This briefing compiles geographically diverse evidence to enable advocates to make the case for the cost-effectiveness of harm reduction.

This advocacy work has never been more important.

HIV continues to rise among people who inject drugs, yet harm reduction funding is in crisis. Financial support for an effective HIV response for people who inject drugs in low- and middle-income countries totalled US$188 million in 2016 – just one-tenth of the US$1.5 billion that is needed annually by 2020.

International donor funding for harm reduction has reduced by one-quarter over the past decade. Middle-income countries are increasingly vulnerable as donors either reduce or withdraw funding. While many governments are investing more in domestic health and HIV responses, few are substantially investing in harm reduction, even where the need is great.

Making the investment case: Cost-effectiveness evidence for harm reduction

By Nazlee Maghsoudi & Jeanette Bowles & Dan Werb

The increasing incidence of fatal opioid overdose is a public health crisis in Canada. While buprenorphine/naloxone and methadone are the standard first-line of opioid substitution options, limitations, including difficulty achieving long-term retention for some people who use opioids, are well known. For this group, injectable diacetylmorphine or hydromorphone can achieve positive outcomes, including high retention rates, reduced use of unregulated opioids, and reduced criminal activity. In May 2019, Health Canada announced changes to increase the accessibility of diacetylmorphine and hydromorphone, and in September 2019, the CIHR-funded Canadian Research Initiative in Substance Misuse released a national clinical guideline for diacetylmorphine and hydromorphone as additional frontline substitution options. While these developments present opportunities for scale-up, significant financial, structural, and practice barriers continue to impede access. This commentary explores the current state of policy and practice for diacetylmorphine and hydromorphone as opioid substitution options in Canada, outlines the rationale for rapid expansion of access, and highlights clinical and policy changes that must be undertaken or the death toll will continue to rise.

Expanding access to diacetylmorphine and hydromorphone for people who use opioids in Canada

By Goro Koto,1 Masayoshi Tarui,2 Harue Kamioka,3 Kanna Hayashi4

1. Japan Advocacy Network for Drug Policy
2. Keio University, Tokyo, Japan
3. Japan Advocacy Network for Drug Policy & Women’s DARC
4. Faculty of Health Sciences, Simon Fraser University, British Columbia, Canada

This briefing paper provides an overview of drug use in Japan, regulatory efforts by police and the judiciary, governmental and legislative responses and support for people who use drugs amongst civil society actors. The paper ends with a number of recommendations developed on the basis of this information.

Since 1995, the proportion of people in Japan who have used drugs in their lifetime has been estimated to be 2-3%, while the proportion who have used drugs in the past year has been estimated to be as low as 0.1%. The most commonly used drugs are methamphetamine and organic solvents (e.g. paint thinner), but the use of cannabis has increased in recent years. Since 2008, the annual number of newly reported cases of HIV in the general population has ranged from 1,600 to 1,400. Approximately 70-80% of those cases are among men who have sex with men, many of whom reported having used drugs during sex.

Stimulants, opioids, cannabis and other drugs are regulated by six laws in Japan, which will be described in detail below. These laws impose severe penalties for all activities associated with the illicit drug trade, with the maximum penalty for drug offences being life imprisonment. As a result, 14,019 people were arrested for drug offences in 2017 alone. Of those, 73% involved methamphetamine, with personal use and possession accounting for 90%. The proportion of repeat offenders, accounting for two thirds of arrests, has recently increased while the overall number of arrestees and first-time offenders fell. The application of severe penalties against drug offenders has led to a large proportion of the prison population being incarcerated for drug offences – in 2017, 27.7% of new male prisoners and 36.7% of new female prisoners were imprisoned for methamphetamine-related offences. While alternatives to incarceration do exist, including a system of suspended sentences es- tablished in 2016, the overall response remains puni- tive in nature.

Unsurprisingly, in Japan, drug use is viewed chiefly as a criminal matter, with emphasis placed on its eradication through intolerance and punishment. The Japanese government’s drug policy is described in its Five-Year Drug Abuse Prevention Strategy. That strategy focuses on education and public awareness, treatment and reintegration of people who use drugs, crackdowns on drug dealers and users, prevention of smuggling and international cooperation. The government’s support for people who use drugs, however, remains inadequate. While the government has finally recognised the effectiveness of harm reduction in other countries at international meetings, it opposes its introduction in Japan and has expressed opposition to the inclusion of harm reduction approaches in UN recommendations on drug policy. Support for drug dependence in the community is largely left to self-help groups, with limited support from medical institutions. Although advocacy for the health and human rights of people who use drugs has been gaining ground over the past decade, led by people with lived experience, their family and their supporters, a view to understanding drug use as a health issue is lacking, and it has become crucial to improve the provision of social support for people who use drugs and respect for their human rights.

Drug use, regulations and policy in Japan

The Organization of American States (OAS) today launched the "Practical Guide to Inclusive Rights-Focused Responses to COVID-19 in the Americas." The guide seeks to support OAS member states in responding to the pandemic, offering them a series of tools to consider responses that take into account the particular circumstances of groups in a situation of vulnerability.

"This pandemic affects all of us, directly or indirectly," said the Secretary General of the OAS, Luis Almagro. "However, for people in situations of vulnerability, the reach of the impact is much deeper and could, very probably, increase the gaps in their access to their basic economic, social and cultural rights. We know that our political systems are going to suffer, that our social fabrics are going to suffer, but we cannot emerge from this situation either less democratic nor with fewer rights. Let us use this challenging moment to reinforce the values that we believe are indispensable for life and human development, and ensure that the people most excluded in our societies are neither left out nor left behind, not for a minute more."

The Secretary General warned that the capacity to survive the pandemic "is much less likely" for people in situations of poverty and extreme poverty, as well as for groups historically discriminated against, such as women, indigenous peoples, afro-descendants, older persons, people with disabilities, migrants or refugees, lesbians, gay, bisexual, trans or intersex (LGBTI), children, adolescents, and people behind bars.

The guide points out that, under emergency situations such as the pandemic, and in a regional context marked by inequality and social exclusion, the vulnerability of these groups worsens. That is why the OAS, through this guide, points out that the member states must place emphasis on guaranteeing the right to health of these groups, using objective and reasonable criteria of distinction, based on the equalization of opportunities to bridge the inequality gap, and avoid arbitrary differences in treatment.

"It is clear that the threat and uncertainty generated by the current global pandemic situation cannot be addressed by any country individually," said the Director of the Department of Social Inclusion of the OAS Secretariat for Access to Rights and Equity, Betilde. Muñoz-Pogossian. “If this unprecedented emergency is teaching us anything, it is that the health of the region and the world depend on the quality of access to health care of each person. The emergency caused by COVID-19 also appeals to the sense of solidarity and cooperation that has characterized the region.”

Practical guide to inclusive rights-focused responses to COVID-19 in the Americas

Building on the previous two European Chemsex Forums, the third European Chemsex Forum took place on 14-26 November 2019 in Paris. The Forum aimed to provide participants with the tools to develop and improve multi-sectoral responses appropriate to their settings and provide a platform to engage in international, multi-disciplinary dialogue and discussions around chemsex. Chemsex was defined as the use of specific drugs ("Chems") in sexual contexts by gay, bisexual, men who have sex with men and trans* people.

The Forum programme focused on 3 key work areas:

The pursuit of sexual pleasure and the right to health

Multi-sectoral responses at local level and adaptation of services to respond to needs

Harm reduction strategies and support for chemsexers

The Forum started with an evening plenary session and was followed by two full days of presentations and discussions, with Day One looking at data and evidence across Europe and Day Two focusing on the community response to chemsex. The film ParTy Boi: Black Diamonds in Ice Castles was presented by director Micheal Rice on Friday the 15th of November.

220 people registered, 193 were able to participate in the Forum over three days, bringing together chemsex veterans, chemsex responders, healthcare providers, researchers, therapists, policy makers, service providers and service users from 23 countries.

Some clear guiding principles emerged from the 3rd Forum:

Forum participants asserted that people engaged in chemsex and chemsex responders need to be included in all intersectoral approaches. Time and again presentations called for more integration of people-centred approaches where people engaged in chemsex and chemsex responders themselves are welcomed into collaborations, across sectors and services, with other key decision-makers in their locales.

In some locations, community-based organisations (like LGBTQ+ and HIV organisations) and/or broader social structures (like city government), institutions (like the police) or services (like drugs services) have been seen to be underperforming or stigmatising regarding chemsex response. This report also presents instances of excellent collaborations, which DO provide integrated services. These are models that can be shared in different locales for your local work.

While there was attention at the Forum to issues amongst migrants, racial and ethnic minorities, sex workers and trans people, too often it was to note the work not yet done or lacking the proper capacity to be done well. It is essential for people aiming to provide health and social services, as well as organisations representing these underrepresented populations, to work with those engaged in chemsex and chemsex responders. We need cooperation and inclusive strategies to address issues related to problematic chemsex.

We’re not just addressing chemsex in our response; we’re addressing our environments in which some people with needs and talents are provided with resources and succeed while others are denied resources and fail. At the Forum, Bernard Kelly cited Montserrat Guibernau, a Spanish politician, who identified five dimensions of belonging: psychological, territorial, cultural, political and historical. In the last 20 years, Bernard stated, the gay community had retreated from many of these dimensions. His comments chime with recent research by John Pachankis at Yale which focuses on gay community stress as an additional stigma source (alongside social stigma, institutional stigma and self-stigma) contributing to high rates of suicide, depression, anxiety and substance misuse in LGBTQ+ populations.

This community stress leads directly to the need for increased attention to the dynamics amongst people engaged in chemsex. A number of presentations noted a lack of agreed understanding of harm, play, consent, and responsibility which showed that education was needed around the notions of self-empowerment and boundaries, the right to self-determination and the ability to say “no”’.

European Chemsex Forum report

Similar advocacy notes have been published with a focus on Africa, Europe and Latin America.

Prisons and detention facilities are a high-risk environment for the spread of COVID-19, especially where they are overcrowded, cannot maintain adequate standards of sanitation and hygiene, and are limited in their capacity to ensure access to medical treatment.

In several countries around the world, the heightened risks of COVID-19 infection in prisons, combined with new restrictions on visits and communication with people outside prison, has intensified anxiety and tensions amongst people held within them, in some cases resulting in riots, escapes and violence.

Ensuring the safety and health of both prison staff, and people deprived of liberty, requires urgent action to reduce the risks and consequences of widespread COVID-19 infection. This advocacy note makes recommendations for reducing such risks and consequences, including by early release from, and suspension of arrests and admission into, prions, jails and other detention settings including drug rehabilitation centres in Southeast Asia.

COVID-19: Prisons and detention in Southeast Asia

: Josefina Alfonsín, Gerardo Contreras Ruvalcaba, Kenya Cuevas, Teresa García Castro, María Santos, Ari Vera Morales

Across the world, trans women have been subjected to discrimination, criminalization, and institutional violence. They often face social exclusion, violations of their human rights, and transphobia. In many cases, these factors lead to them working in highly criminalized informal economies, such as the drug trade, sex work, or sex for survival. As a result, police profile them as being dangerous, making them more vulnerable to police abuse and to being incarcerated. While data is sorely lacking, our research indicates that trans women are overrepresented in prison as compared to other groups, and they are much more likely to suffer abuse and violence behind bars than other populations. In addition to the challenges that incarceration imposes on any person deprived of liberty, trans women face particular challenges with regard to housing, their identification, body searches, access to medical services, privacy, and conjugal visits, among other issues. Despite this situation, trans women who have been deprived of liberty have demonstrated their capacity for agency and created organizations to defend their rights. In countries such as Argentina, Mexico, and Uruguay, groups of trans women are building a social movement based on different types of resistance and the development of political agendas.

Meanwhile, the absence of standards and public policies to protect the rights of trans women deprived of liberty is widespread in Latin American countries. The lack of disaggregated data, efforts to monitor this population’s situation of vulnerability, and related studies have deepened ignorance about these realities and hindered public policy design. Given the dearth of information on this issue, this report explores the framework of rights protection for trans women deprived of liberty, the statistical data available, structural inequalities existing prior to detention, living conditions in contexts of confinement, post-release social reintegration, trans women’s experiences of agency, along with good practices in the region. Furthermore, the report provides public policy recommendations to guarantee the full exercise of this population’s dignity and protection of its human rights.

: Almas Cautivas A.C, Casa Hogar Paola Buenrostro, Casa de las Muñecas Tiresias A.C., Dejusticia, Equis Justicia para las Mujeres, International Drug Policy Consortium (IDPC), Procuración Penitenciaria de la Nación de Argentina, Red Corpora en Libertad, Washington Office on Latin America (WOLA)

Trans women deprived of liberty: Invisible stories behind bars

This guide is aimed at those who work with and advocate for women who use drugs in all their diversity. It equips them with practical, evidence-based interventions which will help advance the sexual and reproductive health and rights (SRHR) of women who use drugs. It is based on the experiences of Frontline AIDS partners and others in implementing community-led harm reduction programmes in Kenya, India, Indonesia, Nigeria, Tanzania, Uganda and Ukraine from 2011 to 2020 through the Community Action on Harm Reduction (CAHR), PITCH, and Integrated Harm Reduction programmes, and others. It is informed by the recommendations of the Guttmacher-Lancet Commission on Sexual and Reproductive Health and Rights 2018 report. The guide was developed in consultation with communities of women who inject drugs in select countries, and technical input was provided by the Women and Harm Reduction (WHRIN) Advisory Group.

Part 1 describes the current context for women who use drugs in relation to their SRHR. This part includes considerations of available data; the intersection of drug use with gender inequality, gender norms and stereotypes that create additional barriers to services for women who use drugs; and gender-based violence. It introduces the Guttmacher-Lancet Commission on Sexual and Reproductive Health and Rights’ 2018 definition of SRHR, and the essential service package, alongside the World Health Organization’s package for comprehensive harm reduction services.

Part 2 elaborates seven essential SRHR interventions for women who use drugs, and an additional sub-section on the sexual health and well-being of women who use drugs. Short case studies from Frontline AIDS and partners’ harm reduction programmes, as well as other NGOs, provide examples of successful interventions. In conclusion, we draw on priority recommendations from the Guttmacher-Lancet Commission for achieving SRHR that are most relevant to the context of women who use drugs.

Advancing the sexual and reproductive health and rights of women who use drugs

The criminalization of people who use psychoactive substances in the Central and Eastern Europe, and Central Asia (CEECA) region, instead of maintenance of public health and safety, increases the financial and social burden on the states. For people who inject drugs, approximately 58% will experience incarceration in their life.

Incarceration costs 2 to 6 times more than treatment from health and social service groups. However, in almost all the countries in the CEECA region, due to de facto criminalization of people who use psychoactive substances, harm reduction and other health services are severely underfunded and depend on international donors. Guidelines from the World Health Organization recommend that at least 40% of people who use opioids receive opioid substitution therapy (OST); however, most countries in the CEECA region barely reach 20%.

Governments should take evidence-based health and human rights approaches and reallocate money from policing, prosecuting, and incarceration of people who use psychoactive substances to community harm reduction and health services.

The guide contains 11 statements, followed by supporting arguments, which should be used in advocacy work. Arguments are prepared based on existing practices and evidence-based information. Arguments are created to advise on advocacy of reallocating funds from law enforcement budgets to health and harm reduction budgets for people who use psychoactive substances.

Criminalization costs in the CEECA region - A pocket guide

In 2019 EHRA together with Support, Research and Development Centre (SRDP), the Ukrainian Network of People who use Drugs (VOLNA), Drug-users Ukraine, the Drop-in Centre and the ENEY developed the methodology to access the client satisfaction with opioid maintenance therapy and conducted the pilot study in Kyiv and Kyiv Oblast region. Our approach to this study was based on the principles of equal partnership with the community of people who inject drugs and/or receive opioid maintenance therapy (OMT).

Almost from their very first days, OMT programmes in Ukraine have come under close scrutiny from the international research community. We believe that attention has been drawn to OMT programmes in Ukraine because of the low annual numbers of new patients throughout the period of the OMT implementation projects. According to UNAIDS, the estimated number of people who inject drugs in Ukraine is 346,000 individuals, of whom only 11,853 (or less than 3.5%) currently receive OMT services. The lack of attention paid to treatment satisfaction in Ukraine can probably be attributed to a shift in emphasis towards the needs of increasing service coverage, even while the quality of service is seldom included in ongoing discussions. Since OMT programmes have been operating in Ukraine for more than 10 years, the study of patient satisfaction with treatment offers opportunities for a better understanding of OMT service development prospects in the long run and of treatment trajectories and changing needs at the patient level.

As the design of this study was based on qualitative and quantitative methodological components, it was implemented in the framework of the mixed–method approach. The protocol and tools of this study were reviewed by the Ethics Review Board of the Ukrainian Institute on Public Health Policy.

The quality component of this study was implemented through semi-structured interviews with patients of OMT programmes.Within the scope of the study, the main purpose of semi-structured interviews was to highlight various aspects and criteria of satisfaction with OMT services among patients in order to develop a data-based questionnaire tool.

376 OMT patients took part in the pilot assessment, 178 structured interviews were conducted with patients who get OMT for free at state-funded OMT sites, 198 interviews were conducted with patients who buy OMT drugs in pharmacies after getting prescription at OMT sites based in private clinics. An overall satisfaction with OMT treatment is assessed as high and very high in 72% OMT patients, but the particular aspects of OMT treatment are not that highly assessed. The quality of medical care at OMT site is assessed as satisfied by 49%, 42% are satisfied with the physical environment at OMT sites and only 34 % of survey participants assess the psycho-social support as satisfied. At the same time, 89% of respondents mentioned that OMT is a vital need for them.

Based on the results of this study, we can draw the following conclusions and make some recommendations for further advocacy:

Studies like this conducted using a routine monitoring format as an integrated component of the monitoring and evaluation framework at OMT sites could help us understand the dynamics of satisfaction with treatment and treatment environment, interactions with OMT service providers and subjective treatment experiences. Which in turn could influence the long-term patient retention in OMT programmes.

For an improved understanding of the goals and outcomes of the treatment of chronic diseases like drug addiction, we recommend considering the assessment of patient quality of life as an indicator of treatment efficiency.

Survey of client satisfaction with OMT services among participants in Kyiv and the Kyiv Oblast region: A pilot study report

Venezuela’s state institutions have deteriorated and the country lacks an impartial, transparent, or even functional justice system. In this environment, armed groups and organized criminal structures, including drug trafficking groups, have thrived. But U.S government data suggests that, despite these challenges, Venezuela is not a primary transit country for U.S.-bound cocaine. U.S. policy toward Venezuela should be predicated on a realistic understanding of the transnational drug trade.

Recent data from the U.S. interagency Consolidated Counterdrug Database (CCDB) indicates that 210 metric tons of cocaine passed through Venezuela in 2018. By comparison, the State Department reports that over six times as much cocaine (1,400 metric tons) passed through Guatemala the same year.

According to U.S. monitoring data, the amount of cocaine trafficked from Colombia through Venezuela is significant, but it is a fraction of the cocaine that is sent through other transit countries. Around 90 percent of all U.S.-bound cocaine is trafficked through Western Caribbean and Eastern Pacific routes, not through Venezuela’s Eastern Caribbean seas.

There was an increase in cocaine flows through Venezuela in the period from 2012 to 2017, but that increase corresponds with a surge in cocaine production in Colombia during that same time. CCDB data suggests the amount of cocaine trafficked through Colombia rose from 918 metric tons in 2012 to 2,478 metric tons in 2017 (a 269 percent increase), and from 159 to 249 metric tons in Venezuela in that same period (a 156 percent increase). When cocaine trafficking in Colombia dropped slightly post-2017, cocaine flows in Venezuela fell as well.

U.S. CCDB data shows that cocaine flows through Venezuela have fallen since peaking in 2017. According to CCDB data, the amount of cocaine flowing through Venezuela fell 13 percent from 2017 to 2018, and appeared to continue to fall slightly through mid-2019.

A peaceful, negotiated, and orderly transition offers the best chance of allowing the reforms needed to address organized crime, drug trafficking, and corruption in Venezuela. The 2009 military coup d'etat and resulting turmoil in Honduras provides a cautionary tale for U.S. policymakers who see intervention or collapse as the best way route for a return to democracy in Venezuela.

Beyond the narcostate narrative: What U.S. drug trade monitoring data says about Venezuela

As the COVID-19 pandemic affects more people in an ever increasing list of countries, PRI has published a briefing note, 

Coronavirus: Healthcare and human rights of people in prison

. With the fast-evolving situation, there is legitimate concern at a further spread of the virus to places of detention. The difficulties in containing a large outbreak in detention facilities are clear. People in prison and the personnel who work with them are in close proximity and in many cases in overcrowded, cramped conditions with little fresh air. People in detention also have common demographic characteristics with generally poorer health than the rest of the population, often with underlying health conditions. Hygiene standards are often below that found in the community and sometimes security or infrastructural factors reduce opportunities to wash hands or access to hand sanitizer – the key prevention measures recommended by the World Health Organization.

While legitimate measures in times of such an emergency are needed to prevent further outbreaks of COVID-19 in prisons, authorities need to ensure human rights are respected. In such anxious times it is even more pertinent that people are not cut off from the outside world, they do not end up in solitary confinement, and most of all they have access to information and adequate healthcare provision – equal of that available in the community.

Our briefing outlines the key measures that criminal justice systems, including prisons and courts, have taken to prevent the spread of COVID-19 – and the impact of these in light of the UN Nelson Mandela Rules and other key standards.

Action needs to be taken now and immediately, given the risk people in prison are exposed to, including prison staff. Such action should be guided by international standards and the values of: Do no harm, equality, transparency, humanity.