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The impact of harm reduction on HIV and illicit drug use Ti, Lianping; Kerr, Thomas Feb 21, 2014

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COMMENTARY Open AccessThe impact of harm reduction on HIV and illicitdrug useLianping Ti1,2 and Thomas Kerr1,3*AbstractThere has been widespread support for harm reduction programs as an essential component for responding to theHIV and illicit drug use epidemics. However, despite the growing international acceptance of harm reduction, therecontinues to be strong opposition to this approach, with critics alleging that harm reduction programs enable druguse. Vancouver, Canada provides a compelling case study that demonstrates that many positive impacts of harmreduction can be attained while addiction treatment-related goals are simultaneously supported. While the evidencefor harm reduction is clearly mounting, it is unfortunate that ideological and political barriers to implementing harmreduction programs in Canada remain. As evidenced by Vancouver and elsewhere, harm reduction programs do notexacerbate drug use and undermine treatment efforts and should thereby occupy a well-deserved space within thecontinuum of programs and services offered to people who inject drugs.Keywords: Harm reduction, Illicit drug use, CanadaCommentaryBackgroundThe widespread support for harm reduction programs asessential responses to the harms of illicit drug use con-tinues to grow [1]. International health bodies, includingthe World Health Organization (WHO) and the JointUnited Nations Programme on HIV/AIDS (UNAIDS),recommend harm reduction programs as best practicesand crucial for reducing HIV infection among peoplewho inject drugs (IDU) [1]. The WHO/UNAIDS com-prehensive HIV prevention package for the prevention,treatment, and care of HIV among IDU recommends theprovision of sterile needles and syringes as well as opioidsubstitution therapy, and in response, public health andnongovernmental organizations in various settings haverolled out these programs [2,3].However, despite the growing international acceptanceof harm reduction approaches as an evidence-based stra-tegy for minimizing the negative consequences relatedto illicit drug use, opposition to harm reduction persists.Those strongly opposed to harm reduction typically arguethat programs such as syringe distribution and supervisedinjecting facilities (SIFs) enable drug use and underminedrug treatment efforts [4]. However, much of these argu-ments have relied on unpublished reports by anti-druglobby groups and have been deemed questionable for fail-ing to meet accepted academic standards [5,6].However, as such criticisms and concern continue tobe aired and repeated by some media outlets [7], the evi-dence in support of harm reduction continues to grow,as does the body of research demonstrating that harmreduction does not enable drug use at the individual northe community level. The city of Vancouver (Canada)provides an interesting case example of such effects. Inthe late 1990s, Vancouver was the site of massive epi-demics of HIV infection and overdose among IDU. Inresponse, the regional health authority launched an ag-gressive public health response, which included scalingup syringe distribution, peer-based programming, me-thadone maintenance therapy, and establishing the firstNorth American sanctioned SIF. A recent report exam-ining data derived from three US National Institute ofDrug Abuse-funded cohort studies revealed that rates ofHIV and HCV infection as well as other indicators ofdrug-related risks and harms have plummeted in Van-couver over the past 15 years [8]. For example, syringe* Correspondence: uhri-tk@cfenet.ubc.ca1British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital,608 - 1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada3Department of Medicine, University of British Columbia, St. Paul’s Hospital,Vancouver, BC V6Z 1Y6, CanadaFull list of author information is available at the end of the article© 2014 Ti and Kerr; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly credited. The Creative Commons Public DomainDedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,unless otherwise stated.Ti and Kerr Harm Reduction Journal 2014, 11:7http://www.harmreductionjournal.com/content/11/1/7sharing has been reduced from approximately 40% in1996 to less than 2% in 2011, and this can be largelyattributed to an increase in the distribution of sterileinjecting paraphernalia [8]. At the same time, there hasbeen a dramatic increase in drug injection cessationamong IDU in this setting. As the report also shows,these health gains have been made despite the failure ofdrug supply reduction efforts, evidenced by the fact thatthe accessibility and price of illicit drugs have remainedstable in Vancouver for over 10 years [8].While it is clear that local policy makers in Vancouverhave been convinced of the value of harm reductionprograms, sadly, it appears that the federal conservativegovernment of Canada has chosen to ignore evidenceand embrace a drug policy approach that is not onlycostly but also ineffective in reducing illicit drug use andsupply [8,9]. Such unsuccessful policies continue to placeundue harm upon IDU by placing an emphasis on failedlaw enforcement approaches in combatting illicit druguse [10,11]. Further, for the first time since 1987, thewords ‘harm reduction’ have been removed from Canada’snational drug strategy [12]. The federal government hasalso remained opposed to Insite, Vancouver’s SIF. How-ever, despite their numerous attempts to shut the facilitydown, a unanimous 9-0 Supreme Court ruling has allowedthis life-saving program to continue to operate underan exemption from federal drug laws [13]. Still, the federalgovernment continues to set unnecessary roadblocks inscaling up SIFs in Canada. The introduction of Bill C-2,known as the Respect for Communities Act, requires localcommunity and police support before a new SIF can beimplemented and gives the federal Minister of Health soleauthority in approving new SIFs to operate under theexemption [14]. In essence, the government is putting‘NIMBYism’ and policing interests ahead of public health.If this new legislation is reintroduced and passed, appli-cants will face significant obstacles in attempting to openSIFs across Canada. This could have the effect ofpreventing IDU from accessing low-barrier healthservices and will thereby threaten the health and lives ofsome of Canada’s most vulnerable citizens.The evidence in support of harm reduction programsonly continues to grow, as does the evidence showingthat harm reduction programs do not exacerbate indi-vidual and community drug use patterns. It is clear thatprograms like Insite save lives and support rather thanundermine treatment efforts by connecting individualsto various forms of addiction treatment. Sadly, despitethe evidence from Vancouver showing that the harmreduction response served to significantly reduce drug-related harms without increasing drug use locally, barriersto implementing harm reduction programs in Canadaremain. These barriers, all social and political in na-ture, have immense potential to exacerbate preventablehuman suffering and place a massive and unnecessaryburden on the Canadian healthcare system.ConclusionThe time to heed the recommendations of the world’sleading health bodies has come. Tired arguments againstharm reduction persist, but these come from those whoignore evidence and put ideology and politics ahead ofpublic health. It can no longer be argued, in a compel-ling fashion, that harm reduction exacerbates drug useand undermines treatment efforts. The evidence fromVancouver and elsewhere clearly shows that harm reduc-tion programs typically do what they are designed todo - they reduce drug-related harm, support addictiontreatment efforts, and thereby occupy a well-deservedspace with the continuum of programs and servicesoffered to IDU.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsLT and TK developed the original arguments and completed the first andfinal drafts of the manuscript. Both authors read and approved the finalmanuscript.AcknowledgementsThe authors thank Tricia Collingham and Deborah Graham for theiradministrative assistance.Author details1British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital,608 - 1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada. 2School ofPopulation and Public Health, University of British Columbia, Vancouver, BCV6T 1Z3, Canada. 3Department of Medicine, University of British Columbia, St.Paul’s Hospital, Vancouver, BC V6Z 1Y6, Canada.Received: 4 February 2014 Accepted: 12 February 2014Published: 21 February 2014References1. WHO, UNODC, UNAIDS: WHO, UNODC, UNAIDS Technical Guide for Countriesto Set Targets for Universal Access to HIV Prevention, Treatment and Care forInjecting Drug Users. Geneva: WHO; 2012.2. Beyrer C, Malinowska-Sempruch K, Kamarulzaman A, Kazatchkine M, SidibeM, Strathdee S: Time to act: a call for comprehensive responses to HIV inpeople who use drugs. Lancet 2010, 376:551–563.3. Strathdee S, Stockman J: Epidemiology of HIV among injecting andnon-injecting drug users: current trends and implications for interventions.Curr HIV/AIDS Rep 2010, 7:99–106.4. Ontario Association of Chiefs of Police: Supervised Injection Sites: A PositionPaper by Ontario’s Police Leaders. Ontario: Ontario Association of Chiefs ofPolice; 2012.5. Wood E, Montaner JS, Kerr T: Illicit drug addiction, infectious diseasespread, and the need for an evidence-based response. Lancet Infect Dis2008, 8:142–143.6. Marshall BD, Milloy M-J, Wood E, Montaner JS, Kerr T: Overdose deaths andVancouver’s supervised injection facility – authors’ reply. Lancet 2012,379:118–119.7. Kay B: Insite clinic enables drug users and helps spread human misery.National Post 2011. http://fullcomment.nationalpost.com/2011/05/18/barbara-kay-insite-clinic-enables-drug-users-and-helps-spread-human-misery/.8. Urban Health Research Initiative of the British Columbia Centre forExcellence in HIV/AIDS: Drug Situation in Vancouver. Vancouver: BritishColumbia Centre for Excellence in HIV/AIDS; 2013.Ti and Kerr Harm Reduction Journal 2014, 11:7 Page 2 of 3http://www.harmreductionjournal.com/content/11/1/79. Werb D, Kerr T, Nosyk B, Strathdee S, Montaner J, Wood E: The temporalrelationship between drug supply indicators: an audit of internationalgovernment surveillance systems. BMJ Open 2013, 3:e003077.10. Milloy M, Wood E, Small W, Tyndall M, Lai C, Montaner J, Kerr T:Incarceration experiences in a cohort of active injection drug users. DrugAlcohol Rev 2008, 27:1–7.11. Ti L, Wood E, Shannon K, Feng C, Kerr T: Police confrontations amongstreet-involved youth in a Canadian setting. Int J Drug Policy 2013,24:46–51.12. DeBeck K, Wood E, Montaner J, Kerr T: Canada’s new federal “NationalAnti-Drug Strategy”: an informal audit of reported funding allocation.Int J Drug Policy 2009, 20:188–191.13. CBC News: Vancouver’s Insite drug injection clinic will stay open. CBCNews 2011. http://www.cbc.ca/news/canada/british-columbia/vancouver-s-insite-drug-injection-clinic-will-stay-open-1.1005044.14. Butler M, Phillips K: Legislative Summary of Bill C-2: An Act to amend theControlled Drugs and Substances Act. Ottawa, ON: Parliament of Canada; 2013.doi:10.1186/1477-7517-11-7Cite this article as: Ti and Kerr: The impact of harm reduction on HIVand illicit drug use. Harm Reduction Journal 2014 11:7.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitTi and Kerr Harm Reduction Journal 2014, 11:7 Page 3 of 3http://www.harmreductionjournal.com/content/11/1/7

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