Road to 2030: Concrete actions to scale up human rights-based approaches to harm reduction. A call to action for HCV, HIV and TB elimination among people who use drugs

By Gefra Fulane1,2, Joana Santos1,3,4, Cristina Bernardo1, Ricardo Baptista Leite1,5,6

Eleven years to reach the 2030 Sustainable Development Goals (SDGs), infectious diseases are still serious health threat. Global estimates indicate that 71.1 million people are living with chronic hepatitis C [1], 36.9 million people are living with HIV/AIDS [2], and 10 million people are ill with Tuberculosis [3]. Higher mortalities and transmission rates are found among key subpopulations such as drug users and drug injectors who, in many settings, lack basic rights to health care [4–7]. Environments like prisons are more likely to carry high burden of HCV, HIV and TB, with, for instance, HIV prevalence in prison worldwide considered to be up to 50 times higher than in general public [7]. Risky drug usage behaviour and lack of affordable health care services are a predominant way of disease transmission [7–10], and sharing needles and syringes among drugs injectors accounts for 23% of new infections globally [4].

Despite the efforts to prevent the initiation or continued use of drugs, many people continue to use psychoactive substances. Harm reduction strategies prove to be cost effective at reducing negative consequences associated with the use of drugs in people unable or unwilling to stop [11]. Notwithstanding, harm reduction exists at some level in only half of total countries in the world, the number of countries implementing needle and syringe programs has reduced from 90 in 2016 to 86 in 2018, whereas prevalence of HCV and HIV are still high among people who use drugs  if compared with general populations [4]. The implementation of harm reduction strategies fall far short of reaching most people in need, who frequently see their health-related human rights violated [13]. 

Photo of Members of Parliament after the signature of the call to action at the Joint Action Policy Day 2019 (Porto, 27 April 2019)

Considering that members of parliament have powerful tools to contribute to the elimination of the threat infectious disease pose within this population group, UNITE UNITE, the Global Parliamentarians Network to End HIV/AIDS, viral hepatitis and other infectious diseases has taken action and organized the Joint Action Policy Day 2019, held in Porto City, Portugal, entitled Road to 2030: Concrete Actions to Scale up Human Rights-based approaches to Harm Reduction. A Call to Action for HCV, HIV and TB Elimination among People Who Use Drugs. Co-organized with the Piaget Agency for Development (APDES) and the Harm Reduction International (HRI), the event was attended by 184 participants coming from 30 countries, across 5 continents, including 15 members of parliament, 37 community organizations, 8 scientific entities, 22 government representatives, and 12 donor representatives. Case-examples of Portugal, China, West Africa, France, Brazil and the US were discussed. Participants agreed that:

Good policies that are effectively implemented are needed to assure human rights-grounded services for people using drugs. Proved to be cost-effective, accessible harm reduction services that are integrated and human-centered, and do not cause financial hardship, have the potential to reduce the burden of Hepatitis C, HIV/AIDS and TB among people using drugs, and ultimately contribute to ending infectious diseases as threat to global health.

 Recommendations on policy actions to accelerate the attainment of health-related SDGs by tackling hepatitis C, HIV/AIDS and TB on people using drugs include:

  1. Drug use is not a criminal issue, it is a health issue! Punishment is counterproductive. Parliamentarians have a role to play in promoting political responses to end drug use criminalization and move towards legal regulation of currently illicit substances in their nations, regions and ultimately across the globe. Portugal is an example of how cost-effective decriminalization can be in reducing drug-related deaths, overdose and HIV/AIDS among drug users. But decriminalization is not a ‘magic bullet’. It is a component within a comprehensive approach that includes the implementation of harm reduction services, while ensuring access to care across the whole cascade from prevention, diagnosis to treatment.
  2. If harm reduction works in your neighboring country it will work in yours! Integrated harm reduction services comprise needle and syringe programs, opioid substitution therapy, test and treatment of HIV, hepatitis C and Tuberculosis, antiretroviral therapy, condom programs, psychosocial, sexual and reproductive health services, education and communication, overdose management, psychosocial support, and livelihood development programs. Lessons from a community-based organization Casa da Vila Nova (Norte Vida) show clearly the impact of service integration in the reduction of hepatis C, HIV, Tuberculosis and syphilis among drug users. This is an issue to advocate for in countries like Brazil where harm reduction’s era is at the end.
  3. Harm reduction and love have a shared common denominator: they must be unconditional! If harm reduction services are introduced, they need to be focused on health determinants and based on human rights. Abuses to rights of people using drugs need to be tackled with good laws, which will ultimately decrease stigma and discrimination. Members of parliament need to guarantee that civil rights and health rights of people using drugs are safeguarded. 
  4. Community-based outreach and peer-support needs to be proved to increase the access and uptake of harm reduction services. Policymakers need to understand, respect and value the role of peers in establishing the bridge towards the access to healthcare services, social services, and psychosocial aid for people using drugs. The recently opened mobile drug consumption room in Lisbon is a step to illustrate that proximity can increase the adherence to health-related services and increases autonomy of people using drugs.
  5. People in prison used to live in the society and they will come back after their release. Go there and Solve it! And take a Micro-elimination approach. “Breaking down national goals into smaller goals for specific populations, for which treatment and prevention interventions can be delivered more quickly and efficiently” [14]., requires a new approach, in which services are moved to outside conventional health facilities to improve the linkage to care. The challenge to strengthen harm reduction in prison settings is not unique to France. Many countries still fail to address prison health as public health.
  6. Actions need to be based on high quality evidence! Gathering data to monitor and evaluate how far we go and whether adjustments are needed, is paramount. Thus, policies must anticipate how results will be monitored, which sources will be used and whether data is available to provide decision makers with the good evidence. Providing good health information systems is central to overcome lack of data and show where we stand. Actors in the Western African region are engaging policymakers to move forward on data driven actions.
  7. Assuring Universal Health Coverage! It is important to go beyond drug users and include other key populations at high risk of being infected with hepatitis C, HIV, and TB. Do not leave anyone behind! GAT, the Activists Group under Treatment, has developed a wide range of actions that provide diagnosis, counselling and treatment to populations with high risk of infectious diseases. Some specific actions include education, as well as network and peer support in outreach strategies, as these increase empowerment and reduce stigma, thus easing the access to health services. Informed citizens are more prone to end with a meritocracy of care, thus ensuring universality of health care coverage.
  8. But First, Funding! Current funding models are not sustainable. Although international funding has a role to play, national governments are invited to fill the gap and replenish harm reduction services. Funding has to guarantee community-based organizations do their work without prejudice of their autonomy. At international level it is important to call attention to this issue to increase allocation of budget. A good example is that ALL Members of Parliament present at the event signed the call to action People before politics: HR19 call to action on harm reduction funding and Global Fund replenishment stating their support to sustainable funding of harm reduction.
  9. New ways of doing partnerships: reinvention and diversification. Partnerships are key to go further as it reinforces engagement and commitment towards common goals. Engaging prosecutors-supported interventions such as law-enforcement assisted diversion in countries, as well as media groups and youth groups is paramount as these are opinion makers; actually, sharing successful stories can have a considerable impact in people´s awareness. At a lower level, alliances like peer networks and support among drug users can help navigate among formal and informal social services. In the United States, the NGO Fair and Prosecution is working with a network of prosecutors to reduce incarceration driven approaches among drug users. Rather, they promote harm reduction by taking advantage of prosecutors unique role in this matter.
  10. Political will, political advocacy, political leadership: people’s health and safety first! Evidence for harm reduction is out there. Actually, it is no longer a matter of what works. It is a matter of political will and leadership to propose and implement proper actions and take the lead. Local and global networks are both required.

References

1. Blach S, Zeuzem S, Manns M, Altraif I, Duberg AS, Muljono DH, et al. Global prevalence and genotype distribution of hepatitis C virus infection in 2015: a modelling study. Lancet Gastroenterol Hepatol. 2017;2:161–76.

2. UNAIDS. Global HIV & AIDS statistics. 2018.

3. WHO. Tuberculosis. 2018.

4. Stone K, Shirley-Beavan S. The Global State of Harm Reduction 2018. London; 2018. www.ihra.net.

5. Csete J, Kamarulzaman A, Kazatchkine M, Altice F, Balicki M, Buxton J, et al. Public health and international drug policy. Lancet. 2016;387:1427–80.

6. Greely J, Bruneau J, Lazarus J V., Dalgard O, Bruggmann P, Treloar C, et al. Research priorities to achieve universal access to hepatitis C prevention, management and direct-acting antiviral treatment among people who inject drugs. Int J Drug Policy. 2017;47:51–60.

7. Sander G. Human Rights, Minimum Standards and Monitoring at the European and International Levels 1 Monitoring HIV, HCV, TB and Harm Reduction in Prisons: A Human Rights-Based Tool to Prevent Ill Treatment HIV, HCV, TB AND HARM REDUCTION IN PRISONS www.ihra.net. 2016.

8. Gountas I, Sypsa V, Blach S, Razavi H, Hatzakis A. HCV elimination among people who inject drugs. Modelling pre- and post–WHO elimination era. PLoS One. 2018;13:1–15.

9. Nelson PK, Mathers BM, Cowie B, Hagan H, Des Jarlais D, Horyniak D, et al. Global epidemiology of hepatitis B and hepatitis C in people who inject drugs: Results of systematic reviews. Lancet. 2011;378:571–83.

10. World Health Organization. Global Hepatitis Report, 2017. 2017.

11. What is harm reduction. IHRA Off Website. 1996;44.

12. Degenhardt L, Peacock A, Colledge S, Leung J, Greely J, Vickerman P, et al. Global prevalence of injecting drug use and sociodemographic characteristics and prevalence of HIV, HBV, and HCV in people who inject drugs: a multistage systematic review. Lancet Glob Heal. 2017;5:1192–207.

13. International Harm Reduction. The Global State of Harm Reduction. 2016. https://www.hri.global/contents/1421.

14. Lazarus, Jeffrey V., et al. "Micro-elimination–A path to global elimination of hepatitis C." Journal of hepatology 67.4 (2017): 665-666.


Affiliations

1. UNITE, the Global Parliamentarians Network to End HIV/AIDS, viral hepatitis and other infectious diseases
2. Nova SBE, New University of Lisbon
3. Instituto Nacional de Saúde Dr. Ricardo Jorge
4. Faculty of Public Health, University of São Paulo
5. Faculty of Health, Medicine and Life Sciences, Maastricht University
6. Institute of Health Sciences, Católica University of Portugal