HIV, injecting drug use and harm reduction: a public health response
By, Andrew Ball, Department of HIV/AIDS, World Health Organization, 2007
ABSTRACT
Injecting drug use is driving HIV epidemics in many countries around the world. There is evidence that such epidemics can be averted, halted and reversed if comprehensive HIV programmes targeting drug users are put into place. The term ‘harm reduction’ is used widely to describe the goals, policies and interventions of such programmes. However, despite its rapidly expanding use, the term has no universally accepted definition. This paper aims to describe the evolution and branding of the term ‘harm reduction’ and the adoption of the concept across a wide range of countries. It highlights a range of issues that remain controversial in the harm reduction discourse related to HIV and injecting drug use, including: the definition of ‘harm reduction’ and related terms; the scope of harm reduction; the promotion of a public health versus drug control dichotomy; the feasibility and appropriateness of harm reduction in low- and middle-income countries; and the strength of evidence on harm reduction interventions. The paper argues that harm reduction should be a core element of a public health response to HIV/AIDS where injecting drug use exists. The effectiveness of policies and programmes targeting drug users should be measured against public health outcomes. This requires the alignment of drug control measures with public health goals. A ‘model package’ for harm reduction is proposed, which provides guidance to countries on the selection of evidence-based policies and interventions, including: interventions for reducing HIV transmission; treatment of HIV/AIDS and associated comorbidities; appropriate models of service delivery; creation of supportive policy, legal and social environments; and strengthening of strategic information systems to better guide responses.
INTRODUCTION
Few terms in the world of drug policy evoke such extremes of emotion as ‘harm reduction’. Drug policy conservatives shudder, believing that traditional values and drug control will be undermined. Drug legalizers see opportunities for radical law reform. Somewhere in between, service providers and community advocates hold to a hope for more pragmatic, evidence-based interventions. These emotions are stirred by the lack of a clear definition, complicated further by a dynamic discourse that has often generated more heat than light. Despite diverse interpretations of the term, its use is expanding globally and is now imbedded in international policies and commitments. Whereas the term is used widely across all aspects of substance use, this paper focuses on harm reduction in the context of HIV and injecting drug use.
Injecting drug use is driving HIV epidemics in many countries and accounts for almost a third of new infections outside sub-Saharan Africa [1]. Across the estimated 13 million injecting drug users globally there is great variation in drug use patterns, behaviours and contexts. Over the past 25 years explosive HIV epidemics among injecting drug users have been witnessed in almost all regions, first in New York City in the late 1970s and more recently in such diverse countries as China, Estonia, Indonesia and Kazakhstan. Just as HIV epidemics and their determinants have been diverse, so have been the responses.
THE EVOLUTION AND BRANDING OF HARM REDUCTION
The term ‘harm reduction’ has been used variously to describe a principle, concept, ideology, policy, strategy, setof interventions, target and movement. One can imagine that harm reduction principles have been practised by communities since psychoactive substances were first used. For centuries, traditional use of opium in Asia and hallucinogens and coca products in Latin America has been guided by rituals and taboos aimed at protecting individual and community health [2]. Charitable organizations provided food and shelter for those intoxicated living on the streets of Europe in the 18th century. Opium was provided in the 18th and 19th centuries to registered ‘addicts’ in a number of European colonies in Asia. Doctors prescribed heroin and morphine to patients dependent on opioids as permitted through the flexibilities of the ‘British System’ of the early 20th century [3]. In the 1960s, ‘underground’ magazines for drug-using communities in Europe and north America provided advice on less hazardous ways of using drugs [4]. In the early 1960s, the prevailing abstinence-based approach of opioid dependence treatment in the United States was challenged directly by the introduction of methadone maintenance programmes [5].
The early part of the 20th century was a defining period for international drug policy, with a divergence in country approaches—some emphasizing a public health approach, but most focusing upon drug control measures. Concern about increasing levels of drug-related health problems was a major reason for the introduction of controls on the availability and use of psychoactive substances, although elements of social control and a desire to protect moral values also contributed to new policies. Despite the long-standing relationship between public health and drug policy, it was not until 1973 that a call for the primacy of public health over drug control was articulated clearly internationally. In that year ‘harm reduction’, as a concept, was recommended as a viable alternative to a drug control approach by the 20th World Health Organization (WHO) Expert Committee on Drug Dependence [6]:
The broad purpose of preventive measure should be to prevent or reduce the severity of problems associated with the non-medical use of dependence-producing drugs. This goal is at once broader, more specific, and with respect to certain drugs in many countries, more realistic than the prevention of-non-medical use per se.
Public health refers to collective efforts aimed at improving the health of populations, including the prevention of ill-health, the treatment, amelioration and control of disease and the promotion of wellbeing. Countries that had adopted a public health approach to drug-related problems, such as the Netherlands and the United Kingdom, were best equipped to respond rapidly when HIV emerged among drug injectors. The mid-1980s saw harm reduction adopted explicitly as the principle for national drug policies in a number of countries. The United Kingdom Advisory Committee on the Misuse of Drugs 1984 report called for a two-pronged approach of reducing risk among drug users and reducing harm associated with drug use [7]. In 1985, Australia was the first country in the world to officially adopt a national drug strategy based on ‘harm minimization’ [8], with harm reduction also included as a key pillar of the Australian HIV/AIDS Strategy [9]. Other western European countries, such as France, Italy and Spain, adopted harm reduction later, in the early and mid 1990s, in response to severe HIV epidemics among their drug injecting populations [10].
The annual International Conferences on the Reduction of Drug Related Harm, held first in Liverpool, UK in 1990, have helped to consolidate an international harm reduction movement and brand harm reduction as a public good. Since then discourse has moved from one heavily influenced by opinion to one that is firmly entrenched in health and social science and policy [11]. The establishment of harm reduction networks has acted as a catalyst for the translation of science and policy into country action.
In the mid-1990s, explicit harm reduction policies started to appear in low- and middle-income countries. This largely reflected a greater engagement of the health sector, particularly ministries of health, in drug policy and in the provision of services for drug users. In many countries, harm reduction has been elaborated in national HIV policies or health sector plans, rather than those for drug control. The Brazilian National AIDS Program adopted harm reduction as its policy in 1993 [12]. In 1996, Manipur, the first state in India to promulgate its own State AIDS Policy, based its policy on harm reduction principles [13]. The Islamic Republic of Iran established a National Harm Reduction Committee in 2002, involving government sectors responsible for health, drug control, welfare, prisons and law enforcement [14]. Harm reduction has been Indonesia's official policy since 2004 [15]. The Vietnamese National HIV Strategy, endorsed by the Prime Minister in March 2004, has harm reduction as a key element. The dramatic scale-up of harm-reduction activities in the Peoples' Republic of China, the development of comprehensive harm reduction programmes in the Kyrgyz Republic and the establishment of pilot harm-reduction programmes in Malaysia and Myanmar have followed national commitments to adopt a public health approach to injecting drug use.
The United Nations System has also moved. In 2001 the UN General Assembly set a target for countries to make available ‘harm reduction efforts related to drug use’ by 2005 [16]. In 2003, all 192 WHO Member States endorsed the Global Health Sector Strategy for HIV/AIDS, which includes harm reduction as a core component of a health sector response to HIV [17]. In 2005, UNAIDS included harm reduction as one of 11 essential programmatic actions for HIV prevention [18].
CONTINUING CONTROVERSIES
We are 25 years into the HIV epidemic, and there is still no universally accepted definition for, and use of, the term ‘harm reduction’. This is not through lack of interest or debate. Lenton & Single [19] dissect some of the key definitional issues, proposing a ‘socio-empirical’ definition informed by (and attempting to find some compromise between) arguments promoting narrow, broad and hard empirical definitions. None of the arguments to date has been convincing enough to prevail.
The proliferation of other terms, such as ‘harm minimization’, ‘risk reduction’ and ‘vulnerability reduction’, confuse matters further. These terms are often used to convey harm reduction principles in situations where the term ‘harm reduction’ is taboo. In other cases they have a specific meaning, although universally recognized definitions do not exist. Harm is a higher-level impact indicator, modulated by vulnerability, exposure and risk. Whereas vulnerability and risk reduction might be major outcome measures, the reduction of harm, as an impact goal, reflects the ultimate purpose of interventions, and therefore would be the preferred indicator against which programmes are measured.
Defining ‘harm’ is one of the more contentious issues. Whereas this paper focuses on harm reduction within the context of drug injecting and HIV, the concept has been and is being used far more widely, addressing alcohol- and tobacco-related harm and, increasingly, broader public health and social issues, such as traffic safety and sex work [20]. Harm occurs at different levels (individual, family, community, society) and in different forms (health, economic, social) and its measurement is often value-laden and determined by cultural norms and beliefs. Whereas significant work has been undertaken in quantifying health-related harm through such instruments as disability-adjusted life years (DALYs) and quality of life measures, there is no methodology for objectively measuring net harm across different domains, such as health, social functioning and economic development. How does one assess the net harm to a society related to injecting drug use, taking into account such harms as HIV morbidity and mortality, public nuisance of discarded needles, economic impact, criminal behaviour and moral outrage at permissive drug policies? Nevertheless, countries have to make difficult decisions, and the protection of public health must weigh heavily. In January 2005, faced with the choice between two ‘evils’, continued drug use in the community or the spread of HIV, and having considered two key tenets of Islam (those of La darara wa la dirar—doing no harm to oneself or others—and Al-darar al-achadd yuzal bil-darar al-akhaff—the worst harm is eliminated by a lesser harm) the Head of the Iranian Judiciary ruled in favour of public health rather than drug control, and issued an executive order supporting harm reduction measures for drug users [14].
Most debate has focused upon English-language terminology. It is unclear how easily ‘harm reduction’ and related terms translate into other languages and to what extent different translations have different cultural meanings, widespread use and recognition. For example, the Dutch translation for ‘harm reduction’ is not used; rather, the English term is preferred. In French, the usual translation is ‘reduction des risques’ rather than ‘reduction des dommages’. On the surface, then, this may appear to be an academic exercise in English semantics. Nevertheless, the distinction may have significant implications for the approaches taken to programming.
The ‘broad’ versus ‘narrow’ definition of ‘harm reduction’ continues to be hotly debated. Should the term be used inclusively to describe any intervention or approach that reduces a defined harm, including those approaches that reduce drug use (including prevention of initiation and abstinence), risk and vulnerability, or should it be used exclusively to describe only those interventions that aim to reduce harm without intending to reduce drug use? Opinions vary greatly. Australia's Drug Strategy opts for the broad definition, using ‘harm minimization’ as the overarching principle, encompassing supply, demand and targeted harm reduction strategies. On the other hand, the Swiss Federal Office of Public Health has used a ‘narrow’ definition since the early 1990s, separating out ‘harm reduction’ as one of four distinct elements of its drug policy, the other three being prevention, treatment and law enforcement. Despite difference in interpretation of the term ‘harm reduction’, both countries have successful national programmes using very similar strategies based on similar broad principles.
Some health and social scientists have a passion for creating and promoting false dichotomies, whether it be prevention versus treatment, vertical versus horizontal programmes, public health versus human rights or drug control versus harm reduction [21,22]. In the real world, although true dichotomies do exist and pose major challenges for public health, a middle ground is often achievable. Harm reduction advocates and practitioners need to be pragmatic and flexible, engaging in both prevention and treatment activities, exploiting what can be offered by both vertical and horizontal structures, maximizing the human rights principles of public health and promoting drug control measures that contribute to harm reduction outcomes. Much has been written about successful experiences in using law enforcement to advance harm reduction interventions, applying harm reduction principles in drug education programmes for young people, integrating harm reduction into HIV/AIDS treatment programmes and taking steps to protect the human rights of drug users within the context of controlling HIV epidemics.
The appropriateness and feasibility of harm reduction programmes in low- and middle-income countries is debated widely. These countries have many competing public health priorities and usually very limited resources. The diversity and dynamics of drug-injecting epidemics and the affected communities pose huge public health challenges for the design of relevant, acceptable and effective harm reduction programmes. Expanding methadone and buprenorphine maintenance treatment will have limited impact in communities where heroin use is being replaced by amphetamines. The establishment of dedicated needle and syringe exchange programmes may not be a priority in settings where affordable sterile injecting equipment is available widely through pharmacies. Without the existence of relevant safeguards and the availability of basic HIV prevention and care services, the promotion of HIV testing among drug users may do more harm than good, resulting in further stigmatization, discrimination and alienation. A thorough understanding of local context is required in selecting the most appropriate mix of interventions and the most efficient models for their delivery. This often requires major adaptation of interventions developed in high-income countries and investment in operational research to support this process.
Finally, certain opinion leaders, politicians and scientists still question the evidence-base for harm reduction relating to HIV prevention among injecting drug users. Across the range of HIV prevention interventions promoted for injecting drug users the volume and quality of evidence varies, particularly with regard to evidence from low- and middle-income countries. On one hand, few public health interventions have been subjected to the same intense scrutiny as methadone maintenance treatment. The body of evidence is significant for other key interventions such as needle and syringe programmes and risk reduction counselling. However, research on newer and more controversial interventions, such as safe injection rooms and the medical prescription of heroin, is limited. Particular challenges exist in identifying effective interventions for those individuals injecting drugs other than opioids, particularly amphetamine-type stimulants and cocaine. Recent reviews of the evidence on the role of harm reduction in HIV prevention demonstrate clearly the public health benefit of a number of key interventions and their relative safety [11,23]. The Institute of Medicine review [12] concluded that there was strong evidence of the effectiveness of opioid agonist maintenance treatment and that such programmes should be made widely available. It also found that there was consistent evidence that multi-component HIV prevention programmes including needle and syringe access interventions reduce HIV risk behaviours, and should be implemented where feasible. The implementation of outreach services for education and risk reduction was also recommended. At the same time, the report identified a number of significant gaps in knowledge and the need for additional research, including research on the potential unintended consequences of programmes, integration of interventions to reduce the sexual transmission of HIV and identification of effective disinfection techniques. Thus, the evidence supports the inclusion of opioid substitution treatment, sterile needle and syringe access and outreach as key components of an effective HIV prevention programme. It is now time to invest in their equitable expansion to the levels required to control HIV epidemics and achieve good service quality.
THE WAY FORWARD
Some welcome the ambiguity of harm reduction terms [24], arguing that it allows for greater flexibility in implementing policies and programmes to respond to critical public health problems. However, for many countries there is now an urgent demand and need for clear guidance on how to address drug-related problems effectively. There is little ambiguity over what works, at least with regard to key interventions for HIV/AIDS prevention, treatment and care for drug users. Defining a model package of harm reduction interventions, minimum standards for services and optimal levels of service coverage will do much to assist countries—comprising, in effect, an operational definition and strategy for ‘harm reduction’.
Within the context of HIV and drug use it is easy to define ‘harm’ and ‘harm reduction’ goals—the reduction of HIV transmission, the reduction of HIV-related morbidity and mortality and the reduction of HIV-related impact on communities (such as AIDS orphans). Given that drug control goals largely had their origins in the need to protect public health and the devastation of HIV epidemics among injecting drug users, the alignment of drug control measures with public health goals must be a priority.
Defining a ‘model package’ for harm reduction helps to address the dilemma of narrow versus broad definitions. Those communities and countries that have implemented comprehensive, multi-sectoral and integrated harm reduction programmes have been most successful in preventing or controlling HIV epidemics among drug users. Single, stand-alone interventions, even when they have good coverage, are likely to have only limited impact [25]. A ‘model package’ should include multiple evidence-based (or at least evidence-informed) interventions that are complementary and synergistic, promote multiple entry points for individuals to access services and ensure flexibility so that approaches can be adapted for different country contexts and changing HIV epidemic and drug use dynamics. The use of harm reduction hierarchies—comprising interventions ranging from prevention of drug use and preventing transitions from non-injecting to injecting forms of drug use to HIV/AIDS treatment and care for drug users—makes good sense [11]. In developing a practical tool for countries, the broad definition for ‘harm reduction’ should be preferred.
In July 2005 leaders of the G8 group of industrialized countries announced their intention to ‘work . . . with WHO, UNAIDS and other international bodies to develop and implement a package for HIV prevention, treatment and care, with the aim of as close as possible to universal access to treatment for all those who need it by 2010’ [26]. This goal was endorsed subsequently by the UN General Assembly in September 2005 [27], and expanded to include universal access to comprehensive prevention programmes, treatment, care and support by the UN General Assembly High-level Meeting on AIDS in June 2006 [28]. Given that ‘universal access’ means access for all, including drug users, there will need to be a massive scale-up of harm reduction services. The ‘model package’ concept can guide this process.
WHO is developing the harm reduction component of a broader public health ‘model essential package’ for HIV/AIDS prevention, treatment and care [29]. The package will promote principles of equity and human rights and interventions that can be scaled-up successfully in resource-limited settings. It will provide operational guidance to countries and other stakeholders on how to select and prioritize interventions and service delivery models, based on local context and available resources, and complementary to broader public health and drug control measures. In itself it will act as an important advocacy tool, describing to policy makers and donors key elements of a comprehensive and quality harm reduction programme and areas for public health investment. The public health model package for harm reduction includes five elements:
• Interventions for reducing HIV transmission, including HIV risk reduction information, education and counselling; HIV testing and counselling; sterile needle and syringe access; safe disposal of used syringes and needles; drug dependence treatment, particularly opioid substitution therapy; condom programming; prevention of mother-to-child transmission of HIV; and STI treatment.
• Management of HIV/AIDS, coinfections and comorbidities, including antiretroviral therapy; HIV treatment preparedness and adherence support; prevention and management of opportunistic infections, particularly tuberculosis; pain management and palliative care; prevention and treatment of hepatitis B and C; management of alcohol and other drug dependence and mental health disorders, such as depression.
• Appropriate models for service delivery and health systems strengthening, including peer outreach; integration of HIV, drug dependence treatment and outreach services; integration of HIV and drug use issues within other appropriate health services; interservice referral networks; defining minimum services to be delivered through different levels of health facilities; strengthening of procurement and supply management systems to ensure affordable and uninterrupted supplies of quality medicines (including methadone, buprenorphine and HIV-related medicines), diagnostics, needles and syringes and condoms; and development of human resources for harm reduction.
• Supportive policy, legal and social environment, including policies that ensure equitable access to HIV services for drug users; laws that do not compromise access to HIV services for drug users through criminalization and marginalization; and campaigns to reduce stigma and discrimination, related particularly to health services and workers.
• Strategic information, including HIV and behavioural surveillance among drug users; identifying programme and national indicators and selecting targets; monitoring quality, availability, coverage and impact of services; monitoring treatment adherence; and including drug users within population-based surveillance of HIV drug resistance and pharmacovigilance.
CONCLUSION
Harm reduction, with deep roots in public health, will continue to be a critical element of a public health response to HIV/AIDS. While we can expect continuing debate about the meanings of harm reduction, further misunderstandings, questioning of evidence, the offering of new definitions and stirring of emotions, we must ensure that any continuing confusion will not delay effective action being taken in countries. The best harm reduction advocates and practitioners are pragmatists rather than idealogues, who are not distracted by definitions and semantics but focus on ambitious but achievable goals, and those who prefer impact to process. Such front-line workers deserve moral support, practical tools and adequate resources to get their work done.
In defining a ‘model package’ for harm reduction for countries it is time to move on from the ambiguity of definitions, the misunderstandings of approaches and the questioning of evidence where it exists. If we are to witness real and sustainable impact in communities we must adopt a comprehensive, public health approach that is consistent with a broad definition of ‘harm reduction’. We need only to look at the success stories where comprehensive harm reduction policies and programmes are being implemented—averted HIV epidemics among drug users in Australia and the United Kingdom [10], epidemics reversed in France, Italy and Spain [10], major and rapid expansion of programmes in Brazil, PR China, IR Iran and Slovakia [10,14,23] and the adoption of supportive public health policies in Indonesia, Malaysia and Vietnam [15,23,30]—to recognize the relevance and value of such an approach.
DECLARATION OF INTEREST
The author is a staff member of the World Health Organization. The author is responsible for the views expressed in this publication and they do not necessarily represent the decisions, policy or views of the World Health Organization.
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Source: http://www.blackwell-synergy.com/doi/full/10.1111/j.1360-0443.2007.01761.x?cookieSet=1
ABSTRACT
Injecting drug use is driving HIV epidemics in many countries around the world. There is evidence that such epidemics can be averted, halted and reversed if comprehensive HIV programmes targeting drug users are put into place. The term ‘harm reduction’ is used widely to describe the goals, policies and interventions of such programmes. However, despite its rapidly expanding use, the term has no universally accepted definition. This paper aims to describe the evolution and branding of the term ‘harm reduction’ and the adoption of the concept across a wide range of countries. It highlights a range of issues that remain controversial in the harm reduction discourse related to HIV and injecting drug use, including: the definition of ‘harm reduction’ and related terms; the scope of harm reduction; the promotion of a public health versus drug control dichotomy; the feasibility and appropriateness of harm reduction in low- and middle-income countries; and the strength of evidence on harm reduction interventions. The paper argues that harm reduction should be a core element of a public health response to HIV/AIDS where injecting drug use exists. The effectiveness of policies and programmes targeting drug users should be measured against public health outcomes. This requires the alignment of drug control measures with public health goals. A ‘model package’ for harm reduction is proposed, which provides guidance to countries on the selection of evidence-based policies and interventions, including: interventions for reducing HIV transmission; treatment of HIV/AIDS and associated comorbidities; appropriate models of service delivery; creation of supportive policy, legal and social environments; and strengthening of strategic information systems to better guide responses.
INTRODUCTION
Few terms in the world of drug policy evoke such extremes of emotion as ‘harm reduction’. Drug policy conservatives shudder, believing that traditional values and drug control will be undermined. Drug legalizers see opportunities for radical law reform. Somewhere in between, service providers and community advocates hold to a hope for more pragmatic, evidence-based interventions. These emotions are stirred by the lack of a clear definition, complicated further by a dynamic discourse that has often generated more heat than light. Despite diverse interpretations of the term, its use is expanding globally and is now imbedded in international policies and commitments. Whereas the term is used widely across all aspects of substance use, this paper focuses on harm reduction in the context of HIV and injecting drug use.
Injecting drug use is driving HIV epidemics in many countries and accounts for almost a third of new infections outside sub-Saharan Africa [1]. Across the estimated 13 million injecting drug users globally there is great variation in drug use patterns, behaviours and contexts. Over the past 25 years explosive HIV epidemics among injecting drug users have been witnessed in almost all regions, first in New York City in the late 1970s and more recently in such diverse countries as China, Estonia, Indonesia and Kazakhstan. Just as HIV epidemics and their determinants have been diverse, so have been the responses.
THE EVOLUTION AND BRANDING OF HARM REDUCTION
The term ‘harm reduction’ has been used variously to describe a principle, concept, ideology, policy, strategy, setof interventions, target and movement. One can imagine that harm reduction principles have been practised by communities since psychoactive substances were first used. For centuries, traditional use of opium in Asia and hallucinogens and coca products in Latin America has been guided by rituals and taboos aimed at protecting individual and community health [2]. Charitable organizations provided food and shelter for those intoxicated living on the streets of Europe in the 18th century. Opium was provided in the 18th and 19th centuries to registered ‘addicts’ in a number of European colonies in Asia. Doctors prescribed heroin and morphine to patients dependent on opioids as permitted through the flexibilities of the ‘British System’ of the early 20th century [3]. In the 1960s, ‘underground’ magazines for drug-using communities in Europe and north America provided advice on less hazardous ways of using drugs [4]. In the early 1960s, the prevailing abstinence-based approach of opioid dependence treatment in the United States was challenged directly by the introduction of methadone maintenance programmes [5].
The early part of the 20th century was a defining period for international drug policy, with a divergence in country approaches—some emphasizing a public health approach, but most focusing upon drug control measures. Concern about increasing levels of drug-related health problems was a major reason for the introduction of controls on the availability and use of psychoactive substances, although elements of social control and a desire to protect moral values also contributed to new policies. Despite the long-standing relationship between public health and drug policy, it was not until 1973 that a call for the primacy of public health over drug control was articulated clearly internationally. In that year ‘harm reduction’, as a concept, was recommended as a viable alternative to a drug control approach by the 20th World Health Organization (WHO) Expert Committee on Drug Dependence [6]:
The broad purpose of preventive measure should be to prevent or reduce the severity of problems associated with the non-medical use of dependence-producing drugs. This goal is at once broader, more specific, and with respect to certain drugs in many countries, more realistic than the prevention of-non-medical use per se.
Public health refers to collective efforts aimed at improving the health of populations, including the prevention of ill-health, the treatment, amelioration and control of disease and the promotion of wellbeing. Countries that had adopted a public health approach to drug-related problems, such as the Netherlands and the United Kingdom, were best equipped to respond rapidly when HIV emerged among drug injectors. The mid-1980s saw harm reduction adopted explicitly as the principle for national drug policies in a number of countries. The United Kingdom Advisory Committee on the Misuse of Drugs 1984 report called for a two-pronged approach of reducing risk among drug users and reducing harm associated with drug use [7]. In 1985, Australia was the first country in the world to officially adopt a national drug strategy based on ‘harm minimization’ [8], with harm reduction also included as a key pillar of the Australian HIV/AIDS Strategy [9]. Other western European countries, such as France, Italy and Spain, adopted harm reduction later, in the early and mid 1990s, in response to severe HIV epidemics among their drug injecting populations [10].
The annual International Conferences on the Reduction of Drug Related Harm, held first in Liverpool, UK in 1990, have helped to consolidate an international harm reduction movement and brand harm reduction as a public good. Since then discourse has moved from one heavily influenced by opinion to one that is firmly entrenched in health and social science and policy [11]. The establishment of harm reduction networks has acted as a catalyst for the translation of science and policy into country action.
In the mid-1990s, explicit harm reduction policies started to appear in low- and middle-income countries. This largely reflected a greater engagement of the health sector, particularly ministries of health, in drug policy and in the provision of services for drug users. In many countries, harm reduction has been elaborated in national HIV policies or health sector plans, rather than those for drug control. The Brazilian National AIDS Program adopted harm reduction as its policy in 1993 [12]. In 1996, Manipur, the first state in India to promulgate its own State AIDS Policy, based its policy on harm reduction principles [13]. The Islamic Republic of Iran established a National Harm Reduction Committee in 2002, involving government sectors responsible for health, drug control, welfare, prisons and law enforcement [14]. Harm reduction has been Indonesia's official policy since 2004 [15]. The Vietnamese National HIV Strategy, endorsed by the Prime Minister in March 2004, has harm reduction as a key element. The dramatic scale-up of harm-reduction activities in the Peoples' Republic of China, the development of comprehensive harm reduction programmes in the Kyrgyz Republic and the establishment of pilot harm-reduction programmes in Malaysia and Myanmar have followed national commitments to adopt a public health approach to injecting drug use.
The United Nations System has also moved. In 2001 the UN General Assembly set a target for countries to make available ‘harm reduction efforts related to drug use’ by 2005 [16]. In 2003, all 192 WHO Member States endorsed the Global Health Sector Strategy for HIV/AIDS, which includes harm reduction as a core component of a health sector response to HIV [17]. In 2005, UNAIDS included harm reduction as one of 11 essential programmatic actions for HIV prevention [18].
CONTINUING CONTROVERSIES
We are 25 years into the HIV epidemic, and there is still no universally accepted definition for, and use of, the term ‘harm reduction’. This is not through lack of interest or debate. Lenton & Single [19] dissect some of the key definitional issues, proposing a ‘socio-empirical’ definition informed by (and attempting to find some compromise between) arguments promoting narrow, broad and hard empirical definitions. None of the arguments to date has been convincing enough to prevail.
The proliferation of other terms, such as ‘harm minimization’, ‘risk reduction’ and ‘vulnerability reduction’, confuse matters further. These terms are often used to convey harm reduction principles in situations where the term ‘harm reduction’ is taboo. In other cases they have a specific meaning, although universally recognized definitions do not exist. Harm is a higher-level impact indicator, modulated by vulnerability, exposure and risk. Whereas vulnerability and risk reduction might be major outcome measures, the reduction of harm, as an impact goal, reflects the ultimate purpose of interventions, and therefore would be the preferred indicator against which programmes are measured.
Defining ‘harm’ is one of the more contentious issues. Whereas this paper focuses on harm reduction within the context of drug injecting and HIV, the concept has been and is being used far more widely, addressing alcohol- and tobacco-related harm and, increasingly, broader public health and social issues, such as traffic safety and sex work [20]. Harm occurs at different levels (individual, family, community, society) and in different forms (health, economic, social) and its measurement is often value-laden and determined by cultural norms and beliefs. Whereas significant work has been undertaken in quantifying health-related harm through such instruments as disability-adjusted life years (DALYs) and quality of life measures, there is no methodology for objectively measuring net harm across different domains, such as health, social functioning and economic development. How does one assess the net harm to a society related to injecting drug use, taking into account such harms as HIV morbidity and mortality, public nuisance of discarded needles, economic impact, criminal behaviour and moral outrage at permissive drug policies? Nevertheless, countries have to make difficult decisions, and the protection of public health must weigh heavily. In January 2005, faced with the choice between two ‘evils’, continued drug use in the community or the spread of HIV, and having considered two key tenets of Islam (those of La darara wa la dirar—doing no harm to oneself or others—and Al-darar al-achadd yuzal bil-darar al-akhaff—the worst harm is eliminated by a lesser harm) the Head of the Iranian Judiciary ruled in favour of public health rather than drug control, and issued an executive order supporting harm reduction measures for drug users [14].
Most debate has focused upon English-language terminology. It is unclear how easily ‘harm reduction’ and related terms translate into other languages and to what extent different translations have different cultural meanings, widespread use and recognition. For example, the Dutch translation for ‘harm reduction’ is not used; rather, the English term is preferred. In French, the usual translation is ‘reduction des risques’ rather than ‘reduction des dommages’. On the surface, then, this may appear to be an academic exercise in English semantics. Nevertheless, the distinction may have significant implications for the approaches taken to programming.
The ‘broad’ versus ‘narrow’ definition of ‘harm reduction’ continues to be hotly debated. Should the term be used inclusively to describe any intervention or approach that reduces a defined harm, including those approaches that reduce drug use (including prevention of initiation and abstinence), risk and vulnerability, or should it be used exclusively to describe only those interventions that aim to reduce harm without intending to reduce drug use? Opinions vary greatly. Australia's Drug Strategy opts for the broad definition, using ‘harm minimization’ as the overarching principle, encompassing supply, demand and targeted harm reduction strategies. On the other hand, the Swiss Federal Office of Public Health has used a ‘narrow’ definition since the early 1990s, separating out ‘harm reduction’ as one of four distinct elements of its drug policy, the other three being prevention, treatment and law enforcement. Despite difference in interpretation of the term ‘harm reduction’, both countries have successful national programmes using very similar strategies based on similar broad principles.
Some health and social scientists have a passion for creating and promoting false dichotomies, whether it be prevention versus treatment, vertical versus horizontal programmes, public health versus human rights or drug control versus harm reduction [21,22]. In the real world, although true dichotomies do exist and pose major challenges for public health, a middle ground is often achievable. Harm reduction advocates and practitioners need to be pragmatic and flexible, engaging in both prevention and treatment activities, exploiting what can be offered by both vertical and horizontal structures, maximizing the human rights principles of public health and promoting drug control measures that contribute to harm reduction outcomes. Much has been written about successful experiences in using law enforcement to advance harm reduction interventions, applying harm reduction principles in drug education programmes for young people, integrating harm reduction into HIV/AIDS treatment programmes and taking steps to protect the human rights of drug users within the context of controlling HIV epidemics.
The appropriateness and feasibility of harm reduction programmes in low- and middle-income countries is debated widely. These countries have many competing public health priorities and usually very limited resources. The diversity and dynamics of drug-injecting epidemics and the affected communities pose huge public health challenges for the design of relevant, acceptable and effective harm reduction programmes. Expanding methadone and buprenorphine maintenance treatment will have limited impact in communities where heroin use is being replaced by amphetamines. The establishment of dedicated needle and syringe exchange programmes may not be a priority in settings where affordable sterile injecting equipment is available widely through pharmacies. Without the existence of relevant safeguards and the availability of basic HIV prevention and care services, the promotion of HIV testing among drug users may do more harm than good, resulting in further stigmatization, discrimination and alienation. A thorough understanding of local context is required in selecting the most appropriate mix of interventions and the most efficient models for their delivery. This often requires major adaptation of interventions developed in high-income countries and investment in operational research to support this process.
Finally, certain opinion leaders, politicians and scientists still question the evidence-base for harm reduction relating to HIV prevention among injecting drug users. Across the range of HIV prevention interventions promoted for injecting drug users the volume and quality of evidence varies, particularly with regard to evidence from low- and middle-income countries. On one hand, few public health interventions have been subjected to the same intense scrutiny as methadone maintenance treatment. The body of evidence is significant for other key interventions such as needle and syringe programmes and risk reduction counselling. However, research on newer and more controversial interventions, such as safe injection rooms and the medical prescription of heroin, is limited. Particular challenges exist in identifying effective interventions for those individuals injecting drugs other than opioids, particularly amphetamine-type stimulants and cocaine. Recent reviews of the evidence on the role of harm reduction in HIV prevention demonstrate clearly the public health benefit of a number of key interventions and their relative safety [11,23]. The Institute of Medicine review [12] concluded that there was strong evidence of the effectiveness of opioid agonist maintenance treatment and that such programmes should be made widely available. It also found that there was consistent evidence that multi-component HIV prevention programmes including needle and syringe access interventions reduce HIV risk behaviours, and should be implemented where feasible. The implementation of outreach services for education and risk reduction was also recommended. At the same time, the report identified a number of significant gaps in knowledge and the need for additional research, including research on the potential unintended consequences of programmes, integration of interventions to reduce the sexual transmission of HIV and identification of effective disinfection techniques. Thus, the evidence supports the inclusion of opioid substitution treatment, sterile needle and syringe access and outreach as key components of an effective HIV prevention programme. It is now time to invest in their equitable expansion to the levels required to control HIV epidemics and achieve good service quality.
THE WAY FORWARD
Some welcome the ambiguity of harm reduction terms [24], arguing that it allows for greater flexibility in implementing policies and programmes to respond to critical public health problems. However, for many countries there is now an urgent demand and need for clear guidance on how to address drug-related problems effectively. There is little ambiguity over what works, at least with regard to key interventions for HIV/AIDS prevention, treatment and care for drug users. Defining a model package of harm reduction interventions, minimum standards for services and optimal levels of service coverage will do much to assist countries—comprising, in effect, an operational definition and strategy for ‘harm reduction’.
Within the context of HIV and drug use it is easy to define ‘harm’ and ‘harm reduction’ goals—the reduction of HIV transmission, the reduction of HIV-related morbidity and mortality and the reduction of HIV-related impact on communities (such as AIDS orphans). Given that drug control goals largely had their origins in the need to protect public health and the devastation of HIV epidemics among injecting drug users, the alignment of drug control measures with public health goals must be a priority.
Defining a ‘model package’ for harm reduction helps to address the dilemma of narrow versus broad definitions. Those communities and countries that have implemented comprehensive, multi-sectoral and integrated harm reduction programmes have been most successful in preventing or controlling HIV epidemics among drug users. Single, stand-alone interventions, even when they have good coverage, are likely to have only limited impact [25]. A ‘model package’ should include multiple evidence-based (or at least evidence-informed) interventions that are complementary and synergistic, promote multiple entry points for individuals to access services and ensure flexibility so that approaches can be adapted for different country contexts and changing HIV epidemic and drug use dynamics. The use of harm reduction hierarchies—comprising interventions ranging from prevention of drug use and preventing transitions from non-injecting to injecting forms of drug use to HIV/AIDS treatment and care for drug users—makes good sense [11]. In developing a practical tool for countries, the broad definition for ‘harm reduction’ should be preferred.
In July 2005 leaders of the G8 group of industrialized countries announced their intention to ‘work . . . with WHO, UNAIDS and other international bodies to develop and implement a package for HIV prevention, treatment and care, with the aim of as close as possible to universal access to treatment for all those who need it by 2010’ [26]. This goal was endorsed subsequently by the UN General Assembly in September 2005 [27], and expanded to include universal access to comprehensive prevention programmes, treatment, care and support by the UN General Assembly High-level Meeting on AIDS in June 2006 [28]. Given that ‘universal access’ means access for all, including drug users, there will need to be a massive scale-up of harm reduction services. The ‘model package’ concept can guide this process.
WHO is developing the harm reduction component of a broader public health ‘model essential package’ for HIV/AIDS prevention, treatment and care [29]. The package will promote principles of equity and human rights and interventions that can be scaled-up successfully in resource-limited settings. It will provide operational guidance to countries and other stakeholders on how to select and prioritize interventions and service delivery models, based on local context and available resources, and complementary to broader public health and drug control measures. In itself it will act as an important advocacy tool, describing to policy makers and donors key elements of a comprehensive and quality harm reduction programme and areas for public health investment. The public health model package for harm reduction includes five elements:
• Interventions for reducing HIV transmission, including HIV risk reduction information, education and counselling; HIV testing and counselling; sterile needle and syringe access; safe disposal of used syringes and needles; drug dependence treatment, particularly opioid substitution therapy; condom programming; prevention of mother-to-child transmission of HIV; and STI treatment.
• Management of HIV/AIDS, coinfections and comorbidities, including antiretroviral therapy; HIV treatment preparedness and adherence support; prevention and management of opportunistic infections, particularly tuberculosis; pain management and palliative care; prevention and treatment of hepatitis B and C; management of alcohol and other drug dependence and mental health disorders, such as depression.
• Appropriate models for service delivery and health systems strengthening, including peer outreach; integration of HIV, drug dependence treatment and outreach services; integration of HIV and drug use issues within other appropriate health services; interservice referral networks; defining minimum services to be delivered through different levels of health facilities; strengthening of procurement and supply management systems to ensure affordable and uninterrupted supplies of quality medicines (including methadone, buprenorphine and HIV-related medicines), diagnostics, needles and syringes and condoms; and development of human resources for harm reduction.
• Supportive policy, legal and social environment, including policies that ensure equitable access to HIV services for drug users; laws that do not compromise access to HIV services for drug users through criminalization and marginalization; and campaigns to reduce stigma and discrimination, related particularly to health services and workers.
• Strategic information, including HIV and behavioural surveillance among drug users; identifying programme and national indicators and selecting targets; monitoring quality, availability, coverage and impact of services; monitoring treatment adherence; and including drug users within population-based surveillance of HIV drug resistance and pharmacovigilance.
CONCLUSION
Harm reduction, with deep roots in public health, will continue to be a critical element of a public health response to HIV/AIDS. While we can expect continuing debate about the meanings of harm reduction, further misunderstandings, questioning of evidence, the offering of new definitions and stirring of emotions, we must ensure that any continuing confusion will not delay effective action being taken in countries. The best harm reduction advocates and practitioners are pragmatists rather than idealogues, who are not distracted by definitions and semantics but focus on ambitious but achievable goals, and those who prefer impact to process. Such front-line workers deserve moral support, practical tools and adequate resources to get their work done.
In defining a ‘model package’ for harm reduction for countries it is time to move on from the ambiguity of definitions, the misunderstandings of approaches and the questioning of evidence where it exists. If we are to witness real and sustainable impact in communities we must adopt a comprehensive, public health approach that is consistent with a broad definition of ‘harm reduction’. We need only to look at the success stories where comprehensive harm reduction policies and programmes are being implemented—averted HIV epidemics among drug users in Australia and the United Kingdom [10], epidemics reversed in France, Italy and Spain [10], major and rapid expansion of programmes in Brazil, PR China, IR Iran and Slovakia [10,14,23] and the adoption of supportive public health policies in Indonesia, Malaysia and Vietnam [15,23,30]—to recognize the relevance and value of such an approach.
DECLARATION OF INTEREST
The author is a staff member of the World Health Organization. The author is responsible for the views expressed in this publication and they do not necessarily represent the decisions, policy or views of the World Health Organization.
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