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GFO Issue 395



Ira Madan and Anurag Paul*

Article Type:

Article Number: 3

ABSTRACT Harm Reduction Advocacy in Asia is implementing the Global Fund multi-country grant that has provided funding and technical support towards advocacy for the health and human rights of people who use drugs in seven high-priority countries. Program interventions focus on removing policy and legal barriers, community systems strengthening, and gathering and using information for advocacy; but have been threatened by the impact of COVID-19. The authors describe how country partners in India and Nepal have adapted and innovated their outreach and services by utilizing and strengthening community systems and community-led response to build resilience in the face of the crisis.

According to the Joint United Nations Programme for HIV and AIDS (UNAIDS) Global AIDS Update 2020, people who use drugs (PWUD) accounted for 17% of all new HIV infections in 2019 in the Asia Pacific region. People in Asia who inject drugs – around four million in total – are more likely to be living with HIV than any other vulnerable population group in the region, with HIV prevalence at about 13.5%. As part of the Sustainable Development Goals (SDGs) and the 2016 Political Declaration on HIV and AIDS, countries have committed to ending AIDS, eliminating the hepatitis C virus (HCV), and attaining universal health coverage (UHC) by 2030. Harm reduction programming is essential if countries are to achieve these goals.

Harm Reduction Advocacy in Asia grant

Harm Reduction Advocacy in Asia (HRAsia), a Global Fund multi-country grant, has provided funding and technical support towards advocacy for the health and human rights of PWUD in high-priority countries, such as Cambodia, India, Indonesia, Nepal, the Philippines, Thailand, and Vietnam. The grant allocation period was from 2017 to 2020, and the program focused on removing policy and legal barriers, community systems strengthening, and the gathering and use of information for advocacy. A key outcome of the regional grant was an increase in the meaningful engagement of communities of PWUD in advocacy as well as service provision. The Principal Recipient for the grant was the India HIV/AIDS Alliance, and the scale and impact of the grant will be discussed in an upcoming publication due out in April 2021.

The impact of COVID-19 on harm reduction services

The COVID-19 pandemic and governments’ actions to contain it have a profound impact on access to essential health services for vulnerable and marginalized populations worldwide. National lockdowns were imposed throughout most countries in Asia to contain the spread of the coronavirus pandemic. This made the situation increasingly difficult for PWUD who, unable to leave their homes, could not access harm reduction programs.

PWUD are already highly vulnerable to COVID-19 infection due to their existing underlying health issues, compounded by stigma and social marginalization as well as higher economic and social vulnerabilities; they also suffer poor access to housing and health care.

People in treatment or institutional care faced severe problems and barriers to obtaining life-saving medications, such as buprenorphine, methadone, and antiretroviral therapy (ART), and obtaining services from needle-syringe programs.  This has contributed to increased incidences of HCV, HIV and drug overdose. Social distancing and lockdown also decreased the likelihood of administration of naloxone, a medicine used to reverse overdoses, potentially resulting in more fatalities.

In prisons, COVID-19 risks are heightened due to overcrowding, poor ventilation and inadequate health services. The provision of opioid substitution therapy (OST) to PWUD is a proven method to deal with the withdrawal symptoms and cravings that arise due to stopping drug use. However, the available medical services were inadequate to deal with medical complications due to lack of OST access and this increased the cases of severe withdrawals. The available medical services were mostly inaccessible due to strict travel restrictions.

The lockdown also impacted PWUDs’ families, as the majority of them are the daily wage earners but could not earn an income while countries were in strict lockdowns. It increased the trauma suffered by communities and resulted in a lack of opportunities to earn resources to support themselves, their families, and their drug use.

The female sex partners (FSPs) of drug users are one such group that remains unnoticed but is one of the most affected by the pandemic. For other reasons, FSPs become exceedingly vulnerable to the chaos caused by COVID-19 and the resulting imposed restrictions, more so because their burden is not just defined by the pandemic but also by the gender norms in and around their respective societies. They are likely to suffer increased domestic violence; physical and emotional abuse. This impacts adversely on their access to food, nutrition, appropriate medication, and sanitary commodities.

Community resilience in response to COVID-19

In response to the risks and vulnerabilities faced by PWUD, the HRAsia program worked closely with country partners to adapt and innovate their outreach and services by utilizing and strengthening community systems and community-led response in countries to build resilience in the face of the crisis caused by COVID-19.

In India and Nepal, advocacy by HRAsia partners contributed to the provision of OST take-home doses, a policy change that allowed people to continue receiving OST during lockdowns. This resulted from community advocacy with governments to issue directives and the development of emergency guidelines for harm reduction services and community-led service delivery.

In India, the period between identifying the first case of COVID-19 and the national lockdown allowed the PWUD community to advocate at local and national levels to ensure adequate ART and OST stocks. The national and state-level networks supported under the grant went the extra mile to maintain critical health services during the crisis. They put systems in place to deliver the OST drug buprenorphine, clean needles and syringes, and even sanitary products for female drug users.

Networks of PWUD also played an important role during the pandemic. Increased leadership, engagement, and participation from drug user communities in advocating for flexible services, appropriate government responses, and enhanced participation of peers in providing critical harm reduction interventions have all helped ensure service continuity. Upon learning of increasing overdoses and withdrawal linked to lockdown, PWUD communities distributed naloxone within the community and advocated for simplified access to OST. The links made with non-traditional faith leaders, faith-based organizations, and individuals enabled the networks to enlist their support to secure food rations and other essential items for the community. PWUD community members in severe withdrawal obtained relief from their pain due to the medicines distributed by the network members.

In several states in India, HRAsia established a helpline facility for community members to call and share their fears and distress. Trained and experienced community leaders managed the helpline. Those who were in immense trauma due to withdrawal, cravings, and uncertainty were relieved to a great extent due to the counseling and moral support provided through the helpline services.

The state drug user forums prioritized reaching out to the street-based and homeless community members who have limited to no access to welfare measures and health services. They were identified and linked to OST (buprenorphine) services. Looking at the challenges faced by women who use drugs, and particularly those who inject, the forum members initiated follow-up with all PWUDs through telephone contact, in case they required emergency services such as food rations or an immediate response to an overdose.

One of the issues that communities highlighted as a priority need was the provision of needles and syringes for women not on the OST program and currently using drugs whose access was curtailed due to the lockdown-related travel restrictions. The forum members acted as secondary distribution ‘peers’ for needles and syringes, deeming it to be an essential service during these times. However, in many cases, peer educators and outreach workers who provided direct harm reduction services during this time and were required to travel were not considered frontline workers, so personal protective equipment (PPE) was not made available to them.


“Direct investment in the community and strengthening community delivery systems is going to shape the future of the HIV response.”
Prashant Sharma, an Indian activist for the health and rights of people who use drugs.

In addition, in response to the possible arbitrary detention of PWUD by police during the lockdown, the drug user forums were supported to advocate and reach out to law enforcement to prevent any random arrests of community members. Instead, they were offered support to provide healthHIV prevention, and harm reduction services to prevent potential morbidity and mortality.


From national to local responses

Traditionally, the approach for community systems strengthening has been very focused on the national capital and city-based national PWUD network, leaving behind the populations that are not linked to any services provided by the national response. Through the HRAsia program, Alliance India was offered the opportunity to work and shift the focus from big cities to actually reaching out to the hard-to-reach and underserved at the state and district level. The process of community strengthening at the state level and the gains from this have reinforced the need to continue supporting drug users in a decentralized manner. This means that communities working at the grass-root level can mobilize their members and support the creation of an enabling environment to increase access to services and reduce stigma and discrimination.

Conclusion and recommendation

The HRAsia program, funded by Global Fund catalytic Investments between 2017-2020, played a crucial role in augmenting the potential of community-led responses in countries. The project’s investment in community systems strengthening has shown that the gains are higher in linking drug users to the national response and increasing their meaningful participation in service delivery and service access, and can result in bridging the gaps to achieving the 90:90:90 fast track goals for PWUD. Evidence from countries in Asia also shows the impact of investment in community-based and community-led systems and their ability to adapt and address PWUD communities’ needs during the current COVID-19 crisis.

Community-based and community-led organizations have also been at the heart of the harm reduction response during the pandemic, ensuring their communities’ needs are met. Donors and governments should recognize these community responses’ value and provide them with the necessary funding to sustain people-centered services. This will reinforce the importance of access to quality and consistent harm reduction, health and HIV services, and the basic human needs of shelter, food, nutrition, and dignity for any effective public health response.

Ira Madan, Senior Regional Advocacy Officer: Drug Use & Harm Reduction; and Anurag Paul, Communications Associate, are from the India HIV/AIDS Alliance.

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