What is Harm Reduction?

Harm Reduction in Principle

Harm reduction is a pragmatic and humanistic approach to diminishing the individual and social harms associated with drug use, especially the risk of HIV infection. It seeks to lessen the problems associated with drug use through methodologies that safeguard the dignity, humanity and human rights of people who use drugs.

This approach is based on the pragmatic acknowledgement that, despite years of trying, there are no known effective interventions for eliminating drug use or drug-related problems in any community, city, or country. In most cultures, adopting a harm reduction approach requires a shift in thinking away from deeply rooted, and understandable, long-term idealistic goals of eliminating drug use and getting all drug users to become drug free.

Harm reduction does not deny the value of helping people become drug free, or the desirability of abstinence as an eventual goal. It simply recognizes that for many drug users these are distant goals and that services to reduce the risk in the interim are therefore essential if personal and public health disasters are to be avoided. Recognizing the reality of drug use, harm reduction programs measure success in terms of individual and community quality of life and health and not in relation to levels of drug use.

Harm reduction entails a prioritization of goals. Given the high individual and social costs associated with AIDS, measures to prevent the spread of HIV are at the forefront of harm reduction priorities.

Harm Reduction in Practice

Harm reduction uses a range of services to achieve its goals. Needle exchanges and replacement therapy treatment are the two of the most effective interventions to reduce drug-related harm. These are often complemented by other supportive services for drug users such as health and drug education, HIV and STD screening, psychological counseling, and medical referrals.

By providing accessible services that meet drug user needs, harm reduction programs often serve as a meaningful point of contact that can connect drug users with other community, medical, and social service resources.

Needle Exchange

Numerous studies confirm that the simple act of exchanging clean needles for used ones can have dramatic effects - especially in reducing the rate of HIV infection among drug users.

Methadone Therapy

Methadone therapy has also been found to reduce an array of drug-related harms including HIV infection and crime.

Do needle and syringe programs work?

Needle and syringe provision has been the subject of widespread scientific evaluation over the past 15 years. These studies have confirmed that needle and syringe programs do not lead to higher rates of illegal drug use or injecting and can:

• Reduce HIV seroprevalence.
• Reduce the need to use a needle more than once.
• Provide an access point for a large disadvantaged group to health and other services.¹

US studies have found that needle and syringe provision can decrease HIV-risk injecting behavior by up to 73%.² A study of 81 cities around the world compared HIV infection rates among injecting drug users in cities that had needle and syringe provision with those that did not. In the 52 cities without needle and syringe provision for injecting drug users, HIV infection rates increased by an average of 5.9% per year. In the 29 cities with needle and syringe provision, HIV infection rates decreased by an average of 5.8% per year.³

An international comparison of five cities⁴ which prevented HIV epidemics among injecting drug users for at least five years found that there were three similarities between them:

• Prevention efforts were initiated early, when less than 5% of injecting drug users were infected with HIV
• Outreach was used to build trust between health workers and injecting drug users, to provide information about HIV testing and counseling and drug treatment and to distribute HIV prevention information, needles, syringes and condoms
• Needle and syringe provision was well established and 20-33% of all injectors in each city were regular users of the service.
• Needles and syringes were also easily available for sale at low cost in four of the five cities.

In California (USA), the effects of needle and syringe provision were studied over a five-year period.⁵ The needle and syringe program did not encourage drug use either by increasing drug use among current injecting drug users, or by recruiting new or young injectors. In fact, injection frequency amongst injecting drug users in the community decreased from 1.9 injections per day to 0.7, and the percentage of new initiates into injecting drug use decreased from 3% to 1%.

Australian needle and syringe programs were evaluated in 1991.⁶ It was found that they had saved an estimated 3,000 lives in that year at a cost per life saved of approximately US $200. The savings in HIV treatment costs for that year were estimated to be about US $150 million.

These effects are not achieved by the distribution of injecting equipment alone. In most countries, needle and syringe provision has been accompanied by programs to educate drug users about the need to use sterile injecting equipment, and the development of treatment and other services which can reduce drug-related harm.

Examples of harm reduction projects in Eastern Europe and the Former Soviet Union.

Belarus, Moldova, Russian Federation and Ukraine
In Belarus, a needle and syringe program has been running for three years in Svetlogorsk. New programs are being started in other regional cities such as Mogilu and Babrusk.

In Soroca, Moldova, needle and syringe provision has been combined with a center providing basic medical assistance and psychological counseling for the city's Roma population.

In the Russian Federation, needle and syringe provision has been established by NGOs in St Petersburg, Yaroslavl, and Volgograd, and by AIDS centers in Pskov, Rostov-on-Don and Novorissisk. In Penza in the south of Russia, a small needle and syringe program was started by epidemiologists and narcologists from within the city's narcology center, though it later moved to a site more convenient to the area where most of the city's drug users live. More than 35 needle and syringe programs have opened in the Russian Federation during 1999-2000.

In Poltava and Mykolayev, Ukraine, non-government organizations (NGOs) run a needle and syringe program with volunteers who receive comprehensive training. They also produce a wide range of leaflets on drugs, HIV/AIDS, sex and the law. In Odessa, three needle and syringe programs started by the city's AIDS center were later taken over by a NGO; and at least 15 other cities have started programs in the past two years.

Central/Eastern Europe
In Prague, Czech Republic a needle and syringe program operated by a NGO provides a shower, laundry and coffee-making facilities.

In the Slovak Republic, the project 'Odyseus' started with six street workers who spend 24 hours on the streets of Bratislava each week offering an outreach service to both injecting drug users and sex workers. Another service providing free injecting equipment is run from a medical center wheremethadone is also dispensed.

In Poland, needle exchanges have operated for several years in cities such as Kracow, Lublin, and Katowice, often in association with a large drug treatment NGO.

Latvia, Lithuania, Estonia
In Lithuania, there is a needle and syringe program in Vilnius (including a mobile service that works with a large Roma population living on the edge of the city) and an outreach program based at the city's narcological service. A drop-in center has been successful in reaching injecting drug users in Klaipeda on the Baltic Sea.

Needle and syringe programs operate from AIDS centers in three cities in Estonia and also in Riga (Latvia).

Central Asia
In Kazakhstan, needle exchange programs have been started in Karaganda, Kostanai, and Aktybinsk.

In Kyrgyzstan, harm reduction programs are operating in Osh and Bishkek.

Southern Europe
In Sofia, Bulgaria, workers from the needle and syringe program, carrying distinctive bags, move from group to group of injectors in a park in the center of the city where much drug buying and selling occurs.

In Skopje, Macedonia the needle and syringe program was started as a non-governmental organization formed by drug users themselves. They have forged links with other organizations to advocate for the legal and civil rights of injectors.

In Slovenia, a needle and syringe program was set up with a drug-user representative from the Netherlands to provide group education to injecting drug users on safer injecting and safer sex.

In Split, Croatia, a program operates every day (including weekends and holidays) to provide injecting equipment not only to drug users in the city, but also from the surrounding rural region and nearby islands.

Footnotes

1 Stimson G.V., Alldritt L.J., Dolan K.A., et al. (November 1998) Injecting Equipment Exchange Schemes: Final Report. University of London, Goldsmiths College. Monitoring Research Group, London.
2 Does needle exchange work? Center for AIDS Prevention Studies, University of California. Website: www.epibiostat.ucsf.edu/capsweb/needletext.html
3 WHO International Collaborative Group, (1994). Multi-city Study on Drug Injecting and Risk of HIV Infection. World Health Organization, Geneva.
4 Des Jarlais, D., Hagan, H., Friedman, S., et al. (1998) Preventing epidemics of HIV-1 among injecting drug users. In: Stimpson, G.V., Des Jarlais, D.C., and Ball, A. (eds) Drug Injecting and HIV Infection: global dimensions and local responses. UCL Press, London.
5 Watters, J.K., Estilo, M.J., Clark, G.L., et al. (1994). Syringe and needle exchange as HIV/AIDS prevention for injecting drug users. Journal of the American Medical Association, 271: 115-20.
6 Feacham, R. (1995) Valuing the past Investing in the Future: Evaluation of the National HIV/AIDS Strategy 1993-94 to 1995-96. Commonwealth of Australia, Canberra.