DRAFT. February 2009

Transcription

1 The Islamic Republic of Afghanistan Ministry of Public Health General Directorate of Health Services Controlling of Communicable Diseases National AIDS Control Program DRAFT POLICY ON OPIOID SUBSTITUTION THERAPY February

2 Contents ACRONYMS... 4 EXECUTIVE SUMMARY... 6 Introduction... 6 Drug Use in Afghanistan... 6 Drug Addiction and the Need for Services... 6 Health and Social Problems Associated with Unsafe Injecting... 6 HIV Situation in Afghanistan... 7 International Agreements on the Suppression of Narcotic Drugs and Psychotropic Substances... 7 The Role of Harm Reduction... 7 Opioid Substitution Therapy Health and Social Benefits... 7 Benefits of OST for People Living with HIV... 7 Objections to Opioid Substitution Therapy... 8 Medications Used in Opioid Substitution Therapy... 8 Supportive Legal and Policy Environment for OST Programs in Afghanistan... 8 Principles of this OST Policy... 9 Policy Commitments of the Government of Afghanistan... 9 INTRODUCTION [ENDORSEMENTS BY MINISTRIES] [OVERSIGHT OF OST POLICY IMPLEMENTATION] PRINCIPLES ON WHICH THIS OST POLICY IS BASED A medical response to a public health issue Implementation of OST Programs in Accordance with the Right to Health of All OST will be implemented in accordance with Afghan law and established policy goals Programs will be evidence-based and consistent with international best practice Programs will be consistent with religious and cultural values of Afghan society Availability of OST in community and closed settings Continuity of care DRUG USE IN AFGHANISTAN HIV SITUATION IN AFGHANISTAN OPIATE DEPENDENCE, HIV/AIDS, AND OTHER HEALTH CONDITIONS HEALTH PROBLEMS ASOCIATED WITH INJECTING DRUG USE DRUG USE: STIGMA, DISCRIMINATION, AND SOCIAL ISOLATION WOMEN, DRUG USE, AND DRUG-RELATED HARM RESPONSES TO DRUG USE AND OPIATE ADDICTION International Agreements on the Suppression of Narcotic Drugs and Psychotropic Substances The Role of Harm Reduction RATIONALE FOR IMPLEMENTING OST OST for detoxification and for long-term maintenance treatment Medical evidence for effectiveness of OST OST is the most effective treatment for opiate dependence Cost effectiveness of OST Effectiveness of OST compared to other interventions Objections to implementation of OST MEDICATIONS USED IN OST Methadone Buprenorphine Tincture of Opium OPIOID SUBSTITUTION THERAPY THE BENEFITS FOR DRUG USERS WITH HIV

3 Use of Opioid Substitution Therapy in Detoxification THE LEGAL AND POLICY ENVIRONMENT FOR IMPLEMENTING OPIOID SUBSTITUTION THERAPY IN AFGHANISTAN Afghanistan National Development Strategy Harm Reduction Strategy for Injecting Drug Use and HIV/AIDS Prevention in Afghanistan National Drug Control Strategy Program Operational Plan for the National HIV/AIDS Strategic Plan Counter Narcotics Law National Essential Drugs List Afghanistan s International Commitments INTERNATIONAL EXPERIENCE OST proven effective in clinical trials OPIOID SUBSTITUTION THERAPY: ISLAMIC REPUBLIC OF IRAN Scaling Up Methadone Maintenance Challenges to HIV prevention among injecting drug users in Iran Need for Community Involvement Role of Police Role of Judiciary Making services accessible through drop-in centers OPIOID SUBSTITUTION THERAPY: REPUBLIC OF KYRGYZSTAN From Soviet Narcology to Harm Reduction Control of Methadone and eligibility restrictions Services offered to clients Evaluation process and outcomes Lessons learned: law enforcement and legal reform OST POLICY COMMITMENTS OF THE GOVERNMENT OF AFGHANISTAN Scale-up of OST Quality assurance Procurement of substitution medication OST to be provided free of charge Sustainability of OST programs Available in both community and closed settings Access criteria consistent with international standards Compliance with licensing and approval requirements of Counter Narcotics Law Permission to administer OST Diversion from criminal justice system Memorandum of Understanding Policing Practices and Public Health Inter-Ministerial Cooperation Initial implementation through vertical programs MOPH will work with partners to provide capacity building of personnel The role of peer workers Data Collection BIBLIOGRAPHY Laws and policies: Afghanistan Reports, articles, presentations

4 ACRONYMS AIDS Acquired immune deficiency syndrome ANDS Afghanistan National Development Strategy DOT Directly observed treatment HIV Human immunodeficiency virus MOCN Ministry of Counter Narcotics IDU Injecting drug user MOPH Ministry of Public Health NGO Non-government organization OST Opioid substitution therapy SAARC South Asian Association for Regional Cooperation STI Sexually transmitted infection TB Tuberculosis TOP Tincture of opium UN United Nations UNAIDS Joint United Nations Programme on HIV/AIDS UNODC United Nations Office on Drugs and Crime WHO World Health Organization 4

5 GLOSSARY Buprenorphine: a prescription medication for people dependent on heroin or other opiates that acts by relieving the symptoms of opiate withdrawal. Cirrhosis: a complication of liver diseases characterized by abnormal structure and function of the liver. Infections such as hepatitis C that can lead to cirrhosis do so because they cause injury to and death of liver cells, and the inflammation and repair that is associated with the dying liver cells causes scar tissue to form. Drug demand reduction: policies or programs directed towards reducing the consumer demand for narcotic drugs and psychotropic substances covered by the international drug control conventions. The distribution of these narcotic drugs and psychotropic substances is forbidden by law or limited to medical and pharmaceutical channels. Dependency: physiological need for and use of a habit-forming substance characterized by the development of tolerance, and of well-defined physiological symptoms of withdrawal on cessation of use. Detoxification: to rid the body of an intoxicating or addictive substance. Harm reduction: Harm reduction aims to prevent or reduce negative health consequences associated certain behaviors through the application of good public health principles to relevant laws, policies, and programs. In relation to drug use, a harm reduction approach recognizes that for some drug users, total abstinence is not feasible in the short term, and that interventions apart from detoxification followed by abstinence may be required. Harm reduction interventions include provision of sterile injecting equipment, access to opioid substitution therapy using prescribed medications such as methadone or buprenorphine, and provision of health information, education, and referral to appropriate services. Methadone: a long-acting synthetic opiate medication used in treatment programs for persons dependent on opiates such as heroin. It is administered in either liquid or tablet form to block the effects of illicit opiate use, and to decrease opiate craving. Methadone is an agonist medication, Opiate: a substance, either a medication or an illicit drug, derived from the opium poppy. Opiate drugs are narcotic sedatives that depress activity of the central nervous system, reduce pain, and induce sleep. Long-term use of opiates can cause addiction, and over-use can cause overdose and possibly death. Opioid: a synthetic narcotic that resembles naturally occurring opiates. Opioids bind to or otherwise affect opiate receptor cells in the body. Substitution therapy: the medically supervised treatment of individuals with drug dependency involving administration of a prescribed medicine with similar action to the drug of dependence. Nicotine replacement therapy for tobacco smokers is the most widely used substitution therapy. Substitution programs for illicit drug users primarily target opiate dependant persons. Medicines most commonly prescribed for opiate dependency are opiate agonists such as methadone and buprenorphine. Medicines for opiate substitution therapy are prescribed to treat both detoxification and withdrawal, as well as for longer-term maintenance of abstinence from opiate use, and relapse prevention. 5

6 Tincture of opium (TOP): a preparation of opium in alcohol and water that in pharmaceutical preparation is standardized to contain 1 percent morphine. TOP is regarded as a traditional medicine in some countries. It has been used successfully in substitution therapy programs for opiate-dependent people, although it is less widely used than methadone or buprenorphine. Its low cost compared to methadone and buprenorphine is an added advantage. EXECUTIVE SUMMARY Introduction This national policy on opioid substitution therapy (OST) draws together the provisions of relevant Afghan laws, strategies, policies, and operational plans, as well as medical and scientific evidence demonstrating the effectiveness of OST in reducing demand for illicit opiate drugs, and reducing the potential harms associated with illicit opiate use. The Government of Afghanistan is committed to policies and programs which reduce the supply of and demand for illicit drugs, and which reduce the potential harms associated with illicit drug use. These programs include of opioid substitution therapy (OST). The Government of Afghanistan makes this commitment in order to protect the health and safety of all Afghan people. Drug Use in Afghanistan The National Drug Survey of 2005 estimated there were 200,000 opiate users in Afghanistan. Including 50,000 heroin users, of whom around 15 percent (7,500) inject their drugs. These figures are likely to have increased since the estimates were made. Needle sharing has been found to be common, and drug demand reduction workers believe that rates of drug injecting are increasing. It is likely that the number of female drug users in Afghanistan is underestimated, and that the number of female drug users is increasing and will continue to increase 1. Drug Addiction and the Need for Services International scientific evidence demonstrates that drug addiction is a treatable condition, and effective treatment interventions are available. Research also demonstrates that drug addiction treatment programmes are highly effective in reducing crime and other problems associated with illicit drug dependence. The most effective treatment intervention for heroin addiction, which is the most common addiction in Afghanistan, is the use of opiate substitution therapies such as methadone and buprenorphine. The use and effectiveness of these medicines has been scientifically studied in many countries and over several decades, and their success is well documented. The adoption and implementation of policies and programs that reduce illicit drug use and the negative social and health consequences of illicit drug use through drug treatment programs such as OST are urgently needed. Health and Social Problems Associated with Unsafe Injecting A range of documented health problems can result from the practice of unsafe injection of illicit drugs. The extent of potential harm confirms the humane and essential nature of harm reduction interventions. The World Health Organization has noted that health problems which commonly affect injecting drug users include infection with blood-borne viruses, HIV, hepatitis B, and hepatitis C, that may lead to serious liver damage and other life-threatening conditions. When drug use is coupled with being HIV positive, drug users often face the double stigma of drug use and HIV. 2 Drug users often experience stigma and discrimination when they attend medical facilities, which can make them reluctant to access medical and related services. 1 Ministry of Counter Narcotics. National Drug Control Strategy 2005, at p WHO. HIV/AIDS Care and Treatment for Injecting Drug Users in Asia: A Guide to Essential Practice,

7 HIV Situation in Afghanistan The HIV epidemic in Afghanistan began among IDUs, with measured HIV prevalence of 3 percent among IDUs in Kabul and 3.1 percent in Herat in Experience throughout Asia and other regions of the world shows that increasing injection drug use and accompanying high-risk behavior can lead to explosive HIV epidemics among injecting drug users, which could subsequently spill over into the general population. International Agreements on the Suppression of Narcotic Drugs and Psychotropic Substances The United Nations Convention Against Illicit Traffic in Narcotic Drugs and Psychotropic Substances and earlier agreements are consistent with implementation of OST programs. The Role of Harm Reduction A harm reduction approach, including the provision of needle and syringe programs and opioid substitution therapy, is endorsed and promoted in numerous best practice documents and guidelines from multilateral agencies such as the World Health Organization (WHO), the Joint United Nation Programme on AIDS (UNAIDS), and the United Nations Office on Drugs and Crime (UNODC). In 2007 UNAIDS noted that harm reduction measures such as access to sterile injection equipment, drug dependence treatment such as methadone and buprenorphine, [and] community-based outreach, are among the most effective and cost-effective measures for preventing HIV epidemics among injecting drug users. Adequate coverage of the full range of harm reduction measures, particularly sterile needle and syringe access and drug substitution treatment, should be promoted. Opioid Substitution Therapy Health and Social Benefits Opioid substitution therapy is the most effective treatment for opiate dependency. Evidence from different drug treatment contexts and settings, has been observed and collected over more than twenty years 4. Randomized control trials, studies, reports and peer-reviewed publications have all shown that OST results in reduced consumption of illicit drugs; reduction in chaotic drug dependency; reduction in most of the drug related crimes to which people resort to pay for illicit drugs; reduction in risk taking behaviors such as sharing of needles/syringes; reduction in the risk of transmission of HIV and other blood borne infections such as hepatitis B and C; increased retention in treatment programs for opiate dependency; improved overall health of patients in treatment; improvement in social relations with family and community; and improved ability to engage in economic activity. In addition, patients in substitution treatment-based programs are more likely to stay in treatment than those in detoxification or drug-free programs. Clinics administering substitution treatment have better outcomes than those that promote only abstinence. Benefits of OST for People Living with HIV A review of research has identified a range of benefits from opioid substitution therapy for people living with HIV. 5 Successful drug dependence management will improve outcomes in terms of improved CD4 counts, survival, and adherence to anti-retroviral therapy. 3 United Nations Conference for the Adoption of a Convention against Illicit Traffic in Narcotic Drugs and Psychotropic Substances, Vienna, 25 November-20 December Methadone maintenance treatment for opiate dependence: A review. British Medical Journal, 309, ; Ward J, Mattick RP and Hall W (1998) Methadone Maintenance Treatment and other Opioid Replacement Therapies. Amsterdam: Harwood. 5 WHO. HIV/AIDS Care and Treatment for Injecting Drug Users in Asia: A Guide to Essential Practice

8 Objections to Opioid Substitution Therapy Objections to OST may be based on moral or religious views that oppose the replacement of heroin dependence, for example, with dependence on another substance. However, a drug user in substitution treatment has a better chance of rehabilitation, access to medical care and effective psychotherapy (where it is available), as well as a decreased risk of contracting or spreading HIV, Hepatitis C, and other bloodborne infections. Treatment for drug dependency is consistent with current laws and policies in Afghanistan, and can be implemented in a way which is consistent with the values of an Islamic Republic, as the experience of Iran demonstrates. There are likely to be particular objections by some families, political groups, and religious leaders, due to the social and cultural factors affecting the position of women in Afghan society. Reasons why OST should be made available to women, and ways in which to overcome barriers to women s access, are considered in more detail in the section below on Women, Drug Use, and Drug-Related Harm. Medications Used in Opioid Substitution Therapy The two main medicines used in OST are methadone and buprenorphine. Tincture of opium (TOP) has also been used successfully in OST programs, although it is less widely used. Methadone is a long acting synthetic opiate, and is the most commonly used medication world-wide in OST. Methadone programs have been introduced, and in many cases scaled up, in India, Iran, China, and a number of other countries in Asia. The introduction of buprenorphine has increased the number of medications available to treat opiate dependence. Empirical evidence collected over 20 years has provided strong support for buprenorphine as an effective treatment for opiate dependence. It is typically therapeutically equivalent to methadone, except in certain patients requiring higher doses of methadone 6. Although methadone is the principal pharmacotherapy utilized in the treatment of opiate dependence, in some parts of the world its cost is a barrier to its widespread use. An alternative is tincture of opium (TOP), which is used in some Asian countries for the management of opiate withdrawal and, less commonly, as a maintenance treatment 7. TOP is a preparation of opium in alcohol and water that in pharmaceutical preparation is standardized to contain 1 percent morphine. TOP is a traditional medicine in some countries, and so is culturally acceptable. Its low cost is an added advantage. Supportive Legal and Policy Environment for OST Programs in Afghanistan The Government of Afghanistan adopts this policy on opioid substitution therapy as one component of the policy and program framework for economic and social development in the Islamic Republic of Afghanistan. The key elements of that framework as they relate to development, counter narcotics measures, health promotion, access to medical services, and disease prevention, are set out in the main text of this policy, and are summarized below: OST, a medical intervention with proven benefits for individual and public health, is consistent with the provisions of the Constitution of Afghanistan obliging the State to create the conditions for a prosperous and progressive society based on social justice, protection of human dignity, and protection of human rights. This includes the right to health of all of Afghan citizens. The Constitution provides that the State is obliged to provide preventive health care and medical treatment, and proper health facilities to all citizens of Afghanistan. 8 Women are entitled to equal access to health care services as men, and drug users are entitled to access appropriate health care 6 Maria Patrizia Carrieri, Leslie Amass, Gregory M. Lucas, David Vlahov, Alex Wodak, and George E. Woody, Buprenorphine Use: The International Experience, Clinical Infectious Diseases 2006; 43:S WHO/UNODC/UNAIDS. Substitution maintenance therapy in the management of opioid dependence and HIV/AIDS prevention: position paper Available at (last accessed 27 March 2008). 8 See Article Fifty-Two. 8

9 services: the Constitution prohibits any kind of privilege or discrimination between the citizens of Afghanistan. 9 The development and implementation of this OST policy is consistent with the Afghanistan National Development Strategy. The Health and Nutrition Sector Strategy of the ANDS commits the Government of Afghanistan to develop relevant legal and regulatory mechanisms that govern health related work in the public and private sectors. In particular, the Ministry of Public Health will develop and enforce relevant legal and regulatory instruments that govern health and health related work to safeguard the public and ensure service quality; Drug substitution therapy is recommended by the Harm Reduction Strategy for Injecting Drug Use and HIV/AIDS Prevention in Afghanistan (2005) and the National Drug Control Strategy 2006; The Afghanistan National Strategic Framework for HIV/AIDS ( ) endorses access to drug treatment services including substitution therapy, and the Program Operational Plan for the National HIV/AIDS Strategic Plan proposes a range of harm reduction services for injecting drug users, including opioid substitution therapy; The Counter Narcotics Law 2005 allows for the medical use of methadone, buprenorphine, and tincture of opium, subject to the licensing requirements in the legislation; The Afghanistan National Essential Drugs List includes buprenorphine, methadone, and tincture of opium; The Afghanistan Opioid Substitution Therapy Protocol developed by the Ministry of Public Health in collaboration with government and non-government stakeholders provides detailed operational guidance on the implementation of OST programs. maintenance therapy for 200 clients, at a cost of US$0.08 per client per day. Monitoring and evaluation show positive results for clients and their families on a range of medical and social indicators. Principles of this OST Policy OST is a medical response to a public health issue; OST will be implemented in accordance with Afghan law and established policy goals; OST programs will be evidence-based and consistent with international best practice; OST programs will be consistent with religious and cultural values of the Islamic Republic of Afghanistan; This policy provides for equitable and non-discriminatory entrance into OST and other drug treatment programs for those in need; OST will be made available in both community and closed (prison) settings; Continuity of care will be ensured for those who transition between community and closed settings. Policy Commitments of the Government of Afghanistan OST programs will be implemented promptly and scaled up as soon as human and financial resources permit; Quality assurance through monitoring by the Ministries of Public Health and Counter Narcotics with the Counter Narcotics Law, this Opioid Substitution Therapy Policy, and the Afghanistan Opioid Substitution Therapy Protocol; Procurement procedures shall ensure that medications used in OST are procured at the lowest possible price while ensuring that medications comply with World Health Organization quality standards; OST will be provided free of charge, in order to ensure that cost of treatment does not operate as a barrier to access; 9 Article Twenty-Two. 9

10 Eligibility criteria for access to OST programs will be consistent with internationally accepted best practice standards; OST will be provided in both community and closed (prison) settings; The Government of Afghanistan recognizes the importance of multidisciplinary teams and the need for flexibility in the allocation of tasks involved in OST implementation, and supports flexibility in the administration of OST programs, while adhering at the same time to the provisions of the Counter Narcotics Law; In accordance with the Counter Narcotics Law and the provisions of this policy, drug addicted persons as referred to in Article 27 of the Counter Narcotics Law shall be dealt with to the extent possible on the basis of their need for medical and other support services, rather than through the criminal justice system; OST programs will comply with the requirements of the Counter Narcotics Law and Afghanistan s obligations under international agreements for the suppression and control of narcotic drugs and psychotropic substances; Ministries of the Government of Afghanistan will collaborate on the implementation, oversight, and evaluation of this policy, including but not limited to the Ministries of Public Health, Counter Narcotics, Interior, Education, Higher Education, Finance, and Religious Affairs (Hajj and Awqaf); While the long-term goal is to integrate OST into general health services, this is not practical in the initial stages of implementation. The need to ensure appropriate technical capacity of all those involved in implementing OST programs, and the stigma and discrimination currently faced by illicit drug users, require the introduction of OST through specialized vertical programs; The Ministry of Public Health will take the lead in providing capacity-building programs, in collaboration with Government and non-government partners, to ensure the necessary skills for implementation and oversight of OST programs in Afghanistan; The Government of Afghanistan recognizes and supports the contribution of peer workers to effective harm reduction and health promotion programs, and supports the mobilization for training and employment of peer workers in OST and other harm reduction programs; Drug use and HIV surveillance systems will be improved through the mobilization of new resources and technical inputs, in order to provide an improved evidence base for further development of OST and other harm reduction programs in Afghanistan; As of 2009, current proposed OST programs are to be funded by donor organizations. In the short-tomedium term donors must commit continued funding for these programs, as continuity of care for those receiving OST is essential. In the longer term, the Government of Afghanistan is committed to identifying and allocating its own resources to ensure the ongoing sustainability of OST programs. 10

11 INTRODUCTION We are an Islamic nation and our religion teaches us compassion for those afflicted with disease and difficulty. Our Constitution aims for civil society free of oppression, atrocity, discrimination, and violence and based on the rule of law, social justice, protection of human rights and dignity, ensuring the fundamental rights and freedoms of the people. 10 While some people consider harm reduction initiatives as a form of drug promotion, they actually constitute realistic methods of protecting individual and public health Harm reduction is neither pro-drugs nor anti-drugs, it is anti-harm. 11 This national policy on opioid substitution therapy (OST) draws together the provisions of relevant Afghan laws, strategies, policies, and operational plans, as well as medical and scientific evidence demonstrating the effectiveness of OST in reducing demand for illicit opiate drugs, and reducing the potential harms associated with illicit opiate use. The Government of Afghanistan is committed to policies and programs which reduce the supply of and demand for illicit drugs, and which reduce the potential harms associated with illicit drug use, including implementation of opioid substitution therapy (OST). The Government of Afghanistan makes this commitment in order to protect the health and safety of all Afghan people. [ENDORSEMENTS BY MINISTRIES] [OVERSIGHT OF OST POLICY IMPLEMENTATION] PRINCIPLES ON WHICH THIS OST POLICY IS BASED A medical response to a public health issue This policy recognizes that opiate dependency is a chronic relapsing medical condition. It affects not just drug using individuals, but the families and communities in which opiate dependent people live. Death and illness caused by drug overdose, infection with blood-borne viruses such as HIV and hepatitis C through the sharing of injecting equipment, economic hardship resulting from loss of employment, and increased levels of criminal behavior, are some of the personal and social harms which can be substantially reduced through effective treatment of opiate dependency. Effective responses to opiate dependence require a range of treatment options to be made available and affordable, in order to achieve appropriate coverage in order to achieve optimum personal and public health outcomes. Opioid substitution therapy is one of the means by which opiate dependency may be successfully treated, and is the most effective method of preventing HIV infection in people who are opiate dependent. The purpose 10 Draft Afghanistan National HIV/AIDS Code of Ethics. HIV and AIDS Coordinating Committee, National AIDS Control Program, Director General of Preventive Medicine and Primary Health Care, June Harm Reduction Strategy for IDU (Injecting Drug Users) and HIV/AIDS Prevention in Afghanistan, HIV/AIDS Unit, Ministry of Public Health, and Demand Reduction Section, Ministry of Counter Narcotics, May 2005, quoting Alex Wodak, 15 th International Conference on the Reduction of Drug Related Harm, Melbourne, Australia, April,

12 of OST medications is the long-term maintenance treatment of narcotic addiction. The main aim is to reduce the personal and social harms that result from illicit drug use and to improve the social functioning of opiate dependent people. While medications used in opioid substitution therapy may have some psychoactive properties, they should be administered by qualified and authorized health care professionals such as physicians and nurses. Implementation of OST Programs in Accordance with the Right to Health of All Afghanistan ratified the International Covenant on Economic, Social, and Cultural Rights (ICESCR) in The Covenant provides that State Parties to the Covenant ensure the equal rights of men and women to all economic, social, and cultural rights set forth in the Covenant. Article 12 recognizes the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, and the obligation of States to take steps to achieve the full realization of this right. The right to health applies to all members of society, including drug users, and the Government of Afghanistan shall implement treatment programs for drug dependency consistent with the ICESCR and the Constitution of Afghanistan. OST will be implemented in accordance with Afghan law and established policy goals Afghanistan s existing legal and policy framework for the prevention of illicit drug use, and the reduction of drug related harm, provides for the administration of opioid substitution therapy programs. This policy on implementation of OST is consistent with current laws and policies as cited above. In particular, this policy is framed in accordance with the provisions of the Counter Narcotics Law, the National Drug Control Strategy, the Afghanistan National Strategic Framework for HIV/AIDS ( ) and the Program Operation Plan which guides implementation of the National Strategic Framework. Implementation of OST is also consistent with the multilateral conventions regarding suppression of the trafficking and use of illicit drugs to which Afghanistan is a party. Programs will be evidence-based and consistent with international best practice There is a wealth of evidence from medical research on opioid substitution therapy, as implemented in numerous countries, which demonstrates its effectiveness and cost-effectiveness. This policy provides only for those interventions that have been proven effective in reducing opiate dependency, and the harms associated with illicit drug use. Programs will be consistent with religious and cultural values of Afghan society The Constitution of Afghanistan provides that Afghanistan is an Islamic Republic 12, and that no law can be contrary to the sacred religion of Islam and the values of the Constitution 13. While the effect of these provisions is to prohibit the ingestion of psychoactive substances, the use of medications for opioid substitution therapy are permitted pursuant to the Counter Narcotics Law and the numerous policies of the Government of Afghanistan cited above. Other Islamic Republics in the region, such as the Islamic Republic of Iran, have demonstrated how programs which reduce the demand for illicit drugs and the harms associated with illicit drug use can be implemented in a way which is consistent with a nation s religious and cultural values. In Afghanistan examples already exist of the valuable contribution which religious and community leaders have made to raising awareness regarding illicit drug use, HIV prevention, and the reduction of other drug-related harms. This policy will build on the work to date by religious and community leaders, in collaboration with government and non-government organizations, to enhance understanding of and support for programs such as OST which benefit individuals, families, and communities. 12 Chapter 1, Article Chapter 1, Article 3. 12

13 Confidentiality of Access In accordance with medical ethics, information concerning a person s drug use or treatment for drug dependency shall be kept confidential by all those involved in the provision of OST services. Information shall not be disclosed without the express consent of the person to whom it relates, and only after they have received appropriate counseling as to the possible social and legal consequences of disclosure. In particular, information concerning a person s illicit drug use or access to drug dependence treatment collected in connection with the provision of such treatment shall not be used as evidence of criminal activity by the person, or for the purposes of initiating or supporting criminal proceedings against a person receiving treatment. Information about a person s illicit drug use or access to drug dependency treatment may only be disclosed without that person s permission where the person is incapable by reason of their age or mental capacity of giving informed consent to the disclosure of such information, and the disclosure is in the best interests of the person taking into account all the circumstances of the case. This exception to the principle of confidentiality shall not apply to disclosure of information for the purposes of initiating or supporting criminal proceedings against the person to whom the information relates. Availability of OST in community and closed settings Globally, prison populations are at high risk for HIV infection. Drug use is illegal in Afghanistan and drug users may be imprisoned, often with the result that they lack access to sterile injecting equipment. As a result, injecting drug users who have been imprisoned are at risk of becoming infected with HIV. There is clear evidence that OST in particular the use of methadone maintenance therapy, is feasible in a wide range of prison settings. 14 Prison-based OST programs appear to be effective in reducing the frequency of injecting drug use and sharing of injecting equipment, if a sufficient dosage is administered and treatment is provided for sufficient length of time. The risk of transmission of HIV and other blood borne viruses will also decrease. In some cases, it may be appropriate to allow opiate dependent prisoners to be treated in drug dependence treatment centers outside of prisons, if OST treatment is not available in a prison. 15 In particular the use of methadone maintenance therapy, is feasible in a wide range of prison settings. 16 Prison-based OST programs appear to be effective in reducing the frequency of injecting drug use and sharing of injecting equipment, if a sufficient dosage is administered and treatment is provided for sufficient length of time. The risk of transmission of HIV and other blood borne viruses will also decrease. In some cases, it may be appropriate to allow opiate dependent prisoners to be treated in drug dependence treatment centers outside of prisons, if OST treatment is not available in a prison. 17 The Government of Afghanistan is committed to the provision of opioid substitution therapy, where clinically indicated, in both community clinics, and in closed settings such as prisons. Continuity of care As noted above, opiate dependence is a chronic relapsing condition, and opioid substitution therapy may need to be provided for extended periods in order to achieve optimum health outcomes. For these reasons it is important that continuity of OST can be assured once a person commences treatment. The Government of Afghanistan is committed to ensuring that opiate-dependent people who commence OST 14 Who, UNODC, and UNAIDS. Evidence for Action Technical Papers. Interventions to Reduce HIV/AIDS in Prisons Drug Dependence Treatments. Geneva, United Nations Office on Drugs and Crime. Drug Abuse Among Prison Populations. accessed 21 May Who, UNODC, and UNAIDS. Evidence for Action Technical Papers. Interventions to Reduce HIV/AIDS in Prisons Drug Dependence Treatments. Geneva, United Nations Office on Drugs and Crime. Drug Abuse Among Prison Populations. accessed 21 May

14 are able to continue with treatment for as long as it is clinically indicated, including through any transition between community and prison. Coordination between prison and community-based OST programs is essential if the benefits of OST are not to be undermined through interruption or cessation of treatment. DRUG USE IN AFGHANISTAN Available data suggest that drug use is widespread and increasing. The rate at which drug use is increasing in Afghanistan, particularly in the cities, is estimated to be one of the highest in the world. The National Drug Survey of 2005 estimated there were 200,000 opiate users in Afghanistan. Including 50,000 heroin users, of whom around 15 percent (7,500) inject their drugs. These figures are likely to have increased since the estimates were made. There are strong indications that estimates of the number of drug users are lower than the true figures, particularly the estimates of women and child drug users, since Afghans are likely for cultural reasons to underestimate the level of drug use in their communities. Needle sharing has been found to be common, and drug demand reduction workers believe that rates of drug injecting are increasing. There is a higher rate of drug use among returned refugees than among other members of Afghan society. Approximately two percent of Afghans have spent time in Iran as refugees, yet returnees account for nearly one third of heroin users and almost the same proportion of opium users in Afghanistan. Current drug treatment services and facilities cannot meet demand. At the time of the National Drug Use Survey, there were no more than 100 places available in residential treatment facilities in the entire country, and many areas identified as having a large number of drug users had no treatment facilities at all. Even where programs operate at maximum efficiency, they were able to treat less than 0.25 percent of drug users in Afghanistan each year. 18 International scientific evidence demonstrates that drug addiction is a treatable condition, and effective treatment interventions are available. Research also demonstrates that drug addiction treatment programmes are highly effective in reducing crime and other problems associated with illicit drug dependence. The most effective treatment intervention for heroin addiction, which is the most common addiction in Afghanistan, is the use of opiate substitution therapies such as methadone and buprenorphine. The use and effectiveness of these medicines has been scientifically studied in many countries and over several decades, and their success is well documented. The adoption and implementation of policies and programs that reduce illicit drug use and the negative social and health consequences of illicit drug use are therefore urgently needed. Care must be taken to ensure that supply and demand reduction initiatives do not compromise public health programmes addressing the needs of people who use illicit drugs, as this defeats the broader objective of protecting the public health of the nation. Where there is a lack of coordination between public health and law enforcement agencies, public health policies and programs addressing issues such as HIV transmission, and reduction of drug-related harm, may be inadvertently compromised by law enforcement activities. HIV SITUATION IN AFGHANISTAN Social drivers of the HIV epidemic in Afghanistan include violent conflict, high numbers of displaced individuals and mobile populations, lack of access to knowledge about HIV, gender discrimination, and policy barriers. The high prevalence of STIs and TB also contribute to the spread and impact of the HIV 18 United Nations Office on Drugs and Crime, and Ministry of Counter Narcotics. Afghanistan Drug Use Survey

15 epidemic. Key risk behaviors include sharing needles and syringes. 19. The HIV epidemic in Afghanistan began among IDUs, with measured HIV prevalence of 3 percent among IDUs in Kabul and 3.1 percent in Herat in ,21. Experience throughout Asia and other regions of the world shows that increasing injection drug use and accompanying high-risk behavior can lead to explosive HIV epidemics among injecting drug users and could subsequently spill over into the general population 22,23. The macroeconomic implications of generalized HIV/AIDS epidemics are numerous and complex. Within a generalized epidemic scenario, AIDS disproportionately affects people aged 15-49, who form the most economically productive segment of the population. This can lead to: reductions in labor force numbers and productivity; reductions in the numbers of workers relative to the total population; increases in wages and other costs resulting from shrinking labor force numbers; lower public revenues, and reduced national savings (private and public); and increased spending on health care and social welfare, which can reduce national savings, investment, and growth 24. Within the context of constrained budgets and public spending choices, the costs of relative inaction must be therefore weighed against the cost-benefit profiles of specific policy interventions. HIV has dramatically increased the potential adverse consequences of injecting illicit drugs. For users of opiates and some other drugs, injecting is considerably more cost-effective than other routes of administration, and provides a more intense drug effect at comparable levels of drug purity. These factors raise concerns that many non-injectors may over time transition to injecting. Preventing the transition from non-injecting to injecting drug use, and encouraging cessation of injecting in favor of noninjecting practices such as substitution therapy, are therefore important measures for reducing the transmission of HIV and other blood borne pathogens by a number of authorities. 25, 26, 27, 28, 29 Prisons may function as reservoirs for HIV transmission in Afghanistan, where prisoners often have limited access to services and where injecting drug use may be common. Data collected from Herat 19 National AIDS Control Program, Johns Hopkins University, and the Indian Institute of Health Management Research. A Desk Review of HIV in Afghanistan. August, Todd CS et al. Mapping and Situation Assessment of High Risk Key Populations in Three Cities of Afghanistan Todd CS. Seroprevalence and behavioral correlates of HIV, Syphilis, and Hepatitis B and C among High Risk Groups in three Afghan Cities Bokhari A et al. HIV risk in Karachi and Lahore, Pakistan: an emerging epidemic in injecting and commercial sex networks. Int.J.STD AIDS 2007 Jul;18(7): Altaf A et al. High risk behaviors of injection drug users registered with harm reduction programme in Karachi, Pakistan. Harm Reduct J Feb 10: Adapted from Sharp S. Modeling the Macroeconomic Implications of a Generalized AIDS Epidemic. Department of Economics, University of Colorado, May 2002, Boulder. Shombi Sharp is the Assistant Resident Representative, UNDP Russian Federation, responsible for Governance and HIV/AIDS programming. A copy of the full paper is available upon request to shombi.sharp@undp.org. 25 Neaigus A., Miller M., Friedman S. R., Hagen D. L., Sifaneck S. J., Ildefonso G. et al. Potential risk factors for the transition to injecting among non-injecting heroin users: a comparison of former injectors and never injectors. Addiction 2001; 96: Des Jarlais D. C., Casriel C., Friedman S. R., Rosenblum A. AIDS and the transition to illicit drug injection: results of a randomized trial prevention program. Br J Addict 1992; 87: Southwell M. Transitions to and from injection. In: Pates R., McBride A., Arnold K., editors. Injecting Illicit Drugs. Oxford: Blackwell Publishing; 2005, p Hunt N., Griffiths P., Southwell M., Stillwell G., Strang J. Preventing and curtailing injecting drug use: a review of opportunities for developing route transition interventions. Drug Alcohol Rev 1999; 18: Wodak A. Injecting nation: achieving control of hepatitis C in Australia. Drug Alcohol Rev 1997; 16:

16 prison in 2008 found 11 percent of injecting drug users to be HIV-positive. 30 A 2007 survey of injecting drug users in Kabul found that 17 percent reported having injected drugs in prison. The same study found that IDUs who injected in prison were five times more likely to be HIV-infected than those who had never injected in prison. 31 OPIATE DEPENDENCE, HIV/AIDS, AND OTHER HEALTH CONDITIONS Injecting drug use is responsible for an increasing proportion of new HIV infections in many parts of the world, including countries in Eastern Europe, South America, and east and Southeast Asia 32. Globally between 5 and 10 percent of HIV infections result from injecting drug use. In some countries in Asia and Eastern Europe, over 70 percent of HIV infections are attributed to injecting drug use, with opiates being the most commonly injected drugs in these regions. Injecting drug use is also the dominant mode of transmission of the hepatitis C virus (HCV). Between percent of HCV infections are chronic, and of these, between 7-15 percent cause cirrhosis of the liver, with some cases progressing to liver cancer. Longitudinal studies suggest 2-3% of people with opiate dependence die each year. The mortality rate for heroin users is 6-20 times higher than those in the general population of the same age and gender. THE NATURE OF OPIATE ADDICTION The American Psychiatric Association (APA; 2000) and World Health Organization (WHO; 1999) define substance addiction as a chronic, tenacious pattern of substance use and related problems: a complex health condition that often requires long-term treatment and care. 2. Opiate addiction is a medical diagnosis characterized by an individual's inability to stop using opiates even when objectively in his or her best interest to do so. Key elements of opiate dependency include: a strong desire or sense of compulsion to take opiates; difficulties in controlling drug-taking behavior; a physiological withdrawal state when drug use is stopped or reduced; evidence of tolerance (increased doses are required to achieve same effect); progressive neglect of alternative interests because of drug use; persisting with drug use despite clear evidence of overtly harmful consequences, such as harm to the liver, depressive mood states or impairment of cognitive functioning. 3. When associated with needle sharing, opiate addiction is often associated with explosive outbreaks of HIV and other blood-borne infections such as viral hepatitis among IDUs. 4. Opiate addiction is defined as a chronic relapsing condition by the Diagnostic and Statistical Manual of Mental Disorders (DSM), which is published by the American Psychiatric Association and provides diagnostic criteria for mental disorders. DSM is used around the world, by clinicians, researchers, psychiatric drug regulation agencies, health insurance companies, 30 The World Ban k. Afghanistan HIV/AIDS Prevention Project Implementation Support Mission (June 1-9, 2008), Aide Memoire. 31 Todd CS et al. HIV, hepatitis C, and hepatitis B infections and associated risk behaviors in injecting drug users, Kabul, Afghanistan. Ererg.Inf.Dis Sep; 13(9): B. Mathers, L. Degenhardt, B. Phillips, L. Wiessing, M. Hickman, S. Strathdee, A. Wodak, S. Panda, M. Tyndall, A. Toufik, Global epidemiology of injecting drug use and HIV among people who inject drugs: a systematic review. The Lancet, Volume 372, Issue 9651, Pages WHO/UNAIDS/UNODC. Position Paper: Substitution maintenance therapy in the management of opioid dependence and HIV/AIDS prevention. Geneva, World Health Organization,

17 pharmaceutical companies and policy makers. 5. Opiate addiction is a health condition that has social, psychological, and biological determinants and consequences. It does not indicate a weakness of character or will. 6. Opiate addiction is rarely cured by detoxification alone. While detoxification is an important prelude to drug treatment, it does not itself constitute treatment since it merely addresses the physical adaptation to a drug when dependence develops. HEALTH PROBLEMS ASOCIATED WITH INJECTING DRUG USE A range of documented health problems can result from the practice of unsafe injection of illicit drugs. The extent of potential harm confirms the humane and essential nature of harm reduction interventions. The World Health Organization has noted the following health problems which commonly affect injecting drug users: Infection with blood-borne viruses, HIV, hepatitis B, and hepatitis C, that may lead to serious liver damage including cirrhosis and hepatocellular carcinoma (cancer of the liver); Injection-related bacterial infections, including septicemia, bacterial endocarditis, and osteomyelitis; Local soft tissue and vascular injury, including skin abscesses and thrombophlebitis; Tuberculosis (both pulmonary and extra-pulmonary); Psychiatric co-morbidity including depression; Overdose; and Poly-substance dependence, including alcohol. People who are opiate dependent may suffer from mental health, occupational, health, or social problems that make their addictive disorders much more difficult to treat. Problems associated with an individual's drug addiction can vary significantly. DRUG USE: STIGMA, DISCRIMINATION, AND SOCIAL ISOLATION Drug use is a prevailing source of stigma and discrimination. People who use illicit drugs face daily harassment, discrimination, and abuse often living these experiences in isolation. When drug use is coupled with being HIV positive, drug users often face the double stigma of drug use and HIV. 34 Drug users often experience stigma and discrimination when they attend medical facilities, which can make them reluctant to access medical and related services. When drug use is an illegal and covert activity, there is no legal protection against discrimination for drug users, even where a legal system provides protection against and remedies for other forms of discrimination. Traditional approaches to drug control in many countries include punitive mandatory minimum drug sentences, physical and psychological violence by police, forced drug rehabilitation in quasi-prison settings whose programs lack therapeutic rationale or benefit, compulsory HIV testing, and the denial of health care services, employment, and social benefits. Fear of discrimination and arrest by police may discourage HIV-positive drug users from seeking treatment or revealing their drug use to an HIV/AIDS health care provider, leading to a greater degree of misdiagnosis or under-diagnosis of health problems, or of undetected pharmacological interactions between HIV treatment regimens and illicit 34 WHO. HIV/AIDS Care and Treatment for Injecting Drug Users in Asia: A Guide to Essential Practice,

18 drugs. Many drug users live on the economic and social fringes of society, and are rejected by their families. People who are most vulnerable to the impact of poverty, racial discrimination, poor health, and lack of education and employment, may also be those who are most vulnerable to drug use. Social problems and discrimination faced by people who are drug dependent and/or HIV positive may in turn exacerbate drug use. 35 It is therefore necessary to educate both the general public and health care workers, as well as provide training and capacity building for those involved in service provision to drug users, in order to reduce the stigma and discrimination associated with drug use, and improve access to treatment, care, and support services. WOMEN, DRUG USE, AND DRUG-RELATED HARM It is likely that the number of female drug users in Afghanistan is underestimated, and that the number of female drug users is increasing and will continue to increase 36. While the United Nations Office on Drugs and Crime estimates that about 80 percent of Afghan drug users are male, underreporting of the number of female drug users may result from the additional stigma placed on women who use drugs illicitly. Though there are no comprehensive survey data measuring injecting drug use among women, staff of drug treatment centers working with IDUs report that injecting drug use among women does occur. 37 International experience suggests that women are generally under-represented as users of drug-related services. Those who do access services benefit from a very narrow range of services which are not at all gender specific and do not recognize the particular needs of women. Women IDUs are more likely than men IDUs to have a sexual partner who is also an injecting drug user. Specific patterns of women s drug use with their sexual partners increase women IDUs risk for acquiring HIV, both from sexual intercourse and from unsafe injecting practices. Women IDUs are more likely than men IDUs to exchange sex for drugs and money. Sex workers who inject drugs are more exposed to HIV transmission than sex workers who do not inject drugs. Inadequate access to harm reduction services and health facilities, along with stigmatization, make female drug users less visible than their male counterparts. As a result, women IDUs appear to be at greater risk for acquiring HIV both from commercial and non-commercial sexual partners. They also have a range of legal, health, and social needs that are presently unaddressed. Women s responsibilities as parents are not accommodated by most services for drug users. Steps must be taken to ensure that women drug users have a full access to health care, social and other supports including opioid substitution therapy where appropriate, in order to protect them and their sexual partners from acquiring HIV, and in order to meet their other health and social support needs. Globally, women drug users are likely to have a male sexual partner who injects drugs. Women tend to be introduced to drugs by a husband, boyfriend or male member of their family. Their access to drugs usually occurs through a male sexual partner. Women are more likely to share needles and to be injected by someone else. Women experience difficulty in avoiding drug use/abstaining/accessing drug treatment if the male partner is an active drug user 38, 39, 40, 41, 42, Ministry of Public Health, National AIDS Control Program, HIV Harm Reduction Working Group, and HIV/AIDS Coordinating Committee. Afghanistan Opioid Substitution Therapy Policy. July, Ministry of Counter Narcotics. National Drug Control Strategy 2005, at p National AIDS Control Program, Johns Hopkins University, and the Indian Institute of Health Management Research, Understanding HIV in Afghanistan: The Emerging Epidemic and Opportunity for Prevention, at p UNODC (2004). Substance abuse and treatment care for women, cases studied and lessons learned. 18

19 Women encounter significant systemic, structural, social, cultural, and personal barriers to accessing substance abuse treatments. In Afghanistan as in most countries women are underrepresented in positions of power that influence awareness of gender differences, policy development, and resource allocation. At the structural level, the most significant obstacles include punitive attitudes towards parenting and pregnant women, which makes them fear losing custody of their children, and prevents them from seeking treatment early enough. Often women do not have money to pay for transportation or treatment. Treatment programs may be located far from where women live and may have inflexible admission requirements and schedules. Much more is now known about strategies that help overcome the significant hurdles that women encounter in accessing and remaining in treatment. What has proved particularly successful in societies with strong cultural taboos and sometimes few resources is informing and educating communities about the issue and training community members, particularly women in the community, in prevention-andtreatment support activities. Training other helping professionals, particularly primary care providers, and networking and linking with health and social service providers, can help in the identification and referral process of women with substance abuse problems. As noted, there is extensive evidence of the effectiveness of opioid substitution treatment, particularly methadone maintenance, in reducing the use of illicit substances and associated problems. Where available, it is the chosen treatment of opioid dependent pregnant women. Appropriate interventions for pregnant and parenting women can reduce substance use, and improve health and social outcomes for pregnant women. OST should not be provided as a stand-alone intervention, but should be complemented by other services that address women s needs. 44 In order to provide a comprehensive response to the problem of illicit drug use in Afghanistan, demand and harm reduction programs must address the needs of women drug users, including pregnant women who are opiate dependent. As noted above, the Constitution of Afghanistan prohibits any kind of discrimination or privilege between the citizens of Afghanistan, and this prohibition applies in the context of access to OST as it does in other contexts. Dosing levels of OST medications, psychological and social needs, and accessibility of services must all be tailored to the specific needs of women. The involvement of women as health care workers, peer outreach workers, educators, and providers of social 39 European Monitoring center for drugs and addiction (2005). Difference in patterns of drugs between women and men. European Drug situation technical sheet. 40 Doherty Mc, Garfein RS, Monterroso E, Latkin C, Vlahov D. (2000). Gender difference in the initiation of injection drug use among young adults, Journal of Urban Health, 77(3): Sherman S., Latkin C., Gielen A. (2001) Social factors related to syringe sharing among injecting partners: a focus on gender, Substance Use Misuse, 36: Gore-Felton et al., op. cit.; Davies, A. G., Dominy, A., Peters, A. D., Richardson A. M. (1997). Gender differences in HIV risk behavior of injecting drug users in Edinburgh. Aids Care, vol.8 no 5 43 UNOCD (2006) HIV/AIDS Prevention and care for female injecting drug users. 44 United Nations Office on Drugs and Crime. Substance abuse treatment and care for women: Cases studies and lessons learned. UNODC, Vienna,

20 support is essential if OST programs are to be accessible to women. Building capacity to implement opioid substitution therapy in Afghanistan must include building the capacity of women to contribute to these programs. RESPONSES TO DRUG USE AND OPIATE ADDICTION International Agreements on the Suppression of Narcotic Drugs and Psychotropic Substances The United Nations Convention Against Illicit Traffic in Narcotic Drugs and Psychotropic Substances promotes a range of measures to reduce the production, trafficking, and use of illicit drugs. Article 3(1) provides that each Party to the 1988 Convention shall adopt necessary measures to create criminal offences against the intentional production, manufacture, extraction, preparation, offering for sale, distribution, sale, delivery, transport, importation or exportation of any narcotic drug or any psychotropic substance contrary to the provisions of the 1961 Convention, the 1961 Single Convention on Narcotic Drugs or the 1961 Convention as amended by the 1962 Protocol, or the Convention on Psychotropic Substances Parties to the Convention may adopt measure for the confiscation of the proceeds derived from any offence referred to in Article 3(1). The 1988 Convention also recognizes the need to adopt appropriate measures aimed at reducing illicit demand for narcotic drugs and psychotropic substances, with a view to eliminating human suffering and eliminating financial incentives for illicit traffic. 46 These measures may be based on the recommendations of specialized UN agencies such as the World Health Organization. The Role of Harm Reduction A harm reduction approach, including the provision of needle and syringe programs and opioid substitution therapy, is endorsed and promoted in numerous best practice documents and guidelines from multilateral agencies such as the World Health Organization (WHO), the Joint United Nation Programme on AIDS (UNAIDS), and the United Nations Office on Drugs and Crime (UNODC). In 2007 UNAIDS noted that harm reduction measures such as access to sterile injection equipment, drug dependence treatment such as methadone and buprenorphine, [and] community-based outreach, are among the most effective and cost-effective measures for preventing HIV epidemics among injecting drug users. Adequate coverage of the full range of harm reduction measures, particularly sterile needle and syringe access and drug substitution treatment, should be promoted. 47 By implementing programs which focus on reducing the harms related to drug use as well as programs that aim to reduce drug supply, harm reduction can prevent the spread of infections including HIV/AIDS and hepatitis; reduce the risk of overdose and other drug-related fatalities; and lessen the negative effects which illicit drug use may have on individuals and communities including poverty and crime. Harm reduction approaches drug use from a realistic and pragmatic public health perspective and focuses on feasible goals. Further, by preventing the spread of blood-borne infection among IDUs, harm reduction helps to prevent the spread of HIV/AIDS among the entire population. RATIONALE FOR IMPLEMENTING OST 45 United Nations Conference for the Adoption of a Convention against Illicit Traffic in Narcotic Drugs and Psychotropic Substances, Vienna, 25 November-20 December Article 14(4). 47 UNAIDS. Practical Guidelines for Intensifying HIV Prevention: Towards Universal Access,