Home Affairs Committee - Drugs: Breaking the CycleWritten evidence submitted by Harm Reduction International (DP098)

Founded in 1996, Harm Reduction International (formerly the International Harm Reduction Association) is a leading non-governmental organisation working to promote and expand support for harm reduction worldwide.

We work to reduce the negative health, social and human rights impacts of drug use and drug policy—such as the increased vulnerability to HIV and hepatitis infection among people who inject drugs—by promoting evidence-based public health policies and practices, and human rights based approaches to drug policy.

The extent to which the Government’s 2010 drug strategy is a “fiscally responsible policy with strategies grounded in science, health, security and human rights” in line with the recent recommendation by the Global Commission on Drug Policy

The extent to which public health considerations should play a leading role in developing drugs policy

Introduction

1. Harm reduction refers to policies, programmes and practices that aim primarily to reduce the adverse health, social and economic consequences of the use of legal and illegal psychoactive drugs without necessarily reducing drug consumption. Harm reduction complements approaches that seek to prevent or reduce the overall level of drug consumption. It is based on the recognition that many people throughout the world continue to use psychoactive drugs despite even the strongest efforts to prevent the initiation or continued use of drugs. Harm reduction accepts that many people who use drugs are unable or unwilling to stop using drugs at any given time. Access to good treatment is important for people with drug problems, but many people with drug problems are unable or unwilling to get treatment. The harm reduction approach to drugs is based on a strong commitment to public health and human rights. Harm reduction principles encourage open dialogue, consultation and debate. A wide range of stakeholders must be meaningfully involved in policy development and programme implementation, delivery and evaluation. In particular, people who use drugs and other affected communities should be involved in decisions that affect them.

2. Harm reduction and HIV in the United Kingdom

The UK has proved itself to be a leader in harm reduction. As a result, the prevalence of HIV among people who inject drugs remains comparatively low in the UK, and it is estimated that approximately one in every 100 is living with HIV.1

In addition to the risk of HIV transmission, other injecting related wounds and health problems are common among people who inject drugs. For example, approximately one-third report having a symptom of a bacterial infection (such as a sore or abscess) at an injecting site in the past year.2

Although needle and syringe sharing is lower than a decade ago, still one-fifth of people who inject drugs continue to share needles and syringes.3

Current UK Drugs Strategy—Omission of Harm Reduction

3. The UK has played a leading role in pioneering harm reduction nationally and globally, as a result it has one of the lowest HIV prevalence rates amongst people who inject drugs in the world. However, the new UK drugs strategy was received by the harm reduction community with disappointment.

4. The phrase “reduction of drug-related harm” is only referred to twice in the entire text of the strategy and “harm reduction” is not mentioned at all. Instead, terms such as “enforcement”, “prevention”, “rebalancing” and “drug free outcomes” are repeatedly emphasised. These are important elements of a comprehensive strategy, but should not be implemented at the expense of proven, effective interventions that reduce the harm faced by those who continue to use drugs, their families and communities. The new strategy under-emphasises the need to support and protect people who will not or cannot become drug free in the immediate future.

5. While we are extremely concerned about the impact the current UK drugs strategy may have on harm reduction services in the UK, we are equally concerned about the mixed messages this strategy is sending at an international level, given the UK’s global leadership role on HIV prevention efforts related to injecting drug use.

Evidence for Harm Reduction

6. International evidence shows that comprehensive harm reduction measures can drastically reduce the transmission of HIV and other blood-borne viruses in prisons and in the community.4 Harm reduction has been adopted in the policies of, inter alia, the United Nations system,5 specific UN programmes and funds including UNAIDS, the World Health Organization (WHO), UN Office on Drugs and Crime (UNODC),6 European Union,7 the Council of Europe,8 and the International Federation of the Red Cross and Red Crescent Societies.9

Needle and Syringe Exchange Programmes

7. Needle and syringe exchange programmes (NSPs) provide people who inject drugs with access to sterile injecting equipment (needles and syringes, swabs, vials of sterile water) and offer access to health education, referrals, counselling and other services.

8. Studies have shown that NSPs are effective in reducing HIV infection among people who inject drugs, and do not increase the use of illicit drugs or the rate of injecting drug use.10 It has been suggested that integrated programmes (eg pharmacy provision of syringes, access to and adherence to Antiretroviral Therapy (ART), in addition to NSP) are most effective in reducing syringe sharing and HIV transmission.11

Opioid Substitution Therapy

9. Opioid Substitution Therapy (OST) in its different forms has become a widely accepted drug treatment and harm reduction measure for people who use opioids. OST substitutes legal oral medicines in place of illegal injected drugs, thus reducing injecting and its associated harms.12 Studies have consistently shown that substituting methadone or buprenorphine for opioid-dependent injecting drug users is associated with statistically significant reductions in illicit opioid use, injecting use, sharing of injecting equipment and a significant decrease in HIV infection amongst people who inject drugs.13

10. The single most important event showcasing the evidence for harm reduction interventions over the past few years was a Lancet special edition entitled “Global HIV epidemic among people who use drugs”. It featured seven reviews of current evidence and a number of invited commentaries concluding that harm reduction interventions are extremely effective in preventing HIV amongst people who inject drugs.14

11. We acknowledge and support the fact the UK has consistently implemented high quality harm reduction interventions mostly in the form of needle and syringe exchange programmes and opioid substitution therapy. However a number of clear gaps remain.

Evidence for the implementation of Drug Consumption Rooms (DCRs) in the UK

12. The recommendation to set up pilot DCRs was made to the Government by the Home Affairs Select Committee in 2002. However, this recommendation was rejected for a number of reasons, including a lack of evidence, legal concerns and the likely media and public hostility.

13. An independent working group was formed by the Joseph Roundtree Foundation to address these issues. That group reviewed the growing body of evidence, commissioned research where there were significant gaps, visited DCRs abroad and heard from relevant witnesses.

14. The group concluded that DCRs are a rational and overdue extension to the harm reduction policy that has produced substantial individual and public benefits in the UK over the last two decades. DCRs offer a unique and promising way to work with the most vulnerable users, in order to reduce the risk of overdose, improve health and lessen the damage and costs to society. The group therefore recommended that pilot DCRs are set up and evaluated in the UK.

15. Harms associated with injecting drug use in the UK

Over the past decade, the UK has consistently had the highest number of drug-related deaths in Europe.15

Health problems include blood-borne viruses, abscesses and cellulitis, frequently resulting in hospitalisation.16

Large quantities of syringes and drug-related litter are dropped in public places across the UK, causing considerable impact on local residents and businesses.17

16. Impact of DCRs

DCRs can prevent drug-related deaths, prevent needle sharing and improve the general health of injecting drug users.

DCRs can lead to a reduction in injecting in public places and an associated reduction in discarded, used syringes and drug-related litter.

Most of those who use DCRs are local drug users.

DCRs do not appear to either increase or decrease levels of acquisitive crime.

Public disorder and drug dealing in the vicinity of DCRS are infrequent and can generally be prevented through good interagency co-operation.18

17. Heroin Prescription

“We will continue to examine the potential role of diamorphine prescribing for the small number who may benefit, and in the light of this consider what further steps could be taken, particularly to help reduce their re-offending.”

UK Drugs Strategy 2010

We welcome this statement to ensure access to injectable diamorphine for those dependent to drugs who persistently fail to benefit from conventional oral substitution treatment. It has been proven that treatment with supervised injectable heroin leads to significantly lower use of street heroin than does supervised injectable methadone or supervised oral methadone. The RIOTT trial recommended that UK Government proposals should be rolled out to support the positive response that can be achieved with heroin maintenance treatment for previously unresponsive people who inject drugs.19

Evidence for the benefits of implementing NSPs in prisons

18. We acknowledge and support the fact that the UK currently operates OST in prison settings. However, we stress the need for immediate implantation and scale up of NSPs in prison which is currently lacking.

19. Evidence-based prison health programmes, including harm reduction interventions, such as needle and syringe exchanges programmes (NSPs) and opioid substitution therapy (OST), significantly reduce drug-related harms among vulnerable populations. Since the early 1990s, a number of countries have introduced these interventions to reduce HIV and HCV in prisons.20

20. Following a comprehensive international review, the WHO, UNODC and UNAIDS recommended that NSPs should be urgently introduced and scaled up in countries threatened by HIV epidemics among people who inject drugs.21 The review also recommended that “prison authorities in countries in which OST is available in the community should introduce OST programmes urgently and expand implementation to scale up as soon as possible.”

21. At present, NSPs operate in over sixty prisons in ten countries in Europe, Central Asia and Iran.22 Systematic evaluations of the effectiveness of NSPs for addressing HIV-related risk behaviours in from ten prison programmes demonstrate that NSPs are feasible in men’s and women’s prisons and prisons of all security levels and sizes.23 Existing research shows that provision of sterile needles and syringes is readily accepted by people who inject drugs across a variety of prison settings, significantly reduces syringe sharing and resulting infection with HIV and other BBVs and facilitates referral to drug dependence treatment programmes.24 , 25 , 26 There is no evidence to suggest that prison-based NSPs have negative unintended consequences, including increasing levels of drug use or injecting, or use of syringes as weapons.27

The cost effectiveness of different policies to reduce drug usage

Value for money

22. An important case for the continued support for harm reduction services is the cost effectiveness of harm reduction. In Australia, NSPs directly averted 32,050 new HIV infections and 96,667 new HCV infections between 2000 and 2009. For every dollar invested in needle and syringe exchange, more than four dollars were returned in health care savings.28

23. The benefit return for methadone maintenance treatment is estimated to be approximately four times the cost of the treatment. According to the US National Institute on Drug Abuse, “Research has demonstrated that methadone maintenance treatment is beneficial to society, cost effective and pays for itself in basic economic terms.”29

24. Prevention of HIV is cheaper than treatment of HIV/AIDS. For example, in Asia it is estimated that the comprehensive package of HIV-related harm reduction interventions cost $39 per disability-adjusted life-year saved,30 whereas antiretroviral treatment costs approximately $2,000 per life-saved. Such figures demonstrate that harm reduction is a low-cost, high-impact intervention.

Whether the UK is supporting its global partners effectively and what changes may occur with the introduction of the national crime agency

25. Harm Reduction and HIV Globally

Up to 3.3 million people who inject drugs are living with HIV31 accounting for up to 10% of all HIV infections linked with injecting worldwide and one-third of all HIV infections outside of Africa.32

Western Europe rates of reported newly diagnosed cases of HIV in injecting drug users on the decline, HIV in Eastern Europe and Central Asia—one in four injectors is believed to be living with HIV accounting for 57% of all infections.33

Hepatitis C prevalence34 reaching 60–90% among people who inject drugs who have been tested for Hep C.

26. The glaring disparities between HIV prevalence globally amongst people who use drugs, have been attributed to the relative action and inaction of governments on harm reduction. For example, early adoption of harm reduction measures in the Netherlands, Switzerland and the UK have led to relatively low national HIV prevalence among people who inject drugs (less than 5%), whereas countries such as Russia where OST is illegal and NSP is limited have an HIV prevalence rate of 38% amongst people who use drugs.35

Funding

27. Funding for harm reduction is a major concern.

28. HIV infection among people who inject drugs is preventable. Harm reduction is cost-effective and drug users have responded well when offered harm reduction advice and tools. It is of the utmost importance that rhetoric around decreasing new HIV infections globally is matched with the necessary financial resources to do so.

29. However, a cautious estimate of global funding for harm reduction concluded that $160 million worldwide was invested in HIV-related harm reduction in 2007, of which $136 million (90%) was from international donors. This equated to $12.80 for each injector per year in low and middle-income countries—or just three US cents per injector per day. This is clearly inadequate when compared with indicative unit costs of providing needles and syringes (approximately $100 per person per year) and methadone (approximately $500 per person per year).36

The majority of funding for HIV prevention and care globally has been provided by multilateral and bilateral donors. For example:

Global Fund: 2007–09—$180 billion.

PEPFAR: 2007–09—$23.1 billion.

30. The Global Fund has recently cancelled its round 11 bid and PEPFAR has reinstated its ban regarding needle and syringe exchange programmes. This will lead to a critical gap in the level of funding available for harm reduction.

The United Kingdom’s Foreign Policy on Harm Reduction

31. For many years the United Kingdom has played a leading role within the European Union and in the United Nations promoting evidence-based, effective and human rights compliant measures to prevent HIV and other blood borne viruses among people who inject drugs. This leadership stems from a legacy of innovation and success in this field nationally, with HIV infections related to injecting drug use in the UK remaining consistently low over many years.

32. The United Kingdom is one of the world’s largest and most important donors to HIV prevention related to unsafe injecting, which forms the majority of new infections in many countries of Eastern European and Asia—and often forgotten in the global response to HIV/AIDS.

33. Harm reduction is central to DFID’s HIV strategy.

34. The new UK drug strategy plays down harm reduction, and if this were to translate into instructions to the Foreign Office or to the Home Office International Secretariat this would be very damaging to the global HIV/AIDS response.

35. Millions of pounds spent on the HIV response through DFID could be undermined unless there is strong, unambiguous international political support, and, crucially, support from host Governments.

36. On a number of occasions the United Kingdom has found itself debating HIV-related harm reduction at the UN with governments receiving UK funds for these very programmes.

37. At present there is considerable antagonism towards HIV prevention from a small number of countries. The United Kingdom has long been a bedrock in the EU’s position protecting and promoting the most effective responses including needle and syringe programmes and opioid substitution therapy.

38. The UK must continue to play a lead role in the global HIV/AIDS response. This necessitates a strong a leadership position on HIV-related harm reduction, one the UK is known and respected for, and has played for many years.

39. Harm Reduction International has assisted DFID on the UK delegation to the UN Commission on Narcotic Drugs from 2008 to 2011 and has seen the positive outcomes in HIV/AIDS policies that have emerged because of the UK’s efforts.

40. Recommendations

The Home Office should co-ordinate closely with DFID in all matters relating to international development which includes HIV/AIDS in the context of injecting drug use. DFID should take the lead in HIV-related harm reduction in international forums.

Clear instructions should be sent to all UK diplomats requiring a strong UK position in favour of HIV-related harm reduction.

The UK should rebalance its domestic drug policy to include strong support for existing harm reduction interventions and should extend this policy to include interventions including DCR’s, heroin prescription and NSPs in prison settings.

A number of pilot Drug Consumption Rooms should be set up in the UK, founded on local accords between the key agencies.

Pilots should be developed in parts of the country where there is already considerable local support for the idea and significant problems with public drug use and overdose deaths.

DFID should advocate for approximately 20% of international funds be allocated for HIV/AIDS prevention at an international level should go specifically to harm reduction.

January 2012

1 HPA (2010) Shooting Up. Infections among people who inject drugs in the UK 2010. An Update: November 2010. Health Protection Agency 2010.

2 HPA (2010) Shooting Up. Infections among people who inject drugs in the UK 2010. An Update: November 2010. Health Protection Agency 2010.

3 HPA (2010) Shooting Up. Infections among people who inject drugs in the UK 2010. An Update: November 2010. Health Protection Agency 2010.

4 See for example, US Institute of Medicine (2006), Preventing HIV Infection among Injecting Drug Users in High Risk Countries: An Assessment of the Evidence, September 2006.
http://books.nap.edu/catalog.php?record_id=11731#toc
Hunt N (2003). A review of the evidence-base for harm reduction approaches to drug use. London: Report commissioned by Forward Thinking on Drugs—A Release Initiative.
http://www.ihra.net/uploads/downloads/50best/HIVPrevention/HIVTop50Documents1.1.pdf
World Health Organization (2004). Evidence for Action Technical Papers: Effectiveness of Sterile Needle and Syringe Programming in Reducing HIV/AIDS among Injecting Drug Users. Geneva, World Health Organization 2004
http://www.who.int/hiv/pub/prev_care/effectivenesssterileneedle.pdf
World Health Organization (2004) Evidence for Action Technical Papers: Effectiveness of drug dependence treatment in HIV prevention, Geneva, World Health Organization 2004. http://www.emro.who.int/aiecf/web203.pdf
Canadian HIV-AIDS Legal Network (2004). Prison Needle Exchange: Lessons from a Comprehensive Review of International Evidence and Experience. Canadian HIV-AIDS Legal Network.
http://www.ihra.net/uploads/downloads/50best/HIVPrevention/HIVTop50Documents8.5.pdf
World Health Organisation, Evidence for Action Technical Papers, Interventions to Address HIV in Prisons: Needle and Syringe Programmes and Decontamination Strategies, WHO/UNODC/UNAIDS, 2007 http://www.who.int/hiv/idu/oms_%20ea_nsp_df.pdf
World Health Organisation, Evidence for Action Technical Papers, Interventions to Address HIV in Prisons: Drug Dependence Treatments WHO/UNODC/UNAIDS, 2007. http://www.who.int/hiv/idu/EADrugTreatment.pdf

5 UN General Assembly, Declaration of Commitment on HIV/AIDS, 2 August 2001, UN Doc No A/RES/S-26/2, paras 23, 52, 62 http://www.un.org/ga/aids/docs/aress262.pdf
Preventing the Transmission of HIV Among Drug Abusers. A position paper of the United Nations System. Annex to the Report of 8th Session of ACC Subcommittee on Drug Control 28–29 September (2000).
http://www.ihra.net/uploads/downloads/50best/HIVPrevention/HIVTop50Documents18.7.pdf
Commission on Narcotic Drugs Resolution 45/1, Human immunodeficiency virus/acquired immunodeficiency syndrome in the context of drug abuse http://www.unodc.org/pdf/document_2002-04-25_1.pdf
Commission on Narcotic Drugs Resolution 46/2, Strengthening strategies regarding the prevention of human immunodeficiency virus/acquired immunodeficiency syndrome in the context of drug abuse
http://daccessdds.un.org/doc/UNDOC/GEN/V03/837/76/PDF/V0383776.pdf?OpenElement
Commission on Narcotic Drugs Resolution 47/2, Prevention of HIV among drug users
http://www.unodc.org/pdf/resolutions/cnd_2004_47-2.pdf
Commission on Narcotic Drugs Resolution 49/4, Responding to the prevalence of HIV/AIDS and other blood-borne diseases among drug users http://daccessdds.un.org/doc/UNDOC/GEN/V06/526/23/PDF/V0652623.pdf?OpenElement

6 UNODC (2008). Reducing the adverse health and social effects of drug use: A comprehensive approach.
http://www.unodc.org/documents/prevention/Reducing-adverse-consequences-drug-abuse.pdf
WHO, UNAIDS & UNODC (2004). Policy Brief: Provision of sterile injecting equipment to reduce HIV transmission. Geneva, World Health Organization, 2004.
http://www.who.int/hiv/pub/advocacy/en/provisionofsterileen.pdf
WHO, UNAIDS & UNODC (2004). Position Paper—Substitution maintenance therapy in the management of opioid dependence and HIV/AIDS prevention. Geneva, World Health Organization 2004.
http://www.who.int/substance_abuse/publications/en/PositionPaper_English.pdf
World Health Organization (2007). Model List of Essential Medicines, 15th list March 2007.
http://www.who.int/medicines/publications/EssMedList15.pdf
WHO, UNAIDS & UNODC (2004) Policy Brief: Reduction of HIV Transmission in Prisons, Geneva, World Health Organization, 2004
http://www.who.int/hiv/pub/advocacy/en/transmissionprisonen.pdf

7 EU Drugs Action Plan 2005–08
http://eur-lex.europa.eu/LexUriServ/site/en/oj/2005/c_168/c_16820050708en00010018.pdf
EU Drugs Strategy 2005–12 http://ec.europa.eu/justice_home/fsj/drugs/strategy/fsj_drugs_strategy_en.htm

8 Council of Europe, Parliamentary Assembly Resolution 1576 (2007). For a European convention on promoting public health policy in the fight against drugs; Council of Europe, Recommendation R(98)7 of the Committee of Ministers to Member States Concerning the Ethical and Organisational Aspects of Healthcare in Prison, adopted 8 April 1998, 627th Meeting of the Ministers’ Deputies; Council of Europe, Recommendation R(93)6 of the Committee of Ministers Concerning Prison and Criminological Aspects of the Control of Transmissible Diseases including AIDS and Related Health Problems in Prison, adopted 18 October 1993, 500th Meeting of the Ministers’ Deputies; Council of Europe, P.A. Standing Committee, Recommendation 1080 (1988). On a Co-ordinated European Health Policy to Prevent the Spread of AIDS in Prison; Council of Europe, Recommendation R(2006)2 of the Committee of Ministers on the European Prison Rules, adopted 11 January 2006, 952nd Meeting of the Ministers’ Deputies.

9 Rome Consensus for a Humanitarian Drug Policy (2005) Italian Red Cross and Senlis Council, signed to date by approximately 110 national Red Cross and Red Crescent Societies.
http://www.senliscouncil.net/modules/media_centre/press_conferences/rome_public_health/rome_consensus

10 WHO (2004) Effectiveness of Sterile Needle and Syringe Programming in Reducing HIV/AIDS Among Injecting Drug Users, World Health Organisation.
Palmeteer et al. (2010). “Evidence for the effectiveness of sterile injecting equipment provision in preventing hepatitis C and human immunodeficiency virus transmission among injecting drug users: a review of reviews.” Addiction. 105.5.
HIV in People Who Use Drugs’ Lancet Series July 2010. <http://www.thelancet.com/series/hiv-in-people-who-use-drugs>.
Wodak, Cooney (2005). Effectiveness of sterile needle and syringe programmes. International Journal of Drug Policy S31–S44.

11 WHO (2004). Effectiveness of Sterile Needle and Syringe Programming in Reducing HIV/AIDS Among Injecting Drug Users, World Health Organisation.

12 WHO, UNOCD, UNAIDS (2007). Interventions to address HIV in prisons: drug dependence treatments. Evidence for Action Technical Paper. Geneva WHO.

13 Mattick et al (2009). “Methadone maintenance therapy versus no opioid replacement therapy: A Systematic Review.”
Mattick et al (2008). “Buprenorphine maintenance vs placebo or methadone maintenance for opioid dependence: a Systematic Review.”
Gowing et al (2008) “Substitution treatment of injecting opioid users for prevention of HIV infection: A Systematic Review.”

14 Lancet Series can be accessed here
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60832-X/abstract

15 EMCDDA (2005). Annual Report 2005: The State of the Drugs Problem in Europe. Lisbon: EMCDDA.

16 Stone, M H, Stone, D H and MacGregor, H A R (1990). “Anatomical distribution of soft tissue sepsis sites in intravenous drug misusers attending an accident and emergency department”, British Journal of Addiction, Vol 85, pp 1495–6.

17 ENCAMS (2005). Drugs-Related Litter Survey 2005. Wigan: ENCAMS.

18 Independent working group on drug consumption rooms (2004). The report of the independent working group on drug consumption rooms. Joseph Roundtree Foundation.

19 Strang, et al (2010). Supervised injectable heroin or injectable methadone verus optimised oral methadone as treatment for chronic heroin addicts in England after persistent failure in orthodox treatment (RIOTT): a randomised trial. The Lancet Vol 975.

20 Jurgens, Lines and Cook (2010). Out of Sight, Out of Mind? Global State of Harm Reduction. International Harm Reduction Association.

21 WHO, UNODC, UNAIDS (2007). Interventions to address HIV in Prisons: Needle and Syringe programmes and Decontamination Strategies. Evidence for Action Technical Paper. Geneva: WHO.

22 Jurgens R, Lines R, Cook C (2010). “Out of Sight, Out of Mind?” Global State of Harm Reduction (London, 2010) International Harm Reduction Association.

23 Jurgens, Lines and Cook (2010). Out of Sight, Out of Mind? Global State of Harm Reduction. International Harm Reduction Association.

24 Jurgens et al (2009). Interventions to reduce HIV transmission related to injecting drug use in prison. Lancet Infectious Diseases 9: 57–66.

25 Menoyo C et al (2000). Needle exchange in prisons in Spain. Canadian HIV/AIDS Policy and Law Review 5(4):20–21.

26 Stover, H (2000). Evaluation of needle exchange pilot project shows positive results. Canadian HIV/AIDS Policy and Law Newsletter 5(2/3):60–64.

27 WHO (2005). Effectiveness of Sterile Needle and Syringe Programming in Reducing HIV/AIDS among Injecting Drug Users. Evidence for Action Technical Paper. Geneva: WHO.

28 Australian Government, Department for Health and Ageing (2009). Return on Investment 2: Evaluating the Cost-Effectiveness of Needle and Syringe Exchange Programs in Australia. Canberra, ACT: Department of Health and Ageing.

29 National Institute on Drug Abuse, NIDA International Program, Methadone Research Web Guide (last accessed March 2010).

30 Commission on AIDS in Asia (2008). Redefining AIDS in Asia: Crafting an Effective Response New Delhi. Oxford University Press: 90.

31 EMCDDA (2010). Drugnet Europe 71, European Monitoring Centre on Drugs and Drug Addiction, 2010. Lisbon.

32 HPA (2010). Shooting Up. Infections among people who inject drugs in the UK 2010. An Update: November 2010. Health Protection Agency 2010.

33 UN reference Group on HIV and Injecting Drug Use. http://www.idurefgroup.unsw.edu.au/regional-data-and-maps/Eastern_Europe (last accessed 5 January 2012).

34 EMCDDA (2010). Trends in injecting drugs in Europe, European Monitoring Centre on Drugs and Drug Addiction, 2010. Lisbon. Table INF-2 . Prevalence of HCV antibody amongst injecting drug users in the EU, 2008 or most recent year.

35 UNAIDS (2009) AIDS Epidemic Update.

36 Stimson et al (2010). Three cents a day is not enough. Resourcing HIV-related Harm Reduction on a Global Basis. International Harm Reduction Association.

Prepared 8th December 2012