|Drug Use and HIV Vulnerability (UNAIDS - Best Practice Digest, 2000, 3 p.)|
Summarised from Drug use and HIV vulnerability: Policy research study in Asia, the report of the Task Force on Drug Use and HIV Vulnerability, UNAIDS and UNODCCP, October 2000.
For further information, contact UNAIDS Asia Pacific Intercountry Team, 3rd Floor, United Nations Building, Rajadamnern Nok Avenue, Bangkok 10200, Thailand Tel: (662) 288 2497-8 E-mail: firstname.lastname@example.org.
Drug use in Asian countries continues to increase and new and ever more hazardous and harmful drug use patterns are continuing to emerge. Many people use multiple substances; inject in preference to smoking, chasing or snorting; share needles, syringes, drug paraphernalia and drug solutions and preparations indiscriminately, and use alcohol and other psychoactive drugs excessively. These Asian countries are highly affected by HIV/AIDS.
This study was commissioned by the UNAIDS Asia Pacific Intercountry Team, Bangkok, to follow upon the report Situation Assessment of Injecting Drug use in South East and East Asia in the context of HIV, which was conducted by the Asian Harm Reduction Network (AHRN) in 1997. The situation assessment indicated that urgent action is needed to reduce the transmission of HIV/AIDS among drug users and their sexual partners.
The main purpose of this study is to establish a basis for effective assistance to governments in the development and implementation of policies and programmes for the prevention of the transmission of HIV among drug users. The study set out to examine drug and HIV laws, policies and strategies focusing on seven countries: China, India, Malaysia, Myanmar, Nepal, Thailand and Viet Nam. It was not designed to compare the situation across countries nor to critique national laws and policies but rather as an exploration of factors nationally and regionally which are serving to either facilitate or hinder efforts aimed at reducing HIV/AIDS vulnerability among drug users and their sexual partners.
a). Drug use and HIV/AIDS in the countries studied
The seven countries studied presented very different drug and HIV situations. The East and South Asian countries contain some of the highest recorded rates of HIV infection among IDUs; a mean of 62% of IDUs in Myanmar, between 30% to 40% in Thailand and 45% in Nepal are HIV positive.
Drug use and HIV are not equally distributed geographically. Some cities or provinces have an over-representation of drug problems and have become the epicentres of the HIV/AIDS epidemic in the region - for example, the large urban conurbations of Ho Chi Minh City and Bangkok, or areas that attract large numbers of seasonal or migrant workers.
The rapid spread of HIV infection among IDUs has been associated with high-risk injecting practices. These include the use of self-made injection equipment, a high level of needle and syringe sharing, little or no effective cleaning procedures and the presence of professional injectors who use the same needle and syringe to inject many customers.
b)The drug laws in the study-countries
In this study attention focused on those aspects of policy and legislation that impact on drug use and HIV/AIDS vulnerability. This included an examination of legislation and policy which influence the kinds of HIV prevention and drug treatment services that are available and accessible to IDUs. The level of penalties and the stringency with which they are applied locally impacts upon the feasibility of reaching out to drug users and information on HIV prevention. Although drug use is illegal in all seven countries, the penalties for drug use and possession vary across these countries.
c) Drug and HIV policies
The most striking finding was that with some notable exceptions, drug policies in the countries pay scant attention to HIV prevention. No mention is made of HIV prevention in the Thai Narcotic Control Plan (1997 - 2001) nor in an official report from China - Chinas Battle against Narcotics. In the Drug Control Master Plans that have been developed in Viet Nam, India and Nepal (with the assistance of UNDCP) only the Viet Nam plan refers to HIV prevention.
In general, when the risks of drug-related HIV transmission are acknowledged at country level, the favoured response is to increase efforts to prevent drug use through drug education and life skills development and to detoxify those who use drugs.
Drug users were not accorded a high priority in national HIV prevention plans. In India, the importance of harm reduction is noted for the first time in a draft National AIDS Prevention and Control Policy; it endorses needle and syringe exchanges as a key strategy for preventing the transmission of HIV/AIDS.
d) Risk reduction strategies
WHO suggests that strategies to reduce the potential harm to IDUs should include a number of key components; strategies to reach out and inform IDUs about the practical ways in which they can reduce their risks of HIV infection, and to provide them with the practical means to apply these (that is, access to sterile injecting equipment, disinfectant materials and easy access to substitution treatment). There are examples of all these in the seven study-countries.
In practice, outreach and peer education have most often been provided by local and international non-governmental organisations. This has meant that these activities are invariably localised, of limited reach and not fully sustainable. Despite numerous pilot projects, there has been little systematic review or evaluation of these projects, and most have not been extended beyond the local pilots.
Legal access to sterile injecting equipment has been limited to informal or pilot projects in three of the countries - India, Nepal and Viet Nam. Very small-scale distribution of sterile injecting equipment has taken place in Malaysia. Nowhere is it public policy to provide cleaning supplies (for example, bleach) or to supply or exchange injecting equipment. A number of concerns are commonly expressed. First and foremost is the notion that the provision of needles and syringes will actually encourage drug use, and runs counter to the major objective of drug policies in all seven countries, which is to attain a drug-free society.
Drug treatment generally focuses on detoxification treatment only, and in all seven study-countries, drug users are afforded limited access to voluntary treatment. In the main, drug treatment is often of a compulsory nature and includes a strong penal element.
There is no consensus in the seven countries on the best mix of drug and HIV prevention approaches nor on how to conduct these interventions.
There is little dialogue between drug prevention and treatment, law enforcement and HIV/AIDS prevention authorities. While a number of the study-countries have nominally established multi-sectoral responses, these are yet to be rendered effective in most cases.
The challenge remains to identify factors that might facilitate change, and to identify useful opportunities and levers that might lead to policy changes in the direction of a more benign and effective policy improving the efficacy of HIV/AIDS prevention. Such opportunities exist in all the seven countries. Many policy makers are beginning to accept that although the goal of a drug-free society is preferable, it might be difficult to achieve in the short term and that the threat of the HIV epidemic necessitates some interim measures to keep the epidemic from growing.
· Countries should examine their drug and HIV policies and attempt to achieve greater congruence and compatibility between the two, ensuring that there are no legislative impediments that constrain the implementation of necessary measures to prevent HIV transmission between IDUs and their sexual partners.
· Countries should adopt a comprehensive approach to treatment and prevention of drug use and HIV transmission. A wide range of services are needed to meet the multiple needs of drug users.
· Policy makers should be urged to consider employing prevention and treatment approaches that are in line with the principles of public health and health promotion in preference to law enforcement approaches that emphasise punishment as the principal means of promoting behaviour change.
· Countries should adopt inter-sectoral training programmes to broaden the knowledge, understanding and skills of drug and HIV/AIDS workers, opinion leaders and decision-makers working in key areas impacting on drug use and HIV vulnerability.
· Special attention should be paid to enhancing the quality of training for direct service providers in the drug field.
· Countries should consider promoting and facilitating the establishment of self-help organizations for drug users that could initiate advocacy and enable users and ex-users to create mutually supportive environments.
· Countries should give special attention to the provision of drugs and HIV/AIDS preventive services among drug users presently incarcerated in prisons and other long-term labour rehabilitation facilities