ACW:Pharmacotherapy

Vietnam to offer heroin addicts methadone

2008-04-29T15:24:00.001+07:00

By, Radio Australia, April 29, 2008

Vietnam has opened clinics offering drug users the substitute drug methadone, to help wean heroin addicts off injected drugs and reduce the spread of HIV/AIDS.

Two clinics have opened in the northern port city of Haiphong, which has a large number of heroin addicts and high HIV infection levels.

It's expected to treat 700 drug users with the heroin substitute methadone from now until December.

More clinics will open next month in Ho Chi Minh City, which has the highest HIV infection rate in the country.

The United Nations AIDS agency UNAIDS has welcomed the program, saying methadone programs can reduce illegal drug use, crime and mortality, as well as reducing the spread of HIV and hepatitis.

Observers say around 300,000 people in Vietnam are believed to be living with HIV, the majority of whom are drug users, sex workers and homosexual men.

Source: http://www.radioaustralia.net.au/news/stories/200804/s2229749.htm?tab=asia

Thailand's Anti-Drug Efforts Hindering Fight Against HIV/AIDS, Advocates Say

2008-04-24T11:01:00.001+07:00

By, Kaiser Network, April 23, 2008

Thailand's efforts to fight drug use are hindering HIV/AIDS control programs in the country, some HIV/AIDS and human rights advocates said recently, Thailand's Nation reports. According to a statement released by the groups on Tuesday, former Prime Minister Thaksin Shinawatra in 2003 implemented a policy aimed at eradicating drug use that included extrajudicial executions, forced drug rehabilitation, and "blacklisting" of suspected drug users and dealers. "The 2003 war on drugs is notorious for the crimes against humanity perpetuated by Thai authorities," Karyn Kaplan, director of policy and development at the Thai AIDS Treatment Action Group, said. She added that the groups are "horrified that Thailand would relaunch such a disastrous government policy."

The 2003 policy also hindered drug users' access to HIV/AIDS services -- such as treatment, prevention and counseling -- by driving users further into hiding, according to the statement. Kriengkrai Aiemprasert -- an outreach worker at the Ban Mit Sampan Harm Reduction Center in Bangkok, Thailand -- said that the war on drugs will have "disastrous consequences for the fight against AIDS in Thailand, and it will not work as a response to drug use in Thai society." Kriengkrai added that Thailand's prime minister should "end the war on drugs and promote a response to drug use based on evidence and human rights."

According to the statement, a large percentage of drug users in Thailand are HIV-positive. In addition, the statement said that although HIV rates are declining overall in Thailand, rates are not decreasing among vulnerable groups such as drug users or men who have sex with men. TTAG Director Paisan Suwannawong said that instead of an effective response to drug use, the Thai government has "pledged to crack down on drugs" and has told advocates to "expect more murders."

The groups plan to organize demonstrations outside upcoming UNAIDS meetings in Chiang Mai, Thailand, and New York City to call on Thailand to reconsider its war on drugs (Nation, 4/22).

Source: http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=51692

Iran's addicts fall victim to geography

2008-03-10T10:20:00.000+07:00

By, Anna Fifield (Tehran), Financial Times Deutschland, February 28, 2008

Iran shares a long border with Afghanistan, which produces 90 per cent of the world's opium, and as much as half of that is smuggled through Iran. The country's proximity to the world's biggest opium producer has led an estimated 5m into narcotics.

Three years ago things could hardly have been worse for Ali-Reza Fatehi. His family had disowned him, he had lost his profitable business selling socks in the Tehran bazaar and his television set was his only friend.

When he was not watching television he was rifling through rubbish bins to collect plastic that he could sell on to recycling companies.

"It was a very degrading job and completely out of character for me," says Mr Fatehi, looking down at his stained shaking hands through dark-ringed eyes. "But at the time I was doing crack and heroin and I wasn't myself."

Explosion in opium production since US-led invasion

Officially there are 1m drug addicts in Iran but international health workers estimate that the figure is much closer to 5m, in a country of 70m people. While much is known about the problem in neighbouring Afghanistan, and particularly about the explosion in opium production since the US-led invasion seven years ago, Iran's significant drug challenge is below the radar.

But Iran shares a long border with Afghanistan, which produces 90 per cent of the world's opium, and as much as half of that is smuggled through Iran, partly for export and partly for consumption by people such as Mr Fatehi.

Iran's addicts spend $3bn - the equivalent of 15 per cent of Iran's annual oil income - on drugs each year and their problem has led to a multitude of social ills, including an increase in HIV infections. There are about 70,000 HIV/Aids sufferers in Iran, about 60 per cent of whom were infected by sharing needles.

But just as Iran is a victim of its geography, Mr Fatehi, 37, was in some ways a victim of his success.

"I dropped out of school and started selling socks and stockings," he says at the Persepolis centre, a non-governmental treatment centre in southern Tehran where he goes every day for methadone, an opiate-replacement therapy.

"I was making very good money so I hired someone to run the business for me. I had a lot of free time to go to my friends' houses and have fun, but one of them introduced me to opium."

He progressed to heroin, crack cocaine and crystal meth and was an addict for more than a decade, until he finally sought help three years ago.

"Physically I'm clean now but mentally I'm not. I can't imagine not having any substances in my life," he says. "But this medicine has helped me a lot."

The Persepolis centre is one of a handful of pioneering institutions that treats drug users. It focuses on harm reduction - giving fresh syringes and condoms to addicts - and provides methadone to about 250 people a day, a fifth of whom are women.

Spread of HIV and AIDS

"Many addicts catch other diseases such as HIV or hepatitis so we teach them how to inject cleanly and to uphold healthy practices," says Gaila Darvishany, one of the centre's managers. Volunteer workers dole out plastic cups of methadone and change the dressings on the wounds of crack users who have accidentally burnt themselves.

Iran is a natural bridge between Afghanistan and Europe - ideal for smugglingThe government is trying to stem the flow of drugs into the country, a struggle that has led to the killing of more than 4,000 police officers in the course of drug control operations since the 1979 Islamic revolution.

Iran has built what Roberto Arbitrio, the head of the United Nations office on drugs and crime in Tehran, calls an "Iranian Great Wall" of ditches and fences along the border with Afghanistan and Pakistan.

Heroin trafficking on a huge scale

"Iran is a natural bridge between Afghanistan and the 'Balkan route' to Europe. Plus, to the north there is the Caspian Sea and the Russian market, and to the south is the Gulf, increasingly a route for hashish," Mr Arbitrio says.

"But this is not a situation where you've got a guy coming across the border with a suitcase containing 1kg of heroin," Mr Arbitrio says. Traffickers in 4WDs carry Kalashnikov machine guns and rocket-propelled grenade launchers, travelling "like an army" and using guerrilla warfare, he says.

After waging waging his own struggle, Mr Fatehi - who has now found himself a cleaner line of work, selling cigarettes from a sack on the pavement - has modest ambitions for the future.

"My life has already got a lot better," he says. "But now I'd like to get married and have kids. I'd like my mother to come and visit me more. I'd like for my dad to accept me. I'd like to be myself again."

Source: http://www.ftd.de/karriere_management/business_english/:Business%20English%20Iran/322896.html

The success and limits of harm reduction

2008-03-10T09:50:00.000+07:00

By, Lawrence D., Gay City News, February 14, 2008

Research presentations by AIDS epidemiologists and medical doctors offer ample understanding of the impact of harm reduction in preventing or slowing the spread of HIV. When it comes to preventing the virus' transmission, the two biggest harm reduction innovations have been needle exchange and safer sex approaches conceptualized and implemented in the US in the mid-to late 1980s.

I work in addiction medicine, specifically methadone maintenance, which fosters needle exchanges and offers opiate-injecting addicts a means of obtaining opiate medication without the use of needles. It has emerged as one of the most effective harm reduction tools.

Two decades later, how do needle exchange and safer sex campaigns compare in terms of results? Harm reduction successes have been stunning in the case of needle use and addiction. HIV rates among needle-using addicts in New York -still the epicenter of AIDS among injection drug users - are down by as much as 80 percent. So much for former New York City Mayor Ed Koch's observation that needle exchanges were an idea whose time had not come and would never come for our city.

Much of this success would have been impossible but for the work of early activists in ACT UP, passionate fighters who bucked the system with a mission of life-saving, the results of which they can be justly proud and likely are beyond their most outsized hopes. Their pioneering advocacy on needle exchange sits alongside ACT UP'S work in spearheading the push for anti-retroviral treatments, which have transformed HIV disease from a certain death sentence to a chronic condition very often compatible with longevity and high quality of life.

Encouraging the use of these treatments led to another clear success of harm reduction - the prevention of HIV transmission from mother to fetus. The success rates in New York now approach 100 percent.

What about the impact of safer sex harm reduction efforts on the rate of sexual transmission of HIV? Have they achieved comparable success?

There is no doubt that safer sex practices have prevented and continue to prevent countless cases of HIV transmission, but the results of this harm reduction approach offer a more complex, variable, and ultimately disappointing picture.

Not only are the declines in new HIV cases these days a lot less dramatic among the sexually active, they are nonexistent or worse in some populations. We are seeing increasing rates of infection, sometimes dramatic, and often accompanied by escalations of other STDs, now including MRSA, the multi-drug-resistance strain of staph. And that phenomenon has been seen in diverse settings - among inner-city men who have sex with men; in the 13-19 year-old demographic, especially black and Latino; in those who use crystal meth; and among middle-aged and older gay men.

It seems clear that safer sex approaches, not to mention abstinence, however intermittently successful, do not currently achieve anywhere near the success of needle exchange in reducing the transmission of HIV. I strongly agree with Gay City News' s condemnation of panic-mongering in the media - articulated in Duncan Osborne's critique of the recent New York Times story on the spread of MRSA in gay men.

But we must recognize that until we find a way to achieve the same sort of success in our harm reduction efforts on safer sex that we've seen through needle exchange, the gay community will have to navigate the tempests of prejudice stirred up every time there is an outbreak or upsurge of infection among us. Coming up with such an approach should earn the innovator the Nobel Prize, a recognition already overdue to ACT UP for its collective achievements.

In the meanwhile, we have no choice but to continue the painstaking work of harm reduction through safer sex, neighborhood by neighborhood, demographic slice by demographic slice, region by region, individual by individual, and, with the migration of sexual hook-up opportunities to the Internet, communications technology by communications technology.

But we need to do this work more innovatively, diligently, consistently, and intensively than we currently are. Perhaps then we will flatten the spikes of outbreaks and lower the rates of new cases to an extent that will be comparable to the successes currently attributable to needle exchange.

Should we close the bathhouses and shut down sex parties? That would make no more sense than expecting to reach needle-using addicts by shutting down shooting galleries and preventing access to clean works. If needle exchanges are the model to emulate, we must find new ways to make safer sex more accessible and appealing, by utilizing rather than eliminating or even policing the venues where sex takes place.

In the 1980s, we thought of safer sex initiatives as a stopgap in advance of a preventive vaccine we felt certain would be forthcoming. Dr. David Sencer, the city's health commissioner, for one - and I agreed with him - did not believe, on the basis of STD history and experience, that sexual behavior would prove particularly amenable to change, at least in the long term. Safer sex options and regulations might be effective in some contexts, but we felt that even where most successful there would be periodic breakdowns.

What we could not foresee at that time was just how elusive an HIV vaccine - and, for that matter, a vaccine for hepatitis C, a virus even more transmissible via contaminated blood - would prove to be. With a vaccine still nowhere in sight, we have no choice but to redouble our efforts at safer sex and harm reduction, undaunted by periodic setbacks, such as those to which we can no longer turn a blind eye.

In the spring of 1981, Dr. Lawrence D. Mass, writing in the New York Native, became the first to report on the emergence of what came to be known as AIDS. He is a co-founder of Gay Men's Health Crisis and the author/editor of "We Must Love One Another Or Die: The Life and Legacies of Larry Kramer."

Source: http://www.gaycitynews.com/site/news.cfm?newsid=19297131&BRD=2729&PAG=461&dept_id=568864&rfi=6

Harm-reduction advocates outraged at UN call to shut Insite

2008-03-10T09:33:00.000+07:00

By, Christina Montgomery, The Province, March 08, 2008

Supporters of Canada's harm-reduction approach to drug addiction are livid that a United Nations monitoring body wants Ottawa to slam the door shut on Vancouver's safe-injection site -- and put an end to distribution of "safe" crack kits to addicts.

In an annual report by the International Narcotics Control Board released this week, the UN board said distribution of the kits in some areas of Canada contravened part of the UN's Convention against Illicit Traffic in Narcotic Drugs.

The board said the drug programs violate international drug-control treaties to which Canada is a party.

The disposable crack-pipe mouth pieces -- usually rubber-tipped glass tubes -- are given to addicts to avoid the spread of blood-borne diseases, including HIV and hepatitis, when addicts share pipes.

Vancouver's Downtown Eastside safe-injection site, known as Insite, allows addicts to inject their own heroin and cocaine under the supervision of a nurse, who provides them with clean needles.

Medical journals report that Insite, the only facility of its kind in North America, has reduced overdoses and blood-borne infections.

But five years into operation, the site's fate is uncertain. It operates under an exemption from Canada's Controlled Drugs and Substances Act, which runs out in June.

The Conservative government has not said whether it will extend the exemption.

But the UN report incensed supporters of Insite.

Sen. Larry Campbell, a former mayor of Vancouver and a former coroner, called the narcotics board "stooges for a failed U.S. war on drugs" and told reporters he would personally block Insite's doorway if officials tried to close it down.

Vancouver Mayor Sam Sullivan also dismissed the board's report by insisting it simply didn't understand Insite's success.

"The way we've approached drug addiction worldwide has been a failure," Sullivan told reporters. "We need new approaches. We need to be open to innovations."

Thomas Kerr, a research scientist at the B.C. Centre for Excellence in HIV-AIDS, voiced concern that Ottawa would seize on the report as an excuse to close Insite.

Richard Pearshouse, speaking for the Canadian HIV/AIDS Legal Network, told reporters the report was "driven more by ideology and a war-on-drugs ideology than the research and the scientific evidence that supports these as a public-health intervention."

cmontgomery@png.canwest.com

Source: http://www.canada.com/theprovince/news/story.html?id=e9cd841a-a468-4634-b9e1-685ce330b864&k=25195

Female IDUs in Asia call for greater access to services

2008-03-06T11:26:00.000+07:00

By,Baralee, HDN Key Correspondent, February, 2008

When the problems associated with injecting drug use in Asia are discussed, stigma and discrimination are often listed among users’ main concerns. For female injecting drug users (IDUs), these problems are often exacerbated.

Onuma, a female IDU from Thailand said, “If you were injecting drugs, you would face discrimination. If you were a female IDU, you would be treated worse than men and if you were a female IDU living with HIV you would be at the bottom of the scale—completely worthless.”

Many Asian countries are adopting harm reduction approaches to the fight against HIV and AIDS and drop-in centres and programs for IDUs are available in some areas. Unfortunately, few of these services cater to the needs of women.

Ekta, a founding member of Recovering Nepal who works with the National Association for AIDS Network in Nepal, said that female IDUs in the country remained largely hidden.

“We have some abstinence-based rehabilitation centres, a methadone program, and syringe exchange services, but women are not informed and therefore do not access those services,” Ekta said.

Women should be told what services are available and how they can be adapted to meet their needs. Women in Asia play an important role in the home and they face the burden of high domestic expectations.

Poverty, illiteracy and a lack of educational opportunities have held many women back, limiting their understanding of their own rights and forcing them to remain heavily reliant on their partners.

“In Nepal, we don’t have legal security, we don’t get citizenship until our father or maybe husband get us citizenship. Women are the key and principal caregivers. They always have children or husbands to take care of,” Ekta said.

“Taking responsibility for the family is more important for women and girls and such responsibilities?are blocking them from getting services. They are concerned with their children and often in our country, many don’t have husbands.”

Many of the services available to IDUs are male-oriented if not completely male dominated. Onuma said few women were treated with respect at her local drop-in centre.

“Male clients at the drop-in centre do not treat female IDUs with respect and some of female clients refused to come to drop-in centre because the male clients were rude to them,” Onuma said.

In areas where separate facilities are not available for men and women, cases of sexual harassment and abuse have been reported. This needs to be addressed and mechanisms should to be developed to educate women’s partners about their needs and to ensure they have support.

Ekta said that many programs for women focused solely on getting them to stop taking drugs and to find work. But when women struggle to quit and relapse, they often face higher levels of stigma and discrimination.

“Personally, my biggest problem is relapse. I have relapsed so many times . . . the rehabilitation people didn’t want to admit me. They said ‘what is the use of enrolling Ekta because she will relapse after three months . . .”

“I am struggling for my life . . . Please accept us as drug users. We cannot stop using drugs all at once.”

Source: http://www.healthdev.net/site/post.php?s=1346

The Goa Declaration

2008-03-06T10:59:00.000+07:00

By, Bobby Ramakant, Health and Development networks KC, January, 2008

Besides being the world’s largest producer of opiates and other drugs such as Amphetamine type substances (ATS), the Asian and the pacific region is home to the largest number of drug users. �Although evidence-based, cost-effective approaches are endorsed and promoted by various agencies people who use drugs in the region continue to be oppressed by discriminatory government policies and non-evidence based ‘solutions’ to drug use, such as imprisonment and compulsory detoxification and rehabilitation. Without taking into consideration the socio-economic factors underpinning drug use in the region, people who use drugs will continue to be harassed, marginalised and discriminated against, stereotyped as dangerous and imprisoned.

The constant oppression, persecution and human rights violation contributes to HIV and hepatitis vulnerability of people who use drugs, particularly those who inject. In Asia, up to 89% of new HIV and 92% of hepatitis C infections are occurring among injecting drug users (IDUs). On average IDUs account for 30-50% of new HIV infections and 40-60% of the IDU population is estimated to be living with hepatitis C virus (HCV) as well. Even though it is obvious that �drug users’ vulnerability to and experience with HIV and HCV make them one of the most important constituents in responses to HIV and HCV in Asia and the Pacific, the level of harm reduction, treatment, support services available as well as involvement of that particular community continues to be grossly insufficient.

If Asian and the Pacific governments, civil society, health care providers and other stakeholders are serious about halting the HIV/HCV epidemic, purposeful attention and action must be given to ensure evidence-based and non-oppressive approaches to address the needs and high vulnerability of the IDU population in Asia and the pacific. Policies on drug control need to be harmonized with HIV and HCV prevention, treatment, care and support efforts and standards of services for harm reduction would also be required in order to have an enabling environment for sustainable service delivery.

In this context, WE, the people who use drugs in Asia and the Pacific, thereby:

Call on governments, various agencies, bi- and multilateral organisations, civil society organisations (CSOs) and the general public to support in:

* Empowering our communities to advocate and protect our rights and to facilitate meaningful participation in decision making on issues affecting us;
* Promoting a better understanding of current drug policies that negatively impact on the lives and rights of people who use drugs, their families and communities;
* Acknowledging and enhancing our knowledge and skills to educate and train others, particularly our peers and members of our community;
* Advocating for Universal Access to harm reduction, HIV/HCV treatment and care programmes, including access to evidence-based and effective drug treatment, appropriate medical care, safer consumption equipment, safe disposal of syringes and needles, up-to-date information about drugs and their effects, and safer facilities for practicing harm reduction;
* Protecting and eexercising our right to evidence-based information on various drugs including their side effects and complications, access to equitable and comprehensive health and supportive social services, safe and affordable housing and meaningful employment opportunities;
* Establishing specifically designed program to address the issues of women who use drugs and allocate enough resources to ensure programs are sustainable while actively promoting their meaningful full participation in all policy, program design and implementation process.
* Supporting local, national and regional networks of people who use drugs are incorporated at all levels of decision-making and equitably remunerated for their contributions;
* Challenging laws, policies and programmes that disempower, oppress and prevent us from leading healthy and positive lives;
* Distinguishing drug dealers from people using drugs who need support, care and treatment instead of oppression and prosecution;
* Providing easy access to affordable antiretroviral medicines including second and third line treatments, TB and HCV treatment for all who need them; if necessary by enacting intellectual property laws to protect the rights of developing countries to implement the safeguards enshrined in the TRIPS agreement and Doha Declarations such as Compulsory Licenses, as endorsed by the 2007 WHO General Assembly;
* Advocating for development and adherence to harm reduction service delivery such as NSP, OST, residential care, ARV/HCV treatment etc.

Affirm our duties and responsibilities as responsible citizens in:

* Contributing to collective efforts against the HIV and HCV epidemics in Asia and the Pacific, including HIV and HCV prevention, and care and support of those already infected and affected;
* Seeking understanding of issues, challenges and needs of drug users in Asia and the Pacific;
* Promoting tolerance, cooperation and collaboration; fostering a culture of inclusion and active participation;
* Respecting the diversity of backgrounds, knowledge, skills and capabilities, and cultivating a safe and supportive environment within the drug user community regardless of the types and routes of drugs consumption;
* Supporting, strengthening and encouraging the development of organizations for people who use drugs in communities/countries where they do not exist.

State our position that:

* The most profound need to establish a network of people who use drugs arises from the fact that no group of oppressed people ever attained liberation without the empowerment and involvement of those directly affected; �
* Through collective action, we will challenge existing oppressive drug laws, policies and programmes and work with government and our constituents to formulate evidence-based drug policies that respect human rights and dignity of people who use drugs.

Source: http://www.healthdev.net/site/post.php?s=1268

Don't give us false illusions of hope: injecting drug users

2008-03-06T10:53:00.001+07:00

By, Bobby Ramakant, Healthdev, January, 2008

Repeated calls for harm reduction approaches to HIV prevention, treatment and care, particularly for injection drug users (IDUs), were answered with a reality check on the second day of the first Asian Consultation on Prevention of HIV Related to Drug Use, in Goa.

During a session that brought together parliamentarians, civil society activists and IDUs, the voices of several users provided delegates with a stark reminder of the reality on the ground.

“Drug users are treated as criminals, as sub-human beings” said Bijaya Pandey from Nepal.

“For the past few years we have been hearing about ‘3 by 5’ and ‘2010’– please, please, don’t give us a false illusion of hope,” Pandey said, referring to the World Health Organization’s (WHO) failed initiative to provide antiretroviral drugs (ARVs) to three million people by end of 2005, and the promise of universal access to prevention, treatment and care by 2010.

Opioid substitution therapy (OST) and needle syringe exchange programmes are not operating or even legal in some Asian countries. Only a handful of states in the region have government-supported OST or syringe exchange programmes.

The combination of the criminalization of injection drug use and a lack of a coherent legal and policy framework on drugs, means that not only are IDUs are at risk while accessing existing services, but service providers are also at risk of being penalized for offering them.

“Bijaya, Tamara and I are the lucky survivors of the war – the war on drugs,” said Fredy Edi, a board member of the International Network of People who Use Drugs and the Indonesian Drug User Network, referring to IDU representatives Pandey and Tamara Speed from Australia.�“The war on drugs is also war on health,” Fredy added.

There is evidence to suggest that ‘war on drugs’ has caused a rise in HIV infections, particularly among IDUs, across the region. The number of new hepatitis C (HCV) infections has also increased since the war on drugs was launched. HCV infection rates are believed to have reached epidemic proportions in many parts of Asia, such as Manipur in India.�

“We have buprenorphine but distribution is limited to less than 10% of people who need it,” a delegate from Manipur said during the meeting.�

Another delegate raised the issue ARV treatment for IDUs. Many IDUs are reportedly being told that they must stop taking drugs before they can receive treatment from ARV centres.

Delegates also expressed concern over the lack of programmes designed to tackle inhaling drug use and the lack of programmes tailored towards women, transgendered users or the partners of male users.

“It is very difficult to find female drug users in public spots,” Dr Tasnim Azim from Bangladesh told the session. About 15% of female IDUs in Bangladesh become pregnant within two years of developing a habit, Dr Azim said, adding that there were no antenatal clinics or services for female drug users.

While we eye the goal of Universal Access for 80% of IDUs, Bijaya’s plea ‘not give a false illusion’ serves as a grim reminder of the reality faced by those who need these services the most.

Source: http://www.healthdev.net/site/post.php?s=1227

Harm reduction is easy: Put your money where your mouth is

2008-03-06T10:20:00.000+07:00

By, Pascal Tanguay, HDN, January, 2008

"Aren’t you ashamed of yourselves?" demanded a European couple stumbling on the opening ceremony festivities here in Goa. "You should be, enjoying parties and conferences that cost millions, while people living with HIV can’t even afford to buy their medication!”

“We pay our taxes and when we get home we are going to contact our member of parliament.”

While many probably share their views about the costs of HIV-related conferences in general, the tirade points to a deep-seated misconception: that taxes in rich nations provide for high quality and comprehensive HIV prevention, care, treatment and support for people living with HIV (PLHIV) throughout the world. The fact is, they don't.

Sources of support for HIV work get even more muddy in relation to the needs of marginalized populations, such as drug users. Injection drug use is driving the HIV epidemic in Asia, and while harm reduction approaches have proven effective at reducing the spread and impact of the epidemic among injecting drug users (IDUs), progress in addressing IDU's needs and priorities moves at glacial pace.

According to Swarup Sakar, senior regional HIV adviser to the Asian Development Bank, only about one-fifth of the resources needed to achieve the agreed target of 80% at-risk population coverage by 2010 has been made available. That means something in the order of 100 million USD is needed every year in the Asia region alone for the so-called 'universal access' targets to be reached.

A similar scale of funding requirements was echoed by the UNAIDS regional chief, JVR Prasada Rao, who told the meeting that over 200 million USD per year is needed for harm reduction approaches to be effectively deployed on a global scale.

In 2006, less than half of that amount found its way into harm reduction programmes across the world – about 0.5% of the total resources invested in curbing the HIV epidemic. That lack of investment translates directly into the sobering figures being repeated in just about every session here in Goa: Outside of Africa, about 30% of new HIV infections are found among drug users; an estimated 18% of drug users have access to harm reduction services (2005 data); and less than 5% of injecting drug users have access to comprehensive HIV prevention, treatment, care and support services.

It is a case of 'one step forward, two steps back' with harm reduction in Asia, where service coverage is even lower than global averages, and falling: from 5.4% in 2003 to an estimated 3% in 2005. This is while across the region, between 30 and 50% new HIV infections are found among IDU communities and in some countries that rises as high as up to nearly 90%.

Although resources to address HIV have been significantly increasing overall, there is a mis-match between where resources are being spent and where they are needed. In Asia, the epidemic is continuing to accelerate and even in countries where the epidemic is showing signs of slowing or leveling off, HIV levels remain high among IDU communities.

Stigma, discrimination and criminalization of drug use contribute to the overall lack of action and practical thinking of governments and high level officials when it comes to drugs and associated issues. The common approach to drug use and drug users is from the public safety perspective instead of health and human rights. Even funds that are destined for harm reduction services may be diverted to other programmes that are deemed more socially desirable and deserving.

There are also specific donor restrictions in place that limit the flexibility of non-governmental organizations (NGOs) and community based organizations (CBOs) in providing effective services to IDUs. "Multilateral agencies have operational costs that constitute 20-30% of their budgets," said Shiba Phurailatpam, regional coordinator of the Asia Pacific Network of People Living with HIV (APN+). "Yet civil society organizations are told to cut their organizational costs below 10% and service delivery suffers as a result."

Although guidelines for effective harm reduction includes a 10% budget allocation for creating 'enabling environments', this investment is usually neglected. NGOs are often prevented from using donor funds to advocate for policy change and the creation of enabling environments for drug users.

The bottom line is that sustainable harm reduction needs political buy-in and commitment, and yet few Asian governments have committed to harm reduction policies and programmes. In fact, most have active legislation that criminalizes harm reduction activities as well as drug use. Where those commitments have been made, drug users are often not involved in the design, deployment and evaluation of such programmes in order to make sure they are appropriate. Further, high-level political commitment rarely translates into implementation at the provincial or community levels. As most of the harm reduction funding comes from external sources, governments do not have the incentive for genuine commitment.

Despite the challenges, there are champions for harm reduction in the Asia region. Launched in July 2007, the HIV/AIDS Regional Project (HAARP) spreads its eight-year budget (56 million Australian dollars) fairly thinly over six countries. But HAARP promotes harm reduction as a key approach to respond to HIV in Asia. It is mainly funded by the Australian government (AusAID) with contributions from the Netherlands government (for Vietnam-based activities). These two donor countries are field leaders in progressive policy-making founded on evidence; as opposed to stigma, discrimination and marginalization of drug users. The HAARP programme draws on comprehensive reviews of current evidence, and is being developed in consultation with civil society including drug users, as well as governments in programme countries.

According to Bijaya Pandey, a drug user activist based in Nepal, "HAARP's donors are putting their money where their mouth is."

Source: http://www.healthdev.net/site/post.php?s=1233

30% of new HIV infections in Asia associated with injecting drug use

2008-01-31T15:25:00.000+07:00

By, Media for Freedom, January 30, 2008

Thirty percent of all new HIV infections in Asia are associated with injecting drug use, estimates the joint United Nations Programme on HIV/AIDS (UNAIDS).

Nearly half of the world's estimated 13 million drug users live in Asia where injecting drug use is a major factor fuelling HIV transmission. Most of the global supply of opium and heroin is produced in Asia where vulnerable groups who inject drugs form a significant population engaged in high risk behavior such as sharing contaminated injecting equipment and unprotected sex leading to HIV infection.

Some Asian countries report HIV prevalence among injecting drug users (IDUs) as high as 85% while others that previously reported little or no HIV transmission relating to IDUs have now detected the virus among this population.

For the first time in Asia, AIDS experts, parliamentarians, civil society and drug user organizations come together for a consultation in Goa, India, on HIV prevention and treatment for drug users. Organized by the Asian Consortium on Drug Use, HIV, AIDS and Poverty, the consultation draws more than four hundred delegates from 27 countries to address political, legal and social barriers to HIV interventions for IDU communities and to advocate for expanded harm reduction programs promoting drug substitution treatment, access to needle and syringe exchange and peer education that has proven effective in stemming the spread of HIV.

"We will address the vulnerability related to drug use and HIV/AIDS affecting millions of people in Asia and the related social hazards including criminalization, incarceration and their linkages to poverty," said Luke Samson, Co-Chair of the consultation and Executive Director of the New Delhi based advocacy group SHARAN.

Across the region, criminalization of drug use, severe stigma and discrimination and law enforcement that marginalize and penalize drug users have driven them underground and deterred their access to life-saving HIV prevention and treatment services.

Gary Lewis, Representative United Nations Office on Drugs & Crime (UNODC) stressed successful models of community-based HIV prevention through outreach and counseling need to be adopted to address AIDS as a social as well as public health issue. "In Asia, the need of the hour is to scale-up interventions to reach out to populations at risk and to save lives. We know what to do, but we need to do more of it."

The consultation is reviewing the alarming spread of HIV in prison and custodial settings and advocate for reformed legislation, engagement with law enforcement and narcotics agencies and national AIDS policies that include services for incarcerated people and those in compulsory rehabilitation programs.

"We must ensure access to prevention and treatment services and protect the rights of most at risk populations such as people who inject drugs by involving them and their communities in every stage of the AIDS response," said UNAIDS Asia Pacific Regional Director, Prasada Rao.

"Regional collaboration for HIV preventions is the most effective mechanism to combat the growing pandemic. This consultation is a unique opportunity to generate enduring solutions to HIV and AIDS issues affecting drug users across Asia," said Shri Oscar Fernandes, Minister of State for Labour and Employment, Government of India, and Convener of Parliamentary Forum on HIV/AIDS in India.

The Asian Consortium on Drug Use, HIV, AIDS and Poverty is a voluntary network on collective issues of HIV prevention, access to health, food, harm minimization and mainstreaming towards poverty alleviation among drug using populations in Asia.

(Citizen News Service)

Source:

Law Enforcement Attempts To Stop Injection Drug Use Undermining HIV Control Efforts Among IDUs in Southeast Asia

2007-10-29T14:55:00.000+07:00

By, Kaisernetwork, October 26, 2007

Efforts by police to stop injection drug use are undermining attempts to curb the spread of HIV among injection drug users in Southeast Asia, law enforcement and health experts said Wednesday at the opening of a conference in Bangkok, Thailand, on reducing health risks for IDUs, AFP/Yahoo! News reports (AFP/Yahoo! News, 10/24).

According to the Open Society Institute, which is sponsoring the conference, HIV is fueled by injection drug use in at least 20 countries in Asia and Eastern Europe (AP/Yahoo! News, 10/24). Daniel Wolfe, deputy director of OSI's International Harm Reduction Program, said that efforts to reduce the spread of HIV among IDUs "can only work if law enforcement understands" harm-reduction measures and "helps to enforce them" (AFP/Yahoo! News, 10/24).

IDUs often are forced to use dirty needles because they are harassed or arrested at needle-exchange centers and drug treatment clinics, the AP/Yahoo! News reports. According to Aditya Anugrah Putra, a human rights researcher at the Indonesian Drug Users' Network, police harass and extort IDUs at methadone clinics and needle-exchange centers throughout the country. Police "wait outside methadone clinics to search patients for drugs, and they arrest syringe exchange clients at will," Putra said (AP/Yahoo! News, 10/24). Precha Knokwan of the Thai Drug Users' Network added that police in Thailand often confuse IDUs and people who sell drugs, hindering efforts to provide treatment to IDUs (AFP/Yahoo! News, 10/24).

Wolfe said that the result of law enforcement arresting or harassing IDUs at needle-exchange centers and clinics is "increased HIV infections, missed treatment opportunities and lost lives" (AP/Yahoo! News, 10/24). According to experts, it has become more difficult to determine the number of IDUs in Southeast Asia because police have caused them to go underground. Some experts say that as many as 50% of IDUs in the region are HIV-positive (AFP/Yahoo! News, 10/24).

Asia: Drug users face extra dangers

2007-10-26T11:04:00.000+07:00

By, IRIN PlusNews, October 25, 2007

Public health experts and rights groups at a conference for community groups working on HIV/AIDS prevention among drug users in Bangkok, Thailand, have warned Asian governments that abuse and persecution by police are undermining harm reduction initiatives by deterring drug users from accessing vital services.

Many local police still saw drug users as engaged in "social evils" and deserving of harsh punishment, said public health expert Daniel Wolfe, deputy director of the Open Society Institute's International Harm Reduction Development Program.

Police abuses often "drive drug users away from life-saving care, and fuel the spread of HIV," he noted. "No HIV prevention measure can be effective if people are afraid to use it; it only takes a few times of somebody being arrested in front of a clinic before drug users don't want to go there anymore."

All Southeast Asian countries have committed to eradicating drug use by 2015, and Asian governments have increasingly endorsed methadone treatment and needle exchanges to reduce HIV transmission among injecting drug users, who are at high risk of contracting the virus by sharing needles.

But many countries have mass round-ups of drug users and other marginalised groups prior to national holidays or big public events. Wolfe, speaking in Bangkok on the sidelines of the conference, said regional health officials and regional law enforcement authorities often worked at cross-purposes.

"There is a tension between what ministries of health plan for and what law enforcement agencies actually do, so you have one hand doing, and another hand undoing effective programmes for HIV/AIDS among injecting drug users," he said. "Until one hand works with the other, the result will be increased HIV infections, missed treatment opportunities and lost lives."

Some of this apparent "schizophrenia" stemmed from a lack of coherence at the highest level of policy-making. But even when high-level law enforcement policies were formally aligned with harm reduction programmes, beat cops on Asian streets did not always pay much heed. "There is this disconnect between law enforcement goals and health needs," Wolfe commented.

Communist-ruled Vietnam, for example, has committed to harm reduction programmes as part of its national AIDS strategy and has allowed needle exchange programmes in several areas with relatively large populations of injecting drug users. Yet many Vietnamese drug users were still reluctant to use these services, as carrying a syringe could leave them liable to arrest and imprisonment.

While Vietnam is due to begin its first methadone programme soon, the country also has over 50,000 people in 'forced treatment centres', where programmes consist of heavy labour, military-style drills and chanting slogans.

China has seen a rapid scale-up of harm reduction projects, with nearly 30,000 people put on methadone treatment, up from virtually nil three years ago. But at the same time, Wolfe said, an estimated 100,000 Chinese were in compulsory detoxification centres for as long as year.

The Indonesian government has five public clinics in Jakarta that supply methadone as part of their overall strategy to promote harm reduction, and police and the National AIDS Commission signed a memorandum of understanding in 2002, agreeing to work together.

But Aditya Anurag Putra, a human rights research with the Indonesian Drug Users Network, complained at the conference that police extortion and harassment of drug users outside HIV testing facilities and methadone clinics was rampant. "It's very difficult for us to engage [with] drug users for [them to use] services in Indonesia," he said. "The situation is not a conducive atmosphere for drug users to access treatment."

Wolfe suggested that raising police salaries, which were low across Asia, could also help end the rampant petty extortion of money from drug users, a major disincentive to accessing services.

"Police wages are often extremely low, and police frequently use drug users as a kind of supplemental income because they can say to drug users, 'either you give me some money or you go to these very punitive treatment centres, or you go to jail for a long time.'"

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For younger children, HIV/AIDS is still equal to syringe

2007-08-21T13:46:00.000+07:00

By, The Imphal Free Press, August 19, 2007

Imphal: In spite of the remarkable decrease in the spread of HIV/AIDS among the IDUs, awareness among the younger children about the mode of transmission is still very low.

Class V student Apanba Paonam of Shishu Nistha Niketan said that his dad told him about HIV/AIDS. He said that as per his understanding, HIV/AIDS spread through injecting drug use, sharing of syringes and transfusion of contaminated blood. He quickly added, "But it is ok to eat together and share other things like clothes, combs, etc." Apanba said that he does not know whether HIV/AIDS is curable or not. He said that he had seen an HIV/AIDS poster at home but none at school.

Class VI student Sonan of Christ Jyoti said, "I painted a person in hospital bed being given glucose with the doctor standing nearby." He said that he heard about HIV/AIDS from elders and from TV. Explaining the condition, he said, "HIV/AIDS cannot be cured by medicines and it is one of the most difficult illness."

Rohan of Shishu Nistha Niketan said that he heard about HIV/AIDS from his parents. He said that HIV/AIDS is a virus that spreads a highly communicable disease which takes time to recover. He painted the map of Manipur below a big syringe.

For Priya Khuraijam, class VI student of RK Sanatombi Devi School, her father told her about HIV/AIDS and said that syringes should never be shared and one should be careful all the time to not get HIV.

Her classmate Sonalika painted skeletal, syringes and blood testing as her vision of HIV/AIDS. She said that the skeletal shows the harmful effects of using drugs.

N Christina of Class VI from Universal Students` Academy said that HIV/AIDS is a virus and it spread through sharing of syringes. She said that her painting described the destruction of the world by HIV/AIDS by showing skeletal of those lost to AIDS, injecting drug use, tablets and chaos.

These children were taking part in a state level spot painting competition for children from class IV-X. The competition, held today at Manipur Press Club, was aimed at assessing their vision of HIV/AIDS.

The competition was organised by Nawa Leikol, a forum for HIV/AIDS infected and affected children. The competition was held in two categories ? A comprising students from class IV-VI and B comprising students from class VII-X. There were altogether 250 students from 12 schools.

L Elena, general secretary Nawa leikol said, "The main objective of this painting competition is to check the awareness level among the school children and find out their visions on HIV/AIDS."

As told by the theme expert judge, A Arjun, secretary SASO, to IFP, "Most of the children lack a clear vision and understanding of HIV/AIDS. At least 70-80% of the children did not have a clear vision of what HIV/AIDS is. Their main focus was on syringes. Maybe this could be due to failure in the awareness programme, especially among the young children."

The other judge, the art expert, was Tombi, principal Imphal College. The toppers in category A were Ricardo of Maria Montessori, Krishna of Shishu Nistha Niketan and Tulsitra of Kiddies Corner High School and that of category B were Rimeeta of Brighter Academy, Amarjeet and Chelsea of Maria Montessori. The prizes will be distributed on 30th August, the 2nd anniversary of Nawa Leikol, at GM Hall Imphal.

Source: http://www.kanglaonline.com/index.php?template=headline&newsid=38977&typeid=1

Injecting drug use major cause for HIV and AIDS growth in Indonesia

2007-05-23T11:17:00.000+07:00

By, Antara News, May 22, 2007

Jakarta - Injecting drug use and risky sexual behavior have been the major causes for the growth of HIV and AIDS in Indonesia since 1999, Indonesian representative at the 61st United Nations General Assembly session in New York, Adiyatwidi Adiwoso Asmady, said on Monday.

"In Papua, an increasing number of HIV and AIDS cases are attributable to men engaging in commercial sex work and premarital sex without condom use," Adiyatwidi said.

She added that there were an estimated 193,000 HIV-infected people in 2006, and there were over 8,000 people with fully developed AIDS. The highest prevalence of AIDS was found among 20 to 29 year olds.

She said national leadership came from the ministerial level, under the guidance of the National AIDS Commission. Management at the provincial level was in the hands of local AIDS commissions, which were multisectoral bodies comprised of Governmental and non-governmental representatives.

"They worked within the framework of the national AIDS strategy, which emphasized family welfare and religion in combating the spread of HIV," she added.

She said the strategy provided strong support for a practical public health approach to the HIV challenge, including condom promotion and harm reduction strategies for injecting drug users.

According to her, the Government had enhanced the capacity of the National AIDS Commission to provide sterile needles and condoms to high risk groups, among other things.

Adiyatwidi said the health sector budget had increased annually and currently amounted to $13 million. Regional Governments received $1.6 million in 2006, a 100 per cent increase from the 2004 budget.

"The President had meanwhile expressed interest in tackling the HIV, AIDS epidemic by making a 250 per cent increase to the health sector budget in 2007," she pointed out.

In light of the continued growth of the global AIDS epidemic, the international community was called on to renew its commitments made in 2001 and 2006.

It was particularly important that low- and middle-income countries received the financial backing that they needed to achieve their national targets.

Meanwhile, a United Nations press statement said that as the UN General Assembly turned its attention to the global response to HIV and AIDS, Secretary-General Ban Ki-moon promised that the pandemic which had killed more than 25 million people in the course of the last quarter century -- would remain a system-wide priority for the United Nations.

Addressing the Assembly on Monday, as it met one year after last June`s high-level session to review the implementation of the Declaration of Commitment on HIV and AIDS, adopted by Member States in June 2001, Ban stressed that only when the international community worked together with unity of purpose -- unity among Governments, the private sector and civil society -- could it defeat AIDS.

"Today, 40 million people are living with HIV. Almost half of them are women. More women -- including married women -- are living with HIV than ever before," he said, adding that without adequate treatment, all those infected will die beacuse some 8,000 people die of AIDS-related illnesses every day.

The UN chief pointed out that at the same time, another 12,000 become infected with HIV. For every person who starts antiretroviral treatment, six more become infected.(*)

Source: http://www.antara.co.id/en/arc/2007/5/22/injecting-drug-use-major-cause-for-hiv-and-aids-growth-in-indonesia/

Adding HIV Risk Reduction Strategies To Drug Abuse Treatment Has Favorable Outcomes For Pregnant Women At Risk Of Infection

2007-05-16T09:48:00.000+07:00

By, Medical News Today, May 14, 2007

Six months after completing an addiction program with an HIV risk-reduction component, 69 HIV-negative, inner-city, pregnant women demonstrated significant increases in favorable attitudes toward condom use as well as factual knowledge about HIV and a significant decrease in the number of sexual partners.

Background: Sexually transmitted HIV infection is rapidly increasing among reproductive-age, noninjection substance abusing women. Data show that 4.3 percent of pregnant women admit using illicit drugs during pregnancy. The period of pregnancy and the early postpartum period represent a window of opportunity for intervening with pregnant women at risk for HIV. Few studies have addressed women's motivation or their ability to employ key behavioral skills for HIV risk reduction during pregnancy.

Study Design: The researchers recruited 81 inner-city minority women receiving alcohol and nonmethadone drug use treatment in a hospital-based addiction program through the pregnancy and postpartum period. Scientists added a foursession cognitive-behavioral skills, HIV prevention training to their intervention plan, and conducted follow-up assessments 6 months later to identify behavioral changes in these women.

What They Found: Among the 69 women who participated in the 6-month follow-up, scientists observed significant increases in favorable attitudes toward condom use and factual knowledge about HIV, and decreases in the number of partners. However, there were no significant differences in response efficacy, intentions to engage in safer sex behaviors, sexual self-efficacy, or alcohol or drug use.

Comments From The Authors: This is perhaps the first prospective evaluation of the determinants of change with regard to HIV-related, high-risk behavior for pregnant alcohol or other drug users in treatment. This information can be very useful in guiding the development of target interventions for this disempowered group of pregnant women.

What's Next: A "one size fits all" approach to HIV prevention among women will not be sufficient. Future studies with larger sample sizes need to address the heterogeneity of women in target populations.

Publication: Dr. Robert Malow of Florida International University and his colleagues published this study in Vol. 41, No. 13, of Substance Use and Misuse.

The National Institute on Drug Abuse (NIDA) is a component of the National Institutes of Health, U.S. Department of Health and Human Services. NIDA supports most of the world's research on the health aspects of drug abuse and addiction. The Institute carries out a large variety of programs to ensure the rapid dissemination of research information and its implementation in policy and practice. Fact sheets on the health effects of drugs of abuse and other topics are available in English and Spanish.

These fact sheets and further information on NIDA research and other activities can be found on the NIDA home page at www.drugabuse.gov.

Source: http://www.medicalnewstoday.com/medicalnews.php?newsid=70861&nfid=rssfeeds

Asian drug users need more HIV prevention help

2007-05-15T09:41:00.000+07:00

By, Ben Blanchard, Reuters, May 14, 2007

BEIJING (Reuters) - Asian countries need to wake up to the threat of HIV transmission via intravenous drug use and spend more money on needle exchanges and other programs or risk a rapid rise in new cases, a U.N. health official said on Monday.

Around one-third of new infections worldwide, excluding sub-Saharan Africa, are from injected drug use.

Asia has about 6 million users, and most new HIV cases are blamed on dirty injecting equipment, according to the United Nations.

But less than one-tenth of Asian users have access to prevention services, UNAIDS Asia Pacific Regional Director Prasada Rao told Reuters in an interview.

"If you look at comprehensive interventions, which means giving the option of both needle exchange and drug substitution, I think very few countries are doing it," he said by telephone from a conference in the Polish capital Warsaw.

"They have to prioritize interventions among intravenous drug users and the aim is for at least 80 percent coverage by 2010," Rao added.

"That requires enormous scale up in terms of resources and also in creating an environment where drug users can come out and access these services. Because in most of these countries they are still criminalized, and police raid them and catch them.

"It needs a change of attitude and a change of legislation relating to drug use. Because most often they don't distinguish between the supplier of drugs and the ultimate victim who is the user," he said.

HARM REDUCTION

Injecting drug users can also easily pass on HIV to the general population, so it is essential to reach them, Rao said.

"Most of them are young people, and they have sexual partners," he said. "So it ultimately gets into the general population as an epidemic if you don't control it at the injecting drug user level."

The global cost of such "harm reduction" programs as providing clean needles is estimated at just $200 million a year, the official said.

"We're not spending even half that. It is less than $100 million throughout the world," Rao said. "It is a very small amount of money, but even that, governments are still not putting into ideal programs."

"In some cases, they think it's not really important. In some cases they think these people are not in the mainstream of society so can be ignored. I think the governments are not sensitive enough to the problem of young people and how they get into injecting drug use," he added.

"The important relationship between injecting drug use and HIV -- still many governments are not realizing it."

Bright spots include China, which has started both needle exchanges and drug substitution work, as well as Indonesia, while India has also started on the right path, Rao said.

He singled out Thailand, though, for doing lamentably little.

"Thailand is a glaring example. A country which has done so well at prevention sexually has not started any good program for injecting drug users even though over 30 percent of new infections in Thailand are among injecting drug users."

NIDA Looks at Non-Injection Drug Use and Spread of HIV/AIDS

2007-05-09T10:17:00.000+07:00

By, NIH News, May 8, 2007

CDC estimates 250,000 Americans Unaware they are HIV-Positive

More than 500 scientists, clinicians and public health specialists met today at the National Institutes of Health (NIH) to discuss the latest research on drug abuse and the evolving epidemic of HIV/AIDS. This is the first-ever two-day public meeting at NIH to include a focus on non-injection drug use and HIV transmission. The meeting was being held in collaboration with the National Institute on Alcohol Abuse and Alcoholism (NIAAA), the National Institute of Allergy and Infectious Diseases (NIAID), the National Institute on Child Health and Human Development (NICHD), and the National Institute of Mental Health (NIMH).

“Approximately one million people in the United States are living with HIV/AIDS, which disproportionately afflicts minority populations — particularly African Americans,” said NIDA Director Nora D. Volkow, who gave opening remarks at the meeting. “To address this significant public health threat, research at NIH is examining every aspect of HIV/AIDS, drug abuse, and addiction, including the risk behaviors associated with both injection and non-injection drug abuse, and how drugs of abuse can alter brain function and impair decision making.”

Participants today heard from leading scientists about how substance abuse affects HIV/AIDS risk in diverse populations, and of the importance of designing interventions that address their specific needs. Today’s session also looked at neuroeconomics — combining brain imaging and economically-based theories to better explain and predict decision making; and neuroimaging to predict relapse to methamphetamine in treated drug abusers. Also discussed were the importance of combining behavioral therapies, and medication in drug abuse treatment to reduce HIV risk behaviors as well as drug abuse.

The Tuesday afternoon session covered the risky behavior related to commonly abused substances like alcohol and marijuana. Scientists have long recognized that alcohol use is associated with behavior that places people at risk for sexually transmitted infections, and similar studies on marijuana use will also be presented. These studies show that not only is marijuana use associated with risky sexual behavior, but is also associated with poor medical appointment-keeping among infected women.

Wednesday’s session — which concludes at noon, will look at the problem of HIV/AIDS within the Nation’s criminal justice system, including prisons and jails. The large-scale incarceration of drug users has resulted in a disproportionate rate of infection and burden of HIV/AIDS among the prison population, and correctional facilities have emerged as critical settings for interventions to prevent, diagnose, and treat HIV and other infectious diseases. The last session of the conference will examine the challenges of HIV screening, testing and counseling, and prevention strategies for inmates who are reentering society, given concerns about confidentiality, stigma, and limited government resources.

A full agenda and speaker list is available at: http://conferences.masimax.com/riskybehaviors/index.cfm.

The National Institute on Drug Abuse is a component of the National Institutes of Health, U.S. Department of Health and Human Services. NIDA supports most of the world's research on the health aspects of drug abuse and addiction. The Institute carries out a large variety of programs to ensure the rapid dissemination of research information and its implementation in policy and practice. Fact sheets on the health effects of drugs of abuse and further information on NIDA research can be found on the NIDA web site at http://www.drugabuse.gov.

The National Institutes of Health (NIH) — The Nation's Medical Research Agency — includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. It is the primary federal agency for conducting and supporting basic, clinical and translational medical research, and it investigates the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit www.nih.gov.

Source: http://www.nih.gov/news/pr/may2007/nida-08.htm

SOUTH AFRICA: New study explores drugs and HIV link

2007-04-20T13:17:00.000+07:00

By, IRIN PlusNews, April 18, 2007

A new study is to put the relationship between illegal drug use and risky sex patterns in South Africa in the spotlight for the first time.

Although there has been a move towards exploring the direct and indirect roles of drug use in the transmission of HIV in other continents, the situation in Africa has been largely overlooked.

"Given the alarming prevalence of HIV in South Africa, as well as findings from similar international studies, its evident there is a growing need for specific data on drug-related sexual trends," Petal Petersen, a substance-abuse expert at the local Medical Research Council (MRC), told IRIN/PlusNews.

The MRC, in collaboration with the United States (US) government, local offices of the US-based Centres for Disease Control (CDC) and a leading gay and lesbian rights group, OUT, will closely monitor drug-induced sexual behaviour among commercial sex workers, injecting drug users and homosexual communities.

Welcoming the opportunity to assist the MRC in this "timely intervention", OUT sexual health manager Jacques Livingston expressed concern over the previously neglected issue of narcotics as a driving factor in the transmission of HIV in the country.

There are currently no figures indicating the relationship between recreational drug use and the spread of HIV in South Africa, but international findings show there is always a greater danger of risky sexual behaviour when drugs are introduced in social settings.

Research by the Integrated Substance Abuse Programmes at the University of California, Los Angeles, in the US, found that if the respondents (all gay men) had used crystal d-methamphetamine hydrochloride, a drug otherwise known as 'speed', in the past six months, there was a low but significant chance that they would be HIV-positive; among those who used it "once in a while" the figure was 25 percent; but when chronic users were interviewed the figure jumped to 40 percent.

"It [drug use/abuse] is really a serious problem in all circles, not just for homosexuals, although I do believe that more gay men might lean towards narcotics as a coping mechanism in coming to terms with their sexuality," Livingston commented.

Supporting Livingston's sentiments, Gordon-John Ho-Lin, 28, a single man living in Johannesburg, who only recently accepted his homosexuality, recalled how he sought refuge in a variety of illegal substances, sometimes with hair-raising consequences.

He told IRIN/PlusNews that the drugs served as an escape from having to face the truth about his sexuality or the rejection he feared from family, friends and co-workers.

"I was a late beginner [at the age of 20], compared to most people who begin in their teens or earlier. The numbness brought on by the drugs helped me shut out reality and there were some added benefits too ... or so I thought at the time," he said.

Ho-Lin said he used cocaine, ecstasy tablets and the hallucinogen LSD (lysergic acid diethylamide), among other drugs, which produced effects that included euphoria, increased energy, insomnia and a heightened sex drive.

"In the nightclubs, most people are 'high' on something, and often on the same [sexual] wave-length, so it's easy to reciprocate when approached for sex," said Ho-Lin.

He believed that under the influence of drugs, unprotected sex and sex with multiple partners was more common among both homosexuals and heterosexuals. "It's no longer an issue of sexual identity, and heterosexuals will have sex with homosexuals because gays are often better employed and can afford to buy the drugs," said Ho-Lin, who declined to reveal his HIV status.

Petal Petersen, of the MRC, said the new study, 'International Rapid Response and Evaluations', was already in its second phase of designing and tailoring appropriate interventions to curb drug use and risky sex. The complete report is due to be published by the end of 2007.

"By early to mid-2008 we should be able to make recommendations on how to respond to changing current drug-using and sexual-risk patterns," Petersen said.

OUT is appealing to gay men and women, men who have sex with men, bisexual and transgender drug users to participate in the study.

ALSO SEE: http://www.irinnews.org/Report.aspx?ReportId=39695

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Achieving a high coverage - the challenge of controlling HIV spread in heroin users

2007-04-11T15:48:00.000+07:00

By, Ming-qiang Li et al, Liuzhou Center for Disease Control and Prevention, Guangxi, China & Stanley Ho Centre for Emerging Infectious Diseases, The Chinese University of Hong Kong, February 15, 2007

Abstract

In China, the national plan to open 1000 methadone clinics over a five-year period provides a unique opportunity to assess the impacts of harm reduction in a country with concentrated HIV epidemic amongst heroin users. To track the progress of this public health response, data were collected from the first methadone clinic in Liuzhou, Guangxi, a province with a high HIV prevalence. In the first 15 months of its operation, a cumulative total of 488 heroin users, 86% of which male, had joined the programme. The first dose of methadone was given efficiently at a median of 2 days after registration. Of the 240 heroin users attending the clinic in August 2006, 61% took methadone for four days or more each week. The number of active methadone users, however, leveled off at around 170 after the first two months, despite the availability of capacity to deliver more services. The reasons for this observation are: firstly, the provision of one single service that may not be convenient to all heroin users; and secondly, concerns of heroin users who may feel insecure to come forward. As broad coverage is essential in ultimately reducing HIV risk, a low threshold approach is crucial, which should be supported by the removal of social obstacles and a refinement of the administrative procedures.

Background

The epidemic of heroin addiction has fuelled the global spread of HIV, a phenomenon that is clearly visible in many parts of Asia [1]. The growth of this dual epidemic calls for the development of effective public health responses, which include the introduction of harm reduction measures targeting injection drug users and the provision of antiretroviral therapy to those infected according to clinical indications [2,3]. The use of opiod agonist substitution treatment has been proven to reduce injection, needles-sharing and HIV infection in various studies, and is now a standard recommendation both for the treatment of addiction and for HIV prevention and control [3,4]. Internationally, the expanded access of methadone maintenance treatment is prioritized, through the scaling up of harm reduction programmes in many countries. Though there is no lack of evidence in support of methadone maintenance [5], debates have continued because of the relative scarcity of fully evaluated programmes in developing countries.

There are lessons to be learned from the recent initiatives of China where the HIV spread in heroin users has taken root in some provinces, especially those bordering the Golden Triangle [1]. Of the estimated 650,000 persons living with HIV in the country, heroin users who shared needles accounted for 44.3% of the total [1]. Over the last year, harm reduction has been introduced as one of the key national intervention strategy. The national plan was to set up methadone clinics in 1000 sites over a five-year period [6]. The future of China's HIV epidemic obviously depends on how effective the country is in its operationalisation of the harm reduction strategy. Guangxi is one of the hardest hit provinces so far, with the HIV prevalence in heroin users in rural areas high at 25% [5]. Methadone treatment has been introduced as a public health programme in the province since about two years ago. To assess the progress of this new targeted population-based strategy, we reviewed the work of one of the first methadone clinics in the country.

Methods

Liuzhou is the second largest city of Guangxi. The reported number of heroin users in the Liuzhou City is around 7000. The clinic is housed within the Skin and Sexually Transmitted Disease Clinic of the City's Centre for Disease Control. While the Clinic is not situated at the heart of the City, it's within reach (3 Km radius) from where most heroin users cumulate. The Clinic is staffed by 5 doctors, 1 counselor, 2 nurses, 2 pharmacists and other supporting administrative personnel. We reviewed the case records and workload statistics of the Clinic since the clinic's opening in May 2005. An unstructured interview of 10 randomly selected clients was conducted by two of the authors at the clinic. Approval was sought from the local health department. Ethical approval was obtained from the Ethics Committee of the Chinese University of Hong Kong.

Findings

Overall, between 11 and 56 (mean = 35) new drug users each month registered at the Liuzhou Methadone Clinic since its opening. As of the end of August 2006, a cumulative total of 488 heroin users, 86% of which male, had joined the programme. Registration is required for joining the programme, with the following entry criteria: (a) heroin use for over one year; (b) age 20 or above; (c) resident of the city; and (d) having passed the physical checkup. Individual application is then submitted for official endorsement by the authorised office. The first dose of methadone is given at a median of 2 days after registration (range: 0 to 9 working days). Of the 240 heroin users attending the clinic in August 2006, 61% took methadone at least 4 days each week.

The number of active methadone users has however leveled off at around 170 after the first two months (see figure 1). Despite a high number of heroin users in the city, new admission to the programme has not increased. Clearly the service of a clinic has not saturated, and there is adequate capacity to take in at least twice the current number of heroin users. Discussions with registered methadone users revealed a number of reasons. First of all, many heroin users may not be living in close proximity to the methadone clinic, and have therefore chosen not to travel long distances to access the service. According to the regulations, methadone must be taken under supervision on a daily basis at the clinic. Secondly, some heroin users did not feel comfortable in coming forward for treatment as they ran the risk of being arrested as drug taking is and has continued to be a criminal offence. It would take time for a common understanding to be developed by different government sectors on the role of methadone clinics at the field level. Thirdly, the strict criteria of admission also meant that only a fraction of the heroin users on the street are eligible for enrolment.

Discussion

Against the background of an escalating HIV prevalence in heroin users around the world, it's reassuring to witness the establishment of substitution treatment in the world's most populous country. From a public health angle, there are lessons from the experiences in Liuzhou. Foremost, one key indicator in assessing the effectiveness of harm reduction is its coverage. Broad coverage serves two purposes: general reduction of risk behaviours [7]. and an alteration to the configuration of social networks of high risk-taking heroin users [8]. In Liuzhou, there're 1000 heroin users who have enrolled in a separate needle exchange programme. These, together with the current ones on methadone, account for some 20% of all heroin users in the city that have access to some forms of harm reduction service. Because of the low HIV prevalence in neighbouring Hong Kong, we use the latter's experience of having >60% heroin users in contact with the territory's methadone clinic network as a yardstick for assessing coverage [7]. With the plateau that has not been reached, it would take a long time before a reasonable coverage can be achieved in Liuzhou.

To improve coverage, substantial changes in social environment are needed, both in removing the obstacles and in facilitating the enrolment of heroin users. Setting up of small multiple clinics would be one strategy to promote coverage. With the functioning of just one clinic, the unmet needs cannot be managed effectively. The operation of multiple conveniently located methadone clinics or even out-reach services are means of solving the problem. The efforts required to set up multiple clinics in remote rural areas would likely be phenomenal. The existing programme falls short of a truly low threshold approach, the latter characterized by a combination of ease of access and the absence of obligatory requirement for staying on in the programme [9]. Restrictions imposed through the entrance criteria and high governmental expectation would easily discount the proportion of vulnerable community that could benefit from substitution treatment. Finally, it is clear that the establishment of methadone clinics reflects only the very first step towards the ultimate target of harm minimization on a population scale. Through this long process, means to improve coverage would be crucial.

References

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3. Sullivan LE, Metzger DS, Fudala PJ, Fiellin DA: Decreasing international HIV transmission: the role of expanding access to opioid agonist therapies for injection drug users.
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6. Qian HZ, Schumacher JE, Chen HT, Ruan YH: Injection drug use and HIV/AIDS in China: review of current situation, prevention and policy implication.
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7. Chan MKT, Lee SS: Can the low HIV prevalence in Hong Kong be maintained.
AIDS Educ Prev 2004, 16(suppl A):18-26. [Publisher Full Text]

8. Rothenberg RB, Potterat JJ, Woodhouse DE, Muth SQ, Darrow WW, Klovdahl AS: Social network dynamics and HIV transmission.
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9. Millson P, Challacombe L, Villeneuve PJ, Strike CJ, Fischer B, Myers T, Shore R, Hopkins S: Determinants of Health-Related Quality of Life of Opiate Users at Entry to Low-Threshold Methadone Programs.
Eur Addict Res 2006, 12:74-82. [PubMed Abstract] [Publisher Full Text]

Source: http://www.harmreductionjournal.com/content/4/1/8

HIV, injecting drug use and harm reduction: a public health response

2007-04-06T13:01:00.000+07:00

By, Andrew Ball, Department of HIV/AIDS, World Health Organization, 2007

ABSTRACT

Injecting drug use is driving HIV epidemics in many countries around the world. There is evidence that such epidemics can be averted, halted and reversed if comprehensive HIV programmes targeting drug users are put into place. The term ‘harm reduction’ is used widely to describe the goals, policies and interventions of such programmes. However, despite its rapidly expanding use, the term has no universally accepted definition. This paper aims to describe the evolution and branding of the term ‘harm reduction’ and the adoption of the concept across a wide range of countries. It highlights a range of issues that remain controversial in the harm reduction discourse related to HIV and injecting drug use, including: the definition of ‘harm reduction’ and related terms; the scope of harm reduction; the promotion of a public health versus drug control dichotomy; the feasibility and appropriateness of harm reduction in low- and middle-income countries; and the strength of evidence on harm reduction interventions. The paper argues that harm reduction should be a core element of a public health response to HIV/AIDS where injecting drug use exists. The effectiveness of policies and programmes targeting drug users should be measured against public health outcomes. This requires the alignment of drug control measures with public health goals. A ‘model package’ for harm reduction is proposed, which provides guidance to countries on the selection of evidence-based policies and interventions, including: interventions for reducing HIV transmission; treatment of HIV/AIDS and associated comorbidities; appropriate models of service delivery; creation of supportive policy, legal and social environments; and strengthening of strategic information systems to better guide responses.

INTRODUCTION

Few terms in the world of drug policy evoke such extremes of emotion as ‘harm reduction’. Drug policy conservatives shudder, believing that traditional values and drug control will be undermined. Drug legalizers see opportunities for radical law reform. Somewhere in between, service providers and community advocates hold to a hope for more pragmatic, evidence-based interventions. These emotions are stirred by the lack of a clear definition, complicated further by a dynamic discourse that has often generated more heat than light. Despite diverse interpretations of the term, its use is expanding globally and is now imbedded in international policies and commitments. Whereas the term is used widely across all aspects of substance use, this paper focuses on harm reduction in the context of HIV and injecting drug use.

Injecting drug use is driving HIV epidemics in many countries and accounts for almost a third of new infections outside sub-Saharan Africa [1]. Across the estimated 13 million injecting drug users globally there is great variation in drug use patterns, behaviours and contexts. Over the past 25 years explosive HIV epidemics among injecting drug users have been witnessed in almost all regions, first in New York City in the late 1970s and more recently in such diverse countries as China, Estonia, Indonesia and Kazakhstan. Just as HIV epidemics and their determinants have been diverse, so have been the responses.

THE EVOLUTION AND BRANDING OF HARM REDUCTION

The term ‘harm reduction’ has been used variously to describe a principle, concept, ideology, policy, strategy, setof interventions, target and movement. One can imagine that harm reduction principles have been practised by communities since psychoactive substances were first used. For centuries, traditional use of opium in Asia and hallucinogens and coca products in Latin America has been guided by rituals and taboos aimed at protecting individual and community health [2]. Charitable organizations provided food and shelter for those intoxicated living on the streets of Europe in the 18th century. Opium was provided in the 18th and 19th centuries to registered ‘addicts’ in a number of European colonies in Asia. Doctors prescribed heroin and morphine to patients dependent on opioids as permitted through the flexibilities of the ‘British System’ of the early 20th century [3]. In the 1960s, ‘underground’ magazines for drug-using communities in Europe and north America provided advice on less hazardous ways of using drugs [4]. In the early 1960s, the prevailing abstinence-based approach of opioid dependence treatment in the United States was challenged directly by the introduction of methadone maintenance programmes [5].

The early part of the 20th century was a defining period for international drug policy, with a divergence in country approaches—some emphasizing a public health approach, but most focusing upon drug control measures. Concern about increasing levels of drug-related health problems was a major reason for the introduction of controls on the availability and use of psychoactive substances, although elements of social control and a desire to protect moral values also contributed to new policies. Despite the long-standing relationship between public health and drug policy, it was not until 1973 that a call for the primacy of public health over drug control was articulated clearly internationally. In that year ‘harm reduction’, as a concept, was recommended as a viable alternative to a drug control approach by the 20th World Health Organization (WHO) Expert Committee on Drug Dependence [6]:

The broad purpose of preventive measure should be to prevent or reduce the severity of problems associated with the non-medical use of dependence-producing drugs. This goal is at once broader, more specific, and with respect to certain drugs in many countries, more realistic than the prevention of-non-medical use per se.

Public health refers to collective efforts aimed at improving the health of populations, including the prevention of ill-health, the treatment, amelioration and control of disease and the promotion of wellbeing. Countries that had adopted a public health approach to drug-related problems, such as the Netherlands and the United Kingdom, were best equipped to respond rapidly when HIV emerged among drug injectors. The mid-1980s saw harm reduction adopted explicitly as the principle for national drug policies in a number of countries. The United Kingdom Advisory Committee on the Misuse of Drugs 1984 report called for a two-pronged approach of reducing risk among drug users and reducing harm associated with drug use [7]. In 1985, Australia was the first country in the world to officially adopt a national drug strategy based on ‘harm minimization’ [8], with harm reduction also included as a key pillar of the Australian HIV/AIDS Strategy [9]. Other western European countries, such as France, Italy and Spain, adopted harm reduction later, in the early and mid 1990s, in response to severe HIV epidemics among their drug injecting populations [10].

The annual International Conferences on the Reduction of Drug Related Harm, held first in Liverpool, UK in 1990, have helped to consolidate an international harm reduction movement and brand harm reduction as a public good. Since then discourse has moved from one heavily influenced by opinion to one that is firmly entrenched in health and social science and policy [11]. The establishment of harm reduction networks has acted as a catalyst for the translation of science and policy into country action.

In the mid-1990s, explicit harm reduction policies started to appear in low- and middle-income countries. This largely reflected a greater engagement of the health sector, particularly ministries of health, in drug policy and in the provision of services for drug users. In many countries, harm reduction has been elaborated in national HIV policies or health sector plans, rather than those for drug control. The Brazilian National AIDS Program adopted harm reduction as its policy in 1993 [12]. In 1996, Manipur, the first state in India to promulgate its own State AIDS Policy, based its policy on harm reduction principles [13]. The Islamic Republic of Iran established a National Harm Reduction Committee in 2002, involving government sectors responsible for health, drug control, welfare, prisons and law enforcement [14]. Harm reduction has been Indonesia's official policy since 2004 [15]. The Vietnamese National HIV Strategy, endorsed by the Prime Minister in March 2004, has harm reduction as a key element. The dramatic scale-up of harm-reduction activities in the Peoples' Republic of China, the development of comprehensive harm reduction programmes in the Kyrgyz Republic and the establishment of pilot harm-reduction programmes in Malaysia and Myanmar have followed national commitments to adopt a public health approach to injecting drug use.

The United Nations System has also moved. In 2001 the UN General Assembly set a target for countries to make available ‘harm reduction efforts related to drug use’ by 2005 [16]. In 2003, all 192 WHO Member States endorsed the Global Health Sector Strategy for HIV/AIDS, which includes harm reduction as a core component of a health sector response to HIV [17]. In 2005, UNAIDS included harm reduction as one of 11 essential programmatic actions for HIV prevention [18].

CONTINUING CONTROVERSIES

We are 25 years into the HIV epidemic, and there is still no universally accepted definition for, and use of, the term ‘harm reduction’. This is not through lack of interest or debate. Lenton & Single [19] dissect some of the key definitional issues, proposing a ‘socio-empirical’ definition informed by (and attempting to find some compromise between) arguments promoting narrow, broad and hard empirical definitions. None of the arguments to date has been convincing enough to prevail.

The proliferation of other terms, such as ‘harm minimization’, ‘risk reduction’ and ‘vulnerability reduction’, confuse matters further. These terms are often used to convey harm reduction principles in situations where the term ‘harm reduction’ is taboo. In other cases they have a specific meaning, although universally recognized definitions do not exist. Harm is a higher-level impact indicator, modulated by vulnerability, exposure and risk. Whereas vulnerability and risk reduction might be major outcome measures, the reduction of harm, as an impact goal, reflects the ultimate purpose of interventions, and therefore would be the preferred indicator against which programmes are measured.

Defining ‘harm’ is one of the more contentious issues. Whereas this paper focuses on harm reduction within the context of drug injecting and HIV, the concept has been and is being used far more widely, addressing alcohol- and tobacco-related harm and, increasingly, broader public health and social issues, such as traffic safety and sex work [20]. Harm occurs at different levels (individual, family, community, society) and in different forms (health, economic, social) and its measurement is often value-laden and determined by cultural norms and beliefs. Whereas significant work has been undertaken in quantifying health-related harm through such instruments as disability-adjusted life years (DALYs) and quality of life measures, there is no methodology for objectively measuring net harm across different domains, such as health, social functioning and economic development. How does one assess the net harm to a society related to injecting drug use, taking into account such harms as HIV morbidity and mortality, public nuisance of discarded needles, economic impact, criminal behaviour and moral outrage at permissive drug policies? Nevertheless, countries have to make difficult decisions, and the protection of public health must weigh heavily. In January 2005, faced with the choice between two ‘evils’, continued drug use in the community or the spread of HIV, and having considered two key tenets of Islam (those of La darara wa la dirar—doing no harm to oneself or others—and Al-darar al-achadd yuzal bil-darar al-akhaff—the worst harm is eliminated by a lesser harm) the Head of the Iranian Judiciary ruled in favour of public health rather than drug control, and issued an executive order supporting harm reduction measures for drug users [14].

Most debate has focused upon English-language terminology. It is unclear how easily ‘harm reduction’ and related terms translate into other languages and to what extent different translations have different cultural meanings, widespread use and recognition. For example, the Dutch translation for ‘harm reduction’ is not used; rather, the English term is preferred. In French, the usual translation is ‘reduction des risques’ rather than ‘reduction des dommages’. On the surface, then, this may appear to be an academic exercise in English semantics. Nevertheless, the distinction may have significant implications for the approaches taken to programming.

The ‘broad’ versus ‘narrow’ definition of ‘harm reduction’ continues to be hotly debated. Should the term be used inclusively to describe any intervention or approach that reduces a defined harm, including those approaches that reduce drug use (including prevention of initiation and abstinence), risk and vulnerability, or should it be used exclusively to describe only those interventions that aim to reduce harm without intending to reduce drug use? Opinions vary greatly. Australia's Drug Strategy opts for the broad definition, using ‘harm minimization’ as the overarching principle, encompassing supply, demand and targeted harm reduction strategies. On the other hand, the Swiss Federal Office of Public Health has used a ‘narrow’ definition since the early 1990s, separating out ‘harm reduction’ as one of four distinct elements of its drug policy, the other three being prevention, treatment and law enforcement. Despite difference in interpretation of the term ‘harm reduction’, both countries have successful national programmes using very similar strategies based on similar broad principles.

Some health and social scientists have a passion for creating and promoting false dichotomies, whether it be prevention versus treatment, vertical versus horizontal programmes, public health versus human rights or drug control versus harm reduction [21,22]. In the real world, although true dichotomies do exist and pose major challenges for public health, a middle ground is often achievable. Harm reduction advocates and practitioners need to be pragmatic and flexible, engaging in both prevention and treatment activities, exploiting what can be offered by both vertical and horizontal structures, maximizing the human rights principles of public health and promoting drug control measures that contribute to harm reduction outcomes. Much has been written about successful experiences in using law enforcement to advance harm reduction interventions, applying harm reduction principles in drug education programmes for young people, integrating harm reduction into HIV/AIDS treatment programmes and taking steps to protect the human rights of drug users within the context of controlling HIV epidemics.

The appropriateness and feasibility of harm reduction programmes in low- and middle-income countries is debated widely. These countries have many competing public health priorities and usually very limited resources. The diversity and dynamics of drug-injecting epidemics and the affected communities pose huge public health challenges for the design of relevant, acceptable and effective harm reduction programmes. Expanding methadone and buprenorphine maintenance treatment will have limited impact in communities where heroin use is being replaced by amphetamines. The establishment of dedicated needle and syringe exchange programmes may not be a priority in settings where affordable sterile injecting equipment is available widely through pharmacies. Without the existence of relevant safeguards and the availability of basic HIV prevention and care services, the promotion of HIV testing among drug users may do more harm than good, resulting in further stigmatization, discrimination and alienation. A thorough understanding of local context is required in selecting the most appropriate mix of interventions and the most efficient models for their delivery. This often requires major adaptation of interventions developed in high-income countries and investment in operational research to support this process.

Finally, certain opinion leaders, politicians and scientists still question the evidence-base for harm reduction relating to HIV prevention among injecting drug users. Across the range of HIV prevention interventions promoted for injecting drug users the volume and quality of evidence varies, particularly with regard to evidence from low- and middle-income countries. On one hand, few public health interventions have been subjected to the same intense scrutiny as methadone maintenance treatment. The body of evidence is significant for other key interventions such as needle and syringe programmes and risk reduction counselling. However, research on newer and more controversial interventions, such as safe injection rooms and the medical prescription of heroin, is limited. Particular challenges exist in identifying effective interventions for those individuals injecting drugs other than opioids, particularly amphetamine-type stimulants and cocaine. Recent reviews of the evidence on the role of harm reduction in HIV prevention demonstrate clearly the public health benefit of a number of key interventions and their relative safety [11,23]. The Institute of Medicine review [12] concluded that there was strong evidence of the effectiveness of opioid agonist maintenance treatment and that such programmes should be made widely available. It also found that there was consistent evidence that multi-component HIV prevention programmes including needle and syringe access interventions reduce HIV risk behaviours, and should be implemented where feasible. The implementation of outreach services for education and risk reduction was also recommended. At the same time, the report identified a number of significant gaps in knowledge and the need for additional research, including research on the potential unintended consequences of programmes, integration of interventions to reduce the sexual transmission of HIV and identification of effective disinfection techniques. Thus, the evidence supports the inclusion of opioid substitution treatment, sterile needle and syringe access and outreach as key components of an effective HIV prevention programme. It is now time to invest in their equitable expansion to the levels required to control HIV epidemics and achieve good service quality.

THE WAY FORWARD

Some welcome the ambiguity of harm reduction terms [24], arguing that it allows for greater flexibility in implementing policies and programmes to respond to critical public health problems. However, for many countries there is now an urgent demand and need for clear guidance on how to address drug-related problems effectively. There is little ambiguity over what works, at least with regard to key interventions for HIV/AIDS prevention, treatment and care for drug users. Defining a model package of harm reduction interventions, minimum standards for services and optimal levels of service coverage will do much to assist countries—comprising, in effect, an operational definition and strategy for ‘harm reduction’.

Within the context of HIV and drug use it is easy to define ‘harm’ and ‘harm reduction’ goals—the reduction of HIV transmission, the reduction of HIV-related morbidity and mortality and the reduction of HIV-related impact on communities (such as AIDS orphans). Given that drug control goals largely had their origins in the need to protect public health and the devastation of HIV epidemics among injecting drug users, the alignment of drug control measures with public health goals must be a priority.

Defining a ‘model package’ for harm reduction helps to address the dilemma of narrow versus broad definitions. Those communities and countries that have implemented comprehensive, multi-sectoral and integrated harm reduction programmes have been most successful in preventing or controlling HIV epidemics among drug users. Single, stand-alone interventions, even when they have good coverage, are likely to have only limited impact [25]. A ‘model package’ should include multiple evidence-based (or at least evidence-informed) interventions that are complementary and synergistic, promote multiple entry points for individuals to access services and ensure flexibility so that approaches can be adapted for different country contexts and changing HIV epidemic and drug use dynamics. The use of harm reduction hierarchies—comprising interventions ranging from prevention of drug use and preventing transitions from non-injecting to injecting forms of drug use to HIV/AIDS treatment and care for drug users—makes good sense [11]. In developing a practical tool for countries, the broad definition for ‘harm reduction’ should be preferred.

In July 2005 leaders of the G8 group of industrialized countries announced their intention to ‘work . . . with WHO, UNAIDS and other international bodies to develop and implement a package for HIV prevention, treatment and care, with the aim of as close as possible to universal access to treatment for all those who need it by 2010’ [26]. This goal was endorsed subsequently by the UN General Assembly in September 2005 [27], and expanded to include universal access to comprehensive prevention programmes, treatment, care and support by the UN General Assembly High-level Meeting on AIDS in June 2006 [28]. Given that ‘universal access’ means access for all, including drug users, there will need to be a massive scale-up of harm reduction services. The ‘model package’ concept can guide this process.

WHO is developing the harm reduction component of a broader public health ‘model essential package’ for HIV/AIDS prevention, treatment and care [29]. The package will promote principles of equity and human rights and interventions that can be scaled-up successfully in resource-limited settings. It will provide operational guidance to countries and other stakeholders on how to select and prioritize interventions and service delivery models, based on local context and available resources, and complementary to broader public health and drug control measures. In itself it will act as an important advocacy tool, describing to policy makers and donors key elements of a comprehensive and quality harm reduction programme and areas for public health investment. The public health model package for harm reduction includes five elements:

• Interventions for reducing HIV transmission, including HIV risk reduction information, education and counselling; HIV testing and counselling; sterile needle and syringe access; safe disposal of used syringes and needles; drug dependence treatment, particularly opioid substitution therapy; condom programming; prevention of mother-to-child transmission of HIV; and STI treatment.

• Management of HIV/AIDS, coinfections and comorbidities, including antiretroviral therapy; HIV treatment preparedness and adherence support; prevention and management of opportunistic infections, particularly tuberculosis; pain management and palliative care; prevention and treatment of hepatitis B and C; management of alcohol and other drug dependence and mental health disorders, such as depression.

• Appropriate models for service delivery and health systems strengthening, including peer outreach; integration of HIV, drug dependence treatment and outreach services; integration of HIV and drug use issues within other appropriate health services; interservice referral networks; defining minimum services to be delivered through different levels of health facilities; strengthening of procurement and supply management systems to ensure affordable and uninterrupted supplies of quality medicines (including methadone, buprenorphine and HIV-related medicines), diagnostics, needles and syringes and condoms; and development of human resources for harm reduction.

• Supportive policy, legal and social environment, including policies that ensure equitable access to HIV services for drug users; laws that do not compromise access to HIV services for drug users through criminalization and marginalization; and campaigns to reduce stigma and discrimination, related particularly to health services and workers.

• Strategic information, including HIV and behavioural surveillance among drug users; identifying programme and national indicators and selecting targets; monitoring quality, availability, coverage and impact of services; monitoring treatment adherence; and including drug users within population-based surveillance of HIV drug resistance and pharmacovigilance.

CONCLUSION

Harm reduction, with deep roots in public health, will continue to be a critical element of a public health response to HIV/AIDS. While we can expect continuing debate about the meanings of harm reduction, further misunderstandings, questioning of evidence, the offering of new definitions and stirring of emotions, we must ensure that any continuing confusion will not delay effective action being taken in countries. The best harm reduction advocates and practitioners are pragmatists rather than idealogues, who are not distracted by definitions and semantics but focus on ambitious but achievable goals, and those who prefer impact to process. Such front-line workers deserve moral support, practical tools and adequate resources to get their work done.

In defining a ‘model package’ for harm reduction for countries it is time to move on from the ambiguity of definitions, the misunderstandings of approaches and the questioning of evidence where it exists. If we are to witness real and sustainable impact in communities we must adopt a comprehensive, public health approach that is consistent with a broad definition of ‘harm reduction’. We need only to look at the success stories where comprehensive harm reduction policies and programmes are being implemented—averted HIV epidemics among drug users in Australia and the United Kingdom [10], epidemics reversed in France, Italy and Spain [10], major and rapid expansion of programmes in Brazil, PR China, IR Iran and Slovakia [10,14,23] and the adoption of supportive public health policies in Indonesia, Malaysia and Vietnam [15,23,30]—to recognize the relevance and value of such an approach.

DECLARATION OF INTEREST

The author is a staff member of the World Health Organization. The author is responsible for the views expressed in this publication and they do not necessarily represent the decisions, policy or views of the World Health Organization.

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Taiwan Legislature Approves Draft Bill That Would Provide HIV-Positive People With No-Cost Treatment For Drug Addiction

2007-04-06T12:19:00.000+07:00

By, Medical News Today, January 12, 2007

Taiwan's legislative branch on Monday approved a draft bill that would allow HIV-positive people to receive no-cost treatment for drug addiction, the Taipei Times reports. The draft bill, which also would provide no-cost treatment for drug addiction to people with mental illnesses, was written by the Ministry of Justice and approved by the Judiciary Committee. Justice ministry representatives on Monday told the Judiciary Committee that drug use is a major mode of HIV transmission and that two of every three new HIV cases in Taiwan occur among injection drug users. They added that the government, therefore, should make no-cost drug addiction treatment available to people living with HIV/AIDS in Taiwan. Under Taiwan's Narcotics Endangerment Prevention Act, first-time and minor drug offenders are not required to face criminal charges, but they can be required to undergo treatment for drug use. The justice ministry last year opened four drug treatment centers in Taipei, Taichung, Kaohsiung and Taitung. More than 3,500 people in Taiwan currently receive treatment for drug addiction, according to justice ministry statistics (Chang, Taipei Times, 1/9).

Source: http://www.medicalnewstoday.com/medicalnews.php?newsid=60515

Suicide risk factors

2007-03-26T17:04:00.000+07:00

By, Heather Muller, The Eureka Reporter, February 25, 2007

On Feb. 3, 2006, Michelle Roskopp lost her long battle with drug addiction, with mental illness, with physical illness and with the circumstances of her short, troubled life. She committed suicide a month before her 37th birthday — a death her mother said “could have been delayed but probably not prevented.”

Why did Michelle die?

The story goes that when Michelle died, her boyfriend was threatening to kill himself after learning she had prostituted herself to buy crack cocaine, according to Michelle’s mother, Fortuna resident Susie Spitzer.

“She said to him, ‘What are you going to do, how are you going to do it?’ So he took the gun and put it in her mouth. And she said, ‘What are you going to do next?’ and he said, ‘Pull the trigger.’ He started screaming at her, just screaming for her to pull the trigger. ‘Pull the trigger, pull the trigger,’” Susie said.

“So she did.”

Though Michelle’s suicide came as a shock to those who knew her, her death at the age of 36 was not entirely unexpected.

“She was sick,” Susie said, “really sick. At that point, she weighed only about 85 pounds.”

Not long before Michelle’s death, her mother received a phone call from a Las Vegas hospital saying that Michelle had just walked out of the emergency room, against the advice of a physician.

She had been diagnosed with extremely severe lupus, was suspected of having hepatitis B and C, and had refused a test for HIV — all of which her mother, a 30-year registered nurse, believed Michelle had.

Certainly physical illness wasn’t Michelle’s only serious problem. She had been diagnosed with schizophrenia as a child, and in recent years had lost her marriage, her job, her home and her two children to habitual drug use.

“I want to emphasize that although she did have some emotional problems, she was not always a bad person,” her mother said. In fact, she was a graduate of the University of Nevada, Las Vegas, and worked as a designer for a major Las Vegas casino. She was by all accounts a good mother to her children.

That was before the drugs.

“She turned into a crack whore,” Susie said. “Saying that makes me want to vomit, but it’s an honest statement.”

So what killed Michelle Roskopp?

The short answer is that she did. But the long answer could be even more troubling.

According to reports from the Humboldt County Coroner’s Office, as much as 60 percent of the 141 people who died from suicide in Humboldt County from 2002 through 2006 suffered from a diagnosed mental illness — depression was most common, followed by bipolar disorder and schizophrenia.

Drugs and/or alcohol were named as factors in 45 percent of suicides during the same period, with prior attempts and/or threats documented in 41 percent of deaths.

Isolation — one of the most common explanations of suicide in sparsely populated rural areas — was identified in less than one-fourth of all deaths.

But probably the most startling statistic gleaned from the coroner’s reports was the high number of suicides in which serious chronic or fatal illness was said to be a factor.

For 61 people — 43 percent — at least one of a list of dire, debilitating conditions was named, ranging from chronic pain to terminal cancer.

Among the risk factors regularly documented in coroner’s reports were five circumstantial or event-based factors, including difficulties relating to various losses — of a relationship, of status and even freedom stemming from serious criminal charges, of a place to live, of a job or of a loved one.

Michelle had almost all of these things working against her. Her risk assessment, if such a thing is even possible, was off the charts.

But in many other suicides in which medical illness was said to be a factor, the person who died did not appear to be otherwise at risk.

According to coroner’s reports, the average number of 10 risk factors in suicide deaths in Humboldt County was three.

But of the dozens of suicide deaths in which only one or two risk factors were identified, the overwhelming majority — more than 60 percent — were chronically or terminally ill.

That wasn’t the only difference between the two groups.

The seriously ill also tended to kill themselves in noticeably different ways. Gunshot deaths were slightly more common in that group, and hanging deaths — which accounted for 23 percent of the deaths of healthy individuals — were practically nonexistent among the physically ill.

And while people without medical problems were almost eight times more likely to hang themselves than those with, the second group was four times more likely to die from a prescription drug overdose, a means readily available to the seriously ill.

Humboldt County Director of Health and Human Services Phillip Crandall said that discussion about the causes of suicide tends to center around mental illness — and not for nothing. Virtually every major suicide organization in the country states that probably 90 percent of all suicide deaths involves some type of mental illness, diagnosed or otherwise.

But, Crandall said, “It needs to be remembered that mental illness is not the only thing that moves people to suicide.”

Researchers agree.

Mental illness can interfere with rational thought processes, they say, and drug or alcohol abuse can increase impulsivity. Prior threats or attempts can indicate whether suicide is within the range of possibility for a particular person, and isolation can limit communication with those who might offer solace.

Similarly, event-based risk factors and losses can trigger a suicidal episode — but researchers consider these not so much an explanation of suicide as an opportunity for suicide to occur.

Noted expert E.S. Shneidman did find some commonalities among all suicides.

According to his research, the common goal is a cessation of consciousness, and the common stimulus an “intolerable psychological pain.”

Perhaps most important is the common emotion of suicide — what Shneidman described as a combination of hopelessness and helplessness, a condition that dominated the years leading up to Michelle’s death.

“I don’t think she thought she had a whole lot of options left in life,” her mother said. “It’s like she painted herself into a corner. She felt helpless. She felt hopeless. I think she thought she had burned all her bridges. They say nothing’s over until it’s over, but maybe that wasn’t the case with her.”

It’s difficult to imagine anything more likely to cause hopelessness and despair than the knowledge of a slow and painful terminal illness.

“I don’t think she thought she could come back from that,” Susie said.

And Susie didn’t think so either.

“I just always assumed she would come home when she got sick enough to die, and I would take care of her. That’s what I thought would happen. That’s what I thought our happy ending would be.”

Instead, a few weeks before Michelle’s death, Susie received a letter from her daughter.

“I’m not going to stay away from you any more,” it stated in part. “I need and love you too much. I’m so sorry for all the pain I’ve caused. I love you very much, Mom. Love, Shelley.”

Source: http://www.eurekareporter.com/ArticleDisplay.aspx?ArticleID=20925

A shot in the arm...or a headache for the law?

2007-03-26T16:15:00.000+07:00

By, The straits Times, March 24, 2007

Malaysia: The "harm reduction" pilot programme introduced in 2005 for intravenous dadah users is a resounding success, at least as far as the Health Ministry is concerned.

Deputy director-general of Health Datuk Dr Ramlee Rahmat said the majority of the addicts involved in the pilot project had kicked the habit.

He said the ministry will start recruiting more addicts in new areas.

He said the ministry had an understanding with the police and the anti-drug agency on the expansion of the programme and on areas which will be out of bounds to raiding parties when the programme is on.

The ministry will, however, not stop the police from arresting addicts involved in the programme caught in criminal activities or dadah abuse outside the programme area.

"The police have their duty to arrest those who are a threat to national security."

The primary thrust of harm reduction is a combination of dadah substitution therapy using methadone and a needle and syringe exchange programme.

The idea of addicts returning used needles is to prevent the spread of HIV/AIDS through contamination.

The ministry’s needle exchange programme manager Datuk Dr Faisal Ibrahim said all addicts in the programme received counselling to ensure they did not return to the habit or share needles.

Some 100-odd addicts in the needle exchange programme have since decided to switch to methadone.

"Our aim is to make sure they fully understand the programme and not violate the rules and regulations stipulated to them."

He said a meeting was held bimonthly between the stakeholders including the police to get feedback on the situation.

According to World Health Organisation figures, the success rate of harm reduction programmes is usually aro- und 70 per cent.

Dr Faisal said there were some 1,200 dadah addicts involved in the needle exchange programme in Johor, Penang and Kuala Lumpur.

"Feedback showed that 60 per cent of those who participated in the needle exchange programme returned used needles. This is good."

On addicts switching to methadone, he said this was a clear sign that the harm reduction programme had ach- ieved its objectives.

THE NEGATIVE

POLICE feel the "harm reduction" programme has given them a headache.

Bukit Aman Anti-Narcotics director Datuk Abang Abdul Wahab Abang Julai said the police had to release hundreds of dadah users back to the streets as they were protected under the programme.

"We have to close an eye in the matter although they should by right be arrested. But since it is a government initiative, we have backed the government 100 per cent."

Abang Abdul Wahab said he had completed a paper for submission to the government on the dadah problem and ways to curb the menace.

"There is a lot of money allocated to curb this problem but the money should be used wisely."

He said First World countries practised the needle and syringe exchange progra- mme (NSEP) but were governed by the Dangerous Drugs Act like in Malaysia.

"In Australia, drug addicts are told to come to centres where a medical assistant administers the drug into the addict using a new needle and syringe."

Abang Abdul Wahab said this was good as addicts could not go back to the streets to share the new needles and syringes with their friends or even sell them.

In February last year, the government started distributing free syringes in exchange for used ones and condoms to dadah addicts in Kuala Lumpur, Johor and Penang.

The cabinet allocated RM100 million over five years on top of the RM40 million annual allocation for the "harm reduction" programme which includes NSEP and the methadone programme.

A total of 100 paramedics have also been trained at a cost of RM600,000 to counsel and administer anti-retroviral drugs to patients.

Source: http://www.nst.com.my/Current_News/nst/Saturday/National/20070324083632/Article/local1_html

UN drug watchdog ignores HIV, rights groups say

2007-03-12T14:55:00.000+07:00

By, Michelle Nichols, Reuters, February 27, 2007

The U.N. drug control watchdog is hindering efforts to fight the global AIDS pandemic and the agency should be independently reviewed, human rights groups and a former U.N. AIDS envoy said on Tuesday.

The Canadian HIV/AIDS Legal Network, the Open Society Institute and Stephen Lewis, a former U.N. special envoy for AIDS in Africa, accused the 13-member International Narcotics Control Board of enforcing drug policies that ignore public health.

"If I had it in my grasp I would take them out behind the international woodshed and give them an intellectual and rhetorical flogging, the like of which they would never forget," Lewis told a news conference.

A report by the groups said one third of HIV infections outside of Africa were caused by injection drug use and while the U.N. board acknowledged drug use was accelerating the spread of the disease in some countries, it failed to encourage any preventive action.

The report, "Closed to Reason," said the International Narcotics Control Board, established in 1968, had not only ignored the public health implications of drug use, but discredited "effective programs" such as sterile syringe exchanges and the use of methadone as an addiction treatment.

"It's as though the HIV/AIDS conjunction has passed the International Narcotics Control Board right by," Lewis said. "They are aligning themselves with the virus rather than opposing it determinedly."

Lewis, a Canadian, also told of how while he was former U.N. Secretary-General Kofi Annan's special envoy on AIDS in Africa between 2001 and 2006, he voiced support for safe drug injection rooms.

He said the control board complained to Annan about his comments. "The fact that they would write a letter attempting to silence a critic is a demonstration of how out of control the International Narcotics Control Board is," Lewis said.

The Vienna-based International Narcotics Control Board (INCB) is an independent judicial body elected by U.N. members that monitors the implementation of international drug control conventions. A spokesman was not available for comment.

Nearly 40 million adults and children in 2006 lived with HIV, the virus that causes AIDS, with more than 25 million in Africa alone, U.N. figures show.

"Millions at risk of HIV in Eastern Europe and Asia can benefit from drug policy that works in tandem with public health," said Daniel Wolfe, deputy director of the Open Society Institute's international harm reduction development program.

"Alleviation of human suffering is one portion of the international conventions that the INCB has done strikingly little to uphold," he said.

Mauritius: HI Virus hits drug users

2007-02-21T10:03:00.000+07:00

By, Nasseem Ackbarally, Inter Press Service (Johannesburg), February 20, 2007

In contrast to the rest of southern Africa, intravenous (IV) drug users have become the group most vulnerable to the transmission of the HI virus in Mauritius. This has led the Mauritian government to introduce a syringe and needle exchange programme in a bid to stem HIV infection among Mauritian drug users.

Sexual transmission among heterosexuals is the most common way of HIV infection in southern Africa, the region which has become the centre of the international HIV/AIDS pandemic in recent years.

Mauritius is unusual in the region as the HIV prevalence rate among its population of 1.2 million people is less than 0.5 percent. Since 1987, 162 Mauritians have died from AIDS-related illnesses. Currently, some 2,345 Mauritians are living with HIV/AIDS according to official figures but some social workers estimate the number to be around 10,000.

Another unusual characteristic of the epidemic in Mauritius is that drug injection with shared needles has since 2003 been the main mode of HIV transmission. The sharing of contaminated needles was responsible for 92 percent of new HIV infections in 2005 and 85.2 percent of new infections in 2006.

Social worker Cadress Runghen ascribes the increased vulnerability of drug users to HIV/AIDS to the fact that anti-AIDS messages focussed on sexual behaviour only.

Sensitisation campaigns helped to ensure that the population was made aware of the risk of HIV infection through sexual means, leading to a drop in such infections during the 1990s.

But, says Runghen, "nobody kept a check on the drug addict community". In the meanwhile the HI virus has been spreading like wildfire among the members of this marginal group.

To address this and other issues, the Mauritian parliament adopted the new HIV and AIDS Act at the end of 2006 which introduced a syringe and needle exchange programme and methadone treatment. Methadone is used to alleviate withdrawal symptoms during the rehabilitation of drug addicts.

In just a few weeks, 2,000 syringes used by drug addicts have been taken out of circulation and replaced by new ones. A few hundred addicts are now being treated with methadone.

Social workers have started this programme in the capital Port Louis and on the outskirts of the capital at Baie-du-Tombeau, Roche Bois and Batterie Cassée where a large number of drug addicts live or come to have their daily dose of heroin or other drugs.

They meet in places which are not generally frequented by other members of the public. Social workers visit these places to hand out new syringes and condoms. The used syringes and needles are collected in a plastic box and destroyed.

Social workers use this contact to sensitize drug users to HIV/AIDS issues. "It is not only a programme to exchange syringes. It is not a mechanical exercise. We are doing it to reach out to drug addicts and convince them to go to one of our rehabilitation centres," says Runghen.

Drug addicts hide themselves from the public eye for fear of being arrested by the police. The social workers have to win their confidence. "This is a long process. Drug addicts want to talk to people. They want to feel the warmth of people who listen to them. They do not want to be rejected," Runghen adds.

One female drug addict, Nalah (not her real name), told IPS that she is now more aware of HIV/AIDS. She and her friends used to share one syringe for days on end because pharmacists would not sell them new ones.

"That is why we come to exchange our syringes. When an addict suffers because you cannot take your daily dose, you will take any syringe you find to shoot up with," Nalah explains.

Another social worker, Imran Dhannoo, is adamant that the programme should be directed at those thousands of drug addicts who are vulnerable and who do not know about the programme. "We should reach out to them. We should not wait for them to come and see us."

The syringe exchange programme is one of a number of initiatives in the comprehensive HIV/AIDS legislation introduced last year.

According to health minister Satish Faugoo, the law provides an effective national framework with prevention and care programmes that will get people involved in curbing the spread of HIV/AIDS while protecting people's human rights.

Emphasis is placed on confidentiality and human rights. Thus, no HIV test can be undertaken without prior consent of the person being tested, and the results of tests must be made available to the person. The law also allows a minor to undergo an HIV test without the consent of her or his guardian.

The law determines that HIV-positive people be referred for treatment. Information about the HIV status of an individual is protected from unauthorised collection, use or disclosure in health care and other settings.

In a bid to stem stigmatisation and discrimination against people with HIV, penalties have been introduced to protect their pension rights and employment conditions, and to prevent prejudice or ill-treatment of any kind.

Faugoo has said that HIV positive people should be guaranteed equal rights to employment and heath care as are accorded all other members of Mauritian society. The law makes it illegal to impose HIV testing as a pre-condition for employment or continued employment.

It is also an offence for a doctor not to provide treatment to a person who is or perceived to be HIV positive. Testing facilities will be introduced in specific public health institutions, as well as pre- and post-test counselling. Testing will happen in accordance with strict guidelines and protocols to ensure the reliability of results.

Nicolas Ritter, spokesperson for a nongovernmental HIV/AIDS organisation, welcomed the new legislation. According to him, many people are living with HIV without knowing it.

Meanwhile, religious leaders are warning people about their sexual behaviour. Catholic priest Jocelyn Grégoire has appealed to Mauritians, saying: "The house is on fire and we cannot save it. But we should save the furniture. You are being told to use condoms. If they cannot protect you from pregnancy, how can they protect you from HIV?"

"Better be faithful," added Homa Mungapen, spokesperson for the Council of Religions.

Source: http://allafrica.com/stories/200702200521.html

Bali: Sanglah Hospital Appointed as WHO's Model for Methadone Treatment

2006-01-31T05:38:00.000+07:00

Denpasar, Bali- The Sanglah Hospital has been appointed by the World Health Organization (WHO) as a model hospital for the treatment (RM) of 20,395 drug-addicts by providing them with methadone medicines in 2005, a spokesperson of the hospital, Putu Putra Wisada, said on Sunday.

"The special unit serves 80-90 patients on average every day," Putu Putra Wisada said.

He said the treatment was provided to cure the drugs addicted people in addition to prevent the spread of the HIV/AIDS, as it was able to change their attitude from using the injection to consuming the medicine. In a low dosage, methadone could prevent the bad impact of the deadly hepatitis virus and other diseases.

"With the treatment, the drug addicts could free themselves from their bad habit," he said, adding that the hospital treats 16 people with HIV/AIDS every month.

In 2005, 29 people suffering from HIV/AIDS died in the hospital, adding the number of HIV infection-related death toll till December to 798.Some 3,000 people were reported to have been infected by the HIV viruss.

Source: Antara News, Indonesian News Agency

Drug substitution treatment in Vietnam to fight HIV/AIDS

2005-11-03T08:18:00.000+07:00

November 2, 2005, Associated Foreign Press

VIET NAM- Substitution treatment for drug addicts will be a key part of the fight against HIV/AIDS in the future in Vietnam, government officials and the World Health Organisation said.

Needle and syringe use account for the majority of new infections of HIV/AIDS in Asia, the WHO said in a statement.

"Extensive research shows that by combining common approaches to the drug problem with harm reduction methods such as drug substitution treatment, an effective response can be achieved," said Hans Troedsson, WHO representative in Vietnam.

"This combination approach can not only avert an HIV crisis but also directly addresses the problem of drug use."

The statement was issued after a workshop co-organized last week by the WHO and the Central Commission for Ideology and Culture of the Vietnamese communist Party.

The number of people infected with HIV/AIDS in Vietnam is still relatively low compared to other countries in the region, but it is spreading at an alarming rate.

Official figures say that in May 2005, a reported 95,512 people were living with HIV/AIDS nationwide, with 15,539 reported cases of full-blown AIDS and 8,965 deaths.Widely admitted estimates however put the figure around 250,000 people living with the virus.

International experts have warned it could grow very rapidly.

"The future of the HIV pandemic in Asia, including Vietnam, will largely depend on response to drug use," said Dr. Dao Duy Quat, vice chairman of the central commission, in the statement.

Source: AFP

Methadone urged for AIDS fight in ex-Soviet states

2005-07-26T10:34:00.000+07:00

By Andrei Khalip, Reuters, 26 Jul 2005

RIO DE JANEIRO, Brazil,- Russia and its neighbors should lift their ban on using opiates such as methadone to treat addicts who inject drugs, scientists at an international AIDS conference said on Monday.

"Methadone is essentially an AIDS prevention tool," said professor Chris Beyrer, founding director of the Center for Public Health and Human Rights at Johns Hopkins University in Baltimore.

Beyrer praised Russia for scrapping, starting this year, a measure barring drug users from participating in free AIDS treatment programs.

"This thrills us a lot. But they are still opposed to methadone use, which remains illegal there. They need to get as many people as possible off the needles," said Beyrer, calling the ban a legacy of the Soviet system.

Methadone is taken orally, avoiding the use of needles that can spread AIDS. This substitution therapy can help satisfy addicts' cravings while allowing them to function normally.

The World Health Organization recently recommended that the treatment be integrated into national HIV/AIDS programs. Another scientist at the Rio de Janeiro conference said Russia agreed to treat drug users with AIDS only because it was a condition attached to millions of dollars in foreign aid.

Others said AIDS screening figures from the region, with the exception of those from Ukraine, were not very reliable. Ukraine, which tops ex-Soviet states in the HIV incidence rate with 1.4 percent of the adult population infected, has a fledgling substitution therapy program.

But it recently upset anti-AIDS groups with a proposal to ban methadone. Researchers say actual rates in other former Soviet countries could be higher. In Russia, the rate is more than 1 percent.

"It's a relatively recent epidemic but it's fast-growing. It is just getting going," Beyrer said. Such fast-growing epidemics have never been seen in countries with declining populations, he added. Belarus, Ukraine, Russia and Kazakhstan are all losing people. "So the implications may be more severe as the disease infects mainly young people and there is already a shortage of them."

"All this is due to a rising tide of heroin, with injection infecting people almost exclusively. But next we'll have a lot to do with sexual patterns of drug users," Beyrer said. On a positive note, there was evidence that condom use was becoming the norm in Russia, at least among prostitutes, he said.

Source: ITPC eForum

Methadone comes of age, at last

2005-07-03T18:55:00.000+07:00

by: HDN Key Correspondent Team
**************************
Imagine there was a simple, effective and affordable medicine that could reduce the death rate among people who use drugs such as heroin by about two-thirds.

Fat chance? Now imagine that medicine does exist, but that because of a reluctance on the part of policy-makers and government officials, it was not widely available in many countries. Hard to believe? Dream no more. The medicine exists and is about to break out of its shrouded history: Methadone is coming of age.

Significantly, and on the eve of the 7th ICAAP, the World Health Organization (WHO) announced that it had added methadone (and buprenorphine, a medicine with a similar clinical profile) to the WHO Model (Complementary) List of Essential Medicines - a roster of drugs endorsed by WHO, and recommended for basic use by health services throughout the world.
"This is important," said Dr Peter Piot, Executive Director of the United Nations Joint Programme on HIV/AIDS (UNAIDS). "Nations who want to provide methadone in their programmes will now have easier access."

Between 5 and 10% of the world's HIV infections are reportedly due to injection drug use and represent a much higher proportion of HIV transmission in some countries - in Asia and Europe in particular. Injection drug use is also now the predominant mode of transmission of hepatitis C virus throughout the world.

Due to the unregulated nature of illicit substances, injection drug users often use drugs of unknown potency and quality, which can frequently lead to overdoses. It is estimated that approximately 2-3% of injection drug users die each year, resulting in a mortality rate for heroin users, for example, of between six and twenty times that seen among those in the general population of the same age and sex.

Substitution therapy using drugs such as methadone, is a treatment approach that helps opioid drug users (e.g. heroin) to reduce the withdrawal symptoms and craving when drug use is stopped or reduced. Methadone is one of the oral medications used for substitution therapy. Because users taking methadone are far less likely to inject drugs, it also has a significant impact on reducing their risk of HIV infection.

In their position paper Substitution maintenance therapy in the management of opioid dependence and HIV/AIDS prevention, the WHO, the United Nations Office on Drugs and Crime (UNODC) and UNAIDS stated that opioid "drug dependence treatment is an important strategy to improve well-being and social functioning of people with opioid dependence and to reduce its health and social consequences, including HIV infection."

Participation in substitution therapy also provides opportunities for early diagnosis of other health problems, HIV, tuberculosis, hepatitis and counselling and testing, as well as referral for additional services. It is arguably the most effective, and cost-effective, treatment option for injection drug users, and brings them into contact with various other services within the health system.

According to several estimates, every dollar invested in opioid dependence treatment programmes may yield a return of between $4 and $7 in reduced drug-related crime, criminal justice costs and theft alone. When savings related to health care are included, total savings can exceed substitution therapy costs by a ratio of twelve to one.

IDUs who do not enter methadone treatment are thought to be up to six times more likely to become infected with HIV than injectors who enter and remain in treatment.

Substitution therapy is not a stand-alone solution, however. Another new UNAIDS policy position paper 'Intensifying HIV Prevention', also endorsed by the agency's governing body just days before the ICAAP congress, lists various essential programmatic approaches to reduce HIV acquisition and transmission among drug users. They include voluntary, confidential HIV testing and counselling, prevention of sexual transmission of HIV among drug users, access to primary healthcare, and access to antiretroviral therapy.

HDN Key Correspondent Team
Email: correspondents@hdnet.org
(July 2005)

HIV+ drug users lagging behind on the road to ARV treatment

2005-05-22T00:53:00.000+07:00

Drug users living with HIV/AIDS make up only a tiny proportion of people receiving antiretroviral (ARV) drugs throughout the world. According to reports presented at the recently concluded International Conference on the Reduction of Drug Related Harm, held in Belfast, Northern Ireland [20-24 March], drug users are being left out of ARV treatment programmes as a result of double-standards within health services, even in countries where drug use is a major determinant of HIV spread.

Basic data were provided by Dr Chris Ford, a British-based general practitioner, who summarised conservative estimates that about 200 million people consume illicit drugs globally. Opiates are used by about 15 million, heroin specifically by 9 million, cocaine by 13 million, marijuana by 146 million and amphetamines and ecstasy by 38 million. Worldwide, there are in excess of 13 million injection drug users in over 130 countries. But most harm reduction and treatment resources go to 20% of those users, and mostly to those living in rich countries. That leaves the vast majority of drug users worldwide with little or no access to treatment options.

For example, injection drug users represent less than 8% of all people receiving antiretroviral treatment in developing and transitional countries.

Referring to the latest UN data on the availability of ARVs, Dr. Carmen Aceijas of Imperial College, London, reports that a total of 53 countries currently provide ARV treatment through some sort of public scheme, and that an additional 41 countries rely on the nongovernmental and/or private sectors. In total, as of Dec. 2004, 432,453 people in 44 developing and transitional countries were receiving antiretroviral treatment.

Of those people in developing/transitional countries receiving ARVs, only 35,391 people are identified as drug users and of these approximately 30,000 of them are in Brazil.

ARV treatment through any means is completely unavailable in at least eight countries: Azerbaijan, the Republic of Korea, Kyrgyzstan, Somalia, Syria, Tajikistan, Turkmenistan and Uzbekistan.

Discussing the urgent need of expanding ARV treatment for HIV-positive drug users, Dr Michel Kazatchkine of the Agence Nationale de Recherches sur le Sida, France, confirms that access among drug users who should be eligible for ARV treatment remains poor in many regions of the world. While injection drug users represent over 80% of patients currently in need of treatment in Ukraine, Belarus and Russia, for example, they represent less than 5 % of patients currently receiving ARV treatment in those nations.

For Kazatchkine, limiting access to treatment raises important ethical and societal issues - because it is an inappropriate approach from a public health perspective; and because there is a high risk of disease progression in patients initiating treatment at later stages and with HIV-associated conditions. For him, limiting IDU access to treatment stems from a double standard of thinking.

Olga Kuzenna and Susie McLean of the International HIV/AIDS Alliance, UK, describe how Eastern Europe has one of the largest and fastest growing HIV epidemics among drug users, who account for 71% of new HIV infections; according to World Health Organization (WHO) estimates, approximately 15,000 people living with HIV/AIDS in the region are in need of ARV treatment.

Prior to the initiation of a Global Fund Against AIDS, Tuberculosis and Malaria (GFATM) in the Ukraine, for example, 118 people were receiving ARV as part of a Medicines Sans Frontieres (MSF) programme and an additional 137 as part of a government programme. Now, after 8 months of the GFATM programme, over 1400 people are receiving treatment. Yet, these are still low numbers relative to estimates of active drug users, and deaths of people on ARV waiting lists, a lack of integrated tuberculosis care, poor access to health care generally for drug users and challenges in changing the attitudes of health care workers all remain formidable obstacles.

Dr Andrew Ball of the Department of HIV/AIDS at WHO provides an update on reaching drug users with through the current ‘3 by 5’ Initiative, aimed at expanding ARV access to reach 3 million people with HIV in developing countries by the end of 2005.

According to Ball, WHO is making it a priority to promote good drug-related practices through policy guidelines and position papers, incorporating harm reduction principles in key WHO resolutions and basic documents, conducting country advocacy visits to countries including China, India, Indonesia, the Islamic Republic of Iran, Libya, Russia, Ukraine and Viet Nam, as well as establishing collaborative partnerships with affected communities, including harm reduction networks.

In addition, WHO is developing models of HIV/AIDS treatment scale-up for countries with high levels of injecting drug use through linking and integration of HIV/AIDS treatment services with drug dependence and drug user outreach services; through advocating continuity of care for prisoners, capacity building, support for pilot programmes, adaptation of relevant tools and guidelines, and assisting countries to mobilize and utilize resources, including funds specifically for treatment of drug users.

As Ball summarised “Drug users are entitled to treatment and are worth investing in.”

[This is an HDN Key Correspondent report from the International Conference on the Reduction of Drug Related Harm, held in Belfast, Northern Ireland, March 20-24, 2005.]

HDN Key Correspondent Team
Email: Correspondents@hdnet.org

(April 2005)

Pharmacotherapy for drug users waiting for ARVs

2005-05-21T02:47:00.000+07:00

Where antiretroviral (ARV) treatment may not be available, can pharmacotherapy therapy, such as methadone, keep drug users with HIV alive until ARV treatment arrives?

Participants at the recently concluded International Conference on the Reduction of Drug Related Harm, held in Belfast, Northern Ireland [20-24 March] comment on this question.

According to Bernard Gardiner, Manager of the Global AIDS Program of the International Federation of Red Cross and Red Crescent Societies: “Methadone can help stabilise the situation of drug users so that they can be in control of their circumstances, this means that they are less likely to share injecting equipment, they are less likely to get HIV in the first place, or if they are HIV positive, they are less likely to have chaotic circumstances.”

“That kind of stability means they actually have real choices to be able to look after their health with the things that are available to them and keep themselves as well as possible until the ARVs are available.”

“They may be less likely to be involved in risk through being marginalised and the desperations that come with addictions and the risk taking that goes on in an illicit context.”

“That is the role that it [pharmacotherapy] can play in keeping people alive. There is 40 years of evidence that methadone works, and it is about time that this way of reducing human suffering was made available to people who need it.”

“It is a rational approach to the treatment of addiction, the reduction of human suffering, and the well being of drug users, their families and the communities that they live in. Methadone can keep them alive to advocate for ARVs to be there, and that is the kind of push that it will probably take to get it there.”

For Joe Salvaretnam, Program Director at the Malaysian AIDS Council, the role of methadone in the care of injection drug users with HIV or AIDS is key.

“It is part of the continuum of care. In countries, like Malaysia, for example, if you contact the drug user and convince them that he can be stabilised through methadone, then you can link them up with other care and support services. When we talk about ARVs in our kind of resource setting, where drug users face extraordinary stigma and discrimination, this could be a vicarious way of getting them on methadone and linking them up.”

Chris Buckner is the Manager of HIV and AIDS and Harm Reduction Services for Vancouver Coastal Health, in British Columbia, Canada. He explains: “In Vancouver there are 1,300 IDU [injection drug users] who are eligible for ARVs but only about 300 have ever been on them, and so that is one of the big challenges: seeing how we can increase that access.”

“Some of the barriers are bureaucratic in that a lot of the programs are clinic-based and maybe you get your methadone there, or maybe you hate the doctor there, or maybe you hate that there is a security guard standing there.”

“Some of the folks, some of the researchers and other people who have control over the ARVs and the protocols are a little bit anxious about those sorts of things, like ‘oh, we are going to get a superbug,’ or ‘oh, we are going to do more harm than good,’ but I think there is an area in between the doomsday and the hyper-control.”

Buckner says we should explore “what adherence mean to someone. Maybe five years of adherence is unrealistic, but maybe there is some benefit in terms of smaller windows of adherence that can be obtained, rather than saying you are at the gold standard of adherence or you are nothing.”

“Some of the unethical practices, saying ‘I will give you this but only if you do this,’ we’ve got to bust that open and call it what it is: It is unethical to withhold medical treatment from people who want it based on this coercion to enter into appropriate drug treatment…you have got to divorce those things. They don’t hold back people who are in treatment for cardiovascular disease, they don’t say ‘we are only going to give you this angioplasty if you never eat McDonalds again.’ So why are we doing this thing with people with addictions?”

“The answer is clear: Because they are in a disadvantaged place and we feel we need to put our moral concept onto them, so you withhold valuable medical treatment.”

“It’s a struggle on the same level as the shift that happened with mental illness or people with physical disabilities having rights to access to care. An addiction is different, but on a purely ethical, theoretical level it shouldn’t be different.”

Fiona Reid, from the Perth Women’s Centre in Western Australia, can’t see any reason why drug users with HIV shouldn’t be able to access methadone and antiretroviral therapies “for the same reason that the women we work with can access treatments for Hepatitis C.”

“The women we work with have children and they are surprisingly used to schedules, they are often involved with courts and law or family disputes. If it is a priority, and for most of them it is a priority.”

“I think that it is a myth or a misnomer that people who use intravenous drugs don’t see their health as a priority, they do, its just whether they can access it and accessing it is about being able to be treated with respect, not being judged for what they do, regardless of their drug use.”

“They will access it [health services] if it is available on those human levels.”

Ralf Jürgens, from the Canadian HIV/AIDS Legal Network, believes it is a “very important step to increase access to methadone… in those countries where methadone is currently not available as well as those where it is available but not accessible.”

“People who are on methadone have a better chance to be able to take the treatments [eg. ARVs]; it is part of the care and the support that some people may need to be able to benefit from treatment.”

However while Jürgens thinks there is a link, he doesn’t believe we should “require that ‘you have to be on methadone to take ARVs’. That is not what we are doing in Canada or in other countries. Access to methadone needs to be a choice and it needs to be very accessible – and ARVs need to be very accessible too.”

“People shouldn’t be forced to take methadone treatment in order to benefit from ARVs, but they should have that option if they choose.”

“There are human rights to health and methadone is a medical treatment – people have a right to methadone, and it is the same with ARVs.”

But Dr Rusli Ismail, a geneticist and member of the Malaysian AIDS Council Harm Reduction Working Group, is more reserved.

“With or without methadone, if they don’t have access to antiretroviral drugs it is not going to change anything because what methadone does is get rid of the craving for the opiate, but it doesn’t do anything for the HIV.”

“If they are free of the needles that can expose them to various kinds of things that is probably the only protection you get in terms of exposure, but in terms of the body function it is not going to change anything.”

Ismail recounts how: “In Hong Kong there was a robbery at one of the big pharmacies, and almost everything was stolen except for methadone, because there was no black market for methadone because in Hong Kong all you need to do is prove that you are a heroin dependent individual and you can get it.”

HDN Key Correspondent
Email: Correspondents@hdnet.org

[These comments were made at the recent International Conference on the Reduction of Drug-Related Harm, held in Belfast, northern Ireland, in March 2005].

Methadone comes of age – almost...

2005-05-03T12:52:00.000+07:00

by HDN Key Correspondent
April 2005

(Cross-posted from the SEA-AIDS eForum)

Moderators’ note: Given a wealth of evidence demonstrating the effectiveness of substitution therapy, including its role in reducing the spread of HIV transmission rates among drug users, it is worrying that the highly anticipated announcement by the World Health Organization (WHO) to include methadone in its Essential Drug List (EDL) has not yet been made. This is despite an apparent agreement by the relevant WHO committee weeks ago.

The EDL is the advisory list that WHO gives to all governments about the basic drugs that their health workers should have available.

Why has the announcement been so delayed? There are suggestions circulating in the international media that the WHO is being pressured by the US government over the new EDL recommendations. With the ‘abortion pills’ mifepristone and misoprostol also on the new EDL list of recommended drugs, however, it is not clear if current US pressure and resulting delay even relates to methadone.

If it does, however, it is vital that the WHO Director-General (DG), Dr LEE Jong-wook, stands by not only WHO’s own process for identifying medicines to be added to the EDL, but also the evidence that methadone is a critical and life-saving treatment option for drugs users throughout the world.

Endorsement of the recommendations of the WHO Expert committee on essential medicines (March 2005) by the WHO DG will be consistent with and support the various positions taken by the WHO, the United Nations Office on Drugs and Crime and the Joint United Nations Programme on HIV/AIDS in their recent joint position paper on substitution therapy.

We had hoped to use an outline of that inter-agency position paper on substitution therapy (see below) to help highlight the methadone/EDL announcement when it was made. In light of the current delay in an EDL announcement, it may be even more important to share that summary now.

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Methadone comes of age – almost...
HDN Key Correspondent
April 2005
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“PROVIDING PHARMACOTHERAPY TO HIV POSITIVE INJECTION DRUG USERS CAN MINIMIZE THE RISK OF FURTHER TRANSMISSION OF THE VIRUS AND STABLIZR THE UNDERLYING CONDITION” [WHO]

Imagine there was a simple, effective and affordable medicine that could reduce the death rate among people who use drugs such as heroin by about two-thirds. Fat chance? Now imagine that medicine does exist, but that because of a reluctance on the part of policy-makers and government officials, it was not widely available in many countries. Hard to believe? Dream no more. The medicine exists and is hopefully about to break out of its shrouded history: methadone is coming of age.

Between 5 and 10% of the world’s HIV infections are reportedly due to injection drug use. The figure may rise to as high as 70% of HIV transmission in some countries – in Asia and Europe in particular. Injection drug use is also now the predominant mode of transmission of hepatitis C virus throughout the world.

Due to the unregulated nature of illicit substances, injection drug users often use drugs of unknown potency and quality, which can frequently lead to overdoses. It is estimated that approximately 2–3% of injection drug users die each year, resulting in a mortality rate for heroin users, for example, of between six and twenty times that seen among those in the general population of the same age and sex.

Substitution therapy is a treatment approach that helps opioid drug users (e.g. Heroin) to reduce the withdrawal symptoms and craving when drug use is stopped or reduced. Methadone is one of the oral medications used for substitution therapy. Because users taking methadone are far less likely to inject drugs, it also has a significant impact on reducing their risk of HIV injection.

In their recent position paper Substitution maintenance therapy in the management of opioid dependence and HIV/AIDS prevention, the World Health Organization (WHO), United Nations Office on Drugs and Crime (UNODC) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) state that opioid “drug dependence treatment is an important strategy to improve well-being and social functioning of people with opioid dependence and to reduce its health and social consequences, including HIV infection.”

Participation in substitution maintenance therapy also provides opportunities for early diagnosis of other health problems, HIV, Tuberculosis, Hepatitis and STD counselling and testing, as well as referral for additional services. It is arguably the most effective, cost effective treatment option for injection drug users, and brings them into contact with various other services within the health system.

The UN paper further enlightens that “methadone maintenance therapy is correlated with reduction in HIV risk behaviours related to drug-taking, or an increase in protective behaviours.” According to WHO, “IDUs who do not enter [methadone] treatment are up to six times more likely to become infected with HIV than injectors who enter and remain in treatment.”

“The death rate for people with opioid dependence in methadone maintenance treatment is one-third to one-quarter the rate for those not in treatment.”

According to several conservative estimates, every dollar invested in opioid dependence treatment programmes may yield a return of between $4 and $7 in reduced drug-related crime, criminal justice costs and theft alone. When savings related to health care are included, total savings can exceed substitution therapy costs by a ratio of twelve to one.

The UN position paper concludes that because substitution therapy (also known as pharmacotherapy) has proven effective in terms of promoting retention of users in treatment, reduction of drug use, improvements of drug users’ psychological and social functioning, as well as reduction of risk-associated injecting and sexual behaviours, it should be given serious consideration both as an HIV prevention measure, and as a treatment measure for individuals with opioid dependence who are already infected with HIV.

“Programmes that combine pharmacotherapy with HIV/AIDS treatment and care should be encouraged as directly observed pharmacotherapy also provides an opportunity for directly observed antiretroviral therapy, as well as therapy for opportunistic infections such as tuberculosis,” the paper states.

“Individuals with opioid dependence benefit from substitution maintenance therapy through increased stability and improved well-being and social functioning. People receiving substitution therapy can make significant progress in their physical and emotional life, as well as in their relationships with others and their ability to contribute meaningfully to their community and society at large.”

HDN Key Correspondent
Email: Correspondents@hdnet.org

Opioid substitution and HIV/AIDS treatment and prevention

2005-03-14T21:32:00.000+07:00

Thomas Kerr, Alex Wodak, Richard Elliott, Julio S Montaner, Evan Wood

The Lancet, Vol 364
November 27, 2004

The HIV/AIDS epidemic remains a global crisis affecting millions of lives as well as the development of many countries throughout the world. About 40 million people are infected with HIV, with an estimated 5 million people infected during 2003 (1). In many of the regions with the fastest growing HIV epidemics, such as parts of Asia, eastern Europe, and the former Soviet Union, injection drug users (IDUs) and their sexual contacts account for most new infections. Opioid dependence is the underlying condition fuelling the HIV epidemic in many countries.

The development of new antiretroviral treatments improved the care of HIV-infected persons (2), although the anticipated benefits have been eroded by poor access to in areas hardest hit by the epidemic (3). While access has been particularly poor in those areas of southern Africa where HIV prevalence is highest, in many regions with large IDU-driven HIV epidemics, access to antiretrovirals is also exceedingly low (4).

In recent years several large international initiatives have attempted to increase access to antiretroviral treatments. Most notable are the 3 by 5 initiative of WHO and UNAIDS, which aims to provide treatment to 3 million people in developing countries by the end of 2005 (5), and the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), which provides millions of dollars each year for the prevention and treatment of HIV in lower income countries (6).

Although regions with IDU-driven epidemics are expected to be targeted by both 3 by 5 and GFATM, the successful implementation of antiretroviral treatment in these settings is impeded by significant problems resulting from untreated opioid dependence. Attracting and retaining IDUs into HIV/AIDS care if antiretroviral treatments are provided without adequate addiction treatment has proved problematic (7, 8).

Clinical studies show that providing drug-dependence treatment services generally greatly enhances uptake, adherence to, and retention in HIV treatment in IDUs (8). One of the most well-evaluated strategies has been the provision of opioid-substitution therapies, such as methadone and buprenorphine, which reduce HIV risk behaviour, overdose deaths, and also improve outcomes from antiretroviral treatment in HIV-infected opioid users (7-13). With many controlled clinical trials (12), the weight of evidence behind these modalities is so strong that substitution therapy has now been recognised as the most effective treatment for opioid dependence (14), and has recently become the cornerstone of treatment in many parts of the world (15). Unfortunately, despite being relatively inexpensive and uncomplicated therapies, methadone and buprenorphine are often not offered, provided in a suboptimal fashion, or banned in many of the countries where injection-related HIV epidemics are currently raging (6, 15).

In light of the challenges in delivering HIV/AIDS care to IDUs (3), WHO has recommended the integration of opioid-substitution therapies in its HIV treatment guidelines for IDUs in resource-limited settings.4 However, methadone and buprenorphine are not presently included in WHO’s Model List of Essential Medicines (16). There are several adverse consequences associated with the status of opioid-substitution therapies in relation to the list as WHO and others work to increase access to antiretroviral treatments and improve the health of IDUs around the world. The primary objectives of WHO’s Drugs Action Programme is to reduce morbidity and mortality by helping countries integrate essential drugs and medicines into their national health system (17). Therefore, the addition of these drugs to the essential medicines list would facilitate greater access to substitution therapies and greater integration of these therapies within the HIV care systems in countries where access is currently limited. Adding these drugs will also remove barriers to securing funding for integrated treatment systems that couple opioid-substitution therapy with HIV treatment because many funding agencies, including GFATM, require justification for the purchase of drugs not currently on the list. Finally, recognition of the overwhelming scientific support for opioid-substitution therapy (7, 12, 23), by the addition of these medications to the essential medicines list, will send a clear message to nations confronted by IDU-driven HIV epidemics that these drugs are regarded as essential components of HIV prevention and treatment for IDUs.

In March, 2005, there will be an opportunity to address these concerns when WHO’s Expert Committee on the Use of Essential Drugs will consider applications requesting that methadone and buprenorphine be added as essential medicines. Essential drugs are selected on the basis of public-health relevance, safety, efficacy, and cost effectiveness, and a large volume of clinical evidence indicates clearly that methadone and buprenorphine satisfy these criteria (7, 12, 13, 18, 19). Given what is now known about the effectiveness of opioid-substitution therapy in HIV prevention and treatment (7, 12, 13), a decision to add these drugs to the list is needed to help ensure greater access to substitution therapies and antiretroviral treatments, and in turn to help to bring the HIV/AIDS epidemic among IDUs under control.

Authors:

Thomas Kerr, Alex Wodak, Richard Elliott, Julio S Montaner, Evan Wood

British Columbia Centre for Excellence in HIV/AIDS, St Paul’s Hospital, Vancouver, British Columbia, Canada V6Z 1Y6 (TK, JSM, EW); Canadian HIV/AIDS Legal Network, Montreal, Quebec (TK, RE); Alcohol and Drug Service, St Vincent’s Hospital, Sydney, New South Wales, Australia (AW); and Department of Medicine, University of British Columbia, British Columbia, Canada (JSM, EW) tkerr@cfenet.ubc.ca

References:

UNAIDS. 2004 Report on the global AIDS epidemic. Geneva: UNAIDS, 2004.
Mocroft A, Vella S, Benfield TL, for the EuroSIDA Study Group. Changing patterns of mortality across Europe in patients infected with HIV-1. Lancet 1998; 352:1725-30.
Wood E, Braitstein P, Montaner JS, et al. Extent to which low-level use of antiretroviral treatment could curb the AIDS epidemic in sub-Saharan Africa. Lancet 2000; 355: 2095–100.
World Health Organization. Scaling up antiretroviral therapy in resource-limited settings. Geneva: World Health Organization, 2004.
World Health Organization. Investing in a comprehensive health sector response to HIV/AIDS: scaling up treatment and accelerating prevention. Geneva: World Health Organization, 2004.
Kerr T, Kaplan K, Suwannawong P, Jurgens R, Wood E. The Global Fund to Fight AIDS, Tuberculosis and Malaria. Lancet 2004; 364: 11–12.
Antela A, Casado JL, Gonzalez MJ, et al. Influence of a methadone maintenance programme on the improved outcome of a cohort of injecting drug users with advanced HIV disease. AIDS 1997; 11: 1405–06.
Wood E, Montaner JS, Bangsberg D, et al. Expanding access to HIV antiretroviral therapy to marginalized populations in the developed world. AIDS 2003; 17: 2419–27.
Caplehorn JR, Dalton MS, Haldar F, Petrenas AM, Nisbet JG. Methadone maintenance and addicts’ risk of fatal heroin overdose. Subst Use Misuse 1996; 31: 177–96.
Moatti JP, Carrieri MP, Spire B, the Manif 2000 study group. Adherence to HAART in French HIV-infected injecting drug users. AIDS 2000; 14: 151–55.
Moreno A, Perez-Elias MJ, Casado JL, et al. Long-term outcomes of protease inhibitor-based therapy in antiretroviral treatment-naive HIV-infected injection drug users on methadone maintenance programmes. AIDS 2001; 15: 1068–70.
National Consensus Development Panel on Effective Medical Treatment of Opiate Addiction. Effective medical treatment of opiate addiction. JAMA 1998; 280: 1936–43.
Johnson RE, Chutuape MA, Strain EC, Walsh SL, Stitzer ML, Bigelow GE. A comparison of levomethadyl acetate, buprenorphine, and methadone for opioid dependence. N Engl J Med 2000; 343: 1290–97.
WHO United Nations Office of Drug and Crime, UNAIDS. Substitution maintenance therapy in the management of opioid dependence and HIV/AIDS prevention: position paper. Geneva: WHO, 2004.
Ball AL, Rana S, Dehne KL. HIV prevention among injecting drug users: responses in developing and transitional countries. Public Health Rep 1998; 113 (suppl 1): 170–81.
World Health Organization. Essential medicines: WHO model list, 13th edn. Geneva: WHO, April, 2003.
World Health Organization. Essential drug policies and programmes. Geneva: WHO, 2004.
Ball J, Ross A. The effectiveness of methadone maintenance treatment: patients, programs, services and outcomes. New York: Springer-Verlag, 1991.
Bell J, Zador D. A risk-benefit analysis of methadone maintenance treatment. Drug Safety 2000; 22: 179–90.

Drug substitution therapy: A dire need in Imphal

2005-03-14T21:30:00.000+07:00

The ever-increasing number of injection drug users (IDU) in Imphal, India, which was last estimated at 14,000 (UNESCO/RSA, 1999-2000) is a matter that needs serious consideration.

Furthermore, the prevalence of HIV infection among IDUs has remained as high as 60 % (MSACS epidemiological report June 2004), indicating a more effective response is much needed. Compounding this issue is the reality that many HIV positive IDUs do not have access to antiretroviral therapy which is critical to extending their lives. In the absence of access to antiretroviral drugs (ARVs), public health officials and policy makers must scale up non-ARV treatments for injecting drug users, such as substitution therapy. In India, while harm reduction programs, are increasing many do not include substitution therapy, a critical component of an effective harm reduction program.

Substitution programs are necessary to improve and extend the health and lives of injecting drug users. The success of a healthy harm reduction program implementation is reinforced by a well designed substitution program. Recently, the Social Awareness Service Organisation (SASO) concluded a substitution program in Imphal, that was in operation for two years. Since the program has ended, many former patients have been continuously asking about the Buprenorphine substitution program. This shows the effectiveness of the program among former clients and clearly indicates that substitution therapy is the preferred mode of treatment among injecting drug users.

Substitution programs are an effective approach to controlling the spread of blood borne infections and thereby reducing the drug-related harm and leading to more productive lives for injecting drug users. However, substitution therapy, despite being endorsed by the state AIDS policy has never surfaced as an undertaking by the health authorities. The effectiveness of such program has been proven around the globe and such program could only bring about a sound response in the dual epidemic of HIV infection and IDUs. Additionally, management of IDUs under a prescribed drug of known potency can enhance the quality of life among IDUs and could further provide opportunities to seek out additional care and services when they are ready to do so. Thousands of HIV positive injecting drug users will lose their lives during the next few years while we wait for expanded ARV programmes to deliver on their promises. It is critical that effective and affordable non-ARV treatments, such as substitution therapy, be made available now to extend the lives of those living with HIV.

HDN Key Correspondent
Email: correspondents@hdnet.org

(July 2004)