The annual Harm Reduction International Conference was recently held in Montreal, Canada from 14- 17 May 2017. The conference brings together people from around the world who are involved in providing health and social support services for people who inject drugs. I was able to attend and represent STOPAIDS to discuss the important areas of cross-over with the global HIV response.
Harm Reduction strategies aim to reduce the harms associated with drug use and commonly include needle exchange programmes and opiate substitution therapy. Harm Reduction is a well evidence essential component of HIV prevention.
There was one overwhelming message I heard from all those at the conference – that message was one of ever-growing alarm. Harm Reduction funding is in crisis. Harm Reduction International’s Global State of Harm Reduction 2016 report found that there has been no increase in the number of countries implementing harm reduction programmes since 2014. Of 158 countries and territories where injecting drug use has been reported, 68 still have no needle and syringe programme (NSP) in place, and 78 have no provision of opioid substitution therapy (OST).
As drug users are disproportionately affected by HIV, the majority of harm reduction services are funded through HIV funding. Therefore, the crisis in harm reduction funding is closely linked to the parallel decline in funding for the global HIV response. The Kaiser Foundation Family Report found that donor funding for HIV had decreased by 13% between 2014 and 2015, the first fall in funding for five years. This is a result of the deprioritisation of HIV by many global donors.
This overall HIV funding reduction is in part fuelled by the reduction in external donor support for middle income countries across all international development aid. This is because HIV prevalence is increasingly concentrated in middle-income countries – UNAIDS estimates that by 2020, 70% of people living with HIV will be living in middle income countries. This issue is even more pronounced for people who use drugs. Approximately 75% of people who inject drugs live in middle-income countries. Donors that had previously provided most of the global harm reduction funding, particularly the Department for International Development and the Global Fund, are reducing or withdrawing support to middle income countries, assuming that rising gross national incomes means that development funding is no longer needed.
These trends have drastic implications for key populations and harm reduction funding. As external donors pull out funding the assumption is that domestic governments will step in to replace funding and services but they often don’t have the political will to do so – especially where there is a national context of criminalization or discrimination of these groups. And so transitions away from donors financing often lead to a gap in harm reductions services and then a spike in new HIV infections amongst people who use drugs.
At the conference I gave a presentation about how civil society in donor countries can and must advocate for donors to take a more responsible and sustainable approach to both HIV and harm reduction financing in middle income countries. This means re-examining whether decisions around ODA are focused squarely on achieving the SDGs; rethinking the narrative and the reality of how donors engage with middle income countries; and finally, when a decision is made to withdraw funding from a middle income country, that it is done in a way that ensure that the health gains secured are maintained and built upon, not squandered.
My presentation builds on work STOPAIDS has been doing for a number of years on this issue both globally and in the UK. At the global level, how the Global Fund to Fight AIDS, TB and Malaria addresses funding for harm reduction and transitions in middle income countries over the coming years is absolutely critical. We are working on this issue through the developed country NGO delegation to the Global Fund Board, through the Global Fund Advocates Network, and through the recently formed Civil Society Sustainability Network. The Global Fund published its Sustainability, Transitions and Co-financing Policy in 2016 and the key work now is to ensure there are strong mechanisms for monitoring ongoing transitions, additional funding mechanisms for countries transitioning, a more nuanced eligibility policy and procurement and supply chains that support access to affordable medicines.
In the UK there is also much work that needs to be done to engage the UK government, parliament, the media and the public around our relationship with middle income countries and the role of ODA should play. STOPAIDS is also calling on The Department for International Development to review the criteria it uses to assess where and how it works and to improve its approach to transitions (withdrawal of UK funding). We support the Independent Commission for Aid Impact’s recommendation, that DFID should develop a policy or framework to guide programme managers during a transition to ensure that the valuable investments and gains made with UK taxpayers money are not lost. In 2016 we published a paper, Principles of Successful and Sustainable Transitions with case studies from 5 DFID and Global Fund programmes containing suggestions for DFID to include in a transitions policy. We also held a Middle Income Country Symposium in March 2016, bringing together 60 representatives from Government, civil society, multilateral organisations, technical partners and private sector to discuss what effective support to middle income countries would look like. We welcome and will fully support the All Parliamentary Party on HIV and AIDS inquiry into the impact of transitions on key populations and women and girls in middle-income countries and plan to submit written evidence.
As we continue to work with donors to achieve responsible and sustainable transitions it is imperative we also continue to question whether the country is ready, willing and able to transition. We should also seriously assess what impact transitions have on people’s lives when services are lost and ask whether we might have an alternative approach to middle income countries that improves our collective ability to meet all the SDG targets, particularly that of ending AIDS.
Alysa Remtulla, Policy Officer