This rapid communication provides an update on drug related hospital emergency presentations in Europe with a specific focus on the latest results for acute drug toxicity presentations to the European Drug Emergencies Network (Euro-DEN). This report is primarily based on presentations and discussions at a two-day meeting of the Euro-DEN Plus network in Lisbon on 7 and 8 April 2016. The meeting provided a platform for the presentation of new analyses from the Euro-DEN dataset, and further development and analyses of the Euro-DEN project were also discussed.

Data presented here relate to analysis of acute drug toxicity presentations to the 16 original sentinel centres in the Euro-DEN network for the first two years of data collection (October 2013 to September 2015). This review also includes highlights from the new findings discussed during the meeting and consideration of the further development of the work of the Euro-DEN network and the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) in this field.

Keep up-to-date with drug policy developments by subscribing to the IDPC Monthly Alert.

Hospital emergency presentations and acute drug toxicity in Europe — update from the Euro-DEN Plus research group and the EMCDDA

The Philippines has been identified as one of nine countries in the world where HIV continues to increase at an alarming rate of more than 25 percent. 1 HIV transmission among people who inject drugs (PWID) expanded rapidly in recent years, from less than 1 percent in 2005 to more than 5 percent in the past five years.2 There are between 12,304 and 16,607 PWID living in the Philippines, with the majority—an estimated 6,000 PWID—in Metro Cebu and between 2,000 and 2,500 in Cebu City.3 HIV and Hepatitis C Virus (HCV) rates among this group have been estimated at 41.6 percent and 70 percent, respectively. 4 In Cebu City, up to 74 percent of people living with HIV contracted the virus through needle sharing,5 and 99 percent of infections among PWID were reported in Metro Cebu.

Global evidence unequivocally shows that distribution of sterile injecting equipment reduces the transmission of HIV and other blood-borne infections like Hepatitis C among PWID; does not lead to an increase in drug use in general or in intravenous injection, in particular; increases demand for health and social care services, often resulting in better monitoring, care, and treatment; and that results are enhanced when such efforts are included in a comprehensive package of health and social care services.7 However, the Comprehensive Dangerous Drugs Act of 2002 prioritizes public security over public health objectives and specifically criminalizes possession and distribution of drug paraphernalia such as needles and syringes.

In March 2013, Population Services International (PSI) was contracted to lead the implementation of the Big Cities Project (BCP) between April 15, 2013 and December 31, 2015 with a total budget of US$1,840,000 committed by the World Bank and the Asian Development Bank (ADB). The ultimate goal of the project was to reduce HIV transmission by reducing risk behaviors among PWID. Specifically, implementation of the BCP aimed to develop friendly drop-in center (DIC) and outreach services; increase demand and uptake of health services through improved peer education and support; and strengthen governance for development and implementation of sustainable, evidencebased policies and interventions.

Keep up-to-date with drug policy developments by subscribing to the IDPC Monthly Alert.

Evaluation of harm reduction service delivery in Cebu City, Philippines (2013 –2015)

The year 2015 saw excellent progress for the International HIV/AIDS Alliance, with 13 out of 14 of our milestones exceeded. The year marked the start of a new era towards ending AIDS. In September 2015, the UN adopted the Sustainable Development Goals (SDGs). The Alliance worked closely with many others to ensure HIV was included as part of a new health goal to promote health and wellbeing for all, with a specific target to end AIDS by 2030.

The coming year will be critical in helping us working to meet this 2030 goal. It is a year where we have the possibility of securing new, bolder commitments to the response to AIDS at the global level through the UN High Level Meeting on AIDS and will be crucial in terms of ensuring that AIDS stays on the agenda for funders. With other competing development priorities like the European refugee crisis, political support for official development assistance (ODA) has continued to decrease. This has created a greater sense of urgency around efforts to diversify financial support. Opportunities and challenges facing the Alliance for the coming year are discussed in greater detail below.

Significant achievements of the Alliance during 2015 included the following:

In 41% of Alliance countries, our Linking Organisations contributed 10% or more of the national coverage for HIV prevention, care or treatment (target 30% of Alliance countries).

1,300,000 defined packages of HIV prevention services were provided to key populations; 30% higher than the target set.

One million people received HIV testing and counselling services for HIV, and received their test results; 25 Linking Organisations contributed to this target in 2015.

Nearly 1.2 million adults and children living with HIV received care and support services; a 29% increase since 2014. • 1,599,000 people were reached with integrated HIV and sexual and reproductive health (SRH) activities; 900,000 were women and girls.

2,174 community-based organisations (CBOs) received grants through the Alliance (target 2000); 83% achieved their programmatic and financial targets.

809 CBOs and networks were supported by the Alliance to monitor and report on human rights-related barriers to access services (2015 target 350).

9 Linking Organisations are Global Fund Principal Recipients (PR), managing one of the largest Global Fund civil society portfolios with a value of $310 million.

We organised a number of high-level events to influence decision makers in the year leading up to the agreement of the new Sustainable Development Goals, including at the Financing for Development Conference and the UN Summit. We also had a strong presence at the international harm reduction and the international family planning conferences.

International HIV/AIDS Alliance annual report 2015

HCV is a bloodborne virus that is often asymptomatic, and symptoms may not appear until the liver is severely damaged. As a consequence, many individuals with chronic HCV infection remain undiagnosed and fail to access treatment. These individuals can then present late with complications of HCV-related end-stage liver disease (ESLD) and cancer, which have poor survival rates.

Hepatitis C is a curable infection, and it is our aspiration to support the WHO in its goal to eliminate hepatitis C as a major public health threat by 2030. This can be achieved via the collective action of all partner organisations involved in the prevention, diagnosis, treatment and care of those living with, or at risk of acquiring, HCV infection. National action plans to tackle hepatitis C are already in place, and being developed across the UK, including the Liver Disease Delivery Plan for NHS Wales and its Partners to 2020 and the Sexual Health and Blood Borne Virus Framework, 2015- 2020 Update in Scotland. In England, NHS England is producing an operational framework setting out its commitment to improve outcomes in hepatitis C, and PHE plans to capture the wider public health activities in an England report later this year.

Informed by Global Health Sector Strategy (GHSS) goals and targets (see Appendix 1), countries are called upon to develop, as soon as practicable, ambitious national goals and targets for 2020 and beyond. These are intended to take into consideration the country context, including the country-specific nature and dynamics of viral hepatitis, the populations affected, the structure and capacity of the health care and community systems, as well as the resources that can be mobilised. Targets also need to be feasible and developed based on country realities, the best possible data, trends and responses, and should be monitored through a set of standard, measurable indicators.

Hepatitis C in the UK: 2016 report

Penal Reform International's Annual Report 2015 tracks progress towards the goals of its new Strategic Plan 2015-2020. The highlights of the year include but are not limited to:

The unanimous adoption of the revised UN Standard Minimum Rules for the Treatment of Prisoners – now the UN 

 – by the UN General Assembly in December 2015. The Rules are regarded by states as the primary source of standards on the treatment of prisoners. The Nelson Mandela Rules contain substantive new guidance for governments and prison management, including on healthcare, the conduct of searches and on the use of solitary confinement. PRI engaged intensively in the four-year revision process.

Growing engagement by PRI on the issue of 

Progress on improving protection of children in conflict with the law in 

. Following research on violence against children in Kazakhstan, Kyrgyzstan and Tajikistan and its presentation at a regional conference, the Government of Kazakhstan and of Tajikistan made concrete commitments to start legal and policy reform.

 to tackle overcrowding in prisons through the introduction of community service programmes. PRI’s popular 10 point plan on addressing prison overcrowding now forms the basis of Tunisia’s national strategy to reduce overcrowding.

Legislative and policy changes improving the treatment of vulnerable prisoners in 

A new juvenile justice code and the introduction of pre-sentence reporting for children in 

. PRI’s South Caucasus office were active in advocating for the new code and in supporting the implementation of the new procedures by probation and social workers.

PRI annual report 2015

The prison setting presents not only challenges, but also opportunities, for the prevention and treatment of HIV, viral hepatitis, and tuberculosis. We did a comprehensive literature search of data published between 2005 and 2015 to understand the global epidemiology of HIV, hepatitis C virus (HCV), hepatitis B virus (HBV), and tuberculosis in prisoners. We further modelled the contribution of imprisonment and the potential impact of prevention interventions on HIV transmission in this population. Of the estimated 10·2 million people incarcerated worldwide on any given day in 2014, we estimated that 3·8% have HIV (389 000 living with HIV), 15·1% have HCV (1 546 500), 4·8% have chronic HBV (491 500), and 2·8% have active tuberculosis (286 000). The few studies on incidence suggest that intraprison transmission is generally low, except for large-scale outbreaks. Our model indicates that decreasing the incarceration rate in people who inject drugs and providing opioid agonist therapy could reduce the burden of HIV in this population. The prevalence of HIV, HCV, HBV, and tuberculosis is higher in prison populations than in the general population, mainly because of the criminalisation of drug use and the detention of people who use drugs. The most eff ective way of controlling these infections in prisoners and the broader community is to reduce the incarceration of people who inject drugs.

From the beginning of the AIDS epidemic in 1981, the association between HIV, tuberculosis, and prisons was apparent, with HIV responsible for a steep rise in tuberculosis in US prison populations. This is important because the prevalence of HIV in prisons in many countries is high, with one review reporting levels greater than 10% in 20 low-income and middle-income countries. Several factors have a role in the epidemics of HIV, tuberculosis, and related infections in prisons. Many individuals who are most likely to be incarcerated are at greatest risk of these infections, whether because of injection drug use for HIV and viral hepatitis or poverty and overcrowding for tuberculosis Drug injection is common in prison inmates, ranging from 2% to 38% in Europe, 34% in Canada, and up to 55% in Australia, in stark contrast with the percentage in the general population, estimated at 0·3% in the European Union and 0·2% in Australia.5 Prisons provide many opportunities both for the spread4 and prevention of these infections.

Global burden of HIV, viral hepatitis, and tuberculosis in prisoners and detainees

Hepatitis C is a disease of the liver caused by the hepatitis C virus (HCV), which if not resolved can lead to chronic liver disease, cirrhosis and cancer. The disease, which affects many millions of people worldwide, is communicable and is spread by contact with infected blood or other bodily fluids. In Europe, the key risk group for HCV infection is people who inject drugs. High rates of HCV infection are commonly found in this group and people with an injecting history, however brief, as well as current injection drug users, are still unaware of their infection status. There are now new opportunities for effective treatment and prevention that, if scaled up sufficiently in Europe, could contribute to a significant reduction in the health harms associated with this disease.

This Insights publication provides both practitioners and policymakers with an analysis of the current epidemiology, harm reduction and treatment measures in relation to HCV infection in Europe. It also covers the barriers to treatment and examples of treatment scale-up and services organisation. Specifically, it provides an up-to-date overview of the new antiviral treatments that have become more available since 2014 and a review of HCV treatment initiatives in Europe. Finally, it presents and discusses modelling projections on the combined effects and synergies of different harm reduction interventions, and examines where improvements in data availability are needed to better inform policy and practice in this area.

Hepatitis C among drug users in Europe: Epidemiology, treatment and prevention

Worldwide, a disproportionate burden of HIV, tuberculosis, and hepatitis is present among current and former prisoners. This problem results from laws, policies, and policing practices that unjustly and discriminatorily detain individuals and fail to ensure continuity of prevention, care, and treatment upon detention, throughout imprisonment, and upon release. These government actions, and the failure to ensure humane prison conditions, constitute violations of human rights to be free of discrimination and cruel and inhuman treatment, to due process of law, and to health. Although interventions to prevent and treat HIV, tuberculosis, hepatitis, and drug dependence have proven successful in prisons and are required by international law, they commonly are not available. Prison health services are often not governed by ministries responsible for national public health programmes, and prison oﬃ cials are often unwilling to implement eﬀ ective prevention measures such as needle exchange, condom distribution, and opioid substitution therapy in custodial settings, often based on mistaken ideas about their incompatibility with prison security. In nearly all countries, prisoners face stigma and social marginalisation upon release and frequently are unable to access health and social support services. Reforms in criminal law, policing practices, and justice systems to reduce imprisonment, reforms in the organisation and management of prisons and their health services, and greater investment of resources are needed.

The criminalisation of drug use and of some sexual behaviours, discrimination against racial and ethnic minorities, and lack of access to protections of due process for socioeconomically disadvantaged groups lead to unjust incarceration, increase the risk of HIV, tuberculosis, and hepatitis infection, and interrupt access to prevention and treatment. Both incarceration and the fear of arrest and harassment by police can prevent individuals from seeking or accessing prevention, harm reduction interventions, testing, and treatment. Consequently, in nearly every country in the world, criminalised populations and prisoners face higher burdens of HIV infection and lower levels of access to treatment than do non-incarcerated individuals.

Prisoners are often held in overcrowded, unsanitary, stressful, and violent conditions, which are ripe for the spread of communicable diseases. Access to prevention and treatment programmes are often non-existent or severely underfunded. According to WHO, “Ill-health thrives in settings of poverty, conﬂ ict, discrimination and disinterest. Prison is an environment that concentrates precisely these issues.”2 Continuity of treatment during imprisonment and upon release is rare.

HIV, prisoners, and human rights

There is no place for the death penalty in the modern world. State execution is a barbaric act that demeans the State that carries it out. The death penalty is cruel and inhumane, and is inevitably associated with miscarriages of justice, the inadvertent execution of innocents, and the disproportionate execution of the poor and ethnic and religious minorities. Not only does an eye for an eye leave the world blind, but the deliberate destruction of human life as a response to crime is an affront to the ‘right to life’, enshrined under international human rights law.

The world has come a long way towards ceasing the practice of capital punishment. Amnesty International tells us that in 1977 only 16 countries had abolished the death penalty. Since that year, Amnesty and many others have campaigned vigorously for an end to capital punishment, and by 2015 140 countries had abolished it law or in practice.

However, there is no room for complacency. There are still 56 countries that actively retain the death penalty, including some that execute hundreds of people each year. Disturbingly, the year 2015 saw the highest number of executions recorded worldwide since 1989. It also saw the appalling executions of Australians Andrew Chan and Myuran Sukumaran in Indonesia for drug trafficking, despite impassioned appeals from many Australians and sympathetic Indonesians.

A world without the death penalty

The HIV, TB & Human Rights in Southern and East Africa 2016 report examines the legal and regulatory framework for responding to HIV, AIDS and TB in countries in Southern and East Africa (SEA) in order to determine whether:

Laws, regulations and policies protect and promote the rights of all people, including key populations, (LGBTI people, sex workers and people who use drugs), in context of HIV, AIDS and TB; and

Populations are aware of their rights, are able to access justice and are able to enforce their rights in the context of HIV, AIDS and TB.

The 2016 Report identifies and analyses both national and regional findings to identify significant developments in creating enabling legal and regulatory frameworks for key and emerging human rights issues (such as the criminalisation of HIV transmission, gender inequality, gender-based violence (GBV) and protection of the rights of key populations). In addition, the report provides country snapshots for 18 countries, updating information on universal access and human rights.

HIV, TB and Human Rights in Southern and East Africa 2016

This report, ‘Taking a New Line on Drugs’, comes at a timely moment for drugs strategy both in the UK and across the world. The special session of the United Nations General Assembly on the world drug problem, which took place in New York in April 2016, represented a missed opportunity to move on from the ‘war on drugs’ and take a new approach, despite the pioneering policies focused on public health and harm reduction being pursued by a number of nations. In the UK, the Psychoactive Substances Act came into effect in May 2016, and we await a refreshed Government drugs strategy later in the year.

‘Taking a New Line on Drugs’ assesses the situation in the UK as regards rising health harm from illegal drugs, with reference to their context within the wider ‘drugscape’ of legal drugs such as alcohol and tobacco, and sets out a new vision for a holistic public health-led approach to drugs policy at a UK-wide level.

Drugs’ are not just those substances that are currently illegal. They also include socially-embedded legal substances, such as alcohol and tobacco, used by the majority of people in the UK. Drugs strategy must reflect this reality, and not create artificial and unhelpful divisions.

All drug use increases the risk of some form of related harm, be it to the individual, those around them, wider society, or all three. However, drug harm cannot be objectively measured on a single scale – it is multi-faceted, including physical, psychological and social harm, both to the user and to others. Every drug has a different harm profile across these categories, and so it is too simplistic to only say ‘drug A is more harmful than drug B’.

Illegal drug use in the UK rose through the 1960s to 1990s, but has fallen over the course of the past decade. However, this overall fall hides the increase in the use of Class A drugs – those deemed most harmful under the existing classification system – and the take up of new psychoactive substances, the rate of which remains uncertain. More importantly, drug harm is not declining in line with the fall in use, and there have been increases in many types of harm including the number of deaths. Levels of drug harm, not simply levels of drug use, should be taken into account when considering the success of drugs policy.

Taking a new line on drugs

In its resolution 27/31, the Human Rights Council, recognizing the crucial importance of the active involvement of civil society, at all levels, in promoting good governance, including through transparency and accountability, which is indispensable for building peaceful, prosperous and democratic societies, requested the United Nations High Commissioner for Human Rights to prepare a compilation of practical recommendations for the creation and maintenance of a safe and enabling environment for civil society, based on good practices and lessons learned.

To this end, on 28 April 2015, the Office of the United Nations High Commissioner for Human Rights (OHCHR) sent notes verbales to Member States, national human rights institutions, civil society organizations and international and regional organizations, followed by a reminder on 8 July 2015. A total of 89 responses were received, demonstrating the importance given to the issues addressed in resolution 27/31.1

The present report reflects input from all regions, based on contributions received from Member States, national human rights institutions and diverse civil society actors, including international and regional networks, academics and faith-based organizations, as well as United Nations and regional entities.

In a context of shrinking civil society space worldwide, it is important to share practices that highlight the benefits of creating and maintaining an enabling environment for civil society. In the present report the High Commissioner focuses on examples of proactive practices that optimize civil society’s transformative potential.2 He identifies five ingredients which are essential in this regard: a robust legal framework compliant with international standards and a strong national human rights protection system that safeguards public freedoms and effective access to justice; a political environment conducive to civil society work; access to information; avenues for participation by civil society in policy development and decision-making processes; and long-term support and resources for civil society.

Publications