Expert Group Meeting of the Eurasian Harm Reduction Association

Posted on by Igor Gordon

Moving Together Towards Quality Harm Reduction[1]

5-7 October 2021

Meeting report

Contents

Rational and background of the meeting. 2

Meeting goals and objectives. 3

Summary of highlights and key themes discussed during the meeting. 4

Immediate next steps in national and regional advocacy. 7

Rational and background of the meeting

Harm reduction as a concept appeared in 1980s as a solution to health problem – the spread of HIV/AIDS among injecting drug users. Since its pioneer days, the key success factor for effectiveness of harm reduction interventions is the adherence to four fundamental principles – (1) respecting the human rights of people who use drugs, (2) commitment to evidence, (3) commitment to social justice and collaborating with community of people who use drugs, (4) free from stigma and discrimination.

A definition provided by the Harm Reduction International is consistent with EHRA understanding of harm reduction. “Harm reduction is policies, programs, and practices aimed at minimizing the negative effects of current policies on the health, social opportunities, and human rights of people who use drugs. Harm reduction is based on justice and human rights aimed at positive changes and the provision of social and medical assistance to people without condemnation, coercion, discrimination, or requiring them to stop using psychoactive substances as a prerequisite for support”[2].

Harm reduction as a comprehensive package of interventions[3] for the prevention, treatment, and care of HIV among people who inject drugs[4] has been endorsed widely, by WHO, UNAIDS, UNODC, the UN General Assembly, the Economic and Social Council, the UN Commission on Narcotic Drugs, the UNAIDS Programme Coordinating Board, the Global Fund and PEPFAR.

Over the years, harm reduction has evolved, new interventions have been added, to meet the needs of people who use drugs and public health challenges.

To date, there are many modalities of harm reduction approaches, however, not all of them adhere to the fundamental principles. In practice, quite vague interpretation of harm reduction concept negatively affects the quality of the programmes, causing lower enrolment rates and efficiency of interventions.

At the moment, as the data shows access to full-scope quality harm reduction services in CEECA countries is limited. In many CEECA countries, existing harm reduction interventions do not include distribution of naloxone, drug checking, access to sexual and reproductive health services, and/or access to social service programs. As a result, harm reduction programs may not have the ability to reduce overdose mortality; protect against HIV and other blood-borne infections; ensure access to HIV, hepatitis B and C, tuberculosis, and sexually transmitted infections (STI) treatment; and/or provide social support and social integration for people who use drugs. The reason for such a significant aberration in provision of harm reduction services lies in criminalization of drug use which creates barriers for effective service provision and significantly influences lack of political will of national and municipal authorities to fund comprehensive harm reduction services. Its more politically and publicly acceptable to finance and deliver harm reduction interventions as blood-borne diseases prevention among vulnerable populations instead of funding and developing programmes aimed at saving the lives, health and social welfare of people who use drugs. If the states would really want to end HIV and preserve public health as it stated in many government strategies harm reduction programs would look differently.

The new Global AIDS Strategy 2021-2026[5] emphasizes the urgent need to change the laws, remove legal barriers, eliminate stigma and discrimination. Thus, harm reduction service providers should include advocacy and change of policies and practices in their work, and communities should engage in monitoring and evaluation of provided services and actively participate in the development of programs and policies[6].

EHRA seeks to ensure that countries in the CEECA region have access to quality and effective harm reduction services based on the needs of people who use psychoactive substances that also consider any new changes in the drug scene. It is important for us that different groups of people who use psychoactive substances have access to harm reduction, including women, youth and adolescents, people with physical or mental health issues, and people living with HIV, viral hepatitis, and tuberculosis. We consider harm reduction services as an integral part of ensuring universal health coverage for people who use psychoactive substances; this population often experiences the most severe forms of discrimination and is the most vulnerable in terms of socio-economic status.

Expert group meeting  was organized to meet EHRA’s strategic objective 2.1[7] from EHRA Strategy 2020-2024: „Contribute to improving the quality and comprehensiveness of existing harm reduction services in the countries of the CEECA region” specifically to support development of a simple system of self-assessment and peer review by professionals and technical assistance to improve the quality of harm reduction programs is developed by EHRA through expert practitioners based on international standards and recommendations.

 

Meeting goals and objectives

Why we need this:

During the transition from international to state funding, the quality of harm reduction

programs is lost with cutting unit costs. The role of EHRA as a professional network is to

define criteria of harm reduction quality and to agree on joint advocacy and capacity

building plan for the network to improve the quality and comprehensiveness of existing

harm reduction services in the countries of the CEECA region.

The EHRA Secretariat initiated a meeting to identify what EHRA, as a professional harm reduction association in the region should do about the deteriorating quality of harm reduction services in CEECA. 20 EHRA member organizations from 14 CEECA countries with vast expertise of harm reduction service provision were invited to the meeting.

Outcomes of the meeting:

– A clear understanding of the harm reduction goals and definition of quality criteria

(EHRA position paper)

– EHRA approaches to ensure quality and support national advocacy

– Establishment of EHRA expert group on harm reduction quality in the region with

regular annual meetings

 

Meeting outline

  • Overview of current state of harm reduction in CEECA
  • Discussion on the key challenges in ensuring quality of harm reduction from position of service provider, clients and donors/state
  • Exploring methods and evidence based best practices in service quality assurance
  • Building consensus on the key approaches to setting targets and measuring the quality of harm reduction services.
  • Map out EHRA’s immediate next steps and in national and regional advocacy on ensuring quality of harm reduction in CEECA

The meeting sought to focus on finding expert consensus, taking into account differences in the state of harm reduction in countries, variations in modes of provision, specifics linked to sources of funding, best practices in insuring delivery of quality services, international guiding documents and recommendations, on the following issues:

 

  • What is the goal of harm reduction services?
  • What are the components of harm reduction?
  • Whcih criteria show that service is of high quality?
  • What are the key criteria to measure harm reduction quality?

Summary of highlights and key themes discussed during the meeting

After comprehensive overview of current state of harm reduction in CEECA, and discussing country specifics shared by experts, the four issues has been identified to be addressed urgently:

  • reduction of harm reduction to HIV prevention and the need to include the broad range of health and social services and/or referral system,
  • need to involve mental health into the concept of harm reduction,
  • lack of services for young people and gender sensitive services,
  • lack of services for the users of new psychoactive substances and overall rigidity of services.

Participants have confirmed that a definition of harm reduction currently used by EHRA  is up to date and must be used for designing any harm reduction intervention.  

Participants one more time stressed that services should be considered holistically and should protect person’s life and dignity at their core. Interventions should be designed to reduce legal, health (incl. psychological, mental, HIV, HCV, TB, Covid) and social harms or risks associated with drug use; and to guarantee access to medical and social care for the most in need (complex of medical + social services for person and family for different groups: women, young people, imprisoned ones, polydrug users).

Experts agreed that in addition to a comprehensive package of 9 interventions for the prevention, treatment and care of HIV among people who inject drugs, that has been endorsed widely, by WHO, UNAIDS, UNODC, the UN General Assembly, the Economic and Social Council, the UN Commission on Narcotic Drugs, the UNAIDS Programme Coordinating Board, the Global Fund and PEPFAR, quality harm reduction should include various additional possibilities and components:

The comprehensive HIV package Additional components that should be included
Needle and syringe programmes Stimulant substitution treatment
Opioid substitution therapy and other evidence-based drug dependence treatment Primary medical care (e.g. treatment of wounds, abscesses)
HIV testing and counselling Peer-work and outreach
Antiretroviral therapy Digital/online outreach;
Prevention and treatment of sexually transmitted infections Mental health support, including peers with double diagnosis (for example, drug dependence and bipolar)
Condom programmes for people who inject drugs and their sexual partners Integrated treatment of HIV, Hepatitis C, NSP and OST services

 
Targeted information, education and communication for people who inject drugs and their sexual partners Everyday housekeeping services (e.g. washing machines, shower, food, etc.)
Prevention, vaccination, diagnosis and treatment for viral hepatitis Shelters for women who use drugs victims of violence
Prevention, diagnosis and treatment of tuberculosis. Overdose prevention interventions (both for opioid and stimulant users)

 
Social care, case management (incl. development of clients social skills, assistance with employment)
Legal consultations/paralegal help
Drop-in centers / safe spaces to relax, spend time
Safe consumption rooms (not only for injectable drugs)
Drug checking
Gender sensitive services for women who use drugs

Expert group agreed, that a good quality harm reduction program should meet the following criteria, it should be:

  • trustful;
  • culture appropriate;
  • accessible 24/7 or at least on a regular basis;
  • sustainable in terms of stable team and working hours;
  • flexible;
  • intersectional, responding to the needs of different communities;
  • client oriented;
  • measurable;
  • accessed without barriers;
  • safe (comfortable, anonymous).

To assess the quality of existing programs there should be:

  • space and tools to provide feedback (e.g. to measure client’s satisfaction);
  • supervision, intervision for staff, performance appraisal;
  • community involvement in decision making;
  • optimization of data collection and sufficient budget for research.

The main role of Eurasian Harm Reduction Association should be ensuring quality of harm reduction services in the region – advocacy and technical support for the members, mentoring, platform for sharing the best practices, collecting related material and information, cooperation with international bodies.

 

Immediate next steps in national and regional advocacy

Participants mapped out EHRA’s immediate next steps and required national and regional advocacy efforts to ensure quality of harm reduction in CEECA. EHRA Expert group on harm reduction quality will be involved in each step of the development of:

* EHRA position on quality of harm reduction services. The position should be developed internally, widely discussed among EHRA members and adopted to strengthen advocacy for access to high-quality, evidence-based, gender-transformative, non-discriminatory harm reduction services in freedom and in closed settings that have proven to be effective and are based on people’s needs and human rights. Before the approval draft position will be presented to the Steering Committee, discussed with the Expert group as well as members of the Association and reviewed by Advisory board.

* Components, arguments, criteria (CAC). Development of the set of evidence-based advocacy arguments organized in on-line platform describing Components, Arguments, Criteria (CAC) for improvement of quality of harm reduction programs in CEECA, considering COVID-19 learnings from national and regional advocacy for quality harm reduction services. Arguments need to contain links on scientific evidence and international recommendations. Developed set of CAC need to include answers on the following questions:

  • What kind of components quality harm reduction program should include to fulfill its goals?
  • Arguments with links to scientific data supporting inclusion of each of the components
  • Criteria that should be used to access the quality of existing services

* Collection of the set of best practices and practical examples of harm reduction programs effectively implementing each of the CAC components in CECCA region.

  • Self-assessment system (toolbox) to assess the quality of harm reduction programs and services.

* Advocacy with WHO, UNAIDS, UNODC, Global Fund to ensure that the quality of services is reflected in their documents.

[1]This meeting was organized Eurasian harm reduction association (EHRA) in the framework of in the project of Eurasian Regional Consortium “Thinking outside the box: overcoming challenges in community advocacy for sustainable and high-quality HIV services” supported by the Robert Carr Fund for civil society networks.

[2] https://old.harmreductioneurasia.org/wp-content/uploads/2020/05/EHRA-Strategy-2020-2024-ENG.pdf

[3] https://www.who.int/publications/i/item/978924150437

[4] https://apps.who.int/iris/bitstream/handle/10665/208825/9789241549684_eng.pdf?sequence=1&isAllowed=y

[5] https://www.unaids.org/en/Global-AIDS-Strategy-2021-2026

[6] “Decision-makers cannot hope to develop and implement new strategies for quality without properly engaging health-service providers, communities, and service users”. https://apps.who.int/iris/bitstream/handle/10665/43470/9241563249_eng.pdf?sequence=1&isAllowed=y

[7] https://old.harmreductioneurasia.org/wp-content/uploads/2020/05/EHRA-Strategy-2020-2024-ENG.pdf