The Senior Level Policy Dialogue "Addressing HIV and TB Challenges: from Donor Support to Sustainable Health Systems" was held in Tallinn, Estonia in December 2017 as an official event in the programme of the Estonian Presidency of the Council of the European Union.
The event, organized by the Ministry of Social Affairs and National Institute for Health Development from Estonia, WHO European Region, UNAIDS, and the Global Fund, brought together representatives of the health and financial ministries of Europe, the Balkan and Eastern Partnership countries, representatives of the European Commission, international organizations, as well as community representatives and institutions involved in funding programmes and offering services to tackle HIV and TB.
DPNSEE and 4 participating member organizations representatives (Margina, Viktorija, Cazas and Juventas) actively contributed to the meeting. Both the experiences from South East Europe and challenges we face were presented, emphasized and mentioned by many participants.
The main focus of the meeting was to:
- Present and discuss good practices at political and technical level of integrating HIV and TB services into national health systems, including challenges, risks, and opportunities;
- Present and discuss current financial and programmatic sustainability gaps and challenges, with particular focus on effective national investment to ensure universal access to health care, including key affected populations;
- Discuss roles and responsibilities of national governments, EU and international partners, as well as civil society partners in transition processes, to effectively and sustainably address HIV and TB.

DPNSEE October-December newsletter 

Drug use is criminalized in all countries of the MENA region, and a large number of PWUD are incarcerated, mostly for drug use, but sometimes even for the mere possession of syringes (UNAIDS, 2016; MENAHRA program data). Moreover, PWUD face high levels of stigma and discrimination in the region (MENA Regional Networks, 2016), which are further reinforced by their criminalization (UNAIDS, 2017a). Both the criminalization of drug use, and high stigma and discrimination faced by PWUD, negatively affect access to health services for this population. A number of studies have reported that this criminalization, manifested by punitive laws, incarceration, and prohibitions on harm reduction services, negatively affects harm reduction efforts. These negative effects include decreases in access to Needle/Syringe Programs, increased risky behaviors of sharing used injecting materials, and an increased HIV burden among PWID (UNAIDS, 2017a). Injecting drug use has been document within prisons in a number of countries in MENA, with unsafe injecting drug use being the primary mode of HIV and HCV transmission among prisoners (HRI, 2017). Furthermore within these settings, OST and ART are often unavailable, discontinued, or severely delayed - further exacerbating negative health consequences.

Police/law enforcement can also be a source of stigma and discrimination. In an Operational Research on PLHIV who inject drugs in 6 countries of the region, 7.7% of participants reported to have faced stigma and discrimination from police (MENAHRA, 2017a).

Of further concern are women who inject drugs, who remain more vulnerable and at higher risk than their male counterparts due to social stigma and gender related factors, whether within prisons or not. These vulnerabilities further hinder access to health services among women (MENAHRA, 2015). Women who inject drugs also have high risks being subjected to sexual violence from police and law enforcement agencies, as has been reported by a study conducted in 2015 (UNAIDS, 2017a).

Policy brief for law enforcement officials on the provision of harm reduction services

The last remaining DEA agents left Bolivia in January 2009, bringing to a close more than three decades of DEA-presence within the country. President Evo Morales had ordered the expulsion of the US agency in response to the harms caused by the ‘war on drugs’ and perceived US-meddling in the internal affairs of Bolivia. As part of the dispute, Morales had also expelled US Ambassador Philip S. Goldberg in September 2008, accusing the US of fomenting civil discord. ‘Without fear of the US empire, I stand before the Bolivian people today and declare United States Ambassador Mr. Goldberg persona non-grata,’ Morales announced, ‘We don't want people here who conspire against our unity. We don't want people who threaten our democracy.’ The period thus marked a nadir in US-Bolivian relations, and a turning-point for the course of counterdrug policy in Bolivia. For better or worse, the Bolivian government would now seek to cut its own path: moving away from the drug war approach of the US. But how did US-Bolivia relations arrive at this point? What were the historical antecedents of this point of fracture? Drawing on 27 oral history accounts with US and Bolivian political actors, the paper considers Bolivia’s post-transition period as a key moment in this history of fractious US-Bolivian relations and the ‘war on drugs’ in the Andes.

Many of the same themes of grievance raised by Morales were apparent during this period. Bolivia transitioned to democracy in 1982 against a background of economic crisis. The imposition of harsh-neoliberal structural reforms would bring stability to the national economy, but at a severe social cost. For large swathes of the population, the coca-cocaine economy provided a vital social-safety net during this period of crisis. Furthermore, narcodollars played a crucial role in helping to stabilise the economy: boosting national reserves and inward investment. Given these socio-economic realities and the relative absence of drug-related violence in Bolivia, there was a level of ambivalence towards the drug trade. Instead, the escalation of the US ‘war on drugs’ was, at-times, viewed to pose the greater risk to Bolivia’s social, political and economic stability. This US drug war approach included the militarisation of counterdrug operations and coca eradication. For many Bolivians, the exercise of US power in advancing its counterdrug goals invoked ‘Yankee Imperialism’ and recent memories of US-Cold War interference in Bolivia. US agencies, for example, operated in Bolivia with little local oversight, while Bolivian politicians from this period believed accusations of drug corruption were used to silence opponents of US policy. Perceptions that US counterdrug policy ran contrary to local interests, and that the US exploited the ‘war on drugs’ to exercise control in Bolivia, created an atmosphere of mistrust between the US Embassy and the Bolivian government. As evidenced by the expulsion of the DEA in 2008 and the breakdown of US-Bolivian relations, such mistrust continues to manifest itself to this day. Speaking in June 2017, Morales stated, ‘I do not regret the decision to expel the DEA. The United States used the “war on drugs” in order to control the country's politics and loot our natural resources’.

The	 coca-cocaine economy, the US	 ‘War on Drugs’ and Bolivia’s democratic	transition (1982-1993)

EQUIS is presenting the following Shadow Report for the Committee on the Elimination of Discrimination Against Women (CEDAW) in light of the pre-sessional working group meeting that will take place in Geneva in November 2017.
EQUIS is a feminist organization whose mission is to transform institutions, laws and public policies, and women’s leadership to improve women’s access to justice. EQUIS contributes to the advancement of women’s human rights and gender equality through the use of advocacy and litigation strategies at national and international level.
This document includes data EQUIS has collected through the implementation of its projects, all of which target issues that converge with recommendations made to the Mexican state.

Shadow report on women's access to justice in Mexico

On November 6, 2012, Colorado and Washington became the first two states – and first two jurisdictions in the world – to legalize marijuana for adult use. Two years later Alaska, Oregon and Washington, D.C. followed suit. In 2016 voters in four additional states – California, Massachusetts, Maine and Nevada – also approved ballot measures legalizing marijuana. In January 2018, Vermont became the first state to legalize marijuana through a state legislature. More states are expected to legalize marijuana in the near future.

Evidence shows that marijuana legalization is working so far. States are saving money and protecting the public by comprehensively regulating marijuana for adult use. This success has likely contributed to the historically high levels of public support for marijuana legalization in the U.S., which has steadily grown to an all-time high of 64 percent. The majority of Americans, across party affiliations, support legalizing marijuana, with 51 percent of Republicans now in favor.

Arrests and court filings for the possession, cultivation and distribution of marijuana have plummeted since voters legalized marijuana for adult use in eight states and Washington, D.C. These states have saved millions of dollars and prevented the criminalization of thousands of people.

Marijuana legalization has a positive effect on public health and safety. Nationally, and in states that have legalized marijuana, youth marijuana use has remained stable or declined. Legal access to marijuana is associated with reductions in some of the most troubling harms associated with opioid use, including opioid overdose deaths and untreated opioid use disorders. DUI arrests for driving under the influence, of alcohol and other drugs, have declined in Colorado and Washington, the first two states to establish legally regulated adult use marijuana markets. In addition, crash rates in both states have remained similar to those in comparable states that have not legalized marijuana.

At the same time, states are filling their coffers with hundreds of millions of dollars in marijuana tax revenues. These revenues are being allocated for social good – to fund education, school construction, early literacy, bullying prevention, behavioral health and alcohol and drug treatment. In addition, the legal marijuana industry is creating jobs; it currently employs approximately 200,000 full and part-time workers across the country.

From prohibition to progress: A status report on marijuana legalisation

The ’war on drugs’ is collapsing. Now let’s build the alternative. The ‘war on drugs’ was built on shaky foundations. Now, countries around the world from Canada, to Uruguay, Portugal and many US states are beginning to dismantle it piece by piece. Its collapse is good news for people and communities around the world, providing us with the opportunity to build a new approach to drugs that prioritises, promotes and protects human health and well-being. This shift, from a criminal justice approach to health-based policy making, is essential if we want to take drug policy into the 21st century. It is time for the UK to catch up, and develop and promote appropriate, evidence-based, and sustainable alternatives both in the UK and globally.

This new approach will ensure that rather than penalising or criminalising people involved in the drug trade, we recognise that it is often injustice, inequality and vulnerability that drives them to engage in that trade in the first place, whether that is as consumers, producers or suppliers. Rather than compounding problems like poverty, powerlessness and stigma with a hard-line prohibitionist approach, which has failed on its own terms, we must aim to approach drug policy in a way that works to address these drivers of engagement with the drug trade, and at the same time makes engaging in that trade as harm-free as possible. If we do this effectively we have the chance to develop and build a whole new paradigm to replace the ‘war on drugs.’ Below are six key steps the UK government can take to lead the way in ending the ‘war on drugs’ at home and abroad.

Building a 21st century approach to drugs

This case study was conducted by the TB/HIV Care Association, which works to prevent, find and treat TB and HIV in communities in South Africa. Partly through funding and support from Bridging the Gaps Alliance partner Mainline, TB/HIV Care and its partner OUT Wellbeing (providing direct health services to LGBT people, MSM, sex workers, and injecting drug users) have established a joint programme for people who inject drugs (PWID). Bridging the Gaps played a key role in the initial procurement of sterile injecting equipment, enabling the launch of the project, and has continued to support Step Up’s advocacy for the human rights of PWID.

This case study illustrates how TB/HIV Care Association (THCA), and its partner OUT Wellbeing (OUT), have implemented the Step Up Project, an innovative joint initiative to support PWID in South Africa.

The criminalisation and stigmatisation that PWID experience in South Africa, combined with a fear of using health services due to the criminalisation of PWID, has contributed to the widespread use of unsafe injecting practices, such as the sharing and improper use of injecting equipment. In addition to facing stigma and discrimination from health service providers and the public, PWID also face abuse by law enforcement agencies.

The prevalence of high-risk injecting practices identified by a United Nations Office of Drugs and Crime (UNODC) 2013 study, indicated that services were urgently required to address the potential public health impact of injecting drug use, and improve the wellbeing of PWID.

Introducing and developing harm reduction strategies in South Africa

Welcome to the Ana Liffey Drug Project’s Strategic Plan for 2018-2020. The last number of years have seen significant and welcome changes in Ireland, both in terms of the general economic outlook for the country and in terms of broad drug policy trends.

The Ana Liffey Drug Project’s primary activity is to provide ‘low threshold - harm reduction’ services to people who use drugs. By low threshold, we mean that the barriers to availing of our services are kept as low as possible. By harm reduction, we mean that we seek to reduce the harm that drug use causes to individuals, families and communities. In addition to our direct services, we also perform advocacy and support roles at an organisational level in the addiction sector in Ireland and beyond.

We will work hard, we will work together internally as a unit and in partnership externally to achieve these goals and ensure that we continue to deliver on our mission to work with people affected by problem substance use and the organisations that assist them.

Safer From Harm: the strategic plan of the Ana Liffey Drug Project 2018-2020

To ensure the 52nd Parliament makes health a central focus of drug policy and law in New Zealand, the Drug Foundation has sent a comprehensive briefing to all MPs.

We are all concerned about the harm caused by drugs in New Zealand. But there are solutions. We need our politicians to see that these solutions are sensible and achievable.

We think we can achieve an Aotearoa free from drug harm, if we focus on these four priorities:

Priority 1: Keep young people in school and keep them safe.

Priority 2: Reform our laws to treat drug use as a health issue

Priority 3: Invest more effectively in prevention, harm reduction and treatment.

Priority 4: Reduce drug harm in communities and respond to emerging challenges.

Briefing to the incoming New Zealand Parliament 2017

The uneven distribution of HIV risks and burdens across populations is a well-substantiated fact, though seldom publicly acknowledged. Gay men and other men who have sex with men, people who inject drugs, sex workers, and transgender women are 24, 24, 13.5, and 49 times more likely to acquire HIV, respectively, than other reproductive aged adults (15 years old and older). Globally, new infections among these key populations account for 45% of all new HIV infections. This figure is likely to be an underestimate, given the intense stigma associated with disclosing and reporting acquisition risks for HIV among gay men, people who use drugs, sex workers, and transgender people. In addition, HIV epidemics in the majority of low- and middle-income countries (90 of 120) have concentrated epidemics among key populations. In countries with more broadly generalized epidemics, risks are still not evenly distributed and key populations still shoulder disease burden that is markedly disproportionate.

Specific interrelated determinants converge to create the higher probability of HIV infection among key populations (biological, social, structural). For example, key populations are rendered vulnerable to HIV by discriminatory laws and politically driven policies, creating stressors that exacerbate risk for HIV acquisition and make the problem of HIV worse. In addition, the absence of protective laws and policies, and the failure of governments to uphold rights also enables the persistence of unchecked stigma and discrimination in healthcare and social service settings. These barriers to healthcare means untreated sexually transmitted infections and therefore heightened risk for HIV infection and transmission.

Propelled by the introduction of powerful and life-saving antiretroviral medications, the increasingly bio-medicalized global HIV response challenges us to rigorously reimagine prevention. While this is a welcome development in the global response to HIV, access to medical interventions is hampered by the costs of medicines, healthcare, testing and monitoring, and the politics of funding. In addition, gay and bisexual men, people who use drugs, sex workers, and transgender people are not prioritized for antiretroviral treatment or are offered only a limited number of places in treatment programs because these groups are not seen as deserving. Moralistic decision-making about who should have access to treatment is common (e.g., the requirement of absolute abstinence from drug use as a condition for services).

Reconsidering primary prevention of HIV: New steps forward in the global response

Upon winning the presidential election in 2014, Joko Widodo, often referred as Jokowi – launched the war on drugs in Indonesia. He claimed that Indonesia is in a drug emergency situation. This emergence is marked by the existence of 4.5 million people who use drugs in Indonesia; worse, 1.2 million of them ‘can no longer be rehabilitated because of their deteriorating condition’.

When Jokowi made such statement, it was expected that he would adopt a policy that was aimed to address the impact of drug trafficking. For example, by providing wider access to drug dependency rehabilitation. The question was and still relevant, is, how drug dependency rehabilitation is currently implemented in Indonesia?

Through this report, LBH Masyarakat seeks to provide information on how drug dependency rehabilitation is carried out in Indonesia. This report consists of information on the type, methodology, inclusiveness and participation, financing, and human resources situation with regard to implementing drug dependency rehabilitation. We find that there are barriers, both practical and structural, that hinder effective implementation of drug rehabilitation. At the end of this report, we develop recommendations for relevant stakeholders with a view that the proposed recommendations would contribute in creating drug dependency rehabilitation in Indonesia that is more accessible and with good quality.

We would like to express our sincere gratitude to …?? for their tremendous help and contribution in the development of this report. We thank the Ministry of Health, the Ministry of Social Affairs, and the National Narcotic Board for welcoming us to interview and observe drug dependency rehabilitation facilities under their auspices, or that they support. We thank all the patients, doctors, health care workers, and managements of drug dependency rehabilitation at YPI Nurul Ichsan, RS Jiwa Atma Husada, RSUD Sanglah, Yayasan Ar-Rahman, Yayasan Hikmah Syahadah, Balai Rehabilitasi Lido, Balai Rehabilitasi Badokka, AKSI NTB, Yayasan Karisma, Puskesmas Gambir, and RSKO Cibubur.

We thank Mainline Foundation for their support and assistance from the beginning until the finalisation stage of this report.

This report is just a part, or even a beginning of the long and winding road in the advocacy towards a more humane drug policy in Indonesia. To close this, we believe that #PrisonIsNotASolution, #BecauseEeryHumanMatters.

Mapping out drug dependency treatment in Indonesia

Mainline works with the Middle East and North Africa Harm Reduction Association (MENAHRA) to improve the position of women who use drugs (WWUD). We designed a manual for local organisations in the MENA region. The aim of this manual is to provide practical guidelines to advocate for harm reduction services for women.

The manual aims to be of practical help to anyone, regardless of their experience level, who wants to advocate for the needs of WWUD within a harm reduction framework. You can be working as a professional within a governmental- or non-governmental organisation or be a journalist, working in health care, be a woman who uses drugs yourself or simply care about the cause. The geographical focus of this guide is the Middle East and North Africa (MENA).

In 2013, the Middle East and North Africa Harm Reduction Association (MENAHRA) which is a network focusing on harm reduction strategies for People Who Use Drugs (PWUD) in the MENA region, conducted operational research on women injecting drug users in 6 countries of the MENA region. In the follow-up on this research, the Guidelines on Gender Equality in HR services and an Advocacy Brief on specific harm reduction services for women were developed. Both the research and the guide clearly show the needs of WWUD and the present situation of limited access and availability of harm reduction services for women in the MENA region. They also describe the most ideal situation of full access and availability of gender specific harm reduction services. Many changes are needed to make harm reduction accessible for women.

Knowing what you want to change and what you want to achieve is essential. Unfortunately, it’s often not enough to make it a reality. That’s where advocacy comes in.

When Mainline set out to develop the manual, it explicitly decided not to reinvent the wheel. There are already many excellent guides available – both to advocate for harm reduction and to advocate for women’s health and rights. Mainline collected what is there, made smart combinations and connected this information to the realities in the Middle East and North Africa. The result is a practical guideline, easy to use and culturally appropriate.

Publications from IDPC Members