harm reduction information note

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Global Fund Information Note: Harm Reduction (May 2010) 1

Ensuring access to HIV prevention, treatment, care and supportfor people who inject drugs

The Global Fund supports evidence-based interventions aimed at ensuring that keypopulations have access to HIV prevention, treatment, care and support. This includes thecomprehensive package for the prevention, treatment and care of HIV among people whoinject drugs as defined by WHO, UNODC and UNAIDS.1 This document describes how thispackage can be incorporated into country proposals to the Global Fund, and points to otherissues to be considered such as advocacy, community systems strengthening, andaddressing psycho-social needs.

What is the Comprehensive Package of Interventions?

An effective and evidence-based response is required to curtail the rapid spread of HIVamong drug-using populations, but also to prevent transmission to the general population.In order to achieve these goals, according to UNODC, WHO and UNAIDS, theimplementation of a comprehensive package of nine interventions for the prevention,treatment and care of HIV among people who inject drugs is essential. This package alsowidely referred to as the harm reduction approach consists of interventions for whichthere is a wealth of scientific evidence supporting their efficacy in preventing the spreadof HIV2:

1. Needle and syringe programs (NSPs)2. Opioid substitution therapy (OST) and other drug dependence treatment3. HIV testing and counseling4. Antiretroviral therapy (ART)5. Prevention and treatment of sexually transmitted infections6. Condom distribution programs for people who inject drugs and their sexual

partners7. Targeted information, education and communication for people who inject

drugs and their sexual partners8. Vaccination, diagnosis and treatment of viral hepatitis9. Prevention, diagnosis and treatment of tuberculosis

1 WHO, UNODC, UNAIDS (2009). Technical Guide for Countries to Set Targets for Universal Access to HIVPrevention, Treatment and Care for Injecting Drug Users.

www.who.int/hiv/pub/idu/targetsetting/en/index.html2 WHO. Evidence for Action Series: Technical papers and policy briefs on HIV/AIDS and injecting drug users.http://www.who.int/hiv/pub/idu/evidence_for_action/en/index.html

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No single intervention will prevent or reverse HIV epidemics. The greatest impact on HIVprevention and treatment will be achieved if the interventions are implemented togetheras a package. The interventions should be delivered using a range of modalities, includingcommunity outreach and peer-to-peer work,3 and should be implemented both in thecommunity, in prisons and other closed settings.4 Services should also be delivered within ahuman rights and public health approach, and alongside supportive (or advocacy to

develop supportive) legal and policy frameworks as detailed below.

Why Providing the Comprehensive Package is Important

Preventing HIV, viral hepatitis, tuberculosis, and other harms among people who injectdrugs and providing them with effective treatment are major challenges. To respondeffectively to HIV, it is vital to know your epidemic through appropriate surveillance andepidemiological research, and to tailor responses to the specific characteristics of theepidemic and needs of the people at risk.

Drug injecting is a major driver of the HIV pandemic. Injecting drug use has beendocumented in 151 countries and in all regions of the world, and between 11 and 21million people inject drugs globally.5 HIV infection among people who inject drugs hasbeen reported in 120 countries,6 accounting for at least 10 percent of global HIV infections(and around 30 percent of HIV infections outside of sub-Saharan Africa).7

People who inject drugs in low and middle-income countries have poor and inequitableaccess to HIV prevention services and to ART.8 In prisons, access to comprehensive HIVprevention, treatment and care is even more limited despite evidence that injecting druguse is prevalent in prisons around the world.9

Global Fund Support for Interventions for People Who Inject Drugs

The Global Fund is the major source of international funding in low and middle-incomecountries for HIV prevention, treatment, care and support for people who inject drugs.Between 2004 and 2009, it has invested around US$ 180 million in harm reductioninterventions in 42 countries.10 This includes funding for HIV and hepatitis prevention, careand treatment services, as well as advocacy for policy improvements related to injectingdrug use and HIV.

3 WHO (2004). Evidence for Action: Effectiveness of Community-Based Outreach in Preventing HIV/AIDS among

Injecting Drug Users. www.who.int/hiv/pub/idu/e4a-outreach/en/index.html4 WHO, UNODC, UNAIDS (2007). Evidence for Action Technical Papers: Effectiveness of Interventions to AddressHIV in Prisons. www.who.int/hiv/pub/idu/prisons_effective/en/index.html5 Mathers B et al (2010). HIV prevention, treatment, and care services for people who inject drugs: Asystematic review of global, regional, and national coverage. Lancet, 375, DOI:10.1016/S0140-6736(10)60232-2.6 Mathers B et al (2008). The global epidemiology of injecting drug use and HIV among people who inject drugs:A systematic review. Lancet, 372 (9651), 1733-1745.7 Cook C, Kanaef N (2008) Global State of Harm Reduction 2008: Mapping the response to drug-related HIV andhepatitis C epidemics. http://www.ihra.net/GlobalState20088 Mathers B et al (2010). HIV prevention, treatment, and care services for people who inject drugs: Asystematic review of global, regional, and national coverage. Lancet, 375, DOI:10.1016/S0140-6736(10)60232-2.9 WHO, UNODC, UNAIDS (2007). Evidence for Action Technical Papers: Effectiveness of Interventions to Address

HIV in Prisons. www.who.int/hiv/pub/idu/prisons_effective/en/index.html10 Atun R, Kazatchkine M (2010). The Global Funds leadership on harm reduction: 20022009. InternationalJournal of Drug Policy, 21, DOI:10.1016/j.drugpo.2010.01.002


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Incorporating the Comprehensive Package into Global Fund Proposals

Global Fund resources are available to fund evidence-based interventions that target keypopulations in the community and in prisons. This includes individual interventions in thecomprehensive package for people who inject drugs. Global Fund policy states thatmiddle-income countries must ensure that their proposals have a focus on poor and/orvulnerable populations and low-income countries may obviously do so as well. The

performance-based funding model of the Global Fund is designed to encourage theinclusion of interventions with proven and measurable impacts within national targetsetting and frameworks.

In considering and designing programs for HIV prevention, treatment and care for peoplewho inject drugs and incorporating the comprehensive package (or as many of theinterventions as possible) into proposals applicants are encouraged to make use of therange of technical guides and support documents available from WHO, UNODC and UNAIDS.

Other Important Considerations

Community involvement. It is important that people who inject drugs actively participatein the planning and delivery of the response. Country Coordinating Mechanisms shouldinclude, or work in close consultation with, this community (or with organizations thatrepresent their needs) in project design, proposal development and projectimplementation. For example, involving people who use drugs in service deliveryrecognizes and utilizes their unique experiences, knowledge and contacts.

Community systems strengthening.11 Many services for people who use drugs are bestdelivered in community-based settings, often through outreach by peers. Applicants shouldconsider including interventions such as capacity building, infrastructure development andpartnership building in their proposals.

Gender-sensitive programming. Women who inject drugs often face additional stigmaand/or barriers to access services. Proposals should address the particular needs of womenwho inject drugs and the female partners of men who inject drugs. Countries should alsocollect sex-disaggregated data and use these data, along with sex-specific denominatorestimates, to monitor service issues and gaps.

Prisons. Imprisonment is a common event for many people who inject drugs. 12 Often, theycontinue using (or injecting) drugs while in prison, despite efforts by prison systems. It istherefore essential to provide the comprehensive package of interventions for people whoinject drugs in prison settings as well as in the community. Particular efforts are needed toensure continuity of ART and TB treatment as well as OST at all stages upon arrest, pre-

trial detention, transfer to prison and within the prison system, and upon release. This willrequire the engagement of different government departments in proposal development.

Ensuring a supportive environment for interventions. Even where interventions such asNSPs and OST are implemented, the lack of a supportive social, policy and human rightsenvironment often creates barriers to accessing these interventions, resulting in negativehealth outcomes. Therefore, applicants should consider including interventions to ensure amore supportive environment, such as:

11 Global Fund Community Systems Strengthening Fact Sheet:

http://www.theglobalfund.org/en/applicantsimplementers/12 WHO, UNODC, UNAIDS (2007). Evidence for Action Technical Papers: Effectiveness of Interventions to AddressHIV in Prisons. www.who.int/hiv/pub/idu/prisons_effective/en/index.html


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reviews of laws, policies and practices related to injecting drug use and HIV, with aview to changing those that create barriers to effective prevention, treatment, andcare and/or violate human rights;

programs to address the double stigma and discrimination related to HIV and druguse;

training and/or sensitization for police, judges and prison staff in evidence andhuman rights-based approaches to drug use and HIV;

social mobilization and campaigns for people who use drugs to better understandthe law and their rights;

legal aid/assistance for people who use drugs, ideally integrated in health services;and

support to ensure that basic needs and underlying psycho-social vulnerabilities areaddressed.

Other programmatic areas. In addition, applicants can also consider the followinginterventions, recognized as international best practices, in their proposals:

improvements to epidemiological surveillance systems, where needed, to betterestimate the size of, and assess the role of, people who use drugs in national HIV

epidemics; research to further expand the knowledge base on HIV and injecting drug use and

on the impact of interventions in particular settings; overdose prevention (as part of the intervention targeted information, education

and communication in the Comprehensive Package) including advocacy forlegislation and policy reform, staff and peer training, the prevention of transitionsfrom non-injecting drug use to injecting, and the provision of naloxone.

Monitoring and Evaluation (M&E). In order to obtain accurate and high quality data,indicators need to be carefully tailored to the applicants M&E systems and capacities. Thefollowing should also be noted:

1. A basic (minimum) package of services provided should be clearly defined for eachof the interventions in the Comprehensive Package. For example, exactly whatservices are being provided?

2. Systems to avoid the double-counting of individuals should be developed (such asUnique Identification Codes) that allow for the monitoring of client numbers aswell as the number of encounters or contacts.

3. When reporting on coverage as a percentage, a reliable population size estimatemust be used as the denominators. These may be available from global reviews 13,14or developed using available guidelines.15

4. When setting targets, programs should aim for high service coverage which isdefined as more than 60% of people who inject drugs being regularly reached byNSPs, and more than 40% being reached by OST.16

13 Mathers B et al (2008). The global epidemiology of injecting drug use and HIV among people who injectdrugs: A systematic review. Lancet, 372 (9651), 1733-1745?)14 Mathers B et al (2010). HIV prevention, treatment, and care services for people who inject drugs: Asystematic review of global, regional, and national coverage. Lancet, 375, DOI:10.1016/S0140-6736(10)60232-2.15 UNAIDS/WHO Working Group on HIV/AIDS/STI Surveillance (2003). Estimating the size of populations at riskfor HIV: Issues and methods. http://data.unaids.org/publications/External-Documents/estimatingpopsizes_en.pdf16

WHO, UNODC, UNAIDS (2009). Technical Guide for Countries to Set Targets for Universal Access to HIVPrevention, Treatment and Care for Injecting Drug Users.www.who.int/hiv/pub/idu/targetsetting/en/index.html


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Further Reading / Resources

UNAIDS and UNODC Fact sheet on Drug Use and the Spread of HIV:www.unodc.org/documents/frontpage/Facts_about_drug_use_and_the_spread_of_HIV.pdf

What Is Harm Reduction? definition from the International Harm ReductionAssociation: www.ihra.net/Assets/2316/1/IHRA_HRStatement.pdf

WHO, UNODC and UNAIDS Technical Guide:www.who.int/hiv/pub/idu/targetsetting/en/index.html

WHO Evidence for Action Series (technical papers and evidence reviews):www.who.int/hiv/pub/idu/evidence_for_action/en/index.html

WHO Basic Principles for Treatment and Psychosocial Support of Drug DependentPeople Living with HIV/AIDS:www.who.int/substance_abuse/publications/basic_principles_drug_hiv.pdf