Safe from harm

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Last month saw the 23rd International Harm Reduction Conference take place in Lithuania. DDN reports on a gathering of activists, policy makers and service users from across the globe.

More reports from the day can be found here.

To read the full HRIC daily update magazines, please click here.

Reclaiming harm reduction

Screen shot 2013-07-05 at 13.47.26HRI executive director Rick Lines explains the reasons for mounting the event in Eastern Europe

‘Eurasia is one of the regions that’s been most severely hit by the HIV epidemic related to injecting drug use,’ says HRI executive director Rick Lines of the decision to stage this year’s conference in Lithuania – the first time the event has been held in the Baltic States, and its first time in Eastern Europe since 2007.

‘It’s also a region where the harm reduction response is underdeveloped,’ he says. ‘There are high levels of need and a lot of countries with generally poor harm reduction services, severely repressive drug laws and human rights violations against people who use drugs. Having the conference in the Eurasian region was an important way to call attention to these issues.’

Lithuania is also home to HRI’s partner organisation, the Eurasian Harm Reduction Network. ‘They approached us with a proposal to hold the conference here and they’re a fantastic organisation so we jumped at the chance,’ he says

 

This year’s theme is the Value/s of harm reduction, with a focus on two key issues. The first is the economic case – the fact that harm reduction ‘not only saves lives but is also a very cost-effective public health intervention’, he states.

‘But we also wanted to focus on the values, because one of the things we’re seeing is the pushback against harm reduction by conservative governments pushing a recovery agenda. Even five years ago the anti-harm reduction lobby was trying to argue against the scientific basis of harm reduction, but you rarely hear that now. Instead they try to frame harm reduction as this kind of morally suspect, very clinical response that doesn’t value people and sees them as simply receptors of services. So it’s also about reclaiming the moral, ethical and philosophical basis of harm reduction.’

The right to life

Human rights should never be sacrificed to the ‘war on drugs’, said ministers

‘If you break stereotypes,’ Lithuania’s health minister Vytenis Povilas Anriukaitis told delegates, ‘you break down walls.’

Human rights included the right to live, to have opportunities and to acknowledge that people are equal, he said. ‘We must always remember that. It’s predetermined positions that destroy people’s lives – we have to fight for leadership.’

Human rights were not invalidated by drug use, former president of Switzerland Ruth Dreifuss told the conference. Lithuania was playing a pioneering role in harm reduction in Eastern Europe, she said, with HIV rates ten times lower than in some neighbouring countries. However, the ‘ticking timebomb’ of hepatitis C meant that adequate coverage of services was vital.

Ensuring that services were accessible and affordable for all was challenging, she said.

International solidarity was essential, with financing from states and NGOs com­bin­ed and pharmaceutical companies making their drugs affordable in poorer countries.

‘HIV was a brutal teacher,’ she told delegates. ‘We learned that mass incarceration for drug possession – far from discouraging drug use – was the place where HIV, hepatitis C and drug use were allowed to flourish. Our approach has to be more comprehensive.’

It was also vital to consider harms ‘beyond the public health approach’, she said. These included the increased power of criminal organisations, which not only challenged weaker states but had actually come to threaten democracy and the rule of law in many parts of the world.

‘Mass incarceration is a huge waste of public resources, and human rights violations are justified by the war on drugs,’ she said. It also remained vital to fight for and finance harm reduction measures, and ensure they were accepted and understood by the public.

‘We are all committed to achieving these aims,’ she told delegates. ‘And you are saving lives.’

The heavy cost of cutbacks

Picture 10Harm reduction is a ‘global best-buy’

‘We all know why we need to worry,’ said David Wilson of the World Bank, in a session on financing harm reduction. ‘If we look at the prevalence of injecting, there are very high rates in Eastern Europe and Central Asia. The picture is alarming, but we all know what works.’ The gaps in needle and syringe programmes (NSPs) coverage globally, however, were profound. ‘Since 2010 we’ve actually seen NSPs scaled back in countries in Eastern Europe and Asia.’ 

The Global Fund was the largest harm reduction funder, and responsible for more than half of the funding coming to the region, he said. ‘But harm reduction is cost-effective in every region, and the return on investment is very positive.’ Total future returns were estimated at up to $8 per dollar spent, and the more interventions were scaled up the more cost-effective they became, he stressed, with figures from Australia showing an estimated yield of $27 per dollar invested.

‘Inaction is costly,’ he told delegates. ‘And it’s not the equivalent of doing nothing. Wherever we can, we need to get upstream before infections start.’ The returns accrued to the whole of society, however. ‘It’s a global best-buy for public health and development money.’

Nonetheless, the trend for investment in HIV prevention for people who used drugs was going the wrong way, Daniel Wolfe of the Open Society Foundations International Harm Reduction Development Programme told the conference. ‘The Global Fund is also likely to be a lot less global and a lot less prevention-focused than it has been,’ he said, with countries in the region having to compete for decreasing resources. 

‘It’s very strange to sit in a harm reduction conference and realise that the last needle exchange programme in Romania will close this year. We in harm reduction will increasingly be at the cold intersection of austerity and social exclusion. We need to press donors to do more on coordination, and we need to do better about deciding who can pay what the other can’t.’

Advocacy for funding at national and regional levels would also be vital, he told delegates. ‘In the same way that we taught people safe injection techniques and how to reverse overdose, we need to be able to read budgets, understand budget cycles and press for local funding.’

Time to be brave

Politicians must lead public opinion, not follow it

‘We introduced harm reduction measures in 1986-87, and it was extremely controversial,’ said former British health secretary Lord Norman Fowler. ‘We were told it would increase criminality. That did not happen, but what did happen is that new drug-related infections have been consistently down to 2 per cent ever since. Harm reduction programmes work.’

One of the key lessons was that countries needed to be brave, he told delegates, with politicians leading public opinion rather than following it. ‘I go around the world and I hear about all sorts of pilot projects, but I don’t think we even need pilot projects any more. The evidence is there, and it’s absolutely clear.’

 Indonesia’s harm reduction programmes had begun in 1999, Anton Djajaprawira of community-based organisation Rumah Cemara told the session, with ‘huge interest’ from donors ever since. ‘But what this has meant is that at times there were the same interventions being implemented in one particular area.’

 There was also often a lack of flexibility, he said, with needs going unmet and a general lack of community involvement. In response, community-based harm reduction initiatives had begun in recent years, with interventions now operating across three provinces.

 ‘Community-based operations decide their actions based on community needs,’ he stated. ‘It’s a participatory approach, and it fills the gaps rather than implementing the same interventions. It integrates all the available harm reduction services.’

 Rumah Cemara’s work now included prison pre-release programmes, capacity building, legal assistance, youth work, needle and syringe distribution and services for remote areas, he said. ‘And for services to work, the involvement of people who use drugs at management level is essential.’

 For now, however, programme sustainability still depended on donors and the government, he said. ‘But grassroots communities can perform very well if they’re given the trust and flexibility to do so.’

 Picture 8‘The war on drugs has failed. When I have a business that fails I shut it down’

Sir Richard Branson told the conference via a special video message. In 2016, the world would be forced to confront this failure at UNGASS, he said, and part of what made drug policy discussions so difficult was that current and former drug users were not properly listened to. ‘If we want to help people we mustn’t even think of throwing them in jail. Harm reduction makes financial sense and saves lives. It is the right thing to do.’

 

 

In the vanguard

Picture 11The Vilnius Centre for Addictive Disorders was home to the first methadone programme in a former Soviet country, as its director Dr Emilis Subata explains

At this year’s conference, Dr Emilis Subata prescribed opioid substitution therapy (OST) in the form of methadone and buprenorphine to delegates who were unable to export medication from their own country.

Dr Subata has led the Vilnius Centre for Addictive Disorders for more than 20 years. A psychiatrist by training, he has been an expert consultant for the World Health Organization (WHO), the United Nations Office on Drugs and Crime (UNODC) and United Nations Development Programme (UNDP) among others, and is also an associate professor at Vilnius University, itself a WHO collaborating centre for harm reduction.

While Eastern Europe has struggled with a well-documented HIV problem, it was at his treatment centre that the very first methadone programme in a former Soviet country was established, in October 1995 – something which may help to explain why Lithuania’s HIV rates are among the lowest in the region.

‘One of the reasons for that is that we implemented opioid substitution therapy in the three biggest cities in Lithuania before HIV had really appeared among injecting drug users,’ he says. ‘It wasn’t a reaction to HIV cases among IDUs – it was prior to the first cases among IDUs. In those three cities, quite a large number of IDUs with long histories of injecting were able to access treatment programmes, and needle exchange programmes were introduced quite early as well – starting around 1996 in the sea port of Klaipėda and then in Vilnius in 1997. So we started harm reduction programmes much earlier than in Latvia or Estonia, for instance.’

Rates of HIV transmission through injecting drug use have fallen substantially in recent years, but it remains the case that HIV testing is not always easily accessible. ‘It’s done mostly by NGOs with external funding, so we might not have the most exact data,’ he acknowledges.

 Most of Lithuania’s major population centres now have needle exchange programmes, however, and the ten largest cities have opioid substitution therapy, accessible free of charge. ‘In most of the cities there are no waiting lists, although we do have some in Vilnius,’ says Dr Subata.

His clinic also operates a mobile needle and syringe exchange service, which means that the service is accessible to drug users throughout the city. ‘We used to have a mobile van – the “blue bus” – but we’ve replaced it with a more advanced vehicle,’ he says. ‘We’ve had a specially designed, heated bus with a counselling room for about two years now.’ All of the service users’ files at the centre are also managed by social workers rather than clinicians, which leaves the doctors free to concentrate on treatment. ‘We find it’s a big advantage, compared to the earlier practice when the physician was taking responsibility for the patient,’ he says. 

Things haven’t always been easy, however, with attempts to close down his service as recently as 2005. ‘At that time there was an attack from some politicians in the parliament who were very strongly against harm reduction,’ he explains. ‘But the programmes survived, and the funding was always available from the Ministry of Health, so there has been a mixed attitude. The ministry was always supportive of harm reduction and opioid substitution therapy, and the government’s drug control offices were also always supportive of these interventions, but from time to time there were politicians who expressed negative opinions about harm reduction – there were discussions in the media, as well as between agencies and so on.’

It all depends on the political climate, ‘the same as anywhere else in Europe’, he states. ‘We have conservative politicians who are critical of harm reduction, and more progressive politicians who are more accepting.’

Unlike many places, however, there has been very little resistance to the implementation of harm reduction interventions from the public, he says. ‘I would say the general public is largely neutral. Some years ago there was a formal survey on attitudes towards opioid substitution therapy, and it found positive opinions. The police are also quite supportive of opioid substitution therapy and harm reduction because they’re disillusioned about the ability of law enforcement alone to suppress the drug trade.’

Right time, right place

Picture 12From the opening session, the conference stressed the need for meaningful participation of people who use drugs

‘The conference is taking place at the right time and at the right place,’ executive director of the Eurasian Harm Reduction Network, Sergey Votyagov told delegates.

Despite increasing wealth, most governments in the former Soviet region still did not invest in harm reduction programmes, he said, with international donors often the only ones providing ‘the financial and moral’ support. ‘So this is the right region to hold the conference, although regrettably for the wrong reasons,’ he said. ‘Lack of investment in harm reduction costs lives.’ Lack of money was not the only structural barrier, however. ‘Money follows priorities and the money is spent on a wasteful law enforcement approach.’ Now was the time to make the transition from donor funding to investment by domestic governments, he said.

‘Our long-term slogan is “nothing about us, without us”, Eliot Albers of the International Network of People who Use Drugs (INPUD) told the conference. ‘For us the centrality of meaningful participation is not negotiable, and a fundamental principle that should lie at the heart of all work.’ No process, document or service could be said to embody this unless ‘our community’s input has been built in from the start’, he stressed. ‘It’s not about being asked to endorse a document we haven’t even seen.

 ‘Some of us have been told we’re troublemakers,’ he continued. ‘But our principles are non-negotiable. We are more than aware of the fact that our community is diverse, and you need to be able to bring that to the table. If you are committed to meaningful participation, you will find us a very willing partner.’

 Voices of the community

 Empowering people to chase opportunity has become the essential mission of a drug users’ union in New York

 ‘It’s not always easy to organise and mobilise people who use drugs,’ said Anastasia Teper of VOCAL-NY (Voices of Community Activism Leaders), a New York-based drug users’ union.

VOCAL was founded in 1997 as an organisation to find housing for drug users, but developed into a means of organising and mobilising people who were substance users and who were HIV positive. ‘It started with two people and one organiser,’ she said.

‘The goal is to build the power of low-income people who use drugs, and end the drug war – which is very much a racial and economic justice issue. We have to find the fire in the belly of the people who are affected by these issues, and help to empower and organise them.’

The organisation recruited through member-led outreach, targeting people at needle exchanges and other services and then with ‘relentless follow-up’ by phone and in person, she said. ‘Mobilising people is not easy – they can have a multitude of issues. But we follow up all new contacts, creating meaningful opportunities for people, and we also want to develop people into leaders – learning while doing.’

A key issue was empowerment, she told the conference. ‘How do you speak to authority if you’ve been put down all your life? That’s a very difficult transition to make.’

VOCAL-NY was able to show people that their participation would ‘result in real and concrete improvement in the lives of people who use drugs’, she said, and it had carried out successful programmes around securing housing for people with HIV, as well as police harassment for syringe possession.

‘Seventy per cent of the people surveyed by VOCAL had been arrested for syringe possession,’ she told delegates. ‘And 87 per cent of them had been carrying docu­mentation saying they were participants in official syringe exchange programmes.’

The organisation had held rallies and secured the attention of the media, and eventually a syringe access law had been passed in 2010. Among its current campaigns, meanwhile, were the mandatory offer of hepatitis C testing for people of the ‘baby boomer’ generation and marijuana decriminalisation.

‘The issues are really deeply felt, because we’re really trying to end the war on drugs,’ she said.

Inside the medical room

Picture 13Gill Bradbury, RGN, coordinated the conference’s healthcare services. She told us what was involved

This year we were able to expand our services to make them truly worthy of a harm reduction event.

Dr Emilis Subata prescribed OST for delegates who were unable to export medication from countries such as Ukraine, Belarus, Kyrgyzstan, Armenia and Tajikistan. Arrangements were also made with a private doctor who facilitated treatment for delegates from Russia who were dependent upon opiates but unable to access OST, due to methadone and buprenorphine not being permissible in that country. 

We offered an open needle syringe programme (NSP), with a variety of needles and syringes, along with other injecting equipment donated by Exchange Supplies, such as stericups (cookers), filters, citric acid and vitamin C, swabs and water. Foil for smoking was also available.

Sharps bins for safe disposal of injecting equipment were available in the main toilets within the venue, as well as in the medical room, and people were supplied with individual disposal units, handed in at the end of the conference.

A new feature of our service was the provision of naloxone, provided by Kaleidoscope drug services. We had more than 100 kits available for distribution, and offered training to those who needed it.

We were also able to provide confidential HIV testing, screening and advice with Demetra, a Lithuanian association for HIV affected women and their families.

As usual, we gave brief consultations relating to minor illnesses and injuries and offered basic first aid. The medical room was staffed by myself, a nurse from the Baltic American Clinic, and volunteers. Thanks to the volunteers, organisations that donated the necessary goods, EHRN and HRI staff, we were able to provide a comprehensive service.

Empower women through ‘respectful’ services

Picture 14Involving women in the design of gender-specific services encourages positive behaviour change

‘We have to make sure women can get treatment – we’re empowering them to fight,’ said Susan Masanja, in a session on developing harm reduction services for women who use drugs.

The fight was against blood-borne viruses, poverty and stigma in Tanzania, where injecting drug use was on the increase, more than a third of IDUs had HIV, and women frequently reported violence and rape. The socio-economic condition of many women who used drugs was poor, she said, with homelessness and lack of income making it difficult to access harm reduction services. Médecins du Monde’s special focus on women had been effective in extending outreach, peer educator training and women-only initiatives, resulting in evidence of the first changes in behaviour.

‘We need to extend outreach services to more locations and days a week and continue income-generating services,’ she said, alongside calling for additional specialist training for medical personnel. ‘We need to keep spreading harm reduction and strengthen advocacy.’

 Visvanathan Arumugam shared experience from the Chanura Kol project in Manipur, India. Around 60 per cent of registered female injecting drug users were engaged in paid sex work, he said, and there were no government-funded targeted interventions. The project, implemented in three districts in Manipur and funded by the Elton John AIDS Foundation, provided comprehensive community-based harm reduction services for women who used drugs, including positive living, education and lifestyle advice, preventative measures, testing and follow-up services.

 The outcomes were positive, with better education, more testing and an increase in the number of women who had successfully completed detoxification treatment. The project was ‘the way forward, showing the need for safe spaces for female injecting drug users and access to harm reduction’, he said.

 ‘Drug use differs greatly between genders,’ said Vlatko Dekov from Macedonia, who offered insights on integrating a gendered perspective into harm reduction programmes. ‘One of the reasons for this is the gender roles in society,’ he said. ‘Men have the decision-making positions and women have more frequent roles in the private sphere.’

 Women tended to be invisible in treatment programmes in the Balkans, he said, only becoming visible in life-threatening situations such as overdose. There was also a gender hierarchy in drug-taking, with women’s injecting frequently initiated and continued by men. Making harm reduction gender sensitive depended on involving women who use drugs in the political decision-making process, he suggested, using their expertise to design services and including them on the staff of harm reduction programmes. On a day-to-day level, women should be encouraged to become more independent, he said, through education, job-seeking, training and employment.

 Claudia Stoicescu told delegates that the HRI report, The global state of harm reduction, gave a comprehensive overview of the risks to women who used drugs, including guidance on gender-sensitive services. ‘Services should be tailored to the documented needs of women in different contexts,’ she said, pointing out that small additions to services could be effective in changing such behaviour as women’s dependence on their partners.

‘Women who use drugs should always be involved in the design of programmes to make sure they’re respectful and appropriate,’ she added.

Reaching out to children in Romania

Picture 15Stopping harm reduction funding spells disaster for many Romanian children

The first harm reduction outreach projects in Romania had begun in 1999, Iona Tomus told delegates in the Children, young people and drug use session. However, as of June 2013, all funding for harm reduction services in Romania would stop.

The implications were dire, she warned. Figures from 2011 showed that there were around 17,000 people injecting drugs in Bucharest, and far fewer syringes than were necessary because of lack of funds. ‘Of course the consequences appeared immediately,’ she said. ‘In 2010 the HIV rate among people who inject drugs was 3 per cent. By 2012, it was 31 per cent.’

 The problem was particularly acute among younger people, she said, exacerbated by rising rates of ‘legal high’ use, particularly mephedrone. The age of initiation could be as young as ten, and rates of equipment sharing were high. ‘In order to have access to health and social services, however, you need the permission of parents. It’s the opposite of “Nothing about us, without us” – it’s “Everything about us, without us”.’

 The children using drugs were mostly in Bucharest, she said, and typically had low levels of education and literacy, as well as behavioural and health problems. Rates of homelessness were also high. ‘I am a harm reductionist, so what should I do?’ she said. ‘Officially, harm reduction service providers state that they don’t offer services to children, but they do.’ This could often lead to confrontations with police, she added.

 ‘There are also moral questions – is it right to give syringes to a child, for example – as well as lack of funding and lack of proper instruments to create child-friendly services. But changing the law is an important issue and something that we’re trying to do on an ongoing basis.’

 It was also vital to standardise the methods by which the number of children using drugs was monitored internationally, she stressed. ‘We need to know our epidemic and how it differs to that of adults, and make guidance specific, accessible and relevant. We have a lot good practice – we just need to bring it together internationally and fill the many urgent gaps.’

Engaging with Indonesia’s young street users

Picture 16Youth peer-support programme thrives on trust

‘Young people who use drugs have unique developmental and situational needs that aren’t addressed by traditional adult-orientated services,’ said Tesa Sampurno of Indonesian peer-support programme Rumah Cemarah. Just over 2 per cent of the Indonesian population used drugs, he said, equivalent to between 3.8 and 4.2m people, with his service targeting young people in the city of Bandung. ‘Many of them are street-involved, poly-drug users and experience a wide range of harm due to their drug use,’ he said. ‘And programmes are failing to reach them.’

 Harassment from law enforcement made it even harder for services to access vulnerable young people, he stressed. ‘They can be beaten up, and even hospitalised, by police officers or security staff just because they’re walking in the mall, for example. So they become closed off.’ His organisation, however, was directly engaging with young people in different parts of the community, he stated. ‘Importantly, Rumah Cemarah has established the trust of young people who use drugs, who now freely share their experiences, seek advice and bring their friends.

 Flexibility and creativity were essential when working with young people, he said, as were demonstrating respect for, and belief in, them. ‘You need patience and the ability to demonstrate a safe and supportive environment, as you need to provide holistic, integrated programmes that recognise drug use as just one part of the broader needs of young people. We don’t just talk about drugs, but about their life problems, their social problems – every aspect of their lives.’

 Challenging the status quo

 Picture 17 The law stands in the way of treatment for too many young drug users in Kyrgyzstan and Tanzania

‘When I started to use heroin I was only 18,’ Irena Yermolayeva told delegates. ‘There is a moment when all drug users want to quit, but in my country of Kyrgyzstan there was no accessible, free detox or rehab available. So I had to wait.’

 Several years later she had met other drug users involved in harm reduction services and was inspired to help people in a similar position to herself, one of whom was a 15-year-old girl. ‘She had syphilis but it wasn’t possible to treat STIs without parental approval. Her partner was also beating her and forcing her to provide sexual services. She needed shelter, but the laws in our country meant that she couldn’t get it.

 ‘Young drug users must have the chance not to be imprisoned and not to become inmates,’ she said. ‘In Kyrgyzstan, there are no rehab centres available for young people and teenagers.’ Young drug users were also experiencing violence from the police, she said, while Inspector Abdallah Kirungu of the Tanzanian police also described how drug users in Tanzania were being criminalised.

 Forty-two per cent of injecting drug users in Dar es Salaam were HIV positive, he said, and the Tanzanian AIDS Prevention Project had initiated meetings with the police to discuss the impact that arresting drug users was having on their work. This prompted him to go incognito to see the actions of the police for himself.

 ‘I found to my shock and dismay that the police were furthering drug-related harms,’ he said, with officers ambushing drug users to confiscate and sell their drugs, harassing clients at HIV and methadone services, and extorting money and demanding sexual favours from sex workers.

 ‘These practices called for an integrated harm reduction intervention for police officers. We need to educate our police force about drug harms to individuals and society, and the police need to be mandated and supported to take drug users for treatment rather than arrest. Police officers who extort sex workers and sexually violate them should also be subject to disciplinary action and prosecution, and we must also empower drug users and sex workers to protect their human rights.’

The Tanzanian police were not able to do this alone, however, he stressed. ‘It needs to be supported by those already in the field.’

Tackling the silent epidemic

Picture 18Panellists at a session on hepatitis C called for collective action to make treatment high on every political agenda

 ‘Sixty per cent of people who inject drugs worldwide are infected with hepatitis C  – it’s the silent epidemic,’ said Azzi Momenghalibaf, chairing a session on access to hepatitis C treatment, before asking panellists to give a snapshot of the situation in their country.

 ‘In Russia we have a very large number of people infected – between 3m and 7m,’ said Sergey Golovin. ‘But these are unofficial figures – we do not have a national programme.’

Fewer than 1 per cent of people with HCV in Russia were accessing treatment and drugs were often left unused at hospitals as people were not coming forward.

 ‘We have highs and lows in Russia,’ he said, the highs being prices, prevalence of HCV and need for treatment, and the lows being awareness, access and demand for treatment. There were signs of activism for a state-funded programme and pressure on producers to lower prices: ‘There will be action and protests,’ he said.

 Amritananda Chakravorty spoke of the long fight ahead for drug users in India, where they were seen as criminals rather than patients. ‘We need political commitment at national and international level,’ she said. ‘It is the ultimate obligation of the international community to respect the right to life of people who use drugs.’

 Paisan Suwannawong outlined the scale of the challenge in Thailand, where ‘the government still excludes people who use drugs’. ‘We must continue to educate and advocate for people with hepatitis C,’ he said. ‘The most important thing is that we continue to fight for decriminalisation of people who use drugs and access to healthcare.’

Dasha Ocheret of the Eurasian Harm Reduction Network had been involved in mapping data. ‘No one officially excludes people who use drugs from treatment, but there are huge gaps between official policies and what actually happens,’ she said. If people injected drugs in Russia, for example, they would have a very low chance of treatment, depending on their doctor.

 With the absence of good national guidelines, a ‘recent wave of activism’ was playing its part in raising the profile of hep C treatment. In Ukraine the government had reacted to pressure and adopted a treatment programme, and in Georgia civil actions and patient groups had been successful in starting a hep C programme in prisons.

 ‘We should never stop fighting for what’s right,’ said Karyn Kaplan, who talked about the new generation of hep C medicine – direct acting anti-virus drugs without significant side effects – that meant cure rates of up to 100 per cent. ‘We need to explore compulsory licences for safe and effective drugs,’ she said. ‘We need to make sure they’re affordable.’

Calling for collective action, she added: ‘This is a matter of public health urgency,’ and encouraged delegates to sign an online petition at www.hepcoalition.org.

 Michel Kazatchkine joined the session to give The Global Fund’s support in advocating for hepatitis C and to launch the Russian edition of The hidden global hepatitis C epidemic. ‘Two thirds of people who use drugs are affected by hepatitis C,’ he said. ‘It’s treatable and curable but so few people are accessing treatment.’

 ‘We need to talk about sex work’

 Picture 19 A healthy and safe working environment is a fundamental right

‘It’s critical that we are able to talk about sex as much as we talk about drugs,’ said Cyndee Clay, executive director of the sex workers’ support organisation HIPS, based in Washington, which offered non-judgemental support.

 ‘For some, sex work is a really hard thing they have to do, for others it’s the best option at the time, and for others it’s what they like to do,’ she said. ‘That’s the parallel with people who use drugs – there are varied experiences. We need to open our minds to this reality.’

 Programmes at HIPS were ‘client directed’ and ‘goal centred’, with participants choosing what they were interested in, for instance reducing violence or making more money. The common thread was to help those engaged in sex work to be able to live healthy, self-determined, self-sufficient lives, free from stigma, violence, criminalisation and oppression, she explained. A major part of the team’s work involved challenging structural barriers to health, safety and prosperity.

 Harm reduction was used as a philosophy – ‘what’s going to make you happier today?’ – and the 100 volunteers and staff were trained to help look out for and reduce isolation. For some, the service was the only support they had with the biggest aspect of their life.

 The important thing to think about in providing services was the need to increase choice, reduce coercion and address circumstance, she said. ‘This unpacks some of the ideas of whether sex work is good or bad… we need to be more comfortable talking about sex and not make assumptions.’

 Anita Schoepp, of the Canadian sex workers’ organisation Stella, said it was important to ask people what they needed from their outreach service, in the context in which they were living. Issues to consider included cultural barriers, family values and complex circumstances around relationships, such as intimate violence.

 Working closely with psychiatrists, Stella explored different models of support, including motivational interviewing, and tried to make sure their clients were offered choices. ‘Harm reduction should be a philosophy to apply to different types of social work,’ she said. ‘We need to help people make choices in the global context of their health.’

 Constant risk

 Addressing TB among people who use drugs should be a public health priority

 ‘Access to TB services remains horribly low,’ said Annabel Baddeley, in a session on harm reduction relating to the tuberculosis epidemic. ‘We need to encourage stakeholders to be more mindful of TB in collaboration with services.’

 Injecting drug users were more at risk of TB, she said, as their immune system could be impaired by lifestyle factors such as poor housing and nutrition. Those in prison were entering ‘highly infective centres’ and the risk of TB was consistently higher in inmates, particularly those sharing equipment. Stigma, discrimination and lack of continuity of care after release could add to the risk.

 ‘Addressing TB among people who inject drugs is a public health priority,’ she said. ‘Harm reduction stakeholders should increase efforts to reach this at-risk group by including TB interventions in their services.’

 TB had become an increasingly important issue for the drug using community, said Mat Southwell, who got involved in developing a practical advocacy guide in his role as a drug user activist. Referring to HIT’s document, TB advocacy guide for people who use drugs, he explained how drug users from around the world came together to contribute to a ‘rich resource’. The key messages included challenging stigma and criminalisation while giving access to anti-retroviral therapy and integrated services.

 ‘We have to bring services to a common place, rather than expecting people to run around looking for them,’ he pointed out.

 Picture 20Dickens Bwana, a programme manager in Tanzania, gave his experience of work­ing at grassroots level, particularly in making TB care possible at home. Witnessing the exclusion and stigmatisation of a drug user attempting to gain access to treatment had prompted his organisation to integrate harm reduction into their services.

 ‘With stigma attached to drugs, plus HIV, plus TB – you can see that these people need help,’ he said. TB was the leading cause of mortality among injecting drug users, exacerbated by poorly ventilated consumption rooms – a breeding ground for infection – and interrupted treatment. Harm reduction education was needed on how to inject drugs and the importance of using condoms, as well as places to test for and treat the disease. Médicins du Monde had supported the opening of the Down to Earth medical centre in Dar es Salaam, a ‘friendly open door’ where trained volunteers offered interventions such as TB screening, HIV testing and referral to methadone programmes.

 In addition, TanPUD (the Tanzanian network for people who use drugs) were giving training sessions to educate on treatment. ‘Addressing TB among drug users should be a harm reduction priority,’ he said.

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