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close this bookThe Asian Harm Reduction Network (UNAIDS, 2001, 48 p.)
close this folderIII. Background
View the document(introduction...)
View the documentA. Epidemiology of drug use in Asia
View the documentB. Drug users’ vulnerability to HIV/AIDS
View the documentC. Drug use and HIV/AIDS: What should be done?
View the documentD. Drug and HIV/AIDS policies in Asia
View the documentE. The pioneers of a comprehensive approach

(introduction...)

This section examines the factors that made it necessary to establish a technical resource network for addressing drug use and HIV/AIDS in Asia. Such factors include: the features of the drug-use problem in Asian countries; drug users’ specific vulnerability to HIV/AIDS; available resources to reduce such vulnerabilities; and aspects of drug policies in Asian countries that either facilitate or impede the implementation of efforts to reduce drug users’ risk behaviour and its underlying causes.

A. Epidemiology of drug use in Asia

For more than a century, Asia has experienced drug-use problems in the form of largescale epidemics with devastating effects on its countries. Such epidemics caused social disintegration, civil unrest, and serious public health problems; exacerbated poverty and problems related to poverty; caused enormous direct and indirect economic costs; and impeded social and economic development. The drug trade, a multibillion dollar operation, has caused wars and abetted them financially; it continues to be a financial resource used by guerrilla armies for purchasing arms. Governments have undertaken strenuous measures to reduce drug-use problems; despite all efforts, however, drug use is not under control.

To date, the production of opiates has been reduced significantly in a number of areas. Trafficking and consumption, however, remain issues of serious concern. Over the past several years, an increasing trend from opium to heroin use has been observed in many countries. Codeine and other narcotic and psychotropic substances are also being used at a significant level, including buprenorphine products Tidigesic or Temgesic, Phensedyl, diazepam and nitrazepam. These substances are either produced in clandestine laboratories and distributed to the drug-user markets or produced legally by large pharmaceutical industries and diverted from there to illegal markets. Smoking or “chasing the dragon” continues to be the main route of heroin administration, though the use of injections is increasing all through the region. The trend towards injection seems to be related to the reduced availability and purity of heroin.


Figure 1: Prevalence of opiate use, selected countries

Source: Based on UNDP, Global illicit drug trends 2000, New York, 2000

Many countries in the region are currently experiencing an epidemic abuse of amphetamine-type stimulant (ATS), particularly of methamphetamine. Virtually all countries in South-East Asia are now affected to some extend. Data indicate that ATS use is generally higher among young adult males, although it is a continuing problem among special occupational groups such as truck drivers, fishermen, and construction workers. Commercial sex workers have also been identified as a high-risk group related to ATS. Because all these groups have a high degree of mobility, they are hard to reach through traditional prevention and treatment services.

In addition to the use of narcotics and psychotropic substances, endemic levels of inhalant use exist in many Asian countries. Such usage is particularly associated with street children living in impoverished, harsh conditions. Many countries have identified inhalant use as a significant drug issue in their cities. The use of cannabis in its various preparations also continues to be widespread in most countries of the region.

B. Drug users’ vulnerability to HIV/AIDS

Drug use has serious social and health consequences. The majority of drug users in Asia are extraordinarily poor and often jobless or relegated to doing odd jobs. Homelessness is widespread. Many of them beg, borrow, or even steal. They are criminalized, stigmatized, and discriminated against. Such factors, combined with low self-esteem and little trust in authorities, make drug users a population to which traditional health and social services have little access.


Social consequences of drug use

Source: AHRN Clearing-house

The health status of drug users, particularly that of injecting drug users, is a matter of great concern: blood borne diseases such as hepatitis and HIV infection, abscesses and serious wounds from inadequate injecting equipment, and death from overdose are common. With the onset of the HIV/AIDS epidemic in the late 1980s, drug use in Asia entered an even more serious phase and became a major public health concern. Drug use has an intricate relationship with HIV/AIDS: HIV is transmitted through the sharing of contaminated needles and syringes and other equipment employed by drug users. In addition, alcohol and stimulant abuse often lower resistance to high-risk behaviour such as unprotected sexual intercourse.


Social consequences of drug use

Source: AHRN Clearing-house

Table 1. Drug use in selected countries of Asia (estimates)

Country

Drug users (000s)

Opiate users (000s)

% injectors

% drug users among HIV+

% HIV+ among drug users

Bangladesh

500-1,000

N/E

10-17

N/E

2.5

China

540

majority

66

69.4

40.5

India

2,250

500

25-90

N/E

1.3-68.4

Malaysia

300

200

50

77.0

10-27

Myanmar

300

majority

30

20-30

65.5-72.5

Nepal

30-50

majority

74.8

12.6

49.7

Pakistan

3,000

1,500

1.8-29

N/E

0.4-1.8

Sri Lanka

240

40

7.5

N/E

N/E

Thailand

1,270

219

60

5.25

30-40

Viet Nam

185

majority

no data

65.5

13.5-64.0

N/E = no estimates

Source: Regional Task Force on Drug Use and HIV Vulnerability, Drug Use and HIV Vulnerability Policy Research Study

Drug users in Asia are highly vulnerable to HIV transmission because of the legal, political, socioeconomic, health service, and cultural situations in which they live. These situations, however, vary considerably from country to country, even from community to community in the same country. In many countries of Asia, as elsewhere in the world, drug policies are highly politicized and are influenced by historical, social, religious, cultural, and economic factors. Strongly held beliefs about drugs and their adverse effects on the society, national experiences with drug use in the past, the extent and seriousness of past and present drug problems, and the interpretation of international conventions all have an impact on the development of policies and legal instruments directed at drug use.

In a number of countries, the law prescribes severe punishments for all drug-related offences including not only drug use but also possession of drugs and drug-use paraphernalia (e.g. needles and syringes). The level of penalties and the stringency with which they are applied locally affect the feasibility of preventive interventions for drug users. Indeed, these penalties may actually preclude providing drug users with information or with the means to protect themselves against HIV infection.

Drug-use practices contribute significantly to the vulnerability of drug users. Many drug users in the region use narcotics such as opium and heroin, and a significant percentage inject. In some countries injecting drug users go to secluded shooting galleries, but in other countries injecting takes place in more public locations: in a designated area users can get an injection from a dealer or person whose job it is to inject users. In most cases, dealers and public injectors have little or no information about HIV infection. The sharing of needles, syringes, and other drug-use equipment is common.


Social consequences of drug use

Source: AHRN Clearing-house

In addition to sharing needles and syringes, the sexual practices of drug users is another important area that contributes to their vulnerability to HIV infection. Drug users tend to be sexually active, and their condom use is often very low. In some countries, condoms are often used in sex with commercial sex workers but not with regular partners. Unprotected sex is often perceived to be less risky than sharing needles and syringes. A high prevalence of sexually transmitted infections among drug users reflects their unsafe sexual practices. They and their partners often act as a bridge to transmit HIV to other populations such as commercial sex workers, clients of commercial sex workers, and then to the general population.

The HIV/AIDS epidemic began to spread in Asia in the late 1980s. In a number of countries - China, Myanmar, Nepal, Thailand, and Viet Nam - drug users were the first to be infected; the epidemic then spread from drug-using populations to other groups, and from there to the general population.

Treatment and rehabilitation centres are often not readily available to drug users. In many countries, services provide detoxification only, or treatment is mandatory and carried out in a military style with a strong penal element to achieve total abstinence - strong reasons for drug users to avoid attending. In many regions of Asia, outpatient and substitution treatment as well as aftercare services are virtually absent. If services are available, they are often provided by non-specialists with limited knowledge about drug treatment and HIV/AIDS prevention.

C. Drug use and HIV/AIDS: What should be done?

A United Nations system-wide position paper, adopted in September 2000 by a subcommittee of the Administrative Committee on Coordination, spells out a comprehensive policy response to drug use and HIV/AIDS that reflects the thinking of many people working in that area over the past decades. Some of the principles of the policy response are:

- protection of human rights is critical for the successful prevention of HIV/AIDS;

- HIV prevention should start as early as possible;

- comprehensive coverage of the entire targeted population is essential;

- drug-abuse problems cannot be solved simply by criminal justice initiatives;

- the ability to halt the epidemic requires a three-part strategy - preventing drug abuse; facilitating entry into drug-abuse treatment; and establishing effective outreach to engage drug abusers in HIV-prevention strategies that protect them, and their partners and families, from exposure to HIV (i.e. encouraging the acceptance of substance abuse treatment and medical care).

D. Drug and HIV/AIDS policies in Asia

GOVERNMENT AGENCIES

For almost all Asian countries, at least two separate government agencies address issues concerning drug use and HIV/AIDS: while drug-use issues are under the purview of specialized drug-control agencies, HIV/AIDS issues are usually addressed by the Ministry of Health or a subsidiary of that ministry. Prior to the establishment of AHRN - and, indeed, even up to the present in several countries - there was little communication and less cooperation between these government entities. Because of this, the process of developing and reviewing drug and HIV policies in Asian countries is difficult. In many countries, drug-control legislation was developed prior to the onset of the HIV/AIDS epidemics, and it is usually based on the United Nations Drug Control Conventions, which have been ratified by most countries of Asia. In general, drug policies are not supportive of effective HIV prevention among drug users. With the exception of law enforcement, drug problems are not generally accorded high funding priority. Consequently there are few government programmes in the region that directly address problems presented by the interface between drug use and HIV/AIDS.

If governments implement measures to prevent the spread of HIV among drug users and their sexual partners, they are often localized, short term, underfunded, and insufficient in scope. Adherence to traditional values is strong in many of the countries, making debate on HIV/AIDS prevention and sexual behaviour sensitive. Drug treatment almost invariably focuses on detoxification treatment. Drug users are afforded no choice of treatment, which is mostly compulsory, residential, and long term. Drug-treatment personnel are often non-specialists in the drug field, coming from the labour, public security, or nongovernmental sectors. Most treatments include a strong penal element.

NONGOVERNMENTAL ORGANIZATIONS

A great number of nongovernmental organizations (NGOs), probably numbering in the thousands, address issues related to drug use in Asia. The International Federation of Non-Governmental Organizations against Drug and Substance Abuse, established in 1981 and based in Kuala Lumpur, currently has 54 members, nearly all of them national umbrella organizations. Forum, another federation of nongovernmental organizations, currently has approximately 15 members. In the past, NGOs in the drug field have typically chosen to organize themselves in federation-type structures at the national and regional levels, the primary goals being to increase political influence and to solicit funding. Such federations are usually organized hierarchically, with information flowing vertically from the members of the federation to its secretariat and from there, after filtering, back to the base. Little interaction occurs horizontally - that is, among the members of the federation. As a consequence, those in the secretariat of the federation are usually better informed and in more powerful positions than the federation’s members.

Another feature of Asian NGOs working in the field of drug use is that they rarely include drug users themselves. In many cases, these organizations work for drug users - or even against drug users - but not with drug users. Some organizations that are closely affiliated with law-enforcement agencies understand their mission as a “war against drugs,” with drug users viewed as criminals and, therefore, the enemy. Interventions developed by such organizations often embark on a fear approach, reinforcing stereotypes of drug users. They sometimes practise cruel and degrading treatment approaches such as “cold turkey,” a method of withdrawal without any supporting medication, or “haircuts,” which entails humiliating a drug user in public if he or she has not adhered to the rules of the treatment facility. All too often, human rights of drug users are violated; such violations are not only tolerated by governments and the public, but also practised by government institutions themselves. Given such practices, these organizations naturally experience problems in reaching out to drug users, identifying their needs, and developing feasible low-threshold programmes - that is, programmes whose pragmatic admission criteria are designed to encourage drug users to seek help - that could address both drug use and HIV/AIDS.

In the field of HIV/AIDS, a great number of national and international organizations have evolved since the beginning of the epidemic, many of them addressing the needs of people living with HIV/AIDS and consequently involving them in the daily operations of the organization. In fact, since the launching of what is called the Greater Involvement of People Living with HIV/AIDS (GIPA) at the Paris AIDS Summit on 1 December 1994, it has become standard for nongovernmental organizations to include people with HIV/AIDS.

Interestingly, there is a similarity in policies between governmental and nongovernmental organizations when it comes to drug use and HIV/AIDS. NGOs working in the drug field state that HIV/AIDS is a health issue that should be dealt with by those institutions specializing in health issues. At the same time, NGOs working in the field of HIV/AIDS state that they do not work with drug users as there are already many institutions working in that field. As a consequence, few NGOs work with both drug use and HIV/AIDS. It should also be noted that drug NGOs have relatively little experience in working with HIV/AIDS, and HIV/AIDS NGOs generally lack adequate knowledge about drug issues. Those organizations addressing both drug use and HIV/AIDS face a number of difficulties; these include:

- isolation and marginalization;

- resource shortages;

- lack of institutional capacity and skills relating to programme design, implementation, and evaluation;

- little recognition that HIV epidemics among drug users are preventable;

- lack of information, such as documentation or research on effective models and interventions, and few suitable mechanisms for sharing information;

- slow or non-existent governmental responses, and little support for nongovernmental responses.

INTERNATIONAL ORGANIZATIONS

Until September 2000, United Nations organizations continued to send mixed messages regarding drug use and HIV/AIDS to governments in Asia. The United Nations International Drug Control Programme (UNDCP) together with the International Narcotics Control Board (INCB) advocated an abstinence-only policy to reduce drug use, believing this would lead to a reduction in the incidence of HIV infection among drug users. Both UNDCP and INCB insisted on adherence to international drug-control conventions, which exclude the use of narcotics for other than medical or scientific purposes. The main sponsor or partner organizations of UNDCP and INCB were usually powerful national drug-control agencies. The World Health Organization as well as UNAIDS, which began its operations in January 1996, promoted various pragmatic risk-reduction strategies, including information campaigns, peer outreach, drug-substitution therapy, and needle- and syringe-exchange programmes. WHO and UNAIDS worked primarily with public health agencies, which are less influential than drug-control agencies with regard to matters pertaining to drug use. Slowly, a more pragmatic approach began to be accepted. In June 1998, the United Nations General Assembly adopted the Declaration on Demand Reduction, which called for addressing the adverse health consequences of drug use; and in April 1999, UNDCP became a cosponsor of UNAIDS.

A similar split can be observed in regional intergovernmental organizations such as the Association of South-East Asian Nations (ASEAN) and the South Asian Association of Regional Cooperation (SAARC). In both of these organizations, drug control was overseen by one entity, and HIV/AIDS by another, with each promoting contradictory policies. It was not until September 2000 that United Nations bodies and entities agreed on a common and system-wide position with regard to drug use and HIV/AIDS.

Prior to this agreement, a number of international organizations began to promote interventions to reduce drug-related harm, particularly the risk of HIV transmission among drug users. In 1996, the International Harm Reduction Association was established at the Sixth International Conference for the Reduction of Drug Related Harm in Hobart, Australia. The purpose of the association is to reduce the health, social, and economic harms associated with drug use. It works with local, national, regional, and international organizations to assist individuals and communities in the areas of public health advocacy.

E. The pioneers of a comprehensive approach

Starting in the early 1990s, some programmes began operating in different Asian countries to address both drug use and HIV/AIDS. One of the first of these was the Lifesaving and Lifegiving Society (LALS), an outreach needle-exchange programme in Kathmandu. According to Nepalese laws, that programme was not legal; but somehow the LALS staff managed, and the government tolerated their activities and carefully observed the effects on the growing epidemic of HIV/AIDS among drug users in this country. Around the same time, similar programmes began operating in other Asian countries; these included:

- Sharan, New Delhi, India

- Ikhlas, Kuala Lumpur, Malaysia

- the SHALOM Project, Manipur, India

- Save the Children Fund, Ho Chi Minh City, Viet Nam

- AIDS Surveillance and Education (ASEP), Cebu City, Philippines

- HIV/AIDS Prevention and Care Project for the Hilltribes of Northern Thailand (HAHP).

Funds and other resources were generated through fundraising activities in the local communities or were provided by foreign donors. Programmes whose prime focus was rehabilitation also began to expand their activities to include prevention of HIV infection through information, communication, and education campaigns, peer outreach, needle- and syringe-exchange programmes, and drug-substitution programmes. With the support of the World Health Organization, the Australian Agency for International Development, and the United Nations Development Programme, among others, capacity-building and training workshops were held in a variety of Asian venues from 1991 through 1995. By 1996, the number of programmes addressing drug use and HIV/AIDS had slowly increased. Although these programmes were small, they were influential: by their very existence they demonstrated that it was possible to reduce the risk of HIV transmission among drug users.