Harm reduction

HIV prevalence among people who inject drugs is 28 times higher than among the rest of the population. Injecting drug use accounts for 30% of HIV infections outside sub-Saharan Africa, and up to 80% of infections in Eastern Europe and Central Asia.

The criminalisation of drug use and high rates of stigma relating to both HIV and drugs means people who use drugs experience social marginalisation and significant human rights violations such as violence and harassment. The fear of arrest or ill treatment makes many drug users reluctant to carry new syringes, attend health services or disclose their drug use to health professionals, which means they are less able to protect themselves from HIV, hepatitis, tuberculosis and other infectious diseases.

A needle exchange and other harm reduction services are provided harbour-side as the fishermen dock at dawn. (c) Alliance A needle exchange and support service aimed at fishermen is delivered harbour-side in Terengganu, Malaysia.  © International HIVAIDS Alliance

Criminalisation also means many people who use drugs are sent to prison, where they are more likely to share needles and have unprotected sex, which further increase their vulnerability to HIV.

Supporting people with harm reduction services such as methadone and needle exchange programmes curbs the spread of HIV.

Yet there is a severe lack of harm reduction services, even in countries where the need is great. Where they do exist, harm reduction services tend to target adult men, who account for the largest proportion of people who inject drugs. But this means women and young people who inject drugs, who are incredibly marginalised and vulnerable, are often overlooked.

Our approach

Person-centred harm reduction services

The Alliance takes a person-centred harm reduction approach, in that we aim to understand and respond to the diverse realities of people who use drugs in order to reduce the negative consequences of drug use. We take an approach that supports rather than punishes people who use drugs because it helps us to better understand their health risks. This approach works – there is overwhelming evidence that harm reduction is effective, practical, feasible, safe and cost-effective.

We provide rights-based, gender-sensitive harm reduction services such as clean needle and syringe programmes (NSP), opiate substitution treatment (OST) (methadone and buprenorphine), naloxone-based overdose management and information about safe injecting. These services are non-judgmental, confidential, and tailored to best meet the needs of the people using them. For example, we look to locate NSPs where drug users live or spend time, and position them so that people can come and go discreetly.

We also advocate for, and provide access to, integrated HIV and sexual and reproductive health and rights services (SRHR) for people who use drugs and their sexual partners. These services include condom distribution, HIV/STI testing, family planning, antiretroviral treatment, opportunistic infection prevention, TB prevention and treatment, and hepatitis C treatment.

For many people who use drugs, HIV is one of many concerns, alongside the need for safety, food, money, a home, a supportive family and community, a job, education and privacy. Many women who use drugs have particular needs for protection from violence and exploitation, and many people who use drugs are parents with children who also have multiple needs. We provide programmes that address these needs alongside the provision of health services.

We understand that people who use drugs are part of wider communities, and we work with these communities to address the social and structural drivers that increase drug users’ vulnerabilities to HIV and other infections.

When faced with human rights abuses against people who use drugs, we advocate to defend their rights, in particular their right to health, advocating for policy makers, police and health authorities to base their policies and practice on the evidence for harm reduction, rather than legal and social norms regarding drug use. We advocate for laws and policies that support HIV prevention, treatment and care, and that protect people who use drugs from harassment and abuse.

We also educate local communities, police and officials about responding to drug use humanely, and in order to protect public health. We challenge stigma and discrimination through campaigns and community education, and we mobilise communities to plan and act together to prevent HIV and care for people with HIV who use drugs.

Involving people who use drugs

The Alliance promotes the meaningful involvement of people who use drugs in decision-making and in the planning, delivery and evaluation of services for drug users.

We support the development of networks of people who use drugs – independent peer-based networks who engage in national and regional advocacy – along with systems and processes that ensure people who use drugs are an essential part of our service delivery  – as managers and other staff, as advisors and key informants – as well as beneficiaries. 

We take this approach because involvement and participation is a right and because it results in more effective, higher quality services. People who use drugs have knowledge and expertise that is different to the knowledge and expertise of other service providers. Drug users can reach other people who use drugs and are more likely to be trusted as credible educators and providers of support.

Involving people who use drugs in advocacy can also put a ‘human face’ to drug use and be an effective tool for diminishing stigma. For example, we will connect advocates from communities of people of use drugs with health care workers so they can better understand the issues they face, resulting in service providers who understand how to treat people who use drugs with respect and dignity.

As a result of the Alliance’s community-led approach, our programmes for people who use drugs will often have strong peer-led and outreach components. These are particularly effective at accessing hard-to-reach drug users.

Our experience

  • 264,342 people who use drugs and their sexual partners and family members were reached by Community Action on Harm Reduction (CAHR), an ambitious project that ran between 2011 and 2015 in China, India, Indonesia, Kenya, Malaysia and Myanmar. Services included needle and syringe exchanges, HIV prevention, testing and treatment, services for other infections such as TB, advocacy work, income generating activities, skills building, and support for drug users’ partners, children and communities. The activities developed in this project are continuing under the the Alliance Integrated Harm Reduction Programme.
  • The Alliance Integrated Harm Reduction Programme (AIHRP) is the next iteration of the Community Action on Harm Reduction programme. Running between 2016-2020, this programme supports Alliance Linking Organisations in China, India, Indonesia, Malaysia, Myanmar, Kenya, Senegal and other countries to explore and implement harm reduction service delivery models that are more effective, and bring harm reduction services to areas where it is currently not available.
  • Partnership to Inspire, Transform and Connect the HIV response (PITCH) is a four year (2016-2020) strategic collaboration between Aidsfonds, the Alliance and the Dutch Ministry of Foreign Affairs that strengthens the capacity of civil society organisations in Indonesia, Kenya, Mozambique, Myanmar, Nigeria, Uganda, Ukraine, Vietnam and Zimbabwe to advocate for equal access to sexual and reproductive health and rights for those most affected by HIV, and decriminalisation of key populations/. 

Our results

  • Alliance Linking Organisations remain global leaders in harm reduction, reaching 303,456 people who use drugs in 2016.
  • In the same year, Linking Organisations were visible and influential actors in global policy spaces such as the 59th Commission on Narcotic Drugs and the UNGASS on Drugs, where member states agreed an Outcome Document that acknowledged the importance of harm reduction approaches and treatments for ending AIDS.

Key resources

Good Practice Guide: HIV and drug use 

This guide is aimed at people who are developing and delivering HIV and harm reduction programmes or services at a community level in resource-poor settings. It is also relevant for those working in contexts with low levels of capacity or political support for harm reduction programmes.

Good practice guide for employing people who use drugs

Practical tools and suggestions on how to meaningfully involve people who use drugs in peer-led interventions. It also looks at policies that routinely exclude people who use drugs from the workplace.

Reaching drug users: A toolkit for outreach workers

A guide on doing outreach work among communities of people who use drugs, in particular among injecting drug users. It includes suggestions on how to optimise the number of clients served by each outreach worker in order to ensure cost effectiveness.

Setting the scene: Assessing and planning with harm reduction partners

This report summarises the results of site assessments on HIV and drug use in China, India, Indonesia, Kenya and Malaysia. 

Policy Position on Decriminalisation and HIV

A declaration of principles that Linking Organisations subscribe to as members of the Alliance.