Criminalization costs pocket guide

The criminalization of people who use psychoactive substances in the Central and Eastern Europe, and Central Asia (CEECA) region, instead of maintenance of public health and safety, increases the financial and social burden on the states. For people who inject drugs, approximately 58% will experience incarceration in their life.[1]

Incarceration costs 2 to 6 times more than treatment from health and social service groups. However, in almost all the countries in the CEECA region, due to de facto criminalization of people who use psychoactive substances, harm reduction and other health services are severely underfunded and depend on international donors. Guidelines from the World Health Organization recommend that at least 40% of people who use opioids receive opioid substitution therapy (OST); however, most countries in the CEECA region barely reach 20%[2].

Governments should take evidence-based health and human rights approaches and reallocate money from policing, prosecuting, and incarceration of people who use psychoactive substances to community harm reduction and health services.

Below, you can find 11 statements, followed by supporting arguments, which should be used in advocacy work. Arguments are prepared based on existing practices and evidence-based information. Arguments are created to advise on advocacy of reallocating funds from law enforcement budgets to health and harm reduction budgets for people who use psychoactive substances.

This guide is supplementary to the “Criminalization Costs” assessment: https://harmreductioneurasia.org/criminalization-costs/.

One example of the cost-effectiveness[1] of harm reduction is the Law Enforcement Assisted Diversion (LEAD) program in the USA. LEAD was first introduced in King County, Washington to reduce recidivism among low-level drug and sex work offenders which now operates across the USA (map). LEAD comprises three primary components: an initial prebooking diversion, harm-reduction case management, and ongoing legal assistance and coordination. Through case management and other supportive services, 58% of people suspected of low-level criminal activity involving drugs and sex work were less likely to be arrested[2]. Also, criminal and prosecution costs, including jail, for LEAD participants were significantly lower than for control participants, with 4763 US dollars (USD) for the LEAD group and 11,695 USD for the control group[3].

In the late 1990s drug use became a serious problem in Portugal that required systemic changes to the country’s legislation[4]. This was mainly due to the injection of heroin and the risks of the spread of HIV/AIDS and viral hepatitis. In an attempt to solve this problem, on February 16, 1998, the government established the Commission for the National Strategy to Combat Drugs. In its 1998 report, the Commission recommended decriminalization as the best way to reduce drug use and drug abuse. In 2000 the Council of Ministers developed its own policy recommendations that were in line with those of the Commission and included a proposal for full-scale decriminalization. On November 29, 2000, the Parliament, with the President’s support, adopted Law No. 30/2000, which guaranteed implementation of the Council’s recommendations. When the law came into force on July 1, 2001, Portugal became the first European country to decriminalize the use and possession of all types of illicit narcotic drugs. After decriminalization and introduction of Dissuasion Commissions, the proportion of drug-related offenders in prison populations declined from 44% in 1999 to under 21% in 2012[5]. Furthermore, the average cost for people who use psychoactive substances and seen by Dissuasion Commissions (2005-2011) was lower than for those who had court cases (average of 357 euros versus 525 euros)[6]. Besides, the number of people choosing voluntary drug treatment increased by 60% between 1998 and 2008[7].

[1] Collins, S.E., Lonczak, H.S., &Clifasefi, S.L. (2019) Seattle’s law enforcement assisted diversion (LEAD): program effects on criminal justice and legal system utilization and costs. Available at: Seattle’s law enforcement assisted diversion (LEAD): program effects on criminal justice and legal system utilization and costs
[2] Collins,S.E.,Lonczak,H.S.,&Clifasefi,S.L. (2015) LEAD Program Evaluation: Criminal Justice and Legal System Utilization and Associated Costs. Available at: https://56ec6537-6189-4c37-a275-02c6ee23efe0.filesusr.com/ugd/6f124f_2f66ef4935c04d37a11b04d1998f61e2.pdf
[3] Ibid.
[4] The Portuguese drug policy framework. EHRA. Available at: https://harmreductioneurasia.org/wp-content/uploads/2018/11/Portugal_twe.pdf
[5] After decriminalization and introduction of Dissuasion Commissions, the proportion of drug-related offenders in prison populations declined from 44% in 1999 to under 21% in 2012. Transform drug policy foundation. Available at: https://transformdrugs.org/drug-decriminalisation-in-portugal-setting-the-record-straight/
[6] Silvestri A., Gateways From Crime To Health: The Portuguese Drug Commissions’(Report, Winston Churchill Memorial Trust, 2014) 11-12. Avaliable at: https://www.wcmt.org.uk/fellows/reports/drug-use-health-issue-learning-portuguese-policies
[7] Gender and drug policy: exploring innovative approaches to drug policy and incarceration, The Portuguese model for decriminalizing drug use, Marie Nougier. Available at: https://www.wola.org/gender-drug-policy-exploring-global-innovative-approaches-drug-policy-incarceration/

Prison generally does not deter people from the use of drugs; mostly, negatively affects the health and permanent socio-economic status of people who use psychoactive substances.Possession of drugs, even for personal use, is a criminal offence in most of th CEECA countries. People with a history of drug use or drug use disorders comprise a substantial portion of the prison population. Despite the assumption that incarceration of drug offenders exerts a deterrent effect, there is limited empirical evidence to support that idea[1]. Incarceration mostly, negatively affects the health and permanent socio-economic status of people who use psychoactive substances. Detainees are a vulnerable population with high morbidity. They frequently have poor medical follow-up given their limited previous access to healthcare due to educational, social and economic disadvantages.

About 1 in 3 people in prisons worldwide are estimated to have used drugs at least once while incarcerated[2]. Despite this, the CEECA region has only 17 countries that provide OST treatment in prisons, only 5 have needle and syringe exchange programs (NSP), and only 4 have both[3]. HIV, hepatitis C, and active tuberculosis infection are disproportionally higher among prison populations, particularly among those who inject drugs in prison. A review of available studies found that people who inject drugs in prison had six times the prevalence of HIV and more than eight times the prevalence of hepatitis C compared with the non-injecting prison population.[4] Criminal convictions severely limit future employment and educational opportunities, further alienating people with problematic drug use from productive re-entry into society[5]. Employers may face direct barriers to hiring formerly incarcerated individuals, in addition, they may be unwilling to risk liability for hiring individuals with criminal records. 

[1] Mitchell, O., Cochran, J. C., Mears, D. P., & Bales, W. D. (2017). The effectiveness of prison for reducing drug offender recidivism: a regression discontinuity analysis. Journal Of Experimental Criminology. Available at: The effectiveness of prison for reducing drug offender recidivism: a regression discontinuity analysis
[2] World Drug Report 2019 (United Nations publication, Sales No. E.19.XI.8). Available at: https://wdr.unodc.org/wdr2019/prelaunch/WDR19_Booklet_1_EXECUTIVE_SUMMARY.pdf
[3] Stone K, Shirley-Beavan S (2018) Global State of Harm Reduction 2018. Harm Reduction International: London. Available at: https://www.hri.global/files/2019/02/05/global-state-harm-reduction-2018.pdf
[4] World Drug Report 2019 (United Nations publication, Sales No. E.19.XI.8). Available at: https://wdr.unodc.org/wdr2019/prelaunch/WDR19_Booklet_1_EXECUTIVE_SUMMARY.pdf
[5] Council of Europe; Pompidou Group (ed.): “Mental Health and Addiction in Prisons. Written contributions to the International Conference on Mental Health and Addictions in PrisonsChapter: Drug use, mental health and drugs in prisons. Available at: https://rm.coe.int/mental-health-and-addiction-in-prisons-written-contributions-to-the-in/168075f532

UN System’s Common Position on Drugs[1] urges the states:

“To promote alternatives to conviction and punishment in appropriate cases, including the decriminalization of drug possession for personal use, and to promote the principle of proportionality…”

Some countries have introduced alternatives to imprisonment for drug-related offences[2], such as fines, suspended sentencing, probation, and disciplinary work (Moldova, Kyrgyzstan). In some countries, court provide pathways to treatment and rehabilitation as an alternative to incarceration (Russia[3], Latvia). Other divert people to harm reduction and social service without any interaction with the justice system (the LEAD program in USA and SUTIK in Estonia). In reality, these alternatives have limited efficacy. Forced treatment often does not work. Fines, suspended sentencing, probation, and disciplinary work still leave the criminal record intact, further burdening the most marginalized and vulnerable. Nonetheless, drug policy responses often include imprisonment to prevent use, generating considerable economic costs and in detriment to harm reduction funding in the community.

[1] UN System Common Position on Drugs (2018). Available at: https://www.unsceb.org/CEBPublicFiles/CEB-2018-2-SoD.pdf
[2] Stevens, A., Hughes, C. E., Hulme, S., & Cassidy, R. (2019). Depenalization, diversion and decriminalization: A realist review and programme theory of alternatives to criminalization for simple drug possession. European Journal of Criminology. Available at: https://journals.sagepub.com/doi/full/10.1177/1477370819887514#articleCitationDownloadContainer
[3] Golichenko, M., Chu, S.K.H. Human rights in patient care: drug treatment and punishment in Russia. Public Health Rev 39, 12 (2018). Available at: https://publichealthreviews.biomedcentral.com/articles/10.1186/s40985-018-0088-5

The criminalization of drug use deters people from treatment programs and has adverse effects on their health and well-being. Recent data have shown that incarceration is associated with an 81% increased risk of HIV and 62% increased risk of hepatitis C infection. Incarceration limits employment and educational opportunities and alienates those who have been incarcerated from rejoining society as productive citizens.

According to the 2018 Report of the UN High Commissioner for Human Rights[1], people who use psychoactive substances face an increased risk of torture and ill-treatment (while in detention). Human rights experts concluded that the use of withdrawal symptoms to obtain information or confessions, to punish or to intimidate or to coerce, may amount to torture. Both international and regional human rights documents prohibit torture and the inhumane or degrading treatment of people in prison or other detention facilities.

“A major obstacle to accessibility of treatment is the criminalization of personal use and possession of drugs. A study shows that over 60 per cent of people who inject drugs have been incarcerated at some point in their lives. The Committee on Economic, Social and Cultural Rights (see E/C.12/PHL/CO/5-6), the United Nations High Commissioner for Human Rights (see A/HRC/30/65), the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health (see A/65/255) and the Global Commission on HIV and the Law have recommended that consideration be given to removing obstacles to the right to health, including by decriminalizing the personal use and possession of drugs. Reports also indicate that decriminalizing drug use and possession, together with the provision of a continuum of support, prevention and treatment measures, can result in a decrease in overall drug use and in the drug-induced mortality rate.”[2]

[1] Report of the Office of the United Nations High Commissioner for Human Rights (2018). Available at: https://www.unodc.org/documents/commissions/CND/2019/Contributions/UN_Entities/A_HRC_39_39.pdf
[2] Ibid.

Fines disproportionally burden society’s most disadvantaged groups. People with drug dependence generally have low incomes and are easy targets for the police. If a person cannot pay a fine, or gets arrested multiple times, the fines grow exponentially, and the person can end up in debt, administrative penalties can become criminal, and/or the debt can be sent to a collection agency[1]. In some countries, a prison sentence does not free a person from debt. As a result, after incarceration, the person may lose housing, all sources of income, and resources needed for basic needs such as food, clothing, and medicine[2].

Returning prisoners have high rates of health, mental health, and substance use problems, and treatment for these conditions is more easily accessible for those who have housing. Returning prisoners also have high rates of tuberculosis, hepatitis B, and hepatitis C. These illnesses require ongoing treatment, and housing stability is often a prerequisite to obtaining continuous care. Housing also takes on particular importance for returning prisoners because of their need for employment, and the challenges they face in finding it. Employers generally require an address on a job application, and need to be able to contact potential employees during the application process. The difference between having stable and unstable housing can be the difference between obtaining a job or not, and can exacerbate the barriers to employment already facing individuals returning from prison.[3]

[1] Every 25 Seconds. The Human Toll of Criminalizing Drug Use in the United States. Human Rights Watch (2016). Available at: https://www.hrw.org/report/2016/10/12/every-25-seconds/human-toll-criminalizing-drug-use-united-states
[2] Jessica Mogk, Valerie Shmigol, Marvin Futrell, Bert Stover, Amy Hagopian, Court-imposed fines as a feature of the homelessness-incarceration nexus: a cross-sectional study of the relationship between legal debt and duration of homelessness in Seattle, Washington, USA, Journal of Public Health Available at: https://academic.oup.com/jpubhealth/advance-article/doi/10.1093/pubmed/fdz062/5510723
[3] Geller A, Curtis MA. A sort of homecoming: incarceration and the housing security of urban men. Soc Sci Res. 2011;40(4):1196–1213. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3173782/

Incarceration is not the only cost for society. The criminalization of people who use psychoactive substances also requires money for larger police forces, temporary detention facilities, medical facilities and examiners, prosecutors, defenders, judges, and other court workers. Furthermore, people who are incarcerated do not pay taxes and afterwards have tremendous obstacles to once again becoming productive citizens.

“Social integration, the costs and harms of criminal justice processes, other crimes, organized crime and health harms will all have an influence on the total social costs of drug use and policy. Gonçalves et al. (2015) found a reduction in total social cost following decriminalization in Portugal, despite the increased expenditure on the drug treatment services to which some people were diverted. These increased treatment costs were mostly cancelled out by reductions in the costs of dealing with viral hepatitis and HIV and substantial reductions in drug-related court cases and imprisonments, with less lost income and productivity due to such incarceration. In the Czech Republic, Zábranský et al. (2001) found that the change to a more restrictive form of decriminalization in 1999 significantly increased the costs of responding to illicit drugs.

The randomized control trial of the Turning Point diversion scheme showed that the average cost of a case diverted to a therapeutic intervention was 45 percent lower than that of cases prosecuted as normal, taking into account the costs of the interventions and court processing found the costs of Australian cannabis cautioning to be 47 percent lower than the costs of arrests. Other researchers have also found cannabis decriminalization with civil penalties in South Australia and de facto police diversion for cannabis in New South Wales to be substantially less costly than arrest.”[1]

[1] Stevens, A., Hughes, C. E., Hulme, S., & Cassidy, R. (2019). Depenalization, diversion and decriminalization: A realist review and programme theory of alternatives to criminalization for simple drug possession. European Journal of Criminology. Available at: https://journals.sagepub.com/doi/full/10.1177/1477370819887514#articleCitationDownloadContainer

“Criminalization costs” assessment shows that in average incarceration costs are 2-6 times bigger than the money spent for health and social services. The assessment of the costs of health and social services includes only cost to provide needle and syringe exchange services (NSP), opioid substitution therapy (OST) and unemployment benefit for one person per year. Nevertheless, it should be kept in mind, that the costs can be bigger or lower, depending on the persons situation.

The criminalization of people who use psychoactive substances can result in homelessness, food deficiency, domestic and police violence, loss of parental rights, and social isolation. Consequently, a person can become dependent on state support (which may include legal aid, social work, housing, etc.). There can also be additional medical costs to treat various health problems attributed to drug use and/or living in poverty, including treatment of HIV, tuberculosis, and hepatitis C infections, as well as sexual and reproductive health testing and treatment.

At the same time, we must understand, that not all people who use psychoactive substances are in need of NSP, OST, unemployment benefit and other state support.

UNAIDS estimates that 56% – 90% of people who inject drugs globally will be incarcerated at some stage during their life[1]. While the lifetime prevalence of drug use in prison ranges from 2% to 76% worldwide[2]. There are numerous international covenants and legal instruments which calls states to ensure access to health. As an example – Article 12 of the International Covenant on Economic, Social and Cultural Rights states: “the States Parties to the present Covenant recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.” This article means, that state must ensure access to the health services, including harm reduction services for all people (regardless of whether they are incarcerated or not).

The health consequences of drug use in detention facilities include acute withdrawal symptoms, which in some cases lead to death, infectious diseases, psychiatric comorbidity, overdoses and intoxication.

To adequately serve this population, all detention facilities must ensure the following:

  1. Access to quality OST for all in need and continuation of it after release. According the WHO “prison-based OST programmes appear to be effective in reducing the frequency of injecting drug use and associated sharing of injecting equipment, if a sufficient dosage is provided and treatment is provided for longer periods of time. The risk of transmission of HIV and other blood-borne viruses among prisoners is also likely to be decreased.” WHO also made a review of analysis of published and unpublished data on the effectiveness of OST in prisons, which revealed, that people who inject drugs and receive methadone substitution treatment in prisons, reported significantly fewer injections per week, than those who are not receiving treatment.

What is more, quality and accessible OST is improving security of prison, serves to improve health and well-being of prisoners, and has positive effect on institutional behavior. Different studies conducted among prisoners and prison staff showed, that OST in prisons have reduced anxiety among prisoners, it helped to prevent illegal trafficking of methadone in prisons, as well as reduced aggressive behaviour of inmates, which was usually caused by withdrawal.[3]

  1. Access to drug paraphernalia (needles, syringes, alcohol wipes, etc.). Studies show, that in prisons, where NSP doesn’t exist and it is hard to smuggle needles and syringes into the prison, 15 to 20 people may inject using the same equipment.[4] In some cases, equipment is made by the prisoners from hardened plastic and ballpoint pens, which imposes great risks to damage veins and leads to severe infections.[5] What is more, some studies reveal that prisoners do not disclose their positive HIV status because of fear not to get syringe to share with other prisoners in future. These are just few examples of why NSP in prisons is needed and how it contributes to a reduction of sharing syringes, which also means reduction of new HIV infections.
  2. Access to counseling & psycho-social interventions, as well as access to HIV, hepatitis C, tuberculosis, and sexually transmitted disease (STD) testing and treatment. HIV testing and counselling is a mean, which enables people to access treatment and get informed on relevant issues. Furthermore, counselling and testing should be voluntary and confidential, because in other case it can have negative effect on health for segregated inmates.
  3. Have trained and prepared staff to administer Naloxone. It is important to train prison staff, as well as inmates on administering Naloxone in case of emergency, to save people’s life. In most of the cases, if there is an overdose, prison staff should seek for a doctor who can give first aid. But in case of overdose – each second counts. The results from the novel opioid overdose prevention and training program in the minimum-security correctional facility in New York City showed that many corrections staff and parole officers recognize the need for naloxone in their communities.[6]

[1] The Gap Report 2014, UNAIDS https://www.unaids.org/sites/default/files/media_asset/05_Peoplewhoinjectdrugs.pdf
[2] Carpentier, C., Royuela, L., Montanari, L., & Davis, P. (2018). The global epidemiology of drug use in prison. In S. A. Kinner & J. D. “J.” Rich (Eds.), Drug use in prisoners: Epidemiology, implications, and policy responses (p. 17–41). Oxford University Press. https://doi.org/10.1093/med/9780199374847.003.0002 Available at: https://psycnet.apa.org/record/2018-08996-002
[3] WHO Library Cataloguing-in-Publication Data, Effectiveness of interventions to address HIV in prisons / Ralf Jürgens. (Evidence for Action Technical Papers). Available at: https://www.who.int/hiv/idu/OMS_E4Acomprehensive_WEB.pdf
[4] Small W et al. (2005). Incarceration, addiction and harm reduction: inmates experience injecting drugs in prison. Substance Use & Misuse, 40: 831-843 Available at: Incarceration, Addiction and Harm Reduction: Inmates Experience Injecting Drugs in Prison; Correctional Service Canada (1994a). HIV/AIDS in Prisons: Final Report of the Expert Committee on AIDS and Prisons. Ottawa: Minister of Supply and Services Canada; Taylor A, Goldberg D (1996). Outbreak of HIV infection in a Scottish prison: why did it happen? Canadian HIV/AIDS Policy & Law Newsletter, 2(3): 13-14
[5] Small W et al. (2005). Incarceration, addiction and harm reduction: inmates experience injecting drugs in prison. Substance Use & Misuse, 40: 831-843; Taylor A, Goldberg D (1996). Outbreak of HIV infection in a Scottish prison: why did it happen? Canadian HIV/AIDS Policy & Law Newsletter, 2(3): 13-14 Mahon, 1996; Hughes RA (2003). Illicit drug and injecting equipment markets inside English prisons: a qualitative study. Journal of Offender Rehabilitation, 37(3/4): 47-64.
[6] Harm Reduct J. 2015; 12: 51. Published online 2015 Nov 5. doi: 10.1186/s12954-015-0084-8, Overdose prevention for prisoners in New York: a novel program and collaboration, Howard Zucker, Anthony J. Annucci, Sharon Stancliff, and Holly Catania. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4635619/

Approximately 95% of incarcerated people with problematic drug use will use after release from prison, and 60% to 80% of them will commit new crimes[1]. In addition, it is highly probable that those who never used drugs will start in prison due to the easy availability of drugs. As an example, significant number of prisoners start injecting in Ireland prisons – 21% of prisoners who inject drugs reported that they had started to inject while in prison.[2]

The use of drugs in prison creates additional health risks because of the lack of harm reduction services in prison settings, the high likelihood of shared injecting equipment, the use of new psychoactive substances as alternatives to illegal drugs, and the altered modes of drug use (i.e., from sniffing to injecting). Drug use exists in all prisons and it is associated with adverse health effects. Furthermore, criminalization increases exposure to violence, aggressiveness[3], as well as stimulates social segregation, stigma and discrimination[4].

In addition, a criminal record limits employment and educational opportunities, and leads to various economic, social, and legal problems. After imprisonment it is usually hard to find a job and studies show that people who use drugs are in the potential risk to start activities such as sex work, which in most of countries is criminalized, or other misdemeanors and crimes, to support their drug use.[5]

[1] Spohn, C., & Holleran, D. (2002). The effect of imprisonment on recidivism rates of felony offenders: A focus on drug offenders. Criminology, 40(2), 329-357. Available at: The Effect of Imprisonment on Recidivism Rates of Felony Offenders: A Focus on Drug Offenders
[2] Allright S et al. Prevalence of antibodies to hepatitis B, hepatitis C, and HIV and risk factors in Irish prisoners: results of a national cross sectional survey. British Medical Journal 2000; 321: 78-82. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC27426/
[3] Werb D, Rowell G, Guyatt G, Kerr T, Montaner J, Wood E. Effect of drug law enforcement on drug market violence: a systematic review. Int J Drug Policy 2011; 22: 87–94. Available at: https://www.ncbi.nlm.nih.gov/pubmed/21392957
[4] Dixon D, Maher L. Anhai: policing, culture and social exclusion in a street heroin market. Policing Society 2002; 12: 93–110
[5] Maher L, Dixon D, Hall W, Lynskey M. Property crime and income generation by heroin users. Aust NZ J Criminol 2002; 35: 187–202. Available at: https://espace.library.uq.edu.au/view/UQ:39428

Taxpayers fund oversized police budgets, drug testing, jails, prisons, medical professionals, public defenders, prosecutors, and courts. In the EHRA assessment on “Criminalization costs” you can find estimations for incarceration costs in the countries of CEECA region. After release from prison, there are further costs to reintegrating ex-inmates into society. Criminalization also creates other risks and threats, such as infections, overdoses, and mental health issues. Not only does criminalization lead to social isolation, stigma, and discrimination against people who use psychoactive substances, expenses associated with criminalization are a chronic drain on state budgets.

Some policymakers believe that public health and safety can only be preserved through the criminalization of people who use psychoactive substances. However, data have shown that this mistaken belief contributes to violence against people who use psychoactive substances; an increased rate of HIV, hepatitis, STD transmissions; and stigma and discrimination that undermines people’s physical and mental health. In some countries, policing deters people from accessing life-saving services, such as NSP and OST.

People who use psychoactive substances should not be criminalized for the possession for personal use of small amounts and should not be afraid to carry drug paraphernalia for minimization of risks related to drug use or Naloxone, which saves lives. Securing public health means also securing the right to health of people who use psychoactive substances and preventing the spread of the newly emerging drugs, which impose high risks to people’s health and life.

The criminalization of people who use psychoactive substances instead of the treatment of the underlying causes of addiction increases costs to the state, robs the state of tax revenue and citizen productivity and creates unnecessary and permanent harm to a person’s right to health and life.[1]

[1] https://harmreductioneurasia.org/wp-content/uploads/2018/11/Law-enforcement-cooperation-with-SCO-policy-brief-2_twe.pdf

[1] Jack Stone, PhD, Hannah Fraser, PhD, […], and Peter Vickerman, Incarceration history and risk of HIV and hepatitis C virus acquisition among people who inject drugs: a systematic review and meta-analysis. Available at: https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(18)30469-9/fulltext
[2] Regional Report: Programmatic and Finance Gaps for Key Populations in a Selection of Eastern Europe and Central Asia Countries, Eurasian Harm Reduction Network (EHRN), East Europe and Central Asia Union of PLWH, 2017