By ITPC, in partnership with Dristi Nepal and the Director of the AIDS and Society Research Unit at the University of Cape Town, Dr. Rebecca Hodes.

The global evidence-base on Covid-19 has been rapidly populated by clinical studies and epidemiological models. But there is a critical lack of data about the impact of the pandemic on the health and human rights of people living with HIV globally. Informed by advancements in HIV treatment and prevention, UNAIDS and its partners (including national governments, bilateral agencies, advocacy coalitions and community-based organisations) had committed to the ambitious 90-90-90 targets, to be met by the year 2020 (UNAIDS 2014). The Covid-19 pandemic threatened to defer or even reverse the gains made in meeting these targets, undermining critical progress in the global HIV response.

In June 2020, the International Treatment Preparedness Coalition (ITPC Global) embarked on an ambitious project to map the impact of Covid-19 on people living with HIV, and to support and strengthen community-led monitoring of essential health services and human rights in specific locations around the globe. From June to July 2020, ITPC worked together with Dristi Nepal (an advocacy organisation of women living with HIV and who use drugs), to gather first-hand accounts of the effects of the Covid-19 pandemic on women living with HIV and using drugs in Nepal, particularly in Kathmandu and surrounding valleys.

A participatory research tool was developed collaboratively by Dristi Nepal (hereafter ‘Dristi’), and ITPC to capture and assess the impact of Covid-19. The qualitative survey tool used images and emoticons to encourage participants, regardless of literacy, to relate their experiences of healthcare services as people living with HIV, and to rank their government’s actions on health provisions and human rights both prior to and during the Covid-19 pandemic. Every component of the tool’s development and implementation was collaborative, from the formulation of indicators, to its inclusive design and analysis of findings.

Impacts of COVID-19 on women living with HIV who use drugs in Nepal

The long-term impact of disruptions in access to essential health services during lockdowns, including harm reduction, sexual and reproductive healthcare, and HIV prevention, testing, and treatment programs, is still unknown. Governments in many regions are using COVID-19 as a pretext to introduce even more repressive policies and criminal measures towards sex workers, people who use drugs, LGBTQ people, migrants, and other vulnerable groups who are also bearing the brunt of COVID-19 restrictions on trade, movement, and health services access.

Other key and evolving needs during the pandemic that, if left unaddressed, will continue to have a devastating impact on the health, well-being, and human rights of people at risk of or living with HIV include: increased mental health issues (anxiety, depression, trauma), gender-based violence (GBV) and violence at the hands of law enforcement and security structures, as well as lack of access to technology for information, care and services which have increasingly shifted on-line. Throughout this period, communities and CBOs have demonstrated incredible resilience, flexibility, and creativity in meeting their own needs—as they always have—and examples are shared in this report.

It is hoped that the findings and recommendations in this report, many of which stem from what marginalized communities have themselves asked for over many years, can serve as a call to action for funders and other actors in the HIV response to “do things differently,” as the environment continues to shift rapidly. Many communities and CBOs are struggling to survive as resources—already severely limited for populations most at risk of HIV—are shifting to COVID response and longer-term health preparedness and security.

COVID-19 has laid bare the consequences of siloed philanthropy and the imperative to accelerate intersectional, multi-level work, with particular attention to integrating the HIV and COVID responses with racial justice efforts in the U.S. While the report highlights many positive and responsive funder practices, both in the U.S. and global context, it is clear from community networks and groups’ feedback that much is left to be done.

Converging epidemics: COVID-19, HIV & inequality

By Villu Kangur, for the Eurasian Harm Reduction Association (EHRA) and the School of Law, Swansea University.

The Republic of Estonia is a country on the eastern coast of the Baltic Sea in Northern Europe. It is bordered to the north by Finland across the Gulf of Finland, to the west by Sweden across the Baltic Sea, to the south by Latvia, and to the east by Lake Peipus and Russia. With a population of 1.3 million people, Estonia is one of the least populous members of the European Union.

According to the general population study on drug use in Estonia4 in 2018, 25% of people aged 16–64 have tried an illegal substance at least once during their lifetime, 7% within the last year, and 3% within the last month. Cannabis was the most commonly used drug, with 24% of the population having tried cannabis during their lifetime. In addition, the use of stimulants (e.g. amphetamine, ecstasy, and cocaine) was reported more frequently than that of other narcotic substances (amphetamine 6%, ecstasy 5%, and cocaine 5% lifetime use). While drug use, including cannabis use, was more common among people under the age of 35, more frequently among men, there was no difference between men and women in the youngest age group (16–24 years).

Estonia has a high prevalence of people who inject drugs (PWID), of whom about half are living with human immunodeficiency virus (HIV). According to a study done between 2010 and 2015, there are an estimated 6,000 to 17,300 PWID. In 2015 the prevalence of PWID was estimated to be 8,600. Among key populations, the prevalence of HIV is 54% among PWID, 13% among prison inmates, 4% among men who have sex with men (MSM), and 13% among sex workers (SWs).

Opioid substitution treatment (OST) with methadone has been available in Estonia since 1999. Currently OST is being offered in nine different institutions across the country (excluding prisons and detention centers, where methadone treatment is also available). In 2018 there were 1,052 registered patients who received OST. OST coverage remains low (under 20%).

New psychoactive substance use in the Republic of Estonia

By the International Network on Health and Hepatitis in Substance Users (INHSU)

Drug use is criminalised in South Africa and people who use drugs in South Africa are subjected to stigmatisation, marginalisation and social exclusion. People who use drugs can face poor treatment from the police and government officials and are routinely targeted by the police. South Africa does not provide any social support for people who use drugs.

Alcohol remains the most dominant substance used in South Africa. Cannabis is the most commonly used illicit drug, followed by methamphetamine, also known as crystal meth or tik. Heroin is also used, and is usually smoked, with a small proportion injecting heroin as the chosen route of administration.

There is no definitive data on the extent of drug use in South Africa. Based on data modelled from a national household survey and expert consensus, there are between 67,000 and 75,000 people who inject drugs in South Africa. The numbers of people who inject drugs in Cape Town, Durban and Pretoria are estimated at 1517, 1245 and 4514, respectively, with 6827 in Johannesburg. Data suggest a high HIV and viral hepatitis burden among people who inject drugs. HIV prevalence among people who inject drugs ranges from 11% in Cape Town to 58% in Pretoria. Hepatitis C prevalence is even higher, ranging from 35% in Durban (before the closure of the needle and syringe service in 2018) to 94% in Pretoria.

Although the South African National Strategic Plan for HIV, TB and STIs 2017 – 2022 includes the provision of harm reduction services for people who inject drugs, there has been resistance to providing harm reduction services. The closing of the needle and syringe programme in Durban in May 2018 for 24 months is an example. Without access to sterile injecting equipment, people who inject drugs had to reuse and share equipment.

Harm reduction responses in the age of COVID-19: Documenting the experiences of people who use drugs in South Africa

A previous version of this paper is available here.

By Jamie Bridge (IDPC), Christopher Hallam (IDPC), Marie Nougier (IDPC), Miguel Herrero Cangas (IDPC), Martin Jelsma (TNI), Tom Blickman (TNI), David Bewley-Taylor (GDPO) & Daisy Bowdery (IDPC)

Diplomatic processes at the United Nations (UN) are notoriously slow and difficult, perhaps increasingly so in a modern world of multi-polar geopolitics and tensions. This is certainly no different for the highly charged issue of international drug control. After the UN General Assembly Special Session (UNGASS) on the ‘world drug problem’ in New York in April 2016 – many stakeholders had come away with mixed feelings at best. Despite acknowledgements of the progress made in certain areas of the debate, and the rich content of some of the country and civil society statements, the UNGASS failed to deliver the ‘wide-ranging and open debate that considers all options’ that had been called for by the UN Secretary-General at the time, Ban Ki-Moon.

Three years later, member states met again – this time in Vienna – at a Ministerial Segment aimed to evaluate progress made since the adoption of the 2009 ‘Political Declaration and Plan of Action on international cooperation towards an integrated and balanced strategy to counter the world drug problem’, and to pave the way for the next decade of drug policy. The event resulted in a Ministerial Declaration that looked back at ongoing challenges, and proposed actions for the way forward.

In order to help digest and contextualise the UNGASS Outcome Document and the 2019 Ministerial Declaration, it is useful to take a broader look at how the agreed UN language on drug control has evolved and developed over the last quarter of a century. To this end, this paper explores a selection of key themes by analysing the consensus based language agreed by UN member states in:

The ‘1990 Political Declaration and Global Programme of Action on international cooperation against illicit production, supply, demand, trafficking and distribution of narcotic drugs and psychotropic substances’ – agreed at the first UNGASS on the topic of ‘drug abuse’.

The 1993 General Assembly resolution entitled ‘Measures to strengthen international cooperation against the illicit production, sale, demand, traffic and distribution of narcotic drugs and psychotropic substances and related activities’ – agreed at a high-level meeting of the General Assembly as a follow-up to the 1990 Political Declaration.

The 1998 Political Declaration – agreed at the 20th UNGASS on the ‘world drug problem’ – and the accompanying ‘Declaration on the Guiding Principles on Demand Reduction’. •

The ‘2003 Joint Ministerial Statement and further measures to implement the action plans emanating from the twentieth special session of the General Assembly’ – agreed at the 46th UN Commission on Narcotic Drugs (CND) after a mid-term review of the 1998 Political Declaration.

The ‘2009 Political Declaration and Plan of Action on international cooperation towards an integrated and balanced strategy to counter the world drug problem’ – agreed at the highlevel segment of the 52nd CND.

The ‘2014 Joint Ministerial Statement on the implementation by member states of the political declaration and plan of action on international cooperation towards an integrated and balanced strategy to counter the world drug problem’ – agreed at the 57th CND after a mid-term review of the 2009 Political Declaration.

The 2016 Outcome Document (UN General Assembly Resolution S30/1) entitled ‘Our joint commitment to effectively addressing and countering the world drug problem’ – agreed at the 30th UNGASS last April.

The 2019 ‘Ministerial Declaration on strengthening actions at the national, regional and international levels to accelerate the implementation of joint commitments to address and counter the world drug problem’.

Edging forward: How the UN’s language on drugs has advanced since 1990 (Version 2)

Harm Reduction International has monitored the use of the death penalty for drug offences worldwide since our first ground-breaking publication on this issue in 2007. This report, our tenth on the subject, continues our work of providing regular updates on legislative, policy and practical developments related to the use of capital punishment for drug offences, a practice which is a clear violation of international law.

Death Penalty for Drug Offences: Global Overview 2020 

There were 30 confirmed executions for drug offences in 2020, down from 116 in 2019. All of the executions took place in 3 countries (China, Iran and Saudi Arabia)

At least 213 people received a death sentence for drug offences in 2020, up from 183 in 2019.

Thirty-five countries still retain the death penalty for drug offences.

There are at least 3,000 people currently on death row for drug offences worldwide.

Vietnam alone accounted for over a third of all confirmed death sentences for drug offences in 2020.

As of October 2020, there were 355 people on death row in Indonesia, of which 214 were convicted for drug offences (a 29% increase from 2019).

Singapore did not carry executions for the first time since 2013.

Data on the death penalty for drug offences is grossly insufficient, partly due to a lack of information on executions in China and Vietnam (both are reported to routinely execute people for drug offences).

Death penalty for drug offences: Global overview 2020

A study undertaken in Kazakhstan, Kyrgyzstan, Tajikistan and Ukraine has shown that training people most likely to witness an opioid overdose and providing them with naloxone, a drug that reduces the effects of overdose if administered rapidly, has the potential to significantly reduce the number of deaths in these countries if scaled up nationwide.

During the study, which began in 2016 and ended in 2020, a short training on how to recognize and respond to an opioid overdose, including administration of naloxone, was given to project participants, and all were provided with a supply of a take-home kit of naloxone. More than 14 000 people were trained as part of the project and around 90% of those participants who witnessed an overdose reported using naloxone. In almost all instances, it was recorded that the person who overdosed survived. Evaluation of the project showed that it was widely accepted by stakeholders, ranging from people who use drugs through to health and law enforcement officials.

A participant in the project from Tajikistan said: “We got a call recently and arrived in time. The guy was overdosed at his home. We saved him ... When we left a kit [for] the family with training, they were so happy. We felt proud.”

The study is part of a broader initiative, called S-O-S (Stop Overdose Safely), jointly managed by the World Health Organization and the United Nations Office on Drugs and Crime, and funded by the U.S. State Department’s Brueau for International Narcotics and Law Enforcement Affairs. S-O-S supports people likely to witness an overdose in the community, with a focus on people who use drugs, their peers, and family members. As well as providing training on use of naloxone and making take-home-kits available, the project makes links between people at risk and treatment services. Moreover, it encourages broad partnerships between national governments, regional organizations, research institutes, civil society, and interested funding agencies.

The effectiveness of community management of opioid overdose with use of naloxone has already been demonstrated extensively in North America, Europe and Australia. This project in three Central Asian countries and Ukraine is important as much less is known about whether such projects can be effective in low- and middle-income countries.

The implementation of this project was undertaken in cities alone. Given the positive outcomes, scale-up at a country level with a strong evaluation component is desirable. Future replication studies, with more advanced study designs, is also recommended in low-and middle-income countries.

Opioid dependence is a disorder of regulation of opioid use, and individuals who are opioid dependent have a high risk of experiencing overdose, leading to death. Worldwide, about 500 000 deaths are attributable to drug use. More than 70% of these deaths are related to opioids, with more than 30% of those deaths caused by overdose. According to WHO estimates, approximately 115 000 people died of opioid overdose in 2017. Opioid overdoses that do not lead to death are several times more common than fatal overdoses.

UNODC-WHO Stop-Overdose-Safely (‎S-O-S)‎ project implementation in Kazakhstan, Kyrgyzstan, Tajikistan and Ukraine: summary report

De 14–16 de Setembro de 2020, a Campanha Regional para Descriminalizar as infracções menores em África (a Campanha) co-organizou com a Comissão Africana dos Direitos Humanos e dos Povos (ACHPR, na sigla inglesa), uma conferência virtual para discutir o impacto das medidas de combate à propagação da COVID-19 às pessoas pobres e marginalizadas. A conferência reuniu mais de 200 participantes e os palestrantes partilharam tanto perspectivas a nível continental, como exemplos específicos, de países tais como a República Centro Africana, Guiné, Quénia, Malawi, Marrocos, Nigéria, Serra Leoa, África do Sul, Tunísia e Uganda.

Tal como foi observado por ABDUL NOORMOHAMED, da International Commission of Jurists, (ICJ, na sigla inglesa) e TEM FUH MBUH da Open Society Initiative for West Africa (OSIWA, na sigla inglesa) nas suas observações iniciais, a pandemia da COVID-19 é a crise de saúde global que define o nosso tempo e, numa tentativa de reduzir a propagação do vírus, os Estados africanos implementaram uma série de medidas extraordinárias. Contudo, a crise também expôs a perniciosidade de criminalizar as actividades que sustentam a vida e enraizou ainda mais a marginalização de milhões de pessoas que já lutavam contra os legados de políticas económicas, sociais e jurídicas falhadas. Aumentou as fraquezas estruturais dentro dos sistemas de justiça criminal do continente e desencadeou uma crise de direitos humanos.

A COMISSÁRIA MARIA TERESA MANUELA, Relatora Especial da ACHPR sobre Prisões, Condições de Detenção e Policiamento em África, saudou a oportunidade de discutir o impacto da COVID-19 e redobrou o compromisso da ACHPR em convencer os Estados Partes signatários da Carta Africana dos Direitos Humanos e dos Povos que as infracções menores podem ser tratados de forma a não comprometer a dignidade e os direitos dos elementos mais desfavorecidos da sociedade.

Relatório: Conferência regional sobre a descriminalização das infracções menores em África

From 14–16 September 2020, the Regional Campaign to Decriminalise Petty Offences in Africa (the Campaign) co-hosted with the African Commission on Human and Peoples’ Rights (ACHPR), a virtual conference to discuss the impact of measures to combat the spread of COVID-19 on poor and marginalised people. The conference brought together over 200 participants, and panellists shared both continent-wide perspectives, as well as country-specific examples from the Central African Republic, Guinea, Kenya, Malawi, Morocco, Nigeria, Sierra Leone, South Africa, Tunisia and Uganda.

As noted by ABDUL NOORMOHAMED of the International Commission of Jurists, Kenya (ICJ Kenya) and TEM FUH MBUH of the Open Society Initiative for West Africa (OSIWA) in their opening remarks, the COVID-19 pandemic is the defining global health crisis of our times and, in a bid to reduce the spread of the virus, African states deployed a range of extraordinary measures. However, the crisis also exposed the perniciousness of criminalising life-sustaining activities and further entrenched the marginalisation of millions of people already struggling from the legacies of failed economic, social and legal policies. It magnified structural weaknesses within the continent’s criminal justice systems and spiralled into a human rights crisis.

COMMISSIONER MARIA TERESA MANUELA, the ACHPR Special Rapporteur on Prisons, Conditions of Detention and Policing in Africa, welcomed the opportunity to discuss the impact of COVID-19 and re-enforced the ACHPR’s commitment to convincing state parties to the African Charter on Human and Peoples’ Rights that petty offences can be dealt with in ways that do not undermine the dignity and rights of the most under privileged members of society.

Report: Virtual regional conference on COVID-19 and the decriminalisation of petty offences in Africa

A civil society-led monitoring of harm reduction can play an essential role in improving service delivery and contribute to the generation of crucial data for advocacy purposes. Civil society organisations (CSO’s) work directly for, and with, people who use drugs (PWUD) and have a good understanding of their daily needs. Their inside knowledge is critical in developing adequate drug policies and practices.

To complement the work of other monitoring agencies, and to bring insight into how the implementation of harm reduction occurs, Correlation -European Harm Reduction Network (C-EHRN) has published a report on Civil Society Monitoring of Harm Reduction in Europe since 2019. It gathers data on the experiences of harm reduction service providers and service users at ground level, building on a network of national Focal Points (FPs) in Europe. For the 2020 monitoring, C-EHRN includes 35 FPs in 34 countries, as shown in the map below. To get insight at the implementation level, and to profit from the experiences and expertise of FPs, the 2020 monitoring focuses mostly on cities rather than countries.

Civil society monitoring of harm reduction in Europe, 2020

The new Global AIDS Strategy (2021–2026) seeks to reduce the inequalities that drive the AIDS epidemic and put people at the centre to get the world on-track to end AIDS as a public health threat by 2030. Decades of experience and evidence from the HIV response show that intersecting inequalities are preventing progress towards ending AIDS.

Developed by the Joint United Nations Programme on HIV/AIDS (UNAIDS) and to be adopted by the UNAIDS Programme Coordinating Board (PCB), this Strategy lays out a framework for transformative action to reduce these inequalities by 2025 and to get every country and every community on-track to end AIDS by 2030.5 The Strategy uses an inequalities lens to identify, reduce and end inequalities that represent barriers to people living with and affected by HIV, countries and communities from ending AIDS.

The Strategy is being adopted during the Decade of Action to accelerate progress towards the Sustainable Development Goals (SDGs), and makes explicit contributions to advance goals and targets across the SDGs.

The Strategy builds on an extensive review of the available evidence and a broad-based, inclusive, consultative process in which over 10,000 stakeholders from 160 countries participated. The results from the UNAIDS Fast-Track Strategy 2016–2021 informed the development of the new Strategy, including the Programme Coordinating Board (PCB) decision to develop the Global AIDS Strategy "by maintaining the critical pillars that have delivered results in the current Fast-Track Strategy, its ambition and the principles underpinning it to the end of 2025, but also enhance the current Strategy to prioritize critical areas that are lagging behind and need greater attention."

The Strategy keeps people at the centre and aims to unite countries, communities and partners across and beyond the HIV response to take prioritized actions to accelerate progress towards the vision of zero new HIV infections, zero discrimination and zero AIDS-related deaths. The Strategy seeks to empower people with the programmes and resources they need to exercise their rights, protect themselves and thrive in the face of HIV.

End Inequalities. End AIDS. Global AIDS Strategy 2021-2026

By DLA Piper with the support of the Association for Prevention of Torture (APT),

Governments around the globe have reduced prison populations in response to the COVID-19 pandemic, with an estimated one million, mostly non-violent offenders, being granted early release according to a new report, 'A global analysis of prisoner releases in response to COVID-19', by global law firm, DLA Piper with the support of the Association for the Prevention of Torture (APT). The global study of prisoner release schemes in 53 jurisdictions found that many governments took swift action to protect the health and safety of corrections staff, prisoners and the wider community, with over 475,000 people released from prisons and other places of detention between March and July 2020 alone.

The first schemes were introduced in March 2020, as the pandemic began to surge, in order to limit transmission of the virus in prisons where overcrowding and poor ventilation can place prisoners and prison staff at greater risk of infection. Some of the most successful early release schemes recorded by the study were in Iran (104,000+), India (68,000+), Iraq (62,000+), Ethiopia (41,000+) and Indonesia (38,000+).

With more than 11 million people detained in prisons in 2019, the schemes have shown that governments can act quickly to mitigate the risk of transmission in prisons. The report found that schemes where certain prisoners are permanently released can be a highly effective strategy, provided they are implemented in a structured, transparent and ordered manner.

 While all 53 jurisdictions had existing mechanisms allowing for the release of prisoners, only 40% relied on those existing measures, while 28% relied on new release measures (created in response to COVID-19) and 32% relied on a combination.

 Only a third of jurisdictions took active measures to release children from detention. The largest reported releases were in Indonesia (939), India (665) and Bangladesh (489).

 Conditions were often imposed as part of the government's agreement to release prisoners. 42% of jurisdictions required prisoners to be of good behaviour and not commit any further offences post release.

 A third of jurisdictions did not report any support measures available to prisoners upon release (pre or post COVID-19). The remaining two thirds reported some level of support for prisoners including programs related to accommodation, financial support, counselling, drug and alcohol rehabilitation and employment.

 Early analysis of recidivism rates for released prisoners suggests that the release schemes have been generally successful with below average recidivism rates.

 Only a quarter of jurisdictions published timely, disaggregated data on prisoner releases.

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