Prepared by the Harm Reduction International (Damon Barrett) and INPUD (Dr. Lisa Norman)

1. Comments and Concerns on the draft of the UNODC Technical Guide to HIV Prevention, Treatment and Care for Stimulant Users Prepared by the Harm Reduction International (Damon Barrett) and INPUD (Dr. Lisa Norman)

2. the document ranks its core interventions in order of importance and puts drug dependence treatment for stimulant users, for which there is little or no evidence of positive effect on HIV epidemics, ahead of condom distribution and

3. Many of the recommendations, such as ART, are generic for all at-risk populations; ART should be scaled up for all people living with HIV. A new technical guide is not required to make this point.

4. Moreover, it is doubtful if other recommendations, such as male circumcision, represent the most appropriate or beneficial intervention specifically to address the risks associated with stimulant use.

5. At a time of financial hardship for HIV/AIDS and harm reduction programs, this document represents a distraction from where scarce resources must be targeted. In an increasingly difficult political environment, it may also play into the hands of policy-makers who wish to promote politically popular abstinence-based drug treatment rather than provide leadership on proven HIV prevention measures related to injecting drug use. In short, it inserts ambiguity into an arena where clarity and unflinching leadership are needed.

6. Page 3, under Section I: Introduction, Preventionparagraph, the last sentence, which states “In addition, not all individuals who use stimulants will want to take ART for HIV prevention because they may distrust medication and the medical system or they may simply prefer not to take medication.” • this statement does not contribute to the document because this statement may be applicable to a number of persons who are HIV+ and don’t take ART, like sex workers, or impoverished persons, especially men and women of color (in the USA)

7. Page 6, under IIBackground, A. HIV risk among crack cocaine users, the first and second sentences of the second paragraph, which states: “Users of cocaine and crack share important characteristics. Users of the drugs in the U.S., are disproportionately African American and poor.” • This is not accurate. Yes while crack cocaine use is reported at higher levels among African Americans and the poor, powder cocaine is more likely to be reported among Whites who are not poor, due to the costs of the drug.

8. Page 6, under Section II Background, A. HIV risk among crack cocaine users, sentence 5, second paragraph, states that use of crack and cocaine by men who have sex with men and MSM who also have sex with women corresponds with homophobia and lack of awareness regarding HIV status. • The relevance of including the issue of homophobia in this document is at question. This is supposed to be focusing on stimulant users, not MSM who also have sex with women, as a result of homophobia. This needs correction

9. Page 7, Last sentence, “Methamphetamine use significantly elevates the risk of HIV infection and increases HIV disease progression, mostly in men who have sex with men.” • Sentence needs to be revised to state that these phenomena have been identified in samples of MSM. However, other samples of persons at risk of HIV, especially those who use stimulant drugs, have not been studied or documented.

10. Page 9, Section III – Interventions for HIV prevention, treatment and care for people who use stimulants. • The entire second paragraph following the displayed list of interventions, no information is provided on the criteria used to rank order these interventions by importance. This information is vital for the reader to understand and assess the validity of the techniques used. • However, the criteria provided for prioritizing responses, it appears that UNODC did not follow the criteria and guidelines provided in this document. It appears that these interventions were chosen arbitrarily. The source is UNAIDS (2007). Practical Guidelines for Intensifying HIV Prevention towards Universal Access. Available at: http://data.unaids.org/pub/Manual/2007/20070306_prevention guidelines_towards_universal_access_en.pdf

11. Page 10, 1st paragraph. 1st sentence, “Opt-out” strategies and “rapid-testing” procedures for HIV testing and counseling reduce barriers in access to health care and help to avoid the problem of people not returning to the clinic to receive their test results, both of which are common when providing HIV testing and counseling to stimulant users.” • I have two concerns regarding this statement. First, these barriers exist for other high risk groups and not just stimulant users. More importantly, the source from where this information is drawn needs/must be provided. Again, the authors are making sweeping statements that can apply to any number of groups who may be at increased risk of HIV, not specific or unique to stimulant users.

12. Page 11, Section B: Antiretroviral therapy for HIV-positive stimulant users, 1st paragraph, 3rd sentence “Stimulant users, as a group, may be thought of as inappropriate candidates for ART owing to concerns over medication non-adherence. • I see no evidence why stimulant users would be viewed as being inappropriate as compared to other groups of drug users, such as opioid users or groups at high risk, like sex workers, or young adults. I think this part of the sentence needs to be removed and just start the sentence with something like the following: “Data reveals that drugs users have more or less equivalence adherence behaviors to other HIV+ populations….”

13. Page 11, last sentence, which states: “Methamphetamine use significantly elevates the risk of HIV infection [27] and increases HIV disease progression [28, 29], mostly in men who have sex with men. • o - My concern is that the last sentence needs to be rewritten. An example could be as follows: “Data examining methamphetamine use among MSMs provide evidence that methamphetamine use significantly elevates the risk of HIV infection and increases HIV disease progression However, this relationship has not been studied in other populations of stimulant users.

14. Page 12, Section C: Drug dependence treatment,the entire paragraph • No support is provided for making these statements. The reference provided at the end of this paragraph focuses on opioid treatment not stimulant treatment. Moreover, the last sentence needs to be changed to say that opioid users in treatment have greater access and adhere better to HIV treatment than those persons not in treatment. It also states in this article that drug treatment alone is not sufficient to change HIV risk behaviors and programs addressing reduction of HIV risk and infection need to be included in drug treatment programs. As such, there is no evidence that “drug dependence treatment” should be listed at the 3rd most important intervention for stimulant users. This paragraph needs to be re-written to include the above-mentioned information as presented in the article. It may have been better to use the following reference: • Natalie D. Crawford, MPH*† and David Vlahov, PhD, RN. (2010) Progress in HIV Reduction and Prevention among Injection and Non-Injection Drug Users. J Acquir Immune Defic Syndr. December; 55(Suppl 2): S84–S87. This reference discusses how drug treatment for stimulant users is lacking and as such needs more focus as well as integrating HIV risk reduction within the context of appropriate drug treatment.

15. Page 13. First paragraph, first sentence or the last of the sentence that is presented on page 12. The sentence written is as follows: “ Behavioral treatments are effective in reducing stimulant use, which corresponds with reductions in sexual risk behaviors, including reduce numbers of sexual partners and few incidents of unprotected anal intercourse” • The additional information needs to be added at the end of the sentence among MSM, a sub-group of stimulant users. However, no data exist that this is the case of stimulant users who are not MSM.

16. Page 13, first paragraph. 1st complete sentence reads as follows: “Additionally, abstinence-based approaches such as residential rehabilitation, therapeutic communities and 12 step programs can be helpful to individuals in meeting their drug-using goals, although the evidence base for this is largely absent. • If evidence does not support this statement, then why is it included in the guidelines? There are no data to support the above statement.

17. Page 18, Section: Sexual risk behaviours concomitant to stimulant use, first sentence, which reads “In countries where HIV is transmitted via heterosexual behaviors, stimulant use increases the risks of HIV transmission by reducing inhibition about unprotected sex (123-125).” • The first two citations (#123 and 124) did not even mention the word stimulant in the entire text. Reference #125 examined focused on condom use and reasons associated with not using; it did not examine stimulant use. As such, none of these three references support the statement that precedes them. As such, these references cited are not appropriate.

18. Page 18, Section Women, 4th and 5th sentences, which read as follows: “Women who use stimulants may use the drug to dull feelings or guilt or despair related to sex work. Stimulant using women have elevated risks for HIV transmission, high rates of gender-based violence, STIs and unintended pregnancies.” • The reference used to support this statement (#129) focuses on opioid-abusing women and doesn’t mention stimulants in the text. As such, it is not appropriate reference. Also, it is only referring to women who engage in sex work and use stimulants, not female users in general.

19. Page 18, Section: Youth, 3rd sentence, which reads as follows: “In addition to having more frequent sexual episodes, young people in this range (identified as ages 15-24 years in the sentences preceding this statement) are more likely to use substances, including at levels that approximate abuse and dependence.” • First, the data presented in this article does not report on this finite age group, but focuses on those 18-29 years of age. Furthermore, the authors do not report on sexual activity among the sample examined. As such, this reference used to support this statement is inappropriate.

20. Page 19, Section: Co-morbid psychiatric condition, last sentence, which reads as follows: “Stimulant-using women who are also living with HIV face significantly enhanced risks for psychiatric and HIV-related morbidities (23, 132). • Reference #132 does not disaggregate the type of drug used. Instead they combine crack, cocaine, amphetamines and heroin. As such, using this reference to support the previous statement is inappropriate.

21. Page 21, Section IV: Target setting process, 1st paragraph, 1st sentence, which reads as follows: “The following framework is based on previous guidelines (2) , and … • This sentence needs to say that it draws or is adapted from a framework that was developed and used with respect to injecting drug users, and is not stimulant use specifically.

22. Page 23, Section IV: Estimating the size of the target population for different interventions, 2nd paragraph, 5th bulleted point, which reads “Users with co-morbid psychiatric conditions: users of illicit stimulants are highly likely to suffer from psychiatric conditions, particularly depression (133) and psychotic disorders (81). • Reference #81 simply reports data from another article and as such, the original article should have been cited as the source of this information. The appropriate citation is as follows: Marshall BDL, Werb D. (2010). Health outcomes associated with methamphetamine use among young people: a systematic review. Addiction2010; 105: 991–1002.In addition, the review article only examined this variable among young persons aged 10 to24 years of age. This information needs to be included in the text. • Reference #133 focus on bipolar and substance use disorder. Was unable to tell if they report that stimulant users who have co-morbidity of bipolarism and substance use disorder specifically examined the relation between these two co-morbidities and depression. However, the abstract of this article does not include this finding. Considering that a large number of references cited as supporting evidence do not address the point that is made in the statement, it makes me suspect that this one does not either.

23. Page 23, Section Measurement of target indicators, 2nd sentence, which reads as follows: “Strategies such as behavioral surveillance methods not only identify individuals within those subgroups, but also yield data that reveal the unique ways which stimulants are used within specific subgroups that engage in behaviors that carry HIV transmission risks.” • The only reference provided for support of this statement is based on MSM. Either the statement needs to be revised to specify that this is the sub-group that the content of the statement is referring to or additional references focusing on other high-risk groups who use stimulants. Furthermore, a closer examination of this article merely asked if they had used methamphetamine and not the circumstances or unique ways they are used. As such, either the statement needs to be rewritten or a different source needed to be provided, as the one provided does not support the statement that precedes it.

24. Page 23, Section: Risk behaviors in the presence of HIV, 3rd paragraph, the sentence written is as follows: “Surveys of the general population, such as household surveys, underestimate the prevalence of stimulant use because stimulants illicit drug users may be reluctant to admit the use it.” • This is a common concern when asking of any socially unacceptable behavior, especially illegal activity. However, the authors did not provide a reference for making such a sweeping statement. Authors need to rewrite the sentence to reflect that this is common among respondents asked sensitive questions and provide a reference for this statement, which would be easy to find, or find the appropriate reference to report after this statement. It is inappropriate to make such a statement without providing an appropriate reference.

25. Page 27, 2nd paragraph, 5th sentence, which reads as follows: “A marker of quality for opioid substitution therapies attended by stimulant users would be whether or not they include information, education and communication programmes or behavioral treatments that address dependence on stimulants.” • This statement needs an appropriate reference to support the content of the statement being made.

26. Thank You