A civil society-led monitoring of harm reduction can play an essential role in improving service delivery and contribute to the generation of crucial data for advocacy purposes. Civil society organisations (CSO’s) work directly for, and with, people who use drugs (PWUD) and have a good understanding of their daily needs. Their inside knowledge is critical in developing adequate drug policies and practices.

To complement the work of other monitoring agencies, and to bring insight into how the implementation of harm reduction occurs, Correlation -European Harm Reduction Network (C-EHRN) has published a report on Civil Society Monitoring of Harm Reduction in Europe since 2019. It gathers data on the experiences of harm reduction service providers and service users at ground level, building on a network of national Focal Points (FPs) in Europe. For the 2020 monitoring, C-EHRN includes 35 FPs in 34 countries, as shown in the map below. To get insight at the implementation level, and to profit from the experiences and expertise of FPs, the 2020 monitoring focuses mostly on cities rather than countries.

Civil society monitoring of harm reduction in Europe, 2020

Internationally, there is a growing understanding and acceptance that policy approaches to personal drug use which rely on the punishment of the individual cause avoidable harms and need to change. A number of evidence-based policy options are available that offer opportunities to improve outcomes for public health and reduce drug-related harm to people who use drugs and their communities, and thereby contribute to reducing social iniquities. One of these policy options is the decriminalisation of drug offences related to personal use (hereinafter, ‘decriminalisation’). Across the globe, a number of jurisdictions have implemented some form of decriminalisation. There is equally a lot of work focused on bringing about progressive change in this policy space ongoing around the world.

The Ana Liffey Drug Project (ALDP), supported by the Global Drug Policy Program of the Open Society Foundations (OSF), invited some advocates for decriminalisation from around Europe to join a two-day meeting in February 2020. The meeting took place in Dunboyne, Ireland, and brought together delegates to share their experiences in advocating for decriminalisation in their own countries and to benefit from the insights of others.

This paper provides some key insights from this event, and from conversations which followed it, with largely the same group of advocates. At its core, this paper has a peer-to-peer focus. The target audience is primarily people who are advocating for decriminalisation in their own jurisdictions, or who are considering doing so. Public health, community safety and criminal justice stakeholders more generally may also find it of interest. The aim is to provide insights from ‘in the field’, sharing the views and experiences of people actively working on advocacy projects related to decriminalisation. It does not purport to be a full or academic treatment of the issue – rather, it is intended to provide insights that can help advocates frame and focus their work.

Decriminalisation Insights for Advocates

Key populations and their sexual partners have higher HIV prevalence than the general population and 62% of global new HIV infections are amongst this group. UN agencies including UNAIDS, WHO, UNODC, UNDP, as well as the Global Fund, PEPFAR, bilateral donors and private foundations, such as the Bill and Melinda Gates Foundation recognize that effective and evidence-based HIV response must focus on key populations who are most vulnerable to HIV transmission. For example, in Pakistan, there is an estimated 37,173 – 111,330 number of people who inject drugs, with a HIV prevalence rate of 38.4%, a mere 4.3% of which are virally suppressed, and low HIV prevention coverage of 29%. In Ukraine, there are an estimated 319,500 people who inject drugs with a 19.1% - 22.6% HIV prevalence rate. In Nigeria, the number of people who inject drugs is estimated at 80,000, with 9.2% HIV prevalence rate.

People who use drugs are a population group disproportionately vulnerable to HIV and AIDS, and are often left out of HIV prevention and treatment services. Criminalisation, stigma and discrimination, including within health care settings, are some of the main barriers they face when accessing services. Accordingly, decriminalisation should be a core component of public health and HIV prevention responses. Moreover, policy makers often make political and moral judgements about who to prioritise in programmes. People who use drugs bear the brunt of these types of decision-making.

Imprisonment, arbitrary detention and compulsory forced rehabilitation is a reality for many people who inject drugs. UNAIDS estimates that 56-90% of people who inject drugs will be incarcerated at some stage during their life. Therefore, it is essential to promote harm reduction and provide services in closed settings as well as in the community.

Harm reduction interventions are evidence-based and have a proven record of effectiveness and cost-effectiveness in the fight against HIV. Additional benefits include a reduction in criminal activity related to the need to access drugs, and individual, family and community social and health benefits. The unit costs of harm reduction interventions are relatively low, making it good value for money at $100 - $1000 per HIV infection averted.

From Invisibility to Influence: The evolution of participation of people who use drugs in the Global Fund

Gender-based violence (GBV) is caused by systemic gender inequalities and encompasses all acts of physical, emotional, sexual and psychological violence perpetuated against a person due to their gender (UNHCR, 2020). It is estimated that 35% of women worldwide have experienced some form of physical and/or sexual violence by an intimate partner, or sexual violence perpetrated by a non-partner (WHO, 2013a). Prevalence is estimated to be higher in sub-Saharan Africa (Pack, L’Engle, Mwarogo, & Kingola, 2014).

Although a number of studies have investigated GBV, including both intimate and nonintimate partner violence in the general population and among sex workers, relatively few studies have investigated the experience of GBV among women who use drugs (WWUD). Data on the prevalence of GBV and its underlying factors among this vulnerable group therefore remains relatively sparse and anecdotal. Considering literature that has found links between intimate partner violence, substance use, sexual decision making and HIV/AIDS, there is a gap in evidence on vulnerable populations especially WWUD in sub-Saharan Africa. This study therefore seeks to explore the lived experiences of WWUD and their children in Kenya, in relation to different types of GBV; and structures that perpetuate GBV among this population.

Physical abuse intersected with psychological control and included demands to stay indoors, violence, humiliation e.g. tearing of clothes or destroying WWUD’s personal and other effects sometimes in front of a victim’s family or their children. The reasons ranged from stealing partner’s money or drugs, suspicion of unfaithfulness, stealing from clients, partner’s frustration at WWUD for not earning money from sex work, refusing partner selling household goods, and rejection of partner’s forceful demands for sex.

Physical abuse was aimed at ensuring control and dependence of partners. Psychological abuse took many forms including family isolation and feelings of diminished worth, and was normalised by WWUD. Children of WWUD also suffered psychological abuse through separation from their mothers and direct verbal abuse from others.

Understanding experiences of gender-based violence among women who use drugs (WWUD)

The former communist countries of Eastern Europe and Central Asia (EECA) are transition economies, attempting to manage rising healthcare costs whilst reforming their health systems. EECA is one of the few regions in the world where the incidence of Human Immunodeficiency Virus (HIV) is going up. Because of competing needs, public health interventions for HIV have been low on policymakers priority lists, with the allocation of domestic funds to scaling-up HIV prevention programmes falling short of demand.

Criminalisation of drug use and incarceration for drug-related offences are one of the main influences behind an increase in prison populations in EECA countries. Arresting and putting people who inject drugs (PWID) in prison is both expensive and associated with an increase in HIV infections. The funds allocated to incarcerating PWID massively outweigh those spent on prevention and treatment for this group. The stigma associated with drug use in EECA further hinders the expansion of HIV prevention programmes within mainstream public health.

In parts of Western Europe, evidenceinformed, properly scaled up, community-led harm reduction services exist, where criminal sanctions for individual use and possession of drugs are removed and human rights are respected.9 Such harm reduction approaches have helped decrease problems with drug use, reduce overcrowding in prisons and dramatically reduce the incidence of HIV in PWID.9 The case for addressing punitive criminalisation strategies and stigma associated with HIV in PWID in EECA is clear, yet progress towards decriminalisation remains slow.

This Economist Intelligence Unit (EIU) report aims to capture the attention of policy-makers in four study countries in the EECA region; Belarus, Kazakhstan, Kyrgyzstan and Russia to make the case for the cost effectiveness and health gains achieved when the criminalisation of drug use is reduced, harm reduction is scaled up and stigma and discrimination towards PWID and other vulnerable populations is reduced.

Drug control policies in Eastern Europe and Central Asia - The economic, health and social impact

By Jerome Evanno / Paroles Autour de la Santé (PAS)

Between 4000/6000 “problematic / precarious” drugs users (DU's), frequent at least a hundred open consumption scene (in Monrovia). There are between 10 to 20% of women, the average age is 32/36 years and it has been noted the presence of children. The main illegal drug consumed remains cannabis. However, we were able to observe and confirm a significant consumption of cocaine in the form of crack, heroin (white) smoked with aluminum foil (the most common way of use is smoking), and non-prescription drugs (tramadol, valium, diazepam, etc.). At first, it was easy to see that in Liberia, and more particularly the capital Monrovia, that interventions related to the use and abuse of drugs (from a global health point of view), will require a multisectoral and holistic approach. The analysis of the data collected revealed a strong will on the part of all stakeholders to reform the current law « obsolete and very repressive » and strong expectations and needs on the part of the DU's.

Regarding the recommendations, they have been classified into 5 parts. Firstly, addictology, it will be more precise to reflect on the implementation of a « national rehab center », a « therapeutic community », « capacity building » of medical staff (more specifically for health staff and prescribers), « promote the prescription of methadone and OST », and « create self-support groups and / or support groups ». Then, for the aspects of Harm Reduction, it's recommended to carry out a « community and participatory diagnosis » of the needs and assessments of the DUs, to create « adapted tools », « self-support groups » and to promote « socio-economic reintegration activities ». It will also promote the activities and the Harm Reduction approach during the next funding requests and more particularly with the Global Fund (GF) and PEPFAR.

Regarding health care, we must support and validate the relevance of the implementation of « specific services », « TB / HIV adapted services », « food activities », « mobile health care service » and give « primary medication » without forgeting the mental health approach. Regarding drug policy, the organization of a « symposium for NGO » (position paper, recommendations, etc.), « promote the West African drug model law », support a « technical group » and drug policies / advocacy / lawyers team, a better knowledge of the current law, purpose of « alternatives of incarceration », and fostering participation and « regional / international technical/High level/experts groups ». Finally, for the community approach, although transversal, it is recommended to strengthen them in capacities and promote empowerment and support the implementation of the first community based organization.

Community and contextual analysis on drug use and drugs policies in Liberia

By Alexander Söderholm, PhD Candidate at the London School of Economics and Political Science

The disruption caused by the COVID19 pandemic has exposed the health inequities within our societies, and particularly in prisons. By February 2021, at least 504,000 people deprived of liberty had tested positive for COVID19 -approximately a 4.5% of the global prison population. This resulted in a minimum of 3,800 deaths, though this is likely to be an underestimate as many countries lack testing equipment within prisons. Across the world, our overcrowded prison systems have failed to protect the life and health of people deprived of liberty.

Through four case studies that focus on the response to the pandemic in Colombia, Indonesia, Ireland, and Kenya, this briefing, launched by IDPC together with Harm Reduction International, Penal Reform International, LBH Masyarakat, and Reprieve, draws several lessons from this still ongoing crisis.

At the outset of the pandemic, a number of countries committed to reduce the number of people in prison in order to prevent the spread of the virus. However, in many cases decongestion measures have arbitrarily excluded people detained for certain drug offences.

Many countries that implemented de­congestion measures simultaneously failed to halt the disproportionate imprison­ment of people for drug offences, thus undermining attempts to reduce prison overcrowding.

In most cases, states responded to the pandemic by isolating prisons from the community. As a result, people deprived of liberty have been unable to access the most basic legal, health, and drug services. In many countries, this also means that incarcerated people cannot receive the food, clothes, and money regularly provided by their families.

Before COVID19, there was already a dramatic lack of appropriate drug treatment and harm reduction services in prisons. Even were such ser­vices existed, incarcerated people have ex­perienced serious restrictions in accessing them during the pandemic.

Community integration programmes have failed to support people released from prison dur­ing the COVID-19 pandemic. Upon release, formerly incarcerated people have faced severe challenges, including exclusion from the formal economy, social stigma, and exploitation.

Prisons and COVID-19: Lessons from an ongoing crisis

In the same way that the COVID-19 pandemic has profoundly impacted all aspects of our lives, it is reasonable to expect that with lockdowns and global restrictions on movement, the drug market will also be impacted. The European Monitoring Centre for Drugs and Drug Addiction has stated that there is “a critical need to investigate the impact of these developments on drug markets in order to identify changes that may require an immediate policy or operational response… and to learn lessons about how we might better anticipate emerging threats in the future”.

The availability of controlled drugs - whether bought via online platforms or via face-to-face transactions - will likely be compromised by COVID-19, particularly where those drugs are transported across borders. In anticipation of possible drug shortages, some people who use drugs may ‘stockpile’ their drugs of choice; contributing further to potential shortages. Given a rapid shift to online purchasing of licit goods during the pandemic, we might expect a similar shift in respect to drug purchasing behaviour, with an increase in darknet purchasing.

Since the beginning of the first national coronavirus lockdown, Release has operated a public, online survey designed to monitor how people are buying their drugs. The purpose of this survey, which is open to anyone residing in the UK over the age of 18, is to determine the impact that the COVID-19 pandemic, and corresponding restrictions, have had on buying illegal substances. Release also set up a national ‘Drug Market Monitoring Network’, made up of people who use drugs, harm reduction and recovery activists, as well as people working on the frontline, who continue to regularly report on developments in their local drug markets during the pandemic.i Qualitative feedback from the Drug Market Monitoring Network will be used where appropriate to contextualise quantitative findings from the survey.

Drugs in the time of COVID: The UK drug market response to lockdown restrictions

2020 was a year of organizational strengthening for Youth RISE, with the aim of ensuring our legal registration and financial independence in the near future having been very capably fiscally hosted again this year by our friends at » YOUTH ORGANIZATIONS FOR DRUG ACTION (YODA). This year we successfully managed three separate projects from two different funding sources - » THE ROBERT CARR FUND FOR CIVIL SOCIETY NETWORKS and » THE GLOBAL FUND TO FIGHT AIDS, TUBERCULOSIS AND MALARIA.

Youth RISE has created a number of key organizational policies and procedures, such as our Financial Policy, Risk Management Policy, Human Resources Policy, as well as our Articles of Association and Memorandum of Association for us to register in Estonia. On top of this we have expanded our organization by accepting 7 new International Working Group Members, bringing us to a total of 18, including an Executive Director, three Project Managers, a Communications Officer, a Latin America and the Caribbean Communications Officer and a Monitoring and Evaluation Officer.

We have also been able to provide opportunities for our members to develop their local organizations through our small grants program. Small grants were distributed to Peru and Mexico, Argentina, the United States of America, Spain, Hungary, and Lithuania to help develop organizations in those countries and wider regions. As the year developed, we were also delighted to be able to offer Covid relief small grants to address the developing needs of young people who use drugs during the pandemic to our members in Pakistan, Nepal, and Argentina.

This year we also took part in a number of campaigns, primarily online given the nature of the pandemic, including » Support. Don’t Punish., where we were happy to give funding and other supports to organizations in Ireland, Nepal, and Pakistan, as well as for an art contest across all of Latin America. We also helped organize a webinar as part of the Paradigma DeCentralized E-Conference with Youth RISE being represented by MJ Stowe and Carolina Ahumada making presentations on the call.

Youth RISE's 2020 Annual Report

By Aileen O’Gorman and Eberhard Schatz / Harm Reduction Journal

In recent decades, a range of civil society organisations (CSOs) (such as drug user groups, non-governmental or third sector organisations, and networks of existing organisations) have sought to shape the development of drugs policy at national and international levels. Tese CSOs engage in peer, professional, and public policy advocacy and seek to efect change mainly through legislation, resource allocation, and service provision.

Civil society involvement in drug, and other, policy making has been enabled by the expansion of ‘democratic spaces’ for civil society participation at national and supranational level. By participating in such spaces (e.g. by writing submissions, or contributing to government committees and consultative fora) and seeking to infuence the formal policy making process, many CSOs have shifted focus from their traditional ‘outsider’ activist role to adopt an ‘insider’ strategy in the belief that social change occurs through politics.

However, the capacity for civil society to infuence harm reduction discourses and drug policies from the inside is shaped by the contexts in which they operate. At a national level, the level of ‘enabling environment’ for civil society is key. So too are the prevailing views regarding drug use and harm reduction, the extent and range of public health services to address drugrelated harms; and the local level of drug regulation and law enforcement. At a supra national level, there are spaces with varying levels of scope for infuencing drug policy. For example, the Vienna NGO committee (VNGOC) facilitates CSO access to the United Nations Ofce of Drugs and Crime and the Commission on Narcotic Drugs (CND); and the EU Civil Society Forum on Drugs provides a platform for dialogue and interaction with the European Commission and for feeding grassroots experience, expertise, and recommendations into European drug strategies and action plans.

Civil society involvement in harm reduction drug policy: Reflections on the past, expectations for the future

By Marie Nougier (IDPC) and Adrià Cots Fernández (IDPC)

For centuries, criminal laws, justice systems, and prisons have been designed for, and by, men. The 2010 United Nations Rules for the Treatment of Women Prisoners and Non-custodial Measures for Women Offenders, also known as the ‘Bangkok Rules’, break away from this history by establishing the first set of international human rights standards that focus on the specific needs and experiences of women deprived of liberty.

Ten years after the adoption of the Bangkok Rules by the 193 countries represented at the UN General Assembly, states across the world have largely failed to implement them, while the number of women in prison has continued to raise dramatically. By 2020, an estimated 741,000 women were incarcerated worldwide, compared to 636,000 in 2010. The global female prison population is estimated to have increased by about 59% from 2000 to 2020.

This worrying trend has been fuelled by the harshly punitive drug laws adopted at the end of the 20th century. In many countries in Asia and Latin America, drug offences are the main cause for the incarceration of women. In most cases, women are detained for carrying out low-level drug activities, such as transporting drugs, that are characterised by high risk, a high degree of replaceability within illegal drug organisations, and very little financial reward.

Although theoretically ‘gender-blind’, punitive drug policies such as the disproportionate use of pretrial detention, mandatory minimum prison sentences, and the dearth of harm reduction and evidence-based treatment in prisons, have impacted women disproportionately. They have also ignored the causes for women’s involvement in illegal drug activities, which include the intersection of poverty and caretaking responsibilities, and coercion or influence at hands of a male relative or partner. In other words, they have undermined the application of the Bangkok Rules.

For advocates across the world, the 10-year anniversary of the Bangkok Rules is an opportunity to remind states that 

gender equality policies, criminal justice rights and drug laws are not isolated from each other

. If states want to implement a genuine agenda for gender equality, they need to review the laws and policies that undermine it – including drug legislation.

This briefing paper provides analyses the concrete ways in which punitive drug legislation has impacted upon the achievement of the Bangkok Rules, and offers several recommendations on how to translate the commitments set in the Bangkok Rules into drug policy. These include the following urgent recommendations:

Address prison overcrowding by immediately releasing all women incarcerated for minor or non-violent drug offences, including but not limited to drug use and possession for personal use, and non-violent drug supply offences committed by women in situations of vulnerability, and ensure adequate support to transition into the community.

In the context of COVID-19, it is especially urgent to release women with health risks, and women in situation of vulnerability, such as older women, disabled women, pregnant women, women with children, and women responsible for other dependants.

Urgently amend existing laws and policies to ensure that women charged with, indicted for, or convicted of minor or non-violent drug offences are eligible for diversionary measures and alternatives to incarceration and punishment.

Ensure that women who remain in prison during the pandemic have access to strictly voluntary evidence-informed, rights-based, gender-sensitive drug services, including drug dependence treatment, harm reduction and additional support services focusing on addressing past histories of trauma, gender-based violence and mental health.

Punitive drug laws: 10 years undermining the Bangkok Rules

There is an increasing tendency to get service users, such as Drug Users (DU’s) involved in health services and health policies. Participation is seen as an indispensible ingredient for good and effective policymaking and there exist numerous best practice examples of peer involvement in the field of health promotion and prevention. Health policies and health interventions are considered to be more effective and supported, when all relevant parties and communities (including civil society and the final target group) are being involved equally. In addition, policy makers and professionals realise that it is no longer appropriate to talk about and not with the final target group. All kind of communities and also DU’s demand their rights: they want to be heard and they want to be taken serious.

There are numerous ways and forms of participation and also the purpose varies from case to case. One could think of information sharing and consultation or focus on empowerment and joint decision-making. Saying this, it can be assumed, that participation is not only a tool and a method, but also a process and a principle. Yet there are numerous drawbacks which jeopardize the process and make it difficult to respond appropriately. DU’s are often poorly represented in service provision and decision making, although there is evidence that their knowledge and expertise is important and most useful for the development of tailored responses and policies.

Publications from IDPC Members