Summary/Abstract

“Harm reduction” is a pragmatic, non-judgmental set of strategies to reduce individual and community harm caused by drug use. The focus is on taking incremental steps to reduce harm rather than on eliminating drug use. Abstinence may or may not be the end goal. For people who use drugs, harm reduction aims to prevent the spread of infections (including HIV/AIDS, hepatitis C and other blood-borne infections); reduce the risk of overdose and other drug-related fatalities; and decrease the negative effects drug use may have on individuals and communities. Shaun Shelly weighs in on where the harm reduction movement is losing its way and how to get back on track.

Content

I participated in many discussions about harm reduction during the AIDS2016 conference in Durban last month. One panel, at the networking zone for people who use drugs, was organized by Harm Reduction International. Its title—“Left behind? The funding crisis facing harm reduction and the AIDS response among people who use drugs”—essentially repeated the message that was given by civil society in 2014, when it was reported that harm reduction funding was meeting only 7 percent of global need.

I doubt we needed the question mark in the panel’s title. People who use drugs have been ignored by those who loudly proclaim they are “leaving no one behind.” (Then again, is it possible to leave behind people who were never recognized as part of the group in the first place?)

My fellow panelists and I already knew that people who use drugs had been rendered virtually invisible by the main conference—a subject I’ve written about for the Open Society Foundations (OSF), who were also represented on the panel. The UN Office on Drugs and Crime (UNODC) representative was possibly wondering about his future, knowing that UNAIDS have recently cut their funding to the UNODC HIV Program—the only UN’s only dedicated HIV capacity for people who inject drugs. UNAIDS also have no point-person representing the rights of drug users.

We also knew that the targets set by the 2011 Political Declaration to reduce HIV among people who inject drugs were missed—by 80 percent. Policymakers have utterly failed.

Disturbingly, however, people who use drugs are being marginalized even within the world of harm reduction advocacy.

Almost all funding for harm reduction is HIV funding, and the majority of that money comes from the Global Fund. Because of this focus on HIV, the term “harm reduction” is increasingly being used in the narrowest sense—ignoring the philosophy of harm reduction, which is based on the far broader concept of compassionate common sense.

Officially, harm reduction can be described as ‘‘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 International, 2011).

In my opinion, this definition does not capture the true spirit of the original harm reduction movement. Harm reduction is about meeting people where they are at, without judgement, and helping them find them achieve their drug use aims (including abstinence) in the way that causes the least harm to them, irrespective of the current legal and policy framework.

This is the spirit of needle and syringe programs delivered by peers illegally out of backpacks, or of the testing of drugs at festivals under threat of arrest.

In the world of HIV funding, by contrast, harm reduction is typically reduced to the so-called “comprehensive” package of services described by the World Health Organization, UNODC and UNAIDS in their technical guidelines (see Table 1, below).

Even then, opioid substitution therapy and needle and syringe programs are emphasized above other important interventions—such as education about drug-mixing, dose response, drug-testing and, of course, challenging and changing national policies that criminalize drug use. It is very seldom that I hear anyone being funded by HIV funding talking about the broader concepts of harm reduction in academic, policy or health debates.

We need to remember: Harm reduction is not an HIV intervention—it is a basic human right that should be available to everyone.

Through their search for funding and a platform from which to advocate for drug-user rights, harm reductionists and even drug-user networks have arguably become complicit in the marginalization, pathologizing and exclusion of the very people they seek to defend.

The fact that US Drug Czar Michael Botticelli can receive a standing ovation at a harm reduction conference tells me that harm reduction has become mainstream and compromised.

Many in the field seem to have forgotten about the vast majority of drug users—non-injectors, people who aren’t using opioids exclusively, and particularly, the many people who would never develop any sort of problem with their drug use if it weren’t for government policies.

This does not mean that the sub-populations who are vulnerable to HIV are not important—they are—but it is deeply disappointing that so often, funding for harm reduction is motivated by a benevolence born of self-interest.

I, too, am guilty of using this platform to sell compromise to policymakers. In pitching to them, I regularly use examples that show how HIV can spread from people who inject drugs into the wider community—drawing the conclusion that in order to protect the wider community, we need to protect drug users.

Why the need to justify lifesaving interventions? People who inject drugs deserve protection, period—regardless of any impact on the “wider population.” And, by the way, drug users and “the wider community” are inseparable; they are one and the same.

In some of the presentations in Durban last month, I saw harm reductionists nodding their heads as doctors and policymakers called for increased opioid substitution therapy programs designed in a way that makes them more a form of social control than an aid to those accessing them.

Methadone, for example, is typically delivered from high-threshold programs with expectations of abstinence, using the lowest dose possible. Take-home doses are delayed as long as possible.

In the United Kingdom, programs are becoming increasingly “recovery”-orientated, and there have been calls for programs to be time-limited. In the United States, federal guidelines seem intent on preventing methadone users becoming integrated into their communities and buprenorphine is limited to those who can access private doctors, with numbers per doctor strictly limited.

Often, programming is dictated by funder-prescribed criteria, with little regard given to the local situation. For example, in South Africa where I live, smoking is by far the most common form of ingesting heroin or methamphetamine. Yet most of our funding from international donor funds is for the WHO comprehensive package and excludes non-injecting drug users in the indicators. These indicators are how programs are evaluated—providing services to non-injecting users does not “count,” according to these criteria.

Funders such as PEPFAR will talk about the evidence base for needle and syringe programs, but Congress still bans the use of federal funds to purchase syringes (although they recently allowed the funding of other aspects of needle and syringe programs). This is based on ideology, not science. The evidence around opioid substitution therapy is seldom taken to its logical conclusion: heroin prescribing. Some people just do better on heroin.

The concept of harm reduction needs to be advocated for in the broadest possible sense and we need funding for programs that will achieve this. Where will this money come from?

It ought to happen through the immediate decriminalization of drug use—quite simply, no longer arresting anyone for drug possession.

Harm Reduction International have called for a diversion of 10 percent of funding spent on “punitive responses” to go to harm reduction. I would argue that there should be no funding for punitive responses. If you’re not talking decriminalization, you cannot call yourself a harm reductionist.

Decriminalization should be top of the agenda not because “the current policies haven’t worked,” but because drug use should never have been criminalized in the first place. Decriminalization is the easiest, most immediate change that can be made to the policy landscape and it would significantly reduce the harms associated with drug use.

Our aim is not to rid the world of drugs, nor to stop people using drugs—both are unachievable and, on closer inspection, undesirable. Our aim is to mitigate the significant harms that drug policies have caused.

If harm reduction is reduced to a list of WHO-prescribed interventions, avoiding the imperative for decriminalization, then harm reduction becomes part of the problem. It becomes a mechanism whereby autonomy is wrested from drug-using members of the community and placed in the hands of prescriptive, paternalistic medical structures.

HIV funding has resulted in vertical and parallel programs (services that are separate from other, general health services) being established around the world for key populations—those that society seeks to exclude and control, such as sex workers, drug users, transgendered and other-gendered people. Access to day-to-day health services for drug users should not be channeled through these limited programs.

A public health approach that seeks to create healthier communities and include the health needs of drug users within the existing system is practical, essential and logical. It is only stigma that stops this from happening.

Stigma leads to the erroneous belief that drug users, especially dependent drug users, are suffering a pathology—a “substance use disorder.” The reality is that while some drug users may suffer a variety of pathologies that mediate the effects of their drug use, “problematic” and undue salience attribution (the ascribing of undue importance and meaning) to drug use, is largely created by psychosocial dislocation driven by inequality, marginalization and other factors.

In support of this understanding, it has been shown repeatedly that a simple therapeutic relationship can make a difference in people’s lives. It is incredibly sad that drug users sometimes only find these relationships in an artificial setting reserved for “treatment.”

Harm reduction service providers, such as the needle exchange I am involved in, often see significant changes in drug-using behavior simply because we demonstrate to our services users that their lives are important and meaningful.

The natural pragmatism of some harm reductionists has perhaps led to a level of diplomacy that sustains the status quo. This is understandable when the only money available to drug user advocates is HIV-related. However, we need to be creative in how that money is used, at ways of sharing resources and at ways of genuinely achieving what our movement set out to do.

We need to look at breaking the rules.

Perhaps only when the HIV funding dries up altogether will we once again have a movement that is uncompromisingly for the people and owned by the people who use drugs and their true allies and advocates.

Perhaps when the HIV imperative comes to an end we will realize that the only reason anyone cared was because they were scared by what would happen if they didn’t provide harm reduction services.

But I’m hoping for harm reductionists to wake up right now and become radical again—to think creatively, to demand decriminalization, to demand restitution for those persecuted by the War on Drugs.

We need to demonstrate to the “wider community” that we are them and they are us. When this happens, no one can be left behind. Until then, we must use HIV harm reduction funding to deliver more than a set of prescriptive interventions designed to protect those who are afraid and continue to marginalize people who use drugs.

We must use the money for harm reduction in its truest sense.

The image above shows Dean Wilson and other protestors in Vancouver, Canada campaigning for the establishment of the city’s supervised injection facility. The photograph was taken by Elaine Briere.

Table 1:

The “comprehensive package of services the World Health Organization, UNAIDS, and UNODC endorse and recommend for the prevention, treatment and care of HIV among PWID:

1.    Needle and syringe distribution, collection and disposal
2.    Opioid substitution therapy and other evidence-based drug dependence treatment
3.    HIV counselling and testing
4.    Referral for antiretroviral therapy and HIV care and support
5.    Prevention of, screening, treatment and/or referral for treatment of STIs
6.    Condom and lubricant distribution
7.    Targeted information, education and communication for PWID and their sexual partners
8.    Prevention, screening and referral for diagnosis and treatment of TB
9.    Prevention, screening and testing for hepatitis B and C (where funding allows)
10. Peer-based outreach (not always included in the list)

Shaun Shelly is dedicated to the understanding of drug use, addiction and the development of effective drug policy. He is on the advisory boards of Families for Sensible Drug Policy and Harm reduction Abstinence and Moderation Support Network (HAMS), and is a pioneer of harm reduction in South Africa. His last piece for The Influence was “’I Have Rights Like Any Other Person’—How the World’s Drug Users Created Something Great in Durban Last Week.” You can follow him on Twitter: @ShaunShelly.