 Good morning everyone. So thank you very much also for the introduction. So I'm currently working with UNDC and I'm the senior advisor on HIV and I'm also the global focal point on HIV and people who inject drugs. Thank you so I will try to do a brief presentation on the international standards and policies. So just before I start so briefly, UNDC is the United Nations Office on Drugs and Crimes and it has many main dates related to drug control, drug demand reduction, drug traffic reduction and also on crime prevention and criminal justice. But UNDC is also one of the cosponsors of UNH and as you might know UNH is a joint program of the United Nations on HIV and AIDS and it is composed of 11 cosponsors and one secretariat. In Geneva you have the secretariat and each cosponsor has a clear responsibility so we have a division of flavour based on our other main dates. There's a light? There's a pointer? No, okay. And so that's the reason UNDC is responsible for the HIV and people who inject drugs and for HIV in prisons. So what is the current situation globally based on the World Report 2014? We have an estimated almost 30 million people who inject drugs which correspond to a prevalence worldwide of 0.27%. And out of the 12.7 million people who inject drugs at least 13% or 1.7 million are living with HIV. And the HIV prevalence is as you can see on the map it's mainly in Eastern Europe and in Asia. But it is also affecting almost all parts of the world. But the situation is most severe in Eastern Europe and Central Asia and Asia. And the highest prevalence rates are observed among people who inject drugs are observed in Southwest Asia where almost 30% HIV prevalence among people who inject drugs. And in South Eastern Europe where you have 23% of people who inject drugs living with HIV. I'd just like to make a comment on the target. I mean in 2011 all the countries committed to reducing having the HIV incidents, so the number of new cases of HIV among people who inject drugs by 50% by 2015. And currently as of 2013 the reduction of new infection was only 10% so very far from the 50% targets. And just to add something to that it will be the new targets that are going to be considered 75% reduction of new infection by 2020 and 90% reduction of new infection by 2030. And this considering that the law progress we have made at the global level so only 10% reduction in three years it will require drastic and very focused interventions. I just want to add before that I mean the HIV prevalence in prisons is always higher than in the community and I took here examples from countries where you have a high prevalence of people who inject drugs which means that you have and because of the high excessive incarceration of people who inject drugs this HIV prevalence can be very, very high. And you can see for example in the room you have the HIV prevalence in the prison and in reddish in the general population you can see in Mauritius or in Ukraine or in Kyrgyzstan. In Kyrgyzstan for example the HIV prevalence in prisons is 45 times higher than in the general population. So what are the international recommendations for the UNDC and the WHO UNDC and UNDC recommend a comprehensive package of nine interventions. These nine interventions are neither in the same program, operation substitution therapy and other evidence based drug development treatment, HIV testing counseling and ARV, prevention and treatment of sexually transmitted infections, condom programs for people who inject drugs and their sexual partners, targeted information education and communication for people who inject drugs and their sexual partners, prevention and vaccination diagnosis and treatment of iron lattice and prevention treatment diagnosis diagnosis and treatment of tuberculosis. These nine interventions are classified by order of priority. So the first four are the most important one, neither in same program, operation substitution therapy, HIV testing and access to ARV. And in order to prevent HIV among people who inject drugs, countries are urged to implement neither in same program and operation substitution therapy. This comprehensive package has been endorsed by all UN bodies including the UN General Assembly, the ECOSOC, the Commission on Narcotic Drugs, the UNA's program collecting board and it's also endorsed by the Global Fund and by PEPFAR. Peter showed you earlier at the beginning of his presentation the global coverage of neither in same program and of OST and ARV, which indeed is very low. And if you look at a number of people who get access to the tree, it's even much much lower because if the situation remain like this, we will not be able to reach 50% or 75% or even 90% reduction of new HIV infection. Just very quickly, so why these interventions? All these interventions are evidence-based and the first one is another insurance program. HIV, as if that is C or that is B, is transmitted among people who inject drugs through sharing injection equipment. It is the sharing of the equipment that is transmitting HIV. It is not the use of the drugs. And so it is quite obvious, rationally, that if you give clean, neither in same program, you will stop the transmission. So it has all the data to review. It has shown that it is effective in reducing the rate of HIV transmission and NTC, that it doesn't need to do the initiation of injecting among people who are not injecting drugs previously. It doesn't increase the frequency of injection and it doesn't increase the frequency or duration of illicit drug use. On the other hand, it has also, in addition, it has other advantage and it allows to provide information, to provide on the disease, on the services available, to the people who inject drugs. For many people who inject drugs, neither NTC program is the very first contact with the health program and it allows to give information and to refer them if necessary to apply substitution therapy, to HIV testing, to HIV and to TB. It reduces also the number of use in public areas. Indeed, we say neither NTC program, we don't say neither exchange program and we don't say neither NTC programs because exchange constitute a buyer from people who inject drugs to access the needles. So clearly we talk about neither NTC program. But nevertheless, I mean, it allows also you to inform the people who inject drugs on the need, not to discard the use needles in public areas and it can also encourage for returning the needles. But as long as the police will arrest people who inject drugs carrying needles, I mean, you will never get a return, use needles return because no one will take the risk of being arrested for returning a use needle. So I mean, everything is going together that the major message is that we are talking about neither NTC program. So the second one is the effectiveness of applying substitution therapy. I mean, this effect, I mean, just I want to go back, I'm sorry, I just want to say that, I mean, the effectiveness of the NTC program has been demonstrated both in the community and in prisons. The effectiveness of applying substitution therapy has also been demonstrated very effectively both in the community and in in prisons. I mean, it reduces the use of opioid, it reduces the frequency of injection, it reduces the risk of overdoses and the risk of miscarriage or abortion for pregnant women. It increases also the retention interdependence treatment and it's increased the adherence to ARV treatment and to NTC treatment. So it should never never be an exclusion criteria to be on OST for accessing ARV or NTC treatment. And generally speaking, it improved the well-being, the health status, people can operate, they have a social life, they can have an economical life also and they can work. So and it reduces interdependent behavior and in prisons it reduces the racism and violence in prisons and drug-seeking behavior. So now why am I talking about a comprehensive package? And this is a mathematical model. It was deployed many years ago, I think. And here you can see what will be the natural evolution of an HIV epidemic among people who inject drugs in the absence of a needle and syringe program in the absence of OST. This line is for HIV. If you had hepatitis it would be much steeper because I mean almost 80% of the people who inject drugs get in the absence of prevention, get infected with hepatitis C in less than one year. So if you add OST only this would be the reduction of HIV prevalence. If you add a needle and syringe program and the reduction is much higher than OST alone. And now if you have both, I mean OST and needle and syringe program you have the best combination. But clearly I mean it's needle and syringe program which is the most effective and it is the most cost effective. And it is not only cost effective, needle and syringe program it also gets benefits. So you have a return on investment. If you invest on needle and syringe program the benefits are higher than the investment. I mean what are the criteria for needle and syringe program, OST, that first of all they have to be physically accessible and so it means that there should be geographically well distributed and including in a hard to reach location and it means also including in presence. There should be affordable for patients should not have to pay for the services. I mean there should be free. And there should be equitable and non-discriminatory so you shouldn't have no exclusion criteria except for medical ones but that is mainly for OST and there is almost no exclusion, medical exclusion criteria. So a prescription therapy should not be limited to people who inject drugs who are only living with HIV or failed other drug dependence treatment and you shouldn't have compulsory treatment. And finally the services should be not rationed. It means that you should not limit the number, for example the number of syringe. You should, for example you should never have a strict exchange because if a drug user comes and returns to syringe and you have programs where they would give only two syringe in exchange to use syringe, the problem is that it doesn't correspond to the need of the person. And the person if she or he doesn't have enough needle will share. And the objective is that they don't share, they don't use other needles. So it would fail your objective. So there is no reason for restriction. Also according to the drug use, I mean the syringes might differ. And people who inject heroin typically would inject three times a day. So people who inject cocaine or amphetamine might inject 20 times a day for a short time, a short period of time, a few days and then stop. And so the needs might differ a lot from one person to another. Just to destroy the effectiveness, this is in Mauritius, so it's not in Europe. And in Mauritius it's a special situation in Africa because it's an island on the Indian ocean and it has very high prevalence of people who inject drugs. And it's one of the highest, it's a small population but if you look in prevalence it's very high, it's a small person or more, I can't remember. And so they were facing a very severe HIV epidemic of people who inject drugs and it was completely concentrated on people who inject drugs, the epidemic. They don't have general epidemic. And you can see in blue here you have the total new cases of HIV and the orange line is the new HIV cases on people who inject drugs. So you can see how it increased dramatically very fast between 22 and 25. And in 25 they decided to introduce the Nivea and Sting program and the drop in the number of new cases is very important, it's very impressive and immediate. And then a year later they start introducing OST and the drop continued. But I think this illustrates very well the effectiveness of Nivea and Sting program and OST to control an epidemic, even in this case it was a new epidemic among HIV, among people who inject drugs. I just mentioned earlier that most Nivea and Sting program and OST should be available accessible in presence also and I just want to mention the Comprehensive Package from HIV in presence which has 15 interventions but out of these 15 interventions you have all the nine interventions from the Comprehensive Package for HIV and people who inject drugs. So all the harm reduction interventions are there. I will not go through all the principles but the main one is that the in present, present health is public health and that the services in present should be based on numerous standards which means which in one of the most important is the principle of equivalence that people who are in present should access the same services, health services as the people in the community. Now we come back to the justice reform and prison reform. Just to show you an example how effective it can be in presence. On the upper part of the slide you have the HIV, the number of new cases of HIV in the two area. Resort, Nivea and Sting program, Resort of a substitution therapy with HIV testing but it's mandatory HIV testing and with a low coverage of HIV therapy and some pre-education program. And you can see the number of new cases of HIV cases increasing in Lithuania. And in Lithuania again we have the same pattern, it's an epidemic driven by sharing injection equipment. On the lower part you can see in Spain where you have emergency program in all present, you have a substitution therapy, you have HIV testing and you can see the drop in the number of new cases of HIV infection in presence. I mean there are many, it's not only the services themselves and we know what needs to be done and we know what is necessary to control the epidemic. However as it was mentioned several times before the coverage is very low and the access is very low and even, I don't know, 25 years after all the evidence has been developed many countries are still struggling for giving access of people inject drugs to new disease program and operation therapy. You can see we have a strategy for trying to support the countries to reach the 50% reduction of new HIV infection by 2015 and the strategy was global and so we had identified 24 high priority countries and in each of these countries we asked them to develop a plan of action from 2013, from 2015 focusing on the bottlenecks and even if these 24 countries were in all parts of the different parts of the world from Asia to Latin America from East to Latin America and the bottlenecks were almost everywhere the same. I mean we put the first one the strategic information. The lack of strategic information is not a bottleneck as such for implementing. You don't need very solid strategic information to start implementing. If you know the situation that you don't need it. The problem is that you need it for advocacy. Very often if you don't have data it's very difficult to advocate and also for monitoring. So the poor access and the poor quality of harm reduction services was certainly a problem and the need for capacity building was everywhere identified. But mainly what I want to insist is on the lack of supportive policy and legislative environment and it's not only the legal framework that this might be not adequate. Sometimes the legal framework is adequate but the attitude of the law enforcement agency is inadequate, is not supportive. So I think that the policy the legal framework is one thing and one is the attitude of law enforcement agencies. And then the lack of financial resources. I mean globally 92% of the funding for harm reduction programs rely on international donors. Which means that the data international donors leave. Like it was in Romania the programs are not sustained. And this is really a problem and really need to find ways to increase the domestic funding and the ownership of the countries. But all this situation all these bottlenecks are really underpinned by the high level of stigma and discrimination against people who inject us. And this stigma and discrimination is in the general population, but also in the health general health care services and certainly among the law enforcement agencies. And this is really the major the major point. That's why in addition to trying to improve access to leadership to provide to make available the best program and OST you also have to address what we call the critical enablers. Maybe the wording is not the best one, but anyway. And the one we mentioned already is the supportive legal and policy framework. Vis-à-vis the people who inject us, but also the service providers I would like to come back to a comment to something you mentioned earlier saying that you are trying to organize meetings and municipality etc. And indeed it's very important because I mean the HMV when people are injecting us it's not only a health issue it's a legal issue it's a criminal justice issue that you need to have all the stakeholders around the table to agree and to to see how we can best improve the life for the people who inject drugs and for the community in general so far the response to be effective the rights of people the rights to health of people who inject drugs have to be respected so you need to address also the stigma and the legal framework and I want to just to show no I cannot show you I want to I wanted to show you this picture I mean last year in 2013 2014 we conducted workshops with law enforcement agencies and CSO in 18 countries and in each of these workshops we had about 30 participants 50 from CSO and 15 from law enforcement agencies and the objective of these workshops were to inform the law enforcement agency or what these HMV people inject what these people inject what is the the influence of their attitude on people who inject drugs to access services and how they can become supportive for people who inject drugs to access the services and on the other hand for the CSO the objective was to increase their capacity to advocate with the police so for two days over 30 people went together in the same room exchanging on their concern parties trying to understand each other and understanding how best to work together what was really amazing maybe not amazing but it was the first time for all of them it was the first time that they had an opportunity to have a dialogue an open free dialogue and it was something where they evaluated as one of the best results of this experience so I think the lesson is that there is a need for dialogue there is a need for dialogue to explain to each other what are the needs and what can each of us do it is important to mention that HMV are not in contradiction with the international drugs convention and that the international drug policies do really require incarceration of drug users nor the criminalization of the use of drugs and this is very important when you try to address the legal framework I mean there is no need to criminalize the use of drugs or the possession of drugs for personal use according to the international drug convention and last but not least I mean it is very important to ensure appropriate funding and I think we will also see the example of Greece the negative impact of stopping funding as I mentioned before domestic funding because first of all there is a benefit for the countries to invest in harm reduction and number two for the sustainability just before I stop I just would like to show three new publications we had this year so the first one is a training manual for police and on HIV and people who inject drugs and the idea is that the police could use that in the training academy to sensitize them on HIV and drug drugs the second one on the right is a policy brief on HIV and women who inject drugs which goes beyond the comprehensive package but also address the specific needs of women and the last one is a handbook on how to implement neither insurance program in prison so before I start I would like to quote our executive director and and this is the quote from the species at the U.N. its prime hunting board last July unfortunately many national drug control systems rely on sanctions and imprisonment rather than evidence based health care in full compliance with human rights standards and these are major bias to HIV and harm reduction services including prisons and other closed settings thank you you can see here the website and my email address