HARM REDUCTION INFORMATION NOTE

Ensuring access to HIV prevention, treatment, care and support for people who inject drugs
The Global Fund supports evidence-based interventions aimed at ensuring that key populations have access to HIV prevention, treatment, care and support. This includes the comprehensive package for the prevention, treatment and care of HIV among people who inject drugs as defined by WHO, UNODC and UNAIDS.1 This document describes how this package can be incorporated into country proposals to the Global Fund, and points to other issues to be considered such as advocacy, community systems strengthening, and addressing psycho-social needs. What is the Comprehensive Package of Interventions? An effective and evidence-based response is required to curtail the rapid spread of HIV among drug-using populations, but also to prevent transmission to the general population. In order to achieve these goals, according to UNODC, WHO and UNAIDS, the implementation of a comprehensive package of nine interventions for the prevention, treatment and care of HIV among people who inject drugs is essential. This package also widely referred to as the harm reduction approach consists of interventions for which there is a wealth of scientific evidence supporting their efficacy in preventing the spread of HIV2: 1. Needle and syringe programs (NSPs) 2. Opioid substitution therapy (OST) and other drug dependence treatment 3. HIV testing and counseling 4. Antiretroviral therapy (ART) 5. Prevention and treatment of sexually transmitted infections 6. Condom distribution programs for people who inject drugs and their sexual partners 7. Targeted information, education and communication for people who inject drugs and their sexual partners 8. Vaccination, diagnosis and treatment of viral hepatitis 9. Prevention, diagnosis and treatment of tuberculosis
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WHO, UNODC, UNAIDS (2009). Technical Guide for Countries to Set Targets for Universal Access to HIV Prevention, Treatment and Care for Injecting Drug Users. www.who.int/hiv/pub/idu/targetsetting/en/index.html 2 WHO. Evidence for Action Series: Technical papers and policy briefs on HIV/AIDS and injecting drug users. http://www.who.int/hiv/pub/idu/evidence_for_action/en/index.html

Global Fund Information Note: Harm Reduction (May 2010)

No single intervention will prevent or reverse HIV epidemics. The greatest impact on HIV prevention and treatment will be achieved if the interventions are implemented together as a package. The interventions should be delivered using a range of modalities, including community outreach and peer-to-peer work,3 and should be implemented both in the community, in prisons and other closed settings.4 Services should also be delivered within a human rights and public health approach, and alongside supportive (or advocacy to develop supportive) legal and policy frameworks as detailed below. Why Providing the Comprehensive Package is Important Preventing HIV, viral hepatitis, tuberculosis, and other harms among people who inject drugs and providing them with effective treatment are major challenges. To respond effectively to HIV, it is vital to know your epidemic through appropriate surveillance and epidemiological research, and to tailor responses to the specific characteristics of the epidemic and needs of the people at risk. Drug injecting is a major driver of the HIV pandemic. Injecting drug use has been documented in 151 countries and in all regions of the world, and between 11 and 21 million people inject drugs globally.5 HIV infection among people who inject drugs has been reported in 120 countries,6 accounting for at least 10 percent of global HIV infections (and around 30 percent of HIV infections outside of sub-Saharan Africa).7 People who inject drugs in low and middle-income countries have poor and inequitable access to HIV prevention services and to ART.8 In prisons, access to comprehensive HIV prevention, treatment and care is even more limited despite evidence that injecting drug use is prevalent in prisons around the world.9 Global Fund Support for Interventions for People Who Inject Drugs The Global Fund is the major source of international funding in low and middle-income countries for HIV prevention, treatment, care and support for people who inject drugs. Between 2004 and 2009, it has invested around US$ 180 million in harm reduction interventions in 42 countries.10 This includes funding for HIV and hepatitis prevention, care and treatment services, as well as advocacy for policy improvements related to injecting drug use and HIV.

WHO (2004). Evidence for Action: Effectiveness of Community-Based Outreach in Preventing HIV/AIDS among Injecting Drug Users. www.who.int/hiv/pub/idu/e4a-outreach/en/index.html 4 WHO, UNODC, UNAIDS (2007). Evidence for Action Technical Papers: Effectiveness of Interventions to Address HIV in Prisons. www.who.int/hiv/pub/idu/prisons_effective/en/index.html 5 Mathers B et al (2010). HIV prevention, treatment, and care services for people who inject drugs: A systematic review of global, regional, and national coverage. Lancet, 375, DOI:10.1016/S0140-6736(10)602322. 6 Mathers B et al (2008). The global epidemiology of injecting drug use and HIV among people who inject drugs: A systematic review. Lancet, 372 (9651), 1733-1745. 7 Cook C, Kanaef N (2008) Global State of Harm Reduction 2008: Mapping the response to drug-related HIV and hepatitis C epidemics. http://www.ihra.net/GlobalState2008 8 Mathers B et al (2010). HIV prevention, treatment, and care services for people who inject drugs: A systematic review of global, regional, and national coverage. Lancet, 375, DOI:10.1016/S0140-6736(10)602322. 9 WHO, UNODC, UNAIDS (2007). Evidence for Action Technical Papers: Effectiveness of Interventions to Address HIV in Prisons. www.who.int/hiv/pub/idu/prisons_effective/en/index.html 10 Atun R, Kazatchkine M (2010). The Global Funds leadership on harm reduction: 20022009. International Journal of Drug Policy, 21, DOI:10.1016/j.drugpo.2010.01.002

Global Fund Information Note: Harm Reduction (May 2010)

Incorporating the Comprehensive Package into Global Fund Proposals Global Fund resources are available to fund evidence-based interventions that target key populations in the community and in prisons. This includes individual interventions in the comprehensive package for people who inject drugs. Global Fund policy states that middle-income countries must ensure that their proposals have a focus on poor and/or vulnerable populations and low-income countries may obviously do so as well. The performance-based funding model of the Global Fund is designed to encourage the inclusion of interventions with proven and measurable impacts within national target setting and frameworks. In considering and designing programs for HIV prevention, treatment and care for people who inject drugs and incorporating the comprehensive package (or as many of the interventions as possible) into proposals applicants are encouraged to make use of the range of technical guides and support documents available from WHO, UNODC and UNAIDS. Other Important Considerations Community involvement. It is important that people who inject drugs actively participate in the planning and delivery of the response. Country Coordinating Mechanisms should include, or work in close consultation with, this community (or with organizations that represent their needs) in project design, proposal development and project implementation. For example, involving people who use drugs in service delivery recognizes and utilizes their unique experiences, knowledge and contacts. Community systems strengthening.11 Many services for people who use drugs are best delivered in community-based settings, often through outreach by peers. Applicants should consider including interventions such as capacity building, infrastructure development and partnership building in their proposals. Gender-sensitive programming. Women who inject drugs often face additional stigma and/or barriers to access services. Proposals should address the particular needs of women who inject drugs and the female partners of men who inject drugs. Countries should also collect sex-disaggregated data and use these data, along with sex-specific denominator estimates, to monitor service issues and gaps. Prisons. Imprisonment is a common event for many people who inject drugs.12 Often, they continue using (or injecting) drugs while in prison, despite efforts by prison systems. It is therefore essential to provide the comprehensive package of interventions for people who inject drugs in prison settings as well as in the community. Particular efforts are needed to ensure continuity of ART and TB treatment as well as OST at all stages upon arrest, pretrial detention, transfer to prison and within the prison system, and upon release. This will require the engagement of different government departments in proposal development. Ensuring a supportive environment for interventions. Even where interventions such as NSPs and OST are implemented, the lack of a supportive social, policy and human rights environment often creates barriers to accessing these interventions, resulting in negative health outcomes. Therefore, applicants should consider including interventions to ensure a more supportive environment, such as:

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Global Fund Community Systems Strengthening Fact Sheet: http://www.theglobalfund.org/en/applicantsimplementers/ 12 WHO, UNODC, UNAIDS (2007). Evidence for Action Technical Papers: Effectiveness of Interventions to Address HIV in Prisons. www.who.int/hiv/pub/idu/prisons_effective/en/index.html

Global Fund Information Note: Harm Reduction (May 2010)

reviews of laws, policies and practices related to injecting drug use and HIV, with a view to changing those that create barriers to effective prevention, treatment, and care and/or violate human rights; programs to address the double stigma and discrimination related to HIV and drug use; training and/or sensitization for police, judges and prison staff in evidence and human rights-based approaches to drug use and HIV; social mobilization and campaigns for people who use drugs to better understand the law and their rights; legal aid/assistance for people who use drugs, ideally integrated in health services; and support to ensure that basic needs and underlying psycho-social vulnerabilities are addressed.

Other programmatic areas. In addition, applicants can also consider the following interventions, recognized as international best practices, in their proposals: improvements to epidemiological surveillance systems, where needed, to better estimate the size of, and assess the role of, people who use drugs in national HIV epidemics; research to further expand the knowledge base on HIV and injecting drug use and on the impact of interventions in particular settings; overdose prevention (as part of the intervention targeted information, education and communication in the Comprehensive Package) including advocacy for legislation and policy reform, staff and peer training, the prevention of transitions from non-injecting drug use to injecting, and the provision of naloxone. Monitoring and Evaluation (M&E). In order to obtain accurate and high quality data, indicators need to be carefully tailored to the applicants M&E systems and capacities. The following should also be noted: 1. A basic (minimum) package of services provided should be clearly defined for each of the interventions in the Comprehensive Package. For example, exactly what services are being provided? 2. Systems to avoid the double-counting of individuals should be developed (such as Unique Identification Codes) that allow for the monitoring of client numbers as well as the number of encounters or contacts. 3. When reporting on coverage as a percentage, a reliable population size estimate must be used as the denominators. These may be available from global reviews13,14 or developed using available guidelines.15 4. When setting targets, programs should aim for high service coverage which is defined as more than 60% of people who inject drugs being regularly reached by NSPs, and more than 40% being reached by OST.16

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Mathers B et al (2008). The global epidemiology of injecting drug use and HIV among people who inject drugs: A systematic review. Lancet, 372 (9651), 1733-1745?) 14 Mathers B et al (2010). HIV prevention, treatment, and care services for people who inject drugs: A systematic review of global, regional, and national coverage. Lancet, 375, DOI:10.1016/S0140-6736(10)602322. 15 UNAIDS/WHO Working Group on HIV/AIDS/STI Surveillance (2003). Estimating the size of populations at risk for HIV: Issues and methods. http://data.unaids.org/publications/ExternalDocuments/estimatingpopsizes_en.pdf 16 WHO, UNODC, UNAIDS (2009). Technical Guide for Countries to Set Targets for Universal Access to HIV Prevention, Treatment and Care for Injecting Drug Users. www.who.int/hiv/pub/idu/targetsetting/en/index.html

Global Fund Information Note: Harm Reduction (May 2010)

Further Reading / Resources UNAIDS and UNODC Fact sheet on Drug Use and the Spread of HIV: www.unodc.org/documents/frontpage/Facts_about_drug_use_and_the_spread_of_ HIV.pdf What Is Harm Reduction? definition from the International Harm Reduction Association: www.ihra.net/Assets/2316/1/IHRA_HRStatement.pdf WHO, UNODC and UNAIDS Technical Guide: www.who.int/hiv/pub/idu/targetsetting/en/index.html WHO Evidence for Action Series (technical papers and evidence reviews): www.who.int/hiv/pub/idu/evidence_for_action/en/index.html WHO Basic Principles for Treatment and Psychosocial Support of Drug Dependent People Living with HIV/AIDS: www.who.int/substance_abuse/publications/basic_principles_drug_hiv.pdf

Global Fund Information Note: Harm Reduction (May 2010)