This tool aims to support countries in fast-tracking their response to HIV among people who inject drugs, who are 28 times more likely to be living with HIV than the general population and whose global rate of hepatitis C virus (HCV) is 52%. Topics covered in the report include community empowerment, human rights and law reform, stigma and discrimination, a comprehensive package of harm reduction interventions, service delivery approaches, community involvement, and programme management. Featuring examples of good practices from around the world, the tool describes how services can be designed and implemented to be accessible and acceptable to people who inject drugs. This requires respectful and ongoing engagement, and the publication gives particular attention to programmes run in close partnership with, or by, organisations of people who use drugs. It is itself the product of a collaborative process including people who inject drugs, advocates, service providers, researchers, government officials, and non-governmental organisations (NGOs) from around the world, as well as United Nations (UN) agencies and other development partners.
The tool's creators - United Nations Office on Drugs and Crime (UNODC), International Network of People Who Use Drugs (INPUD), Joint United Nations Programme on HIV/AIDS (UNAIDS), United Nations Development Programme (UNDP), United Nations Population Fund (UNFPA), World Health Organization (WHO), and the United States Agency for International Development (USAID) - recognise that "criminalization of drug use, restrictive drug policies and aggressive law-enforcement practices are key drivers of HIV and hepatitis C epidemics among people who inject drugs," together with discrimination, marginalisation, stigmatisation, and violence. These factors drive people who inject drugs underground and exclude them from proper access to the harm reduction and health services they need to prevent overdose and protect themselves from HIV and hepatitis C.
The tool's 5 chapters fall broadly into 3 parts. The first 2 chapters describe approaches and principles for developing programmes and critical enablers (interventions that address structural factors underlying the HIV and HCV epidemics among people who inject drugs). Chapters 3 and 4 describe how to implement recommended interventions for HIV prevention, diagnosis, care, and treatment. Finally, Chapter 5 describes how to manage programmes. More specifically, some of the communication-centred elements of the resource include:
- Chapter 1 - Community Empowerment - describes how empowerment of people who inject drugs is both an intervention in itself and also essential for ensuring community-led planning, implementation, and monitoring of all aspects of prevention, treatment and care for HIV and other bloodborne diseases. It also shows how groups and networks can be formed, and practical ways to strengthen their capacity for harm reduction and advocacy. In the field of HIV, HCV and drug use, community empowerment describes a process whereby people who inject drugs take individual and collective ownership of activities, programmes, and policies to achieve the most effective responses to HIV and HCV, and to address social and structural barriers to their health and their human rights. Seven key elements of community empowerment include:
- Working with communities of people who inject drugs;
- Fostering outreach and service provision led by people who inject drugs;
- Adapting to local needs and contexts;
- Developing organisations of people who inject drugs;
- Strengthening organizations and building capacity;
- Shaping policy and creating enabling environments; and
- Sustaining the movement.
"Community empowerment should take a flexible approach, adapted to the needs of each community....[T]he process may flow from working with communities of people who inject drugs to community-led outreach, the development and strengthening of organizations and networks led by people who inject drugs and, consistent with local needs and contexts, shaping human rights-based policies and creating an enabling environment for a sustainable movement."
- Chapter 2 - Legal Reform, Human Rights, Stigma and Discrimination - focuses on the need to counteract the impact of stigma, discrimination, and criminalisation upon people who inject drugs, for protection of their human rights and for effective HIV and HCV prevention. Because stigma and discrimination operate at both institutional and individual levels, the experiences and suggested practices presented in this chapter are directed at national programme-planners and policy-makers, and also at implementing organisations working at the local level, including organisations led by people who use drugs. For example, a section on changing attitudes towards people who use drugs explores the strategies of influencing the media, creating a voice for people who use drugs (e.g., online resources to provide an alternative, humanising perspective), and advocating with stakeholders.
- Chapter 3 - Health and Support Services - describes considerations for delivering the comprehensive package of harm reduction services for people who inject drugs. Harm reduction programming involves efforts to change knowledge, attitudes, beliefs, and behaviour, as well as build community solidarity. For example, information, education, and communication (IEC) materials can complement and add value to these interventions. IEC materials, whether printed or electronic, can be shared from person to person without loss or misinterpretation of information. "Giving people who inject drugs the opportunity to lead in producing materials (websites, newsletters, video documentaries, IEC etc.) can be very empowering. The production of periodic newsletters or regular maintenance of websites and social media sites can bring people together and create a forum for creative expression, as well as be places where people can be informed about and discuss emerging health and rights issues."
- Chapter 4 - Service Delivery Approaches - describes how to design services and how community members can be involved in varying aspects of service delivery, including (but not limited to) outreach to people who inject drugs, peer navigation, and running drop-in centres. "With sustained support, community-led harm reduction services can...provide the basis for a strong advocacy movement that challenges structural barriers and the stigma and discrimination that underpin many institutional responses. Whenever possible, therefore, community members should be recruited to the programme team. These should be current or former people who inject drugs who live in the service area and know it well, and who also know and are respected and trusted by their peers. The steps outlined in Chapter 1 to build trust and rapport with the community should be followed....With appropriate training opportunities, peer outreach workers can become powerful advocates, by articulating changes needed in services, and in society as a whole, and by challenging the stereotypes often held by the wider community that people who inject drugs are unreliable, dishonest or victims of circumstance."
- Chapter 5 - Programme Management - provides practical guidance on planning, starting, scaling up, managing, and monitoring an effective programme. Insights from the needs assessment phase include: "Local authorities can become allies following dialogue and negotiation to clarify the benefits they may see from harm reduction services....Some of this information can be gathered through desk research, but most will require informal conversations with residents and local communities, partners and interested groups, and possibly more formal meetings with local authorities. In more open contexts, it may be possible to use established forums such as meetings of community councils to have a structured dialogue."
Each chapter begins with an introduction that defines the topic and explains why it is important. Interventions are then broken down into stages or steps wherever possible, and topics or points of particular interest are presented in text boxes. Case examples from programmes around the world illustrate how an issue or challenge has been addressed and aim to inspire ideas about approaches that could work in the reader's own context. The forms, charts etc. presented from various programmes have the same purpose. Each chapter ends with a list of further resources - tools, guidelines, and other practical publications - available online. Cross-referencing is provided to assist the reader in making connections between chapters.
The intended users of this tool are: public health officials and managers of HIV and harm reduction programmes; non-governmental, community, and civil society organisations, including networks of people who use drugs; and health workers. It may also be of interest to advocates and activists for the rights of people who use drugs, and to international funding agencies and health policymakers.
UNDP website, May 17 2017. Image credit: UNODC/HAS