People who inject drugs

The probability of infection with blood-borne viruses is dramatically higher among PWID than among those who do not inject drugs, since blood-borne viruses are easily transmitted by sharing contaminated substance use equipment such as syringes, needles, cotton wool, and spoons, which encourages direct blood-to-blood contact (^{Marín-Navarrete, Magis-Rodríguez, Medina-Mora, & Uribe-Zúñiga, 2018}).

It is estimated that there are about 13 million PWID globally, 1.7 million of whom are HIV positive. It is therefore that approximately 10% of HIV infections worldwide are associated with injection drug use, with a 28 times higher probability of infection compared to the rest of the population affected by HIV (^{Joint United Nations Programme on HIV and AIDS, 2014}). PWID are also disproportionately affected by the HCV and it is estimated that over 80% of infections of this virus are due to injection drug use, implying that approximately one in two active PWID will be infected with HCV. It is also known that there are approximately 2.3 million coinfections globally due to HIV-HCV viruses, more than half of which correspond to PWID (^{Platt et al., 2016}).

In this scenario, over half the 158 countries where the use of injection drugs has been documented have adopted harm reduction programs (^{United Nations Office on Drugs and Crime, 2017}). Programs for the prevention, treatment, and care of blood-borne viruses in PWID with more general scientific evidence include needle/syringe strategies and opioid replacement therapy, and are supported by internationally renowned organizations and agencies such as the ^{World Health Organization (2016)}. However, the implementation of these programs poses an enormous challenge in terms of the policies and laws associated with the criminalization of drug use and stigma, which in many countries constitutes a structural barrier to access to health services based on harm reduction, since they are either unavailable or only available to a limited extent (^{United Nations Office on Drugs and Crime, 2017}).

Likewise, international recommendations indicate that the integration of a more comprehensive program for harm reduction in PWID with multiple strategies at multiple levels of action increases success. Recommended strategies or subprograms include: a) needle/syringe programs, b) opioid replacement therapy, c) HIV testing and counseling, d) HIV treatment and care, e) condom programming, f) behavioral interventions, g) prevention and management of viral hepatitis, tuberculosis, and mental health conditions, h) sexual and reproductive health interventions, i) provision of naloxone, training in overdose prevention for the PWID (^{WHO, 2016}), and j) drug consumption rooms (^{European Monitoring Centre for Drugs and Drug Addiction, 2018}).

The HIV epidemic in Mexico is concentrated in key populations: men who have sex with men (17.3%), transgender women (17.3%), sex workers (7.0%), and PWID (2.5%) (^{Secretaría de Salud & Centro Nacional para la Prevención y Control del VIH/SIDA, 2017}). The Encuesta Nacional de Consumo de Drogas, Alcohol y Tabaco 2016-2017 (ECONDAT) reports that 1.3% of the population aged 12 to 65 in the country has injected some type of illegal drug in Mexico (1.5% of men and .6% of women). However, the distribution of use is not uniform, since in states on the northern border, the prevalence of illegal drug use in the last year is 3% in Baja California, 2.3% in Chihuahua, 2.6% in Coahuila, 2.2% in Sonora, 1.9% in Nuevo León, and .9% in Tamaulipas (^{Villatoro-Velázquez et al., 2017}). This is probably due to social determinants such as: the age, low educational attainment, unemployment, and poverty of border people, as well as vulnerability factors for illicit drug use, delinquency, prostitution, and increased morbidity (^{Strathdee, Magis-Rodríguez, Mays, Jiménez, & Patterson, 2012}).

Moreover, in Mexico, there are just over 2 000 community-based addiction treatment centers, approximately 25% of their patients have used injection drugs lifetime, 64% of which reported having shared syringes despite knowing the health risks and 2% of which reported living with HIV/AIDS (^{Comisión Nacional contra las Adicciones, Centro Nacional para la Prevención y el Control de las Adicciones, & Comisión Interamericana para el Control del Abuso de Drogas, 2011}). Given the national scenario and in keeping with the trends in good evidence-based practices for the care of PWID in Mexico, actions aimed at the adoption of models based on harm reduction have been developed for over 30 years. So, the purpose of this Editorial is to present an overview of the harm reduction actions and programs implemented in Mexico for PWID.

History of harm reduction in Mexico

The first case of a PWID with HIV in the country was reported in 1986. However, it was not until 1988 that the first informal syringe exchange program was set up in Ciudad Juárez, run by the non-governmental organization (NGO) Compañeros AC, the only syringe exchange program in Mexico documented until 2000. In 1990, the HIV epidemiological surveillance program in PWID was launched in Tijuana (^{Strathdee et al., 2012}).

In 1994, the first paper was presented at an international conference on PWID in Mexico and in 2000, the Comisión Nacional para la Prevención y Control del SIDA (CONASIDA) was held in conjunction with Compañeros AC, which led to the production of a harm reduction manual. In 2001, Centros de Integración Juvenil AC opened the first public methadone clinic in the north of the country, and there are currently two, located in Tijuana and Ciudad Juárez. In 2003, the Mexican government, through the Centro Nacional para la Prevención y Control del VIH/SIDA (CENSIDA) and the Comisión Nacional Contra las Adicciones (CONADIC), released a statement in favor of harm reduction, in addition to presenting the manual for HIV prevention in PWID (^{Centro Nacional para la Prevención y Control del VIH/SIDA & Consejo Nacional contra las Adicciones, 2008}). This important statement was issued at a critical moment for the country, due to the antagonism between demand reduction strategies, which in some ways encouraged the criminalization and stigma of PWID, and harm-reduction strategies that regard PWID as sick and therefore provide them with specialized health services (^{Magis & Barrientos, 2009}).

Between 2004 and 2005, the second syringe exchange program run by the Prevencasa AC NGO was created in the city of Tijuana, Baja California. At the same time, the federal government implemented workshops in the states on the northern border of the country for the dissemination of harm reduction activities. This led the states of Baja California, Chihuahua, and Sonora to formally launch needle exchange programs (^{Strathdee et al., 2012}).

In 2006, the CONASIDA began distributing free syringes as part of a national program. The period from 2007 to 2009 was crucial for harm reduction strategies in Mexico, since needle exchange programs were extended to seven states (Baja California, Chihuahua, Coahuila, Nuevo León, Oaxaca, Sonora, and Zacatecas). In the cities of Tijuana and Ciudad Juárez, the first Outpatient Centers for the Prevention and Care of AIDS and Sexually Transmitted Infections (CAPASITS) were inaugurated. In 2008, the International AIDS Conference in Mexico City, CONASIDA together with the Baja California authorities presented the first harm-reduction video in conjunction with the Secretaría de Salud of this state, promoting evidence-based strategies. This led to a shift in public policies, promoting the destigmatization of substance users by decriminalizing the possession of small amounts of illegal drugs. In 2009, Mexico received 76 million pesos in financing in resources from the global fund in response to the data presented on the HIV epidemic (^{Strathdee et al., 2012}).

In 2009, a modified version of the Official Mexican Standard for Addiction Prevention, Treatment and Control was published, stating that harm reduction is the “set of actions aimed at preventing or reducing risk situations and limiting the harm associated with psychoactive substance use, meaning that it is necessarily linked to prevention and treatment. It does not necessarily seek abstinence. In the case of HIV/AIDS, it is a strategy which considers that providing information to users about HIV/AIDS, instruction on the proper cleaning of syringes, the use of sterile needles and syringes, the provision of condoms, chlorine, gauze and other equipment, in addition to medical advice, conducting HIV testing, community work to approach injection drug users, training interdisciplinary groups and counseling on drug use, is the safest, most effective way to limit the transmission of HIV by injection drug users” (^{Secretaría de Salud, 2009}).

In 2010, Mexico signed the Vienna Declaration, the official declaration of the international AIDS conference (^{Wood et al., 2010}), calling for the implementation of scientific evidence in the policies regarding the control of illicit drugs, since it declares that, “The criminalization of illicit drug users contributes to the HIV epidemic, which has caused great social and health consequences; and therefore feedback is needed on current public policies[...]” (^{Wood et al., 2010}). In 2016, Mexico signed the Joint United Nations Programme on HIV and AIDS (UNAIDS) Political Declaration on HIV/AIDS: On the Fast Track to Accelerate the Fight against HIV and End the AIDS Epidemic by 2030, announcing the lack of progress in reducing HIV transmission among PWID, in addition to the limited coverage of programs that include the affected population (^{Joint United Nations Programme on HIV and AIDS, 2016}). That same year, the government, through the Secretaría de Salud, published the first guide for the use of Methadone as an opioid replacement therapy (^{Romero-Mendoza et al., 2016}).

CENSIDA’s program for the Promotion of Harm Reduction Strategies

According to data from the CENSIDA, this institution financed 31 social and research projects between 2011 and 2017. Of these, 19 were implemented with NGOs, and have reached 44 444 participants directly and 22 468 indirectly with an investment of approximately 23 million mexican pesos. In the past three years, however, CENSIDA has supported 12 projects focused on harm reduction, with a total expenditure of 9.5 million mexican pesos.

Lessons from harm reduction in Mexico

Harm reduction is a controversial, polemic paradigm for the prevention and treatment of people who use drugs. Nevertheless, scientific evidence has shown its usefulness as a tool for complementing strategies to combat the epidemic of blood-borne viruses such as HIV and HCV in PWID. In the past 30 years in Mexico, progress has been made in harm reduction (e.g., in 2016, over one million syringes were distributed at a rate of 6.1 per person). However, much remains to be done to achieve a complete package of strategies in keeping with international recommendations. Achieving this goal requires the participation and coordination of the various institutions that converge in this field of public health and being able to influence in: the improvement of public policies; the allocation of national funds for research, implementation, and evaluation of harm reduction programs; to develop in the public health system, reference algorithms between HIV/STI treatment centers and addiction treatment centers; the implementation of more specialized units in opioid replacement therapies, and the inclusion of more specific molecules in addition to methadone (e.g., suboxone); the generation of training programs for health professionals for the care of PWID (with emphasis on the care of addictions and other co-occurring mental disorders); as well as on the use and adoption of the guides available in the country (e.g., Guía para la detección, orientación y referencia del VIH y otras ITS en Centros para la Atención de las Adicciones; Guía para el uso de metadona en usuarios adultos con VIH dependientes de la heroína intravenosa), the development and dissemination of counseling and psychological evaluation interventions based on scientific evidence, the launching of programs for opioid overdose prevention; and the implementation of drug consumption rooms.