Excluded by their families, stigmatized in public, and shamed at health clinics: These were everyday experiences for the men and women I encountered in my work on HIV in Nepal. It didn’t matter that they were mothers, fathers, sons, and daughters — the fact that they used drugs meant they were pushed to the edges of society, where it became easier to ignore their health, rights, and vulnerability to HIV.
People who inject drugs are one of the most at-risk populations for HIV and over 20 times more likely to contract the virus than the general public. The risks are entirely preventable. Harm reduction services, such as needle and syringe programs and opioid substitution therapy, are proven to prevent HIV and hepatitis C among people who inject drugs and are cost-effective.
The majority of people who inject drugs live in low- and middle-income countries, yet there is a severe shortage of lifesaving harm reduction interventions in these countries. Though there is a clear need to scale-up these services, our new research shows international donor funding for harm reduction is falling, and with it placing the global HIV/AIDS response in peril. UNAIDS wrote last week of its concern in the 20 percent funding shortfall in the fight to end AIDS. For harm reduction in LMICs, this funding shortfall is close to 90 percent.
The consequences of insufficient harm reduction services are evident. New HIV infections among people who inject drugs increased by a third globally from 2011-15 and epidemics related to injecting drug use are commonplace in Eastern Europe and Asia. It is astounding that in the face of this crisis and with governments claiming they are committed to ending AIDS by 2030, financial support for harm reduction is waning.
Donor governments, such as the United Kingdom, have largely pulled direct support for harm reduction over the past decade on the basis they are contributing this money through institutions such as The Global Fund to Fight AIDS, Tuberculosis and Malaria. The Global Fund remains the largest and most important funder of harm reduction globally, yet our research found that its funding allocations for harm reduction dropped significantly between 2011 and 2016, despite little change to its overall budget.
This situation is compounded by the gradual withdrawal of international aid from countries as they become wealthier, meaning the responsibility increasingly lies with domestic LMIC governments to fund harm reduction. Sadly, politics and stigma cloud smart public health decisions and we see limited examples of governments committed to addressing the health issues faced by people who use and inject drugs.
A case in point would be Romania. When The Global Fund support for harm reduction ended earlier this decade, services collapsed and HIV infections among people who inject drugs spiked. The Romanian government had little desire to acknowledge the existence of people who use drugs, let alone their vulnerability to HIV and the implications this had for society.
Such attitudes are sadly not uncommon. The majority of governments exclude, criminalize, and demonize people who inject drugs, in the process creating a barrier for them to access HIV services. Governments are, in effect, creating their own public health crises. Even when support for harm reduction is in place it remains fragile at best. Kazakhstan, for example, is currently considering cutting opioid substitution therapy programs despite their demonstrated effectiveness in HIV prevention. Political ideology, as ever with drug use, is trumping what’s best for public health.
The outlook for HIV rates among people who inject drugs appears dire. If governments are serious in realizing their shared goal of ending AIDS, donors must increase support for person-centered harm reduction services. This includes support from The Global Fund, which must not be withdrawn from countries without assurances that governments will continue to operate harm reduction services. The transition from international to domestic funding has to be secondary to maintaining the gains in HIV prevention made because of harm reduction.
Domestically, LMIC governments with constrained budgets don’t need to find new money. As Harm Reduction International has shown previously, redirecting just a fraction of what governments spend on drug law enforcement to harm reduction could end AIDS among people who inject drugs. Further, it would begin to break down some of the wider social-political barriers to HIV services that come with criminalizing vulnerable groups.
The International AIDS Conference taking place this week promises to focus on how better to uphold the rights of marginalized people and ensure they are reached with lifesaving HIV services. For people who inject drugs, the timing couldn’t be more urgent.
I recently received a sharp reminder of this urgency, when I learned that one of the community leaders I knew in Nepal had passed away. Deaths from HIV-related complications are unnecessary and avoidable. We know what works to prevent HIV among people who inject drugs. There is no excuse for failing to back harm reduction.
By Naomi Burke-Shyne