefits of HIV and HCV testing and using condoms. These same peer educators can direct drug users to health care services that are drug user-friendly, and that provide HIV treatment or sexual and reproductive health services using a harm reduction approach.

Needle and syringe programmes are cost effective, low threshold and bring multiple health benefits to people who inject drugs. So, the lack of expansion of these services to new countries where injecting is being reported is a cause of serious concern.

To add to this alarming picture, Harm Reduction International reports that rates of injecting of stimulants (as distinct from opiates) are increasing. The practice of injecting stimulants often carries greater HIV transmission risks than the injecting of opiates because stimulant users often inject more frequently – so the potential HIV and HCV transmission risks increase with each injection. Rises in injecting of amphetamine-type substances have been linked with HIV outbreaks in a number of countries, according to Harm Reduction International.

UNAIDS estimates that between 50 and 90% of people who use drugs will be incarcerated at some point in prison, pre-trial detention or in compulsory drug detention centres. These dramatically high incarceration rates undermine the capacity of HIV programmers to reach people who use drugs with HIV prevention and care services, and underline the need for decriminalisation of drug use in order to reach ambitious HIV targets for people who use drugs.

But these high incarceration rates also underline the need for better HIV and other health services in prisons. On this, Harm Reduction International report that access to harm reduction services for people in prison is very poor. Only eight countries report provision of needle and syringe programmes in at least one prison.

Other studies point to high levels of drug use in prison, along with high rates of drug overdose both in prison and immediately following release from prison. So the HIV and other health needs of people in prison are largely unmet in most countries, yet Harm Reduction International reports that mass incarceration remains the most common approach to drug control.

Harm Reduction International is critical of this trend and its health and human rights impacts. They estimate that the costs of a punitive approach to drug control that focuses on police arrests, criminalisation and mass incarceration cost something in the vicinity of US $100 billion per year, with little impact on levels of drug consumption. 

“The Sustainable Development Goals pledge to end AIDS by 2030, but there is no way we’ll ever achieve this goal in the current climate given the lack of leadership and funding for harm reduction for people who inject drugs”, said Stone.

Harm Reduction International estimates that a reinvestment of just 10% of that $100 billion towards HIV and harm reduction services for people who use drugs would finance the global effort to meet HIV prevention and care targets for people who use drugs by 2030.