_Global Harm Reduction Advocacy
Reduce Harm Through Education and Access
The calls for worldwide governmental support for harm reduction strategies continue to be voiced at the international conference. A multinational panel of epidemiologists and health care providers presented evidence regarding the effectiveness of free and available condoms and clean syringes in reducing HIV transmission. The panel concluded that any national strategy to reduce the number of new HIV cases must include a significant harm reduction model in order to be truly effective.
Global harm reduction strategies
Although regular local evaluation of harm reduction strategies are vital, only global studies are likely to result in sufficient political will to make a real dent in the spread of HIV among injecting drug users (IDUs). Speakers at Monday's harm reduction session stressed that there were no "quick fix solutions" but that needle exchange programmes (NEPs) were indeed proving effective.
To lend a global perspective, Dr Theresa Perlis, of the National Development and Research Institutes in New York, reported the preliminary findings of the WHO's Rapid Assessment Research (RAR) on the extent and nature of intervention coverage. This forms the first phase of the "WHO Drug Injecting Study Phase 2: 2000-2002", a comprehensive questionnaire survey and needs assessment of harm reduction centres worldwide.
The RAR focused on programmes in Beijing, Bogota, Hanoi, Kharkiv, Lagos, Minsk, Penang, Nairobi, Rosario and St Petersburg.
The study found that although narcotic use remained illegal and carried extreme social stigma, most governments officially supported harm reduction programmes. Inadequate resources and infrastructure, however, continued to constrain effective implementation. Users were usually forced to pay for expensive rehabilitation treatments like methadone substitution. They were also often afraid to exchange needles at centres or buy equipment from pharmacies for fear of police arrest. The WHO study recommended that a quality comprehensive service would include needle social marketing; offering syringes, condoms and bleach/disinfectants free at NEPs, and also making these affordable at pharmacies.
The next speaker, A Hauri of the Safe Injection Global Network (SIGN), added that unsafe needle practices were particularly worrying in South Asia, the Middle East and the Western Pacific. He said that exchange programmes would be more effective if integrated into other health promotion programmes such as HIV prevention, essential drugs, vaccines, contraception and waste disposal management.
The three other session speakers focused on the efficacy of NEPs in specific regions. David Burrows, an Australian consultant specialist, reported on the work of 16 Russian NEPs in community and prison settings for a 2001 World Bank study to recommend best practices.
Two surprising findings in the study were that a third of the 600 NEP employees were doctors (probably due to low medical salaries in the state sector) and another third were IDUs or ex-IDUs. He recommended that doctors slowly be replaced by more peer educators. Such support had proven particularly effective: 60% of clinic attendees had been HIV tested and/or involved in support programmes. The key problem with programmes in this region however, was that coverage was estimated at less than 5%.
Peter Vickerman of the London School of Hygiene and Tropical Medicine contributed his mathematical model of a study in Svetlogorsk, Belarus. This model was falling into line with observations at the NEP where HIV prevalence had fallen from 74% in 1997 to 71% in 2000.
Vickerman stressed that reducing HIV incidence through NEPs was no "quick fix." His model predicted that reducing HIV incidence to 30% would take 17 years. The HIV infection rate could only be reduced from its current 46% to 25% if the incidence of needle sharing was halved. Life expectancies among HIV infected IDUs were ten years, and 24 years for those not infected (through overdoses, etc.). Across the Atlantic, Sylvia Inchaurraga of the Latin American Harm Reduction Network (Relard) reported on increasing drug use and related HIV infection, closely associated with rising poverty in South America.
Here cocaine is the injected drug of choice, particularly in Argentina, Brazil and Uruguay. Harm reduction education campaigns had spread through the region since 1993 with some cautious state support, but NEPs existed in only Brazil, Colombia and Argentina to date.
From further north, Dr Susan Sherman, of the Bloomberg School of Public Health, focused on secondary syringe exchange in Baltimore. Her group's study had found that high volume exchangers had adopted lower risk injection and disposal practices compared with other IDUs, and that women, who possibly also exchanged for their partners, were twice as likely to be high volume exchangers.
Harm reduction and policy implications
Four presentations were made during this session, two less than announced. Despite the fact that harm reduction projects and experiences are widely reported to be successful, it is still difficult to develop and implement them. All presentations made at the session tried to analyse why this is so and how can we get out of this blocked situation.
The first contribution concentrated on safe injection facilities, particularly in Canada. Legal issues were examined. Arguments against such facilities are outweighed by the expected benefits. In Canada, the law doesn't forbid the setting of safe injection facilities. Even international treaties don't mention them. On the legal side, it could be assumed that the obligation to respect a person's right to health make them possible. Government should support their implementation.
Lazzarini presented a rapid policy assessment tool which helps to assess the policies adopted by countries towards harm reduction. This framework allows us to identify where the legal-structural problems are, what kind of changes in the legal system are needed. The research must also help to find solutions and to identify the legal changes which are needed.
Gustavo Hurtado presented the Argentinean Harm Reduction Project. In Argentina, IDUs are almost impossible to reach because of the very repressive policy followed by the police and prescribed by the law. One of the most efficient actions of the project is distributing information about their rights in case of arrest to youngsters using drugs. Addressing the need to change the law is also an important task of the project.
For a long time, the incidence of IDUs into the AIDS epidemic in Indonesia was ignored. But, according to the presentation of Irwanto, HIV infection through needle sharing among IDU has been increasing significantly (less than 1% of HIV cases in 1999 to over 19% in 2001). Injecting drug use seems to be increasing rapidly in Indonesia. In order to implement harm reduction measures, convincing all opinion leaders is needed (in the politics, religion, health system, and so on).
All the presentations stressed the fact that the benefits of harm reduction are well documented. But they are too often ignored by politicians. The chosen way to change is often a mix of pragmatism and advocacy. It allows small progress, step by step, which isnot likely to bring the decided response the HIV epidemic in IDUs is asking for. Furthermore, there is still a certain denial in some countries about the reality and the prevalence of injecting drug use. Denial is often the main argument to not fund harm reduction projects or to not even consider them.
The discussion also put into light the negative effect of the policy of USA, which advocate a drug policy aimed at strict abstinence only, or at least present themselves as such on the international level (lots of harm reduction projects happen on a local basis in the USA). UNDCP was also criticised for its attitude condemning systematically harm reduction and substitution policies. Often, UNDCP states that harm reduction programs are not permitted by international treaties, which can be seen above all as an ideological attitude.
More networking is needed in order to have more harm reduction for injecting drug users. Sharing and publicising positive outcomes is certainly the best tool, as the evolution in Europe for the past decade shows clearly. Sound optimism is possible, even if this slow evolution will mean a lot of new HIV infections.
Health disparities and IDU HIV interventions
Three papers dealt with issues relating to IDU populations. The first paper looked at an empowerment-based, woman-focused intervention for African-American women who use drugs, and its possible adaptability for South Africa. The second paper was about health disparities and their impact on HIV prevention among ethnically diverse sample of drug-using women living north of the US/Mexico border. The third paper that was presented was also about drug using in South Africa.
The studies were focused on women as drug users and as sex workers. Some of the women were married, living with partners and were doing sex work as a source of income because of unemployment. Some of their partners knew that they were sex workers. They in return did not know whether their partners were involved in any other relationships.
The studies also looked at condom use. One of the studies specifically highlighted the use of two or more condoms used during sexual intercourse. This showed that some of the sex workers did not know how to use a condom. Some of them also claim that they don't use a condom when they sleep with their partners
All three of the studies looked at women, their drug use and sexual behaviours. Within all three presentations the social-economic issues could not be ignored. Other social factors like power relations, abused relations, and cultural issues could not be ignored.
These factors were directly linked to the abuse of drugs. It was further emphasised that drugs help the women to forget, especially if they work as sex workers.
All three studies still need a lot of work because very little is known about women drug users and their sexual behaviors in relation to health care. The cultural, social and economic pressures are on the increase that puts further pressure for complete sample studies.
Time to scale up harm reduction
One of the most striking and pleasant ways that this Barcelona conference differs from the conferences of the past is that that there has been broader coverage of issues related to providing a continuum of prevention and care to one of the most stigmatised and vulnerable and difficult to reach groups world wide - injecting drug users.
This reflects both a growth in the awareness of the needs of this group and a growth in the body of scientific evidence about effective means of promoting health and preventing HIV transmission in this group.
There were well-attended sessions on Harm Reduction every day. The sessions presented a range of experience and evidence including proof that this group can be accessed successfully, proof that their risk behaviors can be chanced, proof that changing their behavior lowers HIV transmission, proof that needle exchange does not increase drug use, and proof that drug users can be compliant to ARV therapy regimens.
The sessions also made it clear that these effective approaches are still under funded and under-practiced. Political will which is a key factor in scaling up effective programs is still lacking in most parts of the world.
A closer look needs to be taken at the processes of advocacy for political will in countries like Spain and Brazil which have successfully scaled up harm reduction activities. The evidence is clear and available. Now it is time to advocate for its application.
Health & Development Networks/Key Correspondent Team
< Spanish NGO "No Mas SIDA En Prision" [Clean Needles in Prisons] Action
Red2002 Press Release
8 July 2002
NO HEALTH NOR RE-INTEGRATION IN PRISONS
One of our main worries amongst the groups and associations (affected or engaged) which have been working for many years on HIV prevention, is the exchange of syringes by drug users and more specifically amongst the ones who have lost their freedom.
In the last few years the risk and harm reduction polices which have been implemented throughout the entire community have resulted in a considerable reduction in the incidence of blood transmitted diseases amongst IVDU (intravenous drug users) and have proved to be efficient and reliable.
At the present time everybody is aware that drugs are available and used in prisons. Anybody who knows about the "correctional" system knows that it is easier to find illegal drugs in prison than sterile syringes, which increases the incidence of HIV and HCV (Hepatitis C virus).
However the programs in the penal centers (PC) are limited to methadone maintenance programs (MMP) as a substitute for drugs. Anybody who is not currently able or willing to stoop using intravenous drugs have no other option but to exchange contaminated material.
The number of HIV+ people is alarming (12,000) in penal centers ( in Spain) where AIDS is one of the most common causes of death.
The penal system was originally created to isolate anybody who has committed a crime from the rest of society, in order to educate them for a possible social re-integration. however we have to admit that an essential issue such as health is being denied to this group of people, which makes it harder for them, if not impossible in some cases, to have successful re-integration.
Plataforma por los derechos de las personas usuarias de drogas de Cataluña (Catalonia association for the rights of drugs users) and Red2002 are denouncing the absence of preventive measures in penal institutions and the violation of the right to medical coverage for people who have lost their freedom.
Amongst the Catalan community, which is welcoming the International AIDS Conference this year and has full independence on health and judicial decisions, the use of those programs have not been possible yet and an alarming number of prisoners are still getting infected, as shown in several studies.
In the rest of the country, a total of 10 centers have started the programs. There is also a number of pilot tests which are being evaluated (none of them in Catalonia).
The programs have proven to be efficient, with successful results and no increase in the number of drug users, a decrease in the new cases of transmission and with few problems.
In Red2002, we see the situation as a clear violation of the prisoners' rights and discrimination in the medical services available in the penal centers, in comparison with the community in general, which is a damaging factor for people's health.
For all these reasons, during the last 4 years we have been putting pressure on the government in order to start these programs on a large scale and in all the penal institutions (in Catalonia and the rest of Spain), but at present, in our community, and despite the repeated efforts of the community, the programs have not yeat been started.
The Catalan government, whose role is to guarantee our right to health care, has to resist the pressure put on them by certain groups of the population who want to place the improvement of work conditions before prisoners' health. Also they have to refuse to practice electoral favoritism when they carry out public health policies.
We are shocked at the incapacity of the Catalan Government to apply these programs to all penal institutions and we really wonder who is in charge of our Government.
In the name of everyone who in involved in prevention and for the improvement of quality of life for drug users, we declare that we are not ready to accept this violation and we will keep fighting till we obtain equal rights for this part of the population, in order to preserve their health, individually and as a group.
Red2002 firstname.lastname@example.org www.red2002.org
PRISON AND HEALTH - A VIRTUAL REALITY? .Manifesto from Red 2002
....HARM REDUCTION POLICIES BY THE U.S. GOVERNMENT :
How our Federal Government uses AIDS as Social Blackmail
....Latest U.S. Policy Fiascos :
Washington Times Profiles New Jersey State Senator's Fight Against Governor's Proposed Needle Exchange Program, Jul 19, 2002
The Washington Times today profiles the efforts of New Jersey state Sen. Gerald Cardinale (R) to fight Gov. James McGreevey's (D) proposed needle-exchange program. In his effort, Cardinale plans to highlight a recent Johns Hopkins University Bloomberg School of Public Health study indicating that "high-risk sex," not needle sharing, is the "strongest predictor" of HIV infection among injection drug users. The study tracked 1,800 initially HIV-negative injection drug users from 1988 to 1998 and found an HIV incidence rate of 10.4% annually among sexually active homosexual males who injected drugs, compared to 4.5% per year for those who shared needles. Among female injection drug users, 8.1% contracted HIV through sex with infected men and 4.4% contracted it through sharing needles. McGreevey in February proposed the hospital-based program, in which injection drug users would exchange used needles for clean ones in order to prevent the spread of HIV and hepatitis. Cardinale said, "It's counterproductive for the government to be facilitating injection drug use," adding, "The best program is to tell people, starting when they are young and in grammar school, that the use of drugs is destructive and stupid behavior." Johns Hopkins researchers said that the findings of their study "should not be interpreted as meaning there is less need for needle-exchange programs to reduce HIV risk" (Howard Price, Washington Times, 7/19).
said Roland Foster, a republican congressional "aide" on Criminal Justice, Drug policy and Human Resources and former senior legislative aide to Rep. TOM COBURN and frequent hack to the Conservative "Americans for a Sound AIDS/HIV Policy" and the Conservative movement in Washington:
"It turns out many of the assumptions of needle-exchange proponents have been wrong. Frequency of drug use and sex are the behaviors that are most likely to cause addicts to become infected. Needle distribution does nothing to address these risks but contributes to the drug abuse that fuels both," said Roland Foster, staff member of the House Committee on Government Reform's subcommittee on criminal justice, drug policy and human resources.
The Washington Times July 19, 2002
HHS Secretary Tommy Thompson held a press conference after the Barcelona AIDS Conference GMHC Zap [ transcript ] and said the following about the history of Government Policy on Needle Exchange: "and we came to the conclusion that, from a scientific standpoint, the answer to those questions is that it does prevent the spread of HIV infection and it does not contribute to drug abuse.
HHS Secretary Thompson : You know, I have found the administration to be really quite flexible about considering a number of things. You all know the history of this and I see people around us who know the history the history was that during the second term of the Clinton administration, a group of us were myself, Jeff Copeland, David Satcher (MS?), and a number of other people, Alan Leshener (MS?) who was at that time the Director of the National Institutes of Drug Abuse were asked to examine all the existing data, to try and answer two questions. A, does needle exchange promote drug use? And B, does the needle exchange help prevent HIV infection? We went over, on a weekend, literally hours and hours and piles and piles, and we came to the conclusion that, from a scientific standpoint, the answer to those questions is that it does prevent the spread of HIV infection and it does not contribute to drug abuse. We made the recommendation to Secretary Shalala at the time, that she embraced, but for a variety of reasons that are very complicated, including, for example, members of the African-American community in Congress and out of Congress who were uncomfortable with that program, because it looked like one was essentially giving up on the predominantly African-American and Latino communities that comprises much of the injection drug users. So the scientific data we gathered and we made a recommendation, I think there was some confusion the other day, is that I was part of the scientific group that said we should definitely consider seriously, if not implement, a needle exchange program. But at the time, when the recommendation was made to the President, because of so many conflicting issues, the ultimate decision was not to implement it. Not to block it we were allowed, and I can clearly remember the instructions we got from Secretary Shalala, that we were allowed to interact with programs that had needle exchange programs associated with them, but there would not be federal dollars that were directly appropriated and directly assigned to that. So there were a lot of programs that we were involved with that also had issues in which individuals were on programs that were needle exchanges, at the same time that they were doing that. The point that I made when the Secretary asked me, when the question was thrown upon us, was that had not been a major issues under briefing items, was that, in fact, the policy has not changed. I can't address anything beyond that, but I can just explain what the history is of how that came about.
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