Harm reduction philosophy
People who use drugs are often reluctant to use traditional healthcare services and are more comfortable requesting health support in harm reduction services, opioid substitution treatment programs or addiction services.
HIV/HCV INTEGRATED SERVICES IN HARM REDUCTION
Harm Reduction’ refers to policies, programs and practices that aim primarily to reduce the adverse health, social and economic consequences of the use of legal and illegal psychoactive drugs without necessarily reducing drug consumption. Harm reduction benefits people who use drugs, their families and the community.
- Harm Reduction International (HRI)
People who use drugs are often reluctant to use traditional healthcare services and are more comfortable requesting health support in harm reduction services, opioid substitution treatment programs or addiction services. For this reason, relocating or co-locating HIV/HCV testing, treatment and care services in harm reduction settings can have benefits related to access and adherence. Inclusion of HIV and HCV rapid testing in these programs may increase the effectiveness of diagnosis in those populations that may not access conventional health facilities.
The World Health Organization (WHO), the United Nations Office on Drugs and Crime (UNODC) and the Joint United Nations Program on HIV/AIDS (UNAIDS) strongly recommend harm reduction as an approach to HIV prevention, treatment and care for people who inject drugs. Specifically, they advocate for a comprehensive package including:
- needle and syringe programs (NSPs);
- opioid substitution therapy (OST) and other drug dependence treatment;
- HIV testing and counselling (HTC);
- antiretroviral treatment (ART);
- prevention and treatment of sexually transmitted infections (STIs);
- condom programs for people who inject drugs and their sexual partners;
- targeted information, education and communication for people who inject drugs and their sexual partners;
- vaccination, diagnosis and treatment of viral hepatitis;
- prevention, diagnosis and treatment of tuberculosis (TB); and
- overdose awareness.
Combining interventions (harm reduction, HIV/HCV testing and treatment, social support, peer education) in a single setting, such as harm reduction can be an important prevention strategy for people who use drugs. In addition, some services that are already available in harm reduction services, such as rapid testing, could also be extended to other populations exposed to sexual or drug-related risk (sex workers, MSM, some communities of migrants) and general population, creating access to those services without duplicating responses and costs.
Worldwide, the benefits of harm reduction have been proven. Early implementers of harm reduction programs such as Switzerland, the UK and Australia have considerably reduced the number of new HIV infections among people who inject drugs. An example of integration of harm reduction services and testing program is IN-Mouraria, a harm reduction centre, started in 2012 by GAT, an organization of people living with HIV/HCV in Portugal. The center is located in an urban quarter of Lisbon where migration, drug use, sex work, and homelessness coexist. The project goals include increasing awareness, activism and participation of people who use drugs and performing harm reduction interventions and HIV/HCV rapid testing.
Services are provided to clients without an appointment, free of charge, and without the need for personal identification. Trained health professionals, lay workers and peer counselors perform the tests and provide information. Active referrals to hospitals are offered to all clients newly or previously diagnosed HIV/HCV positive, regardless of migrant’s legal status. Those who request it, can be escorted by peers to medical appointments. Testing and other services (condom/lube distribution, information) are also available for general population. IN-Mouraria was included as a case example in the World Health Organization´s Consolidated guidelines on HIV testing services published in July 2015.
BARRIERS TO HARM REDUCTION FOR HIV PREVENTION
A ‘war on drugs’ approach still prevails in many countries. Law enforcement authorities continue to criminalize the possession of needles and syringes and mount ‘crackdowns’ on people who inject drugs even when they are seeking treatment or visiting healthcare centers for clean needles and syringes or other services. Criminalization drives people who inject drugs away from health and HIV services and has a negative effect on HIV prevention and treatment outcomes. A paper provides an overview of the current state of HIV testing and counseling in Central Asia for PWID, highlighted that criminalization of drug use and discriminatory practices among government service providers restrict access of PWID to needle exchange programs and NGOs where HIV testing services are located. Based on interviews with drug users in Kazakhstan, Human Rights Watch (2007) reported that police often arrest clients of harm reduction services, confiscate drugs and syringes and extract bribes for possession of syringes/needles. Medical staff and government health care providers also often stigmatize and discriminate against PWID, which results in negative experiences and lower levels of trust in what the services can offer. A long Soviet initiated tradition of using health facilities for mandatory HIV testing without ensuring confidentiality of the test results contributes to the unattractiveness of these services to PWID.
Moreover, social stigma and discrimination associated with drug use is a barrier to place integration of services, as well as having a detrimental impact on the implementation of testing in this setting. Many advocate for stigma reduction initiatives as part of harm reduction programs.
In addition, the lack of sustainable funding in some countries constitutes one of the most significant barriers to harm reduction initiatives, forcing them to downsize or run at a much reduced rate.
Barriers such as people’s fears of discrimination, fears about getting a positive test result, and fears of social stigma need to be overcome to better implement HIV testing as a prevention program.