 Good morning. Good morning. Seriously, y'all, did you all go party last night? What's going on? Good morning. Well, thank you everyone for waking up bright and early. This is our last day together. Has this conference been amazing or what? Yeah, that's right. Congratulations to the team at HRI for pulling off another successful event. It's really been a lot of fun. For those of you who don't know me, I'm Monique Tula. I'm the Executive Director of Harm Reduction Coalition in the U.S. and I'm super happy to be here. This is only my second international conference. The first one was in Montreal. But this gave me a great excuse to visit Portugal for the first time. It's a beautiful country and I'm so excited to get out outside later today and really explore the city. I have the honor of moderating this amazing group of panelists this morning who are going to talk a little bit about their experience working in harm reduction focused policy. So most of you know that the harm reduction movement in earnest began about 30 years ago and arguably maybe even 50 years ago if you count the work that began in the 60s and 70s in the Netherlands. But 30 years ago it really expanded in direct response to the fact that people who were using drugs at the time were acquiring HIV and they were largely being ignored by the broader HIV movement. And so over the past three decades we've seen a pretty impressive expansion of harm reduction in the public health space. Policies and programs that incorporate harm reduction strategies have dramatically improved issues experienced by people who use drugs, formally ignored issues that are experienced by people who use drugs. However, today there's a growing criticism of how the philosophy and strategies that flow from it are becoming increasingly co-opted and medicalized as more governments and more institutions adopt harm reduction policies. So today's panelists will share their perspectives of how the harm reduction movement, how it's changing and what we're at risk of giving up as we grow. So I have the distinct pleasure of introducing you to this group of really dynamic badasses. So first up we have Catherine Cook who's with Harm Reduction International. Welcome. It's okay, you can come up. Sorry about that. And then Raul Santiago who's with the Colectivo Papo Reto de Comunicau e Cultura. In Brazil. Zoe Dodd who's with the Toronto Overdose Prevention Society. Welcome. And then Luca Stevenson who's with the International Committee on the Rights of Sex Workers in Europe. Welcome. So each panelist is going to give a short presentation sharing their perspective on some of the most critical issues that are driving the international discourse around harm reduction advocacy, the changing and growing movement, and the viability of continued growth and sustainability most importantly in an increasingly complex global environment. And then afterwards we'll have time for a brief Q&A period from the audience. So and let me just note in advance I'm going to be kind of a stickler about time and so if I cut you off it's nothing personal, but then also same for the audience when it comes time for the Q&A if you could frame your questions as questions rather than comments that would be wonderful. Alright Catherine. Hi everyone. Well done for making it to the last day of the conference and for being here so early after a brilliant party. I'm here to give you an overview of where things stand for harm reduction globally and most importantly to talk about the thing that people rarely feel comfortable talking about which is money. Most of this talk will focus on harm reduction in the context of the global HIV response because that's traditionally been the source of funding that we've been limited to though of course harm reduction is much broader than HIV. It's vital to the achievement of improved public health and human rights overall. It's almost four years since governments united behind a set of aspiring development goals to be achieved by 2030 among them ending AIDS, TB and hepatitis C. These goals are ambitious but they are achievable. We have the tools and we know what works. This holds true for people who inject drugs one of the most at risk populations for both HIV and hepatitis C. There's a wealth of evidence on the effectiveness of interventions such as needle and syringe programs, opioid substitution therapy and others in preventing HIV and hepatitis C and they're relatively inexpensive to implement. Yet it's apparent that in the global response to both diseases some lives have greater value than others. To illustrate this on the screen are findings from our latest global state of harm reduction reports released last year. The provision of harm reduction services globally is severely short of what's required. Less than half of the countries where injecting drug use is reported provide needle and syringe programs or opioid substitution therapy. Worryingly after steady increases since 2008 in the number of countries implementing harm reduction in the last five years progress globally has effectively stalled. Also I must stress that countries with harm reduction programs are not meeting the need. A tiny fraction of people who inject drugs live in countries where coverage is sufficient. So what's the effect of all of this? HIV infections among people who inject drugs continue to rise in several regions and in 2007 accounted for over one third of new infections in Eastern Europe and Central Asia and the Middle East and North Africa. Alongside the commitment to end AIDS by 2030 such statistics should be an embarrassment. But when it comes to marginalised populations it's convenient to look the other way. Now to the fun part that underpins everything. The money. In 2016, UNAs estimated that 1.5 billion US dollars was needed annually to reach 90% of people who inject drugs with harm reduction services. This may sound like a lot of money but in the grand scheme of things it's relatively modest. Consider that amount against the 26.2 billion required for the overall HIV response and for that matter against the extortionate amounts spent on punitive drug policies around the world. So with the UNAs figure in mind we worked with Liverpool John Moors University last year to establish just how much international donors and national governments were investing in harm reduction in lower middle income countries. This was a really difficult task for several reasons not least that spending on harm reduction is rarely made public and governments and donors are always differentiate between the money allocated to harm reduction and what is actually spent. There are many other caveats highlighted in the report but what was absolutely clear from our findings is that harm reduction, funding for harm reduction is in crisis. When looking at the slide on the screens please bear in mind that last summer UNAs estimated the funding shortfall for the global HIV response to be 20%. For harm reduction that shortfall is close to 90%. Most striking of all is that funding for harm reduction has flatlined since 2007. Just take a moment to reflect on all that has changed in your own lives and in the world over the past decade and consider again that flatlining of funding. To give you all a better sense of the funding landscape I'm going to break this down into three sections. Domestic funding, international funding and the global fund. And as I start to throw numbers at you in what follows I want you all to keep at the top of your minds that all of this profoundly affects people's lives. So let's start with some positive news. There are some low and middle income country governments working to invest in the health of people who use drugs through a scale up in funding. Our research identified domestic investment of over 1 million US dollars in 10 countries including India, China, Vietnam, Georgia, Thailand and Myanmar. But there are examples too of serious neglect. Russia accounts for 20% of people who inject drugs in low and middle income countries and only 1% of identified harm reduction spending and of course refuses to allow opioid substitution therapy while it experiences one of the fastest growing HIV epidemics in the world. Overall domestic investment still only accounts for a small proportion of harm reduction funding. It's also important to reflect that nearly all national governments including those with higher rates of investment in harm reduction continue to prioritise ineffective drug law enforcement placing the health and rights of people who use drugs and their communities at risk. Our research shows that redirecting just a small fraction of this spending would allow governments to fulfil their commitment to end AIDS among people who inject drugs by fully funding harm reduction. In an era of donor transition away from middle income countries it was important for us to look at harm reduction funding for country income status. As this image reveals country income status does not predict government investment in harm reduction. This is important because donor retreat for middle income countries is based on the premise that wealthy estates will fund their own health responses. While this may hold true for national HIV responses more broadly this is not the case for harm reduction. It is in upper middle income countries where the majority of people who inject drugs live that the funding crisis is most apparent. This image and the poor domestic investment in harm reduction overall underlined just how essential international donor support is for harm reduction. In 2016 international donors accounted for two thirds of harm reduction funding in lower middle income countries. While this is significant there are disturbing signs that this pot of money is shrinking. From 2007 to 2016 donor funding for harm reduction dropped almost a quarter. A trend in stark contrast to rising HIV infections among people who inject drugs in some of the most affected countries. Driving this funding decline are a number of factors. Major bilateral donors such as the UK and Australia have withdrawn direct support for harm reduction. While some donors claim that their money for harm reduction is being channeled through multilateral agencies like the Global Fund the decline in overall funding for harm reduction suggests a general retreat in support. The Global Fund and PEPFAR accounted for 88% of all donor funding for harm reduction in 2016 and before I move on to the Global Fund just a quick word about PEPFAR. PEPFAR was the second largest harm reduction donor in 2016. It's hugely important as the biggest donor for the Global Fund as well. But it's safe to say that PEPFAR is more important for harm reduction than harm reduction is for PEPFAR. PEPFAR's bilateral support for harm reduction amounts to less than 1% of its overall spend. And then there is of course the US federal ban on PEPFAR funds being used to procure needles and syringes which severely limits their impact as a harm reduction donor. So moving on to the Global Fund, the most vital donor for harm reduction. It is really difficult to overstate its importance. It's responsible for nearly two thirds of all donor funding and it's been crucial to initiating, scaling up and sustaining harm reduction programs in many countries preventing countless HIV infections and improving lives. Harm reduction is more reliant on the Global Fund now than it was a decade ago. This year is a big one for the Global Fund with its sixth replenishment taking place in October. A strong and fully funded Global Fund is vital to the harm reduction response and to delivering on government commitments to end AIDS by 2030. The fund is calling for 14 billion US dollars in replenishment for 2020 to 2022. But we don't believe that's enough, which is why we are supporting the Global Fund Advocates Network in their call for an 18 billion replenishment. As part of this support, we have an online call to action that over 150 organizations and parliamentarians have already signed on to. It states, governments, philanthropic donors and the private sector must step up and fully fund the Global Fund. Governments must put people before politics and ensure that people who use drugs are not left behind in the fight to end AIDS by 2030. And regardless of the replenishment outcome, the Global Fund must continue to support harm reduction through country grants and the catalytic funding that is so crucial for supporting advocacy and encouraging domestic investment in these life-saving services. And I have to say, we're really, really pleased to be the place where Portugal, the Portuguese government, chose to make their pledge to the Global Fund on Monday. And it's three times higher than their last pledge, so I would just like to take a moment to say thank you to Portugal. Finally, I want to highlight another important event that's happening this year. Conversations in global health are increasingly moving towards universal health coverage, and world leaders are convening in New York in September for a high-level meeting on UHC. This presents risks and opportunities for harm reduction and its funding. It's an opportunity because health for all means health for people who use drugs. The right to health must not be treated as a privilege for the few. Truly achieving UHC requires reaching those left furthest behind, including people who use drugs. Harm reduction advocates and people who use drugs must be part of these conversations. We must hold governments to account to call on them to include harm reduction within their essential health packages to fund harm reduction and to ensure that when they do fund harm reduction communities are at the centre of the decisions, designs and delivery of those services. That's it. Thank you.