Harm Reduction for Injecting Drug Users

Introduction

  1. Definition of the Prevention Area

    Drug use is a major factor in the spread of HIV infection in many settings. Sharing equipment used for injecting drugs transmits HIV, and drug use is linked with unsafe sexual activity that can increase HIV risk. Harm reduction programs focus on reducing the transmission of HIV associated with injecting drug use, while not necessarily trying to eliminate drug use itself. HIV prevention programs for people who inject drugs (PWID) may focus on decreasing needle use or needle sharing directly or by stabilizing the lives of PWID.

  2. Epidemiological Justification for the Prevention Area

    The Reference Group to the United Nations on HIV and Injecting Drug Use estimates that as of 2008, 3 million people who inject drugs were HIV-positive. While injecting drug use is of particular concern in South and Central Asia, Eastern Europe, and Russia, the practice is also growing in sub-Saharan Africa—particularly Kenya and Nigeria, which already face generalized HIV epidemics.

    Sharing non-sterilized injecting equipment is one of the most efficient ways of transmitting HIV and promoting rapid spread of HIV among PWID. As reported by the International Harm Reduction Association in its 2008 report, in many countries, including China, India, Kenya, Myanmar, Nepal, Thailand, and Vietnam, HIV prevalence among PWID is 50 percent or higher. Injecting drug use is associated with risky sexual behavior that may permit HIV transmission to cross into the non-{WOD population. Evidence from numerous settings suggests that women injectors often exchange sex for material needs. Injection drug use is also associated with the transmission of other infectious diseases, such as hepatitis C.

    Studies conducted over the past two decades confirm that harm reduction programs for PWID consistently reduce HIV risk without increasing drug use. Medically assisted treatment (MAT) using methadone, buprenorphine, buprenorphine/naloxone (suboxone)/naltrexone, or other medications/therapies is associated with declines in HIV-related risk factors, such as injecting drug use and the number of sexual partners. The use of methadone and buprenorphine has been documented to prevent HIV transmission among PWID. Needle and syringe programs (NSPs) are also associated with a decrease in self-reported risk behaviors among PWID, and with reduced rates of HIV transmission.

  3. Core Programmatic Components

    In July 2010, the President's Emergency Plan for AIDS Relief (PEPFAR) issued revised guidance on HIV prevention programming for PWID. The guidance recognizes harm reduction as part of a comprehensive approach combining structural, biomedical, and behavioral interventions. PEPFAR recommends that programs select a combination of interventions and strategies from among the following, as their situation merits, carried out in a manner consistent with human rights obligations:

    • Community-based outreach
    • NSPs
    • MAT
    • HIV counseling and testing (HTC)
    • Antiretroviral therapy (ART) for PWID living with HIV
    • Prevention and treatment of sexually transmitted infections
    • Condom programs for PWID and their sexual partners
    • Targeted information, education, and communication for PWID and their sexual partners
    • Vaccination, diagnosis, and treatment of viral hepatitis
    • Prevention, diagnosis, and treatment of tuberculosis (TB).

    PEPFAR encourages government agencies and civil society to develop the necessary legislation, policies, and regulations to facilitate implementation and scale-up of these evidence-based services.

    In recent years, there has been a rapid increase in the proportion of PWID who are women, especially in Asia and Eastern Europe. In China, researchers have documented a rapid increase in the number of women PWID who share injection equipment. Special attention to the unique needs of female PWID is thus warranted.

  4. Current Status of Implementation Experience

    In PEPFAR countries, only 10 percent of PWID access NSP services; 3.3 percent of PWID are on MAT; and about 4 percent of HIV-positive PWID are on ART.

    Many countries in Asia and Eastern Europe have interventions for PWID to reduce the demand for drugs. Such interventions have had limited success in preventing harmful consequences of drug use, including hepatitis C and HIV. Evidence and data from multiple programs and research studies show that harm reduction is the most successful approach to HIV programming for PWID.

    Successful programs for IDU in under-resourced countries have been characterized by:

    • A combination of behavioral, biomedical, social normative, and structural strategies and harm-reduction approaches that target different audiences
    • An evidence-driven approach integrating program monitoring, evaluation, and operations research designed to help the program adapt to new challenges and reach newly identified key populations
    • The involvement of affected communities in all aspects of the response to the epidemic
    • Effective linkages to government services, ensuring access to basic health care services and treatment
    • Flexible, responsive advocacy for supportive policies and an improved regulatory environment.

    The new PEPFAR guidance calls for governments to reject punitive policies that drive PWID underground, and instead actively support programming for PWID to build an enabling environment for prevention.

UPDATED 8/2016

What We Know

Do No Harm: Health, Human Rights and People Who Use Drugs

Joint United Nations Programme on HIV/AIDS (UNAIDS) (April 2016).

This report gives an overview of harm reduction, an approach for reducing the negative outcomes of drug use. Harm reduction has been shown to benefit individuals, communities, and health and legal systems in a variety of ways. The document provides five policy recommendations, including:

  • Fully implementing harm reduction and HIV services, as outlined in guidance from the World Health Organization
  • Treating people who use drugs with support and care, rather than punishment
  • Integrating HIV services with other health and social protection services for people who inject drugs.

Additionally, the report provides ten operational recommendations, such as:

  • Ensuring that all those who use drugs have access to harm reduction services (including needle exchange, substitution therapy, and antiretroviral therapy) to prevent HIV infection
  • Supporting and empowering community and civil society organizations (including networks of people who use drugs) in the design and delivery of health and social protection services
  • Rebalancing investments in drug control to ensure fully funded public health services, including those for HIV infection, antiretroviral therapy, and treatment for drug dependence, hepatitis, tuberculosis, and other health conditions.
  • The report also emphasizes that harm reduction policies deliver broader social benefits, such as lower levels of drug-related crime and reduced pressure on health care and criminal justice systems.

Double Trouble: Injection Drug Use and Sexual Behaviour

India HIV/AIDS Alliance (April 2015).

This study described factors that influence vulnerability to sexual transmission of HIV between people who inject drugs (PWID) and their sexual partners, and discussed concerns associated with the delivery of various harm reduction services for these couples. The authors conducted 50 separate interviews and four focus group discussions in two districts in the states of Bihar and Manipur. They reported that PWID remained extremely vulnerable to HIV and other sexually transmitted infections. Stigma was reported as a main barrier preventing access to health services. Many PWID reported difficulties accessing harm reduction centers, such as the inconvenient operating hours of needle and syringe exchange programs, which in turn contributed to risky sharing behavior despite ample risk awareness. The authors also noted that group dynamics and social norms were important drivers of vulnerability in instances when reluctance to inject together (and share equipment) was viewed as suspicious. The research also revealed that female sexual partners of male injectors were often unaware of their partner’s HIV status, or felt unable to moderate their risk because of power imbalances in their relationships. This pointed to an urgent need to create effective services that meet the unique needs of women partnered with drug injectors, the authors said. They concluded that programs for PWID must address complex vulnerabilities faced by PWID and their sexual partners.

Comprehensive HIV Prevention for People Who Inject Drugs, Revised Guidance

The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). (July 2010).

On July 16, 2010, PEPFAR released revised guidance on comprehensive HIV prevention for people who inject drugs. The guidance provides support for a comprehensive package of prevention services that have been scientifically demonstrated to decrease HIV infection risk without increasing drug use, including the following three elements: (1) community-based outreach programs; (2) sterile needle and syringe programs; and (3) drug dependence treatment, including medication-assisted treatment with methadone, buprenorphine, and/or other effective medications as appropriate, based on the country context.

The Impact of Methadone Maintenance Treatment on HIV Risk Behaviors among High-Risk Injection Drug Users: A Systematic Review

Karki, P., Shrestha, R., Huedo-Medina, T.B., and Copenhaver, M. Evidence-based Medicine & Public Health  (March 2016), pii: e1229.

This literature review found a significant association between methadone maintenance treatment (MMT) and reduction of sex- and drug-related HIV risk behaviors among high-risk people who inject drugs (PWID). The 12 eligible studies, identified from among articles and dissertations published between 2005 and 2015 consistently revealed a decrease in the reported use of injection, frequency of injection, sharing of injecting equipment, and drug-related HIV risk scores. MMT was also associated with a lower likelihood of multiple sex partners or unprotected sex. The studies also showed significantly lower prevalence of unprotected sex and drug use risk behavior among PWID who received both MMT and HIV testing services (HTS), compared to HTS alone. The authors concluded that their findings pointed to a close and direct association between MMT and reduced HIV risk behaviors, and recommended that policymakers and implementers ensure high rates of access and adherence to MMT.

Global Epidemiology of HIV among Women and Girls Who Use or Inject Drugs: Current Knowledge and Limitations of Existing Data

Larney, S., Mathers, B.M., Poteat, T., et al. Journal of Acquired Immune Deficiency Syndromes (June 2015), doi: 10.1097/QAI.0000000000000623.

The authors conducted a literature review focused on women and girls who use and/or inject drugs to explore risk factors and determine HIV prevalence and mortality rates among these groups. They found that although crude mortality rates were consistently lower among women who use and inject drugs compared with men, standardized mortality ratios were higher among women who use and inject drugs. Their findings suggest that these women experienced relatively greater mortality than their age-matched peers in the broader community compared with men who use drugs. Social exclusion, stigma, and discrimination can increase HIV risk and undermine HIV prevention and treatment programs for this group. These women and girls are reluctant to disclose their drug use and do not access health services, including drug treatment, for fear of discrimination. Moreover, they may be excluded from family support structures, and those with limited financial or employment options may be more likely to engage in sex work, increasing sexual HIV risk and attracting additional stigma. The authors concluded that special efforts (such as stratified sampling) may be needed to recruit women and girls into studies of drug use and HIV prevalence and risk among people who inject drugs, to ensure adequate recruitment of women and improve the reliability of sex-specific prevalence statistics.

Adherence to Antiretroviral Medications among Persons Who Inject Drugs in Transitional, Low and Middle Income Countries: An International Systematic Review

Feelemyer, J., Jarlais, D. D., Arasteh, K., and Uusküla, A. AIDS and Behavior (October 2014), E-publication ahead of print.

The authors of this literature review examined adherence to antiretroviral therapy (ART) in transitional-, low-, and middle-income countries (TLMIC) among people who inject drugs (PWID) and persons with a history of injection drug use. The authors conducted a systematic review of articles and conference presentations presented between 1996 and 2012 that reported adherence to ART among these groups in TLMIC. They found 15 articles from seven countries that met the inclusion criteria (including documentation of ongoing ART therapy) in a sample of current or past opiate users, and measurement of ART adherence, and follow-up data. ART adherence was associated with different methods of measuring adherence in Eastern Europe and East Asia. The review found that adherence levels reported in the articles ranged from 33 percent to 97 percent; mean weighted adherence was 72 percent. The authors noted that adherence in TLMIC remains suboptimal, and is probably well below the levels needed to achieve positive treatment outcomes for individuals and a population-level effect on HIV transmission. The authors called for more research on ART adherence among PWID in TLMIC, and recommended using standardized methods for reporting adherence to ART in this group.

Optimal Provision of Needle and Syringe Programmes for Injecting Drug Users: A Systematic Review

Jones, L., Pickering, L., Sumnall, H., et al. International Journal of Drug Policy (2010), 21(5), pp. 335–42.

This systematic review of studies looking at needle and syringe programs (NSPs) compared the efficacy of different types of NSPs, other harm reduction services that they offer, and how such programs are delivered. Only 16 studies met the inclusion criteria, including 11 on different types of NSPs, 3 on NSPs and additional harm reduction services, and 2 on the delivery of NSPs in combination with opiate substitution. The studies in general showed limited effects of NSP approaches on drug-injecting behaviors, though one study suggested that using mobile vans and vending machines attracted younger, higher-risk drug users; and one study showed that combining methadone treatment and NSPs was associated with reduced incidence of HIV and hepatitis C. The authors concluded that there is insufficient information to draw firm conclusions about what type of NSP works best overall, and called for further studies.

The Lancet Series: HIV in People Who Use Drugs

The Lancet. (July 2010).

This collection of 13 articles represented a call to arms for greater efforts to tackle HIV among people who use drugs. Commentaries addressed the myths surrounding drug use and HIV, and the special burden borne by women. The papers covered the risk environment for people who inject drugs (PWID), HIV prevention in this population, and treatment of comorbidities among drug users living with HIV. The series examined biomedical issues such as antiretroviral HIV treatment, opioid substitution, and needle and syringe programs, and also included social issues that prevent effective HIV prevention among PWID; and proposed a human rights-based approach to prevent HIV among PWID.

HIV Prevention, Treatment, and Care Services for People Who Inject Drugs: A Systematic Review of Global, Regional, and National Coverage

Mathers, B. M., Degenhardt, L., Ali, H., et al. The Lancet (February 2010), 375(9719), pp. 1014–28.

This seminal review of estimated national, regional, and global coverage of HIV services for people who inject drugs (PWID) examines the extent to which needle and syringe programs (NSPs), opioid substitution therapy (OST), and antiretroviral therapy have been implemented. The review spelled out the wide regional variations in access to harm reduction and HIV treatment services. Despite the large number of countries with HIV prevention services (with NSPs implemented in 82 countries and OST in 70 as of 2009), coverage of PWID is too low to prevent HIV transmission in most countries. The authors explained the policy implications of their findings and called for similar reviews of other health problems affecting PWID, such as tuberculosis and viral hepatitis

HIV Prevention among Injecting Drug Users: Strengthening U.S. Support for Core Interventions

Needle, R. H., and Zhao, L. (Center for Strategic and International Studies Africa Program Roundtable, June 2010).

This presentation presented big-picture data on injecting drug use in 151 countries and the situation of the 3 million (mid-range estimate) people who inject drugs (PWID) who were HIV-positive. Using data sourced from a review of official reports and a survey of country experts, the presenters found that only 1 in 10 PWID in PEPFAR (U.S. President's Emergency Program for AIDS Relief) countries use needle substitution services, and that those that have access to these services do not receive a sufficient annual supply of needles. Antiretroviral therapy and medication-assisted treatment are also only available to a tiny minority of PWID in PEPFAR countries. The presentation highlighted the barriers to service implementation and the cost of scaling up services, concluding with recommendations for future service provision targets.

Women, Harm Reduction and HIV

Pinkham, S. & Malinowska-Sempruch, K. Reproductive Health Matters (2008), 16(31), pp. 168–81.

This paper examined the unique issues that increase women’s risk of acquiring HIV through injecting drug use and impede their ability to seek support, treatment, and care. Among people who inject drugs (PWID), women are more likely to be HIV-positive than their male counterparts because of both sexual and injection practices. Furthermore, commercial sex work and injecting drug use overlap in many countries, with PWID more likely to work on the street and experience physical violence. Sexual health services for PWID are rare. Female PWID who are pregnant or mothers often lack proper antenatal care and treatment, and suffer punitive actions from the medical and law enforcement establishments. Programs can address the issues unique to female PWID by adopting policies that encourage women to seek services for drug treatment and harm reduction; incorporating sexual and reproductive health and other women’s services into harm reduction programs; and establishing strong links among services for harm reduction, drug treatment, women’s shelters, and domestic violence and rape prevention.

The Impact of Adherence to Preexposure Prophylaxis on the Risk of HIV Infection among People Who Inject Drugs

Martin, M., Vanichseni, S., Suntharasamai, P., et al. AIDS (April 2015), Vol. 29 Issue 7, pp. 819–824.

The 2005–2012 Bangkok Tenofovir Study, a randomized, double-blind, placebo-controlled study, examined participants' adherence to daily oral tenofovir in an HIV pre-exposure prophylaxis (PrEP) trial; identified factors associated with adherence; and assessed the impact of adherence on the risk of HIV infection among people who inject drugs (PWID). The study took place in 17 Bangkok Metropolitan Administration drug treatment facilities that offer an HIV-prevention package, social services, and medical care. The 2,413 participants attended either daily or monthly visits during which nurses observed participants swallowing the study drug, and participants from both groups initialed a diary, which the authors used to assess adherence. Higher levels of adherence were associated with reduced risk of HIV infection (83.5 percent among participants with at least 97.5 percent adherence, compared to a 48.9 percent reduction overall). Analysis showed better adherence among participants aged 40 years and over, and among women. Participants who had been incarcerated or had injected methamphetamine before enrollment were more likely to report below 95 percent adherence, suggesting poor adherence among some at-risk participants. These findings were consistent with findings from trials among men who have sex with men and HIV-discordant heterosexual couples. The authors suggested that PrEP could provide high levels of protection against HIV for PWID, provided adherence is high.

Interventions to Address HIV in Prisons: HIV Care, Treatment and Support

Jürgens, R. (World Health Organization Evidence for Action Technical Papers, 2007).

This technical paper states the case for implementing HIV prevention interventions in prisons. It reviews existing evidence to determine whether prison-based HIV interventions: are effective; avoid unintended negative consequences; are acceptable to the target group; have any additional benefits; and are feasible in diverse prison settings. The author presents evidence from both the community and prisons to make recommendations for action at international, country, and local levels—in particular, making opioid substitution therapy, antiretroviral therapy, and HIV testing and counseling available in prisons. The report also highlights the counterproductive nature of mandatory HIV testing and segregation of people living with HIV. 

A Review of the Efficacy and Effectiveness of Harm Reduction Strategies for Alcohol, Tobacco and Illicit Drugs

Ritter, A., and Cameron, J. Drug and Alcohol Review (November 2006), 25(6): 611–24.

This review of over 650 articles on harm reduction strategies found that most strategies concerned illicit drugs. The review found compelling evidence to show that needle substitution programs and outreach are useful and cost-effective, but findings to support noninjecting routes of administration, supervised injecting facilities, and naloxone distribution are only beginning to emerge. The existing evidence on brief interventions, HIV testing, and education is not conclusive, the authors said. The review also evaluated harm reduction as a policy approach and found that despite difficulties interpreting data, the evidence supports harm reduction as a driver of policy, rather than simply the basis of individual interventions.

Do Needle Syringe Programs Reduce HIV infection Among Injecting Drug Users: A Comprehensive Review of the International Evidence

Wodak, A., & Cooney, A. Substance Use and Misuse (February 2006), 41(6-7): 777–813.

Using commonly accepted criteria for evaluation of public health interventions, the authors reviewed evidence from 45 studies to find strong evidence that needle and syringe programs (NSPs) are effective, safe, and cost-effective. The evidence in favor of NSPs as an HIV prevention intervention is overwhelming, they said, but the availability of sterile needles and syringes from pharmacies is a common confounder in studies looking at NSP implementation and HIV prevention. Moreover, although the benefits of NSPs are proven, they are insufficient on their own to prevent HIV among people who inject drugs. The authors made recommendations for future action and also provided a useful glossary of terms.

Can HIV-1 Contaminated Syringes be Disinfected? Implications for Transmission among Injection Drug Users

Abdala, N., Gleghorn, A., Carney, J. M., et al. Journal of Acquired Immune Deficiency Syndromes (2001), 28(5), pp. 487–94.

In the absence of support for needle substitution programs in the United States, harm reduction programs encouraged people who inject drugs (PWID) to disinfect their syringes with bleach. Several population-based studies in the 1990s cast doubt on the effectiveness of bleach in decontaminating used syringes among PWID. This study recreated real-life situations among PWID in the United States, including common injection practices, using 2-mL syringes. Based on other studies indicating that PWID did not always follow the strict bleaching protocol, the study used multiple rinsing permutations (water only, diluted bleach, full-strength bleach; rinsing one, two, or three times; storing syringes for up to 48 days at room temperature) to assess whether these practices could remove HIV from a used syringe. While even one rinse of water could reduce the presence of HIV, increasing the number of rinses and adding bleach to the rinsing procedure furthered the decreases in amount of HIV recovered. The authors recommended encouraging needle rinsing, preferably with bleach, as part of harm reduction interventions.

Laws Prohibiting Over-the-Counter Syringe Sales to Injection Drug Users: Relations to Population Density, HIV Prevalence, and HIV Incidence

Friedman, S. R., Perlis, T., & Des Jarlais, D. C. American Journal of Public Health (May 2000), 91(5): 791–3.

Some states in the U.S. have antidrug policies that permit the sale of syringes only to those with a prescription. Some researchers argue that such restrictions increase the extent to which people who inject drugs (PWID) share syringes and perhaps other drug paraphernalia. This cross-sectional analysis compared HIV prevalence and incidence among PWID in the 96 largest metropolitan areas in the U.S., based on whether syringes were available over the counter (OTC). The average HIV prevalence among PWID in areas allowing OTC sales of syringes was 7 percent, compared to 14 percent in those with anti-OTC laws, a statistically significant difference. The difference in estimated average HIV incidence among PWID was even greater: 61 percent in anti-OTC areas versus 17 percent in the other areas. Furthermore, there was no difference in the percentage of PWID in each area, indicating that anti-OTC policies may have no effect on drug use. While these results may have be due to other factors, this study supported the hypothesis that an association exists between anti-OTC policies and increased HIV prevalence.

Putting it Into Practice

Structural Interventions for HIV Prevention among Women Who Use Drugs: A Global Perspective

Blankenship, K.M., Reinhard, E., Sherman, S.G., and El-Bassel, N. Journal of Acquired Immune Deficiency Syndromes  (June 2015), doi: 10.1097/QAI.0000000000000638.

The authors provided a global overview of contextual sources of HIV risk among women who use drugs (WWUD) and structural interventions (SIs) to address WWUDs' vulnerability to HIV. They argued that there is a need to modify SIs to meet the needs of WWUDs—for example, engaging more women's peer networks—and identified challenges to policies that affect WWUD disproportionately, if not exclusively. Additions to existing harm reduction programs, such as providing on-site child care; employing female, nonjudgmental staff; offering mobile services; and being located in relatively safe and discreet areas, can make these programs more accessible to women. Additionally, given the potentially harsher consequences to women of revealing their drug use, and their reluctance to interact with men (possibly ensuing from histories of abuse), SIs for WWUD have also involved offering “women-only” hours and services, such as women-only drug treatment programs. The authors suggested that a potentially powerful set of SIs for WWUD could integrate health and social service models, such as “one-stop shops” that enable WWUD to access multiple services at one site. Thus, women could receive a constellation of services at a single site, including harm reduction; screening, treatment, and care for substance use, HIV, tuberculosis, hepatitis, sexually transmitted infections, mental health, trauma, and interpersonal violence; and other physical, social, and emotional health services.

Using Hepatitis C Prevalence to Estimate HIV Epidemic Potential among People Who Inject Drugs in the Middle East and North Africa

Mumtaz, G., Weiss, H., Vickerman, P., et al. AIDS  (August 2015), 29(13): 1701–1710, doi: 10.1097/QAD.0000000000000761.

The authors of this study examined the association between HIV and hepatitis C virus (HCV) among people who inject drugs (PWID) in the Middle East and North Africa (MENA) region, and used HCV prevalence to estimate the HIV epidemic potential among PWID. They based their analysis on data from a recent systematic review assessing the status of the HIV epidemic among PWID in 23 MENA countries. Their analysis showed that HCV prevalence was not associated with HIV in low-level HIV epidemics, but was a significant predictor of HIV prevalence in settings where the HIV epidemic is emerging or established. In emerging epidemics, HCV was significantly associated with the highest increase in HIV prevalence compared with other epidemic states; country and study site were also significant predictors. In established epidemics, HCV prevalence was the only predictor of HIV. The authors concluded that HCV prevalence could be a predictor of future endemic HIV prevalence, and predicted further growth of the HIV epidemic in MENA countries. They also stated that their methodology can identify PWID populations that should be prioritized for HIV prevention interventions.

Making Harm Reduction Work for Women: The Ukrainian Experience

Pinkham, S., and Shapoval, A. (Open Society Institute, March 2010).

The special needs of women in terms of harm reduction are well illustrated in this report, which describes the outcome of gender-responsive harm reduction programs in six Ukrainian cities. Each project was an enhancement to an existing harm reduction program. Several key themes ran through the projects, namely sexual and reproductive health, parenthood and family preservation, legal aid and social support, empowerment of women, and referrals and networks of providers. The programs achieved impressive results with limited funding, but the authors argue that a multi-sectoral approach will be needed to provide comprehensive and effective care for women who inject drugs. The authors give recommendations for future policies and services. 

Human Rights and Drug Policy: Harm Reduction in Places of Detention

Human Rights Watch, Open Society Institute Public Health Project, Canadian HIV/AIDS Legal Network, and International Harm Reduction Association (2009).

This briefing explains the relationship between injecting drug use and HIV transmission in the context of prisons, citing examples from Lithuania and South Africa to illustrate the vulnerability of prison populations to HIV. It describes the key requirements for interventions in prisons; and highlights the importance of introducing harm reduction measures such as needle and syringe programs. Although some countries have introduced limited harm reduction programs in prisons, lack of political will, policies that favor zero tolerance over evidence-informed harm reduction, and negative public attitudes toward drug users are significant obstacles to widespread introduction of programs targeting this vulnerable population. .

Saved by the Nose: Bystander-Administered Intranasal Naloxone Hydrochloride for Opioid Overdose

Doe-Simkins, M., Walley, A.Y., Epstein, A., et al. American Journal of Public Health  (May 2009), 99(5): 788–91.

This report describes an opioid overdose prevention program in which needle exchange clients were trained by nonmedical exchange program staff to administer intranasal naloxone hydrochloride, and successfully intervened to reverse opioid overdoses. The report showed that given the necessary support and regulation, overdose prevention programs do not require a direct encounter between the patient and a health care provider, and programs training nonmedical personnel to use naloxone are feasible in city settings. The article also provided responses to the typical legal and regulatory barriers to the implementation of such a program. 

Reducing HIV Infection among New Injecting Drug Users in the China-Vietnam Cross Border Project

Des Jarlais, D.C., Kling, R., Hammett, T.M., et al. Journal of Acquired Immune Deficiency Syndromes (December 2007), 21(Suppl. 8): S109–14.

This project assessed whether large-scale HIV prevention programs among people who inject drugs (PWID) in developing and transitional countries could bring the HIV epidemic under control in this population. A peer outreach model in five Vietnamese and four Chinese sites provided PWID with information on reducing drug use and sexual risk behaviors. Safe injection equipment, sterile water for injection, condoms, and vouchers for these items were widely distributed. This project had the support of law enforcement, government leaders, and community members. Cross-sectional survey data on HIV prevalence and estimated incidence among new injectors mirrored the project’s implementation and scale-up—there was no change during start-up, but there were sustained decreases in HIV prevalence and incidence once the project reached full coverage. HIV incidence and prevalence declined by about 75 percent at endline 36 months later. Such data are the first in developing and/or transitional countries, providing evidence that programs can be implemented in such countries. .

Assessing the Role of Syringe Dispensing Machines and Mobile Van Outlets in Reaching Hard-to-Reach and High-Risk Groups of Injecting Drug Users (IDUs): A Review

Islam, M.M., and Conigrave, K. M. Harm Reduction Journal (October 2007), 4(14), doi: 10.1186/1477-7517-4-14.

This review of studies on the use of needle and syringe dispensing machines and mobile vans by needle and syringe programs (NSPs) evaluated their effectiveness in reaching people who inject drugs (PWID) who are otherwise not easily reached. Typical hard-to-reach PWID include those who are homeless, young, female, and from an ethnic minority; prisoners; and new injectors. The review showed that mobile vans have gained more acceptance than dispensing machines, but also that the services complement each other. Dispensing machines offer complete anonymity at the expense of interaction with health staff, while mobile vans mitigate the lack of anonymity with greater convenience for clients and acceptability among local residents.

Assessing the Feasibility of Harm Reduction Services for MSM: The Late Night Breakfast Buffet Study

Rose, V.J., Raymond, H.F., Kellogg, T.A., et al. Harm Reduction Journal (October 2006), 3(29), doi: 10.1186/1477-7517-3-29.

One of the few studies specifically looking at harm reduction among men who have sex with men (MSM) and are also people who inject drugs or PWID, this paper describes the Late Night Breakfast Buffet, a van-based harm reduction service providing needle exchange, oral HIV testing, urine-based tests for sexually transmitted infections, and harm reduction information between 1:00 a.m. and 5:00 a.m. in three neighborhoods of San Francisco. High use of methamphetamine was identified in this population. Although only a pilot project, the service established such harm reduction interventions as feasible for reaching an otherwise disenfranchised, high-risk population. 

Pointing the Way: Harm Reduction in Kyrgyz Republic

Wolfe, D. (2005).

Site visits and interviews with multiple stakeholders working in harm reduction in the Kyrgyz Republic formed the basis for this report documenting current best practices. While most former Soviet countries continued with the punitive Soviet model of treating PWID, the Kyrgyz Republic adopted harm reduction on multiple levels. The report details best practices such as mobilizing stakeholders across various government offices, donor coordination, syringe and needle exchange programs, and harm reduction in prisons. While these activities were too new and on too small a scale to show changes in key macro-level indicators, project data suggest that risky injecting and risky sex practices have declined, as have overdoses. Furthermore, field experience shows how to work in small, tight-knit communities, involving family members, sex workers, and many populations that routinely are shunned and punished in the former Soviet countries.

Drug Policy and Harm Reduction in the Middle East and North Africa: The Role of Civil Society

Aaraj, E. and Jreij Abou Chrouch, M. The International Journal of Drug Policy (May 2016), 31: 168–171, doi: 10.1016/j.drugpo.2016.03.002.  

This article reviewed the situation with HIV and people who use drugs in the Middle East and North Africa (MENA) region, focusing on the central role played by civil society organizations (CSOs) in advocacy, policy development, and services. The authors noted that many countries in the region have repressive laws on drug use, sex work, and same-sex relations; and that criminalization, stigma, and discrimination pose barriers to the HIV response and help fuel the epidemic. There is a need for services that acknowledge the broader gender norms that contribute to HIV among women, including women who use drugs or whose partners use drugs. Research and programming are also needed to address drug use among the rapidly growing refugee populations in the region. Only a limited number of countries in the MENA region are eligible for support from the Global Fund to Fight AIDS, Tuberculosis and Malaria. CSOs provide harm reduction services, and need resources and capacity building to continue providing services, policy development, and advocacy; monitor service quality; and document rights abuses. The authors cautioned that the region may be on the brink of a large wave of new HIV cases, and that various actors must work together to address the twin challenges of drug use and the HIV epidemic in the region.

Implementation of Rapid HIV and HCV Testing Within Harm Reduction Programmes for People Who Inject Drugs: A Pilot Study

Fernàndez-López, L., Folch, C., Majó, X. et al. AIDS Care (June 2016), 28(6): 712–716, doi: 10.1080/09540121.2016.1164290.

This study assessed the acceptability and feasibility of rapid oral HIV and Hepatitis C (HCV) tests in harm reduction programs (HRPs); identified HIV and HCV prevalence rates in HRPs; and determined the percentage of people with a reactive test who went to a hospital for confirmation and follow-up. It was conducted in 13 HRPs (6 facility-based, 5 mobile or outreach, 2 mixed) in Catalonia, Spain. A total of 172 HCV tests and 198 HIV tests were conducted, with refusal rates of 1.7 percent and 10.4 percent, respectively. Acceptability of both HIV and HCV tests was high among HRP users and staff. Some staff (40%) were only partially confident of the result, though these concerns were outweighed by benefits. All of those who tested positive were new diagnoses (2.5% for HIV and 20.3% for HCV). Rates of referrals and follow-up (60% for HIV and 71% for HCV) underscored the need for strengthened referral. The authors concluded that including HCV and HIV rapid tests in HRP for people who inject drugs (PWID) could increase detection in high-risk populations who do not seek conventional health care, and was especially useful in mobile HRP for PWID, who are at greatest risk of HIV and HCV and have lowest access to health services.

Tools and Curricula

HIV in Prisons: Situation and Needs Assessment Toolkit

Weilandt, C., & Greifinger, R. (2010).

Aimed at national governments, particularly those of low- and middle-income countries, this toolkit first explains HIV in the prison context. It then provides the necessary tools to conduct the situation and needs assessments required before HIV intervention programs can be implemented. Although it focuses on HIV and tuberculosis-related HIV, it is also relevant to sexually transmitted infections and hepatitis. The toolkit recommends the establishment of a multidisciplinary steering committee and lays out a stepwise assessment process. Annexes include templates for consent forms and questionnaires, checklists, and information about sampling methodology.

Good Practice Guide: HIV and Drug Use: Community Responses to Injecting Drug Use and HIV

International HIV/AIDS Alliance. (2010).

This comprehensive guide to HIV and drug use, written in clear, accessible language, aims to support community-based harm reduction and HIV programs, with a focus on developing and transitional countries. The guide thoroughly explains the issues of drug use, HIV, and health; and covers programs for special populations—women, children and young people, and prisoners—in a separate section. It spells out approaches to harm reduction, including community mobilization and gender-sensitive programming, and highlights the importance of involving all stakeholders, including people who use drugs, in programming. The guide describes the HIV/AIDS Alliance good practice standards in detail, and spells out the key characteristics of effective programs.

Overdose Prevention and Response: A Guide for People Who Use Drugs and Harm Reduction Staff in Eastern Europe and Central Asia

Curtis, M., & Guterman, L. (2009).

Although this guide was produced with harm reduction staff and people who use drugs in Eastern Europe and Central Asia in mind, the information it contains is useful worldwide. The guide explains the basics of overdose, such as what happens to the body during overdose; and the duration, potency, and overdose risks of different drugs. It describes the risk factors associated with overdose prevention and explains how to recognize an overdose. There is a section on responding step-by-step to an overdose, including a guide to rescue breathing and instructions for administering naloxone in the case of opioid overdose. A chapter for trainers on how to use the information provided completes the guide.

Technical Guide for Countries to Set Targets for Universal Access to HIV Prevention, Treatment and Care for Injecting Drug Users

World Health Organization (WHO), U.N. Office on Drugs and Crime (UNODC), and Joint U.N. Programme on HIV/AIDS (UNAIDS) (2009).

This guide explains the rationale for including nine different evidence-based interventions in a comprehensive package of HIV prevention, treatment, and care for people who inject drugs. Recommended interventions include harm reduction measures, HIV testing, counseling and treatment, and prevention and treatment of sexually transmitted infections, viral hepatitis, and tuberculosis. Frameworks are given for each recommended intervention. A checklist offers guided assessment of the availability, coverage, and quality of each intervention. 

Guide to Starting and Managing Needle and Syringe Programmes

World Health Organization (WHO), U.N. Office on Drugs and Crime (UNODC), and Joint U.N. Programme on HIV/AIDS (UNAIDS) (2007).

This guide is designed to help programs expand the response to HIV among PWID. Many more needle and syringe programs (NSPs) will need to be established to meet the harm reduction needs of the growing population of people who inject drugs. Sections I and II of this guide describe how to foster this process. Sections III and IV discuss how existing NSPs can expand the services that they offer and greatly increase their coverage. Scale-up of such programs must include establishing more NSPs in prisons and detention centers. Section V presents the particular needs of NSPs in such “closed settings.” A list of useful websites, publications, and networks appears at the end of the guide.

Advocacy Guide: HIV/AIDS Prevention among Injecting Drug Users

World Health Organization (WHO), U.N. Office on Drugs and Crime (UNODC), and Joint U.N. Programme on HIV/AIDS (UNAIDS) (2004).

This guide provides a systematic approach to advocacy for HIV prevention and care among people who inject drugs (PWID) that can be replicated and adapted to various cultural, economic, and political settings. General principles of advocacy for HIV prevention and care for PWID are presented first. The guide provides a step-by-step process for establishing advocacy groups with specific goals, undertaking a situation analysis, developing a strategy, and implementing the strategy. It also contains descriptions of many tools and methods for achieving advocacy goals, and examples of their use in various country settings. Frequently used arguments related to HIV prevention among PWID are also included. Most methods in the guide can be used, after adaptation, at community, district, and national levels. 

Opioid Overdose: Preventing and Reducing Opioid Overdose Mortality

United Nations Organization on Drugs and Crime (UNODC) and World Health Organization (WHO) (2013).  

This discussion paper was developed in response to a 2012 resolution that called on UN Member States to include effective measures to prevent and treat drug overdose in national policies. In that resolution, the Commission asked the UNODC and WHO to review scientific evidence on preventing and treating of drug overdose, especially opioids, and derive best practices. This paper outlines what is known about opioid overdose and gaps in knowledge; and identifies approaches to preventing and treating opioid overdose. It includes information on risk factors: availability, combining opioids with other psychoactive substances, lack of treatment, and reduced tolerance following abstinence. The paper describes how to recognize and react to overdose, including use of naloxone, as well as policy and program strategies that could help prevent fatal overdose, such as reducing availability of opioids and increasing availability of treatment. It identifies gaps between current practice and recommendations, and outlines a number of potential new areas of work, including addressing overdose of prescription opioids.

Training Guide for HIV Prevention Outreach to Injecting Drug Users: Workshop Manual

World Health Organization (2004).

This training package is for workshops orienting and training public health policymakers, program developers, program managers, implementers, and field workers on outreach to injecting drug users (IDUs) to prevent HIV transmission. The training package has four workshop modules. Orientation to Outreach among IDUs provides evidence for the effectiveness of outreach programs and assists decisionmakers in introducing and developing such programs. Developing Outreach Programs for HIV Prevention among IDUs provides assistance to individuals interested or involved in developing outreach programs. Managing Outreach Programs among IDUs is for those who have never managed an outreach program, but can also be used as additional training for current managers and outreach field supervisors. Core Skills in Outreach among IDUs is designed for initial training of outreach workers, or as a resource for ongoing training and review among experienced outreach workers.

Manual for Reducing Drug Related Harm in Asia

Centre for Harm Reduction, Macfarlane Burnet Centre for Medical Research, & Asian Harm Reduction Network (2003).

This comprehensive manual grew out of the combined efforts of people in Asia to stop HIV. The first section presents background information on drug use and HIV vulnerability, the rationale for harm reduction, and balancing and integrating the approaches of supply, demand, and harm reduction. Briefing papers on critical issues, such as mapping drug use in Asia and care and support of people who inject drugs with HIV, are included for use as advocacy tools in the region. The second section contains nine chapters on program design, implementation, and maintenance, including rapid assessments, voluntary counseling and testing, and addressing the needs of specific groups. The third section contains appendices with information on hepatitis A, B, and C; HIV; illicit drugs and their characteristics; and sexually transmitted infections. 

Additional Resources

The Global Fund to Fight AIDS, Tuberculosis and Malaria's Investments in Harm Reduction through the Rounds-based Funding Model (2002–2014)

Bridge, J., Hunter, B.M., Albers, E., et al. The International Journal of Drug Policy (September 2015), doi: http://dx.doi.org/10.1016/j.drugpo.2015.08.001(link is external).

The authors of this study reviewed grant budget data for the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund) between 2002 and 2014 to develop a comprehensive dataset on the Global Fund's investments in harm reduction for people who inject drugs (PWID).They identified 151 grants for 58 countries and one regional proposal, with a total budget of USD$620 million. Of the 58 countries, 21 were from Eastern Europe and Central Asia, 17 from Asia, 10 from the Middle East and North Africa, 7 from sub-Saharan Africa, and 3 from Latin America and the Caribbean; the regional grant was for the Middle East and North Africa Harm Reduction Network. Global Fund investments targeting PWID mainly focused on the nine interventions comprising the United Nations’ ‘‘comprehensive package’’ for PWID, with 15 percent allocated overall for program management and grant overheads. The budget analysis also identified USD$7.7 million for interventions and activities in compulsory drug detention centers in Asia. The authors recommended using this study as a baseline, and undertaking further analysis to understand the impact of the new funding model on harm reduction allocations as new grant agreements are signed. The analysis should also inform the development of the Global Fund’s new strategy for 2017–2021.

The Harm Reduction Coalition

The Harm Reduction Coalition. (2010).

The Harm Reduction Coalition is a national U.S. advocacy and capacity-building organization that promotes the health and dignity of individuals and communities affected by drug use. It advances policies and programs that help people overcome the adverse effects of drug use, including overdose, HIV, hepatitis C, addiction, and incarceration. In addition to training materials, calendars, and community resources, the website provides links to local services as well as ways in which people can get involved. 

Open Society Institute: Harm Reduction and Drug Use

Open Society Institute (OSI). (2010).

One of the components of the OSI's Public Health program is harm reduction and drug use. This website contains OSI's resources and information on their work, including publications, articles, and multimedia on harm reduction and drug use. Events and resource links are also available.

HIV and Young People Who Inject Drugs

World Health Organization (2015). 

This technical brief summarizes the complex interplay among the factors that place young people who inject drugs at risk of HIV, and how services and programs can engage them and address their needs while protecting their rights and dignity. Young people's risks derive from their drug use as well as other factors: unprotected sex, social marginalization and discrimination, and sexual exploitation and selling sex, among many other issues. The brief notes that while governments are charged with protecting children and young people, they often enact policies that further marginalize them by penalizing and criminalizing their behavior, especially for young key populations. Government policies and programs also often fail to ensure that young people who inject drugs are included in or prioritized by services, including harm reduction, drug dependence treatment, or HIV testing, counseling and treatment. The document summarizes the limited available data on young people who inject drugs, knowledge about their HIV risk, and barriers they face in accessing services. It describes how programs and services can better address their needs while protecting their rights, including illustrative case studies and examples. Finally, the brief advocates for mobilizing the strengths and perspectives of young people who inject drugs in designing programs and policies that affect them.

People Who Use Injecting Drugs—Technical Policies of the UNAIDS Programme

Joint United Nations Programme on HIV/AIDS (UNAIDS) (2009). 

A critical resource for policy development, this website brings together technical guidance, position papers, and policy briefs from UNAIDS. The technical guide lays out targets for access to HIV prevention, treatment, and care for people who inject drugs (PWID). There are policy briefs on antiretroviral therapy and on the reduction of HIV transmission through drug dependence treatment, outreach, and needle and syringe programs. Position papers outlining the UN system's policy on HIV prevention among PWID and a statement on HIV prevention and care strategies for PWID round out the collection.

Harm Reduction Developments 2008: Countries with Injection-Driven HIV Epidemics

Open Society Institute (2008).

In 2007, people who inject drugs (PWID) comprised the largest share of total HIV cases in at least 20 nations in Asia and the former Soviet Union. This report provides an overview of harm reduction efforts in Central and Eastern Europe, the former Soviet Union, and five Asian countries. Examples of effective programs being implemented include syringe and needle exchange programs, advocacy, opioid substitution therapy (OST), harm reduction work in prisons, and programs with commercial sex workers, among others. Data presented include PWID as a percentage of HIV cases, OST availability, and estimates of PWID reached by HIV prevention services in these countries. Despite advances in harm reduction, much work remains. Issues identified as needing increased investigation and action in the future include women and harm reduction, sexual health and harm reduction, African injecting drug use epidemics, and evidence-based and humane drug treatment. 

"Nothing About Us Without Us": Greater, Meaningful Involvement of People Who Use Illegal Drugs: A Public Health, Ethical, and Human Rights Imperative

Canadian HIV/AIDS Legal Network, International HIV/AIDS Alliance, and Open Society Institute (2008).

People who use illegal drugs have demonstrated that they can organize themselves and make valuable contributions to the community, including expanding the reach and effectiveness of HIV prevention and harm reduction services, by making contact with those at greatest risk, providing much-needed care and support, and advocating for their rights and the recognition of their dignity. This report documents the public health and human rights rationales for including people who use drugs in the development of HIV harm reduction programs. Recommendations on how to increase their involvement include addressing systemic barriers to allow a greater involvement of people who use drugs; supporting organizations of people who use drugs; involving people who use drugs in consultations, decisionmaking or policymaking bodies, advisory structures, and community-based organizations; and providing international leadership on greater involvement. 

High Coverage Sites: HIV Prevention Among Injecting Drug Users in Transitional and Developing Countries: Case Studies

Burrows, D. (2006).

Part of the Joint United Nations Programme on HIV/AIDS (UNAIDS) Best Practice Collection, this document contains seven case studies from countries in the former Soviet Union, Asia, and Latin America. These sites were selected because over half of people who inject drugs (PWID) have been reached by at least one HIV prevention program, hence the term high coverage. Each case study includes an overview of the country’s drug use and epidemiology, services, and state of coverage. The last chapter synthesizes the lessons learned, identifying common features among them as well as challenges for comprehensive HIV-related programs. The report’s most significant finding is that high-level coverage can indeed be attained by programs addressing HIV among PWID in developing and transitional countries.

HIV/AIDS Prevention and Care for Female Injecting Drug Users

United Nations Office on Drugs and Crime (2006).

This four-page brief highlights why among people who inject drugs (PWID), females are more vulnerable than their male counterparts. Risks include infected injections (women PWID commonly inject after their male partner has), high-risk sex, stigma over behavior that contradicts expectations of women as nurturers, and physical vulnerabilities. Women who are even more vulnerable are commercial sex workers, women in prison, and pregnant females. Many existing services do not reach female PWID because the services cannot meet their specific needs. To better reach female PWID, comprehensive gender-sensitive services are recommended, including HIV counseling and testing, treatment for sexually transmitted infections, antiretroviral therapy for prevention of mother-to-child transmission, condoms, sterile needles and syringes, and gender-sensitive treatment for drug dependence.

A Handbook for Starting and Managing Needle and Syringe Programmes in Prisons and Other Closed Settings

United Nations Office on Drugs and Crime (2014). 

This handbook is a practical guide to support implementation of needle and syringe programs (NSPs) in prisons and other closed settings. Although NSP programs are recognized as critical to preventing HIV and hepatitis among drug users, only eight countries reported enacting such programs in prisons. The handbook is aimed at decisionmakers and staff who can approve and implement NSP programs: prison administrators and staff, ministry and public health officials, national HIV and drug programs, and others. It addresses practical, legal, and security issues that can preclude such programs from being implemented. It reviews the prevalence of HIV and other bloodborne diseases in prisons, and how drug use and risk behaviors contribute to these epidemics, the scientific evidence for prison NSP (PNSP) and other interventions for harm reduction, and relevant legal frameworks. The handbook lays out elements of PNSP, including analyses of advantages and disadvantages of specific approaches. It includes specific advocacy strategies and tools: documentation, legal and policy analysis, outreach to diverse decisionmakers, and engaging media. Clear and specific steps for implementing a PNSP program are laid out in tables and checklists, and explained in text. Case studies throughout illustrate real-world experience with policy development, implementation, and problem-solving. The handbook concludes with a list of regional and international resources, and annexes include policies and questionnaires used in an existing program.

Center for AIDS Prevention Studies Prevention Toolkit

University of California, San Francisco. (2006).

This content-rich website houses a wealth of HIV prevention resources, including over 60 referenced fact sheets that summarize important HIV prevention topics in a readable two-page format. There are detailed descriptions of model programs, both ongoing and completed, and interventions with full curricula available for download. Survey instruments that have been tested by the Center for AIDS Prevention and are adaptable to local settings are also available, as are evaluation manuals and a selection of resources guides. All content is also available in Spanish.

Drug Abuse and HIV/AIDS: Lessons Learned: Case Studies Booklet, Central and Eastern Europe and the Central Asian States

Joint United Nations Programme on HIV/AIDS and United Nations Office for Drug Control and Crime Prevention (2001).

Profound social and economic change in Eastern Europe and Central Asia has created conditions that make the countries in these regions particularly vulnerable to drug use and the spread of HIV. This booklet, aimed largely at policymakers and practitioners, presents an overview of lessons learned and challenges for the future. Examples from 11 countries (Belarus, Bulgaria, the Czech Republic, Hungary, Kazakhstan, Lithuania, Poland, the Russian Federation, Slovakia, Slovenia, and Ukraine) illustrate how drug abuse and HIV prevention strategies and interventions have been introduced into specific national and local contexts, and the responses to a number of important challenges. The case studies are grouped according to the focus of the project, as follows: fieldwork, political mobilization and strategy development, and training and networking. This collection shows the different adaptations that take place in response to local concerns, and also provides an up-to-date picture of the challenges commonly confronted in developing HIV prevention strategies among people who inject drugs.

The Asian Harm Reduction Network

AHRN is regional information and support network created to link and support the courageous people operating programmes providing assistance to injecting drug users in Asia to prevent HIV transmission.

Injecting Drug Use and Prisons Publications

World Health Organization (WHO) (2016).

This section of the WHO website houses a wealth of publications pertaining to injecting drug use and prisons. The site is divided into several sections The first comprises documents on injection drug use in general; the second covers technical publications on the topic; the third provides publications on policy and advocacy. The site also contains a section on training materials, and related topics and links.

International Harm Reduction Association

International Harm Reduction Association (IHRA). (2016).

The website of this important global advocacy organization houses the Global State of Harm Reduction 2014 report.

The latest edition of the Global State of Harm Reduction includes the latest estimates around the response to drug-related HIV, viral hepatitis and tuberculosis.

It also integrates updated information on harm reduction services into each regional chapter, including on needle and syringe programs and opioid substitution therapy; harm reduction services in the prison setting; access to antiretroviral therapy for people who inject drugs; regional overdose responses; policy development; civil society developments; and information relating to funding for harm reduction.