24 th Meeting of the UNAIDS Programme Coordinating Board Geneva, Switzerland June 2009

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1 8 June th Meeting f the UNAIDS Prgramme Crdinating Bard Geneva, Switzerland June 2009 HIV preventin amng injecting drug users

2 Page 2/25 Additinal dcuments fr this item: nne Actin required at this meeting - the Prgramme Crdinating Bard is invited t: (See decisin paragraph 70 belw) i. Request the UNAIDS Cspnsrs and the Secretariat, in particular UNODC, t wrk with natinal gvernments t address the uneven and relatively lw cverage f services amng injecting drug users and t develp cmprehensive mdels f apprpriate service delivery fr injecting drug users in line with the UNAIDS/UNODC/WHO Technical Guide fr cuntries t set targets fr Universal Access t HIV preventin, treatment and care fr injecting drug users ; ii. Request UNAIDS and its stakehlders t wrk with multilateral dnrs, and natinal gvernments, t facilitate greater resurce mbilizatin n this issue, cnsistent with the level f identified need recgnizing that resurces shuld be expanded fr service delivery and capacity develpment t enable cmmunities t prvide preventin, care and supprt services t drug users living with HIV n a larger scale whilst, at the same time, tackling the issue f stigmatizatin and discriminatin; iii. Request UNAIDS t intensify its assistance t, and wrk with, civil sciety, including glbal, reginal and natinal harm reductin assciatins and assciatins f peple wh use drugs, aimed at advcating fr anti-stigmatizing, anti-discriminating, evidencebased appraches t HIV and Hepatitis C Virus (HCV) epidemics at natinal, reginal and glbal levels; iv. Call upn Member States t further harmnize laws gverning HIV and drug use, bth frm a public health and a human rights perspective; v. Request the UNAIDS Cspnsrs and the Secretariat, in particular UNODC, t supprt natinal authrities t align plicies, clarify rles and respnsibilities f varius natinal entities - including drug cntrl, the penitentiary system, public health and civil sciety - and supprt increased capacity and resurces fr prvisin f a cmprehensive package f services fr injecting drug users; vi. Call upn Member States and civil sciety rganizatins, in additin t specific interventins that target injecting drug users, t develp guidance and prgramme mdels t respnd t the needs f ther sub-grups f drug users, including female drug users, drug users wh als exchange sex fr mney r drugs, drug users wh end up in prisn settings, underage and yung drug users, migrant drug users, drug users amngst refugees and ther displaced ppulatins, stimulant 1 and ply-drug users and men wh have sex with men wh use drugs; (cntinued verleaf)

3 Page 3/25 vii. Call upn Member States, civil sciety rganizatins and UNAIDS t increase attentin t certain grups f nn-injecting drug users, especially thse wh use crack ccaine and amphetamine type stimulants, and their link t increased risk f cntracting HIV thrugh high-risk sexual practices, as well as t respnses t emerging epidemics f injecting drug use in many African cuntries; and viii. Recgnizing that existing data n HIV and drug use are far frm adequate in bth quality and quantity, requests UNAIDS t supprt greater investment in data cllectin required t infrm the develpment f HIV preventin, treatment, care and supprt initiatives, resurce allcatin and cmprehensive service delivery, including a system f regular and rapid assessments f the risk ptential fr new epidemics where anecdtal evidence indicates an emerging prblem, and calls upn Member States t ensure accurate estimates are made f the size f IDU ppulatins, while taking int cnsideratin the shifting patterns f injectin. Cst implicatins fr decisins: draft decisin pint (viii) wuld require a budget f USD 400,000 fr implementatin

4 Page 4/25 I INTRODUCTION 1. Decisin 11.9 f the 20th Prgramme Crdinating Bard meeting requested; the UNAIDS Secretariat and Cspnsrs, as a matter f pririty, t wrk at the natinal level t assist gvernments t scale up HIV preventin amng injecting drug users, in line with the decisins f the PCB n the UNAIDS Plicy Psitin Paper n Intensifying HIV Preventin. This paper reprts n prgress made by UNAIDS since the adptin f the Plicy Psitin Paper in 2005 in supprt f scaled up effrts in relatin t HIV preventin amng injecting drug users, and related plicy and guidance issues. 2. The UNAIDS Plicy Psitin Paper made the fllwing recmmendatins in relatin t HIV preventin respnses amng injecting drug users: Prevent transmissin f HIV thrugh injecting drug use by develping a cmprehensive, integrated and effective system f measures that cnsists f the full range f treatment ptins, (ntably drug substitutin treatment) and the implementatin f harm reductin measures (thrugh, amng thers, peer utreach t injecting drug users, and sterile needle and syringe prgrammes), vluntary cnfidential HIV cunseling and testing, preventin f sexual transmissin f HIV amng drug users (including cndms and preventin and treatment fr sexually transmitted infectins), access t primary healthcare, and access t antiretrviral therapy. Such an apprach must be based n prmting, prtecting and respecting the human rights f drug users (p. 34) There are apprximately 16 millin injecting drug users wrldwide, with abut 3 millin being infected with HIV. The largest numbers f HIV psitive peple wh inject drugs are in Eastern Eurpe, East and Sutheast Asia and Latin America. HIV prevalence amng sme grups in these regins is estimated at ver 40 per cent. New epidemics f injecting drug use are als emerging in sub-saharan Africa. 4. Injecting drug users ften have multiple risks f cntracting r transmitting HIV, Tuberculsis (TB) and ther infectius diseases. The use f cntaminated injectin equipment amng injecting drug users is amng the mst explsive f the rutes f transmissin f HIV. Drug users ften face incarceratin fr pssessin f drugs and/r sex wrk, and where injecting drug users are als invlved in sex wrk and/r male t male sex, risks and vulnerability are als increased. Drug use is als highly stigmatized bth within the general cmmunity and by health care wrkers, further marginalizing peple with drug dependence prblems. This means that HIV interventins may nt be available t them, r that they are unable r unwilling t access services fr fear f recriminatin. 5. There is evidence that injecting drug users are willing t prtect themselves, their sexual partners and the sciety at large. HIV transmissin thrugh injecting drug use can be effectively prevented by prviding a cmprehensive package f services in utreach t injecting drug users and their injecting r sexual partners. The earlier the implementatin f HIV preventin prgrammes, the mre effective and cheaper the specific measure will be. 1 Nte that in its decisins endrsing the Plicy Psitin Paper the PCB als nted the United States statement that the United States culd nt fund needle and syringe prgrammes because such prgrammes are incnsistent with current United States law and plicy and ntes that this external partner cannt be expected t fund activities incnsistent with its wn natinal laws and plicies (decisin 8.6). Mre recently hwever the United States delegatin t the 22 nd Cmmissin n Narctic Drugs meeting in Vienna in March 2009 nted frmally that the United States nw supprts the funding f needle and syringe prgrammes (cnsistent with the plicy f the Obama administratin t supprt the remval f the Federal ban n funding f needle and syringe prgrammes dmestically).

5 Page 5/25 6. A cmprehensive apprach that includes measures such as access t sterile injectin equipment; piid substitutin therapy such as with methadne and buprenrphine; cmmunity-based utreach; and prviding HIV preventin infrmatin n safer injecting and safer sex is amng the mst effective and cst-effective way t prevent the epidemic amng injecting drug users 2. Additinally, injecting drug users have brader health needs linked t HIV, such as preventin f hepatitis, tuberculsis, mental health, and verdse preventin. As well, wider scial cnditins need t be addressed, including prtecting human rights and reducing stigmatizatin in health and ther settings, and making specific interventins amng peple in detentin, f which large prtins are injecting drug users. Invlvement f drug users is essential cmpnent f making HIV plicies and practices mre effective. 7. While the fcus in HIV preventin amng drug users has cncentrated n injectin, as an efficient mde f transmissin f HIV, there are als HIV-related risks attached t ther frms f drug use. In particular, there is a majr nexus between amphetamine use and HIV transmissin in sme ppulatin grups, and there are cncerns abut significant amphetamine use fuelling emerging HIV epidemics amng, in particular, gay and ther men wh have sex with men in parts f Suth-east Asia as well as ther regins. 8. The evidence base in relatin t the effectiveness f needle and syringe prgrammes and piid substitutin therapy in reducing HIV risks is cnsiderable 2, hwever there remain majr unmet challenges principally related t the illegal status f sme f these prven interventins in many cuntries. When these prgrammes are nt legal r are incnsistent with plicing practices, injecting drug users can be driven away frm services and/r int prisns and these plicies can fuel the spread f the epidemic. 9. UNAIDS has prvided cnsiderable supprt t scaling up f effective HIV respnses amng drug users since the adptin f the Plicy Psitin Paper n Intensifying HIV Preventin, including technical supprt and building the capacity f civil sciety and gvernment respnses. Hwever, majr gaps in cverage and barriers t effective prgramming remain. The present reprt prvides a summary verview f respnses that have been implemented between by UNAIDS Secretariat and its Cspnsrs, in particular UNODC and WHO, tgether with civil sciety rganizatins, in respnding t the epidemics thrugh a range f activities at natinal, reginal and glbal level. Epidemilgical situatin n HIV and injecting drug use 10. Injecting drug use is well established in every regin f the wrld and appears t be an emerging phenmenn in many cuntries where it has nt been previusly reprted. In 2008 injecting drug use had been reprted in 148 cuntries and territries 3, 19 cuntries mre than in ; these 148 cuntries accunt fr 95 per cent f the wrld s ttal ppulatin. 11. The prevalence f injecting drug use varies cnsiderably arund the wrld bth between and within cuntries (see Figure 1). It is estimated that, wrldwide, there are 15.9 millin peple wh inject drugs. Because f the limitatins f the data available there is cnsiderable uncertainty arund this figure which might range anywhere between 11 and 21 2 Institute f Medicine (2007) Preventing HIV Infectin amng Injecting Drug Users in High Risk Cuntries: An Assessment f the Evidence Natinal Academies Press, Washingtn DC 3 Mathers BM, Degenhardt L, Phillips B, Wiessing L, Hickman M, Strathdee SA, et al. Glbal epidemilgy f injecting drug use and HIV amng peple wh inject drugs: a systematic review. The Lancet. 2008;372: Ball AL, Rana S, Dehne KL. HIV Preventin amng Injecting Drug Users: Respnses in Develping and Transitinal Cuntries. Public Health Reprts June;113 (1):12.

6 Page 6/25 millin (see Table 1). China, the United States, the Russian Federatin and Brazil have the largest (midpint estimate) ppulatins f injectrs and accunt fr 45 per cent f the ttal estimated wrldwide ppulatin f peple wh inject drugs. 12. HIV infectin amng peple wh inject drugs has been reprted in 120 cuntries. In a further 20 cuntries where injecting is knwn t ccur, n reprts f HIV amng injectrs are available, and in 8 cuntries HIV has nt been detected r is less than 0.01 per cent. The prevalence f HIV amng injectrs varies dramatically between and als within cuntries. Taking int accunt the different sized injecting drug user ppulatins, Latin America and Eastern Eurpe were determined t have the highest estimated reginal prevalence f HIV amng injectrs. 13. It is estimated that wrldwide up t 3 millin peple wh inject drugs are infected with HIV (see Table 1). Because f the limitatins f the data available there is cnsiderable uncertainty arund this figure, which might range between 0.8 and 6.6 millin. 14. Regins with the largest numbers and highest cncentratin f HIV psitive injectrs include Eastern Eurpe, East and Suth East Asia, and Latin America; these three regins accunt fr nearly three quarters f the wrld s injectrs estimated t be living with HIV. The prevalence f HIV amng injectrs is higher than 40 per cent in many natinal and subnatinal injecting drug use ppulatins in these regins. 15. In rder t effectively target preventin, treatment and care t thse wh need it, data cllectin abut injecting drug use, HIV and ther infectius diseases requires much greater attentin.

7 Figure 1. Estimated midpint prevalence f injecting drug use amng yearlds. UNAIDS/PCB(24)/09.9.Rev.1 Page 7/25

8 Page 8/25 Table 1. Reginal and glbal estimates f 2007 prevalence and the number f peple wh inject drugs and the prevalence and number wh may be HIV psitive. Regin Eastern Eurpe Western Eurpe East and Suth East Asia Estimated number f peple wh inject drugs Midpint estimate 3,476,50 0 1,044,00 0 3,957,50 0 Suth Asia 569,500 Central Asia 247,500 Caribbean 186,000 2,018,00 Latin America 0 Canada and 2,270,50 United States 0 Pacific Island States and Territries 19,500 Australia and New Zealand 173,500 Middle East Nrth Africa 121,000 Sub-Saharan 1,778,50 Africa* 0 Extraplated glbal 15,861,5 estimates 00 Range Estimated reginal mid-pint prevalence f injecting drug use amng year lds Estimated number f peple wh inject drugs and wh are HIV psitive Mid-pint estimate (2,540,000-4,543,500) 1.50% 940,000 (816,000-1,299,000) 0.37% 114,000 (3,043,500-4,913,000) 0.27% 661,000 (434, ,500) 0.06% 74,500 (182, ,000) 0.64% 29,000 (137, ,500) 0.73% 24,000 (1,508,000-2,597,500) 0.59% 580,500 (1,604,500-3,140,000) 0.99% 347,000 Range Estimated reginal midpint prevalence f HIV amng injecting drug users (18,500-2,422,00 0) 27.04% (39, ,500) 10.90% (313,000-1,251,50 0) 16.70% (34, ,500) 13.08% (16,500-47,000) 11.81% (6,000-52,500) 12.90% (181,500-1,175,50 0) 28.77% (127, ,000) 15.29% (14,500-25,000) 0.36% 500 (105, ,500) 1.03% 2,500 (89, ,500) 0.05% 3,500 (534,500-3,022,500) 0.43% 221,000 (11,008,500-21,222,000) 0.37% 2,997,500 (< ) 1.37% (500-6,000) 1.51% (1,500-6,500) 2.94% (26, ,000) 12.43% (764,000-6,589,00 0) 18.90% * Estimates fr sub-saharan Africa shuld be viewed with cnsiderable cautin as the prevalence estimates were derived frm three f 47 cuntries in the regin (Suth Africa, Mauritius, and Kenya). Additinally, the estimated range f injecting drug use fr this regin was derived by applying the reginal bserved errr; this large errr band reflects the cnsiderable uncertainty arund these estimates. (Caveat in the riginal) Surce: Mathers BM, Degenhardt L, Phillips B, Wiessing L, Hickman M, Strathdee SA, et al. Glbal epidemilgy f injecting drug use and HIV amng peple wh inject drugs: a systematic review. The Lancet. 2008;372:

9 Page 9/25 Cmprehensive package fr the preventin, treatment and care f HIV amng injecting drug users 16. The UN system wrks glbally and at reginal and cuntry levels t help cuntries and civil sciety rganizatins t develp and implement cmprehensive prgrammes fr the preventin, treatment and care f HIV in relatin t drug use, as part f mainstream public health and HIV preventin prgrammes. The prgrammes and services include thse aimed at reducing the demand fr drugs, including educatin, cmmunicatin and scial change activities, as well as prgrammes and services directed twards imprving the health f drug users. Prrammes directed twards injecting drug users shuld include the fllwing nine activities 5 : Needle and syringe prgrammes (NSPs); Opiid substitutin therapy (OST) and ther drug dependence treatment; HIV testing and cunseling (T&C); Antiretrviral therapy (ART) fr drug users living with HIV; Preventin and treatment f sexually transmitted infectins (STIs); Cndm prgrammes fr injecting drug users and their sexual partners; Targeted infrmatin, educatin and cmmunicatin (IEC) fr injecting drug users and their sexual partners; Vaccinatin, diagnsis and treatment f viral hepatitis and Preventin, diagnsis and treatment f tuberculsis. HIV service cverage amng injecting drug users 17. Data n the cverage f HIV services amng injecting drug users is cllected thrugh cuntry reprts n the mnitring f cmmitments made at the UN General Assembly Special Sessin n HIV/AIDS in The mst recent glbal rund f reprting in 2008 shwed that the number f cuntries reprting n HIV preventin prgrammes fr injecting drug users had increased frm 27 in 2005 t 55 in Hwever, detailed survey infrmatin n the agreed glbal indicatr (the prprtin f injecting drug users wh reprt knwing where they culd receive an HIV test and be prvided with cndms and sterile needles and syringes) was available frm nly 15 cuntries, and in these cuntries the median estimate was that 46 per cent f the ppulatin f injecting drug users was reached with HIV preventin prgrammes The WHO, UNODC, UNAIDS Technical guide fr cuntries t set targets fr universal access t HIV preventin, treatment and care fr injecting drug users (2009) was designed t cntribute t imprving availability f harmnized data at the cuntry level in relatin t all the essential elements f a cmprehensive apprach t HIV preventin and treatment. 19. The Reference Grup t the United Natins n HIV and Injecting Drug Use is presently wrking n a glbal review f Estimates f HIV preventin and care service cverage fr injecting drug users, and its reprt is expected t be available in the curse f That reprt will address the number f sites ffering, and number f drug users reached, with needle and syringe prgrammes, piid substitutin treatment, ther drug dependency 5 WHO, UNODC, UNAIDS (2009) Technical guide fr cuntries t set targets fr universal access t HIV preventin, treatment and care fr injecting drug users. WHO, Geneva 6 UNAIDS (2008) 2008 Reprt n the Glbal AIDS Epidemic UNAIDS, Geneva.

10 Page 10/25 treatment, anti-retrviral therapy, cunselling and testing fr HIV, sexual health services and cndm prgrammes, and hepatitis C screening and treatment. 20. These glbal effrts in estimating the numbers f drug users, HIV amng drug users and cverage f services are als supplemented reginally, fr example, the Eurpean WHO ffice supprt fr HIV/AIDS surveillance in 53 cuntries in that regin lks at the HIV respnse and injecting drug user access t antiretrviral therapy as well as at the prprtin f HIV transmissin thrugh injecting drug use. In additin several mdeling exercises n injecting drug use ppulatins and HIV are being cnducted n a regular basis. Examples are the WHO and UNODC jint cuntry assessments in Estnia and Lithuania. II UNAIDS RESPONSE TO INJECTING DRUG USE AND HIV ( ) 21. UNAIDS, including all the Cspnsrs, especially UNODC which under the technical divisin f labur has the lead rle in relatin t drug use, as well as significant levels f activity by WHO, UNICEF, the Wrld Bank and UNFPA and UNDP in sme regins, as well as crdinating supprt by the UNAIDS Secretariat, have advcated, prmted and prvided technical supprt t relevant gvernment agencies (including health, law enfrcement, judiciary and scial services) and civil sciety rganizatins t develp human rights-based, gender- and age-respnsive and equitable AIDS plicies and prgrammes fr injecting drug users. These activities are designed t assist cuntries in their effrts t reduce demand fr drugs, including thrugh prgrammes directed at yung peple r ther vulnerable grups, as well as prgrammes designed t imprve the health f drug users, including access t a full range f vluntary treatment and rehabilitatin ptins. The activities supprt cuntries in resurce mbilizatin, develpment f evidence-infrmed plicies, develpment and adaptatin f nrmative guidelines and ther tls, establishment f multisectral wrking grups, setting natinal targets, assessment f prgrammatic needs and advcating fr and prviding technical supprt t cuntries fr implementing a cmprehensive package f interventins fr HIV preventin, treatment and care fr injecting drug users. 22. As examples f specific fcus areas f different UN agencies, UNODC advcates fr and prvides technical supprt and training fr prvisin f cmprehensive HIV preventin services t address the special needs f female drug users and implementatin f plicies and prgrammes n HIV amng law enfrcement and prisns staff in several cuntries; WHO supprts the implementatin and scale-up f piid substitutin therapy and HIV treatment and care as well as the develpment f clinical prtcls and delivery f related training; the Wrld Bank has identified gaps in HIV preventin prgramming in relatin t injecting drug users and prvided financial supprt t cuntry prgramming t fill these gaps, as well as supprting natinal and reginal cnsultatin effrts; UNICEF advcates fr and prvides prgramming guidance n wrking with adlescents at high risk f HIV infectin, including thse wh inject drugs, delivers life skills and yuth leadership develpment activities which include addressing drug use, and prvides supprt t interventins in preventing mther-t-child transmissin amng hard-t-reach drug dependent pregnant wmen. 23. As the rle f civil sciety rganizatins in service prvisin, cmmunity engagement and advcacy is indispensable UNAIDS has sught t prmte links between civil sciety, gvernments and ther bdies, and develp the capacity f civil sciety rganizatins. Civil sciety has been a catalyst in alerting the wrld t the undermining effect f stigma and discriminatin; in demanding access t HIV preventin and care services fr injecting drug users; in facilitating meaningful participatin f injecting drug users and f peple with HIV in

11 Page 11/25 the develpment and implementatin f HIV plicies and prgrammes; and in establishing glbal and reginal advcacy netwrks and crdinatin structures. 24. Gvernments and civil sciety have been supprted t develp r adapt legislatin, plicies and strategies fr equitable access t HIV preventin, treatment, care and supprt services and cmmdities amng injecting drug users thrugh varius activities, such as cnducting legal and plicy reviews as they relate t injecting drug users, develping technical guidance and tls, prviding training and ther technical supprt amng parliamentarians, judges and law enfrcement fficials n the human rights f injecting drug users. 25. In cllabratin with relevant natinal and internatinal partners, the UNAIDS Secretariat and Cspnsrs, in particular UNODC and WHO, have develped, adapted and disseminated evidence-based guidelines and best practices related t AIDS preventin, treatment and care fr injecting drug users, including gender respnsive peratinal tls and guidelines and prvided technical assistance t gvernment and civil sciety fr their implementatin. UNAIDS supprt t natinal effrts at reginal and cuntry levels Eastern Eurpe and Central Asia 26. In the Russian Federatin, the activities have cvered a wide range f research and capacity building activities frm cnducting studies, jintly by UNODC and WHO, n HIV risk behaviur and prevalence invlving injecting drug users t training fr the Federal Drug Cntrl Service fficers n internatinal legal framewrk t supprt needle and syringe prgrams and piid substitutin therapy fr injecting drug users. The aim is t institutinalize training f law enfrcement fficers n HIV practices in line with human rights and internatinal standards and t reduce stigmatizatin f injecting drug users. In additin, drug referral and case management prgrams fr injecting drug users have been established, and develpment and implementatin f a lw threshld centre and mbile utreach prgrams fr injecting drug users have been supprted. Als, a training manual n HIV Peer-t Peer cunseling fr injecting drug users has been prduced in Russian. Supprt frm the UNAIDS secretariat and UNDP has been prvided t natinal civil sciety netwrks t develp a cmmn psitin f civil sciety n harm reductin, HIV preventin and participatin f PLHIV in the respnse. The Wrld Bank has wrked with the UK Department fr Internatinal Develpment in relatin t prgramming effrts cncerning drug users. 27. In Ukraine, number f activities in relatin t advcacy, plicy develpment and technical supprt have been carried ut fr the establishment and maintenance f harm reductin prgrammes in the cmmunity and in prisns (including needle-syringe prgrammes and piid substitutin therapy) alng with HIV treatment and care fr drug users (including thrugh the WHO supprted HIV/AIDS Treatment and Care Knwledge Hub in Kiev). Develpment f a Natinal AIDS Strategic Prgramme fr invlving peple wh inject drugs in implementatin f key interventins has been supprted. High level advcacy effrts have supprted the establishment f relevant natinal plicies and prtcls. 28. In Estnia, Latvia and Lithuania, develpment f evidence-based natinal AIDS prgrammes invlving cmmunity grups have been supprted. In Latvia and Lithuania, increasing the number f sites prviding methadne maintenance treatment and needle and syringe prgrammes have been supprted. Activities and availability f strategic infrmatin have included capacity building f individuals and rganizatins thrugh the small grants

12 Page 12/25 prgrammes, supprting a number f studies and reviews, prviding training, implementing study turs and facilitating participatin in prfessinal netwrks. The WHO and GTZ supprted reginal Harm Reductin Knwledge Hub based in Vilnius has played an imprtant rle in delivering technical supprt in the regin. 29. In Rmania, activities have been fcusing n develpment and implementatin n cmprehensive HIV preventin services fr injecting drug users, and prviding related training, including supprt f the technical secretariat fr develping the new HIV/AIDS strategy. Mrever, pilt prjects f needle prgramming and piid substitutin therapy have been launched. 30. In Belarus, UNAIDS (including UNICEF, UNFPA and WHO) has cntinued t empwer NGOs in preventin activities amng injecting drug users especially t address stigma and discriminatin. In Armenia the Glbal Fund supprted Natinal AIDS Prgramme has increased cverage f activities including Injecting Drug Users. In Gergia UNODC has supprted HIV preventin effrts primarily fcused n injecting drug users and prisners, and WHO has assisted with training in relatin t piate addictin treatment; 31. In Central Asia (Azerbaijan, Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan, Uzbekistan), a wide range f capacity building activities fcusing n human rights-based and evidence-infrmed plicies and strategies have been cnducted t prmte the rights and needs f injecting drug users. The activities have als included cnducting legislatin analyses, drafting expert recmmendatins, and prviding technical assistance fr develping and implementing natinal actin plans fr prviding piid substitutin therapy. Specific activities have included scaling up f interventins in specific gegraphic lcatins in Azerbaijan; mbilizing the nn-gvernmental sectr in Kazakhstan; supprting natinal expert reviews f legislatin and standards fr HIV- and drug use-related services in Turkmenistan as well as plice training. 32. In Central and Eastern Eurpe and the Cmmnwealth f Independent States (CEE/CIS), a number f UNICEF supprted activities n preventin f HIV amng injecting drug users have als been implemented, including rganizing the Internatinal Cnference n Drug Addictin, HIV and Pregnancy: Prtecting the Health f the Mther and Baby (Kazan, the Russian Federatin, Nvember 2008), and cnducting analysis and dcumentatin f internatinal practices and lessns learnt n piid substitutin therapy fr pregnant drug users. In Albania, Rmania, Mldva, Ukraine, Bsnia & Herzegvina, Serbia, Uzbekistan, UNICEF has cntributed t strengthening the evidence base n risk prfiles f adlescent and yung injecting drug users (15-24 year lds) thrugh cnducting behaviral and interventin related research; in Ukraine, it has advcated fr and cnducted analysis f the risk and prtective factrs in the initiatin f injecting drug use resulting in a better understanding n key drivers f initiatin int injecting drug use by adlescents and better infrmed HIV preventin strategies, and implemented preventin f mther-t-child transmissin interventins aimed at reaching drug-using wmen in selected sites, in cllabratin with natinal partners and ther UN agencies; in Rmania, Mldva, Ukraine, UNICEF has supprted the develpment f HIV preventin interventins amng adlescent injecting drug users and prvisin f services t street children. In Mldva the Wrld Bank has financed a five year prject n AIDS cntrl which has included methadne treatment, needle exchange and cunseling in prisns.

13 Page 13/25 Suth and Suth-East Asia 33. In India, UNAIDS in the cntext f supprt fr the natinal AIDS prgramme has supprted engagement f NGOs, such as the Indian Harm Reductin Netwrk and the Psitive Wmen s Netwrk, in develpment f the natinal plan fr scaling up piid substitutin therapy. The Indian Netwrk f Psitive Peple has been supprted in addressing existing barriers t access free antiretrviral therapy fr injecting drug users and develping related gender-sensitive training mdules. The Psitive Wmen Netwrk has been supprted t reach ut t regular partners f male injecting drug users and develp apprpriate interventins, including thrugh assisting establishment f apprximately 300 self-help grups f partners f drug users and female injecting drug users in Nrtheast India. Publishing legal and plicy reviews n impediments t harm reductin in Suth Asia have been supprted. The Gvernment has been prvided with evidence t supprt its effrts n develpment f a plicy fr piid substitutin therapy, and technical supprt has been prvided t Natinal AIDS Cntrl Organizatin fr develping peratinal guidelines and standard perating prcedures n piid substitutin therapy, as well as supprt t prgramming aiming t reach 190,000 injecting drug users with HIV preventin effrts. 34. In Nepal, the injecting drug user cmmunity has been actively engaged in prgramming and scaling up f substitutin therapy services, and harm reductin cmpnents have been supprted t be included in the Natinal Actin Plan and a related Natinal Advcacy Plan. The develpment f a Natinal Harm and Demand Reductin Strategy 2008 has been supprted in accrdance with the human rights-based apprach. Service prviders, civil sciety representatives and plicy makers have been jintly trained n Treatment fr Psitive Injecting Drug Users by Family Health Internatinal (FHI), WHO and UNODC. NGOs have been supprted in varius ways in prvisin f a cmprehensive package f services fr injecting drug users. 35. In Afghanistan, Pakistan and Nepal, new prjects have been designed and launched fr female drug users addressing their special needs, and necessary training fr civil sciety rganizatins and gvernment agencies rganized. In Afghanistan, prvisin f piid substitutin therapy has been prmted amng all relevant senir gvernmental cunterparts. Relevant service prviders, including civil scieties and gvernmental partners, have been trained n gender sensitive, human rights -based HIV preventin measures fr injecting drug users. In Pakistan, new services have been established fr female injecting drug users and spuses f HIV psitive drug users, and internatinal study turs fr plicy makers t piid substitutin therapy prgrammes have been rganized. UNHCR and UNODC are als cllabrating in a three year reginal prject t ensure that refugees in Iran and Pakistan and returnees in Afghanistan have access t harm reductin services. 36. In Bangladesh the Wrld Bank has supprted a natinal HIV preventin prject thrugh which 11 NGOs were cntracted t prvide harm reductin services including cndm prmtin, STI management, needle and syringe exchange, detxificatin, as well as peer educatin and advcacy, thrugh 145 drp in centers. As well UNAIDS has facilitated the methadne maintenance prgramme, and in-service training was given t frntline plice persnnel in Dhaka t sensitize them arund drug dependence in rder t help prevent spread f HIV infectin amng IDUs and their partners. Tgether with ther partners, UNAIDS supprted the establishment f a drug detxificatin and rehabilitatin facility at the central Plice Hspital

14 Page 14/ In Iran, an extensive supprt has been prvided acrss a wide range f HIV preventin and treatment activities amng injecting drug users. Invlvement f ex-injecting drug users in Gvernmental plicy making prcesses has been supprted, and technical assistance prvided fr develping gender respnsive and equitable AIDS plicies and prgrammes fr injecting drug users. The WHO-supprted Harm Reductin Knwledge Hub established in Tehran has played a crucial rle in the reginal MENAHRA (Middle East and Nrth African Harm Reductin Assciatin) netwrk and in delivering technical supprt. 38. In Sri Lanka preventin wrk with drug users has included strengthening 5 cmmunity based prgrammes arund the cuntry. 39. In Vietnam, the invlvement f injecting drug users in design, planning, and implementatin f lcal HIV preventin and treatment activities, revisin f the Law n Drugs and surveillance n injecting drug use and HIV have been supprted. Internatinal evidence n drug treatment and efficacy f piid substitutin therapy, and human rights cncerns related t cmpulsry drug treatment centers fr injecting drug users have been disseminated and natinal guidelines n piid substitutin therapy and needle and syringe prgrammes have been drafted. The advcacy fr review and revisin n lng-term detentin f drug users in cmpulsry drug detxificatin centers addressing the needs f ethnic minrity injecting drug users and Peple Living with HIV/AIDS in several rural prvinces has been supprted, and expanding cverage f HIV preventin prgramming in several HIV high-burden rural prvinces facilitated, with a majrity f prvinces nw cvered. Funding supprt fr needle exchange and peer educatin activities has been prvided, bth by the Wrld Bank and a number f ther funders. 40. In Cambdia, cnsiderable advcacy wrk has been undertaken t establish an apprpriate legislative and plicy envirnment and ensure drug cntrl plicies and legislatins adpt harm reductin principles. The revisin f the Natinal Strategic Plan fr Illicit Drug Use related t HIV and AIDS has been facilitated and technical supprt prvided fr the implementatin f methadne maintenance treatment. In the cntext f natinal effrts t reach universal access targets in relatin t HIV and drug users, WHO, UNODC, UNICEF, UNESCO and the UNAIDS Secretariat have all been invlved in supprt t multi-faceted respnses which include wrk with yuth in and ut f schl, creating peratinal framewrks fr needle and syringe exchange and piid substitutin therapy, access t HIV treatment and care fr drug users, and strengthening f cmmunity netwrks t address stigma. 41. In La PDR, the invlvement f drug users in the Task Frce n HIV and Drug Use has been supprted, and the Task Frce supprted t deliver timely interventins t prevent and treat HIV/AIDS and reduce risk f drug use. 42. In Thailand, the Harm Reductin Wrking Grup has been re-established and inclusin f drug users in the grup supprted and guidelines n needle and syringe prgrammes have been prvided t civil sciety partners. Technical, advcacy and resurce mbilizatin supprt has been prvided in relatin t universal access gals, under a csted Natinal Strategic Plan that addresses the challenges and needs in relatin t injecting drug use. 43. In Myanmar, human rights -based, gender respnsive and equitable AIDS plicies and prgrammes fr injecting drug users have been prmted. The civil sciety rganizatins have been supprted t address stigma and discriminatin and ther human rights issues in relatin t injecting drug users in the Natinal Strategic Plan. WHO has played an imprtant rle in facilitating the establishment f piid substitutin therapy prgrammes, including the

15 Page 15/25 prcurement f methadne, and UNODC and the UNAIDS Secretariat have als prvided technical supprt and advcacy resulting in the clear identificatin f pririty areas and prgrammes t address HIV and drug use. 44. In Indnesia, training in a cmprehensive apprach t HIV and injecting drug use preventin and treatment has been prvided fr a range f plicy makers and prfessinals, and technical supprt prvided fr the establishment f methadne maintenance treatment prgrammes and prisn prgrammes. Infrmatin n human rights abuses against drug users drawing n plicy change mdels and successes and findings f cst-effectiveness studies and evaluatins f interventins frm ther cuntries have been disseminated. The establishment f the Indnesian Assciatin f Drug Victim has been supprted. Technical supprt and advcacy effrts have engaged with a range f gvernment partners including the Ministry f Health, Ministry f Natinal Educatin, Wmen's Empwerment, Labur and Transmigratin; Law and Human Rights and the Natinal AIDS Cmmissin. 45. In the Philippines, injecting drug use practices and prevalence f HIV infectin amng injecting drug users in rehabilitatin centers has been dcumented, and training n a cmprehensive apprach t HIV and injecting drug use preventin and treatment cnducted with gvernment partners frm health, interir, labur and AIDS authrities. East Asia 46. In China, significant technical supprt has been prvided in the scale up f methadne maintenance treatment and needle and syringe prgrammes thrugh ut the cuntry, and HIV treatment and care f drug users. Advcacy fr expanding the pssibilities fr rehabilitatin and treatment f drug users with the pssibility t be treated in the cmmunity has been implemented, natinal mnitring and evaluatin systems strengthened, natinal planning fr full scale respnses supprted and prgrammes fr yung injecting drug users supprted. Middle East and Nrth Africa 47. In the Middle East and Nrth Africa, a Task Frce n Drug Use and HIV, including UNODC, UNAIDS Reginal Team and WHO/EMRO have crdinated supprt t natinal respnses t HIV epidemic amng injecting drug users, including the first ever assessment n injecting drug use and HIV in seven cuntries (UNAIDS and UNODC), supprting plicy alteratins based n infrmatin generated and acceptance f a cmprehensive apprach. WHO and IHRA supprted the establishment f the reginal harm reductin netwrk (MENAHRA), and reinfrcing capacities t implement cmprehensive prgrammes in pririty cuntries. MENAHRA cnsists f three sub-reginal knwledge hubs (in Lebann, Iran and Mrcc), a reginal netwrk and prvides direct supprt t civil sciety rganizatins t initiate and/r scale up these measures. 48. In Egypt, Lebann, Mrcc, the Occupied Palestinian Territries and Jrdan, training n implementing utreach activities has been prvided. In Lebann and Mrcc, piid substitutin therapy has been launched, and in Egypt, stigma and discriminatin have been addressed with service prviders, including civil sciety rganizatins, in rder t supprt increasing access t care and treatment fr Peple Living with HIV/AIDS and NGOs have been supprted in the implementatin f HIV preventin services amng injecting drug users.

16 Page 16/ In Egypt utreach prgrammes targeting injecting drug users and prmtin f vluntary cunseling and testing have been supprted. Tunisia was supprted t initiate natinal dialgue n harm reductin. Mrcc has been supprted t prepare and implement a harm reductin prgram fr injecting drug users as well cllecting relevant strategic infrmatin and elabrating a natinal harm reductin strategy and supprt lcal civil sciety rganizatins f drug users. 50. In the United Arab Emirates, a capacity building prgramme n cmprehensive HIV preventin and care services amng drug users has been supprted. In Yemen, training n implementing harm reductin measures has been prvided. Oman was supprted with advcacy as well as technical assistance t review its plicies and assess its preparedness t intrduce piid substitutin therapy and address stigma. Sub-Saharan Africa 51. In Kenya, Mauritius, Tanzania, Uganda, and Mzambique, natinal radmaps t address HIV amng injecting drug users have been develped, and in Kenya, Mauritius, Tanzania (Zanzibar) and Uganda, Natinal Technical Wrking Grups n injecting drug users fr develpment f enabling plicies have been established. Situatin analyses cncerning injecting drug users have been cnducted in Madagascar. 52. In Kenya, priritizatin f injecting drug users has been supprted thrugh Jint AIDS Prgramme Review 2008, Natinal HIV Preventin Summit 2008, Natinal AIDS Strategic Plan and the Kenya Jint UN Prgramme f Supprt n AIDS ( ) t address cmprehensive HIV preventin and care services amng injecting drug users. The inclusin f injecting drug users in the UNGASS cuntry review has been supprted. The plicy makers have been trained n plicies and practices in accrdance with cmprehensive HIV preventin amng injecting drug users. 53. In Mauritius, the establishment f Natinal AIDS Secretariat under the Prime Minister s Office has been facilitated, revisin f HIV legislatin supprted, a pilt needle and syringe prgramme, utreach services and methadne maintenance treatment have been initiated, and technical assistance prvided t the Prisns AIDS Secretariat. 54. In Nigeria natinal preventin effrts have been assisted t develp target specific ppulatins including IDU. Latin America and the Caribbean 55. In Brazil, an integrated harm reductin plan fr , which includes prgrammes n hepatitis and mental health and invlves the Natinal AIDS Prgram and prgrammatic areas f Ministry f Health, have been develped. The Natinal AIDS Preventin Cngress has been supprted, and participatin f harm reductin netwrk representatives in the Cngress facilitated. A frum t discuss the integrated harm reductin plan with civil sciety was rganized. 56. In Argentina, the Natinal Cnference n Drugs Plicy f Argentina has been supprted and an assessment n preventin and treatment f drug use carried ut in partnership with the federal prisn system. In Paraguay an investigatin with high risk drug user s inmates in prisns f 3 different cities f the cuntry was supprted and in Peru studies f nnintravenus drug use have been supprted. Ministries f justice f the suthern Cne (Argentina, Uruguay, Chile and Paraguay) have been supprted in their cmmn respnses.

17 Page 17/ In the Caribbean, injecting drug use remains fr the mment relatively rare, but there are ther drug related HIV risks. In the English speaking Caribbean getting gvernment acknwledgement f the HIV vulnerability f nn-injecting crack ccaine smkers has been a challenge. The general eths that nly injecting drug users are at risk fr HIV has lead t the exclusin f nn-injectrs. Research cnducted in Saint Lucia has clearly demnstrated the higher levels f HIV in the nn-injecting crack using ppulatin and the gvernment there has begun t supprt a respnse. In additin t the ne perating in Saint Lucia a lw threshld harm reductin prgramme serving the needs f nn-injecting crack smkers als exists in Prt f Spain, Trinidad. UNAIDS supprt at the glbal level UNAIDS Plicy Psitin Paper n Intensifying HIV Preventin (references t drug use): 58. At its 17 th meeting in June 2005 the UNAIDS Prgramme Crdinating Bard endrsed a Plicy Psitin Paper n Intensifying HIV Preventin. This psitin paper was the result f extensive cnsultatin and evidence review, and included amng the essential prgrammatic actins fr HIV preventin: Prevent the transmissin f HIV thrugh injecting drug use, including harm reductin measures (p. 33) as well as recmmending review and refrm f legal framewrks including remving barriers t effective evidence-based HIV preventin including amng injecting and ther drug users (p. 32). 59. The plicy psitin paper spelt ut in detail the essential actins t prevent HIV amng drug users as fllws: Preventing transmissin f HIV thrugh injecting drug use by develping a cmprehensive, integrated and effective system f measures that cnsists f the full range f treatment ptins, (ntably drug substitutin treatment) and the implementatin f harm reductin measures (thrugh, amng thers, peer utreach t injecting drug users, and sterile needle and syringe prgrammes), vluntary cnfidential HIV cunseling and testing, preventin f sexual transmissin f HIV amng drug users (including cndms and preventin and treatment fr sexually transmitted infectins), access t primary healthcare, and access t antiretrviral therapy. Such an apprach must be based n prmting, prtecting and respecting the human rights f drug users (p. 34). 60. On the basis f the Prgramme Crdinating Bard-endrsed Plicy Psitin Paper n Intensifying HIV Preventin and the desire f the Bard fr mre peratinal guidance t be develped, UNAIDS subsequently published in 2007 a set f Practical Guidelines fr Intensifying HIV Preventin. These guidelines included a series f prgrammatic HIV preventin actins t be directed t a number f key audiences. The guidelines in relatin t injecting drug users are at Annex 1. General Assembly 2006 Plitical Declaratin 61. Subsequently, at its 2006 high level meeting n AIDS the UN General Assembly adpted a plitical declaratin (UN GA Res 60/262 Plitical Declaratin n HIV/AIDS, A/RES/60/262) which reflected the supprt fr intensifying HIV preventin, as fllws: 22. Reaffirm that the preventin f HIV infectin must be the mainstay f natinal, reginal and internatinal respnses t the pandemic, and therefre cmmit urselves t intensifying effrts t ensure that a wide range f preventin prgrammes that take accunt f lcal circumstances, ethics and cultural values is available in all cuntries, particularly the mst affected cuntries,

18 Page 18/25 including expanded access t essential cmmdities, including male and female cndms and sterile injecting equipment; harm-reductin effrts related t drug use 62. The plitical declaratin and its cmmitments in relatin t HIV preventin were then nted at the 18 th Prgramme Crdinating Bard meeting (June 2006). Draft United Natins Cmmissin n Narctic Drugs (CND) 2009 Plitical Declaratin and Plan f Actin n Internatinal Cperatin twards an Integrated and Balanced Strategy t Cunter the Wrld Drug Prblem 63. At its 52nd sessin the United Natins Cmmissin n Narctic Drugs (CND) adpted a Draft Plitical Declaratin and Plan f Actin n the future f drug cntrl at the cnclusin f its high-level segment. The high-level segment f the CND reviewed prgress in drug cntrl since the Special Sessin f the United Natins General Assembly n drugs in 1998 (UNGASS), and agreed n further steps t reduce the threat psed by drugs t health and security. The Plitical Declaratin recgnizes that cuntries have a shared respnsibility fr slving the wrld drugs prblem, that a "balanced and cmprehensive apprach" is called fr and that human rights need t be recgnized. Ntably, it stresses health as the basis fr internatinal drugs plicy. Paragraph 20 f the Draft Plitical Declaratin: Nte with great cncern the adverse cnsequences f drug abuse fr individuals and sciety as a whle, reaffirm ur cmmitment t tackle thse prblems in the cntext f cmprehensive, cmplementary and multisectral drug demand reductin strategies, in particular such strategies targeting yuth, als nte with great cncern the alarming rise in the incidence f HIV/AIDS and ther bld brne diseases amng injecting drug users, reaffirm ur cmmitment t wrk twards the gal f universal access t cmprehensive preventin prgrammes and treatment, care and related supprt services, in full cmpliance with the internatinal drug cntrl cnventins and in accrdance with natinal legislatin, taking int accunt all relevant General Assembly reslutins and, when applicable, the WHO, UNODC, UNAIDS Technical Guide, and request the United Natins Office n Drugs and Crime t carry ut its mandate in this area in clse cperatin with relevant rganizatins and prgrammes in the United Natins system, such as the Wrld Health Organizatin, the United Natins Develpment Prgramme and the Jint United Natins Prgramme n HIV/AIDS Terminlgy 64. It shuld be nted that while the term "harm reductin" is language which has been adpted in relatin t HIV by the UN General Assembly bth in its 2001 Declaratin f Cmmitment n HIV/AIDS and in its 2006 Plitical Declaratin n HIV/AIDS, as well as by the Prgramme Crdinating Bard f UNAIDS, the term has remained disputed at the Cmmissin n Narctic Drugs. Hwever, it is significant that the Cmmissin at its mst recent sessin referred t abve included reference t the WHO, UNODC, UNAIDS Technical guide fr cuntries t set targets fr universal access t HIV preventin, treatment and care fr injecting drug users. In that guide are targets fr all f the nine essential elements f cmprehensive respnses fr HIV preventin amng injecting drug users, a set f measures which many cuntries chse t refer t as 'harm reductin' measures. 65. Other plicy dcuments, including n best practice, are referenced in Annex 2 t this dcument.

19 Page 19/25 Reference Grup t the UN n HIV and Injecting Drug Use 66. The Reference Grup was established in 2002 fr the purpse f prviding technical advice n HIV and injecting drug use t UNODC, WHO, the UNAIDS Secretariat and relevant cspnsrs. It is an independent bdy f 24 experts frm 20 cuntries wrking in the field f injecting drug use and HIV and includes clinicians, researchers in epidemilgy and plicy as well as injecting drug user representatives. The Secretariat f the Reference Grup undertakes research tasks under the guidance and n behalf f the Reference Grup. The Reference Grup undertakes large scale desk-based reviews f available infrmatin n issues related t injecting drug use and prepares in-depth summary reprts t infrm the develpment f evidence based plicy. The data and findings are the prduct f extensive systematic reviews f the available peer-reviewed and ther literature n injecting drug use. Dcuments are being identified thrugh searching multiple bibligraphic databases and als submitted t the Reference Grup in respnse t requests fr infrmatin. Fr example, fr determining the glbal estimates n injecting drug use and HIV amng peple wh inject drugs 7, the Reference Grup reviewed, graded, and catalgued ver 11,000 dcuments. Further infrmatin regarding the Reference Grup is accessible via: C-spnsrship f the Internatinal Harm Reductin Cnferences and cllabratin with Internatinal Harm Reductin Assciatin (IHRA) and sme reginal harm reductin netwrks. 67. UNAIDS has partnered with the Internatinal Harm Reductin Assciatin t prvide financial supprt fr develping cuntry delegate schlarships t attend the Assciatin s Internatinal Harm Reductin Cnferences. 2nd Infrmal Inter-cuntry Cnsultatin n HIV Preventin and Care amng Injecting Drug Users and in Prisn Settings 68. Twards establishing and maintaining a glbal advcacy netwrk and crdinatin structure, UNODC, n behalf f the UNAIDS family, rganized the 2 nd Infrmal Inter-cuntry Cnsultatin n HIV Preventin and Care amng Injecting Drug Users and in Prisn Settings in The meeting brught tgether the criminal justice and drug cntrl sectrs and natinal AIDS prgrammes and was attended by 140 AIDS, Narctic Drugs Cntrl Prgramme Managers and Natinal Prisn Managers frm 52 cuntries and representatives f Permanent Missins t the United Natins in Vienna frm 20 cuntries, and als by Nn- Gvernmental Organizatins as well as representatives f UNAIDS Cspnsrs. III CONCLUSIONS AND RECOMMENDATIONS 69. Over the past few years, actin t address the dual epidemic f injecting drug use and HIV (and ther infectius diseases) has increased wrldwide. Hwever, despite sme imprvements bserved, much mre needs t be dne, and the barriers which still hinder 7 Mathers, B. Degenhardt, L. Phillips, B. Wiessing, L. Hickman, M. Strathdee, S. Wdak, A. Panda, S. Tyndall, M. Tufik, A. Mattick, R. P. and the Reference Grup t the United Natins n HIV and injecting drug use. (2008) The glbal epidemilgy f injecting drug use and HIV amng peple wh inject drugs: a systematic review. The Lancet, Vlume 372.

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