Back in smokey old London now, but wanted to update you with the happenings on the final, amazing day at the UNAIDS PCB in Geneva. Very recent blogs will give you the brief version on what the PCB does, and some of the issues that were raised over the few days the board meeting was convening.
Mat and I, as I mentioned, were there to input into an excellent document that a series of NGOs had put together, on HIV Prevention amongst Injecting Drug Users. (The paper is attached in the file box). Out of the document, which is an excellent read and a very useful resource for the drugs field, there had been a series of 8 recommendations brought to the fore that the NGO delegation were extremely keen to get passed by the member states – and so become a UNAIDS policy document.
The process itself was very interesting and I promised myself I would try and relay it to you as best as I could so here goes…How the UNAIDS comes to its decisions.
Much of the UN works in very similar ways apparently, except of course the UNODC which has no direct input or involved representation from NGOs and is much less transparent.
The HIV Prevention amongst IDUs report…
Firstly, the NGO delegations had produced a report to assist countries to scale up HIV prevention among IDUs – in line with the decisions of the PCB in its previous Policy Position Paper on Intensifying HIV prevention (another useful paper to refer from for all our work).
By utilising the global communications structures we have at our disposal in 2009, a concise, well researched report was compiled, though INPUD was brought in at a fairly late stage due to, primarily, the fairly recent collaboration and the partnerships being formed with the international HIV community. This is most welcome and certainly reflective of a wider recognition of INPUD and its affiliated groups and networks. But I would like to stress that when we were brought in, we felt fully involved in the work and believe this will only develop and strengthen ties with the global HIV community.
Anyway, before the paper was read out, Christian Kroll from the UNODC set the scene for the discussion by talking about some of the realities on the ground from the new World Drugs Report. He recognised many HIV positive drug users and women are going underground in Central Asia and Eastern Europe because of the intense stigma associated with drug use and pointed out the emerging injecting crisis in countries such as Tanzania and Kenya. He also stated that coverage of services are less than 5% in some places and there is still a lack of political will regarding Opiate Substitution Treatments/therapies (OSTs) and mentioned with concern the fact that he only just saw a letter that Uzbekistan who said OST is not effective! He also mentioned the need for better warning systems for emerging problems and stressed the need to focus also on drugs other than injected ones pointing to the massive stimulant problem China currently faces. See the UNODC’s policy papers in relation to HIV.
After Christian from the UN’s Office Of Drugs and Crime (UNODC) reported, round it went for all the member states to report their thoughts. As mentioned before, due to the huge number of affiliated member states, only 22 are ‘speakers’ yet they speak on behalf of a cluster of countries, usually 3 or 4.
Key messages from member states were:
We had been tipped that Japan was going to be awkward, indeed its no secret as to the views they hold. The Japanese representative agreed that harm reduction came from the public health point of view and accepted it has been used in several key UN documents. But, in implementing harm reduction, Japan felt that countries should take in to account each country’s rates of HIV, the risk of promoting drug use from syringe and needle exchange programmes in case it encourages people to use drugs (!!) and that “because we have a very low rate of people using drugs…we also think that OST isnt always useful and can be harmful.” It regretted that Japan could not support the recommendations in this paper. Basically, they believed that they shouldn’t be made to toe the line because they have cultural and national differences that make harm reduction something they shouldn’t have to adhere too. See the final paper for the additional language Japan insisted on inserting.
Another potential probelm, however Russia was rather coded in its language. The Gov Rep said “What we see happeing in our county is a clash between the moralists and the medicalists (sic) – they are talking past each other and not listening to each other…unless we get some agreements we wont be able to address these problems”. (Now you would think Russia might be coming on board with the paper here but, the gov rep continued)… “Therefore I fully support what Japan says that we need to take into account the particular nuances of every country”!
I must mention here that the UK were excellent on the floor and in supporting the statements and work of the NGO’s. Thank you Alison. “We have known for some years how to effectively prevent the spread the of HIV and serious health problems, harm reduction is indisputable, but it m dosent’t matter how much we know about the evidence or the laws – we need to address the stigma and discrimination. As long as they are stigmatized and criminalized in many countries they will continue to face many difficulties and this gets in the way of initiatives being rolled out. The World Drug Report out today leaves some worrying gaps about where drug use lies and its trends and unless we have better data we will not be equipped to plan. We need to look at what we have data wise and improve that data.”
Now this was certainly awaited for. Dr Eric Goosby had apparently rushed in from the states
before he had even been sworn in (although some said he hurried through this procedure especially so he could be here for the PCB).
The US said they viewed needle exchange as a conduit to reach a difficult to reach community and it has been shown that it is possible to bring these people back not just into a medical frame “but to re-imbrace the person as a patient who has a disease that is treatable and that the history of addiction is full of recidivism” (oh dear!) He thinks the UNODC document and the difficulty around the term harm reduction has confounded the discussion. The US asked for explicitly defining the services that come under harm reduction as people think it means legalisation. (This is interesting readers because in a sense it could open up a can of worms, for example if drug consumption rooms come under the ‘defined’ term of harm reduction, would that mean the US would NOT then support the term? Scary – it could mean going backwards or forcing the HR lobby to exclude certain things from definitions of HR).
Finally, Ill wrap up here, as blogs are supposed to be short and I have a bit left to tell you regarding the final recommendations adopted. But let me say a few short quotes from member states:
France: When the care is given to users in must be comprehensive, they often suffer from other ailments. They said they support recommendations 8 and 9 from the NGOs very strongly.
Denmark; Supports the term harm reduction very strongly; reiterated the use of alcohol and it’s role in increasing HIV infections from unprotected sex, violence etc. (the first time I have heard it stated so far). The term harm reduction must be widely used and acknowledged.
Brazil: This Gov Rep was fabulous. Stating that she remembered a time when IDUs and harm reduction was not mentioned at all. It was approved in 2005 but it was not easily approved. She said crack use was by far the fastest growing group of drug users in her country and also asked Decision point 8.5 made even stronger.
So, the comments were passed from the member states, having had the chance to read the report and then although Vitaly Djuma spoke as our IDU representative after Russia spoke, (and he must be commended all his hard work, nice one Vitaly, huge thanks from all of us!) I have put his recommendations here however for the sake of clarity.
Vitaly, having around 3 minutes to speak, (his speech is in the box file) noted and spoke of the report that was brought before the PCB, and put forward the 8 final recommendations with a few additonal tweaks that had gone on over the last few weeks and days.
Basically, due to the need for TOTAL CONSENSUS in UN policy, and because of the comments made by, in particular Japan, the US and Russia, it was suggested by the chief exec Sibide that the reports recommendations should go to the drafting room over lunch and any countries who wanted changes should be there to hammer it out.
The Drafting Room…
So off we all went, a dozen or so countries and ourselves (observers are are not permitted to speak, only our NGO reps, but we can whisper to the NGO reps!), to hammer out some of the wording.
In order to keep this brief, I’ll mention two of the main changes. Japan wasn’t happy with the fact that they should have to toe the line with initiatives/directives that stem from words like harm reduction etc, when they reckon they have very little illicit drug use or HIV infection. Therefore, they INSISTED on the wording…. “in accordance with relevant national circumstances”. Basically, a bit of a get out clause but Japan just WOULD NOT shift on the matter and it was either that, or potentially watch a series of things collapse – for discussion at a later date. See points 8.9, 8.4, and 8.1 for their inserts. It really is interesting, the power of a word, if not rather excruciating and annoying.
The recommendations were, after additional tweaking, comment, and drafting were;
Agenda item 3: HIV prevention among injecting drug users
8.1 Requests the UNAIDS Secretariat and the Cosponsors, in particular UNODC, to significantly expand and strengthen the work with national governments to address the uneven and relatively low coverage of services among injecting drug users and to develop comprehensive models of appropriate service delivery for injecting drug users in line with relevant national circumstances and the UNAIDS/UNODC/WHO “Technical Guide for countries to set targets for Universal Access to HIV prevention, treatment and care for injecting drug users”; (in red text – Japans addition)
8.2 Recognizing that resources should be expanded for service delivery and capacity development to enable communities to provide prevention, care and support services to drug users living with HIV on a larger scale whilst, at the same time, tackling the issue of stigmatization and discrimination requests UNAIDS and its stakeholders to work with multilateral donors, and national governments, to facilitate greater resource mobilization on this issue, consistent with the level of identified need; (Japan (and I think Russia) inserted that bit.)
8.3 Requests UNAIDS to intensify its assistance to, and work with, all groups of civil society, including those affected by drug use and those that provide services to people who use drugs, aimed at advocating for anti-stigmatizing, anti- discriminating, and evidence-based approaches to HIV and Hepatitis C Virus(HCV) epidemics at national, regional and global levels;
The text in italics was a statement insisted upon by the US. Previously, the text had read ‘…intensify its assistance to, and work with, civil society including global, regional and national harm reduction associations, and associations of people who use drugs.It seemed that asking the US to openly agree to working with associations of people who use drugs was just a step to far. However, after much discussion in the drafting room, which was a fascinating process in itself, the final statement above was decided upon to everyone agreement, including ours. It really is often a case of compromise or get it thrown out all together.
8.4 Calls upon Member States to further harmonize national laws governing HIV and drug use, in accordance with relevant national circumstances both from a public health and a human rights perspective;
Previously this had read… “…harmonise laws governing HIV and drug use including the removal of legal barriers for possession of drug related paraphrenalia.” Sadly, Japan insisted on ‘relevant national circumstances’ appearing here as well.
8.5 Requests the UNAIDS Secretariat and the Cosponsors, in particular UNODC, to support national authorities to align policies, clarify roles and responsibilities of various national entities – including drug control, the penitentiary system, public health and civil society – and support increased capacity and resources for provision of a comprehensive package of services for injecting drug users including harm reduction programmes in relation to HIV as enumerated in the UNAIDS/UNODC/WHO “Technical Guide for countries to set targets for Universal Access to HIV prevention, treatment and care for injecting drug users”;
8.6 Calls upon UNAIDS, Member States and civil society organizations, in addition to specific interventions that target injecting drug users, to develop and implement guidance and programme models to respond to the needs of other sub-groups of drug users, including female drug users, drug users who also exchange sex for money or drugs, drug users who end up in prison settings, underage and young drug users, migrant drug users, drug users amongst refugees and other displaced populations, stimulant and poly-drug users and men who have sex with men who use drugs, spouses and partners of people who use drugs, as well as interventions that target broader health needs of people who use drugs;
8.7 Calls upon Member States, civil society organizations and UNAIDS to increase attention to certain groups of non-injecting drug users, especially those who use crack cocaine and amphetamine type stimulants, and those who abuse alcohol, and their link to increased risk of contracting HIV through high-risk sexual practices, as well as to responses to emerging epidemics of injecting drug use in many African countries;
8.8 Recognizing that existing data on HIV and drug use are far from adequate in both quality and quantity, requests UNAIDS to support greater investment in data collection required to inform the development of HIV prevention, treatment, care and support initiatives, resource allocation and comprehensive service delivery, including a system of regular and rapid assessments of the risk potential for new epidemics where anecdotal evidence indicates an emerging problem, and calls upon Member States to ensure accurate estimates are made of the size of IDU populations, while taking into consideration the shifting patterns of injection;
8.9 Encourages governments to reaffirm commitment to, and intensify harm reduction efforts in relation to HIV as enumerated in the UNAIDS/UNODC/WHO “Technical Guide for countries to set targets for Universal Access to HIV prevention, treatment and care for injecting drug users”; including needle and syringe programmes and opioid substitution programmes, essential for reaching universal access to comprehensive HIV prevention, care, treatment and support for people who use drugs in accordance with relevant national circumstances; (Japan again!)
8.10 Requests the UNAIDS Secretariat and WHO to support countries in the implementation and improved surveillance of hepatitis B and C including co-infection with HIV in all countries, and to develop the necessary guidelines for Member States to elaborate policies, strategies and other tools to prevent and control hepatitis co-infection in people living with HIV;
8.11 Recognizing that stimulant drug use is a rapidly growing health problem, requests UNAIDS to strengthen its work on HIV and stimulant drugs;
So there we have it readers. The final text is in the file box on the right (while the box isnt working files will be attached as links in the articles), do visit the UNAIDS website for further information. I haven’t even touched on the great success had by women around the issues of HIV and gender, which included sex work, perhaps Ill try and get a neat summery of what happened for you. Suffice to say, I would like to stress a big thank you to Kate Thompson, Greg Grey, Natalie Siniora, Sara Simon, Alan Brotherton and Alan Clear, Vitaly Djumas, Alison, and all the NGO reps and observers that put in so much work to support the harm reduction cause.
See chief Exec Michele Sibide’s opening speech here.
See Chief Exec Michele Sidibe’s closing speech here on video
written by Erin O’Mara