Reframing Dutch drug policies: a new era for harm reduction.

In this article the authors offer their perspective on the changes in the Dutch harm reduction field. From the 1970s to the 1990s, the Netherlands emerged as a leader in harm reduction services, driven by grassroots movements like the Medisch-sociale Dienst Heroïne Gebruikers (MDHG) (Medisch-sociale Dienst Heroïne Gebruikers (MDHG) translates to Medical-Social Service Heroin Users in English) in Amsterdam and Junkiebond in Rotterdam. These organisations advocated for health-centred policies, initiated needle exchange programmes, and created safe consumption spaces. Their efforts led to significant public health improvements and policy shifts towards harm reduction, reducing HIV and hepatitis rates among people who use drugs. By the 1980s, harm reduction became institutionalised within local health and social care systems, leading to notable declines in drug-related harm and crime. However, from the 2000s, a shift towards security and crime prevention emerged, influenced by socio-political changes. Increased criminal justice measures and budget cuts for harm reduction services strained the system, making it harder to address emerging drug trends and the complex needs of people who use drugs. Despite challenges, there is renewed momentum for reform, particularly at the local level, advocating for the responsible regulation of psychoactive substances. Amsterdam Mayor Femke Halsema's 2024 conference on drug regulation exemplifies this shift, calling for policies that address prohibition failures and centre harm reduction. International bodies like the UN High Commissioner for Human Rights support this approach, emphasising a health and rights-based framework. As the Netherlands navigates these evolving dynamics, there is a pressing need to reinvest in harm reduction infrastructure, ensuring it meets diverse community needs and reaffirms its foundational rights-affirming principles.

A call to create integrated services to better address the needs of migrants who use drugs in Europe.

Each year, thousands of migrants enter the EU. Data on drug use in migrant populations are scarce and inconclusive. However, several risk factors make them particularly vulnerable to engaging in problematic drug use. In this perspective, we summarize the limited information that is available on migrants who use drugs and make a case as to why it is essential to improve access to health and social services, including harm reduction services, for this population. With this aim, we call for the co-creation of integrated services that better address the needs of migrants who use drugs in Europe.

HIV incidence and associated risk factors in female spouses of men who inject drugs in Pakistan.

INTRODUCTION: Female sexual partners of men who inject drugs (MWID) living with HIV are at risk of HIV transmission. HIV prevalence estimates among non-drug using female sex partners of MWID are scarce, with no studies documenting HIV incidence. We investigated HIV prevalence and incidence among female spouses of MWID registered at Nai Zindagi Trust (NZT), Pakistan, between 2012 and 2019. METHODS: NZT registration and service provision data for female spouses who participated in HIV testing and counselling calculated HIV prevalence and incidence using the person years (PY) method. Cox proportional hazards models identified factors associated with incident infection. RESULTS: Overall HIV prevalence among female spouses of MWID was 8.5%. Among 3478 HIV-negative female spouses, 109 incident infections were observed, yielding an incidence rate of 1.5/100PY (95% CI 1.2-1.8). Independent predictors of incident infection were registration in Punjab province (AHR 1.73 95% CI 1.13-2.68, p = 0.012) and 1-5 years of education (AHR 1.89 95% CI 1.22-2.93, p = 0.004). Knowledge of HIV at registration was protective against infection (AHR 0.51, 95% CI 0.26-0.99, p = 0.047), along with a MWID spouse who had initiated antiretroviral therapy (ART) (AHR 0.25, 95% CI 0.16-0.38, p < 0.001), while incident infection was inversely associated with number of children (≥ 5 children AHR 0.44 95% CI 0.22-0.88, p = 0.022). CONCLUSIONS: Additional efforts are needed to reduce HIV transmission among female spouses of MWID, including targeted provision of HIV education and access to HIV screening. Interventions that target MWID are also required, including evidence-based drug treatment and access to ART, including support to maximize adherence. Finally, consideration should be given to making HIV pre-exposure prophylaxis available to female spouses at high risk of HIV transmission, particularly young women and those whose husbands are not receiving, or have difficulty adhering to, ART.

Peer driven or driven peers? A rapid review of peer involvement of people who use drugs in HIV and harm reduction services in low- and middle-income countries.

INTRODUCTION: Peer involvement of people who use drugs within HIV and harm reduction services is widely promoted yet under-utilised. Alongside political and financial barriers is a limited understanding of the roles, impacts, contexts and mechanisms for peer involvement, particularly in low- and middle-income settings. We conducted a rapid review of available literature on this topic. METHODS: Within a community-academic partnership, we used a rapid review approach, framed by realist theory. We used a network search strategy, focused on core journals and reference lists of related reviews. Twenty-nine studies were included. We developed thematic summaries framed by a realist approach of exploring interventions, their mechanisms, outcomes and how they are shaped by contexts. RESULTS: Reported outcomes of peer involvement included reduced HIV incidence and prevalence; increased service access, acceptability and quality; changed risk behaviours; and reduced stigma and discrimination. Mechanisms via which these roles work were trust, personal commitment and empathy, using community knowledge and experience, as well as 'bridge' and 'role model' processes. Contexts of criminalisation, under-resourced health systems, and stigma and discrimination were found to shape these roles, their mechanisms and outcomes. Though contexts and mechanisms are little explored within the literature, we identified a common theme across contexts, mechanisms and outcomes. Peer outreach interventions work through trust, community knowledge and expertise, and 'bridge' mechanisms (M) to counter criminalisation and constraining clinic and service delivery environments (C), contributing towards changed drug-using behaviours, increased access, acceptability and quality of harm reduction services and decreased stigma and discrimination (O). CONCLUSION: Peer involvement in HIV and harm reduction services in low- and middle-income settings is linked to positive health outcomes, shaped by contexts of criminalisation, stigma, and resource scarcity. However, peer involvement is under-theorised, particularly on how contexts shape mechanisms and ultimately outcomes. Efforts to study peer involvement need to develop theory and methods to evaluate the complex mechanisms and contexts that have influence. Finally, there is a need to expand the range of peer roles, to embrace the capacities and expertise of people who use drugs.

Drug use and access to drug dependency services for vulnerable migrants who use drugs in the European Union: Consensus statements and recommendations from civil society experts in Europe.

BACKGROUND: The number of migrants in the European Union (EU) has been growing, including migrants at risk of using drugs. Little information is available on the actual drug use among first-generation migrants who use drugs in the EU, nor on their access to drug dependency services. This study aims to reach consensus among experts in the EU on the current situation regarding vulnerable migrants who use drugs in the EU and to develop a set of actionable recommendations. METHODS: Between April and September 2022, a panel of 57 experts on migration and/or drug use, working in 24 countries, participated in a three-stage Delphi study to develop statements and recommendations about drug use and access to healthcare services for migrants who use drugs in the EU. RESULTS: High levels of agreement were reached on the 20 statements (mean=98.0%) and 15 recommendations (mean=99.7%). The recommendations focus on four main topics; 1) increasing data availability and quality, to inform guidelines; 2) increasing the availability of drug dependency services for migrants, including screening for mental health issues and involving migrants who use drugs in the development of services; 3) eliminating country and service level barriers for accessing these services, as well as providing migrants who use drugs with suitable information, and combating stigma and discrimination; 4) the need for increased collaboration among and within EU countries regarding healthcare for migrants who use drugs, at the policy level as well as the service level, including civil society organisations, peer navigation and multilingual cultural mediators. CONCLUSION: Policy action and increased collaboration are required by the EU as a whole and by individual EU member states, in addition to collaboration among healthcare providers and social welfare services, to increase access to healthcare services for migrants who use drugs.

Adherence to antiretroviral therapy among HIV positive men who inject drugs in Pakistan.

BACKGROUND: People who inject drugs (PWID) living with HIV have poorer adherence to HIV antiretroviral therapy (ART) and elevated mortality compared to other populations. Little is known about factors associated with adherence among PWID in low-and middle-income countries, including in countries where opioid agonist therapy (OAT) is unavailable. We aimed to estimate ART adherence among men who inject drugs (MWID) living with HIV in Pakistan and identify factors independently associated with adherence. METHODS: Nai Zindagi Trust (NZT) provides a range of HIV prevention, testing and treatment services to PWID in Pakistan. This study utilized data from HIV positive MWID who received ART refill/s from public sector ART Centres via NZT's Social Mobilizer Adherence Support Unit between September 2016 and December 2018. Multivariable logistic regression modelled factors independently associated with ART adherence. RESULTS: Among 5,482 HIV positive MWID registered with NZT who had attended the AAU and were supplied with ART refills between September 2016 and December 2018., 55% were adherent to ART. Independent predictors of adherence were being married (AOR 1.38, 95% CI:1.23-1.55, p<0.001) and >5 years of education compared to those with no education (AOR 1.19, 95% CI:1.05-1.35, p = 0.005). MWID living on the street at night had lower adjusted odds of ART adherence (AOR 0.75, 95% CI:0.62-0.91, p = 0.003). CONCLUSIONS: Findings indicate that MWID living with HIV continue to face barriers to ART adherence in Pakistan. Despite considerable evidence supporting the impact of OAT in increasing ART adherence among PWID, OAT remains illegal and inaccessible in Pakistan. Evidence-based interventions, including OAT, are needed to increase adherence and improve clinical outcomes, health equity and survival among PWID living with HIV in Pakistan.