Harm reduction in action: putting theory into practice

International Journal of Drug Policy 9 (1998) 401–409

Harm reduction in action: putting theory into practice

Gerry V. Stimson

The Centre for Research on Drugs and Health Beha6iour, Department of Social Science and Medicine,Imperial College School of Medicine, 200 Seagra6e Road, London SW6 1RQ, UK

Received 1 March 1998; accepted 5 May 1998

Abstract

Harm reduction interventions have been introduced in a large and growing number of countries. Fundamentalcomponents of harm reduction programmes are the need to raise ‘awareness’, to ‘contact’ people, to provide themwith the ‘means’ to change their behaviour, and to gain ‘endorsement’ for this work. The UK provides a case studyof public health harm reduction measures which to date appear to have successfully averted an epidemic of HIVinfection. In broad terms, the basic techniques for harm reduction projects and programmes are now known, andthere is substantial research and practical evidence to indicate their successful implementation and impact. The globalpublic health challenge in the next decade of harm reduction is therefore to find ways to implement harm reduction.Many elements of good public health practice are found in harm reduction. Harm reduction can learn from publichealth, and public health can learn from harm reduction. © 1998 Elsevier Science B.V. All rights reserved.

1. Harm reduction—from faith to science

This paper started life as an opening talk at theInternational Conference on the Reduction ofDrug Related Harm in Paris in 1997. That confer-ence marked nearly 10 years of harm reduction. Itwas therefore a good opportunity to reflect ondevelopments, to assess what has been achieved,and for participants to be rather self-congratula-tory. That congratulation is justified, because, de-spite all the challenges facing harm reduction, andthe times when no progress seems to be made, it isimportant to recognise that there have been somenotable practical successes in reducing drug-re-lated harm.

Harm reduction has come a long way in the last10 years. Progress in the UK provides an aptmetaphor. In the UK, the first syringe exchange inLiverpool in 1986 was in the Mersey Region DrugTraining and Information Centre. It was locatedin a small toilet cubicle, the only spare spacewithin the agency. In those days, harm reductionwas very much an ‘act of faith’. Since then harmreduction has—to risk a cliche—‘come out of thecloset’. Harm reduction projects have been imple-mented in many places in Europe, Australasia,South East Asia, the Newly Independent States,and in North and South America. There is grow-ing evidence that they have had a significantimpact on the health of drug users.

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G.V. Stimson / International Journal of Drug Policy 9 (1998) 401–409402

In this paper I will first note what I see as thekey components of harm reduction. I will thentake a case study of successful harm reductionwith respect to HIV and drug injecting. Finally Iwill try to draw out some themes about publichealth and harm reduction in the future.

2. Key components of harm reduction

There is a wealth of theorising and model build-ing about the nature and practice of harm reduc-tion, despite the fact that it was—and continuesto be—a grass roots and bottom-up social move-ment. Different writers have tried to set out thebasic principles of harm reduction. In my modestcontribution here, I am trying to keep thingssimple. I have reduced harm reduction to four keycomponents which I think are its essence in prac-tice. I think that most harm reduction pro-grammes and projects comprise these fourcomponents, although the way they are combinedand the prominence given to each will vary fromproject to project, and over time. (An overview oftypes of harm reduction interventions can befound in Rhodes and Hartnoll, 1996; Ball, 19981).

The four key components can be rememberedby the word ACME (Fig. 1)—the need to raiseawareness, to make contact with populations, toprovide the means for people to change theirbehaviour, and to get endorsement for harm re-duction measures. There are numerous ways inwhich these components have been delivered inpractice, i.e. the specific techniques that have beenused.

For example, techniques for raising ‘awareness’about health risks include individually targetedmethods such as mass and local media campaignsor counselling, or through community and subcul-turally targeted strategies for facilitating changesin social norms such as outreach and peereducation.

Harm reduction has been typified by innovativemethods for ‘contacting’ populations, by havingappropriate, attractive and accessible services, byusing outreach to the hard-to-reach, and facilitat-ing the passing of health promotion informationthrough social networks. In many treatment mod-els, failure to complete treatment entails beingdismissed from the programme. Harm reductionemphasises the need to retain contact with peopleand to offer them ongoing help, services andadvice in anticipation that they will eventuallychange their behaviour. In harm reduction, ejec-tion of unsuccessful clients would be a failure ofthe programme rather than the client.

Those promoting harm reduction suggest theimportance of providing drug users with the‘means’ to change their behaviour, through theprovision of sterile injecting equipment or themeans to de-contaminate this, such as bleach; andcondoms for safer sex. Treatment and help fordrug problems is also a means for behaviourchange. Appropriate drug treatment and mainte-nance programmes facilitate contact with drugusers and help them change their drug use. Themost common approach has been methadonemaintenance. Maintenance programmes usingother substitute drugs (e.g. buprenorphine) havealso been tried.

And finally projects include ways of gainingendorsement for harm reduction activities. Thisincludes creating alliances between target popula-tions, local communities, social activists, socialscientists, and government. A major activity formany projects is gaining support for harm reduc-tion activities from the local community, otherhealth workers, and government.

There is an accumulation of international evi-dence about the importance, feasibility and effec-tiveness of different techniques for reducing drugrelated harms. Much of that evidence comes fromprojects designed to reduce the risks of HIV trans-

Fig. 1. Harm reduction—intervention components.

1 As conventional in the ‘International Journal of DrugPolicy’, references have been kept to a minimum. Apologies tothe many people who have influenced me and upon whosework I have drawn.

G.V. Stimson / International Journal of Drug Policy 9 (1998) 401–409 403

mission. Looking back over the 10 years it isextraordinary how much we now know abouttechniques to prevent problems connected withdrug use. Harm reduction techniques work notonly in developed countries, but also in coun-tries with very different economic and socialconditions—harm reduction activities have beenimplemented, for example, in Nepal,Bangladesh, Thailand, Manipur, and in Centraland Eastern Europe. Evidence for success hascome from practical experience of people run-ning projects, from the accumulating interna-tional scientific evidence about the effectivenessof different interventions, from comparative in-ternational studies, and from individual casestudies (see for example overviews in Stimson etal., 1998). An earlier International Conferenceon the Reduction of Drug Related Harm led toa book called ‘Harm Reduction: from Faith toScience’. Harm reduction in the last 10 yearshas now moved from faith to science.

3. A UK case study—evidence for successfulprevention of HIV infection

There are a number of case studies whichcould be selected to show governments and pol-icy makers that harm reduction is not only aphilosophical and practical approach to drugproblems, but that it can deliver the goods.There is now evidence for successful HIV pre-vention in many countries—as has been demon-strated by the WHO Multi-City Study on DrugInjecting and HIV Infection (Stimson et al.,1998) and many other studies.

One of the problems facing harm reductionhas been that it is difficult on grounds of ethics,costs and time to subject it to tough scientificscrutiny using, for example, randomised con-trolled trials. Country and city-wide case studiesare therefore important, because they may helpus understand the interaction between nationaland local policies, the interventions that are de-veloped, how these interventions influence riskbehaviours, and in turn the history of epidemics(Fig. 2). The task is difficult, but not insupera-ble. It requires piecing together information

Fig. 2. Task of comparative HIV policy analysis.

from a wide number of sources about nationalpolicies, the kinds of projects that were devel-oped, risk behaviours, and the direction that theepidemic has taken over time. It takes someimagination—because if we argue that thecourse of an epidemic has been altered by theintervention, we have to argue what might havehappened without the intervention. This we can-not know—but we can imagine what couldhave happened by looking at the histories ofepidemics elsewhere. The question is: wouldthings have turned out differently, but for thepolicies and interventions? (The problem is akinthe Max Weber’s attempt to argue the link be-tween the rise of protestantism and the develop-ment of capitalism.) The analytic task is aidedby comparisons between countries and citieswith different polices, practices, risk behavioursand epidemic histories. We may be therefore beable to learn as much from comparative na-tional and city analyses as from the more fo-cused evaluation of specific interventions. Thislevel of analysis also helps us to begin to under-stand the circumstances under which harm re-duction projects may be successfullyimplemented.

The UK provides a useful case study that cancontribute to this comparative analysis—withstrong evidence that HIV infection among injec-tors has been averted through public health riskreduction measures. It will be for others to as-sess whether a case has been made that whatwas done in the UK helped avoid a major epi-demic of HIV infection among IDUs.


3.1. Conditions for epidemic take-off

Let’s look at the evidence for the claim that theUK has averted an HIV epidemic. First, it isnecessary to speculate what might have happenedin the UK—could a major epidemic of HIVinfection have occurred among drug injectors? Wehave to look at the critical period when HIV firstappeared. In my view three conditions for HIVepidemic take-off existed in the UK between 1982and 1986 (Fig. 3).

First, there was a substantial population ofinjectors. By the 1980s, in common with otherEuropean countries, injecting had spread to mostmajor cities and to many sectors of the popula-tion. In the early 1980s, diffusion of injecting wasespecially apparent in deprived inner-citypopulations.

Second, there was the potential for transmissionof HIV infection. Sharing needles and syringeswas the norm. There was considerable mobilityand mixing, with multiple sharing partners. Manycities, and especially London, attracted injectorsfrom elsewhere in the UK and from Europe.Indeed one of the first deaths from AIDS was ofan Italian drug user who died in HammersmithHospital in London in 1985. Unprotected sexualintercourse was the norm.

The third condition was the presence of HIV.In Scotland HIV appeared in Edinburgh injectorslate 1982 or early 1983, with the first documentedsero-conversion in January 1983. The first AIDScase in an injector was in the South of England in

1984. By that year HIV was present in a smallnumber of injectors in all health regions in Eng-land, and Wales and Scotland. By 1985, the HIVprevalence rate in Edinburgh was 50%.

It would appear reasonable to assume that—given the existence of these conditions—HIVcould have spread among drug injectors through-out the UK. One scenario would have been therepetition of the Edinburgh HIV outbreak inother cities. That such rapid epidemic spread hasoccurred in many parts of the world lends cre-dence to this view.3.2. Epidemic history

What has been the history of the epidemic sincethen? The overwhelming evidence is that our in-jectors have not experienced a major problemwith AIDS and HIV infection. The cumulativenumber of injecting-related AIDS cases is 520,with a further 283 in Scotland. AIDS incidence isabout 100 cases a year. Recent statistical mod-elling suggests that there are 2770 people currentlyliving with HIV infection associated with injectingdrug use (2100 in England and Wales and 670 inScotland). Hickman et al. (1997) estimate thatthere are about 130 (CI 40–240) new HIV infec-tions among injectors in England and Wales eachyear—about 100 of these in London, that is,about two new infections occurring each week.

We do not have good estimates of how manyinjectors there are in the UK: but if we assumeconservatively that in London there might bearound 50000 and around 100000 further in Eng-land and Wales, then the estimated annual inci-dence rate would be in the order of 0.02 per 100person years or less.

Recent modelling of trends in HIV incidence,back-calculating from AIDS data, suggests a peakof new injecting-related HIV infections in Lon-don, and in England and Wales outside London,between 1984 and 1986, with a substantial declinethereafter (Fig. 4). The point at which the declineoccurs is important in terms of epidemic preven-tion—it seems to be coincident with the introduc-tion of HIV prevention measures. The earlierpeaking in 1984 in London could indicate earlysaturation of higher risk groups, or early riskbehaviour changes by injectors.

Fig. 3. Three take-off conditions for an HIV epidemic in theUK—1980s.


Fig. 4. Estimated annual incidence of HIV infections in England and Wales.

Finally we have the evidence from HIV preva-lence surveys. Overall, in England outside of Lon-don, the prevalence of HIV infection is around1% or less among injectors tested by the PublicHealth Laboratory Service in a large number ofdrug agencies. This figure is consistent over timeand across health regions. Our studies in Londonshow a decline in prevalence rate from 13% in1990 to 7% by 1993. Lower rates are found inother studies in London (for an overview, seeStimson et al., 1998). Overall we conclude that theprevalence rate in London amongst chronic long-term injectors is around 7% or less—and lower inyounger injectors. In 1996, Gillian Hunter in ourgroup found a prevalence rate of only 1% in asample of female injectors in London. In Scot-land, studies in Glasgow have never found aprevalence rate above 2%. Prevalence rates inEdinburgh have now declined to 20% or less (forreviews see Stimson, 1995; Unlinked AnonymousSurveys Steering Group, 1996; Stimson andHunter, 1998).

I would now like to turn to risk behaviour. Weare currently undertaking a UK survey of syringeexchange, and currently estimate that there areabout 450 syringe exchange and pharmacy ex-change schemes in the UK, with a total of over

2000 outlets. About 25–30 million syringes aredistributed each year (Parsons and Turnbull, per-sonal communication). There is at least onescheme in every health district. In addition thereare pharmacy sales of syringes and needles. Mostinjectors obtain their syringes from pharmaciesand syringe exchange schemes: in London about75% of injectors obtain their syringes this way.Very few get second-hand syringes from otherinjectors. Sharing when it does occur is discrimi-natory; injectors who share do so mostly withsexual partners and close friends: sharing withstrangers is rare. There is a low rate of partnermixing—in a recent study we conducted acrossCentral and Southern England the mean numberof sharing partners for the total sample in the lastmonth was just over 1.

Data indicate that before 1987 syringe sharingwas relatively high, that it declined between 1987and 1990 coincident with the introduction of pre-ventive interventions, and that thereafter it hasremained relatively low and stable (Stimson andHunter, 1996). We have, however, to be cautiousabout the interpretation of risk behaviour data.Some studies and routine information systemshave asked fairly crude questions about syringesharing. More recent work asking more detailed


questions, and investigating a range of sharingpractices (both direct sharing of needles and sy-ringes and indirect sharing of injecting parapher-nalia), is getting higher reports of sharing. We donot know whether this suggests an increase in riskbehaviour, or that it was not measured well in thepast by ourselves and others. Nevertheless, thenumber of sharing partners is low—indicatinglow opportunity for transmission. In low preva-lence situations, the rate of partner mixing may bemore important than the frequency of sharing.

A word of warning is in order: HCV prevalencerates are high, as they are in some other countrieswhich like the UK have low HIV rates (e.g.Australia). On the face of it this might argueagainst the hypothesis that HIV has been pre-vented by behaviour change. However, the expla-nation may possibly be found in the differentepidemic history of HCV in relation to behaviourchange (it is possible that the prevalence of HCVwas high before the introduction of risk reduc-tion); the higher infectiousness of people withHCV; and the higher viral transmissibility ofHCV compared with HIV. Urgent work needs tobe conducted to answer these questions.

We have not observed major changes with re-gard to sexual behaviour: condom use is low withregular partners, higher with casual partners andhighest for injectors who are commercial sexworkers with respect of paying partners. TimRhodes and Alan Quirk have pointed out thatwhilst there is a norm of not sharing injectingequipment, there is still a norm of unprotectedsex. However, although condom use is low, it ishigh in comparison with injectors in many devel-oping countries.

4. Historical conditions for HIV prevention in theUK

I am arguing here (and have done so in moredetail elsewhere) that there is a plausible linkbetween HIV and drugs policy, the HIV preven-tion interventions which were introduced, the re-duction in risk behaviour and the lack of majorspread of HIV infection among people who injectdrugs (Stimson, 1995, 1996). Public health inter-

ventions appear to have helped us avoid the ma-jor spread of HIV infection that has beenobserved in many cities and countries throughoutthe world.

4.1. What helped make the UK response possible?

People working in harm reduction in the UKhad it fairly easy in the first few years—at least incomparison with their colleagues in many othercountries. Harm reduction gained ready accep-tance at many levels in British society. There wereno major political or community objections, andno major legal obstacles. My colleagues in theUK might disagree—but, for example, peopledistributing needles and syringes have not beenarrested, as they have in the USA. That harmreductionists have had it easy is indicated in thefact that there is no national harm reductionassociation or formal network, and that harmreduction conferences and meetings are rare. Thisis not to suggest that there were not battles to befought at a national or local level—rather that ithas not been as hard in the UK as in other places.(There are now indications that the situation ischanging—but that has to be the topic of anotherpaper.)

What facilitated the harm reduction response inthe UK was, firstly, a ‘supportive IDU/AIDSpolicy’ (Fig. 5). The key policy document, pro-duced by the AIDS and Drug Misuse WorkingGroup of the Advisory Council on the Misuse ofDrugs, formulated the problem in the followingterms: there was—in the mid-1980s—a substan-tial number of current injectors who were unable

Fig. 5. Features of successful intervention in the UK.


or unwilling to stop injecting; they might eventu-ally wish to stop injecting, but in the meantimethey provided a large population in which HIVinfection could spread; the public health prioritywas therefore to contact that population, and helpthem reduce their risk of HIV infection.

The report prioritised HIV over drug prob-lems—HIV was seen as a greater threat to publicand individual health than drug misuse. The re-port argued for the need to work with continuinginjectors—implicitly this was harm reduction—although this term does not figure in the report.

Policy does not come from thin air: the reportof the Advisory Council helped to coalesce ideasand practices which had been developed by oth-ers. The first syringe exchange was in Peterbor-ough, and the first pharmacy exchange at Bootsthe Chemists in Sheffield. In Liverpool—whichled the rest of the country—the ideas for HIVprevention came directly out of public healththinking through the work and influence of JohnAshton and Howard Seymour. By 1987, there wasenormous interest in HIV prevention at a grassroots level in drugs agencies throughout the UK.By the time the ACMD report was published in1988, risk reduction was already common in drugagencies. There was a growing development ofsyringe distribution and exchange, an expansionof methadone treatment, and of outreach to lessaccessible populations.

There was also a ‘supportive context and dis-course’ at the policy and political level. By 1985AIDS policy was handled as a liberal consensualissue. By 1986 the UK entered what VirginiaBerridge called a period of ‘war time emergency’(Berridge, 1996). AIDS was officially a high-levelnational issue. It was feared that the UK faced anHIV epidemic in all sectors of society. This was ahistorical moment, which facilitated co-operationand policy consensus and helped weaken the po-tential influence of populist fears. Some newspa-pers tried to stigmatise people with HIV infectionand AIDS, but this did not dominate. The gov-ernment embarked on a campaign to persuadeand educate. Virginia Berridge has argued thatAIDS revived a ‘welfare state ethos’ which else-where was on the way out in Britain in the 1980s.An alliance developed between civil servants, pub-lic health medicine, AIDS activists and politicians.

Politicians indeed were well aware of the out-breaks of HIV infection among injectors in Edin-burgh, in many other European cities and inNorth America. Injectors were seen as a bridgefor HIV infection into the general population.

This was the climate in which potentially unac-ceptable approaches to dealing with drugs couldemerge. Syringe exchange became acceptable. (Inthis brief history I do not wish to deny that therewere considerable difficulties and uncertaintiesabout these approaches in government.)

AIDS prevention became a ‘social movement—an example of ‘single-issue’ politics that devel-oped in the 1980s and early 1990s—in a contextof the disruption of, and decline in, party politicalactivism at a local level, as a result of the Conser-vative government’s attack on trade unions andlocal government. A feature of successful publichealth interventions is that they become publicissues around which a social movement is devel-oped—but that is the subject of another debate.

Other features were ‘financial resources’—itgoes without saying that this is a requirement,and ‘infrastructures’—the rapidity of the responsewas facilitated by having a structure of commu-nity level drug and information agencies in mostcities. These agencies were staffed by nurses andsocial workers, and there was little medical domi-nance. These workers avidly grasped HIV as akey issue.

Others have argued that successful HIV preven-tion requires an alliance with drug injectors, togive them a voice. However, the UK at that timedid not have significant drug user groups, anddrug injectors were not drawn formally into thepolicy-making and intervention development.However, in my view the community level agen-cies fulfilled the function of user groups—by act-ing as advocates for their clients.

The next feature was that a ‘discourse on harmreduction’ was not uncommon in the response todrugs problems in the UK. Many people whoattend the International Conference on the Re-duction of Drug Related Harm know that ideasabout reducing harm in the UK can be tracedfrom the 1920s, with the prescribing of narcoticdrugs to opiate addicts. This practice was legit-imised in the report from Lord Rolleston, whose


name has been taken by the conference—in theform of the ‘Rolleston Award’—to express theideals of harm reduction. It would be naı̈ve tosuggest that there has been a single, continuousview on drug problems in the UK, or that harmreduction has dominated. However, the possibilityhas been there to talk about drugs and respond tothem in this way.

Two other things were important. First, that wedid not put all the effort into one type of interven-tion. Some are more important than others—es-pecially access to syringes—but it is equallysignificant that single solutions were not pur-sued—there was a beneficial ‘complementary andsynergism’ between interventions (which, again,makes analysis of impact at a national level asimportant as the impact of specific interventions).

And finally, what is extremely important is thatthe interventions occurred ‘early’ in the epidemic.It may be that the UK was fortunate. With theevidence for rapid spread of HIV infection inmany communities around the world, early inter-vention must mean having preventive activities inplace as soon as is possible, i.e. wherever there arepeople who are injecting drugs.

5. Harm reduction in the next decade: from faithto science to action

Finally, let us turn away from this case study tobroader issues in the future of harm reduction.What are the prospects as we enter the seconddecade of harm reduction?

Drug injecting and HIV infection continue tobe global issues. The number of countries report-ing drug injection is now 121, and the numberreporting injecting related HIV infection is now82 (Adelekan and Stimson, 1997). In the nextdecade particularly vulnerable areas will be partsof China, India, countries in South East Asiawhich have largely avoided these problems todate, sub-Saharan Africa, parts of South America,and central and eastern Europe.

Evaluations of specific harm reduction interven-tions help us to understand what works in HIVprevention. There is always more work to do onfine-tuning interventions and in adapting them to

Fig. 6. Harm reduction—the next decade.

local circumstances, but in broad terms, I thinkthat we know what works (Fig. 6). The issueahead is not so much knowing what to do, but ofpersuading others what needs to be done. In thenext decade of harm reduction, the task of per-suading others that action is needed will be helpedby the growing evidence for success.

Case studies of national responses, of the sort Ihave presented here raise some very difficult issuesregarding the successful implementation of harmreduction in other places. Were the circumstancesin the UK fortuitous—in that harm reductionfitted into the mood of the time? Did the UKresponse occur in a particular set of historicalcircumstances? These questions are important,both for the future of harm reduction in the UKand other countries with harm reduction, and forits introduction elsewhere.

This suggests to me that our task is then notonly of knowing which harm reduction techniquesto use, but what determines whether they will beacceptable and will work. In looking in a compar-ative way at different national responses we canpotentially understand the conditions which haveto be created to make harm reduction acceptableand successful.

The national level of analysis also raises somedifficult issues for intervention research. Mostmethods are designed to assess the impact ofspecific interventions. Little work has been con-ducted on assessing the impact of policies and thewhole package of interventions that might—ormight not—be available. We need to developmethods that are suitable for international com-parative studies to address the questions raisedhere about whether policies and interventionshave an impact on the overall course of an epi-demic within a country.

Finally, harm reduction was born in a crisis.The time is now right to move from crisis tomainstreaming harm reduction within public


health. These points are well made by AndrewBall (Ball, 1998) who elegantly shows how harmreduction follows the basic tenets for publichealth and health promotion as set out in the‘Declaration of Alma-Ata on Primary HealthCare’, the ‘Global Strategy for Health for All bythe Year 2000’, and ‘The Ottawa Charter onHealth Promotion’. Drug use should not be han-dled as a unique issue, but as one of the manyharms in a population that can be reduced bypublic health interventions. Indeed harm reduc-tion for drugs can be held up as ‘model’ for publichealth more generally. Many elements of goodpublic health practice, as set out in these WHOdocuments—such as building healthy public pol-icy, creating supportive environments, strengthen-ing community action, developing personal skills,re-orienting health services—are found in harmreduction. Harm reduction can learn from publichealth, and public health can learn from harmreduction.

Acknowledgements

I am grateful for critical comments from GillHunter, Matt Hickman, Jim Parsons and PaulTurnbull. The Centre for Research on Drugs andHealth Behaviour is core-funded by the NorthThames Regional Office of the NHS Executive.

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Harm reduction in action: putting theory into practice