Prepared for PrEP? More food for thought

theNewCondom

PrEP?! Not another acronym! Help! PrEP stands for Pre Exposure Prophylaxis (- Not the similar sounding PEP, which is Post Exposure Prophylaxis). Keep reading, all will be made clear. This is one of the latest HIV subjects on the table these days, with debate now rather well formed. The utilisation of the realms of research that has finally began to emerge now after the numerous PrEP trials that have lasted through the last decade.

In a nutshell, what is PrEP?

(Excerpt from earlier INPUD Diaries article) “It is an experimental HIV prevention strategy that, if proven, would use HIV drugs / anti retrovirals (ARVs) to drastically reduce the risk of HIV infection in HIV negative people who may be at a greater risk of contracting it due to circumstance etc.”  However, while the empirical research is coming in, there remains questions. Some big ones. INPUD has taken a clear position, that among other things, PrEP must not come to eclipse other essential harm reduction interventions. It also loudly questions the ethical position of advocating for for PWID not living with HIV is unethical when 4% of people who inject drugs and living with HIV are not receiving ART.

“People who use and inject drugs must have the right to choose for themselves which HIV prevention options best suit them, and all well-evidenced options must be available.”

The previous INPUD blog excerpt from PrEP’s early days in 2009 continues with this statement, “So, could PrEP, through the ingestion of a single drug (or combination) taken daily, reduce the chance of exposure to HIV infection – in HIV negative people? If found to be effective, how would such a prevention approach be rolled out? And to whom? In combination with what other prevention measures? And would HIV negative people even adhere to such a potentially uncomfortable and serious drug regime with no immediate tangible benefit – and perhaps even possible long term consequences from such a drug regime? And what about drug resistance – could we be making a rod for our own backs?

INPUD rolls out a useful introduction on PrEP for the drug using community

Well, INPUD has released a basic introduction statement to Pre-Exposure Prophylaxis (PrEP) for people who inject drugs, outlining some of the pros, cons, and concerns surrounding this relatively new method for preventing HIV infection.  INPUD states “People who took pre-exposure prophylaxis every day were significantly less likely to get infected with HIV. In an open label study, involving men and transwomen where participants were offered PrEP at the end of the trial, there was zero new HIV incidence amongst those who took between 4 and 7 doses per week, suggesting that PrEP could be somewhat forgiving with regard to missed doses.” INPUD went on to warn however that “Though clinical trials have shown efficacy for PrEP, INPUD stress that PrEP must not come to eclipse other essential harm reduction interventions. People who use and inject drugs must have the right to choose for themselves which HIV prevention options best suit them, and all well-evidenced options must be available.”

The advantages among the complexities

Another excerpt from a previous Diaries article on PrEP said “One of the potential

A Jagged Little Pill

A Jagged Little Pill; Dont miss AIDSMAP’s piece on PrEP for yet more discussion, info and facts.

advantages of PrEP is that those who are unable to negotiate condom use with their sexual partners, would still be able to reduce their risk of infection, (especially women living and struggling to protect themselves  in machismo/misogynistic cultures or where wars break out…PrEP could theoretically be given to women who may be able to protect themselves from the ravages of war rapes and HIV incidence?) And, people who inject drugs may be able to protect themselves much more effectively despite being in higher risk environments.” However, nothing is ever so straightforward.

The data is flooding in

All the previously developed trials are finally coming in for the real number crunching and many have just been published.. “The research has looked at a range of transmission routes in diverse populations such as; Serodiscordant couples (one positive, the other negative); heterosexual men and women in high prevalence areas; people who inject drugs; gay men and other men who have sex with men. ” However, most of the now conceptualized data out there seems to focus on gay men and not on women and drug users, both who could potentially have a real part to play in properly targeted and thoughtfully implemented PrEP pilots etc. More on this in Silvia’s blog.

However do click here for INPUDS INTRODUCTION TO PrEP and information on how it all relates to the drug using community. A thorough run through of the data in a one sitting, article size piece of information that’s reprintable and available for dissemination to your peers and drug user groups etc. It provides a useful position statement on the subject as well.

Where is the World Health Org Standing on PrEP?

Status of PrEP globally: the CDC and the WHO
(Excerpt from INPUD’s introduction to PrEP) “PrEP has been approved for use in some

Truvada; FDA approved for use in PrEP

Truvada; FDA approved for use in PrEP

countries. Notably, the United States Center for Disease Control (CDC) recommends PrEP for groups at high risk of HIV exposure, including at risk HIV negative men who have sex with men, at risk HIV negative people who inject drugs, as well as persons of any gender in serodiscordant couples. It is recommended by the CDC as an element of a comprehensive set of HIV prevention services, to be accompanied by quarterly monitoring of HIV status, pregnancy status, side effects (which can include nausea, cramping, and long-term effects including kidney problems), medication adherence, and risk behaviours. The CDC note that PrEP delivery for people who inject drugs should be integrated with prevention and clinical care for additional health concerns, which, in this context, include hepatitis B and C infection, abscesses, and overdose.”

And a Few Other Views?

Below is an article I’ve linked from a blog by the highly respected UK based HIV activist, Silvia Petretti. This excerpt from her blog which is entitled HIV Policy Speak Up  gives her usual refreshing look at yet another tricky HIV subject.  In Silvia’s blog piece on PrEP, Silvia looks at an important UK based study called PROUD which was released this year which looks at “how men who have sex with men who are HIV negative can take Truvada,  a drug used to treat HIV , to prevent getting the virus through sex. The Proud study showed that Truvada could offer an 86% protection to HIV. But Silvia reminds us that “Truvada…is relatively safe. However, it must not be forgotten that it has potentially harmful effects, especially on the kidneys and bones. People who take it need to be strictly monitored.”

Silvia does however, look further into the case for women and she raises some good points about women and PrEP, pointing out issues we must take on board sooner rather than later as rolling out PrEP picks up pace. There is a unique role in PrEP for women, especially women who use drugs and sell sex who face violence and rape on a regular basis, as do many millions of women and girls across the world.

In her blog Silvia asks the uncomfortable yet important questions but clearly states “I believe that it has been proven that  PreP, if provided properly, could save many lives. I know that PrEP research has been community driven, and this is also important. But Silvia asks, “What about other vulnerable populations, such as black women and migrants? What about trans women? All the data we have here [in the UK]  is about men who have sex with men, and this worries me.  I have so many questions in my head….For now I would just like to share some questions I have  regarding  women’s access to PrEP that keep popping into my head. What are yours?…”

You can see the key questions Silvia raises in her blog such as:

  • How will healthcare providers be trained in providing PreP to women? How will they be trained to deal with HIV stigma and gender based violence?
  • How are we going to ensure that provision of PrEP for women provides pathways to other key services for women: including mental health services, drug and alcohol services, access to refuges and safe housing (for those exiting abusive relationships) etc. ?

For her article “Are Women Prepared for PrEP and a link to her very interesting blog, click here.

To add to the debate, a very useful article published by Daniel Wolfe, who as Director of the International Harm Reduction Development Program, Open Society Foundations and writing for the Huffington post (see full article here)  warns us to not get swept away with the hype that is coming with PrEP. Wolfe goes on to give us a quick look behind the research figures revealing just how impossible it is to supplant the trial results in one country, as an affirmation of what will work in another. In this case it is about the large PrEP trial held over some years involving over 2,400 men and women who use drugs in Thailand.

Wolfe explains “The Bangkok Tenofovir Study was the first study of its kind examining a once-a-day HIV prevention method known as PrEP, or pre-exposure prophylaxis, among a population of injection drug users in Thailand. The study gave a single Tenofovir pill, along with counseling and risk reduction education to half of study participants, and offered placebo and counseling and risk reduction to the other half. Results showed overall reduction of almost 50 percent among those who received the medicine, and reduction of 74 percent for those who adhered best to the daily regimen.”

He continues, “The clinical trial finding that a once-daily pill halved HIV infection among people who inject drugs in Thailand is an important development in HIV prevention science, and brings welcome attention to a group often excluded from clinical trials.”

However, what makes this article so interesting is that he explains just how difficult it is

Money for big pharma...

Money for big pharma…

to assess the relevance of these trials in the real world when supplanted amongst communities of people who use drugs in countries where the simple act of just accessing your medication could be dangerous.  For example, Wolfe tells us that the trial relied primarily on “directly observed therapy, meaning that most study participants had to come daily to receive the medicines.” Now to try and expect to roll out a PrEP process and gain similar positive results in another country where “going for an HIV test or even admitting that you have used drugs can result in the addition of your name to government registries shared with police” is outlandish. It also begs the question about the role of big pharma and the over medicalisation of the HIV prevention field.

“Pharmaceuticalization of HIV prevention for injecting drug users without corresponding reform in law enforcement and healthcare delivery is in no one’s interest, and will result in money wasted, new infections, and lives lost.”

In a fascinating piece of additional information which Wolfe says would of given us the chance to compare PrEP to effective needle and syringe programmes, Wolfe tells us where there lies a rather worrying case of missed opportunity; “Firstly, this study had an ethical obligation to compare the pharmaceutical intervention with needle and syringe programs — the recognized standard for HIV prevention among people who inject drugs. This standard was not observed, since the government in Thailand fails to offer needles and syringes through government programs. The omission means we lost a real opportunity to see how this daily pill compared to standard harm reduction services.”

I personally (not INPUD’s views here)  have to wonder about the thought processes behind this examination which, if the data came out to be significantly similar and PrEP was compared to good quality NSP services, the drug companies could have lost out in a big way.

Indeed in his summary Daniel Wolfe states things a little more clearly for us saying “Pharmaceuticalization of HIV prevention for injecting drug users without corresponding reform in law enforcement and healthcare delivery is in no one’s interest, and will result in money wasted, new infections, and lives lost.”

Back to INPUD and the WHO 

In the INPUD fact sheet on PrEP no 2, it summarises with the statement “The World Health Organisation, in the recently released Consolidated Guidelines on HIV Prevention, Diagnosis, Treatment and Care For Key Populations concluded on the basis of systematic reviews of the scientific evidence, and also the review of benefits, harms, costs as well as values and preferences of the community of people who inject drugs that it should not recommend PrEP for people who inject drugs. INPUD is in the process of developing a position statement on PrEP, so that we can systematically review the evidence and the opinions and values of the community so that they can be taken into consideration in forming policy.”

And finally, if that hasn’t given you some food for thought on PrEP, here are just a few fascinating insights into what concerns drug users have had around PrEP and its future implementation. (Note: INPUD is compiling a multi country consultation around what people think about PrEP and result will be published this year).

– advocacy for PrEP is likely to undermine advocacy for proven harm reduction interventions (this has already happened on a rhetorical level in Russia with the Chief Sanitary Physician announcing that given that PrEP could be provided, there is no need to provide methadone)
– given that proven harm reduction interventions are far from scale, PrEP is a costly, and moreover unethical diversion from the core interventions
– there is no evidence that PrEP reduces transmission via blood borne routes, only sexually
– the only trial so far conducted specifically with injectors was multiply flawed – both ethically and methodologically
Get in touch with your views or add them to the comments section below.
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Treatment as Prevention? Or get to the back of the queue!

 Hi everyone, this is a very interesting article doing the rounds at INPUD at the moment about Hepatitis C and the new drug treatments available. It is about treatment costs, but it is also about discrimination as the question has changed from ‘can we cure?’ to ‘who should we cure first?’.  Commenting on the article INPUD’s executive Director Eliot Albers says  “It is good to see a human rights framework being introduced into considerations about allocation of HCV treatment and rejecting the frequently cited reasons for not treating people who inject drugs”.
 
Please note: The blogger here has taken a small liberty to include subheadings of my choosing in order to ease reading, headings which are of course, not in the full article.
The link to the FULL article is here FULL ARTICLE

Current and emerging antiviral treatments for hepatitis C infection

Written by: Joseph S. Doyle1,2,3,*,Esther Aspinall7, Danny Liew4,Alexander J. Thompson5,6,8and Margaret E. Hellard1,2,3  British Journal of Clinical Pharmacology  Volume 75, Issue 4, pages 931–943, April 2013
The hepatitis C medication Sovaldi costs $84,000 for a 12-week course of treatment

The new hepatitis C medication Sovaldi costs $84,000 for a 12-week course of treatment.

Direct-acting anti-viral (DAAs) therapies have changed the hepatitis C landscape. Previously, only small numbers of people with hepatitis C infection underwent treatment, even in countries with highly developed health systems. Now, due to DAAs’ high efficacy, low side-effect profile and relatively short treatment duration [1], concepts such as ‘treatment as prevention’ and ‘cure and prevention’ and hepatitis C elimination are being discussed [2-4]. Achieving hepatitis C elimination will require a significant increase in the number of people being treated for hepatitis C. Rather than ‘can we cure?’, the question is now ‘who should we cure first?’. This question is driven partly by the prohibitively high cost of DAA treatment [5]. If DAAs were cheap, then anyone who wanted treatment would be given treatment—but that is not the current reality. Instead, the high cost of DAAs is driving discussion about whether treatment should, at least initially, be restricted to people with severe hepatitis fibrosis to reduce the risk of hepatocellular carcinoma, liver failure and death to keep costs in check.

 “Models suggest that, depending on the initial population prevalence, treating as few as 15 of 1000 PWID per year can halve the prevalence of hepatitis C in 15 years.”

Many argue that despite the initial costs we should also treat people who engage in behaviours that lead to hepatitis C transmission, such as people who inject drugs (PWID), the group at greatest risk of hepatitis C infection in developed countries, because of a broader community benefit and probable long-term cost-effectiveness. Models suggest that, depending on the initial population prevalence, treating as few as 15 of 1000 PWID per year can halve the prevalence of hepatitis C in 15 years [6].

As highlighted in the paper by de Vos et al., the impact of treatment on reducing hepatitis C virus (HCV) prevalence in the population can be enhanced by targeting HCV treatment by risk level [7].

Similarly, modelling by the Burnet Institute in Melbourne, Australia suggests that targeting the injecting network delivers greater population health benefit than treating PWID randomly for their hepatitis C [8]. It is postulated that these ‘treatment as prevention’ approaches can lead to hepatitis C elimination in 15–20 years.

The answer to the question of who to cure ‘first’ may also be driven, in part, by the stigma and discrimination associated with injecting drugs [9, 10]. In the recent pegylated interferon (PEG-IFN) and ribavirin era, many PWID were not offered hepatitis C treatment due to concerns about compliance and poor treatment response. However, the evidence suggests that PWIDs’ compliance and treatment outcomes were no different to those of other groups [4, 11].

Risk; Ours or Theirs?

In the DAA era, there is a view that PWID should not be treated because of their high risk of hepatitis re-infection. While hepatitis C re-infection in PWID is quite common outside the treatment setting [12, 13], re-infection post-treatment with PEG-IFN and ribavirin is considerably lower, estimated by one meta-analysis of five studies at 2.4 [95% confidence interval (CI) = 0.9–6.1] per 100 person-years [14]. Despite this, many of the current models measuring the impact of treatment on HCV prevalence (including de Vos et al. and the authors of this commentary) build high levels of re-infection into their model’s assumptions, perpetuating this probable overstatement of re-infection risk. That treatment appears to lower future risk suggests that injecting risk categories may be temporal, and models that incorporate risk levels that change throughout the course of an injecting career should be considered instead.

This makes allocating treatments by risk status a less well-defined approach, and the resources required to do so may not be worth the marginal benefits that modelling suggests could be gained [7]. Hence, PWID should not be excluded from treatment based simply on their risk behaviour at one moment in time.Also, there is no reason to expect that PWID treated with DAAs are more likely to become re-infected than PWIDs treated with the PEG-IFN and ribavirin in the past.

“The view—which has been expressed publicly at large international meetings—that current treatment is ‘easy’, and consequently PWID will not fear re-infection and re-treatment, is simply not evidence-based.”

The view—which has been expressed publicly at large international meetings—that current treatment is ‘easy’, and consequently PWID will not fear re-infection and re-treatment, is simply not evidence-based.While models and empirical evidence are important tools in our efforts to convince policymakers of the cost-effectiveness and broader public health benefit of increasing access to hepatitis C treatment, it is vitally important to recall that we are talking about individuals infected with a chronic blood-borne virus.

The stigma associated with hepatitis C warps judgements about treatment allocation. It is difficult to think of another potentially fatal disease for which we would not make the >90% effective cure widely available. For example, people with hypertension and raised cholesterol are treated routinely to stop them developing cardiac disease. Similarly, it is difficult to think of another disease for which we refuse to provide treatment for fear that the sufferer may require further treatment in the future; cardiac disease, often related to behaviours such as poor diet and lack of exercise, again comes to mind.

“Similarly, it is difficult to think of another disease for which we refuse to provide treatment for fear that the sufferer may require further treatment in the future;”

In the arguments to come about the cost and cost-effectiveness of hepatitis C treatment and who should be treated ‘first’, it is important to keep in mind that a cure for hepatitis C changes the landscape. Adequate health care is a basic human right; providing the existing cure for hepatitis C to all—when they want treatment, regardless of how they became infected—is our responsibility.

End

Thanks to the authors and to British Journal of Clinical Pharmacology for the reprinting of this article.

Note: INPUD gets involved with supporting more affordable access to Hepatitis C drugs by joining with other global HIV/AIDS organisations and writing to UNITAIDS. The response has been seen as an ‘advocacy win’ and a tiny step forward in the long and comp!ex road ahead. Letters posted here over the next days.

Also, stay tuned for blogging about the roots of the European Network of People who Use Drugs to be decisively planted next week in London.

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Sister Morphine, Mother Methadone

Guest blog: Thank you to our guest blogger this month, who has given us, incredibly in just under 600 words, an engaging, intimate yet candid reveal of over 38 years of a life entwined with heroin. A small yet perfectly formed piece of literature, complete and ready for the drug user’s historical book of insight and prose. Now there’s a book in the making friends: Page 1…

Written by Anon: or rather A Mature User – AKA Muser.

Sister Morphine, Mother Methadone

After that first snort – that was it – I thought ‘my life was sorted’.  I just felt like, I was at peace. I had confidence. It got rid of the fear of intimacy, I enjoyed sex. It really was a eureka moment. I didn’t wake up with a hangover (little did I know) and it just seemed like you didn’t have to pay the piper.  I thought, ‘You and I can get on well together, Sister Morphine’.

Flaming June: By Fredrick, Lord Leighton, 1830-1896

Flaming June: By Fredrick, Lord Leighton, 1830-1896

I shoulda known it couldn’t last.

Even as a very young kid, when someone used to put their arm around me and say ‘everything is going to be ok’, I never believed them. Never. But heroin, then, made me believe that all was good with the world, for a while anyway. The ritual, the scoring, bringing it home – it was like a present, unwrapping it, it was exciting. It takes away that angst. Until it becomes all about where that next hit is coming from.

I sometimes think I’ll probably never give it up. Because over the years it became more than just about the drug, it became a habit – it became everyone, and touched everything,  I knew.  It’s not exciting anymore. I think now, ‘why the fuck am I still doing this?’.  Sister morphine has become mother methadone, and the thought of withdrawals terrify me.  I have to say methadone is the most boring fucking drug…Its just so BORING!

usingTime Flies

What have I got from 38 years with heroin, apart from ageing and hepatitis C?! ….. Well, I’ve  met so  many ‘interesting” people, the good, the bad and the ugly and all sorts in between; worked with some wonderful people and I’ve ducked, dived and taken some mind-blowing gambles that I’d never have considered taking without the need for smack pushing me on. I was never gonna make it as a suburban housewife anyway. I think the older users’ voice needs to be heard. There is this old people’s home up the road from me and when I pass it I look in the window and I just think I couldn’t do it. The patients, people, and none of them would be users, I mean what would they do with people like me; how would we get treated? Older junkies with attitude …..Crash, bang, pow!!

But Then Again…

But…I dunno. I often wonder what I would of done if I didn’t take heroin. I think I would

Les Morphinees, illustration from 'Le Petit Journal', engraved by H. Meyer and F. Melville, 1891.

Les Morphinees, illustration from ‘Le Petit Journal’, engraved by H. Meyer and F. Melville, 1891.

have been an alcoholic. Coz I’ve always needed a little something between me the world.  Wordsworth said in some poem, ‘“The world is too much with us”’*  I often think that’s one of the truest sayings ever, it could be my motto.  For me and I’m sure for many others, we just need a filter between us and reality. Wait, that’s a bit strong…It’s like, when you’re walking across the road and there’s bright lights and cars and horns blaring, it’s like an assault; Heroin is the filter that helps make things a bit more bearable.

I do think tho that, people have such low expectations of drug users, yet the people I’ve met, seriously, are so amazing, different, sensitive and…yeah, it really saddens me when I talk to people and how they think drug users are. Because it’s not just about the publics’ attitude to us; it’s  about how powerfully that can impact our view of ourselves. So, what to do?  An older woman .with Hep, C , on a methadone script, using on top with hepatitis C with other aches and pains?…beam be up Scotty!! A Mature User AKA Muser.

* The World Is Too Much with Us

william_wordsworth

By William Wordsworth, 1806

The world is too much with us; late and soon,
Getting and spending, we lay waste our powers;
Little we see in Nature that is ours;
We have given our hearts away, a sordid boon!
This Sea that bares her bosom to the moon,
The winds that will be howling at all hours,
And are up-gathered now like sleeping flowers,
For this, for everything, we are out of tune;
It moves us not. –Great God! I’d rather be
A Pagan suckled in a creed outworn;
So might I, standing on this pleasant lea,
Have glimpses that would make me less forlorn;
Have sight of Proteus rising from the sea;
Or hear old Triton blow his wreathèd horn.

For More Information about the poem and its meaning go to…

http://en.wikipedia.org/wiki/The_World_Is_Too_Much_with_Us

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The Netherlands – Coffee Anyone?

Catching Up on Dutch Coffee Shop News

Hello folks,

coffee-shop

Just thought readers might like a small update on the coffee shop / marijuana situation in the Netherlands and the city we all adore, Amsterdam. For a while now we have been hearing about a ban on cannabis for any foreigners visiting Amsterdam, in fact there were a lot of rumours and myths going around as to what exactly was going on.  The reality today is quite a complex set of rules pressing down on the coffee shops of old and making their existence that much more difficult.

In fact, as is usual when the government gets involved and doesn’t really seek the views of the affected communities (and only focuses on the needs of big business), it seems the Netherlands’ has become more of a place where its coffee shops are being run and supplied by those without any community mindedness while others are busy tying up legislation to make sure only the right kind of fat cats will reap the rewards. There is angst and consternation behind the scenes of our dearly loved Dutch coffee shop system these days!

Let’s just put things in a little perspective; there were around 400 coffee shops dotted around Amsterdam in the 1990’s, of every shape and size, ambience and groove to suit even the fussiest dope smoker – we all remember the sounds, smells and conversations emerging from those smokey hubs of conversation, chillin’  and ‘the big lazy idea’! But today,  in 2015, there are less than half of those coffee shops  left.

dope leaf

The Poke in the Blind Eye

For decades now, it has been Dutch leaders who have been agreeing to turn a blind eye to the running of the coffee shops as long as they met certain requirements and the locals declared they were happy enough too. However, those requirements are now constantly changing and are being too often being implemented alongside the popularity contests and whims of local politicians.

So today, many more rules and regulations have come to the door of the Dutch coffee shop, some owners felt they were being squeezed out of business; rules such as  –

  • not more than 5 grams per person per day may be sold;
  • hard drugs must not be sold;
  • there must be no sales to minors and minors must not be allowed into a coffee shop;
  • no alcohol may be served on the premises;
  • there must be no advertising of drugs;
  • there must be no disturbances in the vicinity of the shop;
  • the shops’ stock must not exceed 500 grams.

OK – all of those sound relatively reasonable. But it isn’t those rules, it is others that are cause the difficulties, such as the particularly challenging ‘a premises cannot be within 250 meters from a school’, which caused 40 coffee shops to instantly close. (A coffee shop is unable to re-open once it is shut, causing people to rightly fear that, after a time, no coffee shops will be left at all). And there are more discretionary rules like “do not cause a nuisance.”  In the end, each municipality has to decide if these rules are being followed.

Another rule has become known as the ‘Wietpas’, better known as ….

The Weed Pass for Foreigners

This ‘Wietpas’ or Weed Pass rule is probably the most infamous one to have happened. It is also the one all of us foreigner’s want to know about. What has happened to this law?

In 2012, which we reported on here, the ‘wietpas’, or weed pass, was  brought in. It was designed as we know,  to curb cannabis tourism by banning those annoying, drunk foreigners from the many usually peaceful, coffee shops. Fortunately for many, cities were allowed to opt out of the scheme, and for Amsterdam – which stood to lose millions of tourist dollars – the decision was simple, the mayor said,  ‘No Thanks’. The national law that was banning foreigners from buying weed at the legal coffee shops has actually become widely ignored in most of the country since its inception, including Amsterdam and Rotterdam, the two largest cities whose mayors basically refuse to comply with the central government’s decision.

Currently, it is only the country’s southern provinces that have implemented the ban outlawing the sale of drugs to tourists by the infamous coffee shops and have limited sales to government-issued “weed pass”-carrying locals.

The coffee shop owners argue that the ban has devastated their business, damaged the local economy and led to an increase in illegal street dealing.

We Told You So!

A Dutch News article comparing ‘police and city council figures’ reports that “the decision to ban foreigners not resident in the Netherlands’ from the country’s cannabis cafes have led to an ‘explosion’ in drug-related crime in the south of the country. The governments’ decision to turn the cafes into ‘members only clubs’ in the southern provinces last May led to a sharp rise in street dealing. In Maastricht, at the forefront of efforts to reduce drug tourism, the number of drug crimes has doubled over the past year while in Roermond they are up three-fold with at least 60 active street dealers.”

Although according to other surveys recently published in the local Dutch press, two-thirds of the entire country’s 478 cannabis cafes continue to sell marijuana to tourists, it appears to be creating a new, north-south cannabis selling divide. And although there were many tourists in the border areas in the past, they were busy buying food, smoking dope, staying in hotels, spending money in legal places, etc. Now the local inhabitants seem to be really annoyed at the ‘change’ of the atmosphere into ‘pushy drug dealing’. Cannabis buyers must now buy off the local heroin or crack dealer in some darkened street, which is a real shame when all of us could have just bought it in a COFFEE SHOP like a normal person! Prohibition strikes again.

In any case, the ban at least appears to leave a loophole for a local, ‘tailor-made’ approach, permitting licensed coffee shops to continue selling small amounts of cannabis to any adult for personal use and there has been a court case brewing declaring the ban ‘unconstitutional’, which it may indeed be.

coffee shop

Amsterdam’s mayor, Eberhard van der Laan, for example, has made clear that his city will not ban tourists from its 220 coffee shops because “the legislation makes it possible to take local circumstances into account.” The mayors of many other towns support and follow his position, and a recent visit to Amsterdam by yours truly also confirms this kind of weedy old fashioned kindness still extended to foreigners. Phew!

Once again, the grey areas in Dutch laws, mean the rest of us can breathe a massive sigh of relief and can still squeeze quietly through the doors marked ‘this way, just more quietly please’. And do keep in mind, while possession is not legal the police do turn a blind eye to people with less than five grams. So civilised!

At least 10 of Netherlands’ local councils, among them some of the biggest cities like Amsterdam, Rotterdam, Utrecht and The Hague have called for regulated growing, arguing that legalized production would remove organized crime from the equation. But others think that such solution would just require only government-licensed growers, and that would mean an even greater crackdown on foreign imports and possibly even dumping any local producers in favour of the slicker big business types.

What About Americas’ Smokin’ Hopefuls?

If vast legal grey areas are still the Dutch model’s biggest liabilities, then, where America is concerned, stability is Washington’s biggest strength. Very little is going to be left to chance under ruling I-502. “Each marijuana grower, processor, and seller will be vetted, licensed, and watched over. Marijuana will be traceable, tested for quality, and come equipped with a lot number, a warning label, and the concentration of THC. Retailers will look more like pharmacies than drug dens and, most importantly, smoking pot inside the stores will be strictly verboten. Prohibiting Amsterdam-style coffee shops wasn’t an oversight, but a pragmatic decision meant to allay the fears of some of Washington’s more conservative voters. After spending much time and money on public opinion research, I-502 organizers realized the idea – however unfounded – of a bunch of perpetually stoned kids lurking around neighborhood coffee shops was just too much for many Washingtonians to stomach.”  Thanks to  C. Rodreigez from Forbes Life.

With thanks to  Cecilia Rodriguez from ForbesLife   and  C. Christofferson CityLab.com

BUT!!! Don’t Miss This!!!

for all the best films on drug reporting

This terrific new short movie, supplementing the fascinating report of the Open Society Foundation

, tells the story of the Dutch model and highlights its successes, as well as the challenges ahead of it. Drugreporter says ” It is an English website created by the Hungarian Civil Liberties Union. The website was created in 2004 to promote drug policy reform advocacy in the region. In 2007 we started our video advocacy program and our website has become an international hub for English and Russian language news articles, blogs and films about harm reduction and drug policy reform. Our film database has hundreds of short films aiming at educating and mobilising people.”

But Wait Again!!

Drug-related death and disease are less prevalent than in many countries with restrictive drug laws. This is the conclusion of the report produced by the Open Society Foundations, authored by two excellent researchers, Jean-Paul Grund and Joost Breeksema. Click the link ahead  to download the report! coffee-shops-and-compromise-20130713

Check Out The DR Film, thanks HCLU!

Final note: Just a thought – this was a story about Britain getting its first cannabis coffee shop in Kent, discussed just last year! Click here if your interested. We in Britain await with baited, but ageing, breath…

 

 

Posted in Europe, Europe, Regional News & Info, videos | Tagged , , , , , , | 5 Comments

The Global State of Harm Reduction for 2014

We Must Not Be Left Behind 

“In most communities, people who inject drugs don’t have access to syringes to prevent infections, opioid substitution treatment, or naloxone to prevent overdose. Moreover, people who use drugs are denied basic health services. They have no access to non-judgmental primary care, mental health and drug treatment services, and the support they need to maintain stable, healthy lives. And yet, harm reduction has been proven time and again to be extremely effective in curbing HIV transmission. In settings where comprehensive harm reduction has been implemented, HIV rates among people who inject drugs are low—in some cases, almost negligible.”  The Global State of Harm Reduction 2014

So why, why why  are such effective solutions still being left behind on the political table? We can see the results of what being ‘Left Behind’ really means – burgeoning disease and death. It’s all so avoidable!

One of the sectors most useful and interesting reports released its 2014 data, last week.  The report -The Global State of Harm Reduction which was first published back in 2008 by Harm Reduction International, provides independent analysis of the state of harm reduction across the world.  This enabled a really useful baseline to be developed, against which we can now measure actual progress of harm reduction in its global march of common sense. It now allows us all to see much more clearly,  the actual mapping  of harm reduction policy adoption as it occurs, as well as programme implementation globally. It has also permitted the documentation of the various, associated responses to the HIV and hepatitis C epidemics that are related to  injecting and non-injecting drug use and perhaps most importantly, we can see the results of  implementing harm reduction practices on the health of drug users across the world.

About US $ 2.3 billion annually is estimated by UNAIDS to be required to fund HIV GSHR-2014-coverprevention among people who inject drugs in 2015. At the last estimate, only US$ 160 million was invested by international donors – approximately seven per cent of what is required. In contrast to the lack of funding for harm reduction, each year governments spend over $100 billion on arrest and imprisonment of people who use drugs, destruction of drug crops and other drug control measures. HRI argues that if just a tenth of this money were redirected to harm reduction, it could fill the gap in HIV and Hepatitis C prevention for people who use drugs twice over.

Eliot Albers, our Executive Director at INPUD,  wrote the forward for the Global State of Harm Reduction 2014, and explained just how profoundly linked are the entwined issues of donor funding, prevention spending and the epidemiological spread of HIV and HCV disease. Investment in harm reduction as part of overall prevention spending is nowhere near proportionate to the reality affecting people who inject drugs on the ground, illustrating, Eliot says, that “donor priorities are out of alignment with epidemiological trends”.

It seems clear that as long as governments refuse to invest equally in prevention, those incredible strides forward during the last 30 years of HIV, end up being whittled away.

The INPUD Executive Director added, “Whilst the retreat from investment in harm reduction places the lives, health, and rights of millions of people who use drugs around the world in jeopardy, the international drug users’ movement has never been stronger, having successfully fought to occupy our rightful place as a vital partner in every debate that impacts upon our lives and health on the global, regional and national stages”.

However, he went on to say that success of this agenda is contingent upon investment in community systems, strengthening and empowering organisations, networks, and communities of people who use drugs.  Eliot also stated  “If [harm reduction] services are to be truly accessible, acceptable, and appropriate, they must be returned through a process of power-shifting to the communities they serve.”

We must fight to be seen as the solution to improving the health of our communities, and to never to be framed as the problem. And we must never accept the reality of what it means to be ‘Left Behind’.

“Every person left behind is a fellow human being – someone’s child, someone’s parent, someone’s friend, someone’s partner. Every one of them has a right to life and to health. Every one of them deserves compassion, and dignity, and love.” (David Furnish, Elton John Foundation: Forward in the Global State of Harm Reduction, 2014)

Some of the main points to emerge from this report over 2014 were (actually this report is a biennial document -all relevant links below)

Main Points to Emerge Over 2014:

  • Good and Bad: In 2014, 90 countries and territories implement Needle and Syringe Programmes (NSPs) to varying degrees but another 68 countries with reported injecting drug use, do not provide any NSP services
  • Good: Malaysia, along with Iran and Australia, had experienced the steepest increase in the number of NSP centres, from 297 sites in 2012 to 728 in 2014.
  • Bad: The provision of NSP in prisons globally has declined since 2012 with only 43 countries provide OST in the prison setting;
  • Good: In 2014, 80 countries and territories implement OST (Opiate Substitution Therapy/treatment -mainly methadone and buprenorphine);
  • Bad: An estimated eight percent of the world´s injecting drug users can actually access opioid substitution therapy such as methadone or on a global average they are only able to access two clean needles per month.
  • Worrying: New and emerging patterns of injecting drug use in sub-Saharan African countries such as Tanzania, Uganda, Senegal, Zanzibar and Kenya will require a further scaling up of the provision of opioid substitution therapy (OST) such as methadone and buprenorphine and needle syringe programmes (NSP) in order to effectively respond to the growing HIV/AIDS epidemic amongst people who inject drugs in the region. In 2012 the Kenyan government announced the initiation of NSPs within the country, resulting in ten newly operational sites in 2014.
  • Worrying: It also notes the concerns over the documentation of high-risk injecting practices, including that of flashblood occurring in Tanzania and Zanzibar (see link) and the marked increase in stimulant use that is evidenced in research into increased risk behaviours for sexual transmission of HIV. It cites as an example, that in Western Cape Province, the proportion of admissions to drug treatment facilities for methamphetamine as the primary drug used increased from 0.8 per cent in 2001 to 52 per cent in 2011.  The recent establishment and scale up of community based opioid substitution therapy (OST) in Tanzania is a significant step forward, rising from one site to three in the city of Dar es Salaam. This makes the OST programme in Tanzania the largest government-run programme in the region, with over 1,200 people receiving methadone in 2013.  There has also been a scale up of NSPs in Dar es Salaam, Tanzania, increasing from one site in 2012 to seven in 2014.
  • Good: In 2014 there were 88 drug consumption rooms (DCRs) operating worldwide – outside of Europe two DCRs are in operation, one in Australia and one in Canada. In Western Europe, Denmark saw the implementation of five DCRs, and both Spain and Switzerland, who had previous DCRs in operation increased their site provision by six each.
  •  Good: The provision of overdose prevention medication (e.g. Naloxone) has increased most markedly in North America.In the United States, as of June 2014, there are 30 states plus Washington DC that have at least one point of access for laypersons to obtain Naloxone for people who use drugs – or friends and family;
  • Worrying: In the Middle East and Northern Africa region (MENA), one of only two regions in the world that continue to experience increases in HIV infection rates, harm reduction coverage is non-existent in many countries. However, small scale implementation of needle syringe programs now operate in Egypt and Jordan.
  • Good: Iran continues to be word leader both in and outside the region – OST and NSP are widely available in the community as well as prisons;
  • Worrying: The Eurasian region is home to an estimated 3.1 million people who inject drugs, with two of the largest populations living in Russia (1.8 million)) and Ukraine (310,000). Eastern Europe and Central Asia is one of two regions globally where rates of HIV infection are continuing to rise. Opioid substitution therapy (OST) is available in 26 countries of the region, with only three countries reporting evidence of injecting drug use not providing OST: Russia, Turkmenistan and Uzbekistan. In Russia it is a criminal offence to promote or supply methadone;

To download your copy of the Global state of Harm Reduction 2014, click here.

INPUD discusses the International Harm Reduction Conference, 2015

Twitter: @HRInews / http://www.twitter.com/HRInews

Posted in Eastern European Countries, Europe, Hepatitis C, HIV/AIDS, IHRA, Latin Countries, law enforcement, methadone | Tagged , , , | Leave a comment