WORLD HEPATITIS SUMMIT: NO ELIMINATION WITHOUT DECRIMINALIZATION! 18 civil society organisations call world leaders to promote harm reduction and decriminalise drug use

São Paulo, Brazil – Novembre 2nd 2017.

At the occasion of the World Hepatitis Summit, a large coalition of patients, clinicians, social workers, representatives of the drug using community, researchers and public health experts express their whole-hearted support to the commitment of World Health Organization (WHO) States members to the goal of eliminating viral hepatitis by 2030; and declare that this goal will only be achieved if people who use drugs access effectively to prevention and treatments.

Injecting drug users are particularly exposed to hepatitis C virus, with one fourth of new infections attributed to sharing of unsterile injecting equipment. Yet their access to prevention and treatment remains far behind the WHO targets, jeopardizing the goal of eliminating viral hepatitis by 2030.

The viral hepatitis community calls on World leaders to urgently increase access to harm reduction interventions and reform criminalizing drug policies that hinder access to health services. See attached their Declaration presented today at the World Hepatitis Summit.

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Declaration of the Hepatitis Community : no elimination without decriminalization!

We, members and representatives of the viral hepatitis community - a community that includes people living with viral hepatitis, doctors, nurses, social workers, researchers, public health experts, and people who use drugs - are concerned over the growing gap between the enormous impact of hepatitis B and hepatitis C over people who use drugs and their almost non-existent access to prevention, diagnosis and treatment services around the world.

Sharing unsterile drug injecting equipment puts people at high risk of hepatitis B and hepatitis C infections. Globally it is estimated that among the 15.6 million people who currently inject drugs 52% are hepatitis C antibody positive, and 9% are living with chronic hepatitis B infection1 ; From a public health and human rights perspective, improving access to prevention and treatment for people who use drugs is crucial to reducing hepatitis C incidence and eliminating the epidemic, as sharing of needles, syringes and other injecting equipment is estimated to account for 23% of new infections2.

Ensuring access to interventions such as low-threshold needle and syringe programmes, opioid substitution therapy, hepatitis C treatment and other harm reduction interventions are essential to reduce hepatitis C incidence and prevalence among people who inject drugs3,4, and these interventions are cost-effective5,6. In 2016, the Member States of the World Health Organization (WHO) adopted the first ever Global Health Sector Strategy (GHSS) on viral hepatitis7. It identified harm reduction as one of five core interventions needed to reach the goal of viral hepatitis elimination by 2030.

Despite the evidence and WHO recommendations, comprehensive harm reduction services are inaccessible for most people who use drugs worldwide. In 2017, among the 179 countries and territories where injecting drug use has been reported, just 86 (48%) have implemented opioid substitution therapy and 93 (52%) have needle and syringe programmes8. Furthermore, the regional and national coverage varies substantially and is most often below WHO indicators, with less than 1% of people who inject drugs living in countries with high coverage of both services8. Even where services do exist, people who use drugs face more difficulties in accessing hepatitis C prevention and treatment due to poor access to health services, their exclusion through treatment criteria, threats of violence and abuse when disclosing status as drug users, and universal stigmatization. As a result, the hepatitis C epidemic continues to grow among people who use drugs9.

This lack of access to hepatitis care for people who use drugs is deeply rooted in and driven by our laws and policies which criminalize drug use, drug possession and, ultimately, people who use drugs themselves10,11. Punitive drug law enforcement is a direct barrier to harm reduction services in many ways:

the prohibition of drug paraphernalia possession impedes harm reduction service delivery and uptake;
many national laws impose severe and disproportionate custodial sentences for minor, non-violent drug offenses (such as drug use, possession and low-level supply);
people who use drugs are frequently incarcerated or extra-judicially detained, often leading to interruption of medical treatments, without access to prevention and other harm reduction services, and at heightened risk of hepatitis infection;
policies criminalizing drug use fuel stereotypes and negative assumptions of people who use drugs, ultimately reinforcing stigmatization and discrimination.
Even in countries that have integrated harm reduction into domestic public health policies, criminalization remains a glass ceiling – as the fear of arrest continues to drive people away from prevention and care services.

A number of countries, such as Portugal and the Czech Republic, decriminalized minor drug offenses years ago with significant public health benefits12,13. These policy changes have proven very successful and have led to an increase of access to harm reduction and health services by people who use drugs – contributing to decreased new HIV infections, and reduced harms associated with drug use and drug dependence14. While our laws and policies that prohibit drugs are portrayed and defended as necessary to preserve public health and safety, the evidence overwhelmingly demonstrates that they have driven unnecessary and disproportionate human rights violations including violence, disease, discrimination, and the undermining of people’s right to health10,11,12. Growing recognition of the need for evidence-based drug policy reform has led several world leaders, public health experts, the WHO and other United Nations Agencies to recommend the decriminalization of minor, non-violent drug offenses, and a strengthening of health-oriented alternatives to criminal sanctions9,15,16,17,18,19,20,21,22.

We, the viral hepatitis community, whole-heartedly support Member States’ commitment to the goal of eliminating viral hepatitis by 2030. In order to achieve that goal, we call on world political leaders to remove all barriers to the uptake of the full range of prevention services by people who use drugs by reforming laws, law enforcement procedures and discrimination that hinder access, including the criminalization of minor, non-violent drug offences and to adopt an approach based overwhelmingly on public health promotion, respect for human rights and evidence.

Initial Signatories :

Alliance for Public Health
Coalition PLUS (international)
Conectas (Brazil)
Correlation Network
European AIDS Treatment Group (EATG)
Grupo de Ativistas em Tratamentos (GAT Portugal)
Global Network of People Living with HIV (GNP+)
Harm Reduction International (HRI)
International AIDS Society (IAS)
International Drug Policy Consortium (IDPC)
International Network for Hepatitis in Substance Users (INHSU)
International Network of People Who Use Drugs (INPUD)
International Committee on the Rights of Sex Workers in Europe (ICRSE)
International HIV Partnerships (IHP)
International HIV/AIDS Alliance International Treatment Preparedness Coalition (ITPC)
Médecins du Monde (MdM)
Open Society Foundation (OSF)
Treatment Action group (TAG)
World Hepatitis Alliance (WHA)

Notes :

[1] Degenhardt et al. Global prevalence of injecting drug use and sociodemographic characteristics and prevalence of HIV, HBV, and HCV in people who inject drugs: a multistage systematic review. Lancet Glob Health 2017. In Press. www.thelancet.com/pdfs/journals/langlo/PIIS2214-109X(17)30375-3.pdf
[2] World Health Organization (WHO). Global hepatitis report, 2017. Geneva, Switzerland; 2017. http://apps.who.int/iris/bitstream/10665/255016/1/9789241565455-eng.pdf?ua=1
[3] Platt L et al. Needle syringe programmes and opioid substitution therapy for preventing HCV transmission among people who inject drugs: findings from a Cochrane Review and meta-analysis. Addiction. 2017 Sep 11. http://onlinelibrary.wiley.com/doi/10.1111/add.14012/abstract
[4] Hagan H et al. A Systematic Review and Meta-Analysis of Interventions to Prevent Hepatitis C Virus Infection in People Who Inject Drugs. J Infect Dis. 2011 Jul 1; 204(1):74-83. academic.oup.com/jid/article/204/1/74/2192163/A-Systematic-Review-and-Meta-Analysis-of
[5] Martin NK et al. Prioritization of HCV treatment in the direct-acting antiviral era: an economic evaluation. J Hepatol. 2016 Jul; 65(1):17-25. www.journal-of-hepatology.eu/article/S0168-8278(16)00086-6/pdf
[6] Wilson DP et al. The cost-effectiveness of harm reduction. Int J Drug Policy. 2015 Feb; 26 Suppl 1:S5-11. www.ijdp.org/article/S0955-3959(14)00311-9/pdf
[7] World Health Organization (WHO). Global health sector strategy on viral hepatitis 2016-2021. Geneva, Switzerland; 2016 www.who.int/hepatitis/strategy2016-2021/ghss-hep/en/
[8] Larney S et al. Global, regional, and country-level coverage of interventions to prevent and manage HIV and hepatitis C among people who inject drugs: a systematic review. Lancet Glob Health 2017. In Press. www.thelancet.com/pdfs/journals/langlo/PIIS2214-109X(17)30373-X.pdf
[9] Global Commission on Drug Policy. The Negative Impact Of The War On Drugs On Public Health: The Hidden Hepatitis C Epidemic; Geneva, Switzerland; 2013. www.globalcommissionondrugs.org/wp-content/uploads/2016/03/GCDP_HepatitisC_2013_EN.pdf
[10] Wolfe D et al. Treatment and care for injecting drug users with HIV infection: a review of barriers and ways forward. Lancet. 2010 Jul 31; 376(9738):355-66. www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(10)60832-X.pdf
[11] Wood E et al. Vienna declaration: a call for evidence-based drug policies. Lancet. 2010;376 (9738):310–12. www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(10)60958-0.pdf
[12] Csete J et al. Public health and international drug policy. Lancet. 2016 Apr 2; 387(10026):1427-1480. www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(16)00619-X.pdf
[13] Transform. A Quiet Revolution: Drug Decriminalisation Across the Globe. Bristol, United Kingdom; 2016. www.release.org.uk/sites/default/files/pdf/publications/A%20Quiet%20Revolution%20-%20Decriminalisation%20Across%20the%20Globe.pdf
[14] Gagnon F. Synthèse des connaissances : actions novatrices en matière de substances psychoactives « illicites ». Québec : Institut National de Santé Publique du Québec ; 2016 www.inspq.qc.ca/pdf/publications/2133_synthese_connaissances_substances_psychoactives.pdf
[15] Grebely J et al. Elimination of HCV as a public health concern among people who inject drugs by 2030 – What will it take to get there? J Int AIDS Soc. 2017 Jul 28; 20(1):22146. http://onlinelibrary.wiley.com/doi/10.7448/IAS.20.1.22146/epdf
[16] Global Commission on Drug Policy. Advancing Drug Policy Reform: a new approach to decriminalization. Geneva, Switzerland; 2016 www.globalcommissionondrugs.org/wp-content/uploads/2016/11/GCDP-Report-2016-ENGLISH.pdf
[17] Joint United Nations Programme on HIV/AIDS (UNAIDS). Do no harm: health, human rights and people who use. Geneva, Switzerland; 2016. www.unaids.org/sites/default/files/media_asset/donoharm_en.pdf
[18] UN Women. A Gender Perspective on the Impact of Drug Use, the Drug Trade, and Drug Control Regimes. New York, United Nations; 2014. www.hr-dp.org/files/2014/12/02/Gender_and_Drugs_-_UN_Women_Policy_Brief.pdf
[19] United Nations Human Rights Council (UNHRC). Study on the impact of the world drug problem on the enjoyment of human rights, Report of the United Nations High Commissioner for Human Rights. Geneva, Switzerland; 2015. www.unodc.org/documents/ungass2016//Contributions/UN/OHCHR/A_HRC_30_65_E.pdf
[20] World Health Organization (WHO). Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations. Geneva, Switzerland; 2014. apps.who.int/iris/bitstream/10665/128048/1/9789241507431_eng.pdf?ua=1&ua=1
[21] United Nations (UN). Joint United Nations statement on ending discrimination in health care settings, Joint WHO/UN statement. 2017. www.who.int/mediacentre/news/statements/2017/discrimination-in-health-care/en/
[22] United Nations Office on Drugs and Crime (UNODC). Implementing Comprehensive HIV and HCV Programmes with People Who Inject Drugs: Practical Guidance for Collaborative Interventions. Vienna, Austria; 2017. www.inpud.net/sites/default/files/IDUIT%205Apr2017%20for%20web.pdf