UN releases revised harm reduction guidance

This month, the World Health Organisation (WHO), United Nations Office on Drugs and Crime (UNODC) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) released the second edition of the “Technical Guide for Countries to Set Targets for Universal Access to HIV Prevention, Treatment and Care for Injecting Drug Users”.

The first version was released in 2009 and, for the first time, provided official UN endorsement of a “comprehensive package” of nine interventions for people who inject drugs:

• Needle and syringe programmes (NSPs)
• Opioid substitution therapy (OST) and other evidence-based drug dependence treatment
• HIV testing and counselling
• Antiretroviral therapy
• 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

Since then, this package has been endorsed at the highest political levels – including by the Commission on Narcotic Drugs, the UNAIDS Programme Coordinating Board, the UN General Assembly, ECOSOC, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and PEPFAR. It has proven to be an invaluable technical resource as well as an important advocacy tool – but has also been criticised for omitting some key interventions (the International HIV/AIDS Alliance, for example, has outlined 15 interventions in its own harm reduction list).

Crucially, although the list was originally created in order of priority and evidence – i.e. with NSPs and OST being the most important, proven interventions of the nine – this point was omitted from the final guidance in 2009. As a result, countries could congratulate themselves on delivering seven out of the nine interventions, while omitting the two most important ones!

In the second edition released this month, the package itself has remained unchanged (as to change it would have been a much more difficult political process). However, the revised guidance makes a clear distinction between “drug-user-specific” interventions and general interventions in the comprehensive package:

“To successfully address HIV where injecting drug use occurs, countries should prioritise implementing NSPs and evidence-based drug dependence treatment (specifically OST)… Most countries have some level of provision of the [other] interventions from the Comprehensive Package that are not specific to drug users”. (Page 11)

This distinction is essential, as it increases the pressure on those countries which continue to block NSP and/or OST provision.

The revised guidance provides countries with a more user-friendly framework of indicators and targets – including important new measures of the drug policy environment in which they operate. The guidance also endorses the provision of “low dead-space syringes” where appropriate (Page 12 – see the recent IDPC blog on these here). It explicitly includes overdose prevention and naloxone provision under the heading of “Targeted information, education and communication” (Page 19), and once again denounces compulsory drug detention programmes (Page 14).

There is also a section on “Structural factors influencing risk and intervention impact” which need to be considered in addition to the “comprehensive package” – such as drug policies and laws that need to be addressed to create a supportive environment (Page 23). Suggested interventions include advocacy, law reform, community mobilization and stigma reduction.

Click here to view the revised UN guidance.