The needles revolution: reducing damages while protecting the health of drug users

The drug user population and, in particular, people who inject themselves with drugs are among the most marginalized and stigmatized groups in urban spaces. Living along societal margins, mistreated by police, despised by the community, and ignored by hospitals, users who inject themselves represent a headache for local governments.

In the 1980s, several cities in Switzerland found themselves dealing with a drug problem, not knowing how to combat an alarming increase in HIV infections rooted in the practice of sharing needles. After brainstorming on how to address the situation, they found a solution that would trigger a revolution: cities began distributing clean needles at key drug consumption points in Bern, Switzerland.

Gradually, these interventions were implemented in other countries with similar problems. Public health and social care professionals found in harm reduction programs a tool to serve populations without requiring abstinence or hospitalization in a treatment center. This offered a solution that would address the problem without judging drug users’ decisions about consumption or living on the street. It would allow healthcare professionals to care for this population in their own context and according to their own realities.

In these programs, needles are an excuse to promote meetings, build bridges, offer spaces to chat, establish networks of protection and support, and establish routes to other types of care drug users may need. The evidence in favor of needles exchange programs is so strong that in 2012, in his speech to the Committee against Torture, the United Nations Special Envoy on the Right to Health argued that these interventions are cost-effective, do not have adverse consequences, reduce the spread of HIV, Hepatitis B and C, and are consistent with the standards established by public health principles.

Ten years ago, the needles revolution landed in Colombia in response to the increase in heroin use in eight cities across the country. Thousands of users benefited every day, which prevented HIV/AIDS infections as well as the transmission of other diseases. Asia has also seen its fair share of interventions. When the cost-effectiveness of these programs was studied, it was found that the average cost of the needles program (USD 39 per year), is significantly smaller when compared to the cost of HIV/AIDS treatment (USD 2,000 per year). In the United States, estimates indicate that the provision of these services saves between $3,000 and $ 50,000 USD in health costs each year, while the cost per needle is only 97 cents. Despite all this evidence, services are scarce and insufficient given the number of people who need them. In 2015, the funds allocated for this type of service only covered 7% of the global need.

Source: Global State of Harm Reduction 2016. Harm Reduction International.

In addition to the scarcity of existing efforts, harm reduction programs have suffered a worldwide underfunding crisis. In many countries, these programs are run through international cooperation resources, and when these resources are exhausted, users are left adrift, returning to the dangerous practice of sharing needles. According to UNAIDS, new HIV infections were decreasing among the global population at the same time they increased by 33% in the user population between 2011 and 2015. In Puerto Rico alone, 50% of HIV infections can be traced to the use of contaminated needles.

The wave of defunding also affected Colombia. In 2018, it resulted in program cuts for heroin users in Dosquebradas. Located in the center of the country, Dosquebradas is a municipality that does not have more than 200,000 inhabitants, and yet has one of the highest rates of heroin use (including injection) in the country: approximately one thousand users according to the 2013 national study on consumption.

Before the withdrawal of cooperation funds to finance these programs happened, it was understood that local governments would become responsible for this public health intervention. However, delays, bureaucratic obstacles, institutional inertia, among many other predictable factors, delayed the operation of services until February 2018. Thirty long days passed by while heroin users clung to their needles as if they were treasures. Nobody had showed up to deliver the hygienic injection kits.

I spoke with Lina*, one of the of the professionals working in the program at the end of February. While nothing happened in January, the team reassembled everything to deliver the kits the following month. When they arrived to the neighborhoods in Dosquebradas, Lina was shocked by several men recognizing the team and asking them to perform general HIV tests. “We have shared needles all the time, do the tests.” Just like that, years’ work aimed at lessening damages and eliminating the risk of contagion of infectious diseases was all thrown way.

For Lina and many of the people who work in the field, this situation could have been prevented. Since 2017, residents knew that the project would have to go to the Mayor’s and the Governor’s Office, rendering the absence of service during the month of January 2018 nothing more than a display of institutional negligence. However, this passed unnoticed since heroin does not generate empathy among the public, nor the neglect of users results in societal indignation.

Graph showing the increase in new HIV infections after budget cuts to harm reduction programs. Source: Harm Reduction – Open Society Foundations

What happened in Colombia is not an isolated case. In Greece, drug users programs were eliminated during the financial crisis. This almost immediately led to an HIV outbreak, which in turn, would represent significantly higher health costs than it would have cost to maintain harm reduction programs running.

In light of Colombia and other countries’ speech about about drug reform, nationally and internationally, this sort of negligence is unacceptable. For several years an important group of countries has insisted that the drug problem, with respect to its problematic use, must be treated as a public health issue, and not with repression or punishment.

Heroin users, like any other Colombian citizen, have a right to health care that guarantees their basic well-being, regardless of moral judgments about the decisions they have made. This is about a revolution based on common sense: the greater availability of hygiene kits programs, the lower the rate of new HIV infections. For a health system with scarce resources, this should be a priority.

*The name has been changed for the purpose of this blog.

Featured photo: Andres Rodriguez