Injecting drug users at the interface between humaneness and the law

Injecting drug use is driving HIV epidemics in many parts of the Asia-Pacific region: in some countries, injecting drug users (IDUs) make up more than half of people living with the virus.

Prof Adeeba Kamarulzaman, of the University of Malaysia's Infectious Diseases Unit, told delegates at the 8th International Congress on AIDS in Asia and the Pacific (ICAAP) in Colombo, Sri Lanka, this week, that even in countries where HIV infections among IDUs were relatively low, "injecting drug users don't live in isolation"; they are connected to the general community through sex workers and spouses.

Until recently, HIV prevention efforts for IDUs were hampered by global drug control policies that favoured law enforcement and incarceration over "harm reduction", a more scientifically based approach that prioritises health and human rights.

This approach is gradually gaining ground in the region, with countries such as Malaysia, Vietnam and Taiwan pioneering the use of needle exchange programmes, substitute treatment with synthetic forms of heroin, HIV/AIDS education, and health and social services tailored to IDUs.

Paul Hardacre, training manager at the Thailand-based Asian Harm Reduction Network, which also runs programmes in Vietnam and Myanmar, said civil society organisations had tended to take the lead, but governments were increasingly convinced by the evidence in favour of harm reduction.

"They're very pragmatic. It's not necessarily that they embrace the philosophy behind harm reduction, but they can see the demonstrable effects," he told IRIN/PlusNews.

Presenting the case for Taiwan's rapid adoption of harm reduction strategies in the past year, Lin Sheuerong, director of public health for Taoyuan County, said 60 percent of new HIV infections in 2006 were among IDUs.

After an intensive period of training and consultation with police, teachers, healthcare workers and IDUs themselves, hundreds of needle-exchange sites were set up at local pharmacies, and more than 5,000 heroin addicts were now receiving methadone treatment. According to Sheuerong, there was already evidence that HIV infections were falling.

The World Health Organisation and UNAIDS have also recommended harm reduction as an HIV prevention strategy. "There's undisputable evidence [that harm reduction] works," Kamarulzaman told conference delegates. Yet, worldwide, risk-reduction messages reach only one in eight IDUs, and only one in 33 has access to a clean needle programme.

Lingering medical, political and societal prejudices against IDUs, with legal restrictions on needle distribution and substitution drugs, still form the basis of policies in many countries. For example, methadone is still illegal in many countries, including Sri Lanka, despite its inclusion on the WHO's essential drugs list.

"Harm reduction is at the interface of drugs and HIV, so even if a health department would like to offer more compassionate services, their policies tend to clash with drug control policies, and drug control usually takes precedence," said Hardacre.

"Harm reduction" can describe widely varying models: Thailand, for example, provides methadone treatment to addicts, but only for a period of 45 days; other countries favour a maintenance programme in which some addicts will depend on the drug for years if they are to lead anything approaching a normal life.

The most effective harm reduction strategy, according to Hardacre, is one that goes beyond methadone treatment and needle-exchanges to incorporate psycho-socio services and even poverty alleviation programmes.

He cited a non-governmental organisation in Pakistan that began by offering traditional drug detoxification facilities, then moved into providing health services and clean needles, and now helps its clients to get involved in successful businesses, like manufacturing furniture and leather goods, growing table grapes and customising old US army jeeps. "That's harm reduction in its broadest sense," said Hardacre.

While there is no such thing as one model that fits all situations, Kamarulzaman outlined some best practices. Involving drug users in developing the programmes and determining the most convenient places where IDUs could access them was vital, as was the involvement of law enforcement and health departments.

"Often, the burden of service delivery has fallen on civil society organisations, which has led to high staff turnover," she said. Hardacre agreed. "NGOs are taking the lead, and they can be important for capacitating governments," he said, "but, ultimately, only governments can scale up programmes nationally."

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