Manual for

REdrugDU relatedCI harmNG in Asia

The Centre for Harm Reduction, Macfarlane Burnet Centre for Medical Research and Asian Harm Reduction Network

Revised and Updated Manual for reducing drug related harm in Asia The Centre for Harm Reduction, Macfarlane Burnet Centre for Medical Research and Asian Harm Reduction Network

This publication was made possible through support provided by the Office of Strategic Planning, Operations, and Technical Support, Bureau for Asia and the Near East, U.S.Agency for International Development, under the terms of Award No. HRN-A-00-97-00017-00 to Family Health International.The opinions expressed herein are those of the author(s) and do not necessarily reflect the views of Family Health International or the U.S.Agency for International Development. The Manual for Reducing Drug-Related Acknowledgements Harm in Asia For contributions to chapters in section two: Sujata Rana (1), Dr Peter © Copyright The Centre for Harm Deutschmann (2), Paul Deany (3), Dave Reduction, 2003 Burrows (4). Thanks to the members of the Asian Harm Reduction Network Contact details (AHRN) particularly Palani Narayanan, The Centre for Harm Reduction Manisha Singh, Jimmy Dorabjee, Luke The Macfarlane Burnet Institute for Samson, Dr Salam Irene Singh, Ching Medical Research and Public Health Ltd Hangzo, Dr Chawalit Natpratan, Dr Commercial Road, Melbourne, Langkham, Dr Muana, Aaron Peak. Victoria, 3004, Australia Thanks also to Mangai Balasegaram, PO Box 2284, Melbourne, Odette Jereza, Don des Jarlais for Vic, 3001, Australia feedback on draft copies. Thanks to all Tel: +61 3 9282 2169 who responded to SEA-AIDS requests for Fax: +61 3 9482 3123 information especially Maria de Bruyn, E-mail: [email protected] John Strand and Ann Smith. Website: www.chr.asn.au/ Thanks to Jamie Uhrig, Steve Kraus, Le Asian Harm Reduction Network Thi Minh Chau, Rodi Lalhmingmawii, P.O. Box 235 Phrasingh Post Office Trish Wakefield, Dr Ron McCoy. Chiangmai. Thailand, 50200 Tel: +66 53 801 494 Thanks to the staff at The Macfarlane Fax: +66 53 801 495 Burnet Centre for Medical Research, E-mail: [email protected] particularly Wendy Canobie, Peter Website: www.ahrn.net/ Higgs, Damien Morgan and Valerie Skahill. First published by the Centre for Harm Reduction in 1999 In the revised manual we would like to thank Wendy Holmes for her Reprint by The Centre for Harm contribution towards Chapter Seven Reduction, 2003 HIV/AIDS: Preventing transmission between parent and child. We would ISBN 1876644052 also like to thank Joan MacNeil for contributing towards Chapter Eight, Editor: Nick Crofts Voluntary HIV Counselling and Testing. Lead writer: Genevieve Costigan We are grateful to Lou McCullum for Other writers: Nick Crofts, Gary Reid writing Briefing Paper Four, Care and Cartoonist: Julie Smith support of injecting drug users with HIV Production: Social Change Media and AIDS and Graham Neilson for input into ‘Appendix 3: Sexually Transmitted Reference data Infections’. Costigan G, Crofts N and Reid G, 2003 The Manual for Reducing Drug Related Coordination, revisions and updates for Harm in Asia. Melbourne, The Centre for this Manual undertaken by Gary Reid. Harm Reduction. The Centre for Harm Reduction

2 Contents

Introduction to the First Edition 7

Introduction to the Second Edition 8

Section 1 Background and Rationale 9

Chapter One Drug Use and HIV Vulnerability 11 • The history of the drug trade in Asia • Emerging trends: drug use • Explosive epidemics • HIV among IDUs in Asia and the West.

Chapter Two Rationale for Harm Reduction 33 • A practical approach • Harm reduction: common elements • Education • Needle and syringe programs • Drug treatment and substitution programs • Peer education • Sales and purchasing of injecting equipment • Primary health care • Counselling and testing • Removing barriers • Special groups and circumstances.

Chapter Three Balancing and Integrating the Approach of Supply Reduction, Demand Reduction and Harm Reduction. 43 • Supply reduction; cultivation, processing, transport, distribution, finance • Demand reduction; education about drugs, treatment for drug abuse, community development • Harm reduction • Summary of the three approaches.

Briefing papers • Briefing Paper One 59 – Injecting Drug Use and AIDS: An Explosive Combination • Briefing Paper Two – Mapping Drug use in Asia in the Context of HIV/AIDS • Briefing Paper Three – A Review of Amphetamine Type Substances • Briefing Paper Four – Care and Support of Injecting Drug Users with HIV and AIDS

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3 Section 2 Program Design, Implementation 89 and Maintenance

Chapter One Rapid Situation Assessments. 91 • What are rapid situation assessments? • Finding and analysing existing information • Conducting interviews • Questions to ask • The outcomes of an RSA.

Chapter Two Establishing and Sustaining a Program. 121 • Planning the intervention • Drawing up a project plan • Implementing the plan • Monitoring and evaluation.

Chapter Three Working Together. 145 • The community • Religious groups • Police and law enforcement. Prisons • Governments.

Chapter Four Education. 169 • Educating drug users • Types of education • Educating police and policy makers • Educating youth.

Chapter Five Injecting Safely. 193 • Sharing of injecting equipment • Increasing IDUs awareness of HIV • The supply of sterile equipment • Safer injecting • The disinfection of used equipment • The disposal of unsterile equipment.

Chapter Six Drug use and Substitution. 223 •Drug use • Drug substitution • Methadone • Buprenorphine.

Chapter Seven HIV/AIDS: Preventing Transmission – Through Sex – Between Parent and Child. 247 • Sexual Transmission • Reducing sexual transmission •Women’s position in society • Transmission of HIV to babies • Preventing parent to child transmission of HIV, within a child survival approach.

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4 Chapter Eight Voluntary HIV Counselling and Testing. 273 •What is VCT? • The counselling process • The HIV Contents testing process • Staff: burnout and stress.

Chapter Nine Specific Groups. 299 • Refugees • Prisoners • Sex workers • Men who have sex with men • Migrants (mobile populations).

Section 3 Appendices 327

Appendix One Blood borne Viruses: 329 Hepatitis A, B, C and HIV/AIDS

Appendix Two Drugs and their Actions 337

Appendix Three Sexually Transmitted Infections 351

Glossary of Terms 359

Abbreviations 361

Internet Resources List 362

International Contact List 366

WHO List of Appropriate Publications 374

Index 376

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5 Contents

Introduction to the First Edition

F ALL the epidemics of HIV This Manual grew out of the combined (the ‘AIDS virus’) among the efforts of many people battling in Asia to different groups in the stop HIV. It contains the accumulated community whose behaviours experience of over decade of attempts to Oput them at risk, none is more rapid or change policy and implement programs to devastating than epidemics among people stop this devastating scourge, collected over who inject drugs. But at the same time, several years from many countries in Asia. nowhere in the field of AIDS prevention We sincerely hope this Manual will provide a are there such dazzling success stories than valuable resource for those arguing to get with prevention of HIV among injecting programs to stop HIV and other harms drug users. among drug users, their sexual partners and We know how to prevent spread of HIV children in Asia; for those beginning among injecting drug users: where this has programs; and for those already in the fight. been done, not only does it give breathing There are two enemies: one is HIV, the space to tackle the problems of use of illicit other is the ignorance, fear and prejudice drugs, it also prevents extensions of these which support and fuel HIV epidemics. We epidemics to sexual partners and to children hope this Manual will help in some small of drug users. Compared with achieving way those battling to overcome both these behaviour change to stop HIV infection with threats. We welcome feedback from anyone other groups, stopping HIV among injecting using this Manual on ways to make it more drug users is relatively easy. useful, and we will continue to try to Why then are there raging epidemics of upgrade it, finding funding to produce HIV among injecting drug users, their sexual country-specific versions in particular. partners and their children in many parts of HIV will be defeated, but to achieve this world, especially over the last decade in Asia? we must defeat ignorance, fear and prejudice. Action has not been taken to stop these We wish you all the greatest success in your epidemics because of ignorance – about the most important work to achieve these goals. importance of prevention, and about how to go about it; because of fear – the fear that Dr Nick Crofts acting to prevent HIV among drug users will Director somehow encourage drug use; and because of The Centre for Harm Reduction prejudice – that people who inject drugs are somehow less than human, and that their human rights have vanished because they use drugs.

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7 Contents

Introduction to the Second Edition

INCE THE publication of the first But further advocacy is required. IDUs Manual for edition of The Manual for Reducing are still subject across the region to neglect, reducing drug Drug Related Harm in Asia (in incarceration and discrimination; HIV related harm 1999), and partly as a result of its epidemics among IDUs are still relatively Spublication and of that of two editions downplayed in most countries, with more in Asia (1997, 2002) of The Hidden Epidemic, a socially palatable epidemics the focus of regional situation analysis of drug use and attention. HIV vulnerability in Asia, there has been It is very clear that this epidemic can and heightened awareness and recognition of the must be stopped; we know exactly how to do HIV epidemics among IDUs in most Asian this. We hope this updated, revised and countries. An increasing level of awareness expanded second edition of the Manual for has been partly matched by an increasing Reducing Drug Related Harm in Asia will level of funding for programs and for prove as useful a tool for advocacy and for program development. It is no longer the guiding program design and implementation case that these epidemics are seen as as was the first. And again, we wish all those unimportant; there have been trials of most engaged in the fight against HIV, harm reduction strategies in Asia, including discrimination and other human rights outreach, peer education, needle and syringe abuses the best in their continuing struggle. programs, and substitution therapies. However, programs are still too few and Nick Crofts too small. Few harm reduction programs in Director Asia are government supported or integrated The Centre for Harm Reduction into mainstream service delivery, be it primary health care or drug treatment. There is little if any evidence that a decade’s work has actually had any significant impact on the rate of growth of the multiple HIV epidemics centred around IDU transmission. There is now the challenge of scaling-up programs which have been demonstrated to be safe and effective to a point at which they will have a significant impact – this is being attempted in Dhaka, Bangladesh; Manipur State, India; and Nepal. It is to be hoped these scaling-up efforts will show the way forward.

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8 Contents

Section 1 Background and Rationale

19 Contents SECTION

Section 1 Chapter One 1 Drug Use and HIV Vulnerability

History of the drug trade in Asia Emerging trends: drug use Explosive epidemics HIV among IDUs in Asia and the West

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11 Contents > Section 1-Chapter 1

Drugs in Asia – The Ever-Changing Scene

he consumption and injecting of illicit drugs is increasing around the Manual for world, involving at least 15 million people in over 130 countries. reducing drug Patterns of production, consumption and administration have changed related harm T in Asia rapidly since the early 1990s, and continue to change rapidly. Countries where the biggest changes are occurring, involving the biggest populations, are in the developing world, especially in South and South-East Asia and in Latin America. Many western countries experienced epidemics of heroin injecting beginning in the late 1960s, and these have continued. Many Asian countries began to experience such epidemics in the late 1980s, and this trend is continuing across Asia into the new millennium. Changes from the smoking of opium to the injecting of heroin have come about with changing distribution routes, changes in the purity of available drugs and the introduction of injecting as a route of administration. The injecting of drugs is now a problem in over 130 countries worldwide, with an estimated 15 million people regularly injecting drugs globally; over 110 of these countries have reported HIV infection among these injecting drug users (IDUs). These three epidemics – of opiate use, of heroin injecting, and of HIV infection among heroin injectors – can develop extremely quickly, and often unexpectedly. However, the epidemics have developed differently and to varying extents in different countries. It is worth examining these developments in several parts of the world to discover what makes them different and to discover whether there is anything that can be done to prevent such epidemics. This Manual is primarily about the prevention of HIV infection among injecting drug users in Asia. It will also cover questions of the prevention of drug use and of drug injecting, as these are fundamental to the spread of HIV among drug injectors. However, it must be borne in mind that prevention and control of drug use are long-term issues, whereas HIV can spread

Globalization of the HIV/AIDS pandemic in IDUs

1992 1991 1996 1998 1999

Number of countries

IDU 80 118 121 128 134

HIV+ 52 78 81 103 114

Source: WHO, UNAIDS The Centre for Harm Reduction

12 Contents > Section 1-Chapter 1 1SECTION with extraordinary rapidity. The first imperative is to prevent the spread of HIV, because it is so devastating in its effects, and once it has begun to spread Chapter it is much harder to control. In this Manual, we will examine the evidence that One Drug use and these epidemics are predictable and that they are preventable. To understand HIV better why HIV spreads among drug users, and what can be done to prevent vulnerability this spread and protect the community, we will review the experience of several countries – in western countries, in Latin America, in Asia, and in the region of Central and Eastern Europe and the former Soviet Union. By doing this we will be able to see common principles underlying both the spread of HIV among IDUs, and the implementation of effective responses to prevent the spread.

production falling to 12 per cent by the The History of the Drug end of 2001. However, since the fall of Trade in Asia the Taliban, Afghanistan is once again the world’s largest opium producer). Opium has been produced throughout south Until the 1960s, much of the opium and central south-east Asia for centuries. The produced in the Golden Triangle was for extracted opium from the opium poppies was local consumption, where it was smoked fundamentally administered by smoking (as a especially by the older people in the region. recreational drug) and also ingested by mouth During the US war in Vietnam, several (for medicinal purposes). China was a major things changed. Firstly, trade in opium to the producer of opium and, until 1949, the outside world was stimulated to raise revenue world’s largest consumer. In 1949, China to carry on the wars in Cambodia, Laos and had an estimated 20 million people (about Vietnam. Secondly, supply routes to the US 5 per cent of the population at the time) who were opened up, partly through the were addicted to opium. Currently, the two involvement in drug use by the US Army in major areas producing opium for the illegal Vietnam. Some of these supply routes went market are: through Australia, though the largest went • the Golden Triangle region of Thailand, through the Philippines. In the US itself Myanmar and Laos in south-east Asia. (At there was a ready market among the end of 2002, Myanmar is the second disadvantaged black and Hispanic ghetto largest source of illicit opium in the dwellers in the big cities in the north-east world, with Laos in third place), and and mid-west, whose economic and social • the Golden Crescent region of Pakistan, positions had been growing steadily worse Afghanistan, Iran and Turkey in western through the 1960s. Asia. (In 2000, Afghanistan was the This trade to the US, which rapidly grew world’s largest opium producer but civil to become a billion-dollar market, consisted conflict, military attacks on the country mostly of opium exported from Burma and and the overthrow of the Taliban regime, Thailand, especially through Bangkok. The resulted in their share of global opium was refined into heroin for the US The Centre for Harm Reduction

13 Contents > Section 1-Chapter 1

market in the Philippines and in the preventing trafficking from the south of Manual for Mediterranean, particularly by the Mafia in Myanmar. However, the demand for the reducing drug the south of France, Italy and Corsica. drug, and therefore the market, did not go related harm Throughout the 1970s, US-led efforts to away; in fact, the opposite happened – it in Asia prevent the trafficking of opium had several continued to grow. effects: heroin refining factories in the There were two immediate effects of this Philippines and the Mediterranean were restriction of traffic through the south coast closed down, and trafficking through of south-east Asia and the closure of the Malaysia and Singapore became much more heroin factories in other countries. Firstly, difficult. Thailand managed to restrict the new trafficking routes opened up: through trade through Bangkok, and the Myanmar the north of Myanmar, across the Indian government had minor successes in border through the north-east Indian states

CHINA Hong Kong

Kunming Nanning

INDIA

Imphal Hanoi Tama Kalewa LAOS MYANMAR Vientiane Mandalay Chiang Mai Rangoon THAILAND VIETNAM CAMBODIA Bangkok Phnom Ho Chi Minh City Penh

Song Khla

Golden Triangle and supply routes The Centre for Harm Reduction

14 Contents > Section 1-Chapter 1 SECTION

Emerging trends: drug use 1 of Manipur and Mizoram, and across the Throughout most of the 20th century, north of India through Pakistan and national and international interventions to Chapter Afghanistan to Europe. This route was aided control illicit drugs have been progressively One by increasing involvement of Afghanistan strengthened. Penalties for cultivating, Drug use and mujahadeen in the drug trade to finance their producing, transporting, distributing, selling HIV purchases of arms through the south of China or administrating psychoactive substances vulnerability to Hong Kong and Macao, and onwards to have been increasingly severe (except for the US, Europe and Australia. This was aided alcohol and tobacco). In the latter part of the by China’s ‘Open Door’ Policy in 1982, century, patterns of illicit drug use emerged freeing up traffic across the borders. that are now becoming globalised and Secondly, the refinement of opium into standardised. Simple strategies to deal with heroin moved back to the actual production the drug problem have become largely countries, especially to Myanmar. There are ineffective due to the complexity of global several advantages in trafficking heroin as drug production, distribution networks, opposed to opium: it takes up less than a diversified marketing and new and emerging tenth of the volume, it has less smell markets that are both dynamic and thriving. (making it more difficult for sniffer dogs The changes in production and distribution to detect), and it is more profitable. patterns have exposed new populations to Additionally, it is ready for the market, opiates, both for their consumption and for so there are fewer middle men involved, their trade. This has resulted in an increase in which means more profit and less chance opiate use in many populations in Asia who of detection. had not used opiates before. The shift to production and distribution of high-grade heroin made injecting a reality. Combined with increasing costs due to law enforcement crackdowns, and as a response to what was seen as a western fashion, injecting drug use followed hard on the heels of these opiate epidemics. A generation or two ago, heroin injection was rare on the Asian mainland. In recent years the production, distribution and use of amphetamine type substances (ATS) have flourished. Based on global ATS seizures most ATS production occurs in the Asia, and worldwide over 50 per cent of ATS use is found in Asia. It is the drug of choice or fast becoming so in Thailand, South Korea, the Philippines, Taiwan, Japan, Cambodia, Laos, China and Indonesia.

Currently, countries where injecting is not found in Asia are the exception rather than the rule.

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15 Contents > Section 1-Chapter 1

among IDUs has been reported in Smoking or inhaling of drugs does not carry a Bangladesh, Brunei Darussalam, Cambodia, Manual for direct risk of HIV transmission. reducing drug China (including Hong Kong and Macau), related harm When the drug becomes scarcer as a India, Indonesia, Iran, Japan, Lao PDR, in Asia result of drug control efforts, it becomes Malaysia, Mongolia, Myanmar, Nepal, uneconomical for the drug user to smoke or Pakistan, the Philippines, Republic of inhale the drug, as much of it is lost in South Korea, Singapore, Taiwan, Thailand smoke. This is a major reason why drug users and Vietnam. turn to injecting, and this route of One of the consistent features of this administration ensures that all of the drug is epidemic has been the close relationship used. In most settings in the developing between the spread of HIV infection among world, for many reasons, injecting involves IDUs and drug trafficking routes. Drug frequent reuse of the same equipment by trafficking routes have become less stable different people without adequate cleaning over time as intense efforts by law in between. This is the perfect situation enforcement to control drug supplies have for the rapid transmission of blood-borne resulted in the movement of these routes to viruses such as HIV (the AIDS virus) and new areas where there are – temporarily – the hepatitis B and hepatitis C viruses. lower risks. This instability of drug It also causes many other illnesses among trafficking routes has, unfortunately, had the the drug injectors, including septicaemia unintended negative consequence of exposing and heart disease, and occasionally outbreaks additional larger populations to the threat of of malaria. HIV infection among and from drug Changing patterns in the production, injecting users. trafficking and use of heroin, especially from Populations of drug users develop rapidly the Golden Triangle region of Myanmar, along trafficking routes, creating new drug North East India, China, Thailand and Laos, markets and HIV threat in host countries. has led to a series of HIV epidemics among drug injectors across Asia. HIV infection

Figure 1: HIV prevalence among IDUs in selected locations, 1987–1996

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16 Contents > Section 1-Chapter 1 SECTION

Explosive epidemics HIV among IDUs in Asia and the West 1 The diffusion of HIV among IDUs has been To understand better why HIV spreads most pronounced in drug producing and among drug users, and what can be done Chapter transport countries in south-east Asia. to prevent this spread and protect this One Epidemics of HIV that can only be called community, we will review the experiences Drug use and explosive have been documented among of several countries in western countries – in HIV IDUs in China, Thailand, Myanmar, Latin America, in Asia, and in the region of vulnerability Malaysia, Indonesia, Iran, Vietnam and Central and Eastern Europe and the former north-east India. The prevalence of HIV Soviet Union. By doing this we will be able infection among injecting drug users has to seek common principles underlying both often reached 60-90 per cent within six the spread of HIV among IDUs, and the months to a year from the appearance of implementation of effective responses to the first case. In many countries, explosive prevent this spread. epidemics among IDUs then form epicentres for wider diffusion of the HIV epidemic to other parts of the community. In some The United Kingdom places up to 60 per cent of IDUs have been infected with HIV within the first two years When testing for HIV began in England in of injecting. 1985, over 90 per cent of all those found to Several communities in Asia have had be infected were homosexual men. Only a HIV among IDUs for some time and are now very small proportion of IDUs were HIV in the grip of multiple ongoing epidemics: infected, and this has been maintained. •of drug use and its consequences Currently a substantial proportion of HIV •of HIV infection among IDUs infections in England (70 per cent) are • of HIV transmitted from IDUs to their acquired thought heterosexual contacts, of sexual partners and their children whom most are from, or have lived in or • of subsequent AIDS visited, high HIV prevalence countries. • of tuberculosis. In Scotland, however, just north of While the scenario of these epidemics is England and with no effective border totally predictable, and much scientific between them, the picture was very different. evidence is available to support the belief When testing first began in Scotland, over that they are preventable, implementing 80 per cent of those found to be infected action to prevent such epidemics has often were IDUs. Since then this proportion has been fraught with legal, ‘moral’, religious been reduced for two reasons: firstly, because and political obstacles. the spread has slowed among IDUs, and secondly because HIV has spread more widely in other groups, especially heterosexuals and children. As in the US, much of this spread to other groups has come from the IDUs. Why did the epidemic take such different forms in two countries which are so close, geographically and culturally? In fact, if we were to look more closely into the situation, the differences are just as profound within the countries as between them. For instance, Edinburgh had a massive epidemic of HIV The Centre for Harm Reduction

17 Contents > Section 1-Chapter 1

among drug users beginning in the early Even where there is much drug use and Manual for 1980s (exceeding 40 per cent within two much injecting of drugs, and HIV is around, reducing drug years of the first reported case), while in it is not inevitable that an epidemic of HIV related harm Glasgow, another Scottish city only 70 miles infection will occur among IDUs. This is the in Asia away, the HIV prevalence was around 1 per first major point: cent. The low rate was due to implementing HIV epidemics among IDUs can be early, wide-scale interventions, including a prevented. needle syringe program (NSP), encouragement to use bleach if sterile The second major point is that although equipment was not available, and the IDUs may form only small proportions of the development of an HIV awareness campaign population, they can be extremely important targeting IDUs. in the development of the HIV epidemic in a By 1990 there were approximately 250 particular community, this being more so if NSPs operating in England and Wales and substantial proportions of IDUs are sex by the end of the 1990s there were over workers and vice versa. This is so, firstly, 2,000 outlets (pharmacies and other outlets) because HIV can spread so rapidly through throughout the United Kingdom IDUs, and secondly because having done so distributing an estimated 27 million syringes they can then spread HIV to their sexual annually. Drug treatment services partners, their children and the rest of the experienced a major expansion from the mid- community. 1980s and methadone as a substitution Injecting drug users provide an important therapy became widely available. In 1999, focus for spread of HIV to the rest of the the HIV prevalence among IDUs in England community. was 1 per cent and there are no HIV infections among IDUs under 25 years of age.

Figure 2: Testing for HIV in England and Scotland

Homosexual men Hetrosexuals Injecting drug users Children SCOTLAND ENGLAND 80% 80% 70% 70% 60% 60% 50% 50% 40% 40% 30% 30% 20% 20% 10% 10% 0 0 1985 1986 1987 1988 1989 1990 1985 1986 1987 1988 1989 1990

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18 Contents > Section 1-Chapter 1 1SECTION prison. However, drug use occurs in every USA prison in the world, and because of the Chapter scarcity of equipment every injection is very In the mid-1960s, America started to One likely to be unsafe and the same syringe and Drug use and experience an epidemic of heroin use. On the needle may be shared by 50-100 people. supply side, this was because of the opening HIV up of trafficking routes from the Golden HIV spreads most rapidly among injecting vulnerability Triangle region of south-east Asia due to the drug users when equipment is shared US involvement in the Vietnam War. On the between many people. demand side, it was due to the disintegration of the inner areas of the big cities of the Figure 3 shows the major causes of death north-east and the mid-west of the US: New in the United States among men aged 25-44 York, Baltimore, Jersey City, Chicago, years, the most productive years of life and Philadelphia and so on, especially among the the major reproductive years. While most black and Hispanic minorities. For example, other causes of death have been slowly during the 1970s, in some of the black areas coming down (with the exception of of Chicago or the Bronx in New York, adult homicide), over a single decade in the 1980s unemployment reached 80 per cent or more, HIV infection has gone from not being a and poverty, crime and drug use became the cause of death to being the second leading predominant feature of these societies. cause. Throughout the 1990s, HIV was the At this point it should be noted that, for leading cause of death of young men. a variety of circumstances, through the Much of the HIV infection in the US has 1970s, a phenomenon known as ‘shooting been among homosexual men. However, galleries’ grew up in the US. They are named since the start of the epidemic more than after the slang term for injecting, ‘shooting’. one-third of all AIDS cases (36%) in the They are places where an injector buys and country have been directly or indirectly prepares the drug, and then injects using the linked to drug injecting, and this trend has syringe and needle that are kept there. He or not changed. In New York City in 1993, 50 she then leaves this syringe and needle per cent of new HIV/AIDS cases were among behind for the next person to use. In this drug users, with only 33 per cent among way, the one syringe and needle might be homosexual men. Over half of all women used by 20-50 different people. Around infected with HIV in the US are either drug 1977, when HIV arrived in the US, users or the sexual partners of drug users. thousands of these shooting galleries existed. Most of the children who are born infected In this setting HIV spread rapidly, and still with HIV have one or other parent who is a does. We will look into the reasons for these drug user. In 2000, the prevalence of HIV shooting galleries later, but what needs to be among IDUs in New York City has dropped emphasised here is that the worst situation to around 30 per cent and this is largely a for the spread of HIV among IDUs is when result of the introduction and impact of equipment is shared among many people. NSPs. The epidemics of drug use and of HIV The other setting in which this occurs in the US, and globally, is in prisons. There is less drug use in prison than on the outside because drugs are more difficult to obtain in

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19 Contents > Section 1-Chapter 1

Figure 3: Leading causes of mortality among males aged 25-44 in the United States Manual for 60% reducing drug Unintentional injuries related harm 50% in Asia HIV Infection 40%

30% Heart Disease Cancer Homicide 20%

10% Chronic Liver Disease Pneumonia and Influenza Diabetes Mellitus 0 1982 1983 1984 1985 1986 1987 1988 1989 1990 1990

are strongly associated with race: in 1998 the drug injecting associated HIV infection Australia rate was 10 times higher among African Americans than among whites. This is HIV infection appeared among IDUs in because of the much greater poverty among Australia as early as 1984, but did not spread African Americans than among whites. The greatly. Australia had an epidemic of heroin US has failed to cope with these epidemics. injecting beginning in the early 1970s, and Similarly in Western Europe, while in 1984 continuing today. A second epidemic, of IDUs made up only 7 per cent of AIDS cases, amphetamine use, began in the early 1980s by 1992 they made up 39 per cent, a higher and also continues. Although there is much proportion than among homosexual men, drug injecting in Australia, and HIV has who made up 35 per cent. In 2001, IDUs been present in these populations for over a made up 32 per cent of AIDS cases, a larger decade, the rates of HIV infection among proportion than among homosexual/bisexual injecting drug users remain very low, less men, which stood at 19 per cent. Hetero- than 2 per cent. sexually acquired cases among males and The major reason why HIV has not females form the largest group at 36 per cent. spread among IDUs in Australia is because policy makers there took heed of what they It is not drug use which causes HIV infection, saw happening in the US and realised that if it is not even drug injecting, it is the sharing of they acted quickly they could prevent the contaminated injecting equipment that HIV epidemic among IDUs from taking off. transmits HIV infection. From the outset the response was based on public health, with harm reduction accepted at the most senior level. Starting in 1984, Australia introduced harm reduction policies and programs, especially community education, peer education, needle and syringe distribution and disposal programs, and substantially boosted drug treatment programs, especially methadone The Centre maintenance. for Harm Reduction

20 Contents > Section 1-Chapter 1 1SECTION especially in Sao Paulo State and on the south Brazil coast. In Santos, HIV prevalence among Chapter IDUs reached 50-60 per cent in the early Brazil does not produce much cocaine. The One 1990s and in Rio it reached approximately Drug use and coca tree, from which cocaine is derived, 25 per cent. While HIV first spread among grows best at higher altitudes and the central HIV drug users, it moved into the heterosexual vulnerability countries for production are therefore those populations, through prostitutes who were in the Andes mountain ranges: Colombia, drug injectors and through their clients. Bolivia and Peru. Historically, the cocaine The main lesson here is that: has passed from these countries northwards through Central America to the United Epidemics of drug use and drug injecting can States, where from the late 1970s a huge occur extremely quickly, where there is an epidemic of cocaine use has existed. Much of at-risk population and where supply routes this cocaine came through Panama, onwards change so that the drug becomes available. to Florida and the east coast. In 2000, 21 per cent of AIDS cases were Through the 1980s, the US government found among IDUs. Nationwide the HIV spent billions of dollars trying to stop this prevalence among IDUs fell from 63 per in trafficking. There were two fronts to this 1992 to 42 per cent in 1999, although it has drug war: stopping production in South been suggested this may be related to the America, and preventing trafficking through transition from cocaine injecting to crack Central America. The first battle has so far cocaine smoking. Brazil was the first country failed; the second battle has been successful, in Latin America to introduce a range of risk but at the cost of the US invasion of Panama. reduction activities targeting IDUs, and in The effect of these efforts has been to 1995 in the City of Salvador the first NSP decrease the flow of cocaine through Central was opened. In 2001, 41 NSPs operated America, but not to stop either the supply of, throughout Brazil. or the demand for, the drug in the US or Europe. As with the export of heroin from the Golden Triangle, traffickers have simply found different ways of getting the drug out Thailand of Central America, mainly through The first cases of AIDS were reported in Brazilian ports and on to Europe and the east Thailand in 1984, in people who were either coast of the US. As a result, since the foreign born or had contact with foreigners, beginning of the 1990s, enormous amounts particularly in America. Through 1987 there of pure cocaine, particularly from Colombia, did not appear to be very much spread of began leaving Brazil, especially from the port HIV, but in late 1987 and early 1988 there cities of Santos and Rio de Janeiro. Even was suddenly an extremely rapid spread of though the drug can be inhaled or smoked, the virus through IDUs. This spread was so and it is pure and cheap, the people in these rapid that almost half of all the thousands of cities are so poor that they cannot afford to drug injectors in Bangkok were infected buy much and cannot afford to waste any. In within 18 months. This again illustrates the the early 1990s there was a huge epidemic of speed with which HIV can spread through a cocaine injecting in the large cities in Brazil, population of IDUs given the wrong and along with this an explosive epidemic of conditions. HIV infection. In Brazil, IDUs have played a central role in the HIV/AIDS epidemic, The Centre for Harm Reduction

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Thailand did not heed the warning signs. Manual for Throughout the mid-1980s, many in the India reducing drug Thai health services said that AIDS was not a threat to Thailand. They were disastrously In the late 1980s, the opening up of supply related harm routes through northern Myanmar and across in Asia wrong. Since the beginning of the epidemic nearly 300,000 people have died of AIDS the Indian border into the north-east states of and it has been estimated at the end of 2001 Manipur, Mizoram and Nagaland merely an estimated 670,000 adults and children followed a centuries-old smuggling and were living with HIV/AIDS. In 2001, an trading route. However, it was also estimated 55,000 people died of AIDS alone. responding to new markets in the Middle Many in the public security services have said East and Europe, with rapid expansion of the that stamping out drug use was more number of drug users from Pakistan to important than preventing an HIV epidemic. Turkey and beyond. While HIV prevalence in recent years among With this influx of drugs and money, the army conscripts, pregnant women and sex young men of north-east India rapidly workers has declined sharply, this has not developed very heavy heroin habits, in a been observed among IDUs. In 1995, the situation where accessing sterile injecting national HIV prevalence among IDUs was equipment was difficult. Therefore much 32 per cent, increasing to 51 per cent in sharing of injecting equipment (often 1999 and 54 per cent in 2000. It has been homemade) and a resultant explosion of HIV estimated that 5-10 per cent of drug users occurred throughout the north-east: from become HIV infected each year. virtually none in mid-1989 to over half Preventing an epidemic of HIV among infected by the start of 1990. In India it is drug injectors may not have prevented an common to hear politicians blame this AIDS epidemic in Thailand totally, but as phenomenon on Myanmar, ignoring the fact the risky behaviour among this group has not that there are many Indians involved in the been addressed it does consequently stand trafficking. This is the first example of the out as a major cause of continued HIV next major lesson: transmission in the country. Since the late Every country blames its neighbours for its 1990s there has been a dramatic increase in AIDS epidemic. methamphetamine use and there are now an estimated two to three million drug users in the country. While most methamphetamine Prevalence of HIV Infection among IDUs is smoked or ingested it may still facilitate in various cities, India, 2000 (%) increased sexual risk taking and thus the City HIV Prevalence potential for HIV to occur. Imphal (Manipur) 58% New Delhi 45% Chennai 27% Mumbai 24% Kolkata 2% Source: Dorabjee and Samson 2000; Dorabjee 2000

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22 Contents > Section 1-Chapter 1 1SECTION While there may be some truth in this that primarily affects IDUs. As of the end of from an epidemiological point of view, it is 2001, 76 per cent of all reported HIV Chapter too often used as an excuse for not doing infections were to be found among IDUs. One anything to stop the epidemic within one’s The only response to the problem of HIV Drug use and own borders. Heroin use has been spreading among IDUs has been to increase HIV rapidly in the major metropolitan cites of incarceration in drug rehabilitation centres, vulnerability India since the early 1980s. By the 1990s an the recidivism rate for which is over 70 per epidemic of injecting pharmaceuticals, in cent. There is widespread sharing of injecting particular buprenorphine, often used as an equipment, which is not only a result of drug alternative among heroin users, was found in using etiquette but also because getting all major metropolitan cites and has not injecting equipment is not always that easy. abated. The sharing of injecting equipment Drug users can be fearful of being identified among India’s drug injecting community is by law enforcement authorities and do not widespread and consequently in some cites wish to be seen buying needles and syringes and regions the prevalence of HIV is high from pharmacies or being in possession of among these people. such equipment, which legally is an offence. Research in Malaysia, as elsewhere, has illustrated the role of sharing of injecting Malaysia equipment: those with the most sharing partners are the most likely to be infected. In north-east Malaysia there is much cross- Again, this emphasises the fact that in border traffic - in drugs and sex – into south relation to drug use it is not the use of Thailand to purchase and use drugs and to drugs, nor even the injecting of drugs, use prostitutes. In Malaysia, as is commonly which causes HIV infection; it is the found throughout Asia, drug use is on the sharing of equipment, especially with rise. In the mid-1990s there were an many other people. estimated 20,000-50,000 IDUs and by the end of the 1990s this figure increased to an estimated 200,000 IDUs. In Kota Bharu (the Vietnam capital of Kelantan State in the north-east on the border with Thailand) the proportion of Vietnam’s epidemic of injecting heroin use drug injectors entering the drug goes back to the American War in Vietnam, rehabilitation centres who were infected with when there was a huge influx of cheap opium HIV in 1991 was 9 per cent; by 1992 this for use by the US Army. The Americans had reached 30 per cent. More importantly, generally smoked opium, rather than most of these drug injectors had not been out injecting heroin, but some injected and it is of Malaysia; despite the official belief that likely they taught the Vietnamese to inject. HIV was present only among those who The Vietnamese for a long time made do went to Thailand; the virus was spreading with injecting ‘blackwater’ opium, the within Malaysia itself. The drug injecting residue left over from smoking opium, and as population of Malaysia is extremely mobile a result they were ready when heroin started and the opportunities for HIV infection to replacing opium in the 1970s-1980s. HIV spread to other parts of the country have did not arrive among drug injectors in Ho been considerable; currently no state in Chi Minh City (HCMC) until mid-1992, but Malaysia is free from IDUs or HIV infection. when it did, it spread very rapidly, rising Malaysia is a country with a HIV epidemic from 1 per cent in mid-1992 to 42 per cent The Centre for Harm Reduction

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Trend of HIV Infection among IDUs in selected Provinces,Vietnam, 1994-2001 Manual for 90% reducing drug Binh dinh related harm 80% HCMc in Asia 70% Hai phong 60% 50% 40% Cantho 30% An Giang 20% Hanoi 10% 0 1994 1995 1996 1997 1998 1999 2000 2001

Source: Nguyen Tran Hien 2001

in 1995, and continues to remain at high cent of the total reported HIV cases; high levels. A major reason for this initial high prevalence rates among IDUs have been prevalence was the way heroin was injected. evident since the mid-1990s. A recent It was common practice in HCMC, and the phenomenon is the high prevalence of drug rest of the country, for drug injectors not to injecting among sex workers in various cities inject themselves but to be injected by the of Vietnam: the implication is for a rapid dealer or by a professional injector. At the spread of HIV infection from this group of time it was estimated that in HCMC alone IDUs to the wider community. there were up to 3,000 professional injectors. The emergence of this injecting trait is due It is common practice in many Asian in part to it being a cultural habit, and in countries to purchase medicines and inject part because of the scarcity of injecting them at home, and so, culturally, many people equipment. This led to the development of a are used to needles and syringes.Additionally phenomenon, similar to the shooting there is often a shared belief in the greater galleries in the US, where many people are efficacy of injected rather than swallowed injected with the same equipment, without medicines. Such practices and shared beliefs any or adequate cleaning between injections, can further facilitate the spread of HIV/AIDS although it is now believed that shooting in Asia. galleries are rare. Most explosive outbreaks of HIV occur in situations where many people share or reuse the same injecting equipment. The predominant mode of HIV transmission in Vietnam is drug injecting and in 2000, HIV infections among IDUs accounted for 65 per

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24 Contents > Section 1-Chapter 1 1SECTION spread along the various trafficking routes China and has entered provinces previously Chapter untouched by HIV infection. By 2001, a Since the late 1980s, China has experienced One total of 27 of the 31 provinces had identified Drug use and the phenomenon of epidemics of opium and HIV among their drug injecting population heroin use, injecting of heroin and HIV HIV and, of these, seven provinces have serious vulnerability infection. This occurred largely as a result of HIV epidemics among IDUs. The spread of changes in trafficking routes and the opening HIV infection among IDUs first occurred in of the Chinese border, particularly with Yunnan in the late 1980s and was mainly Myanmar. By the mid-to-late 1980s the concentrated among ethnic minorities. Yunnan Province, which borders with While reported HIV infections in China Myanmar, became a principal trafficking continue to be concentrated among IDUs (70 route for drugs entering China and a focal per cent of all reported infections), the spread point for serious drug problems and an of HIV infection has moved into the majority explosive HIV epidemic. As a result of the Han population and is increasingly porous border separating China and transmitted sexually. While most drug users Myanmar it is all too easy to go across the are male the number of females using drug is border to buy and use drugs; in most places increasing and in the provinces of Yunnan there is effectively no border. Drug use has and Guangxi they make up 16 to 25 per cent become widespread in China: 2,033 out of of all drug users in treatment - the majority 2,143 counties have currently reported drug are also involved in sex work to support their using problems. In 1990, China had 70,000 heroin addiction. registered drug users increasing to 860,000 Despite efforts to curb the growth of drug by 2000. However this number of drug users use and injecting, and to prevent continued is not reflective of the true situation, as it is a spread of HIV among injecting drug users, severely punishable offence. It is estimated provincial HIV epidemics among IDUs have there may be up to 6 to 7 million drug users, been spreading progressively. With a rapid of which half are IDUs. implementation of risk reduction activities In recent years the connection between targeting IDUs these epidemics could have heroin use, trafficking routes and the spread been prevented. of HIV/AIDS in China has been shown. By China continues to be a major transit using advanced molecular epidemiology, country for heroin and methamphetamines, linking HIV subtypes to specific trafficking produced in the Golden Triangle, routes, it has been shown that HIV has particularly Myanmar. Heroin and opium

Provinces and sites with highest infection rates among IDUs in 2000 Provinces Sites and Rates Xinjiang Yining 84% Urumqi 39% Yunnan Ruili >80% Wenshan 75% Kaiyuan 58% Yingjiang 70% Guangdong Sentinel site: 21% Guangxi Baise 30-40% Pingxiang 12% Liuzhou 12% Jiangxi Sentinel site: 17% Source: China Annual STI and HIV/AIDS Sentinel Surveillance Report 2000 Annual Report, Guangxi Epidemic Prevention Station as cited in UNAIDS 2002 The Centre for Harm Reduction

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are still the drugs of choice but there are Non-government organisations generally increasing amounts of amphetamine type Manual for take the lead in instigating harm reduction substances being produced, trafficked and reducing drug programs but these programs are few in used in the country. This suggests that related harm number and small scale and unlikely to reach methamphetamine may become, over time, in Asia most drug users. the drug of choice because of its cheapness, accessibility and availability. Indonesia Nepal In Indonesia the subject of illicit drug use and in particular injecting drug use was Nepal is not a major producer of narcotics or previously an extremely sensitive issue. Poor on any major trafficking route, and most documentation and data suggested heroin used in the country has its origins assessments were often very restricted and too elsewhere. The most commonly used drug is problematic for government authorities to buprenorphine (commonly called ), Tidigesic openly discuss. However, this is generally not which is mainly injected. Drug injecting has the case any more, with major assessments become increasingly popular and, although taking place and public debate on drug use sharing of injecting equipment occurs, issues increasing. While Indonesia is not a surveys among IDUs in 1991 through to major producer of drugs (except for 1994 found HIV prevalence among IDUs marijuana), heroin is being smuggled into was very low (it remained below 2 per cent) the country, mainly from Myanmar, and and was not spreading to any degree, perhaps there is a major increase in production and as a result of small and isolated networks. In use of methamphetamines. Since the late 1991, an outreach needle exchange and 1990s, the country has been faced with an primary health care program for IDUs was unstable political environment, accompanied established in Kathmandu, which continues with economic and social upheaval. At the to operate, but with limited resources only same time drug use also increased an estimated 10 per cent of an estimated substantially, with drug assessors estimating 15,000 IDUs in the Kathmandu Valley are there are up to 1.3 to 2 million drug users contacted. In 1997, 50 per cent of IDUs and suggestions that up to half are IDUs (in tested in Kathmandu were HIV positive. The the late 1990s it was estimated to be 30,000- latest research in 2002 shows 68 per cent of 40,000 IDUs). IDUs in Kathmandu Valley tested HIV Surveys undertaken show a high positive and nationwide the HIV prevalence prevalence of risky behaviours among drug among IDUs is around 45 per cent. users. Sharing of injecting equipment is Nepal has learnt the lesson that it is not widespread and often takes place between enough simply to have small, NGO-run two to 11 other users, most of whom do not harm reduction programs which cannot clean their needles properly before reuse. provide national responses on the same scale Before 2000, HIV infections due to drug as the epidemic. These programs must be injecting made up less than 1 per cent of taken up by governments and integrated into total cases: in 2001 this figure had increased normal primary health care delivery if they to 19 per cent of all cases. HIV infections in are to be effective. specific environments is alarming, with the main prison in Bali showing that among the The Centre incarcerated IDUs 56 per cent were HIV for Harm Reduction

26 Contents > Section 1-Chapter 1 1SECTION infected and almost all of these having a In recent years efforts have been made to history of sharing injecting equipment stem the tide of the HIV epidemic through a Chapter outside the prison. Recent studies show that variety of risk reduction activities, with One 35-40 per cent of all IDUs in treatment in many tailored to the specific political, legal Drug use and Jakarta are HIV infected. and social context in which they operate. HIV Services such as outreach and peer education vulnerability for IDUs, disinfecting material, NSPs and so Central and Eastern Europe and on have been introduced, mainly by the non- the Newly Independent States government sector. Only by capacity (NIS) of the former Soviet Union building and a major scaling up of activities can a decrease in HIV infection among IDUs The governmental structures of the former become a reality. Soviet Union, Eastern and Central Europe collapsed in the late 1980s and early 1990s following years of economic crisis and social Central Asia - Kazakhstan unrest. Alcoholism and drug use increased and the opening of the various borders The collapse of the Soviet Union had a severe resulted in the mass movement of narcotics economic impact upon Central Asia. The throughout the region. As a consequence transition to a free market economy created there was an increasing availability and substantial economic and social instability, accessibility of imported substances such as resulting in a dramatic rise in unemployment opium and heroin from Afghanistan. The and poverty accompanied by an increasingly drug industry flourished, and with many fragile health infrastructure and decreasing people affected by poverty and government spending on the social sector. unemployment the selling of drugs became a Poverty has fuelled a massive expansion of growing source of income. With many the drug trade in this region and Kazakhstan people increasingly vulnerable and seeking has been hit particularly hard by the twin an escape from hardship and the growing epidemic of drug use and HIV/AIDS. Several social uncertainties, consumption of illicit major drug trafficking routes transporting substances increased markedly. raw opium and heroin from Afghanistan, Until 1995 there was little sign of a ultimately for Russia and Europe, pass major HIV threat in the region but a rapid through various countries of Central Asia, of diffusion of drug injecting had reached which Kazakhstan is included. Over time the epidemic proportions and this new narcotics trade became deeply embedded into phenomenon resulted in an explosive the economy and access to more potent drugs HIV/AIDS situation. By the end of 2000 it is now easier and cheaper. The effects of the was estimated there were 4 million IDUs in increased drug trade in Kazakhstan have the region and in Russia alone there could be been an increase in drug addiction, and by as many 2.5 million IDUs. By the end of 1999 there were 37,000 drug users officially 1999 the estimated number of HIV registered. However, unofficially it is infections in the region reached 420,000 and estimated there were 200,000-300, 000 drug a year later it had risen to 700,000. In the users, with many believed to be IDUs. NSI (Ukraine, Belarus, Moldova, the Russian Currently Kazakhstan is believed to have the Federation, the Baltic states and Central highest number of IDUs in Central Asia. Asia) the large majority of the HIV cases are linked to drug injecting. The Centre for Harm Reduction

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Conclusion

It was not until the mid-1990s that the Countries in all regions of the world have experienced rapid increases in drug use, drug Manual for number of HIV/AIDS infections increased injecting and subsequent HIV epidemics, reducing drug dramatically, and between 1995 and 2000 which began among IDUs and moved to related harm there was a 38-fold increase in HIV their sexual partners and onwards to the in Asia infections being detected. As of January 2001, there were just under 1,400 HIV- general community. Those countries which infected individuals but unofficially the have most successfully stemmed the tide of estimated number of HIV cases was 10,000. this last epidemic are countries which: have Currently 85 per cent of all HIV infections acted early in the course of the epidemic (e.g. are attributed to drug injecting. There is before HIV prevalence has reached 5-10 per widespread sharing of injecting equipment cent among IDUs); developed programs and it has been documented that blood is based on the principles of harm reduction; introduced into the drug preparation prior to and integrated and generalised these injecting. Many drug users are reported not programs on a national scale, so the response to be aware of HIV/AIDS prevention is as large as the threat. methods. A recent study among sex workers (SWs) in the city of Almaty estimated there were 10,000 SWs, of which 30 per cent used illicit drugs and many injected. The risk behaviours of low condom use and the sharing of needles suggest they and their clients are likely to facilitate the spread of HIV to the general population in the future. Kazakhstan also has the problem of having a relatively high rate of incarceration, and two- thirds of the 80,000-90,000 prisoners are drug users. Drugs are smuggled into the prisons and injecting does occur, consequently exacerbating the spread of HIV/AIDS. The response to the rising rate of HIV infections among IDUs has been slow but in recent years harm reduction programs have been implemented, including NSPs, outreach and the dissemination of information on ways to prevent the Section One, Chapter One: Drug transmission of HIV infection to others. Use and HIV vulnerability However, it is estimated that approximately only 5 per cent of all drug users utilise harm For further information refer to reduction programs in Kazakhstan and all WHO resources : Policy and known prevention initiatives related to drug Programming Guide for HIV use and HIV are dependent upon the support Prevention Among Injecting Drug of the international donor community. Users & Evidence for Action Papers. Refer to following website: www.who.int/hiv (publications expected online from May 2003) The Centre for Harm Reduction

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References 1 Academy for Educational Development. EuroHIV. 2001. HIV surveillance in Europe. 2000. A comprehensive approach: preventing End of the year report. No 66. For more Chapter blood-borne infections among injecting drug detail [www.eurohiv.org] See tables 6 & 7. One users. Academy for Educational Ghys PD, Bazant W, Monteiro MG, Calvani Drug use and Development. United States. S and Lazzari S. 2001. The epidemics of HIV Ball A. 2000. Drug use and HIV/AIDS. injecting drug use and HIV in Asia. vulnerability Summary papers given in Track D of the AIDS. 15 (suppl 5): S91-S99. XIITH International AIDS Conference, Green C. 2000a. AIDS: A nightmare Durban. South Africa, 9-14 July. ingredient in the Indonesia development Bastos FI, Strathdee SA, Derrico M and Pina broth. Development Bulletin, 52: 52-53. F. 1999. Drug use and the spread of Grund JP. 2001. A candle lit from both HIV/AIDS in South America and the sides: the epidemic of HIV infection in Caribbean. Drugs: Education, Prevention & Central and Eastern Europe. In McElrath Policy 6(1): 29-50. K (ed), HIV and AIDS: a world view. Burrows D, Holmes D and Schwalbe N. Westport, Ct. Greenwood Press. United 2002. Drug use injects HIV/AIDS into States. Former Soviet Union. AIDSLink. Issue 2. Hien NT. 2000. HIV prevalence trends and risk March. behaviours among injecting drug users (IDUs) Burrows D, Panda S and Crofts N. 2001. in Vietnam. Global Research Network HIV/AIDS prevention among injecting drug Meeting on HIV Prevention in Drug- users in Kathmandu Valley. Report for The Using Populations, Third Annual Meeting Centre for Harm Reduction. Melbourne, Report. July 5-7 Durban, South Africa. Australia. Higgs, P. 2001. HIV and drug use in Burrows D, Rhodes T, Trautman F, Bilj M, Vietnam, (briefing paper for Pathfinder Stimson G et al. 1998. Responding to International delegation). The Centre for HIV infection associated with drug Harm Reduction. Macfarlane Burnet injecting in Eastern Europe. Drug and Institute for Medical Research & Public Alcohol Review. 17: 453-463. Health, Hanoi, April. Dallabetta G and Gavrilin S. 2001. Assessment International Crisis Group (ICG). 2001. of the HIV situation in selected sites in Central Asia: drugs and conflict. ICG Asia Kyrgzstan, Uzbekistan and Kazakhstan. Report No 25. Osh/Brussels. Report prepared for the USAID/Regional Irwanto I. 2001a. Drug use epidemic in Mission for Central Asia. Indonesia: some warning signs. Paper Dorabjee J and Samson L. 2000. A presented at the 25th Anniversary multicentre rapid assessment of injecting meeting of the community epidemiology drug use in India. International Journal of work group. June 12-15, Rockville. Drug Policy. 11: pp 99-112. Maryland. USA. Dorabjee J. 2002. Building the capacity of Karki BB. 1999. RAR survey among drug users NGOs and other institutions to work with in Nepal. Paper prepared for the ‘The injecting drug users in India. Report Harm Reduction Planning Workshop’ 7 - submitted to Family Health International, 11 June 1999. Kathmandu. Nepal. New Delhi, India.

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MAP (Monitoring the AIDS Pandemic). Reid G. and AHRN. 1998. The hidden Manual for 2001. The status and trends of HIV/AIDS/ epidemic: a situation assessment of drug use in reducing drug STI epidemics in Asia and the Pacific. MAP. South East Asia and East Asia in the context related harm Provisional Report October 4. of HIV vulnerability. Asian Harm in Asia Ministry of Health. 2001. Statistical case of Reduction Network. Thailand. HIV/AIDS in Indonesia. Directorate Reid G and Costigan G. 2002. Revisiting the General of CDC and EH, Ministry of hidden epidemic: a situation assessment of drug Health, Republic of Indonesia use in Asia in the context of HIV/AIDS. [http://www1.rad.net.id/aids/data.htm]. Burnet Institute – Centre for Harm NCAIDS, Department of Behavioural Reduction. Melbourne. Australia. Intervention. 2001. IDU rapid assessment Rhodes T, Ball A, Stimson G, Kobyshcha Y, and response, WHO Drug Injecting Project Fitch C et al. 1999. HIV infection PHASE II. Final Report. June 21. associated with drug injecting in the NCAIDS. Beijing, China. Newly Independent States, Eastern Open Society Institute (OSI). 2001. Drugs, Europe: the social and economic context of AIDS and harm reduction: how to slow the epidemics. Addiction. 94(9): 1323-1336. HIV epidemic in Eastern Europe and the Shrestha L. 2001. Briefing note: HIV/AIDS in Former Soviet Union. OSI, International Central Asia. World Bank Harm Reduction Development. New UNAIDS & World Health Organisation. York. United States. 2002. Epidemiological Fact Sheet on Parsons J, Hickmen M, Turnball P, HIV/AIDS and sexually transmitted diseases, McSweeny T, Stimson G et al. 2002. Over Thailand. Update. a decade of syringe exchange: results from UNAIDS. 2001. Update on the HIV/AIDS 1997 UK survey. Addiction. 97: 845-850. epidemic in China. Report on the situation Peak A. 2000. Fact finding mission to as of early August 2001. Beijing. China. Kazakhstan. Report submitted to Soros UNAIDS and UNDCP. 2000. Drug use and Foundation, Open Society Institute, HIV vulnerability: policy research study in International Harm Reduction Asia. Regional Centre for East Asia and Department. the Pacific. Bangkok. Thailand. Peak A. 2001. Drug use and HIV/AIDS in UNAIDS. 2002. HIV/AIDS: China’s titanic Thailand in the year 2000. Family Health peril. 2001 update of the AIDS situation and International Asia Regional Office. needs assessment report. The UN Theme Peak MJ, Rana S and Rai LB. 2001. HIV and Group on HIV/AIDS in China. injecting drug use in selected sites of the terai, UNDCP. 2000. China country profile. Nepal. Kathmandu. Family Health Regional Centre for East Asia and the International. Kathmandu. Nepal. Pacific. Bangkok. Thailand. Reid G. 2001. The challenges and activities Vu Doan Trang. 2001. Harm reduction for of responding to the drug using situation injecting drug users in Vietnam: a in Bali, Indonesia. National AIDS Bulletin. situation assessment. Report for Macfarlane Vol 14 (5): 28-30. Burnet Centre. Victorian Public Health Training Scheme. March. Melbourne. Australia. [http://www.chr.asn.au/projects.html]

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30 Contents > Section 1-Chapter 1 1SECTION Wodak A and Lurie P. 1996. A tale of two countries: attempts to control HIV among Chapter injecting drug users in Australia and the One United States. Journal of Drug Issues. 27(1): Drug use and 117-134. HIV World Bank. 2000. Thailand’s Response to vulnerability AIDS, building on success, confronting the future. Report commissioned by The World Bank. Bangkok. Thailand. World Health Organization and Ministry of Health, Malaysia, 2001. STI/HIV consensus report on STI, HIV and AIDS epidemiology, Malaysia. Regional Office for the Western Pacific. Manila. Philippines. Wu Z. 2000. Country situation and responses – China. Presentation to Regional Task Force on Drug Use and HIV Vulnerability. Beijing. November.

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31 Contents SECTION

Section One Chapter Two 1 Rationale for Harm Reduction

Introduction A practical approach Harm reduction: common elements Education Needle and syringe programs Drug treatment and substitution programs Peer education Sales and purchasing of injecting equipment Primary health care Counselling and testing Removing barriers Special groups and circumstances

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Introduction

N RECENT YEARS there has been ample research evidence to Manual for indicate that drug use can spread very rapidly, given the wrong reducing drug social, economic and political conditions. Traditionally, in Asia, the related harm I in Asia consumption of opium was by smoking but prohibitive laws against opium consumption and production inadvertently promoted the consumption of heroin, initially by smoking and later by injection. It was this transition towards injecting drug use (IDU) that resulted in the prevailing epidemic of HIV among injecting drug users (IDUs) in a number of developed and developing countries; the Asian region being among the worst affected. The transmission of HIV among IDUs has proven both extremely rapid and a focus for spread among other sections of the community, particularly those who are sexually active and to their children. Reducing the supply of drugs is fraught with difficulties. Effective measures do not often produce quick results and many successful actions have a diminished effectiveness when they have simply led to new distribution routes, new dealers and traffickers, and new groups of people at risk of drug use. Any effectiveness they might have is over the medium to long term. Reducing the demand on drugs through education, social and economic development of the community, and rehabilitation and treatment of drug users, also works only in the long term. Many programs for education about drugs probably do not even work in the long term, as they are often based on assumptions and prejudices rather than on honest education, and often the reasons people – especially |young people – use drugs are not reasons education about drugs can effectively address. As HIV transmission among IDUs can be extremely rapid, approaches to intervene and obstruct the spread of HIV infection has needed to be explored by many countries. What has emerged, both within the developed and developing world, is the approach of ‘Harm Reduction’.

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Harm Reduction: A Practical Approach 1 A clear example of a harm reduction strategy in many countries is the compulsory wearing Defining Harm Reduction Chapter of seat belts in cars. By themselves seat belts Two do not prevent motor car accidents from Harm reduction can be viewed as the Rationale for occurring, but when these accidents do occur prevention of adverse consequences of illicit Harm the wearing of seat belts significantly drug use without necessarily reducing their Reduction decreases the mortality and injury rates consumption. among the occupants. Making seat belts compulsory is not condoning bad driving, The harm reduction perspective can speeding or drunkenness, but it is admitting encompass various aspects of psychoactive the reality that these things do occur, and it drug use, from restricting the advertising of is attempting to cope with the effects of cigarettes to promoting hepatitis vaccination these socially undesirable activities. Making programs for IDUs. It was during the mid seat belts compulsory is not an excuse for 1980s that harm reduction was catapulted inaction on all other aspects of accident into the official drug policy of the United prevention, such as driver education, road Kingdom, Australia, Switzerland and building and law enforcement: it is elsewhere, with the recognition of the link complementary to these other efforts which between injecting drugs and HIV infection. will take longer to have effect. It is a similar Since the growth of harm reduction philosophy which underlies harm reduction activities, a single generally accepted approaches to illicit drug use – they do definition has yet to emerge. However, there not condone drug use, and are entirely are a number of common elements that assist compatible with education, treatment and us in both defining the term and concept of law enforcement approaches to decrease harm reduction. These are as follows: drug use. 1. Short term goals Deng Xiao Ping: • there is an emphasis for short term “it does not matter if a cat is black or white pragmatic goals over long term idealistic as long as it catches mice”. goals. Efforts to prevent rapid HIV transmission are implemented as quickly as possible. The rapid, potentially explosive spread of HIV infection must be prevented first, or the longer term goals of abstinence and vocational rehabilitation will be invalid.

2. A scale of means to achieve specific goals • an encouragement for the drug user to stop using illicit drugs • an encouragement for the drug users to stop injecting illicit drugs

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• ensuring that the drug user does not share These programs all aim to change behaviour Manual for any of their injecting equipment, and thereby reduce the risks of HIV reducing drug especially needles and syringes, with any infection among IDUs. related harm other person A number of countries implemented a in Asia • lastly, if sharing does occur the injecting combination of these identified measures equipment must be disinfected early in the epidemic such as Australia, New between each use Zealand, the United Kingdom, the Netherlands and Denmark. The early, 3. Involvement of drug users vigorous implementation of these combined •drug users are not to be considered as approaches has resulted in a lower HIV passive recipients of services but must be infection among IDUs than in most other viewed as playing a vitally important role countries. The success of these measures will in the prevention of HIV/AIDS. It has now be briefly reviewed. been shown consistently that drug user organisations contribute greatly to the Education about safe injecting strategy development of harm reduction. Education of drug users about safe injecting and HIV prevention is a critical factor in Harm reduction involves alternative harm reduction programs. When HIV enters methods, and it must be remembered that a group of IDUs, before the introduction different programs are to be considered as and implementation of any HIV/AIDS complementary rather than in conflict. education awareness, the rapid spread and A broad range of programs has been speed of the epidemic has proven to have a implemented to foster harm reduction devastating impact. The strength and principles and to prevent HIV infection impact of drug education initiatives include among IDUs. These include: graphic representations of harm reduction • the provision of information programs messages targeting drug users. Much of this to inform IDUs of the risks education material is provided in a “user • the establishment of drug treatment friendly” style and language, with the substitution programs content being both credible and comprehensive • outreach education using peer and the information designed to suit both educators new recruits and those with a long history of • sterile needle/syringe /distribution drug injecting. It has been shown that a and disposal programs little education can go a long way in • over the counter sales of injecting reducing the harms associated with drug equipment injecting, including HIV infection. • counselling and testing for HIV It needs to be emphasised that HIV infection among IDUs can be transmitted not only by needles and • increasing access to primary health care syringes but also by the sharing of spoons, • removing the barriers to safer bottle tops, cotton wool and any materials injecting, including laws and police used to draw up and prepare the injection, practices all of which become contaminated and • targeting special groups and transmit infection. circumstances

The Centre for Harm Reduction

36 Contents > Section 1-Chapter 2 1SECTION The costs to the community in human Needle and Syringe Programs life, and the financial implications in not Chapter (NSPs) reducing the incidence of HIV infection Two among IDUs clearly indicate that NSPs have Rationale for The availability of, and encouragement to much validity. Conservative assumptions Harm use, sterile injecting equipment is a second indicate that the USA could have prevented Reduction crucial factor in harm reduction programs. an estimated 4,400 to 10,000 HIV A decline in risk behaviour among IDUs has infections among IDUs, at a cost to the occurred in many countries as a result of the health care system of $US240 million to HIV epidemic. Since the early 1980s, NSPs $US540 million if NSPs had been adopted have emerged as particularly important in in 1987 and expanded until 1995. preventing HIV infection among IDUs. Conclusions from a wide variety of sources A recent report from Australia has found have clearly indicated that NSPs are that between 1990 and 2000 nearly $150 effective, and cost effective, in the million (Australian) had been invested in prevention of HIV. In the US, a country that NSPs. This level of investment and return has great difficulty in accepting NSPs (only from NSPs over 10 years has resulted in: providing tenuous funding and generally •an estimated 25,000 cases of HIV only permitting their operations on a small being avoided scale), six major government reviews have • an estimated 21,000 cases of found that hepatitis C being avoided • an estimated saving of over 5,000 lives NSPs reduce HIV transmission without by 2010 serious unwanted side effects. •an investment of $150 million has resulted in an estimated return Exhaustive reviews of evidence have also of somewhere between $2.4 and concluded that 7.7 billion. NSPs do not increase drug use or recruit new IDUs. The establishment and expansion of NSPs have now occurred in various regions of the Other studies around the globe have also world and in over 40 countries including: confirmed that in cities with NSPs, there Western Europe, North America, Australia, has been, on average, a decrease in the New Zealand and in the developing world prevalence of HIV among IDUs, compared they are found in China, Nepal, India, to cities without NSPs where the prevalence Philippines, Thailand, Pakistan, Bangladesh, of HIV has continued to increase. The Vietnam, Russia, Kazakhstan, Brazil, effectiveness of these programs, which Argentina and Colombia. include the dissemination of information about the risks of HIV/AIDS, the reduction of the risks of sharing of injecting equipment by providing sterile needles and syringes, and assisting in the disposal of used injecting equipment, have reduced the transmission of HIV and other blood borne infections by and among drug injectors. The Centre for Harm Reduction

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world and moves them into the world of a Manual for Drug Treatment and Substitution socially acceptable clinic, where they can reducing drug Programs receive counselling and other medical and related harm social services. in Asia It is very important that any drug treatment The fundamental aim of substitution offered is both effective and attractive to programs is to retain the drug user in the drug users. Research has shown that drug program – the longer the drug user stays in treatment is most effective when it is the program, the more successful the program available to the drug user at the time when is at reducing adverse health and social he or she seeks it voluntarily. A consequences of drug use and achieving long comprehensive approach to HIV prevention term benefit. Methadone maintenance has among IDUs requires a flexible, accessible proven to be the most effective treatment in and caring drug treatment system. In many attracting and retaining heroin dependent countries, drug addictions are left under the patients, far more than any other non- care of the penal system or to rehabilitation pharmaceutical treatments. Currently there centres which are effectively prisons. These are dozens of countries that dispense oral systems aim for long term abstinence but methadone, including Nepal, Vietnam, and often prove ineffective; relapse rates are Thailand, indicating their willingness to consistently very high. Detoxification adopt and maintain this effective harm succeeds in removing people from the drug reduction approach. Alternative drug scene in the short term, but the impact of substitution programs, such as detoxification programs on long term drug buprenorphine, are currently being use is very small. investigated and trialled, to broaden the In most countries, the most common applicability of such approaches beyond those drug injected is heroin and the most who can benefit from methadone. effective treatment developed so far for Methadone maintenance therapy within a heroin addiction is drug substitution programs. harm reduction framework aims to reduce The most acknowledged and extensively the individual and social harm associated researched substitution program is methadone with illicit opiate use. maintenance. There is now overwhelming evidence that methadone maintenance is • safe •effectively improves health outcomes Peer Education Programs •reduces deaths •reduces crime Research has shown that education and • enhances social functioning behaviour change around safe injecting and HIV prevention among IDUs is most effective There is clear indication that those receiving and sustainable when it is delivered by peers – methadone maintenance therapy are at lower drug users themselves – in a supportive risk of HIV transmission as they inject less environment. Peer education of IDUs allows frequently and therefore decrease their contact with those who are not being seen at sharing of injecting equipment. Methadone treatment or law enforcement agencies. It maintenance does not ‘cure’ the addiction. delivers health education from a source more However, it removes IDUs from the various credible to the IDUs than are most agencies, adverse and criminal circumstances of their especially agencies identified with governments. The range of tasks undertaken The Centre for Harm Reduction

38 Contents > Section 1-Chapter 2 1SECTION by peer educators includes the provision of In many countries where needles and injecting equipment and supplies of bleach, syringes are for sale, they are seen by Chapter the collection of used injecting equipment, authorities to be cheap, and therefore there Two disseminating information about the is no need for programs for distribution of Rationale for disinfection principles of bleach and issues sterile equipment. However, this neglects Harm related to primary health care and counselling. the extreme poverty of many IDUs, and Reduction This wide range of services clearly their need for clean needles and syringes demonstrates that peer support and peer perhaps two or three times a day every day of education fits into the framework of harm the week. This cost mounts up very quickly, reduction. and drug users whose main priority is The development of organisations of IDUs purchasing the drug will use their very to provide peer education has proven to be an scarce money on drugs rather than needles effective strategy. These organisations can and syringes. provide program planners and policy makers Ensuring that each injection is performed with informed advice from the IDUs on with sterile needles and syringes is sufficient education and/or other interventions. The to break the chain of transmission and to importance of these groups is they can prevent the majority of HIV infections advocate on behalf of IDUs about both human among IDUs. rights and HIV prevention. It should to be recognised that such community development is not always possible in all communities. Primary Health Care

Gaining access to primary health care Sale and purchase of injecting services is often difficult or impossible for equipment IDUs because of their status of being involved in illegal activities and due to There are a number of countries that have backgrounds that are largely poor, both not accepted NSPs but have instead accepted socially and educationally. The often that sterile needles and syringes be readily widespread discrimination and abuse of IDUs available through pharmacies and other has frequently promoted their outlets. In Italy, during the early 1980s, marginalisation within the community. needles and syringes could be purchased from There are many adverse health problems that retail outlets cheaply but IDUs were not IDUs can suffer from including other encouraged to buy them and the result was infections associated with drug injection, an extensive spread of HIV infection among malnutrition and other ailments common to IDUs. It must be emphasised that simply their community. Accessible primary health having injecting equipment accessible at care services for IDUs can not only respond retail outlets, including pharmacies, and at a to their immediate multiple health cheap price does not thwart HIV infection problems, but can also address HIV among IDUs unless they are encouraged to prevention strategies and, in the long term, buy and use the sterile injecting equipment assist those who seek drug treatment. and are discouraged from sharing their injecting equipment.

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the possession of needles and syringes. Manual for Counselling and Testing This is one of the major reasons behind the reducing drug development of ‘shooting galleries’ in US related harm Counsellors should provide support for IDUs cities, which have contributed so markedly in Asia making a decision about having an HIV test to the rapid and continuing spread of HIV and in the follow up when providing the in those cities. This is a clear example of result of the test. The aim is to provide both how laws to control drug use, which do psychological support for those whose lives not work in controlling drug use, can have or may be affected by HIV/AIDS and unexpectedly promote the spread of HIV. to prevent HIV transmission to other Abolishing such laws removes a major people. Prevention messages achieve greater barrier to safer use for the motivated IDU. acceptance when they are presented as relevant to the IDU’s needs and lifestyle. While the counsellor provides the necessary Special Groups and information and comprehensive risk Circumstances reduction advice, any modification of lifestyle will still depend on the individual Special groups may be numerically smaller responsibility of the IDU. Confidentiality than mainstream groups, but they can, and informed consent are crucial to pre- and and often do, contribute disproportionately post-test counselling. Potential benefits of to the HIV epidemic. The more counselling for the IDU include reduction in disenfranchised or marginalised the IDU, risk behaviour, motivation to maintain or the less opportunity he or she will have to initiate safer drug related behaviour, earlier modify their behaviour relating to HIV risk. access to care and treatment/prevention for Prisoners that inject drugs are often at HIV related illness, emotional support and extreme risk of HIV transmission due to the improved ability to cope with HIV related rare availability of clean injecting equipment anxiety. and because of the mixing of social groups that may not otherwise meet. Ethnic minorities often feature IDUs and many are Removing the barriers to safer found to be involved in production or injecting trafficking of drugs and have poor access to health care and employment. Women It is important to examine the social, legal, IDUs, and particularly those involved in cultural and political context with a view to sex work, are often at increased risk of HIV removing the barriers which may exist and transmission largely due to their subordinate prevent safer injecting. These barriers status within society. Among all of these include lack of access to information, marginalised groups, it is important to primary health care and drug treatment. implement various special programs to Legal barriers such as criminalising the act prevent or reduce the risks of HIV of being in possession of injecting transmission. equipment to deter IDUs from injecting, can result in sharing common injecting equipment (and therefore HIV transmission); this occurs as individuals attempt to avoid criminal charges related to The Centre for Harm Reduction

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Conclusion References 1 Harm reduction provides an alternative Caplehorn J and Ross M. 1995. Methadone approach and framework to deal with the maintenance and the likelihood of risky Chapter problems IDUs face. Harm reduction has needle sharing. The International Journal of Two been adopted by an increasing number of Addiction. 30(6):685-598. Rationale for countries as it has proven to be pragmatic, Commonwealth Department of Health and Harm humane and an effective holistic public Ageing. 2002. Return on investment in Reduction health measure in controlling the epidemic needle and syringe programs in Australia. of HIV infection among IDUs. Canberra. Commonwealth of Australia [http://www.health.gov.au/pubhlth/public at/hac.htm] Crofts N and Herkt D. 1995. A history of peer-based drug user groups in Australia. The Journal of Drug Issues 25(3):599-616. Des Jarlais DC. 1995. Harm Reduction: A Framework for Incorporating Science into Drug Policy. American Journal Of Public Health. 85: 10-12 [http://www.lindesmith.org/library/ tlcdjarl.html] Des Jarlais DC and Friedman SR. 1993. AIDS, Injecting drug use and harm reduction. In Heather N, Wodak A, Nadelmann E and O’Hare P (ed) 1993. Psychoactive Drugs and Harm Reduction: From Faith to Science. London. Whurr Publishers. Drucker E. 1995. Harm Reduction: A Public Health Strategy. Current Issues in Public Health 1: 64-70. [http://www.lindesmith.org/library/tlcdru ck.html] Friedman S, De Jong W and Wodak A. Section One, Chapter Two: 1993. Community Development as a Rationale for Harm Reduction response to HIV among drug injectors. AIDS (Suppl 1):S263-S269. For further information refer to Keene J. 1994. High risk groups and prison WHO resources: Policy and policies. The International Journal of Drug Programming Guide for HIV Policy 5(3):142-146. Prevention Among Injecting Drug Lenton S, Single E. The definition of harm Users, Evidence for Action Papers, reduction. Drug Alcohol Rev 1998;17:213- Intervention Guides (NSP) & 220 Training Guides (Outreach). Refer Lurie P and Drucker E. 1997. An to the following website: opportunity lost: HIV infections www.who.int/hiv (publications associated with lack of a national needle- expected online from May 2003) exchange program in the USA. Lancet Vol 349, March 1: 604-608. The Centre for Harm Reduction

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Lurie P and Reingold A. 1993. The public Trautman F. 1995. Peer support as a method Manual for health impact of needle exchange programs in of risk reduction in injecting drug-user reducing drug the United States and abroad. Berkley, CA: communities: experiences in Dutch related harm School of Public Health. projects and the European Peer Support in Asia Mulleady G. 1992. Counselling drug users Project. Journal of Drug Issues. 25(3):617- about HIV and AIDS. Oxford. Blackwell 628. Scientific Publications. UNAIDS. 1997. UNAIDS policy on HIV Nadelmann E, Cohen P, Drucker E, Locher testing and counselling. Geneva. UNAIDS. U, Stimson G. et al. 1994. The harm Wodak A. 1996. Prevention works: effectiveness Reduction Approach to Drug Control: of prevention of HIV spread among injecting International Progress. drug users. Paper presented July 6, 1996 [http://www.paranoia.com/drugs/ Vancouver, Canada. Unpublished. war.on.drugs/debate/ harm- Wodak A. 1995. Needle exchange and reduction.html] bleach distribution programs: The Nadelmann E. 1998. Commonsense Drug Australian Experience. The International Policy. Foreign Affairs 77(1) January- Journal of Drug Policy 6(1):46-56. February. Wodak A. 1997. Needle Exchange: just do [http://www.lindesmith.org/library/foreig it! (Guest Editorial) AIDS Target na.html] Information 11(5). Normand J, Vlahov D and Moses L. 1995. Wodak A, Crofts N and Fisher R. HIV Preventing HIV transmission: the role of sterile infection among drug users in Asia: an needles and bleach. Washington D.C. evolving public health crisis. AIDS Care National Academy Press. 5: 313-320. Paone D, Des Jarlais DC, Gangloff R, Wodak A and Des Jarlais DC. 1993. Milliken J and Friedman SR. 1995. Strategies for the prevention of HIV Syringe Exchange: HIV prevention, key infection among and from injecting drug findings, and future directions. The users. Bulletin on Narcotics. 45(1):47-60. International Journal of the Addictions 30 Wodak A and Lurie P. 1996. A tale of two (12):1647-1683. countries: attempts to control HIV Power R, Jones S, Kearns G, Ward J and infection among injecting drug users in Perena J. 1995. Drug user networks, Australia and the United States. Journal of coping strategies and HIV prevention in Drug Issues. 27(1):117-134. the community. Journal of Drug Issues World Health Organization. 1990. 25(3):565-581. Guidelines for Counselling about HIV Riley D. 1993. The Policy and Practice of Infection and Disease. Geneva. World Harm Reduction. Unpublished paper. Health Organization. Canadian Centre on Substance Abuse, Policy and Research Unit and University of Toronto, Department of Behavioural Science. Stimson G. 1993. The global diffusion of injecting drug use: implications for human immunodeficiency virus infection. Bulletin on Narcotics. XLV (1):3-17.

The Centre for Harm Reduction

42 Contents 1SECTION Section One: Chapter Three Balancing and integrating the approaches of Supply Reduction, Demand Reduction and Harm Reduction

Supply reduction Cultivation Processing Transport Distribution Finance Demand reduction Education about drugs Treatment for drug abuse Community development Harm reduction Integration of the three approaches

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Supply Reduction

Throughout the world, international and The countries where cultivation of these Manual for national approaches to the control of drug crops takes place are often beset by reducing drug use traditionally have focused on law structural problems which make it difficult related harm enforcement to reduce supply; targeting or impossible to raise the issue of curbing in Asia both the production and trafficking of illicit crop cultivation to a high level on the drugs. Many attempts to prevent the supply political agenda. These countries are beset of illicit drugs are linked to several steps by political instability, often have extremely involved in the production and distribution high foreign debt against a background of of these drugs to their consumers. These poor economic growth, and the result is poor steps include cultivation, processing, infrastructure development. Some countries transport and distribution. The various are occupied with fighting rebellions or strategies which have been implemented secessionist movements and spend high require assessment as to: how effective they are proportions of their scarce resources on and what the consequences have been. It is also supporting large armed forces. A number of worth examining the economic aspects of governments lack the time, resources, skills the drug trade and the structural barriers to or consistent commitments to take up the interdiction and prevention methods. struggle against the cultivation of illicit crops, even when they acknowledge the problem as a priority. In some instances Cultivation there is involvement of the central government or its regulatory arms in the Cultivation of the crops from which many trade, either through control of the trade or illicit drugs are derived often takes place in through bribery and corruption. The settings where intervention is difficult, for political will to curb this cultivation is not many various and familiar reasons. The areas always present, or if it seems to be, it may of cultivation are often in regions that are not be strong enough to ensure that relatively inaccessible, such as the programs are carried through in the face of mountainous areas of Myanmar, Thailand resistance from corrupt authorities. and Laos for the opium poppy, or of Bolivia Crop substitution is another strategy to and Colombia for the coca tree. Some of decrease cultivation. Strategies to develop these areas are often either uncontrolled by sustainable cropping systems can be complex central governments, or are at least and multifaceted. They often require the politically unstable. For example: the Wa existence of good markets, the provision of people of north east Myanmar are in areas education and other social services, a better controlled by separatist movements or other road system and sometimes the securing of guerrilla groups, and who depend on the land use rights. There are current production and sale of the drugs to raise collaborations between authorities in money for their armies. Many of the Yunnan and Wa authorities in Myanmar to communities who cultivate illicit crops are replace opium crops with tobacco and the poor and of an ethnic minority within their Vietnamese have embarked on an ambitious own country. campaign of crop replacement, without much overall effect as yet. Crop substitution programs which are designed to persuade poor rural communities to grow legal crops often cannot compete with the profits from harvesting illicit crops. The Centre for Harm Reduction

44 Contents > Section 1-Chapter 3 1SECTION Potential opium production in the South-West and South-East Asia, 1994–2002 Metric tons Chapter Year 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 Three Balancing and Afghanistan 1,970 2,330 3,416 2,335 2,228 2,804 2,693 4,565 3,276 185 3,400 integrating Myanmar 1,660 1,791 1,583 1,664 1,760 1,676 1,303 895 1,087 1,097 828 the approaches of Supply Laos 127 169 120 128 140 147 124 124 167 134 112 Reduction, Thailand 14 17 3 2 548866N/A Demand Reduction Source: UNDCP Global Illicit Drug Trends 2002 N/A - not available and Harm Reduction Attempts have been and continue to be made to eradicate illicit drugs in some Processing countries. The military government in Myanmar has over the years attempted to destroy some areas of poppy cultivation, but The chemicals required for the processing of these attempts are generally too limited in opium into heroin are reasonably common duration and scope to have had a significant and are used in a variety of other industrial impact. However, opium cultivation levels processes. While attempts can be made to have been depressed in recent years largely interdict supply of these chemicals, this is because of unfavourable weather conditions difficult when their transport is occurring in during opium growing seasons, as well as the midst of much other trade, especially increased eradication efforts. Between 1996 industrial trade. For example, since the and 2000, potential opium production has mid-1980s when China and Vietnam been steadily declining, from 1,760 tons to adopted economic ‘open door’ policies there 1,087 tons. A recent study conducted in has been a marked increase in industrial 2001 estimated that opium production had trade with their neighbouring countries and been reduced to 828 tons. However, in 2000 a perceived increase in the surge of -2001 the ban on opium cultivation in trafficking in and use of illicit drugs. In Afghanistan resulted in Myanmar becoming several Asian countries, precursor chemicals the largest source of opium and heroin in the are not subject to international levels of world. It is important to add that while control due to inadequate legislative opium production in Myanmar has declined provision and limited administrative substantially the country is currently the infrastructure and resources. In the 1960s, primary source of amphetamine type the close of chemical production factories in substances in Asia producing an estimated the Philippines and the Mediterranean 800 million tablets per year. resulted in a shift of the production processes closer to the source of the raw materials. The use of technology has increased as has the sophistication of the producers of refined drugs. This has allowed a skillful mobilisation of factories, which have become highly transportable when detected and threatened with closure by law enforcement. The Centre for Harm Reduction

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A particular tactic, which is common to Manual for Transport drug traffickers, is using transhipment ports reducing drug which have not before been seen to be related harm In several settings worldwide it has been involved in drug trafficking routes. In the in Asia estimated, despite the effort put into early 1980s, when the supply of drugs from interrupting supply routes for drugs, such Thailand through Malaysia and Singapore to efforts are at best only 5-10 per cent Europe was becoming increasingly difficult, effective. This means, of all the drugs being the Thai traffickers began to make use of shipped into and out of any country on Thailand’s connections with Nigeria, in west earth, even with the best interdiction efforts, Africa. There were many students from 90 per cent get through to the consumers of Nigeria in south-east Asia, and much travel the drugs. This is a situation which is between the regions, as well as much travel worsening for drug control agencies between Nigeria and Europe. By shipping internationally, as free trade agreements the drugs first to Nigeria and then on to abolish many of the existing barriers to trade Europe, the traffickers opened up a new and and as the volume of international trade and unexpected route. Customs authorities in travel continues to expand dramatically. the end ports in Europe were not concerned Much of this trade is becoming about drugs coming in from Nigeria, which depersonalised, and it is much harder to is not a producing country, and were less detect the existence of shipments of drugs, vigilant than they would have been with especially heroin which is small in volume people coming from Asia. Rampant and does not smell much in containers from corruption within the Nigerian Government ships or planes. virtually assures Nigerian trafficking In 1996, the potential yield of opium in organisations a favoured place in the heroin the Yunnan Province of China was estimated trade. One result of this change in to be 16 metric tonnes. In the same year trafficking routes is that Nigeria now has Myanmar had a potential yield of opium developed a heroin dependent population, estimated to be 2,560 metric tonnes while and opium is beginning to be produced in Thailand’s potential yield of opium was Nigeria to meet the local need. estimated at 30 tonnes.

Seizure of heroin and raw and prepared opium (kilograms) in 1995–2000

1995 1996 1997 1998 1999 2000 Heroin Opium Heroin Opium Heroin Opium Heroin Opium Heroin Opium Heroin Opium

Iran 2,075 126,554 804 149,557 1986 162,413 2894 154,453 6,030 204,485 6,189 179,053

China 2,375 1,110 4,347 1,745 5,477 1,880 7,358 1,215 5,364 1,193 6,281 2,428

Myanmar 72 1,060 504 1,300 1,401 7,883 403 5,705 273 1,759 158 1,773

Thailand 517 927 597 381 323 1,150 507 1,631 405 421 385 1,591

Source: UNDCP Global Illicit Drug Trends 2002

The Centre for Harm Reduction

46 Contents > Section 1-Chapter 3 1SECTION Seizure of amphetamine type substance in kilograms (excluding ecstasy) in 1995–2001 Metric tons Chapter Year 1995 1996 1997 1998 1999 2000 2001 Three Balancing and China 1,303 1,599 1,334 1,608 1,659 20,900 4,890 integrating Myanmar N/A 531 455 1,441 2,599 2,408 2,877 the approaches of Supply Thailand 561 812 2,183 3,013 4,518 7,422 8,338 Reduction, Source: UNDCP Global Illicit Drug Trends 2002, UNDCP Bangkok 2002 N/A - not available Demand Reduction and Harm Distribution Finance Reduction The import price of drugs like heroin According to the United Nations reaching western countries for their markets International Drug Control Program, the is only five per cent of what the drug costs illicit drug trade generates as much as the consumer, because of middlemen and US$400 billion in trade annually – all of it accumulating profit. One of the major part of the ‘black economy’. It is one of the reasons for the profits generated at every step largest sectors of international trade, and is of the trafficking route is the need for money completely outside of government control. In to fuel corruption and to protect the supply terms of global industries, as part of the route. The drug industry requires a wide black economy, it is second in magnitude range of specialised personnel including only to the arms trade, and just ahead of the chemists, chemical engineers, pilots, prostitution industry. The three are often communication specialists, money launders, inextricably linked, with money from drugs accountants, lawyers, security guards and and prostitution financing arms deals. ‘hit men’. Because of this enormous profit The enormous profits available to major margin, removal of any one link in the chain drug traffickers are usually enough to corrupt of trafficking leads to immediate any authorities who stand in their way, replacement by another. This happens at any thereby protecting the supply routes. stage in the chain: for example, the current According to United Nations sources, in efforts of the Burmese government to close 2000 a kilogram of heroin in Pakistan cost down the production of opium by one Shan an average of US$2,720, and after transport producer is merely leading to a jockeying for to the United States was then sold for an position on the part of other major opium average of US$129,380. Similarly the UN producers in Myanmar. Similarly, the death reported that in the late 1990s a kilogram of of one cartel boss in Bolivia simply left the coca base in Colombia cost an average of field open for other major producers of US$950; it then retailed for US$25,000 in cocaine to take control of the trade. Further the United States. It is little wonder that down the trail, the removal of Colonel corruption associated with the illicit drug Noriega in the invasion of Panama resulted trade is universal. in a change in supply routes but no decrease The drug trade needs corruption in order in the amount of drugs entering the US to flourish and the powerful instrument for corrupting any society is money.The current enormous profit margins derived from the drug trade are without historical precedent. The Centre for Harm Reduction

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Expenditures on the US War on Drugs, Manual for 1988-2002 India: Manipur and Madras reducing drug related harm $20 billion in Asia The epidemics of drug use, drug injecting and HIV infection in the north-eastern states of India, Manipur in $15 billion particular, left the authorities with only one available response: to imprison drug injectors, as there were no treatment facilities available. In fact, many of the drug injectors in Manipur prisons were $10 billion referred there by their parents, who had despaired of their sons’ drug habits and had no alternatives for treatment. However, recidivism to drug use after $5 billion release from prison in Manipur is virtually 100 per cent. As a result of police crackdowns, many drug injectors moved to Madras and Bombay, carrying 0 their habits with them. Meanwhile, in Madras, another 1988 19921999 2002 situation was emerging. Drug users in Madras had had a fairly cheap and readily available supply of opium, with most of Against these resources, the US federal it coming from Sri Lanka where the budget committed US$19.2 billion to its Tamil separatists trafficked in the drug war on drugs in 2002, rising from 5 billion with their ethnic brethren on the in 1988. State and local governments will mainland to support their armed spend at least another US$20 billion. The struggle. To the end of the 1980s the vast majority of this expenditure goes into predominant method of administration attempts to prevent drugs entering the of opiates in Madras was smoking. With country and in detecting, arresting and the assassination of Rajiv Gandhi in incarcerating individuals involved in drug 1991, the border with Sri Lanka was trafficking and dealing. In 1980, closed, and the smuggling of opium approximately 50,000 people were became more difficult. As a result, heroin imprisoned in the US for violating a drug became the predominant drug, along law. By 2000 the figure was nearly 500,000 with pharmaceuticals such as injectable and the overall inmate population has Tidigesic (Buprenorphine): the price quadrupled to nearly 2 million and continues went up, purity became less, and the to rise. The expenditure involved in the addict population of Madras turned from war on drugs has had little impact on smoking their drugs to injecting them. diminishing the problems associated with This occurred at the same time as the drug use in the US. refugees from Manipur arrived in Madras which now has an explosive outbreak of HIV among its thousands of IDUs. The Centre for Harm Reduction

48 Contents > Section 1-Chapter 3 1SECTION It needs to be acknowledged there are Conclusions millions of people throughout the world Chapter who much prefer the experience of drugs Three over the experience of their daily lives and Balancing and The lessons of the changing routes of supply the result is that their demand will integrating in South America from Central America to stimulate the growth of further supplies. the approaches Brazil, and in Asia from the south coast of of Supply south-east Asia to north-east India and south • Closing one supply route merely leads to Reduction, China, are universal. the opening up of others Demand •Removing one supplier leads to the Reduction Without a decrease in demand and with appearance of others and Harm drug trafficking remaining profitable, the • Large-scale trafficking cannot exist Reduction closing of one supply route merely leads to without large scale corruption the opening up of others. • Public health prevents drug use, rehabilitates drug users and prevents HIV Drug smuggling and trafficking has infection become very profitable, offering new • Supply restriction only works when economic advantages to many people. Drug demand restrictions is working trafficking on any scale produces large-scale profits for those involved and this has two Public Security efforts are best directed effects: against major criminals, traffickers and •a need to protect the trade from the corrupt officials, and not against minor attentions of narcotics authorities criminals such as drug users themselves. • sufficient profit to do so, by bribing and corrupting these authorities A snake is not killed by cutting off the tail, but by cutting off the head. Large-scale trafficking cannot exist without large-scale corruption. Public Health efforts are best directed Increased profits means an increased towards the drug users themselves, to ability to bribe. To protect the drug traders’ rehabilitate them and to prevent them from investment, there is an incentive for the becoming infected with HIV and other drug trafficker to increase the volume of the diseases, and towards the general drug traded. Therefore, we must consider community for health education. The that: consequences of attempting to cut off the • on the one hand, efforts to stem the flow supply of drugs is demonstrated in the case of drugs will fail if there are not also of India: measures taken to tackle corruption in society • on the other, corruption is often a worse social evil and more destructive to a society than the drug use is itself.

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Demand Reduction

It is only when the demand for drugs is low, Manual for detection is easy and substitutes are not Education about drugs reducing drug readily available, that restricting the supply related harm of drugs will help reduce drug problems. Educational programs about drug use and its in Asia This suggests that reducing the supply of dangers are generally targeted at three levels: drugs will only become a successful strategy, the general community, youth (through for the decrease of the harm associated with school based programs), and drug users drug use, when effective demand reduction themselves. strategies have been implemented. In 1987, Mass education campaigns can be the International Conference on Drug Abuse effective in providing a background and Illicit Trafficking in Vienna (attended understanding among the general by 138 nations with representatives of community about drugs and their effects, Government and Non Government about the threat of HIV epidemics and delegates under a United Nations mandate) about the need for harm reduction called for a balanced approach in dealing approaches. However, experience has shown with the demand and supply of illicit drugs. that they have only a minimal effect in Demand reduction, it was announced, would decreasing the amount of drug use. If they be given the same importance in policy and consist solely of messages aimed at making priority in resource allocation, as supply drug users appear as the enemies of society, reduction. then their net effect is often simply to drive Many strategies have been tried for the drug users underground. This makes reducing the demand for drugs in various their activities more hidden but does not countries. They are generally built on an decrease the numbers of people either imperfect understanding of why people use beginning or continuing to use drugs. different drugs, in different circumstances Mass media campaigns, often based on a and at different times. Drug use is a very slogan and a few facts, can have a limited complex phenomenon, and we must be impact due to their inability to tackle pragmatic in our choice of strategies. These complex problems. strategies have included education of young people and others about the dangers of drug use, the provision of alternatives to drug use Many educational campaigns are to prevent young people beginning to use ineffective because they are unrealistic, and drugs, and treatment for drug users to do not recognise the reality of the situation decrease their consumption of drugs. in which potential and actual drug users Education also includes direct education of live. For instance, if social structures such as drug users, most importantly in the ways to the family or the village are weak and if prevent HIV infection. there is high unemployment, then the drug user’s major social ties may be with his peer group, all of whom may be drug users themselves. In this situation, information about the dangers of drug use will appear to the drug user as an attack on his major social bonds, and will simply have the effect of discrediting the authority from which the messages come. Drug users put themselves outside of society by their drug use, by The Centre for Harm Reduction

50 Contents > Section 1-Chapter 3 1SECTION engaging in an activity which in most its effects on the body and the mind, social countries is illegal. Education campaigns relationships and the community, and Chapter which stress the evil they do to themselves exposure to healthy behaviour which is Three and their society merely have the result of incompatible with drug abuse should be Balancing and putting them further outside society, when available from pre-school through tertiary integrating the intention is to bring them back into and post-graduate education. Such education the approaches society once again as useful members by about drug use and its effects should be seen of Supply helping them to stop using drugs. as one part of a comprehensive approach to Reduction, A more fruitful approach for mass demand reduction. But it should be realistic, Demand education is one of education about drug integrated into life education in the school Reduction addiction as an illness, requiring supportive and in the home, and should not be relied and Harm care. With a supportive community, which upon by itself to achieve anything more than Reduction does not condone drug use but has sympathy long term and background impact. for its victims, the chances of successful However, it must be recognised that the treatment are greatly enhanced. This roots of drug use for most people are not approach makes a clear distinction between associated solely, or often even at all, with the dealers and traffickers of drugs, whose mere ignorance. The reasons why people only motive is profit, and the drug users begin and continue drug use are complex themselves (including those drug users who and multiple, and often to do with social traffic in small amounts of drug to raise the and economic development. Problematic money to pay for their own drug needs). drug use is associated with economic and School based education, similarly, does social poverty in most societies, though of not have a good record around the world. course there are exceptions. In these cases, Education about the dangers of drug use by education by itself is not the answer. For one itself is not effective in preventing initiation thing many people do not have access to into drug use. In fact, the opposite has been education and for another, the alternatives to the case with some education campaigns, drug use, such as meaningful employment or which have led to an increase in strong social structures may not exist or may experimentation with drugs among the be weak. target populations. This is particularly the A young person who is alienated from case where drug education has been mainstream social structures, including conducted by outside specialists, including family and meaningful employment, is not police, who have come into the classroom likely to be touched by information about especially to give lectures on drugs. The the future long term effect of drugs on his effect of this type of approach is to health. This will especially be the case if it is sensationalise drug use, and to make through his drug use with his peer group experimentation more attractive. that he presently gains social meaning in his Good school based education should be life. Like most young people, he is concerned integrated into the whole curriculum, with what is happening now or over the next provided by the children’s normal teachers few weeks, not with what will happen in ten who can provide role models for the children years’ time. to emulate. Proper education about drugs should now include education about HIV and other diseases associated with injecting drug use. Information about drug use (including alcohol and smoking), including The Centre for Harm Reduction

51 51 Contents > Section 1-Chapter 3

detoxification may be counter to the goals of Manual for Treatment for drug dependence eventual abstinence. Where it is appropriate, reducing drug detoxification at all times should be related harm Treatment for problematic drug use, carried out under medical supervision. in Asia particularly addiction, requires more than Detoxification, for perhaps the majority simple detoxification. Injecting of heroin of people, does not need to be carried out in especially is a very difficult condition to an institution; much can be done in the satisfactorily treat. The heroin addict, in community and in the home, where it is most cultures, remains addicted to his vastly less expensive. Various forms of longer opiates for between ten and twenty years, term treatment, such as therapeutic with or without treatment interventions. The communities, have been extensively used first principle to understand is that not all in different parts of the world. But the drug users are alike in their drug needs or experience with such treatment approaches habits, and that many drug users go through is that they are expensive, slow, protracted different stages of their drug use at different and may need constant repetition. They do times of their lives. Many people around the not provide a quick or efficient answer to world smoke opium or heroin, or inject the problems of drug addiction. heroin, without necessarily being addicted It is the common experience of all to it. For most people who use these drugs, treatment approaches that they have long there is a period of time when they are using term success with only a small proportion of the drugs without being addicted: it is only patients on any one occasion: recidivism with regular use over a period of time that rates are very high. It is to be expected that addiction appears. This period may vary treatment for any one addict might be from a few weeks to many years. Therefore, required two, three or multiple times. For treatment approaches should also vary. We those who chronically relapse, who return for need to know much more about who the treatment several or many times, it is worth drug users are, how they use their drugs, considering a drug substitution program. In what their social circumstances are, and many countries, including some countries in what alternatives can be realistically offered Asia, the most common drug substitution in their social setting. program is methadone maintenance. This is different from the use of methadone for A comprehensive understanding of the detoxification; it involves maintaining the drug users must be made in order for the person’s addiction but with a legal drug treatment approach to be beneficial and provided in a socially sanctioned valid. environment. As well as decreasing the person’s use of illegal drugs and stopping It is important to have methods for early injecting (and therefore the risk of HIV identification of drug users, through transmission), this has the effect of bringing unobtrusive monitoring in community the person back into formal contact with the settings. The more that drug addiction can socially legitimate world. be portrayed as an illness, and drug addicts see treatment services as confidential and caring, the more likely they are to seek treatment of their own accord. Not all people who use psychoactive drugs require detoxification. In some instances, The Centre for Harm Reduction

52 Contents > Section 1-Chapter 3 1SECTION world, such programs will fail. These Treatment for drug problems transition programs may include support Chapter through the family and community, Three • REDUCE RISK OF HIV INFECTION employment and support at the workplace, Balancing and WITH METHADONE MAINTENANCE or continued attendance at an outpatient integrating TREATMENT rehabilitation centre for counselling, support the approaches and ongoing treatment. •LONGER DURATION AND HIGHER of Supply DOSE – LOWER HIV Reduction, Demand •METHADONE LOWERS RISK Community development Reduction THROUGH REDUCED INJECTING NOT and Harm REDUCED SHARING Many of the root causes of drug use are in Reduction the social setting that young people, • CLOSE LINK BETWEEN METHADONE particularly, find themselves. The strongest DOSE AND FREQUENCY OF defence against drug use is strong INJECTING integration into meaningful social •A PRIORITY FOR HIV INFECTED IDUS structures. These include the family, the IN THE EARLY PHASE OF AN HIV school system, the community and the EPIDEMIC workplace. If the antecedent causes of drug use are examined in any society, it will Many studies have shown that bringing always be found to be disproportionately patients into methadone maintenance common among those who are alienated, feel programs raises possibilities for involving powerless and have less economic them in other treatment programs, which opportunity in their lives. None of these over the longer term are effective at helping situations can be overcome rapidly, and it them stop drug use entirely. Methadone has to be recognised that strategies to maintenance will be covered more overcome them may in the short term make extensively in Section Two, Chapter Six: things worse. For instance, in an Drug Use and Substitution, but here it will economically underdeveloped community simply be stated that drug substitution, as where there is much poverty, this poverty part of an integrated treatment program, is may be associated with drug abuse. A first the approach which shows the most promise, effect of development strategies aimed at at the present, for long term treatment of raising the economic level of this heroin addiction. community might be to make more money A most important point in all available to people in the community. At rehabilitation approaches is that this point, some of this increased income rehabilitation does not finish with the end of might be spent on drug use, and the actual treatment. If a drug user spends time in a consumption of drugs might increase as a rehabilitation centre, and is off his drugs result of economic development. Economic when he is discharged, but he is discharged development creates social pressures which back into exactly the same environment in must be accounted for – economic which he first began using drugs, the development without social development likelihood is that he will begin using drugs can lead to many untoward effects. again. Without programs to ensure the transition from the drug-free environment of the rehabilitation centre back to the outside The Centre for Harm Reduction

53 Contents > Section 1-Chapter 3

Harm reduction emphasises the need to Manual for Conclusion base drug policy on research rather than reducing drug on stereotypes of both legal and illegal related harm drug users. in Asia Efforts to reduce the demand for drugs are slow, long term and incremental in their effects. Many are expensive, ineffective and Harm reduction accepts the reality that very inefficient because they are unrealistic illicit drugs will not be eradicated in the in their aims, not properly targeted, and foreseeable future: therefore the accessibility stem from a philosophical position rather of illicit drugs and the social conditions than a recognition of the world as it actually creating demand for them will result in their is. Prevention and treatment of drug abuse continued use. Drug policies must be are worthy goals, and comprehensive pragmatic and must not be based on a strategies for both are necessary parts of utopian belief that there will always be safe programs to prevent the spread of HIV drug use among drug users. It is important among IDUs. But by themselves, they are that the drug user be integrated into the not enough. community, not marginalised, so that their health can be monitored and protected and therefore reduce the risk of HIV transmission. While a wide variety of Harm reduction interventions are required, to protect the drug user from individual and social harm, it is not always necessary to reduce drug use Medicine’s Hippocratic oath – “first do no to reduce the harms. The basic components, harm” – should be adopted as a first measures and rationale of harm reduction principle of drug control policy. have been described in detail in Section One: Chapter Two.

Since the mid 1980s and the arrival of HIV/AIDS among IDUs throughout the Integration of the Three world, harm reduction strategies have Approaches become prominent. The strategies of supply and demand reduction are primarily focused Attempts to restrict illicit drug supplies on mid to long term goals which do not have been costly, produced substantial address the rapid transmission of HIV unintended negative consequences, and infection; HIV prevalence among IDUs in rarely have produced significant and many parts of Asia have climbed from zero sustained reductions in drug-related to 50 per cent in just a few months. problems. Only when demand for drugs is Harm reduction policies are increasingly low, detection is difficult to evade and being adopted, or adapted, according to the substitutes are not readily available, can needs of different countries or communities. restricting supply help reduce drug The relatively new approach of harm problems. This suggests that reducing the reduction is consistent with present supply of drugs will only become a scientific knowledge and, within its framework, it has incorporated the current scientific findings. The Centre for Harm Reduction

54 Contents > Section 1-Chapter 3 1SECTION successful strategy for the decrease of the Independent of each other, the three harm associated with drug use when different approaches of supply, demand and Chapter effective demand reduction strategies have harm reduction cannot be regarded as Three been implemented. singularly effective. However, together they Balancing and HIV prevention strategies among IDUs can complement each other – resulting in a integrating are developed and implemented in the favourable environment in which it is the approaches context of both efforts to decrease drug use, possible to contain the problem of illicit of Supply including law enforcement, education and drug misuse and address the public health Reduction, drug treatment on the one hand and, catastrophe of HIV/AIDS among IDUs. Demand meeting other needs of IDUs, such as Reduction primary health and human rights on the and Harm other. Effective drug education both in and Reduction out of school can, with the appropriate approach, decrease experimentation with drugs. But, at the same time, it can ensure that those who do experiment have the knowledge necessary to prevent many of the harms associated with the drug, especially HIV exposure. Law enforcement can continue to effectively target major suppliers of drugs while participating in a public health approach to the users of the drugs. For an individual, drugs may be causing personal and health problems, and the individual therefore requires a personal health approach. For a society, imprisoning drug users, simply for the use of the drug, in no way diminishes demand for the drug. It potentially causes major harm to the individual, who is exposed to more harm in prisons (including a higher risk of HIV Section One, Chapter Three: infection) while usually not receiving Balancing and integrating the treatment for his or her drug or other approaches of Supply Reduction, personal problems. Recognising these factors Demand Reduction and Harm can provide police forces with very Reduction important roles in the prevention of HIV transmission. In some countries, police For further information refer to actively participate in harm reduction, by WHO resources: Policy and referring drug users for treatment rather Programming Guide for HIV than arresting them, and even providing Prevention Among Injecting Drug them with clean needles and syringes. Users & Evidence for Action Papers. Refer to following website: www.who.int/hiv (publications expected online from May 2003)

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References

Bureau for International Narcotics and Law Liang AD. 1992. The Golden Triangle: Manual for Enforcement Affairs, US Department of Burma, Laos and Thailand. In Mc Donald reducing drug State, Washington D.C. International BS and Zagaris B (ed). 1992. International related harm Narcotics Control Strategy Report, Asia Handbook on Drug Control. Westport, in Asia 1996. Connecticut: Greenwood Press. [http://www.state.gov/www/global/ Mc Coy WA. 1991. The Politics for Heroin: narcotics_law/1996_narc_report/ CIA complicity in the global drug trade. New index.html] York: Lawrence Hill Books. Chi’en J. 1997. The Three Reduction Nadelmann E. 1998. Commonsense Drug Approach: A Balanced Strategy for Policy. Foreign Affairs. 77(1) Reducing Illicit Drugs, Supply, Demand January-February. and Harms. Spotlight, The Hong Kong [http://www.lindesmith.org/library/ Council of Social Services. Vol 27, August foreigna.html] 1997. Nadelmann E. 1989. Drug Prohibition in De Haes WFM. 1987. Looking for effective the United States: Costs, Consequences, drug education programs: Fifteen years and Alternatives. Science. September exploration of the effects of different drug 1989:939-947. education programs. In Coomber R (ed). [http://www.lindesmith.org/library/ 1994. Drugs and Drug Use in Society. science/science.html] Dartford: Greenwich University Press. Nadelmann E and Mc Neely J. 1996. Doing Des Jarlais DC. 1995. Harm Reduction: A Methadone Right. Public Interest. Framework for incorporating Science into 123:83-93. Drug Policy. American Journal Of Public [http://www.lindesmith.org/library/ Health. 85:10-12. tlcen-jm.html] [http://www.lindesmith.org/library/ Narcotics Control Strategy Report. 2001. tlcdjarl.html] Myanmar Released by the Bureau for Drucker E. 1995. Harm Reduction: A International Narcotics and Law Public Health Strategy. Current Issues in Enforcement Affairs, US Department of Public Health. 1: 64-70. State Washington, D.C. [http://www.lindesmith.org/library/ Rana S. 1996. Harm Reduction in Asia. Paper tlcdruck.html] presented at the 7th International Ennet TS, Tobler SN. Ringwalt LC and Conference on the Reduction of Drug Flewelling R. 1994. How effective is drug Related Harm, Hobart, Australia, March abuse resistance education? A 6th, 1996. meta-analysis of project DARE outcome Regional Drug Control Profile for Southeast evaluations. American Journal of Public Asia and the Pacific. UNDCP Regional Health. 84(9):1394-1401. Heather N, Centre for East Asia and Pacific. Bangkok. Wodak A, Nadelmann E and O’Hare P Thailand. (ed).1993. Psychoactive Drugs and Harm Rosenbaum M. 1996. Policy Statement; Kids, Reduction: From Faith to Science. Drugs and Drug Education: A Harm London:Whurr Publishers. Reduction Approach. San Francisco: Kumar MS, Mudaliar S and Daniels D. National Council on Crime and 1997. Research Monograph on Drug Abuse Delinquency. and HIV/AIDS. Chennai (Madras): Sahai Trust, Chennai, India.

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56 Contents > Section 1-Chapter 3 1SECTION Segar A. 1996. Drugs and Development in Wodak A and Des Jarlais DC. 1993. Southeast Asia: A Background and Discussion Strategies for the prevention of HIV Chapter Paper. Unpublished paper. Project Drugs infection among and from injecting drug Three and Development in Asia, GTZ, users. Bulletin on Narcotics XLV (1): 47-60. Balancing and Germany. Wodak A and Owens R.1996. Drug integrating Shadow Conventions 2000: Fact Sheet Prohibition: A Call For Change. Sydney: the approaches Compiled by Drug Policy Alliance. 2000. University of New South Wales. of Supply [http://www.lindesmith.org/events/archive Wodak A, Seivewright N, Wells B, Reuter Reduction, /conferences/shadow/factsheet/index.cfm] P, Des Jarlais DC. et al. 1994. Comments Demand Singh M and Peak A. 1997. Increasing trends on Ball and van de Wijngaart’s Article Reduction towards the reduction of drug related harm AA Dutch Addict’s View of Methadone and Harm throughout Asia. Paper presented at the Maintenance: An American and Dutch Reduction 8th International Conference in the Appraisal. Addiction. 89:803-814. Reduction of Drug Related harm, Paris, France, March 23-27. 1997. Smith ML, Thongtham CN, Sadeque N, Bravo AM, Rumrrill R. et al. 1992. Why People Grow Drugs. London: Panos Publication Ltd. Stimson G. 1985. Can a War on Drugs Succeed? In Coomber R. (ed). 1994. Drugs and Drug Use in Society. Dartford: Greenwich University Press. Regional Drug Control Profile for Southeast Asia and the Pacific. UNDCP Regional Centre for East Asia and Pacific. Bangkok. Thailand. United Nations International Drug Control Programme. 1997. World Drug Report. New York: Oxford University Press. United Nations International Drug Control Programme. 1997. Drug Control Briefs. United Nations Drug Control Program Regional Centre for East Asia, July 1997. United Nations Drug Control Programme. 1995. Ky Son Alternative Socio-Economic Development Project, Vietnam. Hanoi: United Nations Drug Control Programme. United Nations Office for Drug Control and Crime Prevention. 2000. Global Illicit Drug Trends. New York, UNDCP.

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57 Contents

Briefing papers

1. Injecting drug use and AIDS: An explosive combination Briefing 2. Mapping drug use in Asia in the context of HIV/AIDS Papers 3. A Review of amphetamine type substances 4. Care and support of injecting drug users with HIV and AIDS

The first paper provides a summary of the global situation of HIV among injecting drug users (IDUs), the rationale for harm reduction approaches, and evidence about the effectiveness of these approaches. The second paper focuses on Asia and describes the illicit drug problem, its links to adverse health consequences (particularly the enormity of the HIV/AIDS problem), current inappropriate responses, and the lack of effective programs for HIV prevention among Asian IDUs. The third paper is devoted specifically to amphetamine type substances as they are of great concern in Asia due to substantial and increasing production and widespread use. The last paper deals with care and support of IDUs with HIV/AIDS, and HIV/AIDS-related stigma and discrimination.

These papers are intended to be used as Briefing Papers for distribution to key people as part of advocacy for the development of harm reduction approaches towards prevention of HIV among IDUs. They also provide an overview of the drug use and HIV/AIDS situation in Asia – for politicians and other policy makers, for key bureaucrats in public health and public security, for police, for journalists, for public health practitioners, and so on. They may be photocopied for distribution as self-contained documents.

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BRIEFING PAPER ONE Injecting drug use and AIDS: An explosive combination Briefing HIV infection can spread very rapidly among injecting drug users, Paper then to their sex partners and children; but is easily controlled by One appropriate interventions.

The injection of illicit drugs has been reported in over 130 countries, and in 114 of these HIV is epidemic among injecting drug users (IDUs). HIV can spread rapidly through IDU populations, and as IDUs often engage in other risk behaviours for HIV, such as sex work or paid blood donation, they are a vector for further sexual and vertical transmission (parent to child). It is vital to include effective measures to prevent HIV transmission among IDUs in any comprehensive HIV/AIDS strategy. IDUs are a hidden and stigmatised group because their behaviour is illegal, thus specialised approaches are required. HIV prevention strategies based on the principles of harm reduction are the only effective approaches and this has been demonstrated worldwide.

BACKGROUND The phenomenon of illicit drug injecting is transmit large quantities of blood. Reasons widespread, involving perhaps 15 million for sharing injecting equipment are many, people in over 130 countries. Directly or but include scarcity or cost of needles and indirectly, injecting drug use affects everyone syringes, cultural practices, and legal or in a community in which it occurs. policing barriers to availability or use. Worldwide, the commonest injected drugs Nevertheless, simply increasing the are heroin, amphetamines and cocaine, availability and accessibility of sterile though many other drugs are also injected, injecting equipment in order to reduce including tranquillisers and other sharing, though this is fundamentally pharmaceuticals. Which drugs are injected in important in reducing the risks of HIV a particular location depends on availability transmission among IDUs, may not be and cost (often reliant on geographic sufficient to control HIV spread. Injecting proximity to production areas or trafficking drug use is embedded in a socio-cultural routes), personality traits and peer group context of which illegality is a defining norms, among other factors. feature. Because IDUs participate in illegal activities, such as property crime to raise the The drug being injected influences to some money to purchase drugs, they are generally degree the behaviours associated with stigmatised, discriminated against or injecting, but, whatever the drug, if the excluded from access to health services, and equipment used to prepare and inject the subject to human rights violations. drug is shared between users without adequate sterilisation, potential for HIV transmission exists. Shared needles and syringes are a particular risk, as they can

The Centre for Harm Reduction

B1.1 Contents > Section 1-Briefing papers

AT A GLANCE

➤ Given the wrong conditions, spread of Manual for Injecting drug use and HIV among IDUs can be explosive, with reducing drug HIV infection: up to 90% of all IDUs in a community related harm infected in the space of a few months. ➤ Illicit drugs are injected in many parts of in Asia This has happened in places as separated the world geographically and culturally as New ➤ HIV spreads among groups of IDUs York, Milan, Edinburgh, Bangkok, mainly because of the reuse or sharing of Santos, Odessa, Ho Chi Minh City, needles and syringes which have become Yunnan Province in China, and Manipur contaminated with infected blood State in India ➤ It is not drug use or injecting drugs per se ➤ Aspects of enforcement of prohibition of which spreads HIV, but unsterile illicit drugs promote conditions for practices – in particular the sharing of transmission of HIV among IDUs needles and syringes ➤ HIV usually spreads from IDUs to their ➤ Reasons for sharing include poverty, lack sexual partners and children of availability of or access to needles and ➤ If IDUs are clients of sex workers or are syringes, cultural factors and ignorance sex workers themselves, HIV spreads more rapidly to the rest of the community.

Figure 1. Rapid increases in HIV prevalence among IDUs, 1978–1998

90

80

70 Ruili Manipur 60 Nikolayev New York Kathmandu 50 Chiang Rai

40

% HIV prevalence Bangkok 30

20 Edinburgh

10 Ho Chi Odessa Minh

0 | | | | | | | | | | | | | | | | | | | | | | ’77 ’78 ’79 ’80 ’81 ’82 ’83 ’84 ’85 ’86 ’87 ’88 ’89 ’90 ’91 ’92 ’93 ’94 ’95 ’96 ’97 ’98 (Ref: Rhodes T et al 1999)

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B1.2 Contents > Section 1-Briefing papers

THE CHALLENGE

Currently all prevention of HIV transmission The scale of HIV spread among IDUs occurs in a context of Briefing among IDUs, their sexual attempting to reduce the use of illicit drugs Paper partners and their children by reducing their supply or decreasing the One depends on: demand for them. Strategies to achieve these objectives often conflict, and a balance must ➤ The drugs injected and frequency of be achieved in the relative emphasis placed injecting on demand reduction, supply reduction and ➤ The social organisation of drug injecting, HIV prevention so as to minimise the harms especially the existence of ‘shooting associated with injecting drug use. Because galleries’ or professional injectors ( of the potential rapidity of the spread of HIV persons skilled to inject others) among IDUs, it is vital that effective ➤ IDUs’ awareness of HIV, hepatitis viruses preventive responses be implemented early in and other infections which can be an epidemic in ways that allows these associated with unsterile injecting responses to coexist with demand and supply ➤ The availability of sterile injecting reduction initiatives. equipment or of the means to sterilise equipment ➤ The availability and accessibility of drug Eliminating sharing of treatment programs needles and syringes ➤ The availability and accessibility of welfare and primary health programs The basic challenge in reducing the spread of for IDUs. HIV among IDUs is to decrease or eliminate the sharing of injecting equipment, and with it the risk of HIV transmission. IDUs share and/or reuse injecting equipment for many reasons, and these must be determined for each locality. Where sharing involves frequent use of the same needle and syringe by multiple IDUs, HIV can spread explosively (see Figure 1). This phenomenon has been documented in environments where there are ‘shooting galleries’ and professional injectors, and in numerous prisons around the world.

A common perception standing in the way of increasing availability of sterile injecting equipment is the fear that these programs will increase drug use and the number of drug users; many studies have demonstrated that this is not the case.

The Centre for Harm Reduction

B1.3 Contents > Section 1-Briefing papers

Reaching the optimum balance between Manual for Integrating and balancing efforts to decrease drug use and to prevent reducing drug harm reduction with drug HIV transmission among IDUs can be related harm control and AIDS programs difficult. Recognition that HIV can in Asia spread faster than strategies can reduce the Most societies have programs in place to at-risk population, however, means the decrease demand for and supply of illicit implementation of HIV prevention programs drugs, in the context of which HIV must take priority. The challenge, therefore, prevention efforts must be implemented. is twofold: firstly, to ensure that HIV Strategies to decrease the demand for drugs prevention is adequately considered in include education, drug treatment and national drug strategies (demand and supply rehabilitation, and a community control); secondly, that injecting drug use is development approach where drug users are adequately considered in national AIDS integrated into meaningful social structures. programs. In general, even the most effective drug use prevention strategies decrease uptake of drug use by small proportions, over relatively long Introducing harm reduction periods, and often do not reach those most at before HIV enters risk of drug use; some well-meaning programs have even been shown to lead to Preventing spread of HIV among IDUs is increased drug use. Treatment options for much easier when prevalence is low or zero drug use are frequently limited in scope, than when the virus has become established; availability and effectiveness, and are however, the measures needed are often inappropriate or unavailable for the majority politically unpalatable, and ironically it is of IDUs most of the time. often the case that appropriate measures are not considered until after HIV has began to spread and the required response has grown Similarly, attempts to reduce supply of drugs larger and more costly. Stimulating political for which there is a persistent demand are action before HIV prevalence among IDUs typically of limited effectiveness and often of has risen significantly, and while there is very poor cost-effectiveness. Worse still, they little perception of this as a public health often divert scarce resources away from drug problem, is difficult but crucially important. treatment and HIV prevention programs. Moreover, harsh application of supply control The common scenario of concern being raised strategies, such as restriction of availability of only after HIV has begun to spread widely syringes or imprisonment of drug users, often among IDUs means that responses must be creates favourable conditions for spread of framed in a context of providing care for HIV. many people with HIV infection and disease, thereby diminishing the availability of resources for prevention and the community’s capacity for response. Very little work has

The Centre for Harm Reduction

B1.4 Contents > Section 1-Briefing papers

been conducted on developing and evaluating HIV prevention measures in areas Care for HIV-infected IDUs Briefing where prevalence of HIV among IDUs is Paper As the number of IDUs with HIV infection already high. This is partly due to the One perception that the problem is intractable and AIDS is continually growing, and as and therefore resources expended on it will many of these people are social outcasts even be wasted. That this is not the case has been prior to their HIV infection, providing for demonstrated in some locations in the West their medical and social needs is a major (Edinburgh, New York City), but there is an challenge. IDUs are disadvantaged in terms urgent need for further demonstration of access to primary healthcare because of projects working in high prevalence areas. their drug use and its associations, such as poverty or ethnicity. Drug treatment is available to a tiny percentage of the world’s HIV prevention in high IDUs, and effective with only a percentage of prevalence populations those. Specific care for HIV-infected IDUs, tailored to their particular needs and HIV prevention programs are working provided in a non-judgmental, caring and successfully among IDUs in many parts of accessible environment, is virtually non- the world, but in most countries they remain existent globally. Creating a healthy small efforts meeting the needs of very few environment for IDUs, especially those IDUs compared with the numbers needing infected with HIV, involves confronting help. In developing-world situations, issues of human rights and discrimination, programs are often operating in isolated and often within medical or other agencies sometimes hostile environments, making charged with providing the care. Educating their task doubly difficult. As well as the service providers is a major priority in this need to see such programs expanded to process, but legal reform is also vitally national levels, supported by national AIDS important. and drug policies, it is important to strengthen their ability to operate through peer support and networking. Through sharing of expertise and experience, networking can foster development of HIV prevention programs in regions where a response is lacking or in its infancy.

The Centre for Harm Reduction

B1.5 Contents > Section 1-Briefing papers

A BALANCED APPROACH FOR A DUAL EPIDEMIC

The most effective response to the spread of For an individual, drugs may be causing Manual for HIV among IDUs is harm reduction - the personal and health problems, and the reducing drug primary aim of which is to reduce the harm individual therefore requires a personal related harm associated with the injecting of drugs, health approach. For a society, imprisoning in Asia especially the transmission of HIV and other drug users simply for using drugs in no way blood borne viruses, without necessarily diminishes demand for drugs, and diminishing the amount of drug use. This potentially causes major harm to the approach is entirely compatible with sensible individual, who is exposed to more harm in demand and supply reduction approaches, prisons (including higher risk of HIV and sees drug use primarily as a public health infection) while usually not receiving issue rather than a law and order issue. The treatment for his or her drug or other harm reduction philosophy acknowledges the personal problems. Recognising these factors humanity and worth of IDUs, and advocates can provide police forces with very important partnerships with IDUs and their roles in prevention of HIV transmission. In communities to protect their common some countries, (e.g. Australia, United health. Kingdom, Netherlands, Switzerland, Germany and in some parts of India) police Conflict between efforts to decrease drug use actively participate in harm reduction by in a community and prevent HIV among referring drug users to treatment rather than drug users is avoidable. Law enforcement can arresting them. continue to effectively target major suppliers of drugs while participating in a public Epidemics of HIV among IDUs have been health approach to the users of the drugs. prevented, even where there is no decrease in drug use or injecting. Countries which have “Prevention of HIV infection among injecting been most successful in this are countries drug users is a higher public health priority which have adopted the public health than is prevention of drug use.” approach known as harm reduction.

– Scottish Home Office

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EFFECTIVE RESPONSES

needles and syringes or other injecting Promoting use of sterile paraphernalia, are the two commonest Briefing equipment reasons for reuse and/or sharing of needles Paper and syringes. Others include ignorance of the One Most HIV transmissions among IDUs result risks of HIV infection and how to prevent from sharing injecting equipment them, cultural factors promoting sharing, contaminated with infected blood. Therefore, and inter-personal factors as in sexual ensuring that each injection is prepared and relationships. performed with sterile injecting equipment is sufficient to break the chain of Two successful models for increasing needle transmission and prevent the majority of and syringe availability are the sale of needles HIV infections among IDUs. and syringes at minimum prices through pharmacies or other outlets, and needle and Strategies to increase the use of sterile syringe programs (NSPs). NSPs operate on equipment vary, depending on local context the basis of providing sterile needles and and the reasons for sharing. Effective and syringes, and include in their aims the sustainable strategies must be built on a distribution of educational material and the sound understanding of the pressures on removal from circulation of contaminated IDUs to share equipment. Scarcity of or lack needles and syringes. A vital principle for of access to injecting equipment, and legal or community acceptance of these programs is policing sanctions against the possession of ensuring that needles and syringes are

Figure 2. Trends in prevalence of HIV among IDUs in cities with and without needle exchange programs.

(Ref: Hurley S et al 1997) The Centre for Harm Reduction

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appropriately disposed of after use, and do Manual for not pose threats to the non-IDU community. Education and information reducing drug The inadequate disposal of used needles is A basic necessity in preventing the spread of related harm often a major reason for rejection of NSPs HIV among IDUs is information about what in Asia by communities. HIV is and does, how it is transmitted, how NSPs and pharmacy sales do not by transmission can be prevented, and how themselves prevent HIV transmission among IDUs can practically change their behaviour IDUs, but are a key and integral part of any to stop HIV transmission. Education and comprehensive and effective response to the information must focus on risk behaviours problem. Figure 2 shows one aspect of the associated with injecting drugs but also success of NSPs as part of programs to include sexual and vertical (parent-to-child) prevent HIV transmission. transmission. This information must be culturally relevant to IDUs, realistic and The use of bleach or other chemicals to practical. Many IDUs distrust official sources decontaminate and sterilise used injecting of information and consequently the most equipment before it is reused is often effective form of education is that performed promoted as a method of preventing HIV by ‘peers’ – that is, current or ex-IDUs who transmission where programs to increase are in contact with other IDUs whom they needle and syringe availability are politically can inform. unacceptable (for instance, in prison). Unfortunately, no chemical method of decontamination is totally effective, Peer education and especially in field conditions. Therefore the organisation use of decontamination as a strategy for HIV Many studies have shown that education and prevention among IDUs should always be behaviour change around safer injecting and seen as a second-best option. HIV prevention among IDUs is most effective and sustainable when it is delivered by peers in a supportive environment, especially with the understanding and cooperation of police. Peer education

Does needle syringe programs (NSPs) increase the use of injected drugs? Six major reviews of the impact of NSPs around the world were unanimous in two major findings: (i) NSPs are instrumental in slowing or stopping the spread of HIV among IDUs; and (ii) NSPs have not been shown to increase participation in drug use, or to encourage people who would not otherwise use drugs to begin doing so.

Many reviews of NSPs have found them to be a highly effective and cost-effective approach to HIV prevention, and an additional means of bringing into drug treatment drug users who would not be reached otherwise. The Centre for Harm Reduction

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facilitates contact with IDUs in the community, delivering health education from Drug treatment and Briefing a source more credible to the IDUs than are substitution programs Paper most agencies, especially agencies IDUs One identify with governments. Treatment for drug dependence has been shown to be highly effective (and cost- Developing organisations of IDUs to provide effective) as an HIV prevention strategy. peer education has been an effective strategy Research has demonstrated that drug in those countries where it has been possible. treatment is most effective when it is Drug user organisations also provide available to the drug user at the time when program planners and policy makers with he or she needs it. Therefore as part of a informed advice from drug users for comprehensive approach to HIV prevention educational or other interventions, and can among IDUs a flexible, accessible and caring advocate on behalf of IDUs in relation to drug treatment system is vital. both human rights and HIV prevention In many places, treatment for drug addiction issues. or other problems is left to the penal system, or to rehabilitation centres that are effectively prisons. These systems are not effective in Primary health care promoting and/or achieving long-term abstinence: rates of relapse on discharge are Because of their engagement in illegal typically 90 per cent and above. activities, and because many have Detoxification programs are beneficial to disadvantaged backgrounds, IDUs’ access to many people in the short term, but have poor primary health care is often limited or non- long-term success rates. The most effective existent. Protection from HIV infection must programs for heroin dependence so far be seen as one part of a holistic approach to developed are drug substitution programs, health care among IDUs, who suffer many the best known and most well researched health problems, including other infections being methadone maintenance. Substitution associated with drug injecting and programs do not ‘cure’ the addiction, but malnutrition, as well as the health problems they allow IDUs to escape the criminal world common to their community. Safer injecting, of illegal drugs into a more socially and therefore HIV prevention, is not a acceptable environment, and have been meaningful concept to IDUs who cannot demonstrated to decrease HIV transmission gain access to basic health care, and who may among IDUs – generally by decreasing the have much more pressing health and social frequency of injecting and needle-sharing. problems; thus HIV prevention approaches must be responsive to these other needs. The key goal of substitution programs is retention of the drug users in the program – the longer the retention, the more successful is the program at reducing adverse healthy and social consequences of drug use, and in achieving long-term benefit. A range of drug substitution programs is currently being investigated and trialled, to broaden the applicability of such approaches beyond those who can benefit from methadone and/or to offer an alternative in countries where The Centre methadone is not acceptable. for Harm Reduction

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Prisons: drug use and injecting occurs in Manual for Removing the barriers most prisons in the world, less frequently reducing drug to safer injecting than among IDUs outside prison but usually related harm with greater HIV risk because of the extreme Behaviours that put IDUs at risk of HIV in Asia scarcity of needles and syringes. Many IDUs infection are not random: they result from are imprisoned at some time, and prisons defined social, legal and political contexts. To bring together IDUs from a wide range of enhance the ability of IDUs to behave in socio-geographic backgrounds, allowing ways which reduce or prevent HIV transmission of blood-borne viruses between transmission, it is most important to social and geographic groups that may not examine the social, cultural and political otherwise overlap. Programs to decrease risk context with a view to removing any barriers in prison can include peer education and to safer injecting. These barriers may include provision of bleach for disinfecting lack of access to information, primary health equipment. care or drug treatment; there may also be legal barriers which do little to control drug Ethnic minorities: injecting drug use is use and simultaneously increase HIV often observed among ethnic minorities, who transmission risk. An example is the so- become involved in production or trafficking called ‘paraphernalia laws’, under which of drugs in many parts of the world largely possession of injecting equipment is because of their subordinate status. These criminalised. Rather than deterring IDUs groups often have low participation in many from injecting, such laws discourage the aspects of the general community, including carriage of new injecting equipment and health care and employment. Special promote sharing and reuse (and therefore programs targeting IDUs in these HIV transmission). Abolishing such laws communities are necessary to reduce HIV does not increase participation in drug use, risk, and must be built on accepted but does remove a barrier to safer use for the community development guidelines. motivated IDU. Women: women IDUs in Asia are increasing in number and can be at high risk of HIV Special groups infection because of their subordinate status and circumstances in many communities, which may require them to provide sex on demand or always use There are many special situations of higher a needle and syringe after their male partner. risk for HIV transmission among IDUs that HIV infection risk is further increased when should be considered separately because of women are also involved in sex work. Again, their epidemiological importance in special programs are required which address promoting epidemics. Though the groups all the relevant issues, not only needle might be numerically small relative to sharing. mainstream groups, they can and often do contribute disproportionately to HIV epidemics and therefore should be central to HIV prevention efforts. Special situations include:

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REFERENCES

Adelekan, Moruf and Stimson, Gerry. Lurie, Peter, and Reingold, Arthur. The Problems and prospects of implementing public health impact of needle exchange Briefing harm reduction for HIV and injecting drug programs in the United States and abroad. Paper use in high risk sub-Saharan African coun- Berkeley, CA: School of Public Health, One tries. Journal of Drug Issues 1997;27(1):97- 1993. 116. Comment ➤ A most comprehensive review of Comment ➤ The only major review of the the effectiveness and safety of needle and current situation regarding drug injecting and syringe exchange as a strategy for limiting HIV in Africa; demonstrates that this largely HIV transmission among IDUs. ignored situation could potentially become very important, very rapidly. Normand, Jacques, Vlahov, David and Moses, Lincoln. Preventing HIV transmis- Caplehorn, John and Ross, Michael. sion: the role of sterile needles and bleach. Methadone maintenance and the likelihood Washington, D.C.: National Academy Press, of risky needle sharing. International Journal 1995. of Addiction 1995;30(6):685-598. Comment ➤ A comprehensive and authori- Comment ➤ A review of the current litera- tative perspective on preventing HIV transmis- ture evaluating the effectiveness of methadone sion among IDUs, very much from an maintenance therapy in HIV prevention American perspective. among IDUs, finding a consensus that it is a very effective strategy. Rhodes T, Stimson G, Crofts N, Ball A, Dehne K and Khodakevich L. 1999. Drug Crofts N, Reid G and Deany P. 1998. injecting, rapid HIV spread, and the ‘risk Injecting drug use and HIV infection in environment’: implications for assessment Asia. AIDS. 12 (suppl B): 569–578 and response. AIDS. 13 (suppl A): S259- S269 Crofts N, Costigan G, Narayanan P, Gray J, Dorayee J, et al. 1998 AIDS. 12 (suppl B): Stimson, Gerry. The global diffusion of 5109–5115 injecting drug use: implications for human immunodeficiency virus infection. Bulletin Friedman, Sam, De Jong, Wouter, Wodak, on Narcotics 1993;XLV(1):3-17. Alex. Community development as a response Comment ➤ A comprehensive background to to HIV among drug injectors. AIDS the HIV epidemic among injecting drug users 1993(Suppl 1):S263-S269 globally.

Hurley S, Jolley D and Kaldor J. 1997. Effectiveness of needle-exchange programmes for prevention of HIV infection. Lancet. 349: 1797–1800

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Trautmann, Franz. Peer support as a method Manual for of risk reduction in injecting drug-user com- reducing drug munities: experiences in Dutch projects and related harm the “European Peer Support Project”. Journal in Asia of Drug Issues 1995;25(3):617-628. Comment ➤ An excellent review of the methods, strengths and weaknesses of peer sup- port among IDUs as a means of HIV preven- tion, specifically looking at European experi- ence.

Wodak, Alex and Des Jarlais, Don. Strategies for the prevention of HIV infec- tion among and from injecting drug users. Bulletin on Narcotics 1993;45(1):47-60. Comment ➤ A comprehensive perspective on HIV prevention strategies among IDUs, with some evaluation of their relative efficacy and appropriateness.

Wodak, Alex and Lurie, Peter. A tale of two countries: attempts to control HIV among injecting drug users in Australia and the United States. Journal of Drug Issues 1996;27(1):117-134. Comment ➤ A clear exposition of why the HIV epidemic among IDUs has evolved so differently in two apparently similar countries – fundamental case studies demonstrating the impact of drug policy on the spread of HIV.

Power, Robert, Jones, Steve, Kearns, Gerry, Ward, Jenni, and Perera, Jan. Drug user net- works, coping strategies and HIV preven- tion in the community. Journal of Drug Issues 1995;25(3):565-581. Comment ➤ An essential review of the role of peers and communities in protecting them- selves against HIV, a perspective which has not often enough been applied to injecting drug users.

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BRIEFING PAPER TWO Mapping drug use in Asia in the context of HIV/AIDS Briefing Paper INTRODUCTION Two Since the late 1980s and continuing into the new millennium, injecting drug use has become one of the major accelerants of the HIV epidemic in the Asian region. Although evidence of burgeoning or mature epidemics of HIV among injecting drug users (IDUs) is found throughout much of Asia, an appropriate response commensurate with the scale of the problem is greatly lacking. Drug production is flourishing, and increasing numbers of new populations are consuming, and injecting, drugs. The high prevalence of HIV infection among IDUs is largely a result of the widespread sharing of contaminated injecting equipment. A more recent phenomenon is the increasing crossover between drug injectors and sex work and consequently the implications for the further spread of HIV infection among and from IDUs to the wider community. The following regional overview shows not only the enormity of the illicit drug problem and its links to adverse health consequences, particularly HIV/AIDS, but also inappropriate responses and the lack of effective programs for HIV prevention among IDUs.

The opium industry of South-East Asia’s Regional availability and sources Golden Triangle – with Myanmar as its of illicit drugs epicentre – continues unabated. In 2001, as a result of upheavals in Afghanistan, Myanmar Up until 2000, Afghanistan had firmly became the largest source of illicit opium in established itself as the world’s largest opium the world, but in 2002 the country once producer, accounting for 72% of the world’s again became the second largest opium illicit opium supply. By 2000 the Taliban producer (with Laos in third place). The most authorities imposed a complete ban on dramatic change in Myanmar has been drug opium cultivation, resulting in the reduction diversification; the country has become the of opium cultivation by 91%. With civil primary source of ATS in Asia, producing an conflict, military attacks on Afghanistan by estimated 800 million methamphetamine the United States and the eventual overthrow tablets per year. Interceptions of of the Taliban regime, Afghanistan’s share in methamphetamine tablets being trafficked global production fell to 12% by the end of from Myanmar across the Thailand border, 2001. In 2002, as a result of ongoing socio- but also through to China, Laos, Cambodia, economic hardships, Afghan farmers once India and Vietnam, have greatly increased in again resumed opium cultivation and opium frequency. In 1999 an estimated 300 million production reached levels not seen since the methamphetamine tablets were imported mid 1990s. In 2002, Afghanistan is once into Thailand but this had doubled by 2000. again the world’s largest opium producer. Based on global ATS seizures it has been shown that most ATS production occurs in the The Centre for Harm Reduction

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Asian region. Prices for a methamphetamine ➤ In 2002, Afghan farmers again resumed Manual for tablet fluctuate: while it may cost US$0.8 to opium cultivation and opium reducing drug produce a tablet can be sold for US$1 in production reached levels not seen since related harm Bangkok and up to US$20 in Tokyo. the mid 1990s. In 2002, Afghanistan in Asia was once again the world’s largest Both heroin and methamphetamines require opium producer precursor chemicals – acetic anhydride for ➤ Myanmar is the primary source of heroin and ephedrine for methamphetamine amphetamine type substances (ATS) in – for their production and these are Asia ... most ATS [global] production principally sourced from China and India. occurs in the Asian region Caffeine is also a major ingredient for ➤ ... populations of drug users develop methamphetamine production, most of rapidly along trafficking routes, which is trafficked from Thailand into creating new drug markets and HIV Myanmar. Many countries in the region are threats in host countries. criss-crossed by trafficking and transiting routes linking drug production zones to lucrative consumer markets. For example, Iran is a major bridge for opium and heroin Drugs of choice en route to the Persian Gulf, Turkey, Russia Use of heroin and opium occurs throughout and Europe. Asia. Opium use as a general rule appears to be on the decline in much of the region, China has recently become a major producer particularly among those geographically of methamphetamines for domestic use and distant from the sites of opium cultivation. has an established record of supplying to Heroin use and addiction on the other hand international markets – primarily Japan, remains an ongoing problem and an South Korea, the Philippines and Taiwan. expanding heroin using population can be Production of methamphetamines in China found in China, Vietnam and Myanmar. appears to have accelerated, with 1,608 Methamphetamine use has skyrocketed in kilograms of the drug seized in 1999, recent years and is the drug of choice, or is increasing to 20,000 kilograms by 2000. fast becoming so, in Thailand, South Korea, The production of cannabis occurs in many the Philippines, Taiwan, Japan, Cambodia, countries of the Asian region; one is the Laos, China and Indonesia. It is believed that Philippines, which is a major source of worldwide over 50% of ATS use is to be cannabis supplied to Japan, Malaysia, found in Asia. In Thailand for example the Taiwan, the United States and Europe. use of ATS is growing at a rate of 50% per Research has shown consistently that year. populations of drug users develop rapidly along trafficking routes, creating new drug ➤ Heroin use and addiction remains an markets and HIV threats in host countries. ongoing problem ... methamphetamine use has skyrocketed ... worldwide over 50% of ATS use is found in Asia.

The use of ecstasy is gaining in popularity throughout the region, as a part of the burgeoning dance party scene found in many The Centre for Harm Reduction

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urban centres. Illicit ingestion of Mongolia, although estimated numbers of pharmaceuticals is popular, and in India, injectors are still relatively small. In Briefing Bangladesh, Pakistan and Nepal the use of countries where opium is consumed Paper buprenorphine (a synthetic opioid) have (Afghanistan, Iran, Pakistan, Myanmar, Laos, Two become widespread. Cough mixtures China, India, South Korea and Thailand) it is containing codeine are commonly used, and a mostly smoked or orally ingested (either in plethora of other analgesics and tranquillisers food or in tea) and is still used in some are trafficked and consumed throughout the communities for medicinal purposes. region. The use of solvents and glue is common (particularly among street children) Among IDUs in the region, sharing of in India, Laos, Cambodia, Indonesia, equipment is common and, as shown in Mongolia, Vietnam, the Philippines and various surveys undertaken, the rate of Thailand. Cannabis and hashish consumption sharing is frequently 50% and above. is commonly found throughout the region, especially among the countries that grow it. ➤ As a result of economic factors, the Cannabis is often the second drug of choice desire for a stronger effect or because of among many drug users admitted into peer pressures, the popularity of treatment for either heroin or ATS addiction. injecting is increasing in Asia. ➤ ... the rate of sharing [injecting equipment] is frequently 50% and Drug taking practices and risk above .... factors The sharing and reusing of injecting Favoured administration routes for drugs equipment is largely driven by issues vary from place to place, over periods of time associated with scarcity, accessibility, relative and in different cultural and social settings. costs of equipment, peer and cultural Heroin is commonly (particularly in the customs and the social environment. It has initial stage) smoked in cigarettes or inhaled also been shown that in most cases the by ‘chasing the dragon’ (heating the drug on methods of cleaning injecting equipment are foil and inhaling the vapour). As a result of often inadequate to prevent the transmission economic factors (the need to minimise the of blood-borne viruses (BBVs). Many IDUs wastage of expensive drugs that can result use cold water to clean needles and syringes; from smoking), the desire for a stronger few use boiling water or bleach. Professional effect or because of peer pressures, the injectors (people skilled in injecting others, popularity of injecting is increasing and often for a fee) and ‘shooting galleries’ are recognised by drug users in all of Asia. found in Pakistan, India, Bangladesh, Nepal, Injecting is most often associated with Vietnam, Myanmar and Malaysia, and heroin, but there are reports of amphetamine inevitably promote the spread of BBVs. In injecting in South Korea and Japan, and in Myanmar for example the practice of small numbers in Thailand, Laos, Indonesia, professional injecting is firmly established, the Philippines and China. In India, Pakistan mainly found in tea shops or shooting and Bangladesh drug users frequently inject galleries, and the risk of HIV is great as buprenorphine, often with a cocktail of sterilisation of the various injecting pharmaceuticals. Countries where drug equipment tools is rarely considered. injectors have become more apparent in recent years are Cambodia, Laos and The Centre for Harm Reduction

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dependent persons. The estimated number Manual for Prevalence of drug use of IDUs remains elusive and figures of reducing drug 100,000-250,000, quoted from the mid- Estimates of the number of drug users and 1990s, are still officially in use. In the related harm IDUs have generally increased over the years in Asia Philippines, another country where and in some countries the rise is substantial. methamphetamines are popular, the number In Indonesia drug use was previously an of drug users is estimated at one million but extremely sensitive issue and the figures were could be substantially higher; at least 10,000 downplayed. In the late 1990s it was people are injecting. In Laos opium use estimated there were 30,000-40,000 IDUs. remains widespread – prevalence could Currently local researchers believe there exceed 2%, making it second only to Iran. In could be 2 million drug users, of whom half some parts of the country 5% of the are drug injectors. In 1990 China had 70,000 population above 15 years old are opiate registered drug users and by 2001 the users. The number of IDUs is considered low, Chinese Government reported a figure of but with a survey showing that among ATS 900,000, an increase of over 200,000 in two users 12% injected, the potential for an years. However, unofficial estimates put the exponential rise is likely. Finally, in Pakistan figure closer to six to seven million, with it has been estimated there are four to nearly approximately half being IDUs. Estimates five million drug users and that half are for India remain elusive; figures of one to five heroin users; there are currently only around million opium users and one million heroin 180,000 IDUs but there is enormous users, which date from the early 1990s, are potential for IDU numbers to increase still quoted by government officials and UN substantially in coming years.. sources. Unofficially the use of heroin is believed to be much greater. Drug injecting is increasingly popular, and in five major Indian urban centres there are now at least Prevalence of HIV/AIDS 100,000 IDUs. Confirmed cases of HIV infection and of AIDS have increased in frequency ➤ Estimates of the number of drug users throughout the region and several countries and IDUs have increased ... in some have serious HIV epidemics among IDUs. countries the rise is substantial. The countries with high prevalence of HIV infections among IDUs are Myanmar, In Myanmar an estimated 300,000-500,000 Vietnam, China, Thailand, Malaysia, people use illicit drugs and up to half are Indonesia, Nepal, India and Iran. In the late injecting. In Malaysia there are as many as 1990s China had sporadic pockets of HIV 200,000 IDUs and in Iran there could be as infection (predominantly among IDUs), but many as 3.3 million drug users, with an is currently facing a massive explosion of estimated 200,000-300,000 IDUs. Japan has HIV. Up until the mid-1990s the estimated an estimated 600,000 addicted users and number of HIV infections was 10,000. By 2.18 million casual users of 2001 the Chinese Ministry of Health put the methamphetamine. Two to three million figure at 600,000 HIV infections while drug users (nearly 5% of the population) are UNAIDS believes it to be 800,000-1.5 believed to exist in Thailand, and with a million. HIV infection appears to have massive increase in the use of ATS there are spread along several trafficking routes; the currently estimated to be 300,000 ATS- main transmission pathway is injecting and The Centre for Harm Reduction

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IDUs now account for 70% of cumulative widespread sharing of injecting equipment cases. (55%-75%) and the use of professional Briefing injectors, often with poor hygiene standards, Paper ➤ ... several countries have serious HIV is common practice. Two epidemics among IDUs ... Myanmar, Vietnam, China, Thailand, Malaysia, Indonesia, Nepal, India and Iran. Profile of drug users

In Malaysia IDUs are the main group The majority of drug users in the region are affected by HIV infection (76% of all men but female drug users are found in all reported cases), a situation that has changed countries; taboos against women using drugs little since the beginning of the HIV and being recognised as drug users impact epidemic in that country. In Indonesia fewer upon gender representation in available data. than 1% of confirmed HIV infections were Nevertheless, the data imply that increasing due to IDU prior to 2000, but by the end of numbers of Asian women are using drugs 2001 this had increased to 19% nationally, and many are involved in sex work. In China, with up to 50% in some parts of the country. in the Provinces of Yunnan and Guangxi, In Iran 75% of HIV infections can be traced 16-25% of drug users in treatment are to injecting drugs. HIV infections among female and in Guangxi, for example, 80% of Vietnamese IDUs accounted for 65% of the them were involved in sex work to fund their total reported cases. Dramatic increases in heroin addiction. Female IDUs are also HIV prevalence among IDUs – reaching increasingly involved in sex work in levels of up to 84% – have been detected in Vietnam, Nepal, the Philippines, India, the north of the country where evidence of Bangladesh, Indonesia, Sri Lanka, Hong HIV was very limited just four to five years Kong and Pakistan. Recent surveys have ago. In Thailand the HIV infection rate found the prevalence of injecting drug use among IDUs remains high and the outlook is among females involved sex work ranging poor. National sentinel surveillance showed from 10%-50%. There is scant information that among IDUs the prevalence of HIV about this group of drug users but the infection was on the rise, increasing from crossover between IDUs and sex work is 32% in 1995 to 54% in 2000. It has been established and will add further to the spread estimated 5%-10% of drug users become of HIV infection to other sections of the HIV infected each year. community.

The Philippines, Laos, Cambodia, Hong ➤ increasing numbers of Asian women are Kong, Macau, Pakistan, Cambodia, using drugs and many are involved in Afghanistan and Bangladesh all face sex work ... the crossover between potential HIV epidemics among IDUs. IDUs and sex work will further spread Hong Kong maintains a low HIV infection HIV infection to other sections of the rate among IDUs but this may be changing community. as IDUs seeking cheap drugs continue to cross the border into mainland China, where Throughout Asia the age of initiation into many are known to inject and where 70% of drug use is declining; drug users’ rates of HIV infections are found among IDUs. The unemployment and levels of involvement in prevalence of HIV infection among IDUs in unskilled work are high; users tend to be Bangladesh is currently low but there is poorly educated, and sexually active but The Centre for Harm Reduction

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infrequent users of condoms; high range from 70%-90%. The reality is in drug Manual for percentages of users have experienced rehabilitation centre style programs it is reducing drug incarceration; and many users are in poor almost universally 90%. related harm health, worsening with length of drug use. in Asia ➤ ... there are insufficient treatment and rehabilitation centres to cater for drug Government responses to illicit users and as a consequence the risks for drug problems the health of those addicted to drugs tend to be severe. The standard drug control policy of the ➤ ... when drug users do receive countries assessed is to impose harsh treatment, recidivism rates, according penalties on people convicted of trafficking, to government sources, commonly production and importing and exporting range from 70%-90%. The reality is in drugs. The death penalty, mostly for drug rehabilitation centre style trafficking, may be applied in China, programs it is almost universally 90%. Singapore, India, Indonesia, Iran, Malaysia, Brunei Darussalam, Myanmar, the As a result some countries are becoming Philippines, Sri Lanka, Thailand and frustrated by this outcome and – for those Vietnam. The penalties imposed upon drug with chronic relapsing conditions – a new users are variable and depend on the type and punitive approach closely linked with ‘social amount of drug in possession. order’ policies is emerging to keep drug users detained for longer periods of time in the It is common in Asia for drug users who hope that this approach will prove more come into contact with the legal system to be effective. coerced into treatment, but in some countries incarceration is the sole outcome. It is In Singapore a person who relapses into drug abundantly clear that there are insufficient use three or more times is imprisoned for five treatment and rehabilitation centres in most to seven years, and the sentence is increased countries to cater for their drug users and as a to 13 years following another relapse. In consequence the risks for the health of those Vietnam the average duration of treatment addicted to drugs tend to be severe. On the has been increased from six months to twelve positive side, while drug use remains illegal, months. Chinese drug users who relapse most countries do regard drug users as following rehabilitation are sent to a victims; China is a case in point – ‘re-education through labour’ camp for two terminology there has recently shifted from to three years. These punitive interventions ‘illegal persons’ to ‘illegal patients’. are often directed by a public security agenda which often overshadows the public health There are few treatment centres in the region priority of improving or maintaining the that offer psychological and behavioural health of drug users. rehabilitation, counselling or after care services for extended periods of time following discharge. Even when drug users do receive treatment, recidivism rates, according to government sources, commonly

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completely embraced MMP, with 21 clinics Government response to drug in operation. Substitution therapy using Briefing use and HIV buprenorphine is in use in some Indian Paper cities. Two Most countries in Asia have been slow to implement HIV/AIDS prevention and control measures for IDUs or are yet to implement appropriate responses. Injecting National AIDS Policy drug use in the context of HIV/AIDS is Most countries in Asia are some years away universally recognised as a major public from creating or implementing specific health problem but is seldom accorded the policies that address the issue of HIV/AIDS priority it deserves. Most governments in among IDUs. Some governments appear to Asia are still more concerned with the legal have taken the view that because an epidemic implications of drug use rather than the of HIV has yet to occur among their IDUs, public health implications of HIV/AIDS. policies and programs focusing on drug use HIV/AIDS and drug use prevention activities and HIV are not necessary. Even in countries in this region have generally focused on where the high prevalence of HIV infection information for the wider population and among IDUs (such as Thailand, China, rarely specifically for IDUs. The available Vietnam, Nepal, Iran, Malaysia and information is often lacking in detail and not Indonesia) is acknowledged, risk reduction explicit or far reaching enough to impact on and prevention activities are held back, drug users. largely due to the constraints of narcotics legislation and the public security agenda. ➤ Most governments in Asia are still Operational links between drug control more concerned with the legal policy and HIV prevention and intervention implications of drug use rather than policies are more often than not poor. the public health implications of HIV/AIDS. ➤ Operational links between drug control policy and HIV prevention Some countries with high HIV prevalence and intervention policies are ... poor. among IDUs have implemented HIV prevention approaches but they are often so India has officially approved a harm limited and reach so few drug users that their reduction philosophy. However, there is ability to effectively impact upon the reluctance among many professionals in the epidemics among IDUs is low. area of HIV prevention to fully support harm Overwhelmingly these approaches and reduction principles, and there remains a activities are implemented by the non- poor understanding of these concepts on the government sector but are sanctioned by part of senior-level drug and health policy government authorities. Needle and syringe makers. In Laos harm reduction is a programs (NSPs), while few in number and component of the National AIDS Plan small in scale, are operating in Vietnam, (although no programs have yet been China, Nepal, India, Iran, Bangladesh, implemented). China announced a five-year Pakistan, Thailand and the Philippines. action plan for HIV/AIDS prevention and Methadone maintenance programs (MMP), control (2001-2005) which includes needle similarly few and small, are currently found and syringe social marketing and promotion in China, Thailand, Hong Kong, Iran, Nepal of the use of clean injecting equipment. and Indonesia. Only Hong Kong has The Centre for Harm Reduction

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➤ .. it is the non-government sector that Manual for Non-government responses to has taken the lead in responding to the reducing drug drug use and HIV issue of drug use and HIV. However, related harm In Asia it is the non-government sector that considering the size of the problem in Asia has taken the lead in responding to the issue the number of [NGOs] working in of drug use and HIV. However, considering this area is small. the size of the problem the number of non- government organisations (NGOs) working NGOs have instigated harm reduction in this area is very small. NGOs in India and programs (including outreach, peer education Bangladesh have implemented numerous on safer injecting, and NSPs) in Iran, harm reduction activities, but demand for Pakistan, Thailand, Indonesia, China, their services is very large. In Kathmandu, Myanmar, Hong Kong, Malaysia and the Nepal, harm reduction outreach services exist Philippines; unfortunately these programs but probably reach fewer than 10% of IDUs. are few in number and small in scale and are The international NGO sector in Vietnam unlikely to reach most drug users. Many has for some years encouraged and treatment centres and rehabilitation centres implemented an array of harm reduction are operated by NGOs and these can be activities but these have always remained found in Hong Kong, Macau, India, precarious and have frequently ceased after Indonesia, Iran, Japan, Malaysia, Nepal, the pilot phase. Pakistan, the Philippines, Bangladesh, Singapore, Sri Lanka, Taiwan, Thailand and Vietnam.

Information in the Asian regional overview is from the report ‘Revisiting the Hidden Epidemic: A Situation Assessment of Drug Use in Asia in the context of HIV/AIDS’. Published by the Centre for Harm Reduction and available on-line at www.chr.asn.au Further reference updates: UNODCCP. 2002. Global Illicit Drug Trends 2002. Report commissioned by the United Nations Office for Drug Control and Crime Prevention. New York. International Narcotics Control Strategy Report. 2002. Southeast Asia and the Pacific and Southwest Asia Released by the Bureau for International Narcotics and Law Enforcement Affairs, US Department of State Washington, D.C. [http://www.state.gov/g/inl/rls/nrcrpt/2001/rpt/8483pf.htm] UNDCP. 2002. Regional Drug Control for Southeast Asia and the Pacific. UNDCP, Bangkok, Thailand. International Narcotics Control Board. 2003. Report of the International Narcotics Control Board for 2002. United Nations, New York.

The Centre for Harm Reduction

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BRIEFING PAPER THREE A Review of Amphetamine Type Substances Briefing In recent years Asia has experienced a massive increase in Paper production of amphetamine type substances (ATS) and,based on Three seizures, much of the world production of ATS now takes place in this region. Production of ATS is primarily found in the border areas of Myanmar/Thailand and Myanmar/China. It has been estimated that over 50% of worldwide use of ATS is to be found in Asia, in particular Thailand, Japan, the Philippines, the Republic of Korea and Taiwan. An increasing number of youth are experimenting and becoming chronic users of ATS. Currently the injecting of ATS is not as widespread as that associated with heroin but many users of ATS are involved in unsafe sexual activity with multiple partners and are consequently at risk of HIV/AIDS. With increased production and widespread use of ATS, and associated sexual risk behaviours, ATS has become an illicit drug of great concern in the Asian region.

WHAT ARE BACKGROUND AMPHETAMINE Amphetamines were first synthesised TYPE SUBSTANCES? in Germany in 1887. In 1919, ATS are chemically similar to adrenalin, a methamphetamine, a derivative of hormone produced by the adrenal gland, amphetamine, was developed in Japan. It was which stimulates the sympathetic nervous not until the 1930s that amphetamines were system (partly responsible for controlling first used for therapeutic reasons, mainly to bodily functions that are not consciously treat asthma and nasal congestion but also controlled) and the central nervous system used to treat schizophrenia, morphine (brain and spinal cord). They are potent addiction, tobacco addiction and low blood stimulants, similar in structure and pressure. During World War II producing similar effects to the naturally methamphetamine was widely used by occurring neuro-transmitters adrenaline, military personnel in the United Kingdom, dopamine and noradrenaline. Germany, Japan and the United States to increase personal endurance and performance. ‘Amphetamines’ is a generic term that refers In the 1960s amphetamines were commonly to a range of amphetamine-based substances used for weight control and to combat that includes amphetamine and depression. New uses have been found for methamphetamine but does not include such amphetamines in recent years, such as for substances as ecstasy, classified instead as an treatment of attention deficit hyperactivity ‘amphetamine analogue’ (similar and disorder in children and narcolepsy chemically related but only in a general way). (uncontrollable sleeping episodes).

Synthetic drugs are a product of the pharmaceutical industry that has flourished throughout the late 20th century. A consequence of this growth, and of increasing attacks on production of heroin and cocaine, The Centre for Harm Reduction

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has been an increase in the number of people Manual for using synthetic substances illicitly. The How are ATS administered? reducing drug growing use of ATS is linked to their increasing availability, low cost and ability to ATS are oil based but are converted to related harm powder for easier handling and manufacture. in Asia be manufactured easily in large quantities from readily available chemical ingredients. The powders can be taken intranasally (‘snorted’), swallowed, smoked or (after being In the late 1990s the World Health dissolved in water) injected. Vapours Organisation estimated there were 35 produced by heating crystallised million regular users of ATS in the world, methamphetamine can be inhaled. making it the most common illicit drug after cannabis. It has been reported that methamphetamines are the most commonly Effects of ATS used intravenous drug in the United States. ATS alleviate fatigue and produce feelings of Methamphetamine first appeared in the US, mental alertness, wellbeing and improved in the mid-1980s, and in its purified form is self-confidence while under the influence of a transparent rock-like crystal resembling the drug. The effects often depend on the crushed ice. It is commonly referred to as route of administration, how much is used ‘ice’ but also has the names ‘shabu’, ‘batu’, and the particular chemicals in the substance. ‘glass’, ‘yaba’, ‘crystal’ and ‘crystal meth’. In Smoking or injecting generally results in an recent years seizures of ATS in Myanmar, intense ‘rush’ that lasts a few minutes, and Thailand, the Philippines, Indonesia and then produces a euphoric high which can last China have soared, suggesting that illicit from 8 to 12 hours. Users of ATS can become manufacture in East and South-East Asia has tolerant to the induced euphoria, resulting in been increasing. Vast profits are made from the desire to use higher dosages. It is not the manufacturing and trafficking of ATS uncommon for users to ‘graduate’ from and many of the criminal groups are often smoking or snorting to intravenous use when the same as those involved in the heroin the desired effects are no longer achieved trade. through ingestion or inhalation. Drug users can also move from smoking to injecting ATS as a result of economic savings. It has How are ATS produced? been suggested that smoking requires twice ATS are chemically synthesised by the the amount of ATS powder as injection to pharmaceutical industry and by illicit receive the same effect. Experienced users laboratories. A crucial component (a claim euphoric and stimulant properties of ‘precursor chemical’) in the production of methamphetamines are greater than amphetamines is ephedrine, derived from amphetamines. plants of the genus Ephedra (a traditional Chinese herb, first used 5,000 years ago) or Short term effects made synthetically. Ephedrine is the most Highly enhanced self-confidence; feelings of common precursor chemical used in the wellbeing and increased potency; insomnia; production of amphetamines, and much of reduced appetite; irritability; talkativeness; what is produced still comes from China. panic attacks; palpitations; anxiety; increased Methamphetamines can be produced in respirations; increased activity; increase several ways using combinations of 32 sexual desire. The Centre different chemicals, one-third of which are for Harm Reduction classed as extremely hazardous.

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Long term effects There are different types of interventions and Depression; paranoia; tendency towards approaches to treatment, but there is no Briefing violence; irregular heartbeat; tremors; consensus as to what constitutes effective Paper loss of coordination; vagueness; distracted treatment. Pharmacological interventions Three and poor concentration; psychosis, such as anti-depressants and the substitute often indistinguishable from paranoid therapy drug dexamphetamine are being schizophrenia; hallucinations; mood swings; trialled in different parts of the world. decreased immunity; poor memory; sexual There are also various non-pharmacological dysfunction; premature births; feelings of interventions and these include: 28-day in- suicide. patient programs; therapeutic communities; 12-step programs; peer interventions; Other health consequences behavioural strategies; cognitive behavioural Injecting ATS usually carries an increased interventions; and non-traditional methods. risk of the transmission of blood-borne In many ways the approach used is to rebuild viruses such as HIV/AIDS and hepatitis B and enhance the personality of those and C through the sharing of needles and recovering from ATS use by promoting injecting equipment. Many users are also relapse prevention techniques, regular urine involved in unsafe sexual activity with testing, family involvement, and links with multiple partners and are at risk of support groups. There is little evidence that HIV/AIDS. Fatalities have been documented any of these approaches is at all effective for among ATS users as a result of poly-drug use the majority of ATS users (other than and accidents while under the influence. substitution therapy, but in this case it is only used for very heavy injectors of ATS).

Treatment and management

Drug treatment services are generally aimed at opiate users and are ill equipped to deal with ATS users. Simultaneously, ATS users are often reluctant to seek treatment even though they face a variety of physical, psychological, inter-personal and social problems. Instead of attending specialist services, many attempt to stop using ATS by replacing them with benzodiazepines, cannabis and alcohol – often to re-establish a normal sleep pattern. Physical health problems may be tolerated but it is the unwanted psychological and behavioural problems that prove the most disturbing for most ATS users. Breakdown of relationships with peers and family members, typically as a result of paranoid or aggressive behaviour, may be the ultimate trigger for an ATS user seeking formal help.

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BIBLIOGRAPHY

Anglin M.D, Burke C, Perrochet B, Stamper Klee H. 1997. Amphetamine misuse: Manual for E and Dawud-Noursi S. 2000. History of international perspective on current trends. reducing drug the methamphetamine problem. Journal of Harwood Publishers related harm Psychoactive Drugs. 32(2): 137-141. Matsumoto T, Kamijo A, Miyakawa T, Endo in Asia Asian Harm Reduction Newsletter. 2000. M, Yabana T et al. 2002. ATS: the emerging drug of choice? Special Methamphetamine in Japan: consequences edition on ATS. Asian Harm Reduction of methamphetamine abuse as a function Network. 19 - 20, January - April. of route of administration. Addiction. 97: Australian Bureau of Criminal Intelligence. 809-817. 2001. Amphetamine Type Substances. In McKetin R and Mattick R.P. 1997. Australian Bureau of Criminal Attention and memory in illicit Intelligence. Australian Illicit Drug Report amphetamine users. Drug and Alcohol 1999-2000. Canberra. Australian Bureau Dependence. 48:235-242. of Criminal Intelligence. Remberg B. 1997. Stimulant Abuse: from Brands B, Sproule B and Marshman J. 1998. amphetamine to ecstasy. In World Drug Drugs and Drug Abuse: a reference text. Report. United Nations Drug Control [section 3, amphetamines] (3rd edition) Programme. Oxford University Press Toronto. Addiction Research Foundation Sattah M, Supawitkul S, Dondero T, Kilmarx Donoghue M.C. 1997. Amphetamine-type P, Young N et al. 2002. Prevalence of and Stimulants: a report from the WHO meeting on risk factors for methamphetamine use in amphetamines, MDMA and other northern Thai youth: results of an audio- psychostimulants. Geneva, 12-15 November computer-assisted self-interviewing survey 1996. World Health Organization. with urine testing. Addiction. 97: 801- Doweiko H.E. 1999. Concepts of Chemical 808. Dependency. Pacific Groove. Brooks/Cole United Nations Drug Control Program Publishing Company. (UNDCP). 2002. Regional Drug Control Fleming P.M. 1998. Prescribing Profile for Southeast Asia and the Pacific. amphetamine to amphetamine users as a UNDCP, Bangkok, Thailand. harm reduction measure. International UNODCCP. 2001. Global Illicit Drug Trends Journal of Drug Policy. 9: 339-344. 2000 . Report commissioned by the Greenblatt J.C. and Gfroerer J.C. 1998. United Nations Office for Drug Control Methamphetamine abuse in the United and Crime Prevention. New York. States. In Analysis of substance abuse and Vincent N, Shoobridge J, Ask A, Allsop S treatment need issues. Rockville, MD, and Ali R. 1998. Physical and mental US Department of Health and health problems in amphetamine users Human Services from metropolitan Adelaide, Australia. [http://www.health.org/txneeds/httoc.htm] Drug and Alcohol Review. 17: 187-195. Kamieniecki G, Vincent N, Allsop S and Lintzeris N. 1998. Models of intervention and care for psychostimulant users. Monograph Series No. 32. National Centre for Education and Training on Addiction. Commonwealth Department of Health and Family Services. [http://www.health.gov.au:80/pubhlth/pu blicat/document/mono32.pdf] The Centre for Harm Reduction

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BRIEFING PAPER FOUR Care and Support of Injecting Drug Users with HIV and AIDS Briefing discrimination from HIV/AIDS clinical and Paper The link between prevention community service providers. Many service Four and care providers stereotype IDUs as difficult clients - prone to anger and erratic behaviour, Harm reduction workers are often in the unreliable when it comes to appointments front line in term of access to marginalised and adherence to treatment protocols, and injecting drug users (IDUs) with HIV/AIDS. more likely to disrupt the smooth running of They can therefore have a significant role in their services. They may also be perceived as the advocacy for and care and support of this somehow more ‘deserving’ of HIV than other group. It is neither easy, nor particularly clients. This discrimination by HIV/AIDS useful, to draw a clear line between service providers may be overt or covert. prevention and care when working in harm Sometimes it is expressed in the rules or reduction and HIV/AIDS. Providing policies that the services put in place - rules counselling, treatment, care and support to effectively preventing IDUs with HIV from IDUs with HIV/AIDS can make a significant accessing the service. There are, however, prevention intervention. People with HIV many HIV/AIDS clinical and support who are informed, supported and provided services that have in place policies to ensure with the skills to avoid passing HIV on to that IDUs with HIV/AIDS have access to others are an important resource for services. These services have often emerged HIV/AIDS prevention. IDUs with from organisations that are firmly connected HIV/AIDS can play an important role in to injecting drug user communities. They are providing peer education and support to often services that have been able to offer their fellow community members, and have IDUs a say in how the services are designed been particularly successful in maintaining and delivered. contact with hard-to-reach groups.

Harm reduction workers are often called HIV Testing issues upon to advocate on behalf of IDUs with HIV/AIDS, assisting them to access health, HIV testing should always be accompanied welfare and drug treatment services, and to by pre-test counselling, and occur only after re-establish contact with their families. voluntary informed consent. However, many IDUs are tested for HIV without their consent and without counselling, often when Stigma and discrimination they are admitted to compulsory drug treatment facilities. Often they do not receive HIV-positive IDUs face a triple stigma. As their HIV test results. In these cases, HIV IDUs, they are often marginalised from testing appears to be primarily used for communities and face difficulties in securing surveillance. Services and government work and gaining access to housing and agencies need to clearly differentiate between welfare services. As people with HIV, they HIV testing for surveillance and clinical HIV face the stigma and discrimination that all testing. Surveillance is conducted to provide people with HIV encounter. As clients of information on the extent of the epidemic support services, they may also face and its changing patterns. HIV testing of The Centre for Harm Reduction

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individuals for surveillance activities needs to appropriate counselling, and agencies should Manual for be separated from HIV testing as part of an endeavour to provide support for HIV- reducing drug ongoing counselling care and support positive individuals and facilitate their access related harm program. If testing is to be more than an to ongoing care and treatment. in Asia exercise in counting, policies need to be developed to make counselling, support and ongoing care available. Continuum of care

The aim of voluntary HIV counselling and HIV/AIDS treatment, care and support is not testing is: just the job of hospitals and health services. ➤ to provide the individual with People with HIV and their families can only information about their HIV status; maximise their health and wellbeing if they ➤ to provide information and the skills to are supported by a continuum of health, reduce HIV transmission in the future; welfare and community support services. ➤ to provide the support for informing Hospitalising or institutionalising IDUs sexual and drug use partners about their with HIV/AIDS for extensive periods is risk; and neither cost-effective nor humane. People with HIV can continue to make a ➤ to provide a bridge to ongoing care and contribution to society and, with support and support. ongoing care, can live productively for many This is both an individual and public health years. Agencies interested in providing care initiative. Before embarking on voluntary and support for IDUs need to examine the counselling and testing for IDUs, agencies full range of needs that people with HIV and need to think about: their families encounter. These include ➤ how they will ensure confidentiality; housing and safety, nutrition, emotional ➤ who will conduct pre- and post-test support, support for continued drug counselling, and how they will do this; avoidance and/or drug substitution, access to ➤ what training they will need to be able to work and income, involvement in ventures to do this sensitively; promote independence and purpose, physical ➤ what information and ongoing care, clinical monitoring, and spiritual counselling they will need to provide; support. Non-government organisations set up by IDUs to provide information, support, ➤ whether they will discharge HIV-positive advocacy and clean injecting equipment have people from compulsory drug treatment; played a key role in HIV/AIDS prevention and and care in many countries. Peer support ➤ how they will ensure that people receive groups and HIV positive support groups support and care in the community. facilitated by current and past IDUs have Some drug rehabilitation services have been particularly successful in reaching into been reluctant to pass HIV positive results injecting drug user communities and on to people in their care, arguing that the mobilising the resources of these diagnosis will interrupt the person’s communities. rehabilitation and lead to anger and violence. To avoid this outcome, staff should be trained to deliver HIV test results with

The Centre for Harm Reduction

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may lead to viral resistance, i.e. HIV mutates Monitoring and HIV and the treatment is no longer effective. Briefing treatment issues Some services use this as a reason not to offer Paper treatment to IDUs with HIV, arguing that Four Even in resource-poor environments there are they are often unreliable when it comes to useful strategies that can be employed to maintaining treatment regimes. It is possible monitor and maximise the health of IDUs for agencies to work with IDUs to determine with HIV/AIDS. IDUs with HIV/AIDS strategies to maximise treatment compliance should have the same access to treatment and (avoiding interruptions or missed doses). care as other people with HIV in the These include simple dose regimens, community. As the immune system becomes supervised treatment (as in methadone damaged by HIV, people become susceptible programs), use of community volunteers to to opportunistic infections that can threaten assist in treatment compliance, use of their health and life. These include sponsors or ‘buddies’ (as in Alcoholics tuberculosis, Pneumocystis pneumonia, Anonymous and Narcotics Anonymous meningitis, candidiasis and many others. The programs), better access to local clinics, and damage to the immune system can be more realistic clinic opening times. monitored using blood tests (CD4 tests), if available, or by observing physical markers like rapid weight loss and other symptoms. Support for families and Many opportunistic infections can be avoided communities by using simple antibiotics. General health can be maximised by providing access to Ultimately, much of the care and support for good nutrition, rest and psychological IDUs with HIV is done within families and support. Many opportunistic infections can communities. Harm reduction workers have be prevented with cheap antibiotics, and an important role to play in assisting families those that do occur can be treated if drugs are and communities to provide this care. In available. order to do this, families and communities have to be assisted in overcoming their fear of IDUs with HIV/AIDS experience a range of HIV infection, their judgement of IDUs as other illnesses and conditions that also need unworthy of care, and the feeling of to be taken into account. Many will be co- helplessness they can often experience in the infected with hepatitis B and/or C, have liver face of a growing AIDS epidemic. damage from multiple drug use, and have injection abscesses and health impacts from There are many examples of families and injection and other complications. Health communities working together to provide service providers will need to take all of these this care. There have been several key lessons conditions into account when providing learned from designing these programs. treatment and ongoing monitoring. These include: ➤ obtaining the support of influential If anti-retroviral therapies are available in the community members (religious, local community, IDUs with HIV should not be government, civil society); discriminated against when they attempt to ➤ involving the person with HIV/AIDS and access them. Anti-retroviral therapies are their family in the design of the service only effective if they are taken consistently. and the policies and procedures it adopts; Interruptions in anti-retroviral treatment The Centre for Harm Reduction

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➤ networking between the community Manual for services and hospitals, clinics and key REFERENCES: health workers; and reducing drug Brandsmaa R. 1999. Stimulating access and ➤ paying attention to the basic physical and related harm compliance to anti-HIV combination therapy welfare needs of people with HIV and in Asia for drug users. Paper presented at the families. International Conference on the Reduction of Drug-Related Harm Geneva Buhringer G, Greenwood J, Gsellhofer B, Grief and loss Kunzel J and Torrens M. 1998. Drug use and HIV infection: the care of drug users and If harm reduction programs are working the treatment system. WHO (Europe) effectively in communities at risk they will Working Group Report. Munich encounter many people with HIV/AIDS and EUR/ICP/LVNG 02 07 10 their families. This will expose them to the Burrows D. 2000. Treatment, care and support range of feelings that people experience as of injecting drug users living with HIV/AIDS: they face a terminal illness or the death of a implications for Ukraine MSF-H Ukraine. relative and friend. In communities with Kiev. May. 2000 (available in English, rapidly expanding HIV epidemics, this grief Russian, Ukrainian and Bahasa Indonesia) and loss can sweep across entire Lert F and Marne M-J. 1992. Hospital care communities. People working in all aspects for drug users with AIDS or HIV infection of HIV/AIDS need to be able to access in France. AIDS Care 4 (3) training and support to deal with individual, Marte C and Gatell JM. 1999. HIV/AIDS family and community grief. Failure to policy issues related to care, treatment and address grief and loss issues can severely support of IDU communities. Dialogue on jeopardise HIV prevention initiatives as AIDS Series: Policy dilemmas facing individual and community reactions to grief governments: Paper 2. UNAIDS/ Health make it difficult to maintain the safe Canada. Montebello. behaviour that prevention programs attempt McAmmond D and Skirrow J. 1997. Care, to inspire. treatment and support for injecting drug users living with HIV/AIDS. A consultation report. Health Canada. Toronto McCallum, L. 2000. Caring for people with HIV/AIDS at home, Medecins Sans Frontiers, Ukraine/ Netherlands (in Russian and English).

WEBPAGES: WHO Fact Sheets on HIV/AIDS for nurses and midwives http://www3.who.int/whosis/factsheets_hiv_nurses/index.html Improving Access to Care in developing countries: lessons from practice, research, resources and partnerships http://www.unaids.org/publications/documents/care/acc_access/JC809-Access-to-Care-E.pdf

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Section 2 Program Design, Implementation and Maintenance

289 Contents

Section 2 Chapter One Rapid Situation Assessments

What are rapid situation assessments? Finding and analysing existing information Conducting interviews Questions to ask The outcomes of a rapid situation assessment

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Introduction

ITHOUT research the most well intentioned program will Manual for fail. For a program or project to be successful it needs to be reducing drug established within the context of solid research. For related harm W in Asia example, it may be determined to introduce needle and syringe program into a particular district but for legal and cultural reasons the intervention, at this stage, would not work. If the necessary research had been done before the project began other more appropriate or acceptable action could have been planned. Or, on a simpler level, a project which is aimed at an often hidden population, such as injecting drug users (IDUs), needs to undertake research to find out the basics of where the IDUs are, how to contact them and what sort of assistance they may need and/or want. If you are going to set up a program aimed at IDUs it is essential to examine the nature of drug policies and the factors influencing drug use and related HIV transmission in that particular country or community. You also need to know what resources exist to respond to drug use and HIV in the community. The programs which are eventually developed must be culturally, socially, and politically appropriate to the specific environment. This chapter will discuss Rapid Situation Assessments (RSA) and concentrate specifically on RSA to do with drug use and HIV/AIDS.

This chapter will examine: 1 What are Rapid Situation Assessments? 2 Finding and analysing existing information 3 Conducting interviews 4 Questions to ask 5 The outcomes of a Rapid Situation Assessment.

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1.What are Rapid Situation Assessments? 2 Rapid Situation Assessments encompass both • Consultation: RSA recognise the need to the assessment of the problem and an consult with a wide range of people, Chapter assessment of the resources available, or that including drug users.2 One might be needed, to address the problem. Rapid Assessing the problem means discovering the The aim of RSA is to uncover what is really situation type, depth and scope of the problem. happening in a community in order to design assessments Assessing the resources available to deal with and implement programs which will be the problem means appraising what resources successful in reducing the harms of injecting are available (funds, people, buildings, drug use and the spread of HIV/AIDS. knowledge) and what resources are needed.1 Rapid Situation Assessments involve Rapid Situation Assessments (RSA) use collecting information from a variety of research tools adapted from anthropology, sources. RSA make use of data such as sociology, epidemiology and evaluation government statistics and less formal research methods. RSA differ from other information from interviews with people social science investigations in: connected to or from the target group. Some • Speed: RSA are usually conducted information may be readily accessible, for rapidly (a few days to a few months) as example the number of drug arrests. Other time is of the essence when tackling sensitive information is not as easy to get – unfolding social and health problems, such as why people start injecting drugs. especially when dealing with HIV and its A person conducting an RSA might find ability to spread quickly through a themselves, in one day, wading through community. official law enforcement figures on recent • Cost: RSA are often conducted by one or drug arrests, interviewing a local community two people who work quickly to gather leader and having an informal chat with a the necessary information hence avoiding local drug user. The techniques involved in long term salaries, establishing offices and collecting these different types of so on. information are numerous and a good RSA •Use of existing data: RSA use usually involves a mix of the following information which already exists as much techniques: as possible. • Finding, examining and analysing • Use of a variety of sources: RSA use a existing information variety of sources and methods to gather • Conducting interviews with a wide range the information. This means the RSA does of people (key informants) not rely on just one source or survey. For • Focus group discussions example, an RSA may use government • Round table discussions statistics of recent drug arrests, enrolments • Observation. in rehabilitation centres, interviews with drug users etc. • Detective work: many societies deny the drug use in their communities. RSA investigate beyond government rhetoric and gather information from a wide array of sources and double check it with key informants, their own observations and official statistics. The Centre for Harm Reduction

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2. Finding and analysing existing information3

• Where do you find the information? •Annual number of drug users first, second Manual for • How do you select the information? and third entry to a detoxification centre reducing drug • How do you manage the information? • Annual number of condoms distributed related harm •How do you interpret statistics? by family planning programs in Asia • Monitoring the mass media. •Newspaper articles on drug use, policy, HIV/AIDS etc. Given that speed and cost are often of great • Records of parliamentary debates dealing consideration when conducting an RSA, with drug use and/or HIV/AIDS locating and examining information which • Annual reports from government and already exists can be of valuable assistance. non-government agencies dealing with Examining existing information should drug use and HIV/AIDS be the first step in an RSA. This information •Minutes of public meetings dealing with will give background information and ensure drugs use and HIV/AIDS. that the researcher does not waste his/her time in amassing information which already This information will be available from a exists. Collecting existing information will variety of sources including: also help in identifying gaps in knowledge. The researcher should approach the Drug treatment programs: can existing data with critical eyes and provide information about the numbers continually ask himself/herself how accurate and characteristics of drug users who the information is. seek treatment and the drugs that are being used.They may also provide contact with drug users for in-depth Where do you find interviews. the existing information? Health care facilities: including The information which already exists may hospital emergency rooms, mental health include: services, STD clinics, dermatology clinics •Official estimates of drug use and the and primary health care sites.They may number of drug users and injectors have information on the complications •Official estimates of sex workers and the arising from drug use, where drug users number of people arrested for sex work live etc. Families of drug users also often •Number and type of arrests for drug- approach doctors at general or related offences psychiatric hospitals about their family •Drugs seized, including analysis of drugs member’s drug use. for purity and dilutants •Prescription tracking STD clinics and/or the HIV •Drug use surveys surveillance system: should be able to •Number of HIV infections among drug provide you with information on HIV, users hepatitis and STDs. • Number and type of hospital admissions for drug related conditions National AIDS organisation: if one • Number of people on methadone and exists they should have useful statistics other drug substitution programs (and on and information about any programs waiting lists)4 in place. The Centre for Harm Reduction

94 SECTION Contents > Section 2-C hapter 1 2 Pharmacists and shopkeepers: if they sell needles and syringes they will How do you select Chapter probably have had contact with drug the existing information? One users, have information on how many Rapid needles and syringes they are selling etc. When beginning an RSA, researchers need to situation establish guidelines about the sort of assessments Police, prisons and other law information they are seeking otherwise much enforcement: can provide information time can be wasted wading through masses on drug related arrests, drugs seized etc. of statistics and reports which may be irrelevant. It can be useful to keep in mind: Social service agencies: may have • Relevance: clearly identify the questions, contact with drug users and their topics and issues the RSA is families. investigating. • Constraints: only collect information NGOs: may work in slum areas and/or which will be used. run facilities for youths and drug users • Time: it is usually better to concentrate or, through providing maternal and child on the most recent and up-to-date health care, have come into contact with information. For a longer term view drug users. concentrate on summaries or commentaries. Traditional healers and religious • Audience: think about who put the workers: may be dealing with drug information together and what their users through traditional medicine, motives may have been (e.g. a counselling etc. and are often consulted government report may concentrate on by families and friends of drug users. the positive, rather than negative, consequences of policy change). Journalists: may provide information • Coverage: who is described in the from their research and/or give you information? Are there people or access to newspaper files. locations left out of the data? Is the information representative? Social scientists and medical researchers: in universities or independent institutions, may have information from studies conducted with drug users or can provide information on particular patterns and behaviours.5

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• Adequacy: existing information is • Note the main findings: these will give Manual for usually produced to meet the needs and you an overview of the context in which reducing drug agendas of other people. Researchers may the RSA is taking place and will help to related harm have to work with imperfect materials identify local behaviours and the in Asia rather than spending time trying to locate experience gained from previous research. sources which answer all their questions.6 • Consider the conclusion: are any criticisms or recommendations in the document justified? Does it raise How do you manage questions for further research? Does it the information? outline any likely interventions or potential developments that the If you manage the information you collect, researcher was not aware of? and keep it in order, it will be easier to write • Record any useful references or up the RSA. Here are some hints: sources: these may have useful • Tag and date materials: including information and/or contacts, or may be details of whom and where the required in the later stages of the RSA. information came from. • Summarise the key points: summaries Remember that the information may be will allow you to quickly identify why biased. Media, political documents, the information is important, what topics government and non-government reports it covers and links to other materials. will have been written from a particular • Distribute information: to other perspective and will often cite only the members of the RSA team information which supports their argument. • File: start a filing system at the Keep in mind also that the research may have beginning of the RSA to avoid being been inadequate or badly done. overwhelmed by the information and so you can quickly locate it. How do you interpret statistics? When you have gathered the information which you think may be relevant: Statistics can seem daunting and difficult to • Determine the aim of the document: interpret but they can be important. They look at the contents page, index, abstract are routinely used by: and summary. This will help you work • government bodies out why the document was written and • heath professionals how it was structured. •economists • Identify how and when the • journalists information was collected: note down • NGOs. the method used for collecting the information and the time period the Statistics may be presented in various forms information covers. If the document is including; raw data, tables, graphs and as from a meeting note down who was at general descriptions. However they are the meeting. presented, the basic principles in interpreting them are the same:

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96 SECTION Contents > Section 2-C hapter 1 2 • Read the title: this should explain what • Can include hidden distortions: keep is being described. in mind the context in which the Chapter • Consult any notes: researchers should statistics were gathered. For example, One look at how the data were collected and drug users interviewed trying to get into Rapid who collected them. a treatment program may answer situation • Read any headings or keys: this will questions in a particular way to improve assessments outline the type of information contained their chances of getting into the program. in each cell, row or column. • Are often used to support a particular • Identify the units or labels: the data argument or conclusion: don’t accept presented may refer to whole numbers, statistics at face value, they need to be percentages, averages or the number of examined thoroughly.7 cases per 100,000 population. • Consider the conclusions: are they justifiable? Monitoring the Mass Media • Consider whether there is sufficient information to interpret the data: note Newspapers and magazines sometimes any problems in interpreting the data. publish articles about drug use and drug users that may be current and accurate. Although statistics can often appear Studying the mass media is an especially persuasive and official it is important to good way to assess how the community at remember that they: large sees the issue of drug use. It can be • Only describe the reported cases: this worthwhile to contact journalists who have is not the same as the actual cases. For displayed an interest in the subject matter example, not all treatment agencies will (e.g. have written sympathetically about comply in reporting data to a central the issues in the past). These journalists organisation and/or people in some areas can play an important role in explaining are difficult to contact. to the general public the rationale behind • Under- reporting of culturally a program aimed at reducing harm to sensitive or shameful behaviours: drug users. statistics are often collected by structured interviews or questionnaires so may miss certain behaviours or respondents may not trust the interviewers. • Use specific definitions: before something can be counted and measured it must be defined. For example, drug users may interpret certain terms differently to the researchers.

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For example, this extract from a Malaysian Manual for journalist’s article published in The Sunday reducing drug Star: related harm in Asia Harm Reduction News

Drug Users Need Options

KUALA LUMPUR, MALAYSIA sation Rumah Pengasih in methadone after 26 months, Kuala Lumpur have success although some may relapse he first step for people rates of 80 per cent. TC pro- and need another treatment” Tgiving up cigarettes, alco- grams include both a med- said Dr Alex Wodak, director hol or drugs is simply making ically based detoxification as of the Alcohol and Drug the decision to stop. well as support and under- Service, Sydney, Australia. “Unless you make the standing from Pengasih’s Methadone is no longer decision to give up drugs, staff, of whom a number are reserved to developed coun- treatment has little chance of ex-addicts. tries. Thailand, Hong Kong working” said Dave Burrows, and even Nepal, one of the poorest countries in Asia, a policy officer on injecting “Methadone is popular as drug use for the Australian have methadone programs. Federation of AIDS Organ- it allows people to Other common programs isations. Burrows has stated continue a ‘normal life’ are outreach and needle “drug users who are forced to and … eliminates needle exchange, which are even enter treatments are essen- sharing…” done in Thailand, India and tially being kept in detention Nepal. Outreach workers and are not being treated.” help the drug users by offer- This may explain why reha- Another highly effective ing medical help, informa- bilitation centres in Malaysia, treatment is methadone, a tion (such as HIV/AIDS), which are nearly all coercive, cheap synthetic treatment, counselling, support and can have a very high failure rate. that is taken as a substitute also do needle exchange. In 1994, 70 per cent of ex- for heroin. Methadone is The typical message on inmates from rehabilitation popular as it allows people to HIV prevention for the out- centres relapsed within a continue a “normal life” and reach worker is: if you can’t year. it also eliminates needle stop using drugs, then stop Alternative programs do sharing – a big plus point injecting: if you can’t do that, exist. The voluntary based today with the rise of then don’t share needles, and therapeutic community (TC) HIV/AIDS among drug users. if that’s not possible, sterilise program used by the organi- “Most people stop taking your needle with bleach.”8

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3. Conducting Interviews 2 • Who should be interviewed? A key informant is: •How do you organise an interview? • someone who is knowledgeable about the Chapter • How do you prepare for an interview? topic One •What are the various types of •someone who is currently involved in the Rapid interviews? activity of interest or has recently been situation •What can a researcher do to improve involved (e.g. a drug user or an ex-user, assessments interviews? drug treatment worker and so on) • What is observation? •someone who is important to either getting the RSA done or the program Interviews are a key part of Rapid Situation going. Assessments. Interviews will give the RSA team: The list of potential key informants is similar • people’s experiences and knowledge about to the list for sources of existing information the area of study (see page 80 of this chapter). But, • information about local meanings and importantly, key informants must also understanding of risk behaviours and include drug users. Drug users will have health consequences current information about the drugs in use, • information from people who are not drug taking behaviours and attitudes. usually consulted by government officials and policy makers9 How do you organise An RSA should involve interviews with a an interview?10 wide range of people in order to uncover Researchers should organise their interviews information about what is really happening in as soon as possible as people are busy and/or relation to drugs and HIV/AIDS rather than difficult to contact. Once a key informant is just hearing the official line. contacted you should: • explain: why you want to talk to them: Who should be interviewed? try to make them interested by discussing the importance of the RSA in a broad Some of the people you contact when you are public health sense or for the individual’s searching for existing information you may benefit also interview later on, or these people may • correct: any misconceptions they may put you in contact with people to interview. have about the RSA For example, a drug treatment worker may • assure: informants that the information be able to put you in touch with current and they provide will be confidential ex drug users. But, yet again, time restraints • negotiate: the time and date for the mean you can’t interview everyone: you will interview and mention how long it will need to work out who are the best people to take interview. • collect: contact details of the informant A key informant interview is a direct, and give them your contact details in case face-to-face meeting which is used to gather a problem occurs and the interview has to information from individuals rather than be rescheduled. from groups. These interviews are carried out with a broad cross-section of people who have some knowledge of, or contact with, the issues of drug use and HIV. The Centre for Harm Reduction

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with the existing information, has prepared Manual for How do you prepare lists of questions and has organised the time reducing drug foran interview? and place for the interview. Generally it can related harm be helpful to: in Asia It is best to conduct your interview in a quiet • Identify appropriate topics and and private place. This will make it easier for questions: think about what information both the interviewer and the key informant. the key informant may have and focus on When you are dealing with traditionally their areas of knowledge (i.e. a drug user taboo subjects, such as drug use and is unlikely to know how many people sexuality, privacy is particularly important. A have been arrested for possession of drugs drug user is more likely to talk frankly if in the last six months but may be able to away from authority figures or family tell you what methods they use to avoid members. Likewise, an official or politician arrest). may tell you quite a different story if they • Decide on the level of detail: know their comments will be taken as “off depending on which method of the record” and/or confidential. interviewing you are using (e.g. It is also useful to use a tape-recorder structured or unstructured questions – see during interviews as well as taking notes. below) you can write a list of topics you You must ask the key informants’ permission want to cover and refer to these in the to tape the interview. interview or you may devise a structured Interviews will be more successful if the questionnaire. researcher is well prepared: he/she is familiar

HARM REDUCTION NEWS

CONFIDENTIALITY: A GOLDEN RULE

NEW DELHI, INDIA interview I commented to feel free not to answer any him that everything he told questions that he didn’t want HAD met LL the previous me would be confidential, to answer. Iday and he had given me a and that his name, and any Somewhat later in the few details about the target name he mentioned would interview, when he was community and his activities describing something about in working with injecting drug injecting, he, perhaps drug users. You’re not going to let playfully, asked “you’re not “ going to let the police see During my previous con- the police see this, tacts with LL I had learned this, are you?” are you? that he is connected with the I answered that I would SHARAN outreach NGO and do all I could to protect these that he works in the slum ” notes and certainly keep area Nizamuddin West. not appear in any written them from the police and This slum area is notable form in any reports or other that it is our duty, as informa- for a high prevalence of written material. tion collectors, to protect injecting drug users as well as I also told him that his these confidential, personal pushers, and other activities. responses were entirely vol- statements from any unau- At the beginning of the untary and that he should thorised people.11

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100 SECTION Contents > Section 2-C hapter 1 2 •Draft the questions: for a more informal 2 Focus group discussions: interview it is still beneficial to have a list A focus group is an in-depth discussion where Chapter of specific questions to refer to – it is easy a small number of people gather, with a One to get sidetracked in an interview (while researcher, to discuss a particular issue or Rapid the tangent may be relevant, you want to issues. In the case of a Rapid Situation situation make sure that you also cover nominated Assessment related to injecting drug use, the assessments areas). For a structured interview the topics will relate to HIV and drug use and its questions will need to be worked out well impact on the community. Participants in ahead of time. It is worthwhile to have each focus group have something in common: your questions checked by a key they could be all ex-drug users, drug informant who may identify gaps or treatment workers or local church leaders. It is suggest areas where you may have to important to have this commonality because change the language to guard against focus group discussions are an attempt to cultural insensitivity. understand the perspectives of a certain group •Order the questions: it is easier for both of people. Focus group discussions try to reach the interviewer and the key informant if beyond superficial responses and focus on the there is a logical order to the questions. For participants’ feelings and firmly-held views on example, you may ask questions about the any given subject. type of drugs available to start with, then In a focus group discussion the researcher move onto the way people take drugs and will need to act as a facilitator, that is then to the specifics of sharing and the key encouraging members of the group to talk informant’s personal experience. Any about relevant issues. The researcher guides particularly sensitive questions are often the discussion to ensure that the discussion better off being asked later in the interview stays on the topic, covers the areas the when rapport has built up. researcher is interested in and allows, as much as possible, everybody an opportunity to talk. Focus groups are good for: What are the various types •producing a lot of information quickly of interviews? •identifying and exploring beliefs, attitudes and behaviours In an RSA you may conduct a variety of interviews. These may include: A focus group may require: 1 One-to-one key informant interviews •a location that is neutral, comfortable, 2 Focus group discussions accessible and free of interruption 3Round table discussions •a list of questions or topic areas •a tape recorder with extra tapes, batteries 1 One-to-one key informant interviews: and labels These interviews will generally involve the •a blackboard, whiteboard or paper and researcher and one key informant. A pens translator may also need to be present and •a key informant to help recruit sometimes another member of the RSA team participants may sit in to take the notes or just to observe. These interviews should allow sufficient time to cover the area of interest but also to give the interviewer and key informant the chance to relax and build up The Centre some trust. for Harm Reduction

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3 Round table discussions • if the interview looks like going on Manual for Round tables discussions bring together longer than expected check with the reducing drug people from different perspectives to discuss informant that this is okay related harm the issues. Such a discussion may include a • always collect demographic information, in Asia health worker, drug user, church leader, e.g. age, position, ethnicity, type of government representative and so on. The drug use idea is to have a broad range of attitudes and •summarise the key issues and opinions interests and yet be able to explore areas of when the interview is finished, ask the agreement and areas of disagreement. informant if there is anything that they The round table discussion will need to would like to say be structured with the researcher having a • carry health promotion leaflets and other list of questions and topics which he/she relevant information to give to the can bring the participants back to if the informant discussion gets off track. As with one-to-one interviews and focus groups, it is worthwhile taping the proceedings and taking notes. What is Observation?13 The researcher needs to be experienced in dealing with group dynamics where Along with gathering and analysing existing prominent individuals or sub-groups can information and conducting various dominate the discussion. interviews, an RSA team will also be observing what is going on. Observation allows the researcher to experience, first- What can a researcher do hand, the meanings, relationships and contexts of human behaviour and to describe to improve interviews?12 these. This may take the form of: •arrive early at the place where you are • casual or unstructured observation going to conduct the interview: try to • formal or structured observation ensure that it is quiet and private • translators should be briefed on what is Unstructured observations may occur at any going to happen time, especially at the beginning of an RSA • make sure tape recorders are working and when the researcher is collecting background have extra tapes and batteries available data on the local area; observing the types of • introduce anyone present to the drug taking behaviour and local conditions. informant and assure them of While it may be possible to take some notes confidentiality on your observations, often it is necessary to • use clear and simple language and allow write up observations later. This should be informants time to answer the questions done as soon as possible after the observation. • sensitive questions can be put by asking Structured observations use pre-selected what other people do, e.g. if a man categories to work out what needs to be wanted to buy some heroin what would observed.14 These usually occur after initial he do? research, that is after examining the existing •reflecting people’s answers back in their information and making contact with the own words is a good way of clarifying key informants. Collecting further issues information may require the observation of • be a good listener and ask how and why specific behaviours or activities, in certain places and at certain times. To help The Centre for Harm Reduction

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Harm Reduction News Chapter One Rapid Working Hard for Community Support situation assessments CHURACHANDPUR, INDIA focus group discussions they their own family or neigh- became more aware and tol- bour’s son taking drugs and hen we started every- erant. In our office we had thought that was more of a Wthing was not easy. We informal ongoing community problem than HIV. had to do the base work. We meetings. They divided into So we had to convince had a lot of focus group dis- different areas, meetings them about the benefits of cussions with different key reducing harm among drug people in the community. For “…to reduce harm users. We told them about the example: church leaders project, about health issues, among drug users takes (almost 10 per cent are materials being distributed, Christians), bureaucrats, time but we must be drop-in centres and facilities police and village authorities. patient because it is such as counselling. They We were preparing them psy- worthwhile.” asked questions about con- chologically and asking their doning free sex and drug use views. Out of those meetings, were with families and so we had to take the trouble we realised we could start our friends of IDUs. We asked to explain. It’s not easy but we project aimed at reducing them questions such as: do have to take the time: they’ll harm among drug users. you see HIV as a problem in listen even if initially they are Many issues arose, such as the town and what do you hostile. Explaining how a pro- distributing condoms and think you can do about it? gram works to reduce harm bleach. Some thought we People responded that they among drug users takes time were encouraging drug use thought HIV was not an but we must be patient and free sex but through the immediate problem but drug because it is worthwhile.”15 users were. They would see

researchers it is useful to use observational Tape recordings, videos and guides and record sheets. photographs: can provide useful records of An observational guide: is useful for observations, as long as this is agreed to by stating what should and should not be the informants. observed. The guide may include broad Sometimes a researcher may want to make reminders of what to observe, specific ongoing observations of a particular event or instructions on how to do this or precise site. For example: monitoring the types, tasks. behaviours and interactions of people who A record sheet: records the presence of a visit a known drug dealing point during a behaviour or the number of times it occurs. 24 hour period. Field notes: are the researcher’s written The researcher could note if people return account of what they have observed. Brief more than once, which direction they came notes may be made during the research, if the from, if they came on foot or by private informants don’t mind, and written up in vehicle or taxi, the police presence on the site more detail soon after. and if any outreach work was conducted.

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Manual for ARM EDUCTION EWS reducing drug H R N related harm in Asia THE HIDDEN WORLD OF ‘SHOOTING GALLERIES’

HANOI,VIETNAM (healed injection sites). She back to the Health Centre for pulled back her long black disposal. As the incinerator NCE it was clear that we hair to show us several had broken they now poured Owere not connected to infected puncture marks on petrol on the syringes and the government or the her neck. All the veins in her burnt them. police, the peer educators arms had collapsed. She had On the table was a large were willing to take us to recently had a fix, her eyes white bowl full of a murky some shooting galleries. We were pinned. She told us she black liquid: this was the caught a taxi to a southern opium. The owner of the café district of Hanoi, about 10 covered the bowl with a minutes from the centre of thatched fan when she saw the city. The area was Phuong has“ been using me looking at it. The owner extremely poor. We were opium for seven years: was also a user. taken through muddy paths at first smoking and Later, we walked further which were lined with tiny then she moved onto through the settlement to shacks on either side made of injecting.” another house. An old bamboo, old tyres and plastic woman ran the place and bags. We came to a shack said she was glad we had with low wooden benches, a could only ” afford one hit a come: “I heard you were here table, a bed in the back- day now, but when she had and I wanted to know why ground and mattresses rolled money she would have three you weren’t interviewing me” and secured in the ceiling. a day. The price depended on she said. The peer educators The shack was called a café: the dose but she generally had been visiting her for over its produce included one paid about 700 dong a year and now she provides bottle of fanta, one of sprite, (approximately 50 cents US). disposable needles and a few bowls of fruit and a Her husband had died five syringes to her customers. glass cabinet with one empty days ago: he was 36 years old. She was very proud of this beer bottle. Hanging from She told us he had decided to fact. A young man came and the bamboo were plastic stop using and had been sat with us and one of the bags; one filled with various clean for three days. On the peer educators collected packets of pills, another with fourth day he had a hit, over- three used syringes from him disposable needles and dosed and died. Phuong has and gave him three new syringes. The woman who been using opium for seven ones. In this house people ran the café looked to be in years: at first smoking and did not inject on the premis- her mid 40s and sat behind then she moved onto inject- es. The old woman would the table. She wore the usual ing. She said she wouldn’t go take clean syringes, measure polyester short shirt and back to smoking. She has the opium into a phial and loose pants. There were sev- been tested for HIV and the draw the drug up. The user eral small children running results were negative. She would take this away and about and four men and four said she now only uses a new inject somewhere else. women. needle and syringe and does The peer workers were The main person we not share. very committed to their work spoke to was Phuong, a 28 The peer outreach work- and had established an easy year old woman with a small ers come here every day and trust with the users.16 child. Her hands, feet and collect the used needle and arms were covered in scars syringes which they take

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4. Questions to ask 2 Although observation can produce rich •What are the types of questions asked and varied information, and paint a more in interviews? Chapter detailed picture than just statistics and • The questions One questionnaires, it can be affected by: Rapid • selective attention: the interests, situation experience and expectations of the What are the types of questions assessments researcher can all affect what is being asked in interviews? observed • selective interpretation: jumping to In an RSA researchers will usually use conclusions different interviewing methods at different • selective memory: the longer a researcher interviews, or in the same interview, to gain waits until writing up notes, the less the information. likely these are to be accurate and The types of questions used are called: perceptive • Semi-structured questions • ‘observer’ effects: being watched may • Structured questions mean people change their normal pattern of behaviour Semi-structured questions Semi-structured questions are generally used in more informal interviews where the topics covered are not constrained by a detailed interview guide. While the interview will still deal with key topics, the more unstructured approach allows the researcher and the informant to discuss issues which are not on an interview guide. The aim of this type of interview is to encourage informants to offer freely their opinions, information and experience. This requires the interviewer to have good communication skills: to listen carefully, to be open to new and interesting information and to be able to guide the informant away from irrelevant matters.

Structured questions Structured questions are used when a researcher wants to have more control over the topics discussed and the format of the interview.17 In this more formal sort of interview the researcher may use a detailed question guide outlining the areas to cover and even the order in which to ask them. The questions may also have to be asked exactly as they are written with no improvisation.

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Structured interviews usually occur mid Core Questions Manual for way through an RSA, after the existing The interviewer may ask these questions of reducing drug information has been analysed and many of their informants. The answers will related harm background research conducted. This helps provide a variety of perspectives on the in Asia researchers to identify areas and topics which problem and you will be able to compare and need further investigation. contrast the responses. These questions are Structured questions: semi-structured, giving the interviewer a • when they are the common format across framework to work from but he/she can each interview it can be easier to code, probe for more details at any stage. These analyse and compare the information questions are just a guide and you may add • the interview guide allows the researcher or delete questions as you see fit. to decide how long to spend on each • How many people do you think use question or topic; this can help in injectable and opioid drugs in this city? running interviews to time or in (this refers to both smokeable and prioritising the questions if time is injectable opioids and the full range of running out prescription drugs which may be • can help inexperienced researchers run injected) their interviews • In what areas of the city are drugs used? • do not allow the informant to discuss • How many people do you think are other areas not covered by the structured currently injecting? Are there some areas questions where drug injecting is more common than others? Where are those areas? •Are different drugs used in different areas? The Questions If so, which drugs tend to be used in which areas? The following section contains a series of •How are these drugs brought into the questions which you may use in interviews city or are they manufactured here? conducted in a Rapid Situation Assessment. •How are they distributed/sold? These questions are just a guide to the sort of •How are they used? issues you may wish to explore. The • Is possession of needles and syringes questions have been divided into: illegal? Core and Supplementary questions (which • Where can you obtain needles and include structured and semi-structured syringes? questions) for: •Do you think it would be feasible to 1Drug users establish a needle and syringe program in 2 Health professionals, government and law this community? enforcement officials • Do you believe drug injecting is more 3 HIV/AIDS related NGO staff and common in this city today than it was management five years ago? Two years ago? Why do 4Drug treatment staff and management you think this change has occurred? • Have you noticed any changes in drug using in this city in the last few years? Why do think these changes have occurred?

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106 SECTION Contents > Section 2-C hapter 1 2 •Do you believe that injecting drug use is Supplementary or Follow-On Questions an important issue in your city? As noted above, not everyone you interview Chapter Why/Why not? will be able to answer all of the core One • What kinds of detoxification facilities questions or give the same amount of detail. Rapid and drug treatment services do you know You will need supplementary questions for situation of in this city? Please describe their specific groups. For example: you may assessments activities. question a local doctor in a drug using area • Can a drug user get into drug treatment who treats IDUs about the sorts of in this city whenever he or she wants to? illnesses/wounds he/she has seen with these What are the obstacles to getting into patients, but you would not question a law treatment? enforcement officer about such detailed • Can a drug user get detoxified in this city medical information. The whenever he or she wants to? What are supplementary/follow-on questions will be the barriers to getting detoxified? different for each group. • Is methadone classified as an illegal drug? • Do you think a methadone treatment or 1 Supplementary questions for drug maintenance program is feasible in this users: community? Drug users can be •How many people in this city do you interviewed by using think are HIV positive? Of these, how a structured many HIV infections do you think are questionnaire and/or a directly or partly related to factors semi-structured surrounding drug injection? questionnaire. The • Do you believe HIV infection among advantage of doing both is that you will be injecting drug users is an important issue able to get a better and more accurate picture in your city? Why/why not? of drug use. For example, information about •Are there any programs/projects in this how many drugs a drug user takes in a week city to: prevent the spread of HIV among can be obtained through a structured IDUs and from drug users to other people questionnaire, but the more detailed in the community? To provide health information such as how they use the drug is assistance to current and ex-drug users best obtained through a less formal who are HIV positive? If so, please interview. describe their activities. What are the Structured questions may include: barriers to these programs/projects’ • Age effectiveness? • Sex • What types of interventions are needed in •Area where you live this city to address these issues? • Ethnicity • What policies or strategies are needed, •When did you start taking drugs? What and what policy changes are needed, to drug was that? address HIV spreading among IDUs? • If injecting, when did you start injecting? What drug was that? What drug(s) do you inject now? • What is the drug you most prefer to use? • What other drugs do you use?

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•How do you use those drugs – by • Have you ever tried to get help to stop Manual for smoking, by injection, by swallowing using drugs? If yes, were you able to find reducing drug pills? Partly or all of the time? any help? If yes, what kind of help did related harm •How much of each drug do you use in a you get? What is your opinion of this in Asia day/in a week? help – was it useful for you? How long • How much do you spend on drugs in a did you stop using drugs? week? •Do you have a girlfriend/boyfriend? •Do you usually use these drugs by • Do you have other sexual partners? yourself or with others? • Do you use condoms? •When you have injected a drug in the • Do you have sex after you have been using past week, how many times did you inject drugs? in a setting where other people were also injecting? Semi-structured/less formal questions may •What was the usual number of people include: who were injecting at the same time? • Please describe, in as much detail as you •Was it usual in these places for each drug can, how you use drugs (for all types of user to have his/her own needle and drug use, but with specific emphasis on syringe or did people share needles and injecting). So, let’s start with the drug. syringes? Say you have just bought it – what do •How many people usually share one you do next? needle and syringe in these places? • If you inject, can you please tell me about • In what places do you usually inject by the first time you injected. Where were yourself or with other people? you? Who were you with? What drug •What is the largest number of people you was it? Please describe each step of the have ever injected with? process when you first injected. •Have you ever met or seen a • What can you tell me about AIDS? “professional” injector who injects drug •What is your opinion of people who have users for a fee? HIV or AIDS? • If yes to the above, have you ever been • Do you believe AIDS is a problem you injected by a professional injector? How should worry about? Why/Why not? many times? • How many people do you know who use 2 Supplementary questions for health drugs? professionals and government health and • Do any of your friends or relatives also law enforcement officials: inject? If so, how many? • Do you have an •Do your friends who use drugs live close HIV/AIDS to each other? In what area(s) of the city strategy or do your friends live? policy related to •Have you ever tried to stop using drugs? injecting drug If so, how many times? When was the use? If so, may I most recent time you tried to stop using have a copy? drugs? •Have you produced any educational materials about HIV/AIDS and injecting drug use? If so, may I have a copy?

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108 SECTION Contents > Section 2-C hapter 1 2 •Are you aware of any educational 3 Supplementary questions for materials about HIV/AIDS and injecting HIV/AIDS related NGO Chapter drug use produced in this city or this staff/management: One state? If so, can you tell me where I might These questions are Rapid find them? designed for HIV- situation • What are the characteristics of programs, related NGOs assessments organisations, policies and strategies that working directly address drug use in this city or state? with drug users or •Of these, what are the characteristics of ex-drug users. In programs and organisations specifically cities where there are no such organisations, addressing injecting drug use and HIV three to four NGOs should be selected who infection? are likely to see drug users, at least, • How adequate and how appropriate do occasionally. you believe the following are in your city: •Do any of your programs address –legal responses to drug use (e.g. law injecting drug use? If so, please describe enforcement) them to me: –prevention of drug use or drug • How long have you been operating? problems • Number of staff and roles? –prevention of HIV transmission • Funding: from where and (if possible) among drug users how much? – care and support of drug users with • What are your activities/objectives/target HIV groups? • What are the laws relating to drug use • Co-operation with other organisations and HIV in this city/state (e.g. needle and • How adequate and how appropriate do syringe distribution and possession, drug you believe the following are in your city: possession, possession of injecting –legal responses to drug use (e.g. law equipment)? enforcement) •How are these policies and laws –prevention of drug use or drug interpreted and to what extent are they problems enforced? –prevention of HIV transmission • What is the level of political support at among drug users the national, provincial/regional, district –treatment of drug problems and local levels for effective HIV – care and support of drug users with prevention among IDUs? HIV • Does the level of political support vary in •What do you think of people who use different parts of the country? drugs? • What are the factors in the levels of •What do you think of people who use support? drugs and are infected with HIV? •Are there formal policies and/or laws which enhance implementation of an HIV prevention program for IDUs? If so what are they? •Who do you think of people who use drugs? •What do you think of people who use drugs and are infected with HIV? The Centre for Harm Reduction

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5 The Outcomes of a Rapid Situation Assessment

4 Supplementary questions for drug A Rapid Situation Assessment should Manual for treatment staff/management: provide: reducing drug • What is the •a detailed snapshot of the drug use and related harm current estimated HIV risks in a particular environment in Asia number of IDUs •a description of the locations, activities in the country? and members of IDU groups that you can • What is the target for interventions geographical • maps of city locations where risk taking distribution of behaviour is occurring and estimates of IDUs in the country? Are there more the population involved IDUs in particular regions, states or •a list of NGOs and other organisations provinces? working in the areas of interest • Is there geographical variation in the level • descriptions of the social and organisational of HIV infections among IDUs in the networks available to address HIV and drug country? If so, which use states/provinces/regions have the most •a network of key informants for future infections among IDUs and why is that? research which will help to identify how •Do you have an HIV/AIDS strategy or local organisations and communities policy related to injecting drug use? make decisions and what structures and •Do any of your programs address processes they use HIV/AIDS? If so, please describe them to • how the IDU community makes decisions me. • identification of the key issues, problems, •How long has your program been and gaps in information and service operating? provision, which the program will hope • Funding: from where and (if possible) to address how much? • What are your activities/objectives/target groups? •Do you have cooperation with other organisations? Who are they? How does it work? • How adequate and how appropriate do you believe the following are in your city: –legal responses to drug use (e.g. law enforcement) –prevention of drug use or drug problems –treatment of drug problems – care and support of drug users with HIV •What do you think of people who use drugs? •What do you think of people who use drugs and are infected with HIV?

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ARM EDUCTION EWS Chapter H R N One Rapid A RAPID SITUATION ASSESSMENT IN CAMBODIA situation assessments PHNOM PENH, CAMBODIA lasting between two to five information obtained from days. key informants. These obser- RAPID Situation Assess- Before visiting Cambodia, vations took place at various Ament (RSA) was under- and following preliminary locations such as provincial taken to determine drug use interviews with a small num- and concomitant HIV risk ber of informants, a series of behaviours in Cambodia. broad questions were identi- Multiple research techniques fied: national “newspapers and activities were used in •Is there a drug problem in … revealed frequent order to identify not only Cambodia? stories about drug what happens to those using •Are drugs such as heroin trafficking… illicit drugs but why it hap- and opium available? pens. • Which segment of Cambodian society is hospitals, ” village market involved in drug taking places or in cafes in Phnom and drug trafficking? Penh where drug trading and Multiple“ research •Are health services drug use were said to occur. techniques … were involved with drug users? Focus group discussions used… •Are there potential were also used as they are an resources in the effective way of checking and ” community to deal with consolidating information An absence of any system- drugs? (e.g. street children attending atic information about drug The interviews were open an NGO facility were inter- use in Cambodia made it nec- ended, followed a topic guide viewed). essary to consider and locate and were conducted with the In the absence of docu- numerous sources of infor- assistance of a trained Khmer mentation in Cambodia on mation to build up a picture researcher. The information drug issues, articles from two of the drug using situation. was systematically recorded English language national Key informants from govern- newspapers were systemati- ment departments (i.e. the cally perused during the study Ministry of Health), non-gov- period and revealed frequent ernment organisations Unobtrusive“ stories about drug trafficking (national and international), observations were also and money laundering. Most private and government used … of the information on the his- health care workers, sex torical background of drug workers, street children, bor- ” use in Cambodia was found der police, fishermen and by the researchers either dur- outside of the country from pharmacy owners were inter- ing, or immediately after, the research centres focusing on viewed in various regions of interview. Unobtrusive obser- Asia.18 the country. Visits to ten vations were also used to provinces took place, each enlarge and to cross check the

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Manual for Harm Reduction News reducing drug related harm in Asia Drug Use Assessment in Myanmar

YANGON, MYANMAR Nine sites in low risk areas abuse has a very bad image with few reports of drug abuse and the penalties are severe. Methodology were also included. The geo- As no single method was suffi- The Rapid Situation Assess- graphical area selected cov- cient to expose the real situa- ment was used in assessing ered about 11 per cent of the tion, multiple methods were the extent and nature of drug total townships of the country used. These included: abuse in Myanmar. It is an and included all major jails. • key informant interviews eclectic approach to data col- •group discussions Study team lection which uses multiple • informal conversations The study team consisted of sources to get multiple indica- •participant observation three psychiatrists from the tors, as no one method of data • small group discussions Drug Treatment Centres, one gathering is sufficient to • interviews with those epidemiologist, one social sci- expose the real drug abuse sit- dealing with drug users entist, two statisticians (one a uation in a community. The • interviews with drug users computer specialist), 23 RSA used both qualitative and The number of participants trained research coordinators quantitative analysis to assess interviewed was: 286 key who are doctors and 124 local the data and the information informants, 672 drug users, 90 interviewers. gathered. informal conversations and 32 small group discussions. Originally the assessment Study period was to be carried out just in The study period was divided Constraints high risk areas but more sites into three phases: Exposing the drug abuse situ- were added which extended 1 the preparatory phase – ation is not without difficulty for designing, planning as the problem tends to be “…no one method of and identifying the hidden. In addition, the data gathering is geographical areas to be addicts are stigmatised by sufficient to expose the surveyed, for selecting socio-cultural prohibition. research coordinators and real drug abuse situation The legal context of Myanmar, training them for research which implies punishment for in a community.” work drug abusers, made it more 2monitoring and making difficult to organise drug the study to 36 townships in field visits to research users’ participation and dis- all states and divisions. These areas and collecting data cuss their drug using habits, included mining areas, border and information despite the reassurance of towns, poppy cultivation 3 compiling and analysing confidentiality. The lengthy areas and high risk urban the information collected monsoon season meant the areas. The reasons for select- and the preparation of the field visits had to be carried ing these sites were: report out a month later than sched- •available statistics from uled, as the muddy roads in drug treatment centres Study method the hilly areas made villages •available media news of To estimate the exact size of inaccessible. Including more drug routes and arrests for the drug problem was a diffi- areas to be studied created dif- trafficking cult task. Although confiden- ficulties in both administra- •drug abuse is more tiality was explained before an tion and implementation. common in urban than interview was conducted, the Nevertheless, the team man- rural areas drug user, or his relatives, were aged to overcome the difficul- •drug traffickers usually sometimes reluctant to reveal ties and developed a large prefer to use border towns the addiction as it is a hidden body of research material for and mining (jade and problem especially in a coun- future use.19 The Centre ruby) areas where money try like Myanmar where drug for Harm is more available Reduction

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Summary 2

Rapid Situation Assessments Interviews and Observations Chapter Rapid Situation Assessments are an RSA interviews with key informants provide One assessment of the problem and the insights about local meanings and Rapid resources available to address the understanding about risk behaviours and situation problem. The research tools used have health consequences. Key informants are assessments been adapted from anthropology, important for information as they are: sociology, epidemiology and evaluation • knowledgeable about the topic research methods. • currently or have recently been involved in the activity of interest Rapid Situation Assessments are: • important to either getting the RSA done • conducted rapidly or the program going • inexpensive •prepared to use existing data An interview should be conducted privately • not reliant upon one source of information and will prove more successful if the • investigative of the various sources researcher is well prepared: this results from a available good understanding of the topic and a well- •consultative with a wide range of people crafted question line. Some good interview techniques to note are a quiet environment, being a good listener, using clear and simple Finding and analysing existing language and summarising key issues and information opinions at the conclusion of the interview. The types of interviews are: Some existing information can include: • one to one key informant interviews •drug surveys • focus group discussions • number and type of arrests for drug •round table discussions related offences Observations assist the researcher to Some information sources are: experience the meanings, relationships and •drug treatment programs contexts of human behaviour and to describe •health care facilities these. Observations are conducted either • National AIDS organisations casually or formally. Research tools such as an • prisons and other law enforcement observational guide of what to observe and/or agencies field notes, can be useful.

All information collected needs to be Observations can be valuable but the validity relevant, representative and sufficiently can be affected as a result of selective useful to the RSA. Ignore information that attention, selective interpretation and will not be used. selective memory. Additionally, behavioural changes can occur when a person is observed. The RSA team should, after collecting the information, address a number of key issues that include determining the aim of the document and examining their conclusions. Note that information collected can be biased or prove inadequate. The Centre for Harm Reduction

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Summary

Manual for Questions Styles Outcomes of a RSA reducing drug The two different interviewing question An RSA should: related harm methods are: •provide insight into drug use and HIV in Asia Semi-structured questions risks in a particular environment •more informal, with few limited • describe locations, activities and members constraints of IDU groups for targeted intervention • informants are free to offer opinions, • discover information gaps which a information and experience program can hope to address

Structured questions • question line more formal, orderly, detailed and with no improvisation • likely to occur after completing analysis of existing information and background research

Core and supplementary questions maybe designed for the following groups: •drug users • health professional, government and law enforcement officials • HIV/AIDS related NGO staff and management •drug treatment staff and management

Core questions are generally semi-structured and provide various perspectives on a problem. This is in contrast to supplementary questions that have been created for specific groups (i.e., drug users), allowing key informants a wider scope of questions to answer. The questions can be structured and/or semi-structured. Section Two, Chapter One: Rapid Situation Assessment

For further information refer to WHO resources:Technical Guides to Rapid Assessment and Response & Evidence for Action Papers. Refer to following websites: www.who.int/hiv (publications expected online from May 2003) & www.RARarchives.org The Centre for Harm Reduction

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CENTRE FOR HARM REDUCTION

▼▲ Rapid Situation Assessments

Rapid Situation Assessments are an assessment of the problem and of the resources available to address the problem.

The research tools used have been adapted from anthropology, sociology, epidemiology and evaluation research methods.

Rapid Situation Assessments are: ➤ conducted rapidly ➤ inexpensive ➤ prepared to use existing data ➤ not reliant upon one source of information ➤ investigative of the various sources available ➤ consultative with a wide range of people

Manual for reducing drug related harm in Asia SECTION 2 • CHAPTER 1 • OVERHEAD 1

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CENTRE FOR HARM REDUCTION

▼▲ Finding and analysing existing information

Some existing information can include: ➤ drug surveys ➤ number and type of arrests for drug related offences

Some information sources are: ➤ drug treatment programs ➤ health care facilities ➤ National AIDS organisations ➤ prisons and other law enforcement agencies

All information collected needs to be relevant, representative and sufficiently useful to the RSA.

Ignore information that will not be used.

The RSA team should, after collecting the information, address a number of key issues that include determining the aim of the document and examining their conclusions.

Note that information collected can be biased or prove inadequate.

Manual for reducing drug related harm in Asia SECTION 2 • CHAPTER 1 • OVERHEAD 2

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CENTRE FOR HARM REDUCTION

▼▲ Interviews and Observations

RSA interviews with key informants provide insights about local meanings and understanding about risk behaviours and health consequences.

Key informants are important for information as they are: ➤ knowledgeable about the topic ➤ currently or have recently been involved in the activity of interest ➤ important to either getting the RSA done or the program going

An interview should be conducted privately and will prove more successful if the researcher is well prepared: this results from a good understanding of the topic and a well- crafted question line.

Some good interview techniques to note are a quiet environment, being a good listener, using clear and simple language and summarising key issues and opinions at the conclusion of the interview.

Manual for reducing drug related harm in Asia SECTION 2 • CHAPTER 1 • OVERHEAD 3

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CENTRE FOR HARM REDUCTION

▼▲ Interviews and Observations

The types of interviews are: ➤ one to one key informant interviews ➤ focus group discussions ➤ round table discussions

Observations assist the researcher to experience the meanings, relationships and contexts of human behaviour and to describe these.

Observations are conducted either casually or formally.

Research tools such as an observational guide of what to observe and/or field notes, can be useful.

Observations can be valuable but the validity can be affected as a result of selective attention, selective interpretation and selective memory. Additionally, behavioural changes can occur when a person is observed.

Manual for reducing drug related harm in Asia SECTION 2 • CHAPTER 1 • OVERHEAD 4

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CENTRE FOR HARM REDUCTION

▼▲ Question Styles

The two different interviewing question methods are:

Semi-structured questions ➤ more informal, with few limited constraints ➤ informants are free to offer opinions, information and experience

Structured questions ➤ question line more formal, orderly, detailed and with no improvisation ➤ likely to occur after completing analysis of existing information and background research

Core and supplementary questions may be designed for the following groups: ➤ drug users ➤ health professional, government and law enforcement officials ➤ HIV/AIDS related NGO staff and management ➤ drug treatment staff and management

Core questions are generally semi-structured and provide various perspectives on a problem.

This is in contrast to supplementary questions that have been created for specific groups (i.e., drug users), allowing key informants a wider scope of questions to answer.

The questions can be structured and/or semi-structured.

Manual for reducing drug related harm in Asia SECTION 2 • CHAPTER 1 • OVERHEAD 5

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119 CENTRE FOR HARM REDUCTION

▼▲ Outcomes of a RSA

An RSA should: ➤ provide insight into drug use and HIV risks in a particular environment ➤ describe locations, activities and members of IDU groups for targeted intervention ➤ discover information gaps which a program can hope to address 120 -C hapter 1 2

Section Section >

Manual for reducing drug related harm in Asia SECTION 2 • CHAPTER 1 • OVERHEAD 6 Contents Contents

for Harm

Reduction The Centre Contents SECTION Section Two 2 Chapter Two Establishing and Sustaining aProgram

Planning the intervention Drawing up the project plan Implementing the plan Monitoring and evaluation

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Introduction

Three stages are basically involved in establishing a program: Manual for • Rapid Situation Assessment (see Chapter One) reducing drug • Selecting the appropriate mix of HIV intervention activities related harm in Asia • Implementing, managing, monitoring and evaluating the intervention activities

In other words, the process includes: • Identifying the problems • Attempting to find solutions to the problems • Establishing a project/program • Evaluating and monitoring the project/program • Reassessing and redesigning the project/program if necessary

This chapter is divided into four sections: 1 Planning the intervention: who do you target? Are there local organisations you can work with? What are the aims and objectives of the program? What activities/strategies are viable? 2 Drawing up the project plan: what is a project plan? How do you get funding? What is a budget? 3 Implementing the plan: how do you manage the program/project? What about staff? What are performance targets? 4 Monitoring and Evaluation: identifying the indicators which can be used to monitor the progress, collecting and analysing data, modifying existing interventions and developing new interventions.

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1. Planning the intervention 2 Who do you target? •lack of drug treatment facilities and Are there local organisations you can options Chapter work with? • behavioural norms that sustain needle and Two What are the aims and objectives of the syringe sharing Establishing program? • stigmatisation of drug injectors and What activities are viable? • low level of knowledge among project sustaining workers aprogram • legislation that prohibits the sale of Who do you target? needles and syringes to injectors and other legal constraints that impede activities If the Rapid Situation Assessment (RSA) has shown a need for intervention in a The sites for activities may include: community, in this case in regard to drug • towns • villages injecting or potential drug injecting and the • city areas • refugee camps risk of HIV transmission, it will be necessary • prisons • brothels1 to devise some programs to deal with these issues. There are two linked stages: Are there local organisations you 1 the identification of target groups, problems and locations; and can work with? 2 the selection of appropriate interventions An important part of the RSA will have been based on the above, the available local to identify and assess the activities of other resources and the range of current activities organisations, especially NGOs. There may be opportunities to complement the project The RSA should provide information which you are establishing with other projects will help to identify: already in existence. This can provide • target groups support and also avoids duplication of • target problems services. • sites for intervention activities The project may be located within an existing program or institution such as a The target groups may include: public health department, a university or an •non-injecting and/or injecting drug users NGO. The advantage of locating the •urban middle class or slum dwellers program within an existing organisation is •rural farmers • fishermen •truck drivers • students •drug users in or out of treatment • prisoners • occasional or recreational injectors or frequent and compulsive injectors • sexual partners of drug users • sex workers who use drugs

The target problems may include: • low levels of knowledge of HIV/AIDS The Centre among injectors for Harm Reduction

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you may be able to use their resources, for Manual for example: buildings, photocopier, telephone What are the aims and objectives reducing drug system, meeting rooms. The disadvantage is of the program? related harm that the host organisation may try to When planning a program it is essential to in Asia influence your program’s activities. For example, it may be difficult to distribute have a overriding sense of what your program needles and syringes or a disinfectant such as is trying to achieve and how you plan to a bleach within an abstinence-based drug achieve it. These aims and objectives help in program. designing the program and serve as reminder Even if your program is established and reference when you are actually running independently of existing organisations or the program. programs it is important to keep in mind Aims: are general statements which how you can work with these organisations. outline what you want to achieve through the program. For example; the aim of a program •You must be willing to network with among IDUs may be to reduce the spread of other drug-related or HIV/AIDS NGOs HIV in this population. throughout the period of implementing Objectives: are more specific and outline your program the changes required to bring about your aim. •One of the primary aims of networking For example; the objective of a program should be to build up services for IDUs in among IDUs may be to reduce needle and the long term syringe sharing in order to reduce the risk of •Organisations working with drug users HIV transmission. should also try to do some advocacy with Activities: are the aims and objectives existing HIV/AIDS organisations and law translated into action, that is, how the enforcement agencies2 objectives may be achieved. For example; the activities of a program among IDUs which A Rapid Situation Assessment in aims to reduce the spread of HIV by the Kathmandu, Nepal revealed that while there objective of reducing the sharing of needles was a need for IDUs to have access to clean and syringes may include a needle and syringe injecting equipment and HIV risk reduction program and/or the distribution of information, some IDUs also expressed the disinfectant to clean needles and syringes. need to go into drug detoxification/ Strategies: A set of activities undertaken to rehabilitation. The organisational strength of meet a specific objective constitute a strategy.3 Lifesaving & Lifegiving Society (LALS) was The strategy describes the overall approach to felt to be in doing outreach to those IDUs achieving the aims and objectives. For who had little or no access to HIV risk example: the strategy to reduce HIV reduction information. Furthermore, the RSA transmission among IDUs might be to had also revealed that there were numerous promote the cleaning of needles and syringes drug detoxification/ rehabilitation facilities. with an appropriate disinfectant. So, LALS took on outreach work but networking and referral to drug treatment facilities also became a priority area of work. Thus, LALS was able to support and What activities/strategies complement the ongoing work of other are viable? NGOs while at the same time providing a much needed service to IDUs which had not The RSA will probably have identified existed before. possible intervention activities for the The Centre for Harm particular community it investigated. The Reduction

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2. Drawing up the Project Plan 2 next stage will be to identify which activities What is a project plan? will be the most appropriate and to devise an How do you get funding? Chapter HIV prevention strategy. What is a budget? Two The strategy will generally consist of Establishing activities to reduce the risks associated with and injecting drug use. These activities may What is a project plan? sustaining include: aprogram •mass media education Before you start your project you will need to • local information campaigns draw up a project development plan. The •providing advice (to IDUs, the plan often takes the form of a project community, police, government etc.) proposal and identifies what is needed to get • information and counselling about risky the project up and running and the stages for behaviours and protective strategies the development of the project. • improving the supply and return of Start with an outline of what needs to be needles and syringes done: more details can be added in later. •providing information about syringe cleaning and providing supplies of suitable decontaminants such as bleach EXAMPLE OF PART OF A PROJECT • designing an information pamphlet with DEVELOPMENT PLAN: drug users about cleaning needles and The RSA identified the need for HIV syringes education leaflets to be distributed among • installing a incinerator for the disposal of drug injectors. used needles and syringes • establishing a drug substitution program, 1Decide on the aim and contents of the e.g. methadone leaflet. • developing outreach services to hard to 2Organise professional staff and outreach reach populations workers to assemble and review existing •providing health care in such a way as to printed material designed for drug attract target groups (e.g. delivering injectors (if any exists). primary health care to IDUs in the neighbourhood where they use drugs) 3 Find a local artist and writer to design the • introducing peer education within local leaflet. drug-using communities 4 Pre-test a selection of leaflets in focus •promoting condoms 4 groups of drug users to see which leaflet is most effective. The choice of a particular strategy may be influenced by the prevailing moral attitudes of 5 Select and/or redesign, based on the focus the government and the community to drug group results. use and sexual behaviour. If the government 6 Do a final pre-test of the leaflet in and/or the community resists certain strategies another focus group. it is important to explore why this is so: •the reasons may be soundly based on the 7Print the leaflets. community’s knowledge of their own 8Distribute the leaflets through outreach culture and history workers. • or the objectives of the program may be based on false perceptions of low risk or The Centre denial of the threat of the spread of HIV for Harm Reduction

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Often, the planned intervention among Manual for injecting drug users will consist of more than How do you get funding? one activity. While part of the plan may reducing drug An important part of planning a project is to include designing and distributing leaflets to related harm consider where you will get the money to get IDUs about HIV transmission, other in Asia the project up and running. Depending on components may include providing primary the project you may need money for: health care to IDUs, teaching IDUs how to •premises clean their needles and syringes and •office equipment providing them with the means to do so and • staff salaries so on. Each component will need to be • supplies planned. • operating expenses A project plan usually includes: • communications • the order of activities (telephone, fax, e-mail etc.) • the timetable of activities • travel •job descriptions and individual staff • training materials responsibilities for the various project activities Some questions you may consider concerning • identification of the supplies needed and funding are: how they will be distributed •How will funds be found for the project? • guidelines on collecting information for •Will funds be sought from local, national monitoring and evaluation or international funders? • guidelines for reporting the project 5 •Will money be sought from the government or private trusts and The project plan needs to show what has to foundations? be done for the project to begin. For • What obligations will you have to the example, if the activity involves distributing funders? needles and syringes or bleach these supplies have to be available before distribution can Wherever the funds are sought, it will begin, or if the project is going to employ probably be necessary to write a proposal to outreach workers the project timetable will the potential funder. have to outline how and when the workers will be recruited and when they will be trained. EXAMPLE OF A PROPOSAL OUTLINE Several activities in a project may be TO SEEK FUNDING FOR A PROJECT: running at the same time. It can be helpful 1 Explain the credibility of your organisation to draw up a flow chart to show at which 2 Explain the need for the intervention (you particular stages of the project an activity can draw on the RSA for this information). takes place. The flow chart can also 3 Give clear, specific and attainable objectives anticipate changes during the life of the for the intervention. project and help to assess the need for 4 Justify the approach you have chosen different resources at different stages.6 For 5Include the methods for evaluating the example, the training of outreach workers project (see later in this chapter) may take place at the beginning of the 6 Prepare a realistic budget (see below) project so time will need to be set aside at 7Use simple language in the proposal, avoid the beginning of the project, later on in the jargon, be brief and pay attention to the project this time may be used for other The Centre presentation of the document.7 for Harm activities. Reduction

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3. Implementing the Project Plan 2 How do you manage the What is a budget? program/project? Chapter What about staff? The budget is a plan which identifies where Two What are performance targets? you can get the money for your project and Establishing how you will use it once you have received and the money. A budget helps to show what sustaining support you may need from outside of the How do you manage aprogram organisation. It also makes sure that money is the program/project? put aside for the various needs of the project. Most programs will have a coordinator or You will need to work through the supervisor who oversees and directs the project plan (as above) to list all the items program. A program may also have a that will need to be included in the budget. management team or committee to oversee The categories in the budget should include, the running of the program. The at least: management team may have representatives from the community and experts who can •Project staff: salaries advise on the project development. If you • Non-staff costs: supplies (e.g. needles establish a management committee you will and syringes, bleach, condoms etc.), need to consider: equipment, training costs •Who will be on the committee? •Project support costs: communications • How will they be chosen? (telephone, fax, e-mail, postage) • What are their terms of reference (i.e. is it production and printing of materials an advisory team or does it have (leaflets, posters), report preparations, management powers)? car/motorbike (if necessary), public • How often will the committee meet? transport costs Other management decisions include: •Project overhead costs: non-project •Who will be managing the staff involved staff support, office accommodation, in the project? utilities, audits, insurance, bank charges, • Who will make the decisions about the office supplies project? • Who will report to whom during the project? • Who will be responsible for reporting to others (e.g. funders, government, the community)? •What form will the reporting take (see the section on monitoring and evaluation further on in this chapter)?

The coordinator, and the management team, will need to provide leadership for the project. They need to keep in mind the aims and objectives of the project. They also need to pay attention to the staff and provide support and feedback to staff who are often The Centre for Harm Reduction

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working in stressful situations. For more Once you have found your staff you should Manual for information on staff stress and burnout see set up training sessions. These sessions will reducing drug Chapter Eight: Counselling and Testing. provide basic training on: related harm • HIV/AIDS and how the virus is in Asia transmitted What about staff? • Risks associated with drug use and injecting Projects working with drug users often have •Risks associated with unprotected sex problems recruiting and maintaining staff. • Information on safer drug use and sexual Working with an often hidden and activity stigmatised population requires workers to • What the aims and objectives of the be non-judgmental, non-coercive and able project are to maintain confidentiality. It is not always •What the workers will be expected to do easy to find people who are willing to work with drug users who are often under the The training session should also look at constant threat of harassment and arrest by attitudes to drug use and drug users. This law enforcement. Many NGOs have tried to will include examining stereotypes, prejudice overcome this problem by recruiting staff and discrimination. Current or former drug from the IDU communities: users can be extremely effective as staff • current users have been recruited as peer trainers in explaining and moving beyond educators and outreach workers and have commonly held views of drug users. They proved invaluable in bridging the gap can also describe the problems that drug between users and NGOs users face. • ex-users are able to work with users In training sessions it is also important to because of the trust and credibility that focus on, and make clear, the expectations exists between the two as they are, or have and responsibilities of the staff. This may been, part of the same community. An include the importance of: important issue surrounding the hiring • Maintaining confidentiality with drug ex-users is the danger of relapse and the users associated loss of credibility with IDU •Treating drug users with respect communities. Strategies exist to overcome •Understanding the local laws this problem but NGOs hiring ex-users •Understanding any health risks and have to be aware of this real threat. taking necessary precautions • Recognising unacceptable risks and knowing how to get out of difficult situations

For more information about working with drug users and outreach see Chapter Four: Education.

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128 SECTION Contents > Section 2-C hapter 2 2 •By (date) the number of IDUs receiving What are performance targets? treatment at treatment sites will be xxx Chapter •By (date) x % of IDUs will be enrolled in a Two Performance targets show the degrees of drug substitution program Establishing change you hope to achieve in a given period and of time. Performance targets should: Performance targets help a program to analyse sustaining •Provide an overall goal and sense of how the project is progressing and, if it is not, aprogram purpose what changes need to be made. A program • Be explicit and able to be monitored will need to keep detailed records to show •Be achievable over a specified time their funders how the project is progressing. • Be challenging8 This information is also useful for the project workers and planners: to see how the project is Some of the targets will indicate the success of progressing and whether changes are implementing activities: depending on what necessary. This is an essential part of a sort of program you are involved with these program and will be discussed in more detail may include the in the next section. • number of staff trained • number of bleach bottle/packets distributed • number of people passing through the drug treatment system • number of HIV/AIDS leaflets distributed to drug users

Other targets will indicate the successful impact of the activities: depending on what sort of program you are involved with these may include the •proportion of IDUs cleaning their needles and syringes with bleach •proportion of IDUs using a new needle and syringe for each injection •proportion of IDUs using condoms •proportion of IDUs sharing needles and syringes

Depending on the program the performance targets may be written up as: •By (date) x % in the target population will be able to cite at least two acceptable ways of protecting themselves from HIV infection • By (date) x % of pharmacies will be supplying injecting equipment to IDUs on request The Centre for Harm Reduction

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4. Monitoring and Evaluation

Evaluation is a crucial part of a program. It There are three main stages of monitoring Manual for provides information about how the program and evaluating a program: reducing drug is progressing and highlights what is • Identifying the indicators which can be related harm working well and what is not. Evaluation used to monitor the progress in Asia should not be an after thought: it needs to be •Collecting and analysing data taken into account from the designing stage • Modifying existing interventions and of a program. Funds need to be made developing new interventions available for evaluation – as part of the budget. Once a program is planned and has Identifying the indicators which begun, it is important to see if the program’s can be used to monitor the activities are being carried out as planned. progress This process, called monitoring, is a continuous collection of relevant information The first task when planning for monitoring about the implementation of the program. It and evaluation as part of your program is to is the way to ensure: select which indicators will best show if your •a coordinated and organised schedule of program is meeting its aims and objectives. supervision of work and workers Indicators are the measures which will show • it results in producing the information you if the intended changes are happening. that funding agencies will want in regular The performance targets, discussed program reports earlier, are helpful for evaluation purposes in that they will have outlined specific levels of Evaluation is the process of collecting and achievement. analysing the information, at regular Two main types of evaluation should be intervals, to look at the effectiveness and the carried out: impact of the program. This may occur on: • an annual basis to assist the development Implementation Evaluation of an annual work plan This involves assessing the extent to which • or at the end of the period for which the the intervention activities have been program was planned or funded developed as planned. The questions that need to be asked are: The purpose of the evaluation is to: • assess the extent to which the intervention is meeting its aims and objectives • establish whether interventions need to be modified to make them more effective

The principles of evaluation are to: • build evaluation into the program from the beginning • use local resources •use existing information where possible • keep the evaluation simple •give feedback from the results quickly to help develop interventions9 The Centre for Harm Reduction

130 SECTION Contents > Section 2-C hapter 2 2 •Has the project been established the target population (e.g. knowledge of successfully? safer injecting practices) Chapter • Is the project reaching or attracting the – The proportion of drug users who inject Two target population? – The proportion of drug injectors who Establishing • Is the project delivering the service as share injecting equipment and intended? – The proportion of drug users who sustaining regularly clean their needles and aprogram Impact Evaluation syringes with bleach This involves assessing the extent to which the intervention has had the desired impact on the target population. The questions that need to Collecting and analysing be asked are: information • Has the desired change in the target group occurred as a result of the intervention? Why should you collect information? • Is the intervention an effective use of Information needs to be collected: resources? • to assist program managers monitor and review the progress of a program Implementation and impact indicators are the • to provide content for project reports measures which will show if the intended • to inform the community involved and activities have been implemented as planned affected by the program and if they are having the desired impact. • to show the funders how the program is Indicators give a structure to monitoring and progressing evaluation. • to use in advocacy to show Implementation indicators which show if government/police etc. the benefits of the the activities have been developed as planned program may include: • to use in articles and other publications • For the establishment of the program – The number of staff recruited and Some information is collected daily or employed weekly, for example workers at an outreach – The number of training sessions clinic will mark down attendances at the organised for the staff clinic, what services were provided, what • For reaching the target population medication and other supplies were – The number or proportion of the target distributed and so on. population contacted Other information is collected • For delivery of service periodically, such as: – The number of items of service • at the start of the program (base line data) delivered (e.g. the number of AIDS • and again at times of annual review information leaflets delivered, the • or at the end of a program evaluation number of needles and syringes distributed and collected) The periodic collection of information allows for comparison of the information over the Impact indicators which show if the activities life of the program. For example: a program have had the desired effect may include: that sets out to reduce the spread of HIV • Desired change as a result of the among IDUs, may measure the sero- intervention prevalence of HIV among IDUs who enter – Levels of HIV/AIDS awareness among the program over a number of years. This The Centre for Harm Reduction

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would involve a measure of sero-prevalence at Manual for the beginning of the project among potential Choosing impact and implementation reducing drug clients and every year afterwards among its indicators clients related harm ➤ If the objective of the intervention is in Asia to improve access to treatment for drug Who should collect the information? problems, an impact indicator could be: the Program staff usually collect the number of IDUs seeking treatment at information for the regular monitoring of the treatment sites, the number of IDUs accepted program. It is important that program into treatment and the number of IDUs managers recognise that this requires time who complete the treatment successfully. and sometimes specific training. Training of staff must be planned early on so that funds ➤ If the objective of the intervention is to for training are allowed for in the budget. increase the availability of injecting equipment Program clients can also participate by from pharmacists for IDUs, with the aim of keeping personal records (medication, needle decreasing the sharing of needles and syringes, exchange etc.). the implementation indicators could include: External evaluation is sometimes a the number of pharmacies supplying injecting requirement of a funding arrangement. equipment and the number of needles and While it can appear threatening, external syringes sold.An impact indicator could be the evaluation can be an objective way of proportion of IDUs who share injecting assessing progress and receiving input from equipment. people outside the program who are ➤ If the objective of the intervention is to experienced and familiar with programs distribute leaflets to IDUs through outreach aimed at reducing harm among drug users. workers, with the aim of increasing HIV/AIDS Participatory evaluation allows awareness, the implementation indicators could community members, including clients, to include: the number of outreach workers participate in the evaluation along with involved, the number of contacts made with program staff and/or an external evaluator. members of the target group, the average The major advantage of this approach is that length of time spent with clients and the the evaluation gains from the insights of the number of leaflets distributed. Such information target group and what is learnt through the can be gathered by asking the outreach process is retained in the community and not workers to keep a diary to record this type of taken away by people outside of the program. information.An impact indicator could be: the proportion of the target population who can cite at least two acceptable ways of protecting themselves from HIV infection 10

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132 SECTION Contents > Section 2-C hapter 2 2 What information needs to be collected? enrolled in a program) at a particular point in Only information that is useful should be time. This can then be repeated at regular Chapter collected. Information that is not used in any intervals, such as the same month every year. Two way wastes time and resources and leads to In a very large program, involving a state Establishing staff fatigue. Staff that spend valuable time in or large district, HIV prevalence may be and the collection of information can be measured in a number of regions among sustaining encouraged by seeing value placed on their selected groups of people (referred to as aprogram work through an analysis and application of sentinel groups) who are at high risk of HIV the results. transmission. In such a situation the program The information to be collected, would be said to be carrying out HIV sentinel depending on the program, may concern: surveillance. Thus trends in HIV infection are • the use of new injecting equipment monitored over time, by group and by place. • number of clients in a methadone For more information on HIV testing see program and their responses to the Chapter Eight: Counselling and Testing. program • the adopting of cleaning practices When should the information be • the general health of the clients collected? • condom usage Although the information will be collected •the training of IDU peer outreach throughout the life of the project workers (monitoring) and periodically (evaluation), it The information may be found in: must be planned for early, when the program • registers is at the planning stage. This allows for •work schedules allocation of time and also resources in the • field diaries budget. • account books Baseline surveys are usually carried out •a standard computer spreadsheet program at the beginning of the program. This allows •the minutes of meetings for comparison and a measure of progress •reports of consultations toward achieving the program’s objectives • events in the life of a program when the survey is repeated later (usually at • accounts, invoices and receipts the end of a funding cycle). Monitoring implies that the information Sero-prevalence information: is collected on a regular basis. Some In programs that specifically set out to information will be collected on a daily basis reduce the transmission of HIV among (e.g. IDUs attendance at the needle syringe IDUs, through a number interventions, an program) and for others monthly (e.g. HIV sero-prevalence study may be established. records of the regular monthly staff planning Such a study measures: meeting). • the prevalence of HIV among IDUs before the program started How is the information analysed? • and the prevalence of HIV among IDUs The way that information is analysed will periodically thereafter, usually on an depend on what sort of information it is. If annual basis the information is about numbers, rates and ratios (i.e. Quantitative data) it may be The prevalence of HIV measures the total analysed mathematically and statistically. For numbers of all HIV cases among the example: this sort of information could be population being studied (such as IDUs about the number of IDUs visiting a The Centre for Harm Reduction

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Manual for Harm Reduction News reducing drug related harm in Asia Behavioural monitoring survey among injecting drug users in Cebu City, Philippines

CEBU CITY,PHILIPPINES and consistent use of con- •Data collection (NGO) doms, the reduction of the • Analysis (PATH) he Regular Behavioural number of sexual partners, •Reporting and feedback TMonitoring Survey (BMS) the seeking of treatment is being conducted by all the from professional health The University of agencies involved in the practitioners for STDs and Southern Philippines AIDS Surveillance and not sharing and Foundation Inc., who han- Education project sponsored cleaning/bleaching of inject- dles the project in Cebu, by the Program for ing equipment. looks after the access and Appropriate technology in Conducting the BMS collection of data from the Health (PATH). The survey involves: injecting drug users. covers high risk groups: free- •Drafting of the survey Systematic fielding out and lance and registered sex (PATH) completion of the question- workers, men who have sex •Revision (NGO) naire follows. All collected with men, sex workers’ •Reformatting data are then submitted to clients and injecting drug (PATH/NGO) PATH for collation and analy- users. •Pre-testing (NGO) sis. The results are reported This survey attempts to •Revision (PATH) to the university to assist in track behaviour changes, •Final printing (PATH) project implementation. 11 particularly on the correct •Training of interviewers (PATH)

program every week, the amount of needles Who should analyse the information? and syringes distributed in a week and the Where possible, the information should be number of IDUs outreach workers have analysed by the person who collected it. The contacted in a week. Analysing this sort of person collecting the information will then information mostly requires time and a appreciate the significance and relevance and calculator. is unlikely to waste time collecting Information gathering methods that use information that is irrelevant and won’t be and analyse words, providing impressions used. This, of course, will be dependant on and context (i.e. Qualitative information), the work load of the person and whether such collect information through recorded a person has the skills for analysing the observation, interviews and group discussions information. Often, in a large program, a and cannot be analysed statistically as can specialist or the program manager will be numerical data. But this information can be: responsible for analysing the information. • categorised • summarised • used anecdotally

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134 SECTION Contents > Section 2-C hapter 2 2 • establishing self-help groups by bringing Modifying existing interventions together various groups during the Chapter and developing new evaluation Two interventions •providing social research on the local Establishing situation and How can reports be generated by •providing the opportunity for publication sustaining monitoring? •providing an opportunity to network aprogram Reports are a feature of all programs. The using the information and the results demand for reports, both formal (written) from the evaluation with in your own and informal (verbal) come from a number of country and internationally sources including: • donor agencies How can an evaluation result in program • governments changes? • the community where the program The findings of an evaluation may show, for functions example, that an intervention has not been • clients and beneficiaries established as planned and/or that it is not • the program staff themselves having the desired impact upon the target group. The evaluation information will help The nature of the reports needed, and their a program coordinator and staff to reassess formats, will vary and may differ the program and make changes to make the considerably. activities more appropriate. An evaluation of the progress of a How can feedback be stimulated by program offers the chance to look back and monitoring ? to look forward. The lessons learnt from a Programs are not just accountable to their program are brought to light by an donors but to their target group and the evaluation. These lessons, together with an wider community. Feedback to those understanding of the actual progress made intimately involved in the program, such as toward achieving the program’s objectives, IDUs, creates an opportunity for greater help to plan the program for the future. involvement of IDUs and a greater sense of As a result, objectives, targets and participation in the program. strategies are often amended in the light of Monitoring and review processes allow for an evaluation. An evaluation allows for feedback about the progress of a program. change and justifies it, to the community, the This progress can be presented at a variety of clients and to the funders. meetings, such as community, project management and staff meetings.

What are the benefits of conducting an evaluation? The benefits of conducting an evaluation may be: •creating a regional approach by sharing information with other programs •providing an opportunity to be culturally appropriate rather than always adopting strategies from other countries’ programs The Centre for Harm Reduction

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Summary

Some strategies believed to be the most Manual for Planning the Intervention appropriate to reduce the risks associated reducing drug with IDU may include: The Rapid Situation Assessment should related harm • improving the supply and return of provide information to assist with the in Asia needles and syringes identification of target groups, target •providing information about cleaning problems and the sites for intervention techniques for injecting equipment activities. Target groups may include • establishing a drug substitution program, urban middle class or slum dwellers, e.g., methadone students and sexual partners of drug • introducing peer education within local users. Target problems may include drug-using communities stigmatisation of drug injectors, inadequate knowledge of HIV/AIDS among injectors and the lack of drug treatment facilities. Intervention Drawing up the Project Plan activities may occur in towns, city areas, A project plan identifies what is needed to prisons, refugee camps and brothels. get the project functioning and the stages for the development of the project. As Identifying and assessing the roles of local interventions will often consist of more than organisations that you can work with, one activity, each component will need to be particularly NGOs, is important for gaining planned. Project plans can include: support and avoiding duplication of services. • the order and timetable of activities Locating the program within an existing •job descriptions and individual staff organisation can result in the availability of responsibilities for the various activities resources (i.e. office space). However, a host • identification of the supplies needed and organisation could influence a program’s how they will be distributed activities and, for example, create difficulties With the implementation of several activities with the distribution of needles and syringes. at the same time the introduction of a flow An independent program should have a good chart can display changes during the life of working relationship with other drug related the project. This may help to assess the need or HIV/AIDS organisations in to order build for different resources at different stages. up services for IDUs in the long term and to encourage harm reduction advocacy. A project may require money for various costs (i.e. the premises, office It is essential to know what the equipment, staff salaries, travel and program is trying to achieve and how this communications). Wherever the funds can be achieved. This is why establishing are sought (i.e. local, national, aims ( what you want to be achieve) and international, government, private trusts objectives ( outlining changes to bring and foundations) a written proposal to a about your aim) are crucial. Aims and potential funder will probably be objectives can then act as a reference necessary. during the implementation of the program. Activities are then A budget plan identifies where money implemented in order for the objectives can be sought for the project and how it will to be achieved. Lastly, strategies establish be used when it is received. Various a set of activities to be undertaken to categories in the budget will need to include The Centre meet a specific objective. for Harm Reduction

136 SECTION Contents > Section 2-C hapter 2 2 salaries for the staff, costs of supplies (i.e. needles and syringes), costs to support the Monitoring and Evaluation Chapter project (i.e. telephone and postage) and Monitoring is a continuous collection of Two project overhead costs (i.e. office Establishing accommodation). relevant information about the implementation of the program. and Evaluation is the process of collecting and sustaining analysing the information, at regular aprogram Implementing the Project Plan intervals, to look at the effectiveness and the A program can be directed by a coordinator impact of the program. This can occur on an or supervisor and may also include a annual basis or at the end of a period for management team to oversee and advise on which the program was planned and funded. the project. The team to advise can include Implementation evaluation involves community representatives and experts. It assessing the extent to which the will need to be decided who is on the team, intervention activities have been developed as how they are chosen and how often they planned. Impact evaluation involves assessing meet. the extent to which the intervention has had the desired impact on the target population. Staff recruited to the project are Indicators measure if the intended changes required to be non-judgemental, non- are occurring and give a structure to coercive and able to maintain monitoring and evaluation. confidentiality. As it may be difficult to recruit appropriate staff many NGOs seek out those from the IDU Collecting and analysing communities. Staff need to attend basic information training sessions examining some areas such as HIV/AIDS and virus Some reasons why information is collected transmission, risks associated with drug can include: use, injecting and unprotected sex, an •providing content for project reports overview of the project and the tasks that • assisting program managers to monitor are involved. Consideration of issues and review the progress of a program related to stereotypes, prejudice and • informing the community involved and discrimination of drug use and drug affected by the program users is required. Throughout the Those who should be collecting information training session expectations and can include: responsibility of the staff must be made •program staff, program clients, external clear. evaluators and community members Information to be collected can include: Performance targets show the degrees of • the use of new injecting equipment change you hope to achieve in a given point •the general health of the clients of time. A target indicating the success of •the training of IDU peer outreach implementing an activity could be, for workers example, the number of bleach bottle/packets •HIV sero-prevalence among IDUs distributed. An example to indicate the successful impact of an activity could be the proportion of IDUs cleaning their injecting equipment. The Centre for Harm Reduction

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Summary

Information should be collected during the Benefits of conducting an evaluation can Manual for following: include: reducing drug • throughout the life of the project •creating a regional approach by sharing related harm (monitoring) information with other programs in Asia • periodically (evaluation) and when the • the opportunity to be culturally program is at the planning stage appropriate and not adopting strategies from elsewhere Information is analysed in the following •providing social research on the local manner: situation and the opportunity for • Quantitative data ( numbers, rates and publication ratios) are analysed statistically • Qualitative data ( interviews, Evaluations resulting in program changes can impressions) are categorised and occur when: summarised • the findings may show an intervention has not been established as planned Analyses of the information should be done leading to a program reassessment and by the following: the need for more appropriate activities •the person who collected the information, • the ability to look back and forward can a specialist or the program manager encourage greater understanding of the progress in achieving the program’s Modifying existing interventions and objectives developing new interventions Reports are generated by monitoring for the following sources: • donor agencies, governments, clients and beneficiaries and program staff Feedback stimulated by monitoring: •creates an opportunity for greater involvement of IDUs • allows a greater sense of participation in the program

Section Two, Chapter Two: Establishing and Sustaining a Program

For further information refer to WHO resources: Monitoring and Evaluation (NAP M& E Guide) & Policy and Programming Guide for HIV Prevention Among Injecting Drug Users. Refer to the following website: www.who.int/hiv (publications expected online from May 2003) The Centre for Harm Reduction

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CENTRE FOR HARM REDUCTION

▼▲ Planning the Intervention

Target groups can include: 1. Middle class or slum dwellers 2. Students 3. Sexual partners of IDUs

Target problems can include: 1. Stigmatisation 2. Low level knowledge of HIV/AIDS among IDUs 3. Lack of drug treatment facilities

Sites for intervention activities can include: 1. City areas 2. Prisons 3. Refugee camps 4. Brothels

A program within an existing organisation has benefits but there also can be disadvantages particularly in relation to fulfilling all program activities.

It is essential to know what the program is trying to achieve and how this can be achieved.

This process involves the establishment of the following: 1. Aims 2. Objectives 3. Activities 4. Strategies

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CENTRE FOR HARM REDUCTION

▼▲ Drawing up the Project Plan

A project plan identifies what is needed to get the project functioning and the stages for the development for the project.The plan can include: ➤ the order and timetable of activities ➤ the identification of the supplies needed and how they will be distributed

A project may require money for costs involving office equipment, staff salaries and communications.

Whether the funds are sought nationally, internationally, from government or a foundation, a written proposal to a funder is likely.

Budget plans identify where money can be sought and how it will be used when it is broken down into categories.

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CENTRE FOR HARM REDUCTION

▼▲ Implementing the Project Plan

Program direction can come from a coordinator, a supervisor and/or a management team (i.e. community representatives and/or experts) to oversee the function of the project.

Staff recruited to the project are required to be non- judgemental, non-coercive and able to maintain confidentiality.

Many NGOs have indicated that seeking staff from the IDU communities can prove invaluable.

Basic training sessions for staff need to examine areas including: ➤ HIV/AIDS and virus transmission and risks associated with drug use ➤ injecting and unprotected sex ➤ an overview of the project and the tasks that are involved

Performance targets show the degrees of change that are aimed for in a given period of time.

Successful changes can be indicated by the implementation and the impact of an activity.

Manual for reducing drug related harm in Asia SECTION 2 • CHAPTER 2 • OVERHEAD 3

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CENTRE FOR HARM REDUCTION

▼▲ Monitoring and Evaluation

Monitoring ➤ a continuous collection of relevant information about the implementation of the program.

Evaluation ➤ a process of collecting and analysing the information, at regular intervals, to look at the effectiveness of the program.

Implementation evaluation involves assessing the extent to which the intervention activities have been developed as planned.

Impact evaluation involves assessing the extent to which the intervention has had the desired impact upon the target population.

Indicators show if intended changes are occurring and give a structure to monitoring and evaluation.

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CENTRE FOR HARM REDUCTION

▼▲ Collecting and analysing the information

The reasons for collecting information include: ➤ providing content for project reports ➤ program managers can monitor and review the progress of a program ➤ to inform the community involved and affected by the program

Those collecting the information can include: 1. Program staff and clients 2. External evaluators 3. Community members

Information to be collected can include: ➤ the use of new injecting equipment ➤ the general health of the clients ➤ the training of IDU peer outreach workers ➤ HIV sero-prevalence among IDUs

Information should be collected during the following: ➤ throughout the life of the project (monitoring) ➤ periodically (evaluation) and the program planning stage

Information is analysed in two ways: ➤ quantitative data – statistically and mathematically ➤ qualitative data – categorised and summarised

Information analyses should be done by the following: 1. Information collector 2. Specialist 3. Program manager

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CENTRE FOR HARM REDUCTION

▼▲ Modifying existing interventions and developing new interventions

Reports are produced by monitoring for certain sources including: 1. Donor agencies 2. Governments 3. Clients and beneficiaries 4. Program staff

Feedback stimulated by monitoring can include: ➤ the opportunity for greater involvement and sense of participation in the program for IDUs can occur

Benefits of conducting an evaluation can include: ➤ creating a regional approach through the sharing of information ➤ adopting strategies that are culturally appropriate ➤ opportunity for local social research and potential publication

Program changes following evaluations can include: ➤ discovering interventions not established as planned resulting in program reassessment and the need for more appropriate activities ➤ ability to look back and forward encourages better understanding of the progress in achieving the program’s objectives

Manual for reducing drug related harm in Asia SECTION 2 • CHAPTER 2 • OVERHEAD 6

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144 Contents SECTION Section Two 2 Chapter Three Working Together

The community Religious groups Police and law enforcement Prisons Governments

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Introduction

Successful harm reduction programs rely heavily on the support and Manual for involvement of different sectors of the community, ranging from reducing drug government leaders through to injecting drug users. related harm Without broad community support and involvement, even the best in Asia designed and funded programs will struggle to succeed. Ongoing community consultations are also critical to the success of the HIV prevention programs targeting IDUs. In this chapter we will examine the key groups to work with: 1 the community 2 religious groups 3 police and law enforcement 4 prisons 5 governments

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1.Working with the Community 2 What does community mean? village of 30,000 people. It all depends on What should the community know? your viewpoint. Chapter Why are injecting drug users a key When one considers the diversity and Three resource? complexity of IDUs and HIV it is not Working How can you mobilise community surprising that there are wide-ranging public together responses to HIV among IDUs? perceptions. These views and community What are some of the main components attitudes can have an enormous bearing on of working with the community? policies and responses towards these problems. Who should you consult? How do you organise community consultations? What should the community know? Community ownership, and participation in programs, have long been recognised as Why does HIV and drug use challenge a essential ingredients in developing effective community’s ability to respond effectively to responses to HIV/AIDS. This is especially a problem that may result in deaths and true for programs targeting injecting drug widespread suffering? The answer is often users. distance and denial. People find it is easier to The most effective responses to HIV say “AIDS won’t happen to me, it will only among IDUs have come from communities affect drug users and other high risk groups. (large and small) where HIV and drug I don’t need to worry”. injecting are seen as everyone’s problem, not Much of the denial fuelling the just a problem for health workers, injecting HIV/AIDS epidemic stems from an attitude drug users or those living with HIV/AIDS. that this disease only affects high risk groups; such as sex workers, male homosexuals or IDUs. Both governments and individuals What does community mean? have wrongly thought that they don’t need to worry about HIV/AIDS: that it only A community can be defined as a group of affects so-called high risk groups. It is, in people who have something in common and fact, high risk behaviour, rather than high will act together in their common interest. risk groups, that is of concern. This common interest may be the However, this misconception has even led neighbourhood or city people live in, it may to people saying that HIV among IDUs is a also be an area of shared interest, such as a good thing because the HIV will wipe out all local community of drug users or the global the drug users, thus cancelling out both the community of people working with HIV and drug users at the same time. HIV/AIDS. But the spread of HIV/AIDS around the Modern communications technology and world in less than two decades shows that the AIDS pandemic have each challenged this disease never stays within the one group and widened the concept of community. But or region. In several Asian countries, IDUs in the end, it is how people identify have been demonstrated to be a key vector themselves as community members that for the spread of HIV into the wider really defines the concept of community. community. Injecting drug users are mobile, For example, the way you identify with widespread and sexually active.1 IDUs are your community’s drug problems may be therefore an important group to target for very different if you live in a city of ten HIV prevention and a key resource in The Centre million people than if you live in a town or developing effective programs. for Harm Reduction

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because you’d be doing everything you think Manual for Why are injecting drug users is right and it might benefit you in your reducing drug a key resource? reports and with your government but it 2 related harm won’t be of any benefit to your clients.” As a growing number of programs are in Asia demonstrating, IDUs are one group that can be successfully targeted to prevent Injecting drug users HIV/AIDS. Injecting drug users can also be • know what they need one of the greatest assets a community or • know what the barriers are agency has when developing effective • know how to achieve what needs to be responses to HIV and drug injecting. They done (e.g. what sort of information and are the ones with the most experience and the form it should take to successfully expertise. reach IDUs) Some people spend a great deal of energy turning drug users into demons, and Although often marginalised and outcast by blaming them for everything that is wrong the community, IDUs interact regularly with with the world. Much can be gained by different members of the community; other turning drug users back into human beings: IDUs, police, health and welfare groups, by simply talking to them and, more their own friends and family. importantly, by listening to them. Program workers involved in responses to HIV and IDU are also important members in “You must take into account the culture, the their own community. social belief, the background and the history of that particular community. If the problem Community concern is drug abuse you have to take into account Many parents, police, politicians and other the history of drug abuse in the country. community members see drug use in their Whatever the intervention, if it is to be community as someone else’s problem. This successful, it needs to build and empower attitude can make it extremely difficult to the community. Empowering comes from respond to the drug use and its associated building self-esteem, giving back ego to risks and harms. Consequently, responses marginalised communities: it is not ego- have been delayed until preventable HIV breaking, it is ego-building. It is giving back infections have become fatal AIDS cases. By responsibilities and trust to the marginalised this time, what began as problems affecting communities that is essential. only a small population of drug users may have expanded to a national problem You cannot be judgemental or moralistic, affecting all sectors of the community. although many times what you are faced A community can be triggered into with is actually against your principles and action by an urgent or perceived problem. beliefs. But, with HIV/AIDS and IDUs, community You need to respond quickly.You need to concern and action often do not occur until know what the community is trying to tell people have been personally touched by you and you need to respond to it.You must knowing a drug user or person living with listen to the community.You don’t decide for HIV/AIDS. This can mean that community yourself what is best for them, you listen to mobilisation does not occur until HIV and them and you respond to what they are possibly AIDS has taken hold; usually years telling you. If you don’t do that then you’re after HIV has begun spreading in the The Centre community. for Harm not going to have a successful program Reduction

148 SECTION Contents > Section 2-C hapter 3 2 Community mobilisation • members are motivated to do something A community that is mobilised, that is aware about this vulnerability Chapter and ready to take action, has most or all of •members have practical knowledge of the Three the following characteristics: different options they can take to reduce Working • members are aware, in a detailed and their vulnerability together realistic way, of their individual and •members take action within their collective vulnerability to HIV/AIDS capability, applying their own strengths and investing their own resources including; money, labour, materials or whatever else they can contribute •members participate in decision-making about what actions to take, evaluate the results and take responsibility for both success and failure • the community seeks outside assistance and cooperation when needed3 In short, a mobilised community is one that takes responsibility for its own problems.

HARM REDUCTION NEWS

HARM REDUCTION WORKS IN SOUTH CHINA

RUILI COUNTY,CHINA mentation of a community paigns and educational activ- oriented drug demand ities relevant to different andeng village is located reduction project. With out- groups were implemented by Hin Long Dao Xiang in a side government assistance, the community. Assistance remote part of Ruili, Yunnan a village leaders’ group, par- and help were given to drug province, China. There are 77 ents’ group, women’s group, users and families of HIV households in the village publicity group and a youth positive people. HIV positive consisting of 304 residents. group were formed to carry drug users were supplied Since the 1980s, 46 drug out activities within the com- with condoms on a regular users have been identified as munity. The various groups basis. After a few years there HIV positive. During the met once a month for activi- was improved knowledge 1990s, increased drug use ties ranging from youth and significant attitudinal created other problems such forums to discuss their spe- changes to contraception as poverty, drug trafficking cific problems and needs to and issues of drug use and and violence. Handeng the implementation of pro- the risk of HIV/AIDS. Since became known, notoriously, cedures to organise detoxifi- 1991, there have been no as the ‘problem village’. In cation and rehabilitation of new cases of HIV/AIDS relat- 1991, Handeng was chosen drug users. ed to drug use.4 as a pilot site for the imple- Public awareness cam-

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Manual for Harm Reduction News reducing drug related harm in Asia The community Gets Involved

CEBU CITY,PHILIPPINES agreed on a multi-sectoral and improvement in the pre- approach. So, when the AIDS vention and control of EFORE any of the AIDS concern was presented, all HIV/AIDS among drug users. BSurveillance and Educat- those representatives reiterat- These people are current ion Projects (ASEPs) in Cebu ed the need for collaborative members of the Cebu City City, Philippines started, the work. Technical Advisory Council City Health officer called up However, they did stress for AIDS Prevention and representatives of different Control and they meet regu- sectors of the community to “…all those larly, every second Tuesday of discuss how a health issue the month. with possibly grave societal representatives They also assist in the repercussions could be reiterated the need for implementation of all ASEP resolved. collaborative work.” projects. They also call on These groups included: support and services from city government, police, that as the issue was delicate other sectors including edu- church, academics, women’s and sensitive it should have a cation, social welfare and the groups, media and rehabilita- low profile until such a time business and financial sec- tion centre members. They all as there were tangible results tors. 5

How can you mobilise What are some of the main community responses to HIV components of working with the among IDUs? community? •Organise community forums and Illicit drugs often provoke strong community consultations responses because of the passionate views, • Pilot different non-government and prejudices and ideas so many people have community-based responses, which have about this topic. You may not get such a the approval of government strong community response to a sudden • Seek funds to support local programs increase in coffee or nicotine usage among • Identify prominent community figures teenagers. But if the increase is in the use of (entertainers, politicians, journalists, etc.) heroin or some other illegal substance, to support efforts to prevent HIV among passionate responses and viewpoints are IDUs likely to both unite and divide communities. • Involve affected people (IDUs, ex-users, If you wish to develop responses to drug their families, health workers) in use and HIV that reflect the concerns and responses, responsible media coverage, needs of the community it is essential to get ongoing planning and debate out into the community and talk to people.

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ARM EDUCTION EWS Chapter H R N Three Working THE COMMUNITY TAKES OWNERSHIP together

CHURACHANDPUR, INDIA and effort to the problem of lengthy talks with the police. drug addiction. “We have chosen to live he Society for HIV/AIDS SHALOM was formed in with the lesser evil of drug Tand Lifeline Operation in 1995, after widespread com- abuse in order to curb the Manipur, (SHALOM), India, munity consultations and AIDS menace, and so far I is a program which works funding from AusAID. During have not had occasion to closely with community the first year of the project, regret my decision to allow members, district health SHALOM staff continued to the syringe and needle authorities and non govern- hold extensive consultations exchange program,” ment and government agen- with Church leaders, different Superintendent Khaute said. cies. This is possible partly tribal groups in Manipur, SHALOM could not have because SHALOM is based in drug users and their families, succeeded without the sup- a small district and township prisoners and youth. These port and “blessing” of police, where community concern formal and informal consul- government and community tations took place both before members. And this couldn’t and during the implementa- have been achieved without tion of controversial harm extensive consultations. The authorities and “ reduction measures, such as community in Manipur needle exchange. embraced their The authorities and com- experiment with harm munity in Manipur embraced …this couldn’t“ have been reduction with relative their experiment with harm achieved without ease … reduction with relative ease, extensive consultations. largely due to the extensive ” consultations carried out to about HIV among IDUs has discover what was acceptable ” been translated into commu- to the community. Civil unrest, poverty and nity ownership and action, No opposition to the nee- other problems at the time of and SHALOM is one of Asia’s dle and syringe exchange has writing mean that SHALOM first Government approved been reported and the and the people of Manipur harm reduction programs. Churachandpur Superinten- still have a long road ahead With a population of dent of Police issued orders before HIV/AIDS is under 180,000. the township of that SHALOM clients and control. But the community, Churachandpur had 3,000 staff should not be detained police and government have intravenous drug users. It for possession of needles and taken on HIV and drug use as also had a pool of highly syringes, normally a jailable their own problem and one motivated community lead- offence. This was a direct out- that they must respond to ers who had given much time come of good relations and themselves.

Who should you consult? • authorities •injecting and other drug users • police • ex-users • government officials • their families • anyone who sees themselves as part of the • school and University teachers/Students community • youth in general The Centre for Harm Reduction

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2. Religious Groups

These groups will probably have been What are the positive roles religious Manual for contacted during the Rapid Situation groups can play? reducing drug Assessment (see Chapter One: Rapid What are the negative attitudes religion related harm Situation Assessments). During the can promote? in Asia establishment of a program, and during the How can you work effectively with life of the program, contact should be religious groups and beliefs? maintained with these groups to inform them of the progress of the program and to Responses to drugs and HIV/AIDS are attempt to keep them onside. closely linked to the morals, attitudes and religious beliefs of a society or community. Religious leaders can play an important part How do you organise community in shaping attitudes and responses to HIV consultations? and drug use. This is especially true in communities where religion plays a central There are many simple ways you can organise part in people’s lives. community consultations: they can be formal On a practical level, church and religious or informal meetings. The main point is to groups often provide the “front-line” of care get out and talk to people and find out what and counselling for IDUs and people living people think, feel and need. with HIV/AIDS. Religious groups can also • Use existing community networks, have a strong influence on the ways drug use gatherings and forums (church meetings, and drug users are viewed by society. This community groups, ethnic associations, can have good and bad outcomes for the etc.) to find out people’s views on drug person with a drug dependence or HIV/AIDS use and HIV risk in the community problem. •Ask school principals if you can talk to the students about HIV/AIDS •Post a wooden box at a school, or outside your program, where young people can What are the positive roles write and leave questions about drugs and religious groups can play? HIV/AIDS • care and counselling for people affected • Convince a local radio station to run a by HIV/AIDS and illicit drugs segment where people can ring in and ask •providing hope and comfort an expert about their concerns • meeting people’s practical needs •Organise more formal consultations with (clothing, accommodation, food) IDUs, ex-users, community members or • community leadership and mobilisation other affected groups (assure •reduction in stigma and marginalisation confidentiality and perhaps also organise a for people affected by HIV/AIDS and meal) illicit drugs • Get out onto the streets and talk to • acceptance, rather than judgement, of people in shops, cafes or wherever they people and their problems gather •Talk to community members at all stages of program design and implementation

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3. Police and Law Enforcement 2 What do you need to find out? What are the negative attitudes How do you get the police to support Chapter religion can promote? your program? Three What else can you do? Working Religious groups and beliefs can also lead to together negative attitudes about drug use and HIV/ Police and law enforcement officials are AIDS, and judgemental attitudes including: central players in any response to illicit • HIV/AIDS is divine retribution for drugs. Law enforcement is an important part people’s sins because it only happens to of reducing the supply of illicit drugs. homosexuals, drug users and sex workers Despite decades of international efforts to •drug users are bad people reduce drug supply and consumption •a moral and god-fearing society won’t be through harsher penalties, specialised anti- affected by HIV/AIDS or drugs narcotics forces, and other stringent • prayer alone can save people from measures, the availability of illicit drugs in HIV/AIDS most countries continues to grow. But police and law enforcement forces can HIV/AIDS is a disease not a punishment. It also be important allies in responses to HIV does not ask if people are Hindu or Christian, infection and other harms affecting drug heterosexual or homosexual, good or bad. injectors. When developing responses to this Religious, moral or cultural beliefs do not pro- problem, the police must be consulted and vide some sort of special protection for com- hopefully involved. This should be pursued munities from HIV/AIDS. While religious whether or not the local police are beliefs and writings can be used to condemn sympathetic to the health risks posed by and judge people affected by HIV/AIDS and needle and syringe sharing, unsafe injecting drugs, they can also be interpreted and used as and overdose. powerful tools against these problems.

What do you need to find out? How can you work effectively with religious groups and beliefs? To understand police activities and their presence in relation to drug users you may • educate religious leaders about want to find out: HIV/AIDS and drug use and tell them • how many police stations are there? they have a role to play and suggest how • how do they operate? they might play that role • what are the relevant laws and penalties? •organise a meeting of religious and other • how do they interpret/enforce community leaders paraphernalia laws, e.g. finding a person • find out if churches, temples, mosques with a needle and syringe on them? and other religious institutions have • what are drug users’ rights? groups or activities targeting youth, • do they enforce the law or express HIV/AIDS or drug use community prejudice? • coordinate with church-based aid and • how many police are there in the area? welfare organisations • how active are they? • examine how religious texts (the Bible, • do they use or sell drugs? Koran, etc.) talk about compassion, forgive- • do the police harass IDUs? ness and non-judgemental approaches • what is their attitude to drug users? • find ways to meet people’s spiritual needs The Centre for Harm Reduction

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The support of senior police/narcotics be peer educators among other police Manual for enforcement personnel has been essential in •use educational opportunities, e.g., reducing drug the establishment of needle and syringe include HIV/AIDS education in police related harm programs in Asia, for example in Nepal, training courses, offer to run the course in Asia India and Vietnam. However, despite the • obtain formal agreement from the police support of senior officials, HIV prevention to suspend police activities relating to programs among IDUs can still suffer IDUs for the period when a harm harassment from local street-level police. reduction trial program is operating • visit police stations and police officers and find out their concerns How do you get the police to •organise a meeting of police and other support your program? community leaders • invite police members to be on the board •involve senior police in early or advisory group of HIV prevention consultations: to gain their permission programs targeting IDUs and ongoing support • obtain police permission, or an amnesty •educate junior level police about what the in writing, for programs attempting to program is aiming to achieve make clean needles and syringes available • use co-operative and supportive police to

Harm Reduction News

Getting the Police On Side

KUALA LUMPUR, MALAYSIA gram) who has diplomatic who were totally supportive, skills and because Karen had committed in their work and t the beginning, because these skills she went to the who you can tap into. Awe are a registered police, spoke to them and In Malaysia, there are just organisation, there wasn’t presented our case: why it so many drug users and so much of a problem with the few rehabilitation centres, we police. What was a problem, “We were amazed at have 28, but they are already was that the police who han- how some of the police overflowing and there is such dled that particular area of a high relapse rate amongst responded very town did not know that we drug users. Some of the drug existed. They would carry on positively. ” users have been in rehab doing their jobs, which was three times. So, the police are to catch drug users and put was important. We were seeing the same people over them into rehabilitation cen- amazed at how some of the and over again and the police tres, or harass them. Also police responded very posi- understand the problem. there were times when we tively. I think many times the They know the circle, they were harassed by the police impression we got of the catch the guy, send him to as well. So, it was very impor- police was “those in the field rehab and then he comes out tant that we worked with the who catch drug users,” but as and goes back to drugs.”6 police. It’s also important to we went higher up in the have a person (in the pro- hierarchy, we found people

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4. Prisons 2 Why are the risks so great in prisons? What else can you do? What can communities do? Chapter How do you reach the prisoners? • educate the police about the rights of Three drug users Working People who use illicit drugs are at great risk • educate drug users about their rights together of being sent to prison for drug offences. • establish a good relationship with the Being in prison poses major health risks for Superintendent of Police (if possible) the dependent drug user because of: • discuss with the police the idea of •the unavailability of health services identity cards for the clients of your • the high prevalence of unsafe drug program practice by inmates •arrange a meeting between program •the unavailability of sterile needles and workers and the police to educate them syringes, condoms and other barriers to about harm reduction harm • consult and include police in decision making processes Taking drugs in prison can mean: •try to personalise the issues for the police, • changes in the type of drug used: from a e.g., if you pat people down you may get less to a more potent kind stuck by a needle or imagine if the drug • increases in the risks associated with the user was your brother drug use • you may need to separate those people in • no effective reduction of drug use your program who do the liaison work with the police from those people involved in the outreach work: if IDUs see outreach workers with the police they Why are the risks may think the workers are linked to the so great in prisons? police People who are put in prison are not sealed off from the risks of HIV and AIDS. Most people who are in prison will be released back into the community. Whatever is contracted in prison can and will be passed on to the outside world once the prisoner is released. Prisons put people at great risk of HIV/AIDS because of: • overcrowding: contributes to the climate of violence and tension and the spread of HIV and TB • continued drug use: many people in prison are there because of drug offences, the atmosphere and availability of drugs doesn’t help in giving up drugs

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• unsafe injecting practices: injecting Possible harm reduction strategies in Manual for equipment is usually scarce in prisons, so prisons may include: reducing drug prisoners share their needles and syringes •providing needles and syringes to related harm (or their home-made equipment such as a prisoners: this usually meets with in Asia ball point pen) without cleaning between resistance in most communities. use, due to lack of sterilising equipment However, it may be possible if it is • unprotected sex and rape: sex between presented as a pilot program to assess its men in prison is common but condoms impact on the spread of HIV in the prison are not •providing cleaning equipment to • tattooing, skin piercing and blood prisoners: give prisoners the means to brotherhood rites: equipment is usually clean their injecting equipment (such as unsterile and shared between prisoners bleach or another disinfectant see • risk of overdose for people leaving prison Chapter Five: Injecting Safely for more if their drug tolerance has lessened information) and information about how to do it •providing condoms to prisoners: denial In Thailand,a country that has endured one about sex going on in prison will not stop of the fastest spreads of the epidemic in Asia, sex from occurring nor the spread of STDs the first wave of HIV infections occurred in including HIV/AIDS 1988 among injecting drug users. From a • setting up health care for prisoners in negligible percentage at the beginning of the prison: health checks for prisoners, tests for year, the prevalence rate among injectors TB etc. will provide an opportunity to give rose to over 40 per cent by September, prisoners information about HIV/AIDS fuelled in part by transmission of the virus as IDUs moved in and out of prison.7 How do you reach the prisoners? What can communities do? Although it may be difficult to establish a program in a prison there are ways to begin: Communities often deny that injecting drug •identify and use the groups who already use is going on in their prisons. In some visit prisons and camps: prison support countries people have put their drug using groups and networks, health workers, children in prison in the hope that they will teachers etc. stop taking drugs. But drugs and needle and • encourage prisoners to educate other syringes will find their way through the prisoners: prisoners who are well-accepted thickest and most secure of prison walls.8 and liked by the other prisoners It is not easy to establish a harm reduction • talk to prison officers about the risks of program in a prison: you need to get the HIV/AIDS authorities on side. • target families and partners of people in prison • HIV messages can be embedded in other health messages • look at ways of reducing the incidence of IDUs being locked up in the first place

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ARM EDUCTION EWS Chapter H R N Three Working JAIL SENTENCE IS NOT THE SOLUTION together

CHURACHANDPUR, INDIA in jail now for four months sleep all day, we have dinner and doesn’t know when he’ll and we sleep.” We go into one he jail is located up get out. He tells me his par- of the barrack-like buildings. Tbehind the town on a hill, ents put him in jail, similar to There is no furniture only in a dirty white walled up many of the parents of the rows of men laying on mats, building. But is not particu- young men here. They get lined against the walls. larly imposing, just barren sick of their sons doing drugs Immediately I am struck by and cold, even in the warm so they get the police to put the mixture of the sweet sun. There is a wide expanse smell of diarrhoea and ganja. of mostly empty dirt between That explains how they can the barracks, with no trees, They get“ sick of their sleep all day. no plants but also no asphalt sons doing drugs so Almost all of the 30 men in this room are IDU, almost or concrete. Down against a they get the police to far wall someone has planted all have AIDS and almost all put them in jail. a kitchen garden. will also have TB. There are We are met by a young very few men here for crimi- man who Grace introduces ” nal offences apart from using to me. She says he is very them in jail. This man tells drugs. The place is very quiet, intelligent and he accompa- me he won’t get out until his the men are too sick and nies us for the rest of the visit. parents say so. stoned to do much else but He is a wealth of information I ask the young man what lie on their mats.”9 and keen to talk. He has been the men (other prisoners) do For further information in jail ten times, freely admits all day. He says: on prisons see Chapter Nine: that he can’t break the habit “Nothing, we get up, have Specific Groups. outside of jail, and has been breakfast about 7.30 am, we

Questions to think about: Is counselling attached to testing? What messages can you give to prisoners? How can you make the sterilising of How are you going to get those messages injecting equipment more effective in to them? prison? Are there any substitution programs What treatment is available to offer to operating in your community? IDUs as an alternative to prison? How are prisoners with HIV treated in prison?

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5. Governments

Which sections of government do you The fact that injecting drug use can fall Manual for focus on? between so many different areas of reducing drug What sort of government responses have government shows the difficulty related harm there been? governments and agencies around the world in Asia How do you strike a balanced approach have in dealing effectively with the public to drug policy and HIV? health, social and legal implications of illicit Where do you begin with governments ? drug use. How do you convince governments to support your program? What sort of government Drug policies make a statement about a responses have there been? society’s fears and concerns that goes beyond the drug use issue. Governments and policy •Prohibition makers respond to these fears, often without • Supply reduction (increased border concrete evidence and research, to decide scrutiny, intensified law enforcement, a what they consider the best response to illicit “War on Drugs”) drug use. • Demand reduction (treatment, education Illicit drug use is a very difficult issue for and other means for reducing the demand governments. For example, is heroin usage for illicit drugs) primarily a legal issue, a public health issue, • Harm reduction (making safe drug use a or both? The way heroin, and other drug use, priority over the eradication of drug use, is treated by government will have a large by targeting harms like HIV, Hepatitis C, bearing on the health and welfare of users. overdoses, abscesses, and other health problems) •Drug Law Reform

Which sections of government For more detailed information on these do you focus on? responses see Section One: Background How drug use is viewed may depend on and Rationale. which section of government you speak to: • the Health Department may see HIV and drug overdose as the fundamental How do you strike a balanced problem posed by injecting drug use approach to drug policy and HIV? • the Police may be more concerned with the crime associated with illicit drugs Whatever approach governments and other • the Home Ministry or border patrol may policy making agencies take towards illicit be primarily concerned with suppressing drug use, it is important that they carefully the supply of drugs consider the full implications of their policy • the Chief Minister may be concerned with decisions. Declaring stringent bans on drug the drug problem’s overall impact on the use and prison for all offenders may sounds community, concluding that a “War on like strong leadership, but if such measures Drugs” may be the most politically and are taken in isolation from other public socially acceptable solution to a problem health concerns, more harm may occur from that affects so many sectors of society HIV than from the drug use itself.

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Harm Reduction News Chapter Three Working Harm Reduction Seen as Constructive Option together

HONG KONG,CHINA able to any drug user none of the three approaches without delay is singularly effective but n Hong Kong, the Depart- • The public education together they complement Iment of Health has given by the CEPAIDS each other and make it pos- screened nearly 20,000 body and the outreaching ser- sible to contain the problems fluid samples (blood, urine vice organised by its of drug abuse. For ideological and saliva) and by end of Working Group on Drugs reasons some treatment September 1996 only 14 and AIDS with the sup- experts, who aim at the total cases of HIV had been identi- port of SARDA, Pui Hong abstinence from all sub- fied: four of whom had devel- Self-Help Association and stances of abuse, claim that oped full blown AIDS. This other agencies harm reduction represents a relatively low infection rate, • The experimental harm defeatist attitude largely as compared with neigh- reduction clinic (includ- through lack of understand- bouring countries, can be ing needle exchange) ing of its close relationship attributed to the following operated by the Medicine with demand reduction. prevention and harm reduc- Sans Frontiers in the Whole person recovery tion measures: Vietnamese Boat People with voluntary abstinence is •Since 1985, the imple- Camps by nature the long term goal mentation of mid-term for rehabilitation, which can prevention strategies by “…risk behaviour hardly be accomplished the Department of associated with drug overnight. Meanwhile the Health: even before the taking if unchecked, harmful effects and risk first HIV case among IDU behaviour associated with often result in fatality or was discovered drug taking if unchecked, • The availability of multi- irreversible disability…” often result in fatality or irre- modality treatment sys- versible disability nullifying tem including: 21 The three reductions of sup- the rehabilitation process. Methadone Clinics, com- ply, demand and harm have However, they can be min- pulsory residential and been in practice in Hong imised or changed much numerous voluntary Kong for about two decades more expeditiously accord- placement programs but have been formally pro- ing to our experience in which makes treatment posed as a policy approach Hong Kong and elsewhere. 10 and intervention avail- only recently. Standing alone,

Uncoordinated policies may lead to a stopped overnight (if at all), so it must be clash between the goals of different agencies made safe. If not, more and more people will involved in combating drug abuse. Drug use become infected by HIV while governments is both a health and a legal problem. grapple with ways to deal with the problems Accordingly, governments must strike a of illicit drug use. balance between the need to curb illicit drug use and the reality that drug use cannot be

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Local government, government and non- Manual for government agencies working together Where do you begin with reducing drug Local government can be especially governments ? related harm important in dealing with drug use and HIV •identify allies and enemies in Asia risk: needle sharing and other unsafe drug • identify the key office holders, taking practices often occur in the streets, e.g. narcotics, police, health lanes, shooting galleries and other settings in • identify levels of government, e.g. federal, the local community. state, local Non-government and community based •promote your program as part of the organisations have often been at the forefront health policy of responses to HIV among drug injectors. • at first, informal approaches often work Non-government organisations can position better than formal approaches themselves between the government and the •use any personal contacts you have within community and provide a means of the government communication and access. They can also • approach public servants who may not be allow a government to support a program as reluctant to deal with sensitive issues as but still keep its distance. politicians, and can be a way into The threat of HIV/AIDS among IDUs is government seeing some governments and policy makers • direct support can take a long time: in Asia treat drug use as a public health indirect support can happen quite quickly problem rather than just a legal one.

How do you convince governments to support your program? • invite politicians to inaugurate programs • educate politicians and involve them on program committees • use video films as advocacy tools •provide opportunities for politicians to be acknowledged, e.g. press coverage to enhance their public profile • give politicians credit as instigators of the program, when acceptable • make contacts with the media to promote your work and make it easier for the politicians to support you • keep government officials up-to-date with the results of your program, pilot program results often have greater effect than talking •organise study tours for senior leaders of government, have experts do the training •avoid conflict: persuade – don’t bully The Centre for Harm Reduction

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Summary 2 • make sure you understand how government works, e.g. levels of power, Working with the Community Chapter bureaucracy Three • use the examples of successful harm Community ownership and participation are essential in developing successful Working reduction programs in other countries to together show that they can work responses to HIV/AIDS and targeting programs for IDUs. Effective responses You can learn a great deal by asking other to HIV among IDUs arise when the issue NGOs how they got support and cooperation is recognised as everyone’s problem. from various sectors of the community. The Unfortunately, community concern often questions may include: only arises when the problem becomes •How did you establish relationships with national and affects all sectors of the various groups: police, government, community. community and religious groups? Various approaches where the community • How successful were your approaches? takes responsibility for its problems may •What problems did you encounter ( with include: setting up a NSP, substitution, etc.)? • community forums and consultations •How did you overcome these problems? • trialling non-government and community • Have these groups’ attitudes changed based responses (government approved) since you began the program? • seeking funds to support local programs • How and why have they changed? • What are the most important areas to The attitude that the wider community focus on when establishing relationships can remain immune from the HIV/AIDS with these groups? epidemic has proven to be false. Many •How can you encourage community Asian countries have experienced IDUs involvement and ownership of the as a key vector for the spread of HIV; program and activities? these have been successfully targeted to prevent further HIV/AIDS. Although often marginalised by the community, it is vital that agencies and programs incorporate the experiences and expertise of IDUs in order to develop effective responses to HIV and drug injecting.

Addressing community concerns and their needs require consultation with various groups ranging from current IDUs and youth in general to police authorities and government officials. There are various ways to implement community consultation by formal or informal meetings but what is crucial is getting out and talking to people to find out what they think, feel and need.

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Summary

Manual for Religious Groups Prisons reducing drug Consultation with religious groups is Prison poses major health risks for drug related harm important as their leaders are often dependent drug users due to: in Asia influential in shaping attitudes and •the unavailability of health services responses among the community towards • the high prevalence of unsafe drug HIV and drug use. Religious groups can injecting practices by inmates play a positive role (i.e. care and • unavailability of clean needles and counselling for those affected by syringes, condoms and other barriers to HIV/AIDS and illicit drugs) or a negative harm role (i.e. moralising judgments about the “badness” of such actions and their As drugs, needles and syringes are certain implications). to be smuggled into prisons, strategies will be required to establish harm To work effectively with religious groups reduction programs. Successful programs and beliefs strategies may include: depend on approval by authorities. •educating religious leaders about Possible strategies include pilot needle HIV/AIDS and drug use and programs that may evolve into • coordinating with religious-based aid and permanent comprehensive programs, to welfare organisations the provision of condoms for inmates • meetings with religious and other acknowledging that sex within prisons community leaders exists.

Establishing programs within prisons Police and Law Enforcement requires various tasks such as: • identifying and gaining access to prison Police and law enforcement officials are support groups and networks, health central players in any response to illicit workers, teachers, etc. drugs. Major international efforts have • using prison peer educators who have attempted to reduce supply and good rapport with other prisoners consumption of illicit drugs but their • communication with prison officers about availability continues to rise. Through risks of HIV/AIDS ongoing consultation, police and law • incorporating HIV messages with other enforcement forces can become health messages important allies responding to both HIV and harm reduction issues. In Asia, gaining the support of senior police officials is essential for harm reduction programs but local street level police support is also important in order the programs may function freely. Various approaches have, and can be, implemented to gain their support.

The Centre for Harm Reduction

162 SECTION Contents > Section 2-C hapter 3 2 Governments must strike a balance Governments and Policy between the need to curb illicit drug use Chapter and the reality that drug use must be Three Illicit drug use is a very difficult issue for made safe. The major threat of governments to deal with. While Working HIV/AIDS among IDUs has seen some together injecting drugs and HIV is clearly a government and policy makers in Asia public health issue, police authorities view the problem not only as a legal one often associate and link illicit drugs with but as a public health concern. Within crime. Additionally, border control this context various successful strategies authorities are focused on suppressing have been and can be implemented to the supply of drugs while the ‘War on convince governments of the merit of Drugs’ is often promoted as the ultimate harm reduction programs. politically and socially acceptable solution. This situation has raised many difficulties for international governments and agencies in the effort to effectively tackle the problem of illicit drug use.

Government responses have included: • prohibition (very often ineffective as demand and consumption of illicit drugs increase) • supply reduction (a very costly exercise while illicit drug sales generate huge profits and demand for drugs remains great; the results are major difficulties in substantially reducing supply over a lengthy period of time) • demand reduction (various strategies including youth education to discourage IDU, drug substitution programs and promoting incentives and alternatives to drug use in community) • harm reduction (pragmatic approach to decrease the adverse consequences of drug use without necessarily (though still desirable) requiring a reduction in drug consumption) Section Two, Chapter Three: Working Together

For further information refer to WHO resources:Advocacy Guide & Evidence for Action Papers. Refer to the following website: www.who.int/hiv (publications expected online from May 2003) The Centre for Harm Reduction

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CENTRE FOR HARM REDUCTION

▼▲ Community

Effective responses to HIV among IDUs arise when the issue is recognised as everyone’s problem not as someone else’s problem

Community Responsibility & Approaches ➤ Community forums & consultations ➤ Trial non-government & community based responses ➤ Seek funds for activities

The wider community does not remain immune from the HIV/AIDS epidemic

Manual for reducing drug related harm in Asia SECTION 2 • CHAPTER 3 • OVERHEAD 1

CENTRE FOR HARM REDUCTION

▼▲ Community Consultation Groups

➤ Current IDUs

➤ Youth in general

➤ Police Authorities

➤ Government Officials

The Centre Manual for reducing drug related harm in Asia for Harm SECTION 2 • CHAPTER 3 • OVERHEAD 2 Reduction

164 Contents > Section 2-C hapter 3

CENTRE FOR HARM REDUCTION

▼▲ Religious Groups

Religious leaders can often have influence in shaping attitudes and responses among the community towards HIV and drug use Effective measures with religious groups ➤ Education on HIV/AIDS ➤ Coordination with religious-based aid and welfare groups ➤ Meet religious and community leaders

Manual for reducing drug related harm in Asia SECTION 2 • CHAPTER 3 • OVERHEAD 3

CENTRE FOR HARM REDUCTION

▼▲ Police/Law Enforcement

Police are important allies, ranging from the senior to local street level in enabling harm reduction programs to function freely.

Manual for reducing drug related harm in Asia The Centre SECTION 2 • CHAPTER 3 • OVERHEAD 4 for Harm Reduction

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CENTRE FOR HARM REDUCTION

▼▲ Prisons

Major Health Risks ➤ Poor or no health services ➤ Unsafe drug practices ➤ No needles, syringes or condoms

Programs within Prisons ➤ Prison support groups/networks, health workers etc ➤ Prison peer educators ➤ Information for prison officers about HIV/AIDS ➤ HIV message included with other health messages Manual for reducing drug related harm in Asia SECTION 2 • CHAPTER 3 • OVERHEAD 5

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CENTRE FOR HARM REDUCTION

▼▲ Governments and Policy

Governments and agencies have great difficulties in tackling illicit drug use.

Conflicts of approach arise, for example law enforcement versus public health issues.

Police often link illicit drugs with crime. Government Responses ➤ Prohibition ➤ Supply reduction ➤ Demand Reduction ➤ Harm Reduction

Increasingly illicit drug use is viewed as both a legal and a public health problem allowing the benefit of harm reduction to be shown

Manual for reducing drug related harm in Asia SECTION 2 • CHAPTER 3 • OVERHEAD 6

The Centre for Harm Reduction

167 Contents SECTION Section Two 2 Chapter Four Education

Educating drug users Types of education Educating police and policy makers Educating youth

The Centre for Harm Reduction

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Introduction

Education is a powerful tool in the fight against HIV/AIDS. People Manual for cannot even begin to change behaviours which put them at risk if: reducing drug • they don’t know which behaviours are putting them at risk related harm •or, if they do know what is risky, they don’t know the ways to minimise the in Asia risk (e.g. using condoms, not sharing needles and syringes, cleaning equipment with disinfectant).

This chapter examines the ways that education can be used in programs aimed at reducing the harm to drug users in Asia and will look specifically at: 1 Educating drug users 2Types of education 3 Educating police and policy makers 4 Educating youth

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1. Educating Drug Users 2 What is the role of education What is effective in an HIV prevention for drug users? program among IDUs? Chapter What is effective in an HIV prevention • having a non-judgmental perspective and Four program among IDUs? accepting that there are many different Education What are some of the principles of work types of people who inject drugs with drug users? •providing information/education about What options are available? HIV transmission and how to prevent transmission, based on an understanding What is the role of education for drug of risk behaviours users? • enhancing injectors’ ability to care for Three elements are needed for successful HIV themselves prevention programs among any group or • targeting everyday injecting behaviour population: •providing a variety of means to prevent • information/education transmission (e.g. needles and syringes, • health and social services bleach) or links information messages •a supportive societal environment1 with the means of prevention and other health and social services The education of drug users generally means • is carried out in a supportive peer attempting to persuade drug injectors to environment2 change their behaviour or to practise safer injecting behaviour. The behaviour change(s) What are some of the principles of sought by these interventions aim to prevent working with drug users? the transmission of HIV which can occur •emphasis on short-term pragmatic goals through sharing needles and syringes, and (e.g. preventing HIV transmission in a other injecting equipment, or through sexual specific circumstance) over long-term transmission. idealistic goals (e.g. stopping drug use) The behaviour changes sought generally • establishment of a scale of behaviours to range from: assist people in achieving specific goals • stopping injecting to using a full new • use of multiple strategies to achieve goals set of injection equipment for every • involvement of people with experience of injection to drug injection in the planning, design, • cleaning needles and syringes before re- production and implementation of all using them programs through recruitment of current • and being monogamous and/or using (or ex) drug users to paid and voluntary condoms for penetrative sex employment, and advisory, project and steering committees Apart from this type of approach, there are other education methods where drug users What options are available? work with other drug users to determine their • Stop using drugs: if you do not use education needs and to meet those needs: injectable drugs you cannot catch researching, interpreting and weighing up infectious diseases through sharing scientific and other data to make decisions. injecting equipment • If you can’t stop using drugs, use them in any way except injecting: if you do not inject drugs, you cannot catch infectious diseases through sharing injection The Centre equipment for Harm Reduction

171 Contents > Section 2-C hapter 4

• If you inject, do not share needles, These include: Manual for cookers/spoons or filters with other drug •Mass media campaigns by governments reducing drug users, use new injecting equipment every •Targeted campaigns by governments related harm time: if you use new injection equipment •Educational/information materials from in Asia every time, you cannot catch viral treatment agencies infections such as HIV •Educational/information materials • If you need to re-use any equipment, use developed and produced by drug users your own injecting equipment every themselves (often through IDU groups) time: if you re-use your own injection •Pre and post HIV antibody test equipment every time, you cannot catch counselling viral infections such as HIV (unless •Group education at IDU group offices someone else has used your equipment and treatment centres without your knowledge) • One-to-one education sessions by drugs • If you need to re-use any equipment and counsellors, GPs, needle and syringe you believe you need to use someone else’s program workers, and other health care equipment (needle or equipment workers sharing), clean needles and syringes by an •One-to-one education by drug users approved method: cleaning reduces the trained by needle and syringe program risk, but there is some risk of HIV workers, drugs treatment centres and transmission after needle cleaning, and IDU groups there is certainly a risk of hepatitis C • Peer education with drug users by drug transmission users with no connection to formal Programs which aim to reduce harm to drug organisations users attempt to assist drug users to move • One-to-one and group education by from the more risky activities to the less researchers risky activities. What sort of behaviour change needs to What sort of education can be useful? happen for programs to be successful? Injecting drug users are marginalised in most Three levels of behaviour change need to be societies, and drug injecting or the use of tackled for effective HIV prevention among injectable drugs is illegal in almost all of the injecting drug users. countries where they are practised. IDUs are 1. Information and education: on the often referred to as a hidden population and are individual level each drug user needs difficult to reach. There is good reason for information and education about: this: most IDUs’ experiences of the –HIV and AIDS authorities have involved discrimination and – HIV transmission through sharing often imprisonment. This means it is not injecting equipment easy to reach IDUs with health education – HIV transmission through messages and specifically with HIV unprotected sex prevention education. – The ways to prevent transmission A range of sources of education is useful Most effective education programs are linked as they can reinforce each other’s messages. A to ways of providing the means to prevent large number of settings and sources for infection: this will normally include HIV prevention education aimed at injecting condoms and some form of assistance in drug users can be found. acquiring new injecting equipment and/or cleaning injecting equipment. The Centre for Harm Reduction

172 SECTION Contents > Section 2-C hapter 4 2 2. Communication and negotiation skills: What is one-to-one education? On a wider level communication between One to one education can take place in a Chapter one drug user and another (or others) needs range of settings. In outreach work, this type Four to be developed. The focus is on negotiating of education usually involves: Education skills, both for negotiating safer sex and safer •Making contact with a drug user injecting. For example, if one drug user •Creating rapport (establishing trust) wants to use new equipment to remain free • Engaging the drug user in conversation of infection but his/her friend does not have •Providing HIV prevention education new equipment, the user needs to be able to deal with the situation. One strategy might One to one education will not work if the be to provide training in cleaning needles outreach worker is the one doing all the and syringes and to encourage users to have talking. An outreach worker should begin by appropriate materials (e.g. bleach) at hand. finding out the drug user’s perspective rather than imposing his/her own. 3. Social and community network: • Find out what their concerns and needs The social network or community (e.g. are (e.g. some medical assistance for groups of friends or acquaintances) with injecting related wounds or TB) whom drug users buy, consume and, perhaps, • Earn and gain their acceptance and trust sell drugs needs to be approached. Drug (put yourself in their shoes: why should injecting social networks are largely based on they trust you?) the shared knowledge and practices of • Be reliable – do what you say you will do injecting drugs, rather than on any wider •Offer to help them move towards safer sense of being part of the same community.3 injecting or offer to help them maintain At this level, the focus is on changing or safer injecting practices. This may maintaining social norms of behaviour. For include: example, if most drug users in a given social •distributing needles and syringes and network share their needles and syringes, it other injecting equipment will be much harder for an individual user to •distributing bleach or other disinfectants maintain safer behaviour. In this situation, an • conducting cleaning demonstrations intervention may attempt to change the •conducting safer injecting demonstrations “norm” of needle sharing so that it becomes normal for members of this social network to use new injecting equipment every time they inject.

Types of Education Education efforts among drug users can be classified as: •one-to-one education • face-to-face group education • targeted education •mass media campaigns

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Manual for ARM EDUCTION EWS reducing drug H R N related harm in Asia HOLISTIC AND HUMANE

KUALA LUMPUR, MALAYSIA ment on the street. We also people are expecting you. brought biscuits etc. to give Eventually, we set up a e didn’t have an office to people on the streets. base in a small office...people Win Chowkit, so we What is important is to keep then had a place to rest that would park the car there and going back and keep up a was safe. Then you could talk go to the streets and give the about HIV and AIDS and tell IDUs bleach and teach them them what it is, how it affects how to clean their needles. their lives and how impor- Twice with water, twice with …he has“ maggots tant it is to take it into con- bleach, twice with water crawling out of his sideration. again. But then we realised legs, he is going to die So really what we did was this wasn’t going to work: he … how could he pay go down to the street and see has maggots crawling out of any notice to HIV… what people needed. From his legs, he is going to die, that time onwards it has just HIV is so invisible, how could been a process of finding out he pay any notice to HIV, he ” their needs and responding needs something more con- constant rapport with peo- to them immediately. All this crete in front of his eyes. ple. One of the major things is done in a non-judgmental So what we did, during we had was every Monday, manner – that is the main our outreach, was incorpo- Wednesday and Friday we’d thing.” 4 rate iodine and gauze so that go out and whatever hap- we could do medical treat- pens you go that day because

• assistance to gain access to detoxification employing each type of outreach worker but and drug treatment programs the disadvantages seem to be lessened by •assistance with housing, employment, employing mixed groups and providing medical treatment etc. appropriate training and supervision. Providing education to drug users, without Outreach necessarily trying to persuade them to go In most countries, outreach is provided by into treatment, can be an effective way to non-government organisations and involves build up trust with drug users. However, in teams of ex-drug users, current users and/or Asian countries, HIV prevention education non-users. Outreach education may change may have to be linked to drug treatment, at between workers: depending on the drug use least initially, for two reasons: status of the outreach worker. For example, a • this approach may be the only politically drug user employed as an outreach worker viable way of working with drug users may be primarily working with his/her •drug treatment services are an established friends and their interaction will be very infrastructure which can begin this type different to the situation of an ex-user who of education work quickly and cheaply: a may see his/her primary role as ensuring that separate outreach program may take the drug user enters drug treatment. many months to establish and require a The Centre for Harm There are benefits and disadvantages to bigger budget to begin the work. Reduction

174 SECTION Contents > Section 2-C hapter 4 2

Harm Reduction News Chapter Four Education One Big Family

CALCUTTA, INDIA of the time spent at the drop- abscesses, cuts, wounds or in centre. They provide edu- infections are treated at the n Calcutta, the Indian cation about how HIV, drop-in centre. Referrals are ICouncil of Medical hepatitis B and C are spread provided to detoxification Research has established a and how abscesses can centres, hospitals, sexually needle exchange and out- occur, together with preven- transmitted disease clinics reach education centre and tuberculosis clinics. staffed by current injecting “We love the user In a group interview, the drug users. The outreach because we think we are outreach workers said they workers are based at a drop- were better able to under- one big family.” in centre in the inner sub- stand drug users because of urb/ward of Mehidibagan, their own drug use: “If users and provide outreach to six tion information. Needles, have a trouble, we know it. other wards. Outreach takes syringes, condoms, bleach Users are happy to talk to us. place for about two hours containers and cotton We love the user because we each morning and evening, soaked in antiseptic are pro- think we are one big family.” five days a week, with the rest vided, and any minor

Other settings Counselling and Testing). Education, in One-to-one education also occurs within these situations, can be extremely effective in institutional settings such as drug treatment making the issues of HIV or hepatitis a centres, prisons, hospitals, etc. In these reality for clients and in impressing upon settings, one to one education is often carried them the need for safe behaviours. out as part of a wider range of counselling activities. People working in these settings need to balance the need for education, which will assist a drug user to remain as healthy as possible, with the need to respect the operating philosophy of the institution. For example: a psychiatrist in Calcutta was concerned about demonstrations of how to clean needles and syringes at his drug treatment centre. He thought the sight of these objects would act as “triggers” on the cravings of the recovering drug user. Where these problems occur, targeted education resources can be useful. One-to-one education also occurs as part of pre and post test counselling for HIV or hepatitis antibody tests (see Chapter Eight: The Centre for Harm Reduction

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Manual for ARM EDUCTION EWS reducing drug H R N related harm in Asia STREET OUTREACH HAS MESSAGE OF MERIT

KUALA LUMPUR, MALAYSIA outreach is restricted to 1-2 to shooting galleries, we have hours per week, usually on a to look at the situation. We enghasi Bakti Kasih (PBK) Saturday or a Wednesday have information cards we Pwas established in 1995 night. Young people at risk of can give. If they’re still high, to provide education and HIV, drug users and sex they can’t be talked to, we support to drug users in the workers are the main targets just say you’re always wel- Chow Kit area of Kuala of street outreach. The main come, though we ask them to Lumpur, Malaysia. The pro- purpose of the outreach is to eventually get detoxified. If ject was established by encourage drug users to visit we can talk to them, we tell Persatuan Pengasih PBK’s drop-in centre and them how to clean needles, Malaysia, a therapeutic com- consider stopping drug use. use condoms with your wife, munity which provides long- The secondary purpose is to if you want to have a (HIV) term residential rehabilita- provide education on test we can help you with tion for drug users, based on counselling. If they have the principles of Islam and wounds, we can often do nursing on the spot. We Narcotics Anonymous. Street If they have wounds, outreach has formed only a “ sometimes go out and leave we can often do small part of PBK’s activities. bottles of bleach and instruc- For the last two years out- nursing on the spot. tions for cleaning. We have a reach has been provided to lot of trouble with this, about 650 current drug users ” because carrying kits and and people at risk on the HIV/AIDS transmission and helping others clean can trig- streets and in the shopping prevention. ger problems for volunteers. malls. The main reason for One staff member said Volunteers are well trained this low number is that street “When we do street outreach but it’s hard.”

What is group education? provide support and information and Group education can also be provided in a encourage safer behaviours. range of settings. Group education relies on Peer education/support programs may be: the notion that drug users form social • set up and run by the target group, e.g. networks which can have a positive effect on adrug user group or their capacity to maintain safer behaviours.5 • based within a professional organisation, Targeting social networks of IDUs has e.g. a health service or drug aid become increasingly popular in recent years, organisation. 7 especially when it is coupled with peer education.6 In reality most peer projects lie somewhere Peer education means people within a between the two: a peer support group subculture or community, such as drug users, supported by an organisation or an devise education strategies for their peers organisation relying on the expertise of which they believe will be appropriate and drug users. then deliver these messages. The aim is to The Centre for Harm Reduction

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Harm Reduction News Chapter Four Peer Educators Embrace Empathy Education

HO CHI MINH CITY,VIETNAM Usually everything goes effective way of communica- really well. We get to under- tion and education. We just irstly, we all go to the stand each other quickly. console, encourage and Fward’s authority and ask This is an advantage of us advise people with all our for the list of people regarded having once been drug heart, we really have no as having social evils. Then addicts. I think peer educa- power to control or suppress we go to the people’s houses. tion is the quickest and most them. If they want to quit Through the conversations drugs we help them with the we know or sometimes they “…peer education is the formalities.” tell us that they are HIV posi- quickest and most Mr.T. is a member of the tive. It depends on the peo- effective way of ‘Friends Helping Friends’ community support group in ple’s attitude and behaviour communication and whether or not we tell them Ho Chi Minh City,Vietnam. we are HIV positive. education.”

Peer education has been used throughout current circumstances. In this approach, drug the communities and networks affected by users create a safe using language and invent HIV and AIDS in many countries as an safer ways to inject. This leads to a effective way to promote behaviour change for: supportive peer environment in their •HIV prevention, particularly for young friendship networks, and allows the people development of materials for “friendly, • for programs about sex supportive” education rather than lecturing. • covert or illegal issues such as drug use • for socially marginalised behaviours.8

In a formal peer education workshop, drug users learn some basic information about HIV including transmission and prevention. In some cases, participants of these groups are also given training in how to pass this information on to other people.

Drug user groups Drug user groups use a different form of group education. Injecting drug user groups often speak of peer education not as “teaching” by a “good user” to change the behaviour of another drug user. Rather, they talk of drug users sharing information on how to inject as safely as possible, given their The Centre for Harm Reduction

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Manual for ARM EDUCTION EWS reducing drug H R N related harm in Asia ‘SHOOTERS’ DISPLAY CARE FOR OTHERS

CEBU CITY,PHILIPPINES of their unsafe injecting, and STDs and HIV/AIDS and sexual practices among their other blood borne diseases if n Barangay Kamagayan partners who also worked as they continued their unsafe I(Cebu, Philippines) the freelance sex workers. practices. After a series of injecting drug users have Ligaya, a community meetings where they were organised themselves into an health outreach worker educated about safe injecting organisation called Shooters (CHOW), who was once an and sexual practices, the which stands for the Sterile IDU herself, initiated a members of Shooters gave Hypodermic Organised the knowledge to new and Outreach Team Educating uninformed IDUs. and Reaching Out to Save For the two years of its …the members of Lives. Shooters is composed “ existence, Shooters has only of 10 IDUs, one of whom is Shooters gave the had six active members who the owner of a shooting knowledge to new and frequently meet in shooting gallery. uninformed IDUs.” galleries. They continue to Shooters was organised as educate IDUs about safe a response to the comm- ” injecting practices. Some of unity’s health problems. The meeting with 10 IDUs. The the members of Shooters majority of the people in approach for such a meeting have been incarcerated, Kamagayan blamed the IDUs was to discuss relevant some have been rehabilitated for an outbreak of malaria issues. During the meeting and some have changed their and hepatitis A and B in 1992. they discussed the possibility lifestyles. 9 They believed it was because of having an epidemic of

Using the drug user group approach, effective •provides information in a way that enables peer education: users to pass the information on • supports the sharing of information • shares power between drug users, rather within networks of users, thus respecting than a formal program which places peer the knowledge, experience and skills drug educators in a position of authority and users already have knowledge over other users •places less emphasis on what is the correct • is based on trust and respect 10 way to inject and more emphasis on why Other types of group education using sterile water (or any other strategy) Apart from peer education, there is a range of may make injecting safer other types of group education, with the • acknowledges that drug users are an information often provided by an extraordinarily diverse group requiring authoritative figure such as a doctor, education in a range of formats and styles epidemiologist, drug treatment worker or • is based on an understanding of the NGO worker. These sessions tend to follow a cultural and situational aspects of similar pattern to the formal peer education injecting for each social or friendship sessions described above. But the control over network The Centre the information, and the education drug users for Harm Reduction

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Harm Reduction News Chapter Four Self-esteem Boost for Ex-users Education

CHURACHANDPUR, INDIA security reasons. For exam- in programs really helps: they ple, one might be tempted to are street wise, they know the e had two drop-in cen- take the drugs but because a ins and outs of the drug Wtres and the outreach friend is there they resist. scene. They can really make workers had to go in pairs Getting ex-users involved an impact on someone firstly, because being an ex- thinking about giving up. user they’d see their old “Getting ex-users They, too, feel that they have friends and all the familiar involved in programs a job, are being accepted peddlers, so they’d be very really helps…” back into society and this tempted. Secondly, it was for helps their self-confidence.11

receive, rests with the person leading the What is targeted education? workshop. Unless this person has a clear idea Targeted campaigns/programs which aim to of the educational needs of the participants, reach a wider audience can: this type of group education may be • raise awareness about HIV/AIDS among ineffective. IDUs Group education also takes place in •provide information/education in a way institutional settings, such as in drug that appeals to IDUs, in language and treatment centres and jails, where HIV visual materials they understand and trust education is often raised as a topic for group • personalise HIV prevention for sub- discussion. But the institution’s policies may populations of drug users not allow full and frank discussion of the various ways that HIV can be transmitted These programs can involve posters, videos, and steps that can be taken to reduce the risk newsletters, keyrings, drug packaging, of transmission. advertising on syringes and toilet doors, In drug treatment agencies, participants booklets, events, etc. or, can use more are usually encouraged to believe that they traditional channels of communication such will remain drug-free after they leave the as street theatre and musical groups. program therefore removing the need to When designing materials for targeted learn specific details about HIV prevention campaigns, consideration must be given to: (such as needle and syringe cleaning • cultural acceptability techniques) while in treatment. Some • literacy levels (e.g. may need to use treatment centres believe that the high rate pictures rather than words) of relapse after treatment (estimated to •preferred way of receiving information average 95 per cent worldwide) means that • available resources (e.g. printing drug users in recovery need explicit materials, publishing) information about safe injecting so that they know how to protect themselves and others if The important features of targeted they return to injecting. campaigns for IDUs are that: The Centre for Harm Reduction

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Manual for ARM EDUCTION EWS reducing drug H R N related harm in Asia REHABILITATION CENTRE PROVIDES HOPE

NEW DELHI, INDIA tional phase, before return- including group dynamics, ing to independent living. psychotherapy, group coun- ahara House is a rehabili- The schedule is similar to selling or a talk from an ex- Station centre in New other rehabilitation pro- resident now working and Delhi, India. It operates from grams, except that there are living independently. a three storey house with only two absolute rules: HIV/AIDS prevention educa- about 12 rooms, housing tion is provided in these about 100-150 clients per group sessions. year. Sahara House takes in a Residents are also wide range of people: people Residents“ are asked informed about the other with low-level psychiatric for a six-month programs operating in Delhi problems, alcohol users, commitment… so that, if they leave or if they brown sugar smokers and are found using drugs on the heroin injectors. Some peo- premises and are asked to ple have both psychiatric and everyone is” woken at 5am leave, they know about drug use problems. and everyone must play foot- places where they can Residents are asked for a ball. Apart from that, there acquire needles and syringes, six-month commitment, and are devotions twice a day, information, advice and sub- are usually requested to and ‘input’ twice a day, which stitution drugs. spend three months in a can be about anything resi- halfway house, as a transi- dents would like to know,

• current drug users are involved in all Another popular form of targeted aspects of the campaign communication is a drug users’ newsletter or • campaigns use media, language and magazine. These have been produced by drug images closely associated with drug users users in countries around the world. To date, • they are explicit in their messages (to the only Asian users’ newsletter has been prevent misunderstanding and confusion): Beyond Appearances, which was started in this is the main reason they cannot May 1997 by a group of users and ex-users in usually be part of a mass media campaign Delhi. In this publication, articles are provided on drug users’ rights under the Targeted campaigns, and outreach, in some Indian Constitution, safer injecting, HIV countries are managed and operated by awareness, the role of drug user groups and current and/or ex-drug users. As drug users experiences of harassment and drug learn more about HIV/AIDS, they begin to treatment. Beyond Appearances was develop safer ways to use drugs. These originally only printed in English but now is messages about safer injecting are then distributed to IDUs on the streets: the Hindi spread through their drug using social version is handwritten, xeroxed and then networks. distributed. A support group of the same name has been established with 100 members who meet twice a month. The Centre for Harm Reduction

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Harm Reduction News Chapter Four Education Messages Target Injecting Drug Users

NEW DELHI, INDIA •Ensure there are no posters could be very prob- bubbles in syringe lematic (in terms of negative HARAN drop-in centre in •Dispose of syringe in safe media coverage, political SNizamuddin in New place interference, etc.) if they were Delhi, India has several small put up on every electricity pole in Delhi. Because the posters on its walls providing “…the posters are specific instructions about posters are carefully targeted safer injection. Messages carefully targeted…” – they are only on display in include: SHARAN offices and the • Always use your own These posters were designed drop-in centre – they are able needle and syringe in English on a computer, to provide specific, explicit •Rotate injecting sites then printed on a colour information to assist in regularly printer. Hand-written Hindi reducing harm from drug • Clean injecting site with versions accompany the use. alcohol swab English posters. These

HIV PREVENTION FOCUSSED ON DRUG USERS

YANGON, MYANMAR tures drawn by Myanmar 2,500 IDUs each year. During artists and two wooden penis the second phase of the pro- he Myanmar National models to demonstrate cor- ject, peer education activities TAIDS program and the rect condom use. were initiated for the drug UNDCP estimate that the The medical staff from six users who could then find HIV prevalence rate among detoxification centre were other IDUs in the shooting drug users in Kachin state is galleries and provide infor- 93 per cent, and in the north- mation about HIV preven- ern Shan state 82 per cent. A tion. In early 1997, a cam- …a campaign began … program to educate drug “ paign began to promote risk users in detoxification cen- using mobile teams reducing behaviour among tres, and to train the centres’ who reached IDUs in the IDUs by using mobile health workers in HIV pre- tea shops and shooting teams who reached IDUs in vention, was devised to galleries. tea shops and shooting gal- address this major problem. leries. Educators from A training kit Smarter than ” Christian organisations are AIDS was created which trained: the new skills specially trained to use the included an information enabled them to organise kit, demonstrate condom use manual written in the local educational sessions for the and show IDUs how to pre- language, a board to display IDUs. They deliver training pare bleach to clean needles plastic covered colour pic- sessions for approximately and syringes.12

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Manual for Harm Reduction News reducing drug related harm in Asia Realistic Strategies for HIV Prevention

YUNNAN PROVINCE, CHINA stood that the demonstration to good trainers’ guiding of the sterilisation of the nee- skills, it was important to be nformation from the dles and syringes was not flexible with the training IYunnan Centre for AIDS meant as encouragement for method and make adjust- Research in China shows that continuing intravenous drug ments to the program as of all the HIV positive persons use but as a realistic consid- required. While the three day monitored in Yunnan, about eration for when they were training did not provide suf- 70 per cent, are injecting drug discharged from the detoxifi- ficient time to fulfil all the users. It was decided that an cation centre. practical needs of the education training course Distrust and suspicion trainees, what did emerge should be implemented for a was newly developed skills of group of drug users under “We did not know China self protection and knowl- treatment in a compulsory had such people as you edge about STDs and AIDS detoxification centre. There prevention. Some trainees who would reach out to were thirty young trainees, commented: “We did not both male and female, with a give us real help.” know China had such people history of sex work among as you who would reach out the women and most having are common problems to give us real help”. At the experienced widespread encountered when imple- end of the session the sharing of injecting equip- menting training among trainees admitted that absti- ment. The training program drug users. To resolve this nence would not be easy, focused on basic knowledge problem, it was important to indicating that they may about AIDS/STDs and pre- make the training more engage in sex work and drug vention, drug use and AIDS interesting and lively. Games, use activities in the future. and demonstrations of vari- role playing, group discus- What has been learnt is that ous techniques (i.e. how to sions and illustrative charts this training program may be use condoms correctly and are powerful means of a realistic strategy for HIV how to sterilise needles and enhancing the trainees’ sense prevention among drug syringes). The trainees under- of involvement. In addition users. 13

What is mass media education?

Mass media advertising campaigns are rarely useful in preventing HIV transmission among injecting drug users because, mostly, the campaigns do not provide explicit advice. However, the mass media can be useful in other ways. As the mass media is the main source of general information on HIV/AIDS for many drug users, it is important that appropriate messages be conveyed in these media. Mass media approval (or, more often, The Centre for Harm disapproval) of education programs can have Reduction

182 SECTION Contents > Section 2-C hapter 4 2 a very important impact on the program’s It is important to gain as much effectiveness. community support as possible to ensure a Chapter Various strategies can be used in dealing successful program. Education by liaison and Four with the media when establishing education consultation to help build this support can Education programs about HIV among IDUs: be done both formally and informally: • ask senior journalists and editors in a city •a formal occasion might be a half-yearly or state to attend a meeting where the or yearly report to the local council on the problems of rapid HIV transmission program’s activities among drug users and the proposed • an informal consultation might be a education interventions are described and private talk with key individuals to find discussed out whether they would support a new • select one or more journalists who seem initiative ‘friendly’ to the idea of helping to reduce harm to drug users and work with them In these consultations, it is useful to have to provide news stories supporting some scientific papers or other reports that programs can assist in showing community leaders and •ignore all media on the basis that they policy makers that a program is needed and cannot be trusted to be supportive and to that it can work. These documents may come maintain a low profile for your program from the Rapid Situation Assessment (see Chapter One: Rapid Situation Assessment). Educating the police and policy makers What are some useful strategies for consultation? How do you successfully educate Building coalitions the police and policy makers? Find other individuals and organisations who It is important to remember that programs are trying to carry out HIV prevention, and among drug users do not occur in isolation: work with them for the changes that are they need the assistance of other individuals needed. A project may have the support of a and organisations. The context in which local charity group who have access to programs are carried out includes: important people in the area. This can lead to •the laws, customs and traditions of a meetings and discussions at a senior level. society (or subgroups within the society) • the rules and philosophy of dominant Identifying common issues religions When working with others, identify: •the political climate and beliefs of those • the most important issues common to all who hold key posts such as the Prime of the groups in the coalition: this can Minister and Minister for Health assist groups to concentrate on those issues where they can work together Several different cultures (for example, ethnic • the issues which are the most pressing groups), political beliefs (conservative and and important to drug users and/or which progressive), customs and so on can exist in a will lessen the HIV risk among IDUs: single city or local area at the same time. All seek assistance from other coalition of these need to be taken into account by members to achieve these goals. people setting up or operating programs. The Centre for Harm Reduction

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In many situations, 10 or 20 different groups Manual for or individuals may be able to influence a Educating Youth reducing drug decision. It is important to find out who has related harm the power to assist or obstruct a program, What do countries concentrate on when in Asia and try to win their support. an HIV epidemic begins? At the beginning of an HIV epidemic among Why is it important to liaise with the drug users, most countries concentrate on police? attempting to prevent people from starting Police are probably the most important to use illicit drugs or, if they have started, group to work with to ensure success for persuading them to stop. This may be done programs aimed at reducing harm to drug through: users. In some Asian countries, other law •mass media campaigns warning of the enforcement groups such as the military or dangers of drug use (including para-military forces may also be important. HIV/AIDS) The police will already know of the problem • youth and school activities to prevent with drug users: they will probably have put drug use many IDUs into prison and/or detoxification •programs to sign young people to a camps and seen that it does not work well. A contract in which they vow never to use program can position itself as finding and illicit drugs providing a ‘solution’ to the police’s problem. Throughout the world, stories are told of Why don’t these programs work? the obstacles that police (often individuals Unfortunately, these programs, have not by rather than in a concerted action) have placed themselves prevented a single HIV epidemic in the way of needle and syringe programs among drug users anywhere in the world. and other programs. It is vital to keep up The reasons for this failure are: liaison with the police and to ensure that • at the beginning of an epidemic, HIV they understand the role of the program and tends to affect injecting drug users who the reasons for its introduction. have usually been injecting for several Much care is needed in balancing a years and who are not at school or in program’s relationship with the police to its youth settings and who therefore ignore relationship with drug users. Even a hint of or do not receive the messages collusion or collaboration with the police, •IDUs have been told by virtually circulating among clients, can cause a everyone (family, police, courts, doctors, program enormous credibility problems. At nurses) for many years that they must the same time, the police may ask for details give up using drugs. But they continue to about drug use in the area (as part of their take drugs in the face of significant health intelligence-gathering exercise). It is up to dangers, arrest, prison, etc. A mass media program managers to judge how close the campaign is not sufficient to change their relationship can and should be with the local behaviour (and may be counter- police. For more information on working productive if IDUs believe HIV is just with police see Chapter Three: Working another tool used by governments to Together. demand they stop using drugs) • there are very good reasons to inject drugs, especially for regular users, including economic reasons: these cannot be dealt with simply by talking about The Centre for Harm the dangers of AIDS or other risks from Reduction drug use

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ARM EDUCTION EWS Chapter H R N Four Education HARSH PENALTIES FOR CARRYING SYRINGES

YANGON, MYANMAR reached by mobile health Police and law enforcement educating teams. The law systems need to be discour- he time was not right, in against the non-medical pos- aged from confiscating T1997, to establish a nee- session of syringes needs to syringes, warned of the dan- dle and syringe exchange ger to themselves when han- program in Myanmar. dling them and persuaded Success depends heavily on that they are not essential in The law against the an agreement with the police “ the prosecution of offenders. that they will not arrest drug non-medical Only when these issues are users carrying syringes (cur- possession of syringes resolved can more effective rently a person, particularly a needs to be changed… HIV prevention and risk edu- young person, found in pos- cation programs for injecting session of a syringe and/or ” drug users be implemented needle is liable to be arrested be changed to allow personal at the grassroots level by and charged), those visiting possession of syringes and to more non-government shooting galleries and those regularise their availability. organisations (NGOs).”14

POLICE HARASSMENT FADES

KATHMANDU, NEPAL One time I was with Chief of Narcotics and they Aaron (the co-founder of knew what he was doing. nitially, we didn’t have LALS) and the police had Because I spoke Nepali it was Itrouble with the police. come to pick him up: they’d easier for me. There was a place, a temple noticed something was hap- At some stage the Chief of where a lot of drug users pening and wanted to take Narcotics communicated were hanging out and we’d be him to the police station. I with the police, so after a meeting early in the morn- happened to be there too so I while we weren’t personally ing. It was right next to the harassed. Every now and Army barracks and the army then, when the CHOWS people would come and pay (Community Health Out- homage and people were We never“ had to bail reach Workers) were out, the curious to see what we were anyone out of prison. police would approach them doing there and whether it but it would be okay because was legal. ” the organisation was regis- Another area where it asked: ‘Is there a problem?’ I tered as an NGO. ‘If you have became an issue was in explained what we were any questions, call the office’ Thamel, a tourist area where doing and it was okay. I never was usually what we said. We there were a lot of police got picked up by the police never had to bail anyone out around, and in Durbar Square but Aaron did, probably of prison.”15 where the police headquar- because he was a foreigner. ters for Kathmandu are. Aaron had spoken to the

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Summary

•drug users do not believe governments Manual for and people in authority, they rely on their Educating Drug Users reducing drug friends and other drug users for accurate A principal educational approach for drug related harm information. If they see that their friends users is to encourage a change in their in Asia have HIV and are not sick, they think behaviour, to practise safer injecting HIV is not a problem and that the behaviour. government is trying to trick them. Various behavioural changes range from: • no longer injecting Drug prevention programs are largely • using a new set of injecting equipment for symbolic in nature. They allow parents, every injection policy makers, politicians and others to say • cleaning needles and syringes before re- they are doing something about drugs using them without addressing the root causes of drug • ‘faithful to one partner’ and/or using use, which are often boredom, alienation, condoms for penetrative sex unemployment, poverty, rapid social and economic changes and so on. Effective HIV prevention programs among In a comprehensive study of US school IDUs include: drug education programs in 1988, in which •a non-judgmental perspective 350 different programs were reviewed, only • information/education about HIV three reported reductions in alcohol, tobacco transmission or drug use. One of the most popular •encourage responsibility and self care programs, DARE, in which 20,000 police •provide the means to prevent transmission officers delivered drug education to 25 • encourage a supportive peer environment million school students, has shown no long term effects. Principles of Educating Hidden While drugs prevention education Populations programs have their place in a holistic • Short-term pragmatic goals over long approach to managing drug use and HIV term idealistic goals prevention, emphasis needs to be placed on • Scale of behaviours assist in achieving those programs which will: specific goals • assist young people to protect themselves •Multiple strategies to achieve goals from HIV infection • Involve those with experience of drug • involve credible outreach and targeted injecting (current or ex-drug users) communications throughout all stages of the program

Programs aimed at reducing harm attempt to assist drug users to move from more risky activities to less risky activities Dissemination of health education messages for IDUs, with specific focus on HIV prevention, can be achieved through various settings and sources. Targeted campaigns by governments, provision of education/information materials from treatment agencies and the use of peer The Centre educators are just some of the ways to for Harm educate this often hidden population. Reduction

186 SECTION Contents > Section 2-C hapter 4 2 Police Types of Education • Good rapport essential Chapter •Maintain balanced credibility Four One to one •Depth of relationship with police must be Education •Trust done with discernment • Conversations •Preventive education

Group Education Educating the youth • Peer education • Simply “say ‘NO’ to drugs” = failure •Workshops •Drug prevention programs largely •Transfer of knowledge symbolic • Sharing of information •Widespread aversion to examine the root • Authoritative figures e.g. doctor of drug taking problem • Institutional settings e.g. jail • Holistic education drug programs have validity Targeted education • Emphasis must be on • Clear and simple information/education 1. Protection against HIV infection • Posters, booklets, newsletters etc 2. Credible outreach with targeted • Issues of cultural acceptability, literacy communication levels, etc • Explicit information • Involvement of current drug users Basic Education Principles for throughout all stages of the program Programs Mass Media •broad categorisation of drugs including •Non explicitness = confusion = alcohol, nicotine and illicit drugs ineffectiveness • total abstinence from all drugs for most •Mass media can help spread effective people is unrealistic information • major determinant of the difference • Can assist in the implementation of between use and abuse is context various strategies • Can create supportive public environment Section Two, Chapter Four: Education

Educating policy makers and For further information refer to police WHO resources: Policy and Programming Guide for HIV Policy makers Prevention Among Injecting Drug •Local community support essential Users,Training Guides (Outreach), •Liaisons and consultation, both formal Advocacy Guide & Evidence for and informal Action Papers. Refer to the • Strategies for building coalitions following website: www.who.int/hiv • Identification of common issues (publications expected online from •Locating those with major influence and May 2003) establishing support networks The Centre for Harm Reduction

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CENTRE FOR HARM REDUCTION

▼▲ Drug users need to be encouraged to change behaviour or practise safe injecting

Behavioural changes ➤ Quit injecting

➤ Use clean injecting equipment for each injection

➤ Clean injecting equipment before re-use

➤ Being faithful to one partner and/ or use condoms

Manual for reducing drug related harm in Asia SECTION 2 • CHAPTER 4 • OVERHEAD 1

CENTRE FOR HARM REDUCTION

▼▲ Effective HIV programs for IDUs

➤ Perspective aimed at reducing harm

➤ Information/Education

➤ Encourage responsibility and self care

➤ Means to prevent transmission

➤ Supportive peer environment

The Centre Manual for reducing drug related harm in Asia for Harm SECTION 2 • CHAPTER 4 • OVERHEAD 2 Reduction

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CENTRE FOR HARM REDUCTION

▼▲ Principles of programs reducing harm among drug users

➤ Short term pragmatic goals

➤ Scale of behaviours

➤ Multiple Strategies

➤ Current or ex-drug users involved at all stages of program

Manual for reducing drug related harm in Asia SECTION 2 • CHAPTER 4 • OVERHEAD 3

CENTRE FOR HARM REDUCTION

▼▲ Types of Education

➤ One to one

➤ Group education

➤ Targeted education

➤ Mass media

Manual for reducing drug related harm in Asia The Centre SECTION 2 • CHAPTER 4 • OVERHEAD 4 for Harm Reduction

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CENTRE FOR HARM REDUCTION

▼▲ Educating Policy Makers & Police

➤ Local community support essential

➤ Liaisons/consultation both formal and informal

➤ Strategic coalitions

➤ Common issues identified

➤ Establish network with the influential

➤ Good rapport and balanced credibility with police

➤ Relationship with police is discerning

Manual for reducing drug related harm in Asia SECTION 2 • CHAPTER 4 • OVERHEAD 5

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CENTRE FOR HARM REDUCTION

▼▲ Educating Youth

➤ Accept youth realities

➤ Symbolism of drug prevention programs

➤ Aversion to the root of drug taking

➤ Holistic drug education have validity

➤ Emphasis on HIV protection & credible outreach with targeted communication

Basic Education Principles for Programs ➤ Broad categorisation of drugs

➤ Total abstinence is unrealistic

➤ Difference between use & abuse is context

Manual for reducing drug related harm in Asia SECTION 2 • CHAPTER 4 • OVERHEAD 6

The Centre for Harm Reduction

191 Contents SECTION Section Two 2 Chapter Five Injecting Safely

Sharing of injecting equipment Increasing IDUs awareness of HIV The supply of sterile equipment The disinfection of used equipment The disposal of unsterile equipment

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Introduction

The objectives for establishing programs dealing specifically with Manual for injecting drug use are: reducing drug • to reduce the spread of HIV among IDUs related harm • to reduce the spread of HIV among non-IDUs in Asia • to reduce the spread of HIV through sexual transmission • to reduce the spread of blood borne viruses • to reduce other harms connected with drug use (overdoses, abscesses etc.)

This chapter explores issues related to injecting drug use including discussion of: 1 Sharing of injecting equipment 2 Increasing IDUs’ awareness of HIV 3 The supply of sterile equipment 4 Safer injecting 5 The disinfection of used equipment 6 The disposal of unsterile equipment

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1. Sharing of Injecting Equipment 2 What are blood borne viruses? The lack of clean injecting equipment Why does sharing happen? In many countries needles and syringes Chapter What are other reasons for sharing? cannot be bought from shops or pharmacies. Five What are the ways that sharing occurs? In other countries, you may be able to buy Injecting How can the sharing of equipment be them, but the cost is prohibitive or users may safely prevented? be denied access to them. Even where needles and syringes are available many drug users are reluctant to carry them for fear they will be identified as a drug user and face possible What are blood borne viruses? arrest and discrimination. These situations make it more likely that people will share The sharing of drug injecting equipment injecting equipment. provides many opportunities for blood to be passed from one person to another. If a person The lack of knowledge about the risks of is infected with HIV and/or hepatitis B and HIV transmission C, he/she can transmit these viruses to One reason people continue to share anyone they share injecting equipment with. injecting equipment is that they are unaware Small amounts of blood, which are not of the risks surrounding such behaviour. necessarily visible, can remain in needles and Misconceptions persist, and while some syringes after they have been used. This is people may be aware of the risk of sexual also true of spoons, filters, water, glasses, transmission, they may not know about the skin, tourniquets, surfaces and other risks associated with sharing injecting equipment used for injecting. If the equipment. This lack of knowledge may equipment is re-used, this blood will be include or lead to: directly injected into the next person. If the • unintentional indirect sharing of pots, blood is infected with HIV then HIV can be spoons, water passed on to that person. • poor understanding of general health principles • unsafe injecting behaviour learnt in their Why does sharing happen? initiation to drug use •inability to inject oneself leading to There is no simple reason why people share reliance on other people to administer their injecting equipment. It may happen injections because there is a lack of injecting equipment •misconceptions about the nature of available or because it is a cultural or socially viruses and how they are transmitted popular practice. Other reasons may include: •a lack of awareness of the risks involved in sharing equipment •intoxication during the injecting What are the other reasons procedure for sharing? • because the person is suffering from • sharing drugs is commonplace and withdrawal symptoms injecting equipment may be the only • or it may be that sharing is seen as an accurate way to divide up the drugs extension of a sexual relationship or • equipment may be deliberately re-used to friendship extract drug residue (for some people this may be their only way of obtaining drugs) The Centre for Harm Reduction

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• only part of the message has been •returning a portion of the drug solution Manual for absorbed (i.e. people may carefully avoid to the cooker from the used syringe reducing drug sharing needles but continue to share • sharing unknowingly (needle and syringe related harm syringes) etc. have been lent to someone else in Asia • lack of perceived risk (i.e. none of my without the IDU’s knowledge) friends have HIV) • backloading: where the drug solution is • being put in prison when drug dependent transferred from one previously blood contaminated syringe to another. In this Situation and circumstantial contexts play case, the plunger is removed from the important roles in the sharing process. syringe into which the drug will be Perhaps the most important route into transferred. The drug mixture is then sharing is through initiation. Unlike other squirted into the back of the syringe routes of administration of illegal drugs •frontloading: where the drug solution is (smoking, inhaling or snorting), injecting of transferred from one previously blood con- drugs not only requires specific technology taminated syringe to another by removing and equipment but also requires a level of the needle on the syringe receiving the expertise. Often an individual’s first solution, and then squirting the drug experience of injecting will also be their first solution into the syringe’s barrel. This is experience of sharing. In our study findings, not possible for needles and syringes most injecting drug users reported that their where the needle cannot be removed.2 first successful injection experience was assisted by another person, most commonly a Apart from the personal reasons people share partner or close friend. This is partly because injecting equipment, other more general the latter will have the expertise but also factors can lead to a widening of the sharing because he/she will have the necessary circle, allowing blood borne viruses to spread equipment. Such circumstances result in the to other regions and countries. These likelihood of sharing being high.1 include: • mobility among IDUs (within one region/country or may extend into other What are the ways countries) which may be due to: that sharing occurs? – the type of work done (truck drivers, fishermen etc.) Sharing may occur directly or indirectly. The – the need to travel to find work most obvious example of direct sharing is – in an attempt to evade the police where people share the same syringe without –tourism (including drug and sex sterilising it between use. Indirect sharing is tourism) less obvious and may include: – civil war or unrest. •sharing water, cooker or filter • The extent of drug injecting and sharing • using a used syringe plunger to stir drug of equipment in prisons solution • The use of shooting galleries, where •recycling used filters to extract any left injecting equipment is shared among over drug residue many people • using unclean rinse water to mix with the • The illegality of drugs in the region drug means IDUs live with the anxiety that •using a dirty syringe to draw up water or they may be caught by police and locked measure shared drugs up: they therefore tend to spend as little The Centre for Harm time as possible injecting drugs in any Reduction

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2. Increasing IDUs’ Aware- ness of HIV and other Harms 2 communal setting, including prisons and How do you make IDUs aware of the shooting galleries risks? Chapter • The change from smoking to injecting What are the other health risks? Five drugs: brought about by a change in the Injecting kind of drugs available and the rise and safely fall in street prices of various drugs How do you make IDUs aware • The widespread practices among some of the risks? IDUs such as ‘blood brother’ rituals, that are used to symbolise the intimacy of Drug users need to be made aware of the drug sharing risks of sharing injecting equipment in terms • The tendency to continue to share of contracting and/or passing on blood borne injecting equipment with sexual partners, viruses. It is likely that most IDUs will regardless of wider sharing practices already be aware of other harms associated • Shifts in where the drugs are cultivated, with injecting such as abscesses, scarring, trafficked and then sold circulatory problems and so on. The most important strategy is education: to give IDUs the information so that they know the How can the sharing of risks and can take measures to minimise the equipment be prevented? harm associated with drug use and injecting. At the same time IDUs need to be given Before implementing programs to encourage information about safer sexual practices (see IDUs not to share their injecting equipment, Chapter Seven: HIV/AIDS Preventing it is important that workers understand both Sexual Transmission and between why sharing occurs in a particular Mother and Child). community and what realistic strategies will Program developers need to keep in mind work in this environment. that: These strategies may include: •the content must be credible and the • raising the level of awareness among presentation acceptable IDUs of the risks associated with sharing • behaviour change requires attitudinal • increasing the availability of sterile change plus the means for behaviour injecting equipment change • decreasing the availability of used •they must adopt realistic and achievable injecting equipment goals • working together with government •the aim is to change peer norms departments (i.e. police) •provide accurate information on: all •working together with IDUs to change injection equipment as a source of peer norms transmission, strategies for cleaning, need • encouraging and facilitating other ways of for change in sexual behaviour (use of taking the drugs condoms etc.), where to find help for •providing IDUs with both the drug problems information and the means to change • use peers as educators risky behaviour •recognise the diversity of IDUs •promoting abstinence • target sub-populations specifically: young • education (see Chapter Four: people, women, sex workers, indigenous Education) groups etc. •drug substitution (see Chapter Six: The Centre Drug Use and Substitution) for Harm Reduction

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Programs will fail to increase IDUs’ • what type of injecting equipment do you Manual for awareness of HIV and other harms if use? reducing drug they are established without the • how often do you re-use your injecting related harm knowledge of, and consultation with, equipment? in Asia drug users. Programs need to be aware of • do you know how sharing equipment can the conditions and practices of drug transmit HIV? users in any particular community: •in what situations do you think sharing • the drugs used may occur? • the routes of administration • do you think you are at risk of HIV? •the availability of sterile equipment • do you want to change your • the prevalence of HIV injecting/drug use in any way? • sharing practices.3 • do you ever borrow someone else’s needle/syringe – under what The drug users in a community will be circumstances? the ones with the most accurate • do you ever lend your needle/syringe to information about the drug scene. By anyone else – under what circumstances? talking to several drug users, program • do you share needles/syringes with your workers will have a much better idea of sexual partner? the drug using situation and how they • does your partner ever share may be able to help. needles/syringes with anyone else? These questions should provide a • what needle/syringe cleaning method do program worker with information about the you use? Under what circumstances (i.e. injecting and sharing practices among drug for cleaning your own needle/syringe or users in that particular community: other people’s)? • do you inject? • where do you inject? • how frequently do you inject? • how long does it take to find a vein? • what drugs do you usually inject? • do you alternate injection sites? • would you be able/willing to consider • do you clean injection sites? What with? safer methods of taking the drugs, such as • do you have any physical problems as a smoking or sniffing? result of injecting? •are their other drugs you occasionally • what do you mix your drugs with?4 inject?

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3. The supply and use of sterile equipment 2 What are Needle and Syringe programs? What are the other health risks? Why does outreach work? Chapter How do you find your clients? Five Apart from blood borne viruses, injecting What are other ways IDUs can get new Injecting drug users are at risk of other medical equipment and/or medical help? safely complications arising from their drug use. What are shooting galleries? These may include: •drug overdose – through mixing drugs or fluctuating purity of the drugs What are Needle and • abscesses – due to irritant drugs or poor Syringe Programs? injecting technique • septicaemia – caused by bacteria in the Often IDUs will share their injecting bloodstream equipment because of the difficulty in • bacterial endocarditis – inflammation and obtaining new equipment. This may be damage to the lining of the heart caused because it is illegal to possess needles and by an infective organism syringes. But, even in regions where •embolism – a substance such as air, or needles/syringes are legal, and can be bought impurities in illicit drugs, carried by the in pharmacies or other retail outlets, IDUs bloodstream until it causes obstruction by may be reluctant to visit such places for fear blocking a blood vessel of being identified as a drug user. • thrombosis – narrowing of the veins, Needle and Syringe Programs (NSP) have causing blood clots been operating successfully for years in many • gangrene – due to damaged circulation countries around the world. In Asia, a needle and poor care of wounds and syringe program was first established in • poor healing of wounds – due to 1991 in Kathmandu, Nepal and now also inadequate general health and poor operate in Asian countries including circulation Bangladesh, Pakistan, China, Indonesia, • circulatory problems Vietnam, Thailand and India. • scarring5 In many countries and regions establishing NSP is extremely difficult Often it may be one of these physical because of legal restrictions. Fears are ailments that brings an IDU into contact widespread that allowing needle and with health workers. Dealing with primary syringe distribution will promote and health care issues, such as lancing an abscess increase drug use. Some law enforcement or dressing a wound, can be a start for agencies can see the benefits in NSPs but establishing a relationship of trust with an they cannot support them in law. IDU which can lead into opportunities for However, in practice, the law is applied giving information on safer using techniques unevenly and to varying degrees, which and treatment. can result in unofficial tolerance at a local level. The small scale and low visibility of many programs can make a certain amount of tolerance possible.

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Manual for Harm Reduction News reducing drug related harm in Asia Hilltribe Villages Accept Injecting Safely Programs

CHIANG MAI,THAILAND tive, satisfying and highly behaviour had entered their portable. This ease of use villages. These communities he Akha hilltribe villagers makes it attractive in the face have watched their social Tof the Mae Chan district, of police harassment: inject- and economic life disinte- in the Chiang Rai province of ing takes little time, can be grate as a result of ever Thailand, live about 30 kilo- done anywhere and needles increasing drug use: young metres south of the Burmese and syringes are easily dis- women have entered the sex border on the lower tip of the posed of and hidden. industry, women have Golden Triangle. There are The needle and syringe become beggars on the approximately 36,000 Akha exchanges were established streets of the city and habitu- people. They have a long his- in three villages: all within al users are increasingly tory of using opium for unable to take part in farm- social, ritual and medicinal “…villagers initially ing and other productive activities, thus impoverishing purposes. Many of those now smoked heroin but found dependent on opium their families. became so through the use of it inefficient and Drug use is, in many opium as a herbal remedy for expensive. Injecting … is ways, an important part of coughs, diarrhoea, fevers and quick, effective, satisfying the daily activity of these to mask the symptoms of and highly portable.” men: they like to sit around hunger. in groups of three or four and Until the late 1980s, spend the day talking and opium was readily available two kilometres walking dis- sleeping. When smoking and the majority of the using tance from each other. The opium they shared the pipe population smoked or ate villages have an average of 47 and often their opium. This opium on a daily basis. Up to households with five to six has changed little with the 60 per cent of adult males, people per house. The vil- switch to injecting heroin. and a smaller percentage of lages were selected on the Needles and syringes were adult females, in these vil- basis of evident drug use and shared, occasionally rinsed lages are habitual users of a clear indication that inject- with water but mostly not. opium/ heroin. As opium ing drug use was not only There had been no sugges- became less available (due to prevalent but increasing. tion that sharing needles and opium crop eradication in There is scarcely a household syringes could be harmful the south and the establish- in these three villages with- and therefore no need to go ment of laboratories produc- out at least one member to the expense and effort of ing heroin in the north) the habitually using opium or always having your own sup- type of heroin available was heroin. ply. more suitable for injecting Injecting drugs was fairly A series of meetings was than smoking. The villagers new behaviour and one that held in each of the villages, initially smoked heroin but the villagers felt unsure involving all the villagers and found it inefficient and about. They were afraid of including; the users, the vil- expensive. Injecting, on the the needles and syringes and lage committee, male elders other hand, is quick, effec- unhappy that this new continued next page

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Harm Reduction News Chapter Five continued from previous page they injected on a daily basis, strong sense of responsibility Injecting the amount of heroin they in their using behaviour. safely and local representatives of used per day and it also gave They had become accus- the Thai government. Various details of the sharing net- tomed to individual use of strategies for preventing the works among IDUs. The vil- injecting equipment, and in spread of HIV were dis- lage committee in each vil- the majority of cases, were no cussed. Alternatives such as lage undertook the responsi- longer sharing needles and boiling needles and syringes bility for distributing clean syringes. for re-use were considered needles and syringes and dis- The NSP now operate on and rejected on the basis of posing of old ones. a two-tiered level: direct incompatibility with lifestyle Each user was educated exchanges and on an on- (i.e. these villages have no individually about safer request basis. The direct electricity or gas and boiling using techniques, following exchanges operate in six vil- water over a slow-burning the 2x2x2 method used in lages, along similar lines to charcoal pit in between Australia – cleaning the nee- the original exchanges but injections was not deemed dle and syringe twice with are now administered by feasible). In addition plastic paid health care workers. syringes would melt after “The death of a 16 year Records are kept of the num- three such treatments. old IDU from a needle- ber of needles and syringes The villagers also rejected distributed and the number related tetanus poisoning the suggestion that they each returned each week. Users buy their own supply of nee- in one village brought who have not attended the dles and syringes from the home the risks exchange are followed up to pharmacy in the nearby low- associated with dirty see what problems they may land town: the trip to the needles.” be encountering and assis- town could cost them the tance is provided where fea- equivalent of one day’s hero- sible. Seventy five IDUs are in (for lighter users). cold water, twice with bleach provided with up to three Over six weeks, after and twice again with cold needles and syringes per much discussion, the vil- water. The uncertainty of week in these district lagers in each village agreed continued needle and exchanges. Of the needles that needle and syringe syringe supply meant they distributed more than 90 per exchange would be useful. had to be conservative with cent are returned each week. The death of a 16 year old the amounts of needles and The exchange programs IDU from a needle-related syringes they distributed. It in the villages have generally tetanus poisoning in one vil- was limited to a maximum of worked well and continue to lage brought home the risks three needles and syringes have the support of the vil- associated with dirty needles. per user per week. lagers until such a time as The needle and syringe The operation of the nee- adequate treatment pro- exchanges commenced in dle and syringe exchanges in grams are implemented. November 1992 with a sup- these first three villages Both the villagers and the vil- ply of 5,000 1cc needle and worked in a fairly systematic lage committee have always syringe fits: an amount con- way for one and a half years regarded the exchanges as a sidered adequate for one until the supply of needles short-term measure until year’s supply. A register was and syringes abruptly ran such treatment programs are drawn up recording users’ out. However, by this time put in place.6 names, the number of times the IDUs had developed a

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Manual for ARM EDUCTION EWS reducing drug H R N related harm in Asia ACTION TO REDUCE SHARING OF NEEDLES

HO CHI MINH CITY,VIETNAM women) are engaged in the river, and wait to be education and exchange approached. Most of their he reports from Ho Chi under the supervision of a clients are poor cyclo drivers TMinh City’s AIDS medical doctor. Their famil- who have been injecting Committee estimate that 80 iarity with IDUs and drugs opium for some years and per cent of people with HIV makes their involvement cru- who now come to get a clean in the city are IDUs. They needle in exchange for their mainly use opium and the used one. As they know each sharing of needles is the other well, chatting and …workers educate major cause of HIV transmis- “ exchange of information sion. IDUs about AIDS between the volunteers and The Needle Exchange prevention and make the IDUs is easy. About 40 – project in Ho Chi Minh city clean needles and 60 needles and syringes are began in 1995 and is sup- syringes available for exchanged each day and ported by WHO and imple- free… mostly by the same users. mented by the National AIDS When new drug users Committee of Vietnam. The ” show up the volunteers inter- program focuses on the cial to the project’s imple- view them on their drug downtown area of the city mentation. using habits and talk to them known as District 1. The pro- Every morning, from 7.00 about drug use. When the gram workers educate IDUs to 9.00, the volunteer work- current project ends the about AIDS prevention and ers, in blue project uniforms Committee will conduct an make clean needles and with full packs of needles and evaluation so that the project syringes available for free in syringes take positions in can be thoroughly reviewed exchange for used ones. Six areas where drugs are com- before planning further.7 former users (men and monly found, such as by the

Distribution: other equipment which can also be an Needle and Syringe Programs (NSP) are indirect route of HIV transmission. usually involved in three areas: • the equipment may include clean water, • syringe distribution swabs, spoons and cooking pots • syringe disposal • the beneficial side-effects of using clean • the provision of advice and information equipment, apart from preventing the transmission of HIV, are a reduction in Needles and syringes may be distributed in abscesses, bruising, collapsed veins and various ways: through shops and pharmacies, other related harms vending machines, health centres and by • this can provide the motivation for outreach workers. adopting safer using practices even before NSP distribute new needles and syringes HIV emerges at a significant level in an to their clients. At the same time they may IDU community also distribute other injecting equipment: the aim being to minimise the sharing of The Centre for Harm Reduction

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Why does outreach work? How do you find your clients? Chapter IDUs are more likely to respond to One of the most difficult tasks in Five approaches from outreach workers who are establishing an NSP is getting people to use Injecting working within the community, than to walk the service. As mentioned above there is a safely through the doors of an established drug great deal of suspicion to overcome. Once the service centre. Some of the reasons for staying local situation has been assessed (see Chapter away from health services include: One: Rapid Situation Assessment) and a •the fear of being identified as a drug user program has found out what the drug users and the resulting stigmatisation and need and what the program can do to satisfy discrimination that need, program workers will need to • because they do not expect a non- establish contact with drug users. It may judgemental response from anybody begin by a relationship with one drug user Most drug users have received ill- who introduces the outreach worker to treatment from police, doctors, nurses, another drug user and so on. Although it pharmacies and other health agencies. may appear at first that the NSP is only in Therefore, it is not surprising that IDUs touch with one network, eventually if the will initially treat outreach workers with outreach worker keeps asking each new some suspicion. The outreach worker has person to introduce them to another, they to build up a level of trust and credibility will start to cross social networks and with the drug user and the wider discover unknown groups who have had no community. contact with the NSP. Outreach is often the most suitable way to make initial contact with IDUs and to gradually convince them that the help being What are other ways IDUs offered is genuine. Involving ex or current can get new equipment users in outreach work can aid in establishing trust. and/or medical help?

Pharmacies/retail In some countries, distributing needles and syringes through retail outlets has been the preferred option. In 14 provinces in Vietnam equipment is distributed in this way.

Health and welfare centres IDUs are often reluctant to visit health and welfare centres due to the discrimination and stigmatisation they have suffered in a health care setting. Programs throughout Asia have tried to encourage people at risk of HIV to visit health care centres. Outreach workers are often able to administer primary health care to IDUs and assist people to visit health care organisations. The Centre for Harm Reduction

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Manual for Harm Reduction News reducing drug related harm in Asia Needle Exchange – A Success Story in Nepal

KATHMANDU ,NEPAL agency in New Delhi visited naires and Jimmy spoke to LALS and accompanied the one IDU). The man com- he Lifesaving and outreach workers on their plained of the lack of facili- TLifegiving Society (LALS) rounds. ties and services that drug was established by two volun- “...CHOWS distributed users in Nepal suffer, the teers, Aaron Peak and Sujata packets of condoms to peo- need to be accepted and Rana, in 1991 in Kathmandu. ple who requested them. I treated as individuals, the LALS now has 24 fulltime was struck by the casualness problems of unemployment workers including eight com- that prevailed, and though bringing down the motiva- munity health outreach work- we stood right outside some tion to stay clean. In the ers (CHOWS). The outreach meantime, two of the IDUs teams include ex-drug users, “Syringes are exchanged had drawn blood and the CHOWS deposited it into nurses and social workers and on a one to one basis they work with approximately glass tubes, to be taken for 860 IDUs. They visit 65 differ- with no limit on the tests for Hepatitis, VDR and ent areas in Kathmandu to number of exchanges at HIV. When I asked why they perform needle/syringe any particular contact.” wanted it done they replied exchange, distribute con- ‘for safety’. The owner of the doms, give primary health cafe was apparently care and counselling to IDUs shops, no-one seemed dis- informed when we entered and their families/sexual part- turbed at the actions hap- about our activities, and did- ners. LALS also educates the pening outside. They’d prob- n’t seem to mind. community about HIV/AIDS ably seen this all before, it “Half an hour later we and prevention methods. was not new. I had been curi- were on the street again, the Syringes are exchanged on a ous to witness reactions on CHOWS making contact with one to one basis with no limit the needle exchanges, won- IDUs at their homes to on the number of exchanges dering at the actual interac- exchange syringes/needles. at any particular contact. tions that took place during It’s strictly one for one From August, 1991 to exchanges...I was initially exchange, probably pre- February 1997, 1,73,798 sceptical about the claims of empting the resale of materi- exchanges had occurred. LALS about needle al. En route I asked what LALS disposes of syringes by exchanges working in con- would happen if I went into a burning them on their ter- servative societies like Nepal chemist and asked for a races: they average 165 per but the two hours I spent syringe. ‘Just go in and see day. with the CHOWS has shown the response’. A little ner- HIV has been in Nepal me how successful they have vously I went in, came out a since 1991 and studies sug- been. few minutes later with a gest that HIV is not spreading “A flight of steep stairs, syringe, costing Nepali Rs.9/. among the IDUs associated onto the first floor of a ‘It was easy, no problem’ I with LALS. Mr Jimmy Tibetan restaurant (where told them.” 8 Dorabjee of the SHARAN clients filled in question-

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ARM EDUCTION EWS Chapter H R N Five Injecting INJECTING EQUIPMENT MADE ACCESSIBLE safely

TAIPEI,TAIWAN scription for $7.12 Taiwan (approximately US$0.25 – the or many years, the Taiwan … the Department“ of average weekly wage in Fgovernment has imposed Health has placed ‘no Taiwan is US $300). harsh penalties on drug users controls on needles Pharmacies that stock nee- and the concept of a needle and syringes: they can dles and syringes are found exchange program has never be purchased without throughout the country. been viewed as acceptable. a prescription’… Government authorities pre- In Taiwan, as required by law, fer this approach arguing drug users are regarded as that HIV infection among criminals but in recent years heroin is” rising, the injecting drug users is cur- they have also been viewed Department of Health has rently low and therefore the as patients that should be placed no controls on nee- need for a needle and syringe sent to hospital for detoxifi- dles and syringes: they can exchange program cannot be cation. While the injecting of be purchased without a pre- supported. 9

What are shooting galleries? One of the problems with shooting galleries is the sharing of equipment. In A ‘shooting gallery’ is the name given to an many shooting galleries the same needle area where IDUs can inject their drugs. The and syringe are used over and over until shooting gallery may be a room in an the needle is too blunt to be used any abandoned building, a shack or hut or more. Mostly, the needle and syringe is someone’s house. The reasons IDUs use not cleaned between clients, or if it is shooting galleries may be because: cleaned it will be just rinsed quickly with • they don’t want to carry needles and water. The opportunity for spreading syringes for fear of being arrested as a blood borne viruses is enormous. drug user Dealers are a good group to involve in • they don’t have their own equipment intervention programs as they have regular •the shooting gallery owner is also their contact with users (through selling them the dealer so they score and use at the same drugs) and because dealers often provide an place extra service as the injector.

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Manual for Harm Reduction News reducing drug related harm in Asia Support for Drug Users with HIV

HO CHI MINH CITY,VIETNAM 30 HIV infected IDUs. They because of their drug using had to establish priority for history. Home Health Care certain IDUs as 10 of their Apart from these services AGroup (HHCG) and a clients developed illnesses they also established the ‘Friend’s House’ (FH) for associated with HIV. Before ‘Friend’s Home’ for IDUs with injecting drug users was the services began the pro- HIV who had no family sup- established in Ho Chi Minh port. The ‘Friend’s Home’ is a City by Save the “…most hospitals would residential house where the Children/UK. They hired a not admit them because IDU receives medical sup- Vietnamese team leader who of their drug using port, counselling on HIV and was responsible for both drug use and help with prac- activities. The team leader history.” tical strategies about how to acted as a facilitator for a reintegrate into their family. staff of volunteers who ject assessed the IDUs: look- The IDU’s family also receive received a monthly ing at medical, social and these services to help them allowance which was deter- psychological needs. The better understand the situa- mined by the amount of time IDUs who required most care tion and to ensure the reinte- and effort they put into the were those without family gration is sustainable. The program. The first six weeks support and those who had aim of the project is to of the program were spent on suffered the most discrimi- become self-sufficient training and information nation. This service provided through income generating about various aspects of enormous comfort to the sick projects and to gain govern- health care. This was fol- IDUs as most hospitals ment recognition. 10 lowed by service delivery to would not admit them

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ARM EDUCTION EWS Chapter H R N Five Injecting SERVICE DELIVERY INSIDE SHOOTING GALLERIES safely

CEBU CITY,PHILIPPINES the middle man in buying and ambience of the galleries the drugs and another may which creates a sense of here are eight shooting be responsible for peddling community and friendship. Tgalleries in Barangay the drugs. This gives the IDUs the com- Kamagayan, Cebu in the fort of being with people who Philippines. Each gallery is lead a similar lifestyle. For open 24 hours and caters to …shooting galleries … those who cannot afford to about 100 to 150 IDUs daily. “ buy the drugs they can pitch (create) a sense of The operation of the gallery in with other people to buy community and has become a family busi- them. Other people prefer to ness where each member of friendship. inject in shooting galleries for the family has to do his/her fear that they might get share in delivering efficient ” caught in possession of regu- services to IDUs. One person Aside from the services lated drugs, punishable by may be in charge of cleaning provided, IDUs prefer to law under the city’s ordi- used syringes with bleach inject at such shooting gal- nance. 11 and water, another may be leries because of the bonding

Distribution and the police It is important to ensure that IDUs Outreach workers may face certain problems contact with outreach workers does not lead by working, technically, outside the law. to their identification by the police. Some Outreach workers may be arrested for programs provide their clients and outreach possession of injecting equipment. It is workers with identification cards which they important to work not only with the police can show the police if questioned or harassed. commissioners but also the local police For more information about working with whom the outreach workers and IDUs are the police see Chapter Three: Working more likely to run into. Some programs Together. register outreach workers with police agencies in order to avoid arrest.

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Manual for Harm Reduction News reducing drug related harm in Asia Shooting Galleries – Trade and Profit

HO CHI MINH CITY,VIETNAM exchange program in this location is safer. The house shooting gallery. But it was provides two injectors and he shooting gallery in discontinued because the four watchers. Those people TBach Dang, Vietnam is dealers would not let them who don’t have as much very popular and visited by exchange syringes at the site money will go to the aban- 50 to 70 IDUs every day. In as the dealers also sold doned army barracks which this shooting gallery there is syringes to the IDUs and the has one injector and the one dealer, two injectors and competition was not good for IDUs have to buy their drugs several watchers. Recently, their profits. from a different source. there have been police cam- The outreach worker paigns to eradicate drug use “…the dealers would not found it easier to gain access and arrest the IDUs in this let them exchange to the IDUs at the barracks because he initially estab- area. syringes at the site as the For this reason the major- lished a good relationship ity of the IDUs will inject in dealers also sold syringes with the injector. However, their neck, groin or behind to the IDUs…” due to the high turn-over in the knee as it takes less time. injectors the process had to The syringes used by the Another shooting gallery be constantly repeated. The injectors are only rinsed with is located in a private house needle exchange at the house cold water periodically and and another in an aban- did not work as well as the never sterilised. doned army barracks field. dealer would not let the IDUs There are many stalls The number of clients varies use a SCF syringe at the located close to the shooting from 100 to 150 every day. house. If an IDU wanted the gallery where Mr Ha is Those clients who have more injector to use a clean syringe allowed to conduct outreach money choose to go to the he would have to buy it from services. Save the Children private house where the the dealer.12 Fund (SCF/U.K.) at one time drugs are more expensive but conducted a pilot needle of a higher quality and the

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Churachandpur, the 17th Aug., 1995 Chapter Five Injecting safely To 1 SDPO/Churachandpur 2C.C.Churachandpur Police Station

As part of harm minimisation program with regard to the spread of HIV/AIDS, the Society for HIV/AIDS and Lifeline operations in Manipur (SHALOM), Rengkai Road Churachandpur will be advocating issue of syringes and needles to its clients. Keeping in view the need to control the spread of AIDS in the district the police is expected to extend maximum co-operation to SHALOM in its endeavour. Police, therefore may allow SHALOM clients undergoing SNEP to carry syringes and needles without harassment. The police may also see to it that the SHALOM staff/volunteers who are supervising the program are not harassed. The SHALOM will be issuing identity cards/badges to the clients and volunteers. Any confusion about the genuineness of the identity cards/badges and the volunteers/clients may be cleared by contacting the Co- Directors, SHALOM, Churachandpur.

Letter from the Superintendent of Police, Churachandpur to local police instructing them not to hinder the work of the SHALOM project.13

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4. Safer Injecting

your needle and syringe should not be in Manual for Why use safer injecting contact with a drug mix that is used by reducing drug practices? other drug users. It is best that each drug user has their own injecting equipment. related harm Safer injecting can prevent the transmission • Add the sterile water (if possible) to the in Asia of HIV/AIDS and other blood-borne viruses drug and mix. You can use the blunt end such as hepatitis B and C. It can also prevent (the plunger) of your clean syringe for bruises, poisoning of blood and abscesses. mixing. When injecting it is important to do so • Draw up the drug solution through a safely and carefully. The best way is to always filter in order to avoid impurities. The inject with a new needle and syringe, sterile best filters are a cotton bud or cotton water, a clean tourniquet, a clean spoon, a wool. If possible, do not use a cigarette clean filter, a clean injecting space and clean filter as they may contain tiny glass fibres hands – and make sure the part of the body which can damage veins. where you are to inject is clean. • Remove air bubbles by pointing the needle skywards and gently flicking the Preparation syringe on the side near the needle. Push •Try to choose a safe, clean and private the plunger up slowly until the air location to inject where you cannot be bubbles escape through the eye of the disturbed. needle. • Injecting equipment needs to be free of dust or dirt. After selecting your location Injecting to inject, place your injecting equipment •Clean the injecting site with soap and on a piece of plastic or newspaper that water, and a sterile swab (or use a clean covers the ground or surface. piece of material that is moist). Rub the •Wash your hands before injecting and area in one direction, not backwards and ensure that the part of the body you are forwards, to avoid putting dirt and injecting into is also clean. Washing your bacteria back onto the injecting site. hands is important as it can remove • If you use a tourniquet, place it around viruses, bacteria and dirt when you are just above the injection site. Do not leave injecting. Make sure you have everything it on too long - never for more than one within reach: new sterile injecting minute. If you have trouble finding a equipment; sterile water if to be mixed vein, release the tourniquet and try again. with a drug (or cooled-down boiled • If you are finding it difficult to find a water); clean spoon; clean filter; clean vein try to run warm water over the tourniquet (if used); and clean sterile injecting site as this may help to raise the swabs (if available). vein, or you can open and close your hand in a pumping action. It can also help to Mixing the drugs gently pat the area where you are trying • If you use a spoon to mix your drugs, to inject. clean the spoon first. • Slowly insert the needle into your arm at • Use new injecting equipment to draw up a 15-35 degree angle with the hole of the sterile water. If sterile water is not needle (bevel) facing upwards. The wider available use cooled-down boiled water. the angle of insertion the greater the •No matter how well your injecting chance the needle will go straight equipment has been cleaned, never let through the vein. If there is no visible The Centre your equipment be used by others, and for Harm Reduction

210 SECTION Contents > Section 2-C hapter 5 2 blood in the syringe, then your needle is • It is best not to reuse any of the following not in the vein and you will need to equipment when injecting: needle and Chapter remove the tourniquet and the needle syringe, the cloth to clean the area, filters, Five from your arm. When the needle is swabs, and any opened sterile water Injecting removed apply pressure (using a cotton ampoules. safely ball, tissues or toilet paper) to stop the • Store all of your injecting equipment in a bleeding. Take a deep breath and start clean safe place so that no one else can again. have access to it or use it. •When you are sure the needle is in the vein (a small amount of blood enters into The only really safe way to protect the barrel of the syringe), loosen the yourself and others from viruses like HIV tourniquet and gently push down on the and Hepatitis B and C is never to share plunger. If you feel any pain or resistance any injecting equipment you may have missed the vein and you will need to start again. • If you have been successful with 5. The Disinfection of Used injecting, remove the needle and keep Equipment your arm straight, in order to avoid bruising. Apply pressure to the injection How can IDUs protect themselves and site for a couple of minutes (using a others? cotton ball, tissues or toilet paper). What are effective ways to disinfect • Regularly change your injection sites to injecting equipment? prevent bruising, abscesses and damage to What are some of the other methods? the vein. If you do not regularly change your injecting sites vein damage may be irreversible. How can IDUs protect Cleaning up themselves and others? •Even if do not intend to reuse your The best scenario is to always use sterile injecting equipment, you should rinse the equipment for every injection. Anything needle and syringe with cold water, short of this carries some risk of infection. several times, straight after injecting - the But in many regions sterile equipment is more the better. This will remove most of unavailable most, if not all, of the time. In the blood and prevent the needle from this case it is important to inform, educate blocking with dried blood in case you are and if possible provide the means for drug forced to use the needle and syringe users to disinfect their injecting equipment. again. However, the success of any cleaning •You should dispose of your rinsing water message depends greatly on the local immediately so that no one else can use circumstances: it, to prevent them becoming • whether the law will permit a needle and contaminated with your blood. syringe program and therefore make the • Carefully recap your needle and ensure message of ‘use a new needle and syringe safe disposal into a puncture-proof for every injection’ possible container like a hard plastic container or • whether there are adequate funds to glass jar, or return the injecting maintain the supply of needles and equipment to an outreach worker. syringes The Centre for Harm Reduction

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Manual for ARM EDUCTION EWS reducing drug H R N related harm in Asia SAFER INJECTING – NOT WITHOUT PROBLEMS

HANOI,VIETNAM went in groups to the com- the leaflet as a means of steril- munity injector. They also ising injecting equipment, as n Lao Cai, Vietnam, a pro- believed that having your own it was not in line with Ministry Iject was established to equipment went against the of Health regulations. Taking design an appropriate leaflet group ethos of sharing every- all the local conditions into for drug users. The aim of the thing. Once explained, they account, the final version of pamphlet was to explain the the leaflet described a best to difference between cleaning less effective practice for drug injecting equipment and cleaning and sterilising. It sterilising it. The project coor- “…having“ your own seemed obvious that the best dinator spoke to injecting equipment went the drug users could manage drug users, who were about against the group was to clean rather than ster- 17 years of age and new to ethos of sharing ilise their equipment. Buying injecting, to find out what everything. ” new needles and syringes, they knew about cleaning and sterile cotton for filters, sterile sterilising and what they water and alcohol for clean- thought was a realistic mes- ” ing was considered unaccept- sage. As the drug users lived understood the difference able. The young drug users with their parents they felt it between cleaning and sterilis- said they could not afford to was impossible to keep their ing but felt they would not be buy this equipment and that own injecting equipment. able to carry out sterilisation any money they had would be They were afraid their parents of equipment. pooled to buy drugs. Peer would find out and that the The provincial authorities pressure and economic rea- police would search them and objected to the mention of sons prevented them from find the equipment. So they alcohol (70 per cent proof) in practising safer injecting.14

•whether a particular cleaning agent is • be quick (drug users will not use a available in the country or region method that demands too much time) •whether a particular cleaning agent is • be easy to use (using the method should acceptable to IDUs require only minor changes in behaviour) •whether the cleaning message is realistic • be safe for injectors (if accidentally for IDUs (i.e. does it take too long? can it injected and for others who may be be done on the streets?) accidentally exposed, such as children) Any cleaning method must: • be cheap • use an effective flushing agent (such as • become a part of a routine bleach) •be available and accessible

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What are effective ways to How to clean needles and Chapter disinfect injecting equipment? syringes with bleach Five Injecting Two effective approaches for disinfecting Cleaning needles and syringes involves three safely injecting equipment are: stages: • the use of heat (continuous boiling for 20 1. Water x 3 (rinsing with water 3 times) minutes) 2. Bleach x 2 (rinsing with bleach 2 times) • the use of chemicals such as bleach 3. Water x 6 (rinsing with water 6 times)

The boiling method is particularly suitable Stage 1 – Water x 3 for glass syringes but can only be used once (rinsing with water 3 times) or twice for disposable plastic syringes. Even • Draw up fresh clean cold tap water from then some disposable syringes will perish the first container into the needle and syringe. first time they are boiled. In terms of Do not use hot water or water too cold as disinfection with chemicals, the longer the this may cause blood to congeal inside the equipment soaks in the cleaning agent the needle and syringe better: the more time the cleaning agent is in • Squirt the water out contact with blood the more likely it is that •Repeat this process 2 more times viruses will be destroyed. • If required keep rinsing until you cannot However, the reality is that drug users are see any traces of blood rarely in a situation where they are able to boil or soak their equipment for long periods Stage 2 – Bleach x 2 of time. These cleaning messages have been (rinsing with bleach 2 times) developed with those constraints in mind. •Draw up bleach from the second container Until 1993 the cleaning message for into the needle and syringe and shake it needles and syringes was the 2 x 2 x 2 at for least 30 seconds technique. The message suggested that • If you do not have a watch, count slowly when re-using or sharing a needle and so that the bleach has enough time in syringe, users should always rinse the contact with any virus present. For needle/syringe twice in water, twice in example count “one thousand, two bleach and twice again in water. But thousand…“up to thirty thousand”. research showed that this method was • The counting is extremely important as not 100 per cent effective in preventing the bleach must be in contact with the the transmission of HIV or hepatitis C. virus for at least 30 seconds for the virus The message was then expanded to to be destroyed maximise the amount of time the • Squirt the bleach out of the needle and cleaning agent (i.e. bleach) is in the syringe. syringe and therefore in contact with the • Repeat the bleach process at least virus as well as increasing the number of 1 more time. times of cleaning with water.

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Harm Reduction News

Disposal Controls in Place Manual for reducing drug CHIANG MAI,THAILAND volume of needles and health care centre and taken related harm syringes increased, a new by the project staff to the method was adopted. The local hospital and disposed in Asia n the early days of operat- Iing the needle exchange employment of primary of in their incinerator. program in the hills of health care (PHC) workers, This is not a burden for Thailand, before we had paid the establishment of primary the hospital, is easy for the employees, members of the health care centres and a staff, and removes any possi- village committee and the strong link with the local hos- bility of needle stick injuries drug users undertook to pital meant the users and the in the village. The practice of jointly dispose of the needles village committee were no disposal reinforces to the and syringes. Every week, longer involved with the dis- health workers and the users one member of the village posal of injecting equipment. the seriousness of HIV trans- committee and one of the mission. users would collect the bot- “…disposal reinforces to As we only exchange old tles which the old needles the health workers and equipment for new equip- and syringes were stored in ment (with a 90 per cent plus the users the seriousness and burn them on the com- return rate) we were able to munal rubbish dump. The of HIV transmission. ” control disposal. Before the plastic would melt and the introduction of our program, needles were dug into the The program operates as needles and syringes were ground and covered over a direct needle exchange and discarded around houses with the ashes from the other not through the method of and the users were uncon- rubbish. This system seemed distribution. Needles and scious of the need to dispose to work well with no cases of syringes are returned to the of their equipment carefully. needle stick injury, nor were primary health care centre The introduction of the pro- there any problems with the and documented in a book gram has resulted in no litter villagers. by the PHC workers. Needles from injecting equipment As the needle exchange and syringes are collected being found in the villages.”16 program expanded and the weekly from each primary

Disposal Controls in Place

CEBU CITY,PHILIPPINES Alarmed by the possibili- that in case of raids the drop ty of spreading disease box would be seen as prima n the early stages of the because of this unsanitary facie evidence of drug ped- Iproject in Cebu ( in the disposal of used syringes by dling. Philippines) used syringes the IDUs, the Community CHOWS regularly collect were scattered all over the Outreach Workers (CHOWS) the used syringes from the place: many littered the of the program came up with drop boxes, and the plastic streets, pathways, canals, in the idea of constructing a containers preferred by other the wooden walls of shanties drop box for used syringes in shooting galleries. They also and in the ceilings of shoot- the shooting galleries. Locks pick up syringes scattered ing galleries. When the rain are provided and the keys are along the pathways to ensure came, used syringes, empty kept safe so that no used that children and adults will injecting drug bottles and syringe can be retrieved. Out not get pricked by the nee- other paraphernalia clogged of the eight shooting galleries dles. The collected syringes the canals and drains: they in the area, only three are then brought to the City were also seen floating in accepted the drop boxes as Health office for incinera- canals and pathways. the rest were apprehensive tion.17

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Stage 3 – Water x 6 (rinsing with water 6 times) 2 What are some of the other • Draw up fresh clean tap water from the methods? third container into the needle and Chapter syringe Other cleaning agents used to clean needles Five •Do not use water from the first glass as it and syringes include household dishwashing Injecting may be contaminated with blood detergent, iodine and alcohol. While it is safely • Flush the water out of the needle and good to rinse syringes with any of these syringe solutions, it is even better to soak them. •Repeat this process at least 5 more times, until all of the bleach is removed. Cleaning with dish-washing detergent 1. Take the syringe apart. Remember the formula – 3 x 2 x 6 2. Soak it in a detergent solution (one tablespoon of detergent in one cup of It is important the needle and syringe be water) for at least two minutes. Make sure rinsed with cold clean water as many times as the whole syringe is covered by the possible immediately after injecting to help solution. remove traces of blood. 3. Rinse thoroughly by flushing with fresh clean cold water several times. The bleach method should only take about five minutes. Be careful not to squirt the Cleaning with alcohol water from the syringe back into the rinsing Medical alcohol (ethanol, isopropanol or water and avoid re-dipping syringes into n-propanol) is the best alcohol to use. If water that may already have been used. household alcohol is all that is available it Flushing several times with water will should be as pure as possible (at least 70 per remove the bleach. Any tiny amounts of cent and preferably a clear spirit). bleach that may remain and be injected are 1. Pull up cold clean water through the not harmful. needle until the syringe is completely full and squirt down a drain or toilet. Do this several times to remove any visible blood. 2. Pull up the alcohol through the needle and allow it to settle for two minutes. Shake the syringe well before squirting the alcohol out. Repeat this process another time. 3. Pull up cold clean water through the needle until the syringe is full and then squirt the water down a drain or toilet. Do this several times.

Alternatively and even better, the syringe can be rinsed in clean cold water and then soaked in a bowl of alcohol for one hour.

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Summary 6.The Disposal of Unsterile Equipment

Boiling the injecting equipment Manual for 1. Rinse the needle and syringe in clean cold What are the aims of disposal? reducing drug water by pulling the water up through related harm the needle and squirting it out down a • to retrieve used equipment in Asia drain or toilet. Do this several times. • to ensure that clean equipment is being 2. If possible detach the needle from the used barrel and pull out the plunger. Place all • to avoid re-sale of clean equipment the parts in boiling water for at least 20 • to ensure appropriate disposal of used minutes. Start the counting from once the equipment water comes back to the boil after you have put the equipment in the water. 3. Allow all the parts to cool down before you put them back together. 4. Rinse the syringe in cold clean water again before using.

The spoon or cooker can also be boiled along with the syringe. The important principle for boiling is to make sure that there is sufficient Needles and syringes may be disposed of by heat for sufficient time. 15 returning them to the place where they were bought: the pharmacy may be persuaded to keep a safe disposal container or they may be disposed of through burning or other methods. In some communities used needles and syringes can be disposed of at the local hospital, burnt in an incinerator or sometimes buried in a deep hole where no-one will be able to find them. Some NSP and hospitals may provide plastic disposal containers which can be returned when full. If these are not available used needles and syringes can be placed in puncture proof glass or plastic jar or bottle with a secure lid. If possible they should be yellow in colour and marked ‘Danger’ ‘Contaminated Sharps’ with the Biohazard symbol in black.

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Summary 2 The promotion of the return of, and/or safe disposal of, used needle and syringes is Sharing of Injecting Equipment Chapter an important component of Needle and Five Syringe Programs (NSP). Safe disposal The transfer of blood borne viruses (HIV, Injecting information should be incorporated in all Hepatitis B and C) can occur through safely exchange transactions wherever possible. sharing injecting equipment including: NSP workers need to pay particular attention • needles and syringes to encouraging safe disposal practices by • spoons, filters, water, glasses, tourniquets, users: used syringes lying around upsets both surfaces, etc. the general community and the police and is the surest way to close down a NSP program. Any uncleaned injecting equipment that Safe disposal can be one issue to discuss with is re-used can lead to visible/invisible the local police and politicians to persuade blood particles being injected directly them of the benefits of NSP. into the next person. Disposal is a complex and difficult issue for many communities. In many countries Some reasons for sharing garbage is recycled and people commonly • lack of injecting equipment comb through rubbish piles and dumps for • popular cultural or social practice recyclable material or even sometimes for • lack of awareness of risks from sharing food. Children also often play at rubbish tips. equipment Although the chance of contracting HIV • extension of sexual relationship or through a needle stick injury is fairly remote, friendship hepatitis B and C can survive for a longer • lack of perceived risks (e.g. none of my time and may be transmitted. friends have HIV) •lack of smokeable opioid (e.g. market dries up)

Some reasons for lack of clean injecting equipment •inability to purchase from shops or pharmacies •prohibitive costs of purchasing injecting equipment •reluctance to carry injecting equipment for fear of arrest and discrimination

Lack of knowledge about risks of HIV transmission • unintentional indirect sharing of pots, spoons, water • poor understanding of general health principles • unsafe injecting behaviour learnt in their initiation to drug use

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Some general factors enhancing the spread of Other health risks that IDUs can Manual for blood borne viruses to other regions and experience are: reducing drug countries •drug overdose related harm • mobility (i.e. truck drivers, fishing men, • septicaemia in Asia etc.) • poor healing of wounds • sharing of injecting equipment inside •abscesses prisons • thrombosis •shooting galleries • circulatory problems • transition from smoking to injecting drugs The Supply and Use of Sterile Some realistic strategies to prevent sharing of Equipment injecting equipment • raise level of awareness among IDUs of Needle and Syringe Programs (NSPs) are risks associated with sharing usually involved in the distribution of •increase availability of sterile injecting new needles and syringes or other equipment injecting equipment to their clients: the • decrease availability of used injecting aim is to minimise the sharing of equipment equipment which can result in the •provide information/education and the indirect transmission of HIV means to change risky behaviour transmission. Countries in Asia such as • united efforts with IDUs to change peer Nepal, India, Vietnam and Thailand have norms implemented NSPs. Implementation of NSPs can be very difficult due to legal restrictions but small scale and low Increasing IDUs’ Awareness of visibility of programs has allowed a HIV and other Harms degree of tolerance within certain communities. Program approaches to make IDUs aware of the risks IDUs tend to respond more favourably to • education/information provided must be outreach workers than institutionalised credible and presented in acceptable health workers. Enrolling ex or current users manner in outreach work helps develop trust and • change in attitude and the means for extend the reach of the NSP to wider behaviour change must be promoted networks of drug users. • use peers as educators • aim to change peer norms A shooting gallery is the name given to an area where IDUs inject their drugs together. Successful programs on IDUs awareness A major problem in shooting galleries is that of HIV and other harms can only happen it is common to share injecting equipment. with the knowledge and consultation of those within the drug user community. This community possess very accurate information about injecting and sharing practices.

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The Disinfection of Used Chapter Equipment Five Injecting Disinfection of used equipment can occur safely when sterile equipment is unavailable The use of heat to boil equipment is effective but in many regions of the world this approach is not practical. The use of a chemical such as bleach is both effective and practical. The bleach method can be done in 5 minutes but effectiveness depends upon the correct technique being used. Other methods include cleaning with dish-washing detergent, alcohol or iodine.

The Disposal of Unsterile Equipment The disposal of and the retrieval of unsterile injecting equipment aims to: •ensure that clean equipment is being used • to avoid re-sale of clean equipment • to ensure appropriate disposal of used equipment •prevent needlestick injuries to others

Some sites for disposal and retrieval: • the place where injecting equipment was bought (i.e. pharmacy) • local hospital, burnt in an incinerator, buried in deep hole • NSPs or hospitals may be able to provide disposable containers that are returned when full Section Two, Chapter Five: Injecting Safely Information on the safe return of or disposal of used needles and syringes For further information refer to should be included in all exchange WHO resources:Training Guide transactions. Although disposal can be (Outreach), Intervention Guide difficult and a complex issue for many (NSP) and Evidence for Action countries, to avoid health hazards it must Papers. Refer to the following be dealt with. Effective disposal eases website: www.who.int/hiv community fears and encourages support (publications expected online from for NSPs. May 2003) The Centre for Harm Reduction

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CENTRE FOR HARM REDUCTION

▼▲ HIV, Hepatitis B & C can come from sharing injecting equipment such as needles, syringes, spoons, filters, water, glasses, tourniquets

Reasons for sharing ➤ Lack of injecting equipment ➤ Cultural and social practice ➤ Unaware of risks ➤ Extension of sexual relationship or friendship ➤ Lack of perceived risks ➤ Lack of smokeable opioid

Manual for reducing drug related harm in Asia SECTION 2 • CHAPTER 5 • OVERHEAD 1

CENTRE FOR HARM REDUCTION

▼▲ Lack of clean injecting equipment

➤ Unable to purchase ➤ Costs ➤ Reluctance to carry injecting equipment

Poor knowledge of HIV transmission ➤ Unintentional indirect sharing ➤ Poor understanding of health principles ➤ Unsafe initiation to drug use

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CENTRE FOR HARM REDUCTION

▼▲ Regional spread of blood borne viruses

➤ Mobility ➤ Prisons and sharing ➤ Shooting galleries/professional injectors ➤ Transitions from smoking to injecting drugs

▼▲ Strategies to Prevent Sharing

➤ Raise level of awareness among IDUs ➤ Sterile equipment freely available ➤ Used equipment unavailable ➤ Information/education on risks ➤ Change peer norms Manual for reducing drug related harm in Asia SECTION 2 • CHAPTER 5 • OVERHEAD 3

CENTRE FOR HARM REDUCTION

▼▲ Approaches on risk awareness

➤ Education/information is credible and acceptable ➤ Promote attitude and behaviour change ➤ Peer educators ➤ Change peer norms

Needle and Syringe programs aim to minimise the sharing of equipment thus reducing the risk of HIV transmission.

Outreach workers help IDUs to use NSP and lessen the problems associated with shooting galleries.

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CENTRE FOR HARM REDUCTION

▼▲ Disinfection of used equipment

➤ Boil equipment

➤ Rinse with water after use

➤ Bleach

➤ Dish washing detergent, alcohol, iodine

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CENTRE FOR HARM REDUCTION

▼▲ Disposing, Retrieval Aims and Sites for Unsterile Equipment

➤ Ensures clean equipment used ➤ Avoids re-sale of equipment ➤ Ensures appropriate disposal ➤ Handed back to place of purchase ➤ Burn in incinerator ➤ Provision of disposable containers

Disposal can be complex and difficult but to avoid health hazards it needs to be addressed

The Centre Manual for reducing drug related harm in Asia for Harm SECTION 2 • CHAPTER 5 • OVERHEAD 6 Reduction

222 Contents SECTION Section Two 2 Chapter Six Drug Use and Substitution

Drug use Drug substitution Methadone Buprenorphine

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Introduction

Manual for reducing drug Drug substitution is one of the options for reducing harm to drug users. related harm For many drug users going “cold turkey” that is, abruptly stopping drug in Asia use, is too painful and fearful to contemplate. Their motivations may be good but the physical pain of withdrawing is too much: before they know it they are out looking for drugs again. Even if the drug user feels highly motivated to give up using drugs, the influence of his/her peers in their social scene can easily lead them to using drugs again. Drug substitution programs aim to stabilise drug users, to give them an opportunity to re- establish their lives. Drug substitution, and other programs aimed at HIV prevention, also offer the opportunity of attending to the primary health needs of drug users and giving them information on ways to protect their health, and the health of others, if they continue to take drugs.

This chapter will look at: 1 Drug use 2 Drug substitution 3 Methadone 4 Buprenorphine

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1. Drug Use 2 What types of drugs do people use? Why do people use drugs? What types of drugs Chapter What are the levels of drug use? do people use? Six What are the reasons people change or Drug use stop their drug use? (For more information on the pharmacology and Why do people relapse? of drugs see Appendix 2 – Drugs and their substitution Actions) “Given the complexity of drug use, the extreme difficulty experienced by many dependent drug Opiates (Opioids) users in changing and staying changed, the Opium is the coagulated juice from the difficulties experienced by clinicians and others in unripe capsule of the poppy plant: it contains seeking to assist them, and the limited morphine and other psychoactive substances understanding of the bio-psycho-social which can be extracted in pure form, such as interaction which shapes drug use, harm codeine. Morphine can quite easily be reduction would seem a pragmatic and socially converted to heroin by a simple chemical responsible policy option.”1 process. There are also many entirely Dr Adrian Reynolds synthetic opiates such as methadone and pethidine. All these substances share the Societies throughout the world have always capacity to: used substances that suppress pain and •relieve pain sorrow and also provide a pleasurable •produce a pleasant, detached, dreamy sensation. In many cultures drugs are used in euphoria traditional religious rituals. Drugs are also • to induce physical dependence leading to used to ease the pain of illness, such as opium distressing withdrawal symptoms when either in its original form or as morphine (or the drug is stopped synthetic versions) in hospitals throughout the world. Archaeological evidence indicates Depressants that cannabis cultivation dates back to at Depressants include alcohol, barbiturates and least 6000 BC.2 synthetic sedatives and sleeping tablets. Many drugs have the capacity to create a These substances cause a degree of drowsiness strong habit in the user, making further use and sedation or pleasant relaxation. They can difficult to avoid. The power of drugs and also have serious withdrawal symptoms. their potential for dependency is obvious in the legal, and often socially sanctioned, drugs Stimulants such as alcohol and tobacco. Stimulants include cocaine which is the Each group of drugs produces its own psychoactive ingredient of the coca leaf. It variety of effects and dependency. But the produces a sense of exhilaration and decreases compulsion (need) to use the drugs is an fatigue and hunger. There are also synthetic important common factor shared by stimulants such as amphetamines. These dependent drug users be it for opiates, substances have a high dependence potential. depressants, stimulants or nicotine.3

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Hallucinogens Manual for Hallucinogens include LSD (lysergic acid What are the levels of drug use? reducing drug diethylamide) and can come from both related harm synthetic and plant derived substances. These Level 1. Experimental in Asia drugs have the capacity to induce highly Single or short term use: motivated by complex psychological effects including ‘out curiosity or a desire to experience new of body’ experiences, hallucinations and other feelings or moods. types of perceptual distortions. Hallucinogens do not induce physical Level 2. Social/Recreational dependence. Well-controlled use in social setting: experienced users know what drug suits Other drugs them and in what circumstances. If they like There are many other drugs people use which the effects and the group, they will use do not fit into the above categories despite its illegality. satisfactorily. They include cannabis, inhalants (glue, paint thinners etc.) and other Level 3. Circumstantial drugs such as kava (used in the Pacific Specific purpose: situations where particular islands and New Guinea) and betel nut (used tasks have to be performed or freedom from widely in Asia and the Pacific).4 pain is sought, where temporary relief is needed. For example; study, stress, bereavement. Why do people use drugs? Level 4. Intensive People may use drugs at particular times in Major doses daily: similar to previous their lives: young and experimenting or old category but borders on dependence. and for pain relief. They may also use drugs in different ways at different times. Many Level 5. Compulsive theories exist about why people use drugs Persistent, frequent high dose: producing but there is no simple answer. Drug use and psychological and physiological dependence drug problems appear to be influenced by a such that the user cannot discontinue range of factors, so that no single theory without experiencing significant mental seems adequate. Some of the reasons people and/or physical distress. 5 may use drugs include: •Tradition: as part of symbolic or religious ceremonies • Self-medication: to relieve feelings of fear, anxiety and depression • Pain relief: to relieve physical symptoms of pain •Enjoyment: for the pleasurable effects, for fun •Lifestyle: to belong to a peer group • Forget: to alleviate misery, poverty and disadvantage

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HARM REDUCTION NEWS 2 MS R. Chapter CHURACHANDPUR, INDIA should do it again and again pletely. I went for a confiden- Six to taste the high. After a week tial blood test and learned my Drug use s R was born in 1976 or so I began to realise that I HIV status. Though deep in Minto a poor family with was already addicted. I had to my mind I had always sus- and five children in the north east- provide for myself so I started pected myself to be positive, substitution ern Indian state of Manipur. cheating people. Every time when I first learned that I was By the age of 10 she had start- people invited us for a drink HIV positive I could not ed drinking alcohol and tak- we drugged them with certain believe it and at one point I ing pills. “When I was in pills and emptied their pock- even thought of committing eighth class my friends told ets when they fell uncon- suicide. During those days me that by injecting heroin scious. After a year of inject- there was a spiritual coun- you get the kick immediately. ing my body became weaker selling session going on at That was tempting as I had to and weaker.” SHALOM for a week and I wait for half an hour for the Ms R. continued to inject joined it. It was there I came to kick while taking pills. One various drugs and developed realise that I had something day I happened to accompa- severe abscesses. “ I got oper- worthwhile to live for. I am ny a friend who was injecting. ated on three places simulta- now committed to helping Being a friend, I could not stay neously by SHALOM staff. I people like me to lead a posi- away while she was injecting. thought that I would surely die tive lifestyle. I can lead a So, I accepted the offer made this time. It was a miracle I cheerful life even if I am HIV by the pedlar to me, and he recovered but I was bedridden positive and anybody else injected me with an old for about seven months. can.” syringe that he kept at home During my illness the Ms R. now works as an for his customers. I vomited SHALOM staff visited me reg- outreach worker for SHALOM instantly and complained that ularly and counselled me. and has appeared on local it was not nice. I decided not They educated me about television as a spokeswoman to inject again at all but my HIV/AIDS and encouraged for people who are infected friend kept on saying that I me to stop using drugs com- with HIV.

By the age“ of 10 she After“ a year of … I came“ to realise had started drinking injecting my body that I had something alcohol and taking became weaker and worthwhile to live for. pills. weaker. ” ” ”

What are the reasons people • having the motivation to implement change or stop their drug use? healthier choices •believing that doing something will There are various models which seek to reduce the perceived threat explain the factors influencing behaviour • having the skills to make the behaviour change. Some reasons behaviour change may change be successful include: • having the means to make the behaviour • believing that one is susceptible change (e.g. clean needles and syringes, (vulnerable) to a serious health problem substitution programs, condoms) (perceived threat) • having the confidence in one’s ability to • having the knowledge and understanding implement behaviours which will protect The Centre of healthier choices one’s health for Harm Reduction

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• having a supportive social, economic, It can be dispiriting for both the drug user Manual for policy and legal environment for and treatment worker when relapse occurs. It reducing drug adopting healthier choices (e.g. needle is important to keep in mind that behaviour related harm and syringe programs, drug use viewed change takes time. The risk of relapse is in Asia as a health rather than criminal issue) another good reason for making sure that • having the basic human needs provided people in treatment know about safer using (e.g. food, shelter, income, employment, practices (see Chapter Five: Injecting education, freedom from violence) 6 Safely). When a drug user comes into contact with an HIV prevention program or a treatment program, it is a good opportunity Why do people relapse? to explain the risks of sharing injecting equipment and having unprotected sex. By Many people who are dependent on drugs giving people information about safer drug may stop using them, for long or short using practices a program worker is not periods, but eventually start using them condoning drug use. The worker/counsellor again. Some people do manage to stop their is instead protecting the health of the drug use but are considered vulnerable to individual, his/her friends and partners and relapse. An alcoholic is generally considered the health of the wider community. an alcoholic for life whether they are drinking or not. Recovery from drug use is a delicate balancing act. Most initial attempts at stopping drug use are unsuccessful and drug dependent people may relapse many times, particularly in the early stages of treatment. 7 Even if the motivation to stop using drugs is strong a person may be unable to resist the temptation. The reasons for relapse are varied and may include: • stopping drug use was not the person’s own decision (e.g. being forced into treatment and rehabilitation) • the level of dose of the substitution drug is too low •recovering health and feeling that no great harm will come from taking drugs • emotional stress • the power of group dynamics – friends persuading the person to take drugs

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2. Drug Substitution 2 • to reduce hazardous drug use, e.g. sharing What is drug substitution? injecting equipment, polydrug use, Chapter injecting crushed/filtered tablets Six Drug substitution means replacing the drugs • to reduce the motivation and need for Drug use a drug user is taking with another drug or a addicts to commit crimes to support their and similar drug. It may also mean using the same drug habits and to keep them out of the substitution drug but taking it in a different way, for dangerous environment of prisons example, sublingual buprenorphine to replace •to maintain contact with drug users injecting of the drug. Often, the initial • to provide counselling, referral and common responses to the idea of a drug treatment substitution program are: why on earth would • to help drug users stabilise their lives and you do that? Isn’t that just encouraging and re-integrate with the general community condoning drug use? But the goal of drug substitution is to reduce the health, social and A variety of drugs can be used for drug economic harms to individuals and to the substitution, these include: community, not to ‘push’ drugs. • Methadone Drug substitution programs have a long • Buprenorphine history. During the first two decades of this •Tincture of opium century many morphine maintenance clinics • LAAM (levo-alpha-acetylmethadol) existed in the United States before being •Morphine closed down under the pressure of law • Codeine enforcement authorities. Until the last • Naltrexone twenty years or so in Asia, government outlets allowed addicts to register and obtain legal access to opium. In the U.K. doctors are still able to prescribe whatever drugs they decide are appropriate: this includes heroin, cocaine, amphetamines and other drugs. Switzerland has been running a heroin substitution and maintenance trial program since 1994.8 Many Western, and some Asian countries, run methadone (and increasingly buprenorphine) substitution and maintenance programs with good results. The aims of drug substitution are: • to lessen the risks of contracting or transmitting HIV/AIDS • to switch users from ‘black market’ drugs of indeterminate quality, purity and potency to legal drugs of known purity and potency • to minimise the risks of overdoses and other medical complications • to switch from an injected to a non- injected substance The Centre for Harm Reduction

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3. Methadone

What is methadone? Methadone is not a cure for opiate Manual for How is methadone used for addiction: while on methadone a client is still reducing drug detoxification? physically dependent on opiates. But, related harm What is methadone maintenance methadone offers people a chance to stabilise in Asia treatment? their lives and lessen the risks associated with What makes a methadone maintenance illegal drug use such as sharing injecting program successful? equipment and contracting and passing on How long should a methadone program blood borne viruses. last? Methadone is widely established in What is the methadone dose? Australia and Europe as a treatment for opiate dependency. Methadone is used both to “Although ideally patients should be able to detoxify people who are dependent on opiates achieve a drug free state, it is accepted that this and as an ongoing treatment. will not be possible for a significant number of drug abusers, given the chronic relapsing nature of narcotic addiction. However, the {methadone} program does provide to every single drug How is methadone used for abuser a readily accessible, medically safe and detoxification? effective alternative to continued illicit self- Programs firmly focused on abstinence administration of heroin.” generally use short-term methadone Action Committee Against Narcotics treatment, which aims at rapid detoxification. – Hong Kong9 The short-term treatment will have a fixed time frame for the client to take the methadone. For example, in Thailand What is methadone? methadone treatment generally consists of a 45 day detoxification regime. Methadone was developed in Germany in However, the research shows that this 1945 as a painkiller and was first trialled in approach is associated with poor treatment New York in the mid 1960s to treat heroin outcomes with the majority of clients addicts who had not responded well to returning to opiate use.11 abstinence-based treatments. The positive Comparative studies between short term outcomes of this trial have been replicated (detoxification) methadone programs and the throughout the world.10 longer term methadone maintenance Methadone belongs to a group of drugs programs show that: called opiates which include heroin, codeine •the more effective programs use higher and morphine. These drugs are narcotic doses of methadone (above 50-60 mg analgesics: that is they are all strong daily) painkillers. Opiates also induce a sense of • have a treatment goal of long-term wellbeing and euphoria. People who are maintenance as opposed to detoxification addicted to heroin, or other opiates, are to abstinence physically, and often psychologically, •have better support services (including dependent on the drug. If the concentration counselling, social and medical services) of opiates falls below a certain level in a • have better staff-client relationships12 dependent user’s body he/she will experience withdrawal symptoms. Methadone is a long- Programs which offer both methadone acting synthetic drug which alleviates the maintenance and detoxification (at the clients’ The Centre for Harm withdrawal symptoms. choosing) have better rates of success. In Hong Reduction

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Harm Reduction News Chapter Six Drug use Methadone Substitution in Northern Thailand and substitution MAE CHAN,THAILAND detox period from 45 to 98 longer using, the community days. The majority of drug as a whole has benefited: uring the early 1990s, the users in each village were stealing has all but disap- DAkha hilltribe villages in admitted to the program. peared, malnutrition rates far north Thailand experi- Methadone was distributed among the children have enced a dramatic increase in at the village twice a day by decreased, attention to per- injecting drug use. In the past the project staff. The maxi- sonal hygiene has improved the Akha people smoked mum starting dose was 40 mg as has employment levels, opium for ritual purposes of methadone and came and the sale of illicit drugs in and for use as a pain killer. down by 5 mg. Once the dose the village has been banned. Continuing political prob- fell under 25 mg a day com- lems in Myanmar, and opium pliance rates were dramati- “… the majority have crop eradication in Thailand, cally reduced (in terms of remained in treatment have led to significant people turning up to the clin- or achieved abstinence.” changes in the nature of ic and abstaining from other opium crop production in the drug use). Relapse rates were mountainous Shan State. high: of the 194 clients in the Methadone is given out at While there is less opium in detox program only six of the community level. This them were abstinent after means: “While there is less two months. 1 clients are able to remain opium in the villages the In 1996, permission was in treatment because the availability of injectable given to the project to intro- services are provided duce methadone mainte- within walking distance of heroin has increased.” nance. The program operates their homes in nine villages with 77 per 2 peer support has been the villages the availability of cent of the drug using popu- organised and is ongoing injectable heroin has lation participating. Metha- and encourages people to increased. done is distributed once a stay in treatment In response to this day at a set time from the pri- 3 the dispensing of increase, and the associated mary health care centres methadone has been harms of injecting and blood which the project built and ‘demedicalized’ by borne viruses, needle and established. The workers also recruiting, training and syringe exchange programs carry out limited follow up for employing young villagers were established in nine vil- people who don’t turn up for as primary health care lages (for more information their dose. workers to dispense the on this part of the project see The results of the methadone (and in one Chapter Five: Injecting methadone maintenance village tincture of opium). Safely). program are encouraging: The successful experience of Eighteen months after the data from one village show methadone maintenance in a needle and syringe program that of 69 habitual users at remote part of northern was established (1995), the the beginning of the program Thailand shows that an inter- project started a methadone the majority have remained vention which has been used detoxification program in six in treatment or achieved almost exclusively in urban of the nine villages, following abstinence. Overall, the use of centres in developed coun- the 45 day schedule of the heroin in the village has tries can be implemented in a Thai government. Later, two declined. With more than 60 variety of settings.13 of the villages extended the former habitual drug users no

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Kong, for example, there is no waiting list failure for both the clients and the workers. Manual for for people wishing to start on a methadone Methadone is not a miracle cure and for the reducing drug program: there is also no time limit for how best results it needs ongoing counselling, related harm long they are on the program. But, if and information and support for the clients. in Asia when patients feel ready and able to go off the program they are offered a detoxification program. The detoxification program What makes a methadone consists of slowly reducing the client’s dose maintenance treatment program of methadone over a period of time until they successful? no longer take any methadone (see p. 219 of this chapter for more detail on dose •the dose of methadone must be sufficient reduction). to keep clients from going into withdrawal (60 mg or more a day). Research in western countries has shown that if the What is Methadone Maintenance dose of methadone is adequate clients are Treatment? less likely to use other drugs and as a result the risk of HIV transmission is reduced 16 Research has shown that longer term • the policies of the program, and the treatment, that is Methadone Maintenance attitudes and skill of the staff, play an Treatment (MMT), is effective in the important part in keeping a client in prevention of HIV infection. MMT is treatment. If clients are treated well and associated with lower rates of HIV prevalence with respect they are much more likely to and reductions in HIV risk related to stay in the program and build a injection and sharing behaviours for relationship of trust with the staff individuals during treatment.14 • the program should provide more than just A methadone maintenance treatment the daily dose of methadone, staff should program aims to minimise the harms be trained about HIV/AIDS, counselling experienced by people who are dependent on techniques, primary health care etc. opiates and to normalise their lifestyles and behaviours.15 Positive features of Methadone The objectives of a methadone Maintenance Treatments: maintenance program are: •methadone can be taken orally • to reduce injecting drug use • methadone lasts long enough in the body • to reduce the risk of premature death (from 24 to 36 hours) so that it only • to reduce illegal drug use needs to be taken once a day • to improve IDUs’ health • is more attractive to many clients than • to reduce involvement in crime other options (i.e. cold turkey, short term • to improve psychological and social detoxification, imprisonment) functioning • scientific research shows that MMT is more effective than abstinence based Methadone maintenance programs have been treatments at keeping clients in found to be successful in improving the treatment, that is it has lower relapse physical, mental and social wellbeing of rates, has reduced injecting drug use and clients. However, it is unrealistic to expect its associated harms that a program will be able to eliminate all •is cheaper than detoxification followed by clients’ drug taking and associated behaviours. outpatient counselling, therapeutic The Centre for Harm Setting such high goals leads to a sense of communities or imprisonment Reduction

232 SECTION Contents > Section 2-C hapter 6 2 Potential side-effects of Methadone Clients need to have the potential side-effects treatment explained to them and weighed up against the Chapter • nausea benefits of being on a program before they Six • vomiting: 10 – 15 per cent of people begin treatment. (See Section Three: Drugs Drug use respond this way to methadone but this and their Actions for more information on and usually settles down over several days to a the pharmacology of methadone.) substitution week • constipation: as with all opioids, diet and exercise can help How long should a methadone • sweating: this may occur as a side-effect of maintenance program last? the methadone or because the dose is inadequate Most methadone maintenance programs have • amenorrhoea: lack of menstrual periods, no set time limit. The programs are more alternatively methadone can make periods likely to encourage clients not to leave the more regular program for at least the first six months. A • libido: may reduce sexual desire program which has adequate resources (that is, • lethargy: may lessen on a lower dose 17 it can continue to supply the methadone and other services to clients) should continue to provide access to MMT for opiate dependent people for as long as they continue to benefit from it. In this it is similar to the way drugs are provided indefinitely for people with a range of other health problems such as heart disease, hypertension, diabetes etc.18 This does not mean that programs accept that their clients will always be dependent on opiates. A MMT offers clients an opportunity to stabilise their lives: to improve family relationships, to find and maintain a job, to feel physically and psychologically healthier. This change in lifestyle can give clients the confidence and motivation to attempt a drug free life.

What is the methadone dose? Starting off: doses of methadone vary from client to client due to differences in metabolism, body weight and tolerance to opiates. It takes a while to determine the correct dose of methadone for each client. At the start of treatment a client needs to be seen daily and assessed to see how he/she is coping with the dose. If the client displays significant signs and symptoms of opiate The Centre withdrawal the dose will have to be for Harm Reduction

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HARM REDUCTION NEWS Manual for reducing drug METHADONE TRIAL IN VIETNAM related harm in Asia HANOI,VIETNAM site. This is to ensure compli- come to the project site three ance with the treatment. times a week and this may be ietnam is trialling a At the beginning of the reduced to once a week. By Vmethadone mainte- study the client has to report the seventh month of the pro- nance program in Hanoi as to the methadone mainte- gram the client’s dose of part of the effort to combat nance centre every day for ten methadone is slowly reduced the HIV epidemic. The pro- days. Up until the third (as this is only a 10 month gram is being run through month the client reports six treatment). the National Institute of days a week with a take-home If, at any time, a client has Mental Health. It is located in dose of methadone on a positive urine analysis a spacious one-room facility Sundays. The take-home dose he/she are required to start at the Institute and is staffed the procedure again and pay part-time by three doctors a fine of 500,000 dong ($40 and full-time by a nurse; all US – the average annual The idea of a come from the psychiatric “ wage in Vietnam is $240 US). department of the Institute. substitution program The management believe The idea of a substitution is new to Vietnam … this will deter clients from program is new to Vietnam using other drugs. The so they are proceeding cau- ” methadone maintenance tiously and providing regular is only allowed if the urine treatment program is only in information to officials from analysis tests and compliance its infancy and has problems various government min- are satisfactory. The take- of staff shortages so the fol- istries to keep them informed home dose is always given to low-up at the completion of of the program’s progress. a reliable family member: this the program is minimal. It is a ten month trial of is one of the reasons the pro- During the program, staff just 70 people, all of whom gram insists the client must attempt to provide some must have support from their have a supportive family. After counselling on drug use and families and live within com- three months, if all is going HIV to their clients. 20 muting distance of the project well, the patient only has to

increased. Many programs start with a dose drug should be at the request of the client. of 20 mg of methadone and will increase the Ideally, by this time the client’s life will have dose 5-10 mg per day according to the stabilised: he/she will have some work, have client’s tolerance. made social contacts outside the drug scene Maintenance: generally clients will stay and have not used other drugs for many in treatment and limit (or stop) their illicit months. The rate of reductions in dose varies: drug use if their dose of methadone is some people reduce their dose very slowly, moderate to high (60 – 100 mg).19 It is others more quickly. important that the dose is increased carefully It is important to closely monitor a client and slowly until the client is experiencing who is withdrawing from a methadone only the mildest of withdrawal symptoms maintenance program. If the client is and is not sedated by the dose. showing obvious physical or psychological Reduction: reducing the dose of distress it may be best to stop the dose methadone with the aim of coming off the reductions for several weeks until the client The Centre for Harm Reduction

234 SECTION Contents > Section 2-C hapter 6 2 is feeling more comfortable and confident drugs which combined with the methadone about the reductions. If, in the face of may lead to an overdose. The most important Chapter distress, the reduction continues as planned thing to remember is that you don’t want to Six invariably clients relapse into using illicit do any harm to the client. Drug use drugs. •You may have to withhold a part of, or and the entire dose, for that day substitution •You may ask the client to return 2 – 6 DOSE REDUCTION: hours later when you will review him/her METHADONE DOSE RECOMMENDED again before dosing is considered RATE OF REDUCTION • If you are extremely concerned about the High greater than 80 mg client’s wellbeing you may ask him/her to 5 – 10 mg per week/fortnight stay at the clinic under medical supervision or be admitted to hospital Medium 40 mg to 80 mg until his/her condition is stable.23 2.5 – 5mg per week/fortnight

Low below 40 mg Missed doses: it is important for clients to 1 – 2.5 mg per week/fortnight 21 receive their dose regularly to make sure they have steady levels of methadone in their Use of other drugs : it is common for bloodstreams: to keep them balanced and to clients to continue to use other drugs when avoid the onset of withdrawal symptoms. If a they first begin on a methadone program. client has missed a dose/s it may be necessary This may occur particularly when their dose to adjust the dose as his/her opioid tolerance has not yet stabilised. While clients may may have reduced unless they have had other continue with some opioid use, they may also opioids in the meantime. It may be a good use non-opioid drugs such as alcohol and opportunity to spend some time with the benzodiazepines. The major concern here is client to discuss why they have missed a that the use of multiple drugs can lead to dose/s and to examine how they are doing on overdose. Workers in methadone the program. maintenance treatment programs need to be aware of the potential use of other drugs by their clients and aim to establish a relationship with their clients where they can openly discuss the drug use and the problems the client is having in stopping other drug use. Often, continued other drug use may be because the dose of methadone is too low for the client. If a client continues to use other opioids while in a MMT, the methadone dose should ordinarily be carefully increased providing there is no significant risk of overdose.22 Intoxication: there are a number of options available if a client turns up at the clinic for his/her dose and it is obvious that he/she has taken enough opioids or other The Centre for Harm Reduction

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Manual for Harm Reduction News reducing drug related harm in Asia Methadone in Hong Kong

HONG KONG,CHINA other offences had dropped SARDA also refer clients to by 70 per cent.24 relevant agencies for residen- ethadone has been Twenty-one methadone tial treatment and health Mused as a substitute clinics now operate in Hong social services. Their prime drug in Hong Kong since Kong which are open either target group is people under 1972. It was initially estab- between 6-10 pm or 7am – 10 21 years of age who are pre- lished as a three year trial as a pm seven days a week. The senting for methadone treat- treatment for heroin addic- Department of Health runs ment for the first time. Since tion. More than a year before all methadone maintenance the 1960s, SARDA has also the study finished the gov- and detoxification treat- ernment had decided to set ments. All new methadone “…it can help heroin up a massive methadone patients start on 30 mg or addicts regain a normal less and the dose can be life …” “Within five years the increased by 5 mg per day. number of addicts The maximum level of provided voluntary in- arrested … had dropped increase within a week is 25 patient treatment centres for mg. The clinics have found both male and female drug by 70 per cent.” that patients who take a users. For people who have higher dose of methadone gone through a methadone treatment program through a are comparatively more sta- detoxification program, network of clinics through- ble than those patients on social workers at SARDA will out Hong Kong. Within two less and they tend to use provide follow up services years the ambitious goal of heroin less often.25 Clients and assess the client’s offering every heroin addict take the methadone orally in progress.26 immediate access to treat- a syrup: they have to take The advantage of metha- ment was met through a net- their dose in front of the dis- done as a substitute for hero- work of 20 clinics. Emphasis pensing staff and are not in is that it can help heroin was still being placed on pre- allowed to take their dose addicts regain a normal life vention, education and local away from the clinic. The and achieve social stability. and international law price of methadone has This has been officially enforcement. Voluntary drug stayed the same for 20 years – recognised in Hong Kong. By free residential treatments $1 (Hong Kong). June 1997, the estimated were still encouraged and Since 1993, social workers number of HIV infections available. By 1976, almost from the Society for the Aid among injecting drug users 10,000 patients were receiv- and Rehabilitation of Drug was 16.27 ing methadone daily. Within Abusers (SARDA) have pro- five years the number of vided counselling services for addicts arrested for drug or the patients at all the clinics.

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4. Buprenorphine 2 What is buprenorphine? Why does buprenorphine work as a Why does buprenorphine work Chapter substitution drug? as a substitution drug? Six Drug use Research into buprenorphine shows that the and “ About 85 per cent of our clients work but use of the drug in substitution programs: substitution very few have jobs on a monthly basis: it is daily •reduces the use of other opioids labour. So they have to work – they can’t • keeps clients in treatment afford to spend time in the detox or rehab • is safe and death from buprenorphine use centres getting treatment while the wife and alone has not been reported children starve – most are married. So they • causes few side-effects have to go on living, they have to continue • is liked by the clients feeding their families but over a period of time • is a good substitute drug for people with that capacity stops. Now they take this low to moderate opiate dependency medication and they find they can go back to • has only mild withdrawal symptoms29 work and do things.” 28 Jimmy Dorabjee, SHARAN, India. Buprenorphine has two characteristics which make it uniquely suitable as an opioid substitution treatment medication: What is buprenorphine? 1 It is unlikely that people will overdose on it Buprenorphine is a synthetic drug which is 2 It is a long-acting drug used as a pain killer. It is easily and widely available in some countries in Asia as an The benefit of buprenorphine as a long- across the pharmacy counter drug. As the acting drug means that it does not have to be price of heroin has increased in certain taken daily. This can make it more acceptable communities, drug users have begun using to clients as they don’t have to visit the clinic buprenorphine as an alternative. every day which gives them more flexibility Buprenorphine is increasingly being in regard to work, other commitments and studied and used as a substitution drug in the sense of being in control of their lives. programs for people who are dependent on Buprenorphine (and other) substitution opiates. The interest in buprenorphine in programs measure their success by: Asia has increased in recent years because: • how many clients remain in treatment •of its acceptability and availability • follow up with clients compared to methadone (e.g. in India • the numbers of people who go back to methadone is not manufactured and using opiates or other drugs when they therefore it would be very expensive to have completed a substitution program import the drug whereas buprenorphine •the client’s physical wellbeing is available in pharmacies) • the incidence of HIV, Hepatitis B and C, • it is increasingly being used by drug users Tuberculosis • it is a relatively safe drug •the client’s quality of life

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HARM REDUCTION NEWS Manual for reducing drug BUPRENORPHINE SUBSTITUTION PROGRAM related harm NEW DELHI, INDIA heroin availability to drop for Clients are given Bupren- in Asia them to take up injecting. orphine for one year for free: HARAN, the Society for SHARAN clearly saw the after this time they are offered SServing the Urban Poor, is need for some intervention prescriptions which are an urban development non- with the IDUs and established reviewed monthly. During government organisation in a trial program of sublingual this time any client who New Delhi, India. Buprenorphine. The trial wants to detox can do so in In the early 1990s, SHA- established that Bupren- SHARAN’s detoxification RAN identified a growing orphine was acceptable to camps or be referred to other problem of injecting drug use heroin addicts, has few side services. Short term rehabili- in the city among urban slum effects, blocks the effects of tation is also offered and dwellers. Many of the IDUs subsequently administered clients can embark on a struc- had serious health problems doses of morphine, binds tured dose reduction pro- associated with their inject- tightly to the opioid receivers, gram. From February 1995 to ing; such as incorrect inject- appears to induce only a low January 1997, 315 of the 1320 ing practices with the conse- level of physical dependence Buprenorphine clients quent development of ulcers, and significantly diminishes attended the clinic regularly. abscesses, cellulitis and the self-administration of Thirty four per cent (447) of thrombophlebitis. SHARAN heroin. the clients were IDUs and of found that there was frequent SHARAN had already these 33 per cent (148) had needle and syringe sharing made contact with many given up injecting. Thirty-five with little cleaning occurring IDUs through their detoxifica- per cent (158) had stopped between uses, increasing the tion camps. The substitution sharing equipment and/or risk of the spread of hepatitis program began on a pilot reduced the frequency of and HIV. basis in early 1993 with 30 injections. Initially, there was As the price of heroin IDUs and quickly expanded some client resistance to tak- increased the users began to 300. Initially the doses of ing their Buprenorphine oral- switching from inhaling hero- Buprenorphine were admin- ly but over time it was accept- in to injecting Bupren- istered through a street deliv- ed. Through a system of peer orphine. Through a series of ery system. SHARAN discov- education and peer research, focus group discussions with ered, that for some clients, the SHARAN has continued to IDUs, SHARAN sought to dis- dose of Buprenorphine was interview and evaluate cover why the injecting of too low and they were going clients’ attitudes to the pro- Buprenorphine had become into withdrawal. They gram: most clients reported such an attractive alternative increased the doses and that their quality of life, eco- to heroin use. They found that found that this also had the nomically, socially and most of the IDUs began added benefit of blocking the health-wise, had improved. As injecting Buprenorphine in effect of any other narcotics a result of this experience, the belief that they would be taken by the IDUs. SHARAN believes that oral able to stop using heroin and As their clients increased, Buprenorphine is a feasible, because Buprenorphine was SHARAN established a drop- low-cost and effective tool cheaper. The focus groups in centre where their clients which diminishes the risk of also revealed that most heroin could receive their dose. The HIV among high risk opiate inhalers are potential injec- drop-in centre also doubles as injectors.30 tors: all that is required is a bi-weekly health clinic.

…33 per“ cent had Many of the“ IDUs had …most heroin“ inhalers given up injecting. serious health are potential Thirty-five per cent problems associated injectors… had stopped sharing… The Centre with their injecting… for Harm ” Reduction ” ” 238 Contents > Section 2-C hapter 6 SECTION

Summary 2 • self-confidence to implement a changed Drug Use behaviour Chapter • supportive social, economic, policy and Six Principal drugs used are as follows: legal environment for healthier choices Drug use Opiates (Opioids): opium is derived from and the opium poppy and contains morphine Recovery from drug use is a delicate substitution and other psychoactive substances. balancing act and drug dependent people Morphine can be converted into heroin. may relapse many times. Temptation to Various synthetic opiates exist such as re-use drugs can be great and relapse can methadone and pethidine. While opiates occur for various reasons: decision to relieve pain and produce a feeling of stop using drugs made by others (e.g. euphoria they can also induce a high level rehabilitation centre), substitution drug of dependency. is inadequate, emotional stress and peer Depressants: are alcohol, barbiturates, pressure to take drugs. It must be synthetic sedatives and sleeping tablets. emphasised that behavioural changes They can cause drowsiness, sedation or take time. pleasant feelings of relaxation. Withdrawal symptoms can be serious. Stimulants: include cocaine that is derived Drug Substitution from the coca leaf and synthetic stimulants such as amphetamines. A sense Drug substitution means replacing the of exhilaration often arises. Potential for drugs a drug user is taking with either psychological dependency is high. the same drug or a similar drug. The Hallucinogens: can be synthetic (e.g. drug substitution goal is to reduce the lysergic acid diethylamide, LSD) or plant health, social and economic harms to derived substances (e.g. certain individuals and to the community, not to mushrooms). While they can induce ‘push’ drugs. highly complex psychological effects they do not induce physical dependency. Some aims of drug substitution: • lessen the risk of contracting or The levels of drug use vary and range transmitting HIV/AIDS from the single or short term use (i.e. • to switch users to legal drugs of known experimental) to the final stage of purity and potency compulsion, when greater drug use is not • to minimise the risks of overdose and only persistent but psychological and other medical complications physiological dependency means • to provide counselling, referral and withdrawal from the drug causes mental treatment and/or physical distress. • to help drug users stabilise their lives and re-integrate with the general community Some reasons to change or stop drug use: • by removing them from the criminal • susceptible to serious health problems scene • knowledge and understanding of healthier choices • motivation, skills and the means to change behaviour The Centre for Harm Reduction

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Summary

Some positive features of MMT are: Manual for Methadone 1. Methadone can be taken orally reducing drug 2. Methadone remains in the body for 24-36 related harm Methadone belongs to a group of drugs hours and therefore only needs to be in Asia called opiates that include heroin, taken once a day codeine and morphine. People addicted 3. Scientific research indicates that MMT is to heroin or other opiates are physically, effective in keeping clients in treatment, and/or psychologically, dependent on the has lower relapse rates and has reduced drug. Withdrawal symptoms occur when injecting drug use and associated harms the concentration of opiates falls below a certain level in a dependent user’s body. Before beginning on methadone all clients Methadone is a long acting synthetic drug need to be told about the potential side which alleviates withdrawal symptoms effects and how they weigh up against the such as aches, pains and cravings etc. benefits. These side effects include, nausea, vomiting (temporary), constipation, Short term methadone treatment (i.e. 45 sweating, lethargy, decreased libido and for day detoxification program as in Thailand) women, loss of periods. aims at rapid detoxification and is firmly focused on abstinence. The success of this MMT programs encourage clients to stay approach is limited as research has shown in the program for at least six months. clients often returning to opiate use. Access to the MMT should be provided Programs offering both long term methadone for as long as the client can benefit from maintenance and detoxification (at the the program. A MMT program allows a client’s choosing) have better rates of success. client to feel physically and psychologically healthier and assists them Methadone Maintenance Treatment in gaining the confidence and motivation (MMT) is a long term treatment that to have a drug free life. successfully improves the physical, mental and social well being of clients and has Methadone dose: proven effective in the prevention of HIV Starting off: dosage varies from client to infection. MMT programs are successful if: client and daily assessment is required • the dose of methadone is sufficient to during the commencement of treatment. overcome withdrawal symptoms The first dose is often 20mg and will have • positive attitude and treatment by the increases of 5-10 mg per day according to staff towards the clients results in a the client’s tolerance. trusting relationship which encourages Maintenance: maintaining client treatment the client to remain in treatment and the limiting or stopping of illicit • besides providing methadone dosage, staff drug use can be achieved if the are trained about HIV/AIDS, counselling methadone dose is 60-100mg. Any techniques, primary health care, etc. withdrawal symptoms must remain mild and sedation of the client must be avoided.

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240 SECTION Contents > Section 2-C hapter 6 2 Reduction: reducing the dose should arise at the request of the client. Physical and Buprenorphine Chapter psychological distress arising from Six methadone reduction must be closely Buprenorphine is a synthetic drug that is Drug use monitored. Ignoring distress signals can used as a pain killer. Interest in and result in the client invariably relapsing buprenorphine as a substitute drug in substitution into using illicit drugs. Asia has increased due to its acceptability and availability compared to methadone, It is important that workers in MMT its increased use by drug users and its programs are aware of the potential use of relative safety. Research into other drugs by their clients. The use of buprenorphine has shown a number of multiple drugs with methadone can lead to benefits: it can reduce the use of other an overdose. Other drug use can be linked opiates, it causes few side effects and its to an inadequate methadone dose, resulting long acting drug effect does not warrant in the need to carefully increase the dose. a daily dosage resulting in greater Intoxication of the client arriving at the flexibility and control for the drug user. clinic for a methadone dose can create a dilemma for the staff. In order to avoid Societies throughout the world have used doing any harm to the client, alternative drug substances for many reasons; from the options must always exist for such suppression of pain and sorrow to desire to circumstances. Lastly, the problem of experience the pleasurable sensations. While missed doses should be avoided so as each group of drugs produces its variety of maintain a methadone balance and to effects and dependency the important avert withdrawal symptoms; such common factor shared by dependent drug situations often necessitate an adjustment users is the compulsion to use the drugs, be of the dose. Discussions as to why a dose/s it opiates, depressants, stimulants or was missed and how the client is doing on nicotine. the program should be encouraged.

Section Two: Chapter Six: Drug Use and Substitution

For further information refer to WHO resources: Evidence for Action Papers. Refer to the following website: www.who.int/hiv (publications expected online from May 2003) The Centre for Harm Reduction

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CENTRE FOR HARM REDUCTION

▼▲ Principal Drugs in Use

➤ Opiates (Opioids): include opium, morphine, heroin, methadone, pethidine, buprenorphine ➤ Depressants: include alcohol, barbiturates, benzodiazepines, synthetic sedatives and sleeping tablets ➤ Stimulants: include cocaine and amphetamine ➤ Hallucinogens: include chemical synthetics (LSD) and plant derived substances (mushrooms)

Manual for reducing drug related harm in Asia SECTION 2 • CHAPTER 6 • OVERHEAD 1

CENTRE FOR HARM REDUCTION

▼▲ Reasons to change or stop drug use

➤ Belief in vulnerability to serious health problem ➤ Knowledge/understanding of healthier choices ➤ Motivation/Skills/Means and self-confidence to change behaviour ➤ Environment of social, economic, policy and legal support for healthier choices Temptations to re-use drugs are great and drug dependent people may relapse many times for various reasons (e.g. emotional stress, peer pressure). It must be emphasised that behavioural changes take time.

The Centre Manual for reducing drug related harm in Asia for Harm SECTION 2 • CHAPTER 6 • OVERHEAD 2 Reduction

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CENTRE FOR HARM REDUCTION

▼▲ Drug substitution replaces the drugs a drug user is taking with either the same drug or a similar drug. Emphasis is on comprehensively reducing harm.

Positive aspects of drug substitution include: ➤ Contracting/Transmitting HIV/AIDS lessened ➤ Legal drugs have known purity and potency ➤ Reduces risk of overdose or side effects ➤ Counselling, Referral & Treatment ➤ Stability and Re-Integration

Manual for reducing drug related harm in Asia SECTION 2 • CHAPTER 6 • OVERHEAD 3

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▼▲ Methadone maintenance Methadone is a long acting synthetic drug that alleviates withdrawal symptoms for those physically dependent on heroin or other opiates.

Methadone Maintenance Treatment (MMT) Approaches ➤ Withdrawal symptoms tolerated with sufficient dose ➤ Clients remain in treatment with good, trusting, empathetic staff ➤ Comprehensive training of staff on HIV/AIDS, counselling , etc

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▼▲ Positive Features of MMT

➤ Taken orally ➤ Long acting, 24-36 hours ➤ Retains clients ➤ Lowers relapse rates ➤ Reduces injecting drug use and associated harms ➤ MMT enables clients to feel physically and psychologically healthier and can promote confidence and motivation towards a drug free life

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▼▲ Stages of Methadone Dose

1 Starting Dose 2 Maintenance Dose 3 Reduction Dose

Potential use of other drugs and adverse consequences experienced by clients on methadone is a reality. Options do exist for staff confronted with such problems.

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▼▲ Buprenorphine substitution

Positive Features of Buprenorphine ➤ Increased acceptability and availability in Asia compared to methadone ➤ Increased use by drug users in Asia ➤ Relative safety ➤ Reduces use of other opiates ➤ Fewer side effects ➤ Long acting drug

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245 Contents SECTION Section Two 2 Chapter Seven HIV/AIDS: Preventing Transmission – Through Sex – Between Parent and Child

Sexual transmission Reducing sexual transmission Women’s position in society Transmission of HIV to babies Preventing parent to child transmission of HIV, within a child survival approach

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Introduction

Injecting drug users (IDUs) are at risk of HIV infection from sharing Manual for injecting equipment and from unprotected sex. Many IDUs are unaware, reducing drug or not fully aware, that they are at risk from both behaviours. Other IDUs related harm may be aware of the risk but continue to practise risky behaviours. Current in Asia evidence suggests that interventions aimed at promoting safer sexual behaviour among IDUs have met with limited success, particularly among IDUs with regular partners, who may themselves inject drugs.

The risk of sexual transmission is closely related to the frequency of equipment sharing, the frequency of risk-associated sexual activity and also to the extent of the epidemic in a given area.

This chapter examines: 1 Sexual transmission 2 Reducing sexual transmission 3Women’s position in society 4Transmission of HIV to babies 5Preventing parent to child transmission of HIV, within a child survival approach

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1. Sexual Transmission 2 How is HIV transmitted through sex? Sexually transmitted infections (STIs) What are the most common signs of Sexually transmissible diseases (STIs) range Chapter STIs? from mild and easily treatable irritations to Seven What are the relative risks of HIV serious diseases which can cause infertility HIV/AIDS infection? and even lead to death. Common STIs are Who is particularly at risk? herpes, genital warts, chlamydia, gonorrhoea, Why is it important to give IDUs syphilis, hepatitis etc. Many STIs have no tell information about sexual transmission? tale signs or symptoms.

How is HIV transmitted What are the most common through sex? signs of STIs? The majority of cases of HIV infection • unusual discharge from the penis or worldwide (approximately 75 per cent) are vagina the result of unprotected sexual intercourse. • burning, stinging or irritation when Any sexual activity that allows an infected urinating person’s semen and sperm, vaginal fluids or • sores, blisters, ulcers, warts, lumps or blood (including menstrual blood) to enter rashes in the genital and/or anal area another person’s bloodstream can spread HIV • itchiness or irritation in the genital and other sexually transmissible diseases and/or anal area (STIs). The way these body fluids enter the • pain during intercourse or a low bloodstream can be through: abdominal pain (in women) • the lining of the vagina or the rectum •a non-itchy rash on the palms of the • the opening of the tip of the penis hands or soles of the feet •a break in the skin’s surface such as a cut, • persistent or recurring diarrhoea scratch, bleeding gums, open sore or ulcer The presence of other STIs, especially Every act of unprotected sexual intercourse diseases which manifest as open sores, with an HIV infected partner, that is without increase the risk of acquiring and using a condom, puts the uninfected partner transmitting HIV in both men and women. at risk of contracting HIV. The extent of the They also indicate sexual activity with one or risk may be determined by: more partners. If a person has active herpes, • whether there are any other STIs present syphilis, chancroid and so on, an open wound • the sex and age of the uninfected partner allows HIV to penetrate tissue and enter the • the type of sexual act undertaken bloodstream much more easily. An STI • the stage of illness of the infected partner causes inflammation which means T-cells •the virulence of the HIV strain involved (which fight infection) are sent to the area to check on the infection. If the person is infected with HIV then some of these cells will be carrying the virus and this can increase the amount of HIV present in the reproductive tract. This magnifies the risk of transmitting the virus. If the other person also has an STI the risk is even greater again. The Centre

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Women are generally more vulnerable to Ty pe of sexual act Manual for STIs, and consequently HIV, for several Sexual transmission of HIV most commonly reducing drug reasons including their biology. In women a occurs through unprotected vaginal or anal related harm larger surface is potentially exposed to intercourse between a man and a woman, or in Asia infection: the vagina and the cervix. There is through anal intercourse between men, when also a higher concentration of HIV in semen one of the partners has HIV. During than in vaginal and cervical fluids. unprotected intercourse semen is deposited Often women do not experience any in the vagina or rectum and the penis comes symptoms of STIs and so don’t seek out into contact with vaginal or anal mucus. treatment. For women who do have Some studies suggest that the receptive symptoms, the stigma of attending an STI partner in intercourse (the person who is clinic may be so great that she will not seek penetrated) is more at risk than the insertive treatment. These untreated STIs leave partner. This is true for both vaginal and anal women more vulnerable to HIV infection. sex (this includes heterosexuals and Women may not recognise a low grade homosexuals having anal sex). infection as an STI as they do not perceive Oral sex is not considered a high risk themselves as at risk : they may not realise activity. It becomes more risky when there their partner is involved in sexual behaviour are cuts, sores or bleeding in the mouth or outside of the relationship that is putting genitals. These inflammations mean that them both at risk. (For more information bodily fluids, including blood, can be about specific STIs see Appendix 3: transmitted into the other person’s Sexually Transmitted Infections). bloodstream. Sexual practices that may cause bleeding are risky. Inserting fingers or Sex and age a fist into the rectum or vagina may cause Young girls are particularly vulnerable to damage and cut or bruise the tissue. Rough infection as an immature cervix and low penetrative sex may also cause this sort vaginal mucus production provides less of a of damage. barrier to HIV. However, older women, who have been through menopause, are also more vulnerable due to the thinning and drying of vaginal mucosa (hence a weaker barrier).

RISK

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What are the relative risks of HIV infection? Chapter RELATIVE RISK ACTIVITY Seven HIV/AIDS VERY HIGH – transfusion of infected blood or blood products – sharing of contaminated needles and syringes – anal intercourse without a condom – vaginal or anal intercourse without a condom in the presence of another STI HIGH – some exposure of broken skin to infected blood – vaginal intercourse without a condom –breast feeding (by infected mothers) MODERATE – needle stick injury – slight exposure of broken skin to infected blood VERY LOW – sexual intercourse with proper use of condoms – oral sex (in the absence of ulcers or broken skin) NEGLIGIBLE – deep kissing – lip kissing – exposure of intact skin to infected blood NONE – any form of sexual activity between two uninfected faithful life- long partners – touching or hugging a person with AIDS – celibacy1

RISK RISK

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The stage of illness: the immune system is under constant Manual for People who are infected with HIV are more pressure to try to slow or stop this reducing drug likely to transmit the virus in the very early replication. This leads to the eventual related harm stages, usually before they have any idea that destruction of the immune system, HIV in Asia they are infected. This is because the viral related illnesses and eventually AIDS.3 load (or the amount of HIV in the blood)is very high just after infection. It can take up to three months after a person is infected Who is particularly at risk? before a test will show whether or not they are infected with HIV. This is because it • IDUs and their partners takes time for the body to produce HIV • Sex workers and their clients antibodies. This is called the window period. •Men who have sex with men The most commonly used tests to diagnose • STI clients HIV looks for the presence of antibodies • Migrant workers rather than for the presence of the virus. (For • Long distance truck drivers more on testing see Chapter Eight: •Military personnel Counselling and Testing). •Women of child-bearing age People are also more likely to transmit the virus when they have advanced HIV- related illnesses because the level of the virus Why is it important to give IDUs in their blood is higher than at other times. information about sexual The more times that an uninfected partner transmission? has sexual intercourse with an infected partner the greater the chance that they will It is crucial to include information about become infected with HIV. how HIV is transmitted sexually when disseminating information on safer using The virulence of the HIV strain practices to IDUs. IDUs are at risk of and viral load contracting and passing on HIV through Part of the success of HIV in defeating the sharing needles and syringes and through immune system and drug treatments is its unprotected sex. Studies have shown that ability to mutate into drug resistant or more while there has been some success in virulent strains.2 There is significant changing IDUs injecting practices, changing variation in HIV around the world, with IDUs’ sexual behaviours has been more some strains affecting particular groups and difficult to achieve. some strains seeming to be more or less IDUs face the same risk of contracting infectious. and passing on HIV through sex as other The viral load refers to the amount of the members of the community. Most IDUs are virus a person has in their body at any one male and in general their partners do not time. Originally it was believed there was a inject drugs. They may be engaged in latency period with HIV infection: a time heterosexual and/or homosexual acts, be between when a person was infected with married, be parents, pay for sex, work as sex HIV and developed symptoms. Research has workers, have STDs and poor access to health since shown that the virus is actually services. In other words, IDUs are a diverse multiplying in the body continuously and group and in terms of sexual transmission

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Harm Reduction News Chapter Seven HIV/AIDS Jamuna

TAMIL NADU, INDIA hospital, complaining of end of the working day it was fever and diarrhoea. normal to buy some toddy amuna is 19 and seven “After examining me the (liquor) and have sex, to relax Jmonths pregnant with her doctor said I would have to the body. My father tried his first child. She is also HIV have a blood test to find out best to get Nagu to see a doc- positive. Three years ago she if I had HIV infection. After tor, but he refused. I haven’t was married to Nagu, a quar- the first test showed I was seen Nagu since. ry labourer who works in the positive, he sent my blood to My parents got me admit- neighbouring state of Andhra another hospital and they ted into hospital because I Pradesh. Nagu’s work often confirmed the result. The feel sick all the time. We’ve took him away from home doctor told me it might be heard that my in-laws have for weeks at a time. He would best for my husband to have decided to find another visit home occasionally and his blood tested too, so my match for Nagu. At first I give his earnings to his par- father went to Andhra and thought I would somehow try ents and wife. spoke to my in-laws about it. to stop them from getting After Jamuna became They think I’ve been pun- him married again, but I just pregnant her in-laws sent her ished with this disease don’t have the energy. to stay with her parents, as is because I must have been “If I can keep enough the custom, in a small town unfaithful to my husband. strength to go through with near the border between the “But Nagu himself told my pregnancy, all I’ll have states of Tamil Nadu and me that he and his friends will be my child. I pray that at Andhra Pradesh. Two months sleep with women at the least my child will be free of ago Jamuna went to the local quarry. He said that at the this disease. 4

they face the same risks and problems as The extent of sexual networks involving other members of the community. But IDUs IDUs is likely to increase as the epidemic have the greatly increased risk of contracting increases. For example, in the early stages of a and transmitting HIV and hepatitis C if they local epidemic HIV infection is likely to share drug injecting equipment. remain within a limited core group of IDUs. A person may contract HIV by sharing a People who only occasionally inject drugs or needle and syringe with somebody who is have sex with IDUs are less likely to acquire infected with HIV. This person can then pass HIV than those people who do so regularly. the virus on to his/her partner through However, as the epidemic becomes having unprotected sexual intercourse. established, more and more people are A person may have been infected with included: a person who is HIV positive and HIV by having unprotected sexual shares needles and syringes in the core group intercourse with somebody who has the may move outside that group and share with virus. This person then shares a needle and someone else. The virus then spreads into a syringe with somebody else and they can pass new group and will be transmitted both the virus on this way. through sharing equipment and unprotected sex. The Centre for Harm Reduction

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2. Reducing Sexual Transmission

Transmission of HIV What are the main strategies for reducing Manual for 1Injecting drug users (mostly male) > sexual transmission of HIV? reducing drug other IDU > partners What questions should you ask the related harm 2 Sex workers > clients of sex workers> community about sexual behaviour? in Asia partners 3 Partners of IDUs /clients of sex workers > children born to infected mothers What are the main strategies Social network interaction of IDU and for reducing sexual transmission HIV transmission of HIV? The main prevention strategies advocated to Community stop the sexual transmission of HIV are: • to reduce the number of sexual partners • to use condoms • to say no to sex IDU • to be faithful to one partner Uninfected with HIV •to have non-penetrative sex • to treat STIs

IDU Shooting gallery However, these strategies can be problematic. HIV (Shared The strategy of reducing the number of infected equipment) partners is irrelevant or impossible for many women: firstly because many women only IDU have one partner anyway, and secondly for HIV infected women who are forced to sell or exchange sexual intercourse for economic reasons. The strategy of using condoms can be difficult for Sex worker Wife has women: if she demands the use of a condom Unprotected sex unprotected Becomes sex suspicions may arise about her fidelity and HIV infected whether she has any diseases, while for sex workers clients may just go elsewhere. Women also do not often have a choice or Clients Casual partner Pregnant wife determination over their own sexuality or Unprotected Unprotected sex Becomes their partner’s faithfulness being unable to sex Becomes HIV infected Become HIV infected insist on either. Additionally for a growing HIV infected number of girls and women, sexual assault is a reality, whereby these strategies are again irrelevant. 5 Clients Other partners Baby partners Unprotected sex HIV infected Unprotected Become sex HIV infected Become HIV infected

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ARM EDUCTION EWS Chapter H R N Seven HIV/AIDS INTEGRATING AIDS EDUCATION

HONG KONG,CHINA mainland China: a situation focused on AIDS specifically, which causes many social it started integrating he Hong Kong AIDS problems. HIV/AIDS with other issues of TFoundation became As in most Asian coun- interest to women such as actively involved in promot- tries, the women knew little health, communication in the ing AIDS awareness among about sex and did not talk family, parent-child and mari- women. The Foundation about it: this reality prohibits tal relationships, assertive- brought the message of basic ness skills and social services. concepts of HIV/AIDS, and The Foundation believes measures for prevention, to that learning about AIDS in the doorstep of each house- (The Foundation)“ the context of other issues hold through funfairs, semi- started integrating has allowed women to learn nars and workshops. HIV/AIDS with other skills needed to better pro- However, eventually it was issues of interest to tect themselves. The discovered that the women women … Foundation is also providing felt constrained by the tradi- peer education training for tional idea that a wife cannot women in various organisa- refuse sex with her husband many women” from attending tions. Peer educators in these because he may go to other programs specifically about organisations share their women. Their concern is sex or HIV/AIDS. The knowledge with their mem- underscored by the reality Foundation changed its bers while being sensitive to that many men have second approach and instead of their group’s values and wives and children across in workshops and seminars needs.6

Strategies for women Strategies for men Social and economic realities of women’s Encourage and increase condom use by lives: develop strategies which give women making condoms readily available and opportunities to earn an income apart from destigmatise them. Inform men of the risks sex work, not as rehabilitation programs for they are taking and what activities are sex workers but to increase young women’s putting them at risk. Encourage men to seek range of options. treatment for STIs and discuss safer sex Extend HIV infection education to all techniques and HIV/AIDS at clinics. women: public education to be directed at •Only limited changes in the sexual all women, not just sex workers. Education behaviour of IDUs is evident around also needs to target girls who are particularly the world at risk. •Becomes increasingly important as Alternative technologies: development prevalence rises of affordable technologies for preventing • Difficulty of IDUs defining themselves HIV infection which women can control, as at risk sexually such as refinement of the female condom. • Safer sex behaviour in sex work

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Manual for Harm Reduction News reducing drug related harm in Asia Faithful Wives Can be At Risk

NEW DELHI, INDIA ferent women every month. When Shenbagam first She also knows that he showed Muthu a condom henbagam is a mother of makes extra money booking and told him how it could Stwo. She and her family clients for sex workers, but is protect them both from live in a crowded tenement in unable to argue with him AIDS, he beat her up. one of Palani’s (in India) about these matters. Shenbagam told someone numerous slums. Her hus- from the Society about the band, Muthu, works as an “…she is extremely problem. This person then auto-rickshaw driver. vulnerable to infection arranged a slide show on After suffering frequently because of her husband’s AIDS for the men in the from genital irritation and neighbourhood and per- sexual behaviour.” discharge, she learnt that suaded Muthu to attend it. what she had was called an The slide show was fol- STD. She also learnt about Fearing that Muthu lowed by a discussion, which HIV and AIDS, and knows would suspect her of having made Muthu examine his that she is extremely vulnera- an affair with someone else, own sexual behaviour. He ble to infection because of Shenbagam did not dare tell now discusses AIDS with his her husbands sexual behav- him she was suffering from friends, and has begun to use iour. an STD. However, she decid- condoms whenever he visits Shenbagam feels that she ed to get treatment, without sex workers. “It took a while must have got the STD from his knowledge, at the to convince him,” says her husband, who spends a Society’s clinic, where the Shenbagam, “but things have lot of money on sex with dif- nurse also gave her condoms. changed for the better.” 7

What questions should you ask appropriately designed and targeted with the community about sexual input from the targeted groups. These behaviour? background questions are a starting point to uncover the nature of sexuality and how it is One of the difficulties facing people working best discussed. in HIV prevention is the need to deal with • What sort of language do people use to issues which are often uncomfortable or discuss sex? rarely discussed publicly. Both drug use and •In what circumstances do people discuss sexuality are surrounded by taboos and sex? secrecy. Sexual practices and drug using •When do young men and women start practices also vary from region to region and having sex? How much choice do they country to country. have in the matter and how does it differ In order to discuss sexuality and drug use, for men and women? without causing offence, it is necessary to • What are the socially acceptable and understand the sexual practices and mores of unacceptable forms of sex? the particular culture. Information about •What is the difference between public safer sexual practices needs to be perception and actual practice? The Centre for Harm Reduction

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3. Women’s Position in Society 2 • Who initiates sex? “The chances are that as a woman you are • Can women say no to unwanted or going to get AIDS because your man has had Chapter unprotected sex? sex with someone with HIV and brings it Seven •How common is forced sex – rape, incest? home to you. How can you protect yourself? HIV/AIDS •Can women get their partners to use By insisting that the man uses a condom? He condoms? Can women obtain condoms? has the power. He says he’s not doing it. So What are the barriers to women what next? For far too many of us it boils obtaining them? down to either no sex and therefore no • What sort of contraception is used? (e.g. support system for yourself and your oral contraceptives, injectable children, or the risk of contracting AIDS.” 9 contraceptives, intra-uterine devices (IUD), condoms, female and male The subordination and powerlessness of sterilisation) many women around the world is sharply • What are the traditional methods of highlighted by, and fuels the spread of, the family planning? How prevalent are HIV/AIDS pandemic. The association these? between the oppression and inferior status of •How common are sexual activities which women and the spread of the disease is not increase risk for transmission of co-incidental. Cultural, legal and economic HIV?(These include: anal sex, dry sex, factors limit the control that women have beating/traumatic sex, sex during over their lives, their sexual lives and their menstruation) ability to protect themselves from HIV and •How common are sexual activities which other STIs.10 decrease risk? (These include non- penetrative sex and oral sex) • How important is sex work for money? • Is it organised? (e.g. brothel-based, street work, night-club-based, escort services, hotel-based?) • Who runs sex work businesses? • What are the types of sex work: female to male, male to male, male to female, transsexual? • Is sex work legal? Are workers registered? • Have sex workers formed organisations? •Are health checks, HIV testing or treatment for STIs compulsory? •What is the level of knowledge about the transmission and prevention of HIV and other STIs? • Do people perceive themselves as at risk? • Which individuals or groups of people are commonly perceived by others to be at risk? 8

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HARM REDUCTION NEWS Manual for reducing drug A WASTED LIFE related harm in Asia NEW DELHI, INDIA clients per day by her brothel because of health problems. owner. It was at this point her Throughout her time as a t puberty, Lakshmi was health problems, including prostitute, Lakshmi had reg- Ataken by her father to STDs, began. After six years ularly attended a mobile stay with an older man in a health clinic for her STDs. nearby community. She Initially she was treated for stayed with this man for six STDs but the failure to weeks and her father She was “being forced respond to treatments sug- received Rs 1,500. Soon after into prostitution but gested she was HIV positive. this, the girl was brought to she resisted … She showed severe weight an area of the city which was loss, fever, loss of appetite, known for prostitution. swollen glands and joint Lakshmi was sold to a broth- at this brothel” she was pains which did not respond el owner for Rs 2,000. She removed from the premises to any medicines. An HIV test was being forced into prosti- by a pimp to another district was performed and she was tution but she resisted for a to continue her work. The confirmed HIV positive. After month: in protest she did not majority of her clients at the a while she became very sick eat at all. After realising that new brothel were truck dri- and was kept in the court- there was no way out she vers and mill workers. She yard of the brothel. Lakshmi conceded and began to work continued to work for anoth- was supported by the brothel as a prostitute. She was er two and a half years but owner until she died.11 forced to take eight to nine was eventually forced to stop

Women often have little access to education, health, training, independent What are the issues and incomes, property and legal rights. In many dilemmas relating to women’s cases women rely on their partners/husbands position in society? for their economic and social status. Women’s economic dependence on their • Sexual double standards: it is generally partners, in order to avoid poverty for expected that women will be faithful to themselves and their children, makes it their husbands but the same standard difficult for women to negotiate safer sexual does not necessarily hold true for men. practices. For women to bring up the subject For many women there is a feeling of of safer sex, such as using a condom, may helplessness in trying to control their lead to the risk of being rejected, beaten up husband’s infidelity and if they ask their or thrown out of their homes.12 Some women husband to use a condom she may in turn have never discussed sexuality and sexual be accused of infidelity. practices with their partners and do not have • Importance of fertility: in many the language or experience to even know societies the bearing of children is a where to begin. Discussions about safer sex woman’s designated role and her only and condom use also bring up the issues of means to gain any social status. Her infidelity and/or injecting drug use. conflict then is between trying to protect herself from infection and the imperative The Centre to have children. for Harm Reduction

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4. Transmission of HIV to babies 2 • Poverty, prostitution, sex tourism, What is the risk of mother-to-child migration: for many women sex work is transmission of HIV? Chapter the only alternative to destitution. What influences the risk of mother-to- Seven Women working in sex work may be child transmission of HIV? HIV/AIDS attempting to provide an income not only for themselves but for their children and The AIDS epidemic is having a profound extended family. It can be difficult to impact on the lives and survival of children insist on safer sexual practices (such as in developing countries. HIV can be condom use) when the client can go transmitted from parents to babies, and elsewhere where he does not have to use a many children are becoming orphaned when condom. Sex workers also travel across their parents die. People who inject drugs, borders. In an unfamiliar community, and their partners, may worry about the risk often confronted with unfamiliar to their children of HIV infection. Men who languages, sex workers have more inject drugs need information about the risk difficulty in negotiating with clients and of infecting their partner through sex and/or managers where they work. If they are in unsafe injecting practices, and the the country illegally, they may also face subsequent risk of infecting their child. the risk of prison or deportation which Women who inject need information about makes them even more powerless.13 The the risk of HIV to their baby if they are sex tourism industry is extremely infected with HIV and become pregnant. lucrative and in the wake of fear about The number of children infected with HIV/AIDS has often led to younger and HIV is increasing rapidly in countries where younger women working as prostitutes HIV has spread widely in adults. Most who are offered to clients as young and women who become infected with HIV are uninfected. in the reproductive age group. UNAIDS has • Stigma and discrimination: Women, estimated that by the end of 2001, 3 million and in particular female sex workers, have children were living with HIV, and that long been characterised as ‘vectors of 800,000 children became infected in 2001 disease’, a description which ignores the alone, with 580,000 deaths.15 To date sub- role of the client. Where women’s status Saharan Africa has been most severely is already low, HIV infection becomes an affected, but children are increasingly added stigma. The discrimination which becoming affected in the Asia-Pacific region. women have experienced when it is HIV is currently spreading rapidly in India, discovered that they are HIV positive, China, and many parts of south-east Asia and can mean that women who know or the Pacific.16 In many countries the gains suspect they might be infected avoid made in child survival have been lost because finding out, hide their status if they do of AIDS. get tested and delay seeking professional Issues of fertility, pregnancy, childbirth treatment and help.14 and breastfeeding are likely to be extremely sensitive for women who inject drugs, or have a partner who injects drugs, especially if they sell sex in order to obtain drugs. It is important for their counsellor or health care adviser to understand this when discussing these issues. The Centre for Harm Reduction

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Other factors that increase risk include: Manual for What is the risk of mother to • any infection during pregnancy, especially reducing drug child transmission of HIV? a sexually transmitted infection or related harm infection of the placenta HIV can be transmitted from an HIV- in Asia • poor nutrition during pregnancy, infected woman to her child: especially micronutrient deficiencies • during pregnancy •premature delivery • at delivery • interventions during labour, such as • while breastfeeding. breaking the bag of waters around the baby Not all babies born to HIV-infected • non-exclusive breastfeeding women become infected with HIV. When •mastitis and cracked nipples the baby is growing in the womb the blood • longer duration of breastfeeding. of the mother and baby come close – but they do not usually mix. Studies show that Several studies have shown that drugs the risk of transmission from an infected that attack HIV (antiretroviral drugs) taken mother to her child is between 15 per cent by women during the final weeks of and 48 per cent.17 pregnancy and during delivery lower the viral load and significantly reduce If 100 HIV-infected women each have a baby, transmission of HIV to the baby. In about 35 of the babies will become infected Thailand, provision of zidovudine for the last with HIV. On average the virus will have four weeks of pregnancy and during labour passed to seven of the babies during the was found to reduce risk of transmission by pregnancy, to 15 at the time of delivery, and half, if babies were not breastfed.19 A study to 13 of the babies afterwards through in Uganda showed that a single dose of a 18 breastfeeding. different antiretroviral drug, nevirapine, given at the time of delivery to the mother and to the newborn, reduced the risk of HIV What influences the risk of infection by half.20 This inexpensive mother-to-child transmission of intervention is able to reduce the risk of HIV? transmission even when babies are breastfed. There are two main risk factors: • The virus is more likely to pass to the baby if the woman becomes infected with HIV during pregnancy or breastfeeding. This is because the amount of the virus in the blood is particularly high in the weeks after a person becomes infected. • The virus is more likely to pass to the baby if the woman has an HIV-related illness (for example, a chronic cough, loss of weight, repeated diarrhoea). This is because the amount of virus in the blood increases during the later stages of HIV infection, when the immune system is The Centre damaged. for Harm Reduction

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5. Preventing parent to child transmission of HIV,within a 2 child survival approach An expert panel convened by WHO in How can we prevent babies becoming October 2000 concluded that nevirapine Chapter should be approved for widespread use. infected with HIV? • Primary prevention Seven Caesarean section before the onset of HIV/AIDS labour can reduce the risk of transmission of •Population-based secondary HIV from mother to child by half.21 In prevention developing country settings it is important • Secondary prevention for women to consider the safety of caesarean section, the known to be HIV positive cost, whether women can access surgery, and Providing follow up care and support for whether they will be able to do so for future mother and baby pregnancies, since there will be an increased What questions are useful to inform risk of rupture of the uterus with subsequent prevention and care strategies? deliveries. Avoidance or modification of breastfeeding can lower the risk to the baby. How can we prevent babies The additional risk of transmission to the becoming infected with HIV? baby from a mother already infected during pregnancy is about 12-16%.22 The risk is greatest in the early weeks, but remains Primary prevention throughout the duration of breastfeeding. The most effective way to prevent babies The risk of transmission to the baby if the becoming infected with HIV is to prevent woman becomes infected during the transmission between men and women. breastfeeding period is higher. But Community education to raise awareness that breastfeeding plays a vital role in protecting babies can be infected with HIV can children’s health and has important contribute to primary prevention by nutritional and immunological advantages. appealing to men’s sense of responsibility for Babies who are not breastfed have a high risk their families. of death from malnutrition, diarrhoea and It is especially important to prevent respiratory infections.23 Breastfeeding also women becoming infected with HIV during has important child-spacing and their pregnancy or while breastfeeding environmental advantages. The health because they are more likely to transmit the benefits of breastfeeding are of most virus to their babies: importance in the first six months of life. • If a woman is injecting drugs and wants The balance of risk for the baby will vary for to become pregnant she (and her partner different HIV-infected mothers in different if appropriate) should be counselled about settings. the dangers to the baby of drug use There is evidence that exclusive during pregnancy, and the risk of spread breastfeeding, when the baby receives of HIV to the baby if the woman becomes nothing but breastmilk, may be safer than infected during or after the pregnancy. mixed feeding, and may even protect against She needs to be supported to stop transmission of HIV at the time of delivery.24 injecting drugs before she becomes It is common for feeds of water or other pregnant, and access to contraception fluids to be given before the milk ‘comes in’, until she is ready to become pregnant. and for cereals to be introduced in the first The woman and her partner should be weeks of life. Babies do not need to receive counselled about the need to practise safe any food or fluids other than breastmilk for sex during pregnancy. the first six months of life. The Centre for Harm Reduction

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• If a woman who injects drugs is already interventions in the community, especially if Manual for pregnant she needs advice about the they are vulnerable to infection with HIV. reducing drug danger of transmission of HIV to herself To do this workers in the field can: related harm and to the baby, and support to stop •prevent unwanted pregnancies through in Asia injecting drugs. increasing access to information and •Men have a right to be informed that contraception unprotected sex or sharing injecting drug • strengthen men’s and women’s use equipment with others carries a high reproductive health services risk of HIV infection to their baby. • counsel women with chronic illness to • During pregnancy and childbirth women postpone pregnancy until they have been are especially likely to receive a blood well for six months transfusion and/or injections. Midwives •promote quality antenatal care with and doctors need to be trained to reduce treatment of STIs and other infections the need for transfusions, ensure blood for and nutrition advice transfusion is screened, and implement •include men in antenatal care strict transfusion criteria and safe • train midwives, doctors and traditional injection practice. birth attendants to reduce unnecessary • ‘Discordant couples’, where the man is obstetric interventions HIV positive and the woman is HIV •promote exclusive breastfeeding for all negative, may ask for advice because they • train health care workers in breastfeeding want very much to have a baby. In this skills to minimise breast problems. situation the couple can be advised to Many of these activities may be have unprotected sex only once each components of existing reproductive health month at the time the woman is most or maternal and child health programs.25 fertile. Although there is a risk of transmission of HIV to the woman, the Secondary prevention for women risk is much smaller than if the couple known to be HIV positive have sex without a condom throughout Before conception the month. Women can learn how to When a woman of child-bearing age recognise the timing of ovulation so they discovers she is infected with HIV she should have sex without a condom when they are be counselled on issues relating to her most likely to conceive. It is important to fertility. This means she will be able to think make sure that neither partner has a about the implications of becoming pregnant sexually transmitted infection. or postponing or avoiding pregnancy. Counselling should also inform her about the Population-based secondary prevention risk factors which increase the likelihood that In countries of the Asian region most women a child will become infected with HIV. A that are infected with HIV do not know their woman should be given clear information status. Few women have access to ante-natal and supported in her choices. She may need VCT (voluntary counselling and testing) as advice about and access to contraception. She yet, and those who do may prefer not to be should be asked whether she would like to be tested for HIV, or may not be in a position to counselled with her partner. If she already has decide. There are prevention strategies that children she may worry about their health do not depend on testing during pregnancy and want them to be tested for HIV. that also assist the health of women and men in general. It is important to promote these The Centre for Harm Reduction

262 SECTION Contents > Section 2-C hapter 7 2 After conception In Thailand routine offering of voluntary A pregnant woman may discover that she is counselling and testing during pregnancy, Chapter infected with HIV after undergoing with provision of zidovudine and infant Seven antenatal VCT for HIV, or she may have formula to those who test positive, has been HIV/AIDS known her status already. Either way she will implemented throughout the country. But need sympathetic and confidential few countries in the region share the features counselling about the risk to the baby and that have enabled Thailand to expand this the things that she can do to lessen the risk. intervention so successfully. Thailand is a This will depend on what services are middle-income country with good health available but might include: care service infrastructure, high rates of • counselling about HIV and infant feeding attendance at antenatal clinics, political choices (see below) support for the program, international • counselling about maintaining good support, a cohesive community, artificial health during pregnancy through good feeding not stigmatised, and care available nutrition and rest for people with HIV. Thailand has also • identifying and treating STIs and other succeeded with impressive primary infections prevention efforts. • identifying and treating preventable These interventions require: causes of premature births • community aware of possibilities for •delivering a short course of antiretroviral prevention of parent-to-child prophylaxis, if available transmission of HIV • elective caesarean section, if appropriate • accessible and affordable high quality • referral to a support group antenatal care •arranging follow up care and support • community acceptance of people infected • discussing contraception after the birth. with HIV • trained counsellors

Counselling on HIV and infant feeding Current recommendations of the inter-agency task force on infant feeding and HIV- infected mothers: 26 • When replacement feeding is acceptable, feasible, affordable, sustainable and safe, avoidance of all breastfeeding by HIV-infected mothers is recommended. • Otherwise, exclusive breastfeeding is recommended during the first months of life. •To minimise HIV transmission risk, breastfeeding should be discontinued as soon as feasible, taking into account local circumstances, the individual woman’s situation and the risks of replacement feeding (including infections other than HIV, and malnutrition). •When HIV-infected mothers choose not to breastfeed from birth or stop breastfeeding two years of the child’s life to ensure adequate replacement feeding. Programs should strive to improve conditions that will make replacement feeding safer for HIV-infected mothers and families. • HIV-infected mothers who breastfeed should be provided with specific guidance and support when they cease breastfeeding to avoid harmful nutritional and psychological consequences and to maintain breast health. The Centre for Harm Reduction

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Summary

• quality testing facilities undermined by the availability of free or Manual for • anti-retroviral drugs available subsidised infant formula. Ideally, if reducing drug • support for replacement infant feeding women are provided with commercial related harm available infant formula this will be in a generic in Asia •resources for follow-up care and support. form rather than with a brand-name label. • It is possible to make home-made These hospital-based programs to prevent formulas from animal milks, such as cow, mother-to-child transmission of HIV (often buffalo or goat milk. Unmodified animal called PMTCT programs) are currently being milk has too great a proportion of protein planned or piloted in many countries in the and can damage the baby’s kidneys and region. To avoid potential harms, community irritate the gut. It is necessary to dilute organisations can play an important role in the milk with water, add sugar for energy, preparing for their introduction by raising and a micro-nutrient supplement. awareness in the community, working to • HIV is killed easily by heat - the virus reduce stigma, training counsellors and dies above 56° Centigrade. Theoretically establishing support groups. It is helpful for a woman could express her breastmilk, groups that work with people who inject boil the milk and feed the milk by cup to drugs to form links with other relevant her baby. However, it is unlikely that groups, such as those that promote and women will be able to express and heat support breastfeeding, and women’s support their milk for a long period of time groups without the stimulation of being able to For most poor women in the Asian region put the baby to the breast. However this exclusive breastfeeding is likely to be their is the least expensive and most safest option, unless resources are available to nutritionally appropriate option and supply them with an adequate replacement women may want to try it. for breastfeeding for at least six months. • It is possible that a female relative could Breast milk is crucial to the health and breastfeed a baby who has an infected wellbeing of most infants. Without mother. In many cultures even post- breastmilk infants are more vulnerable to menopausal grandmothers have relactated diarrhoea and respiratory and other infectious in order to feed a baby. Such traditional diseases, all of which can be life threatening. solutions can be encouraged. It is When an infant is already infected with HIV important to be sure that the wetnurse is at birth, breastfeeding may protect them not infected with HIV and they should be from infections that could hasten the onset of counselled about the possibility that if HIV-related diseases. The woman needs to the baby is infected with HIV there is a receive information from a trained counsellor small risk that it may be transmitted to to assist her to weigh the risks, and to be the wetnurse. supported in the decision she makes. •Whatever replacement is used it is If an HIV positive woman chooses not to important that the mother or carer is breastfeed she will need support to provide taught how to use a cup to feed the baby. an adequate replacement:27 A cup is simple to clean thoroughly and • Where few women are infected with HIV does not need to be sterilised. Even a it may be possible for women who cannot newborn baby can cup feed, and cup afford infant formula to receive subsidised feeding ensures that the mother or or free formula for six to 12 months. Care caregiver holds the baby during feeding. must be taken to ensure that The Centre breastfeeding in general is not for Harm Reduction

264 SECTION Contents > Section 2-C hapter 7 2 If a woman chooses to breastfeed she • An HIV positive women who chooses to needs advice about the importance of giving breastfeed needs advice about stopping Chapter the baby nothing by mouth other than breastfeeding if she becomes ill or Seven breastmilk, and help in anticipating what develops breast problems such as mastitis HIV/AIDS difficulties she might face in exclusive or a breast abscess. In those circumstances breastfeeding: she should express and boil her milk • There are two factors that may complicate before feeding to the baby, or give a exclusive breastfeeding: the first relates to replacement until the condition is better, ‘pre-lacteal feeds’, or substances given in and seek medical help. the first week of life, such as herbal It is a challenging task to counsel a mixtures, which may have a spiritual or mother to help her assess the risk to her baby symbolic meaning, or sugar water, often of different feeding options in her particular related to ‘cleansing’ and the belief that circumstances. Counsellors need support and the baby needs some fluids before the up-to-date information. The pace of change milk ‘comes in’. The second relates to the in knowledge about interventions to prevent early introduction of rice feeds or animal the spread of the virus to the baby from an milk in the early weeks of life because the infected mother has been rapid. The inter- mother fears that the baby is not getting agency task force publishes frequent updates enough breastmilk. Mothers need to be and guidelines for HIV and infant feeding, given information that addresses both available on the UNAIDS website these factors. They need to know that (www.unaids.org). colostrum protects babies, and that no additional water or milk is necessary. They need to be reassured that softening Follow up care and support for of the breasts after a few weeks is normal mother and baby and does not mean that they are making less milk. They need to know that the Follow-up care and support can help mothers way to increase the milk supply is to infected with HIV to live longer, happier allow the baby to breastfeed frequently. lives, meaning they are able to care for their •A woman who chooses to breastfeed children, whether infected or uninfected. should consider stopping breastfeeding Families with children that have HIV need earlier than usual. For example she might assistance to care for them because they will decide to stop breastfeeding between five experience frequent illnesses. and six months when the baby is less When hospital interventions to prevent vulnerable, since the risk of transmission mother-to-child transmission of HIV are of HIV continues throughout the introduced, local NGOs and community duration of breastfeeding. It is important organisations have an important role to play that the woman should not give both in providing a continuum of care and support breastmilk and a replacement for long – between the hospital, the health centre and so the period of transition should be short the community. It will be useful if peer (perhaps one week). It is best to advise groups and those who work with people who against an abrupt transition within a day inject drugs can form links with health care or two because the mother’s breasts will providers. become engorged, the baby will be Women who learn of their HIV infection distressed and the likelihood of reverting as a result of antenatal screening need to breastfeeding is very high, with emotional support, perhaps through peer subsequent increased risk of transmission The Centre for Harm of HIV. Reduction

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support groups, access to treatment for their •Are there any practical, safe, affordable Manual for symptoms, and treatment and prevention for and acceptable alternatives to reducing drug opportunistic infections when they become breastfeeding in this setting? related harm ill. We need to advocate for greater access to •How are sick babies cared for? in Asia effective long-term combination anti- • What facilities are available for voluntary retroviral drugs for all those infected with counselling and HIV testing for couples, HIV that meet the clinical or laboratory and for women? criteria for treatment. • Do HIV-infected women have access to counselling and contraception? • Is abortion available to women with What questions are useful to HIV? inform prevention and care • What is the infant mortality rate and strategies? what are the common causes of child death? Before planning strategies for prevention and care in relation to parent-to-child transmission of HIV, it is necessary to gather information about the current situation in the community. By talking to people working in existing health programs, community groups and individuals one can better understand the current situation and therefore plan more effective strategies. There are a number of questions to consider: • What are the cultural beliefs in relation to pregnancy, childbirth, the post-partum period and infant feeding? • How common is HIV infection among women of child-bearing age? •What proportion of women have access to, and attend, antenatal care? •Who makes decisions about pregnancy, antenatal care, delivery care and infant feeding? Is it the woman, her husband, her mother-in-law or other family members? • What is likely to happen if a pregnant woman tells her family of a positive HIV test result? • What are the common breastfeeding practices, knowledge and attitudes? What influences them? How common is exclusive breastfeeding and what are the barriers to exclusive breastfeeding?

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Summary 2

Parent to child transmission Preventing parent to child Chapter of HIV transmission of HIV within a Seven HIV transmission from mother to child can child survival approach HIV/AIDS occur during pregnancy, at birth and through breastfeeding. If 100 HIV-infected women Primary prevention each have a baby, about 35 of the babies will The most effective way to prevent babies become infected with HIV. On average the becoming infected with HIV is to prevent virus will have passed to seven of the babies transmission between men and women. during the pregnancy, to 15 at the time of Community education to raise awareness that delivery, and to 13 of the babies afterwards babies can be infected with HIV can through breastfeeding. contribute to primary prevention by The risks of HIV transmission increase: appealing to men’s sense of responsibility for •among woman who acquire HIV their families. infection during pregnancy or while It is especially important to prevent breastfeeding women becoming infected with HIV during • when an infected woman has HIV-related their pregnancy or while breastfeeding signs and symptoms because they are more likely to transmit the • if there is any infection during pregnancy, virus to their babies. especially a sexually transmitted infection •with poor nutrition during pregnancy Population-based secondary prevention • if the child is born prematurely Strategies to promote this at a community • if the membranes are ruptured (‘breaking level include: the waters’) artificially •preventing unwanted pregnancies •if the mother has mastitis or a breast through increasing access to information abscess while breastfeeding and contraception • if the child is not exclusively breastfed • strengthening men’s and women’s reproductive health services • counselling women with chronic illness to postpone pregnancy until they have been well for six months •promoting quality antenatal care with treatment of STIs and other infections and nutrition advice • including men in antenatal care • training midwives, doctors and traditional birth attendants to reduce unnecessary obstetric interventions •promoting exclusive breastfeeding for all • training health care workers in breastfeeding skills to minimise breast problems.

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Secondary prevention for women known Appropriate local replacement feeds need Manual for to be HIV positive to be identified. Possible replacements for reducing drug Before conception: when a woman of child- breastfeeding include: related harm bearing age discovers she is infected with • commercial infant formula in Asia HIV, she should receive counselling, • home-prepared animal milk formula information and support. (perhaps combined with a cereal or legume milk such as soy or ragi (millet) After conception: those who test positive milk) following antenatal voluntary counselling • expressing and boiling the mother’s and testing for HIV, or already know that breastmilk or donated breastmilk they are infected, may be offered: • wetnursing. • screening and treatment of STIs and other Replacements should always be given by infections cup rather than bottle. •identification and treatment for To be prepared to implement prevention preventable causes of premature birth strategies for mother-to-child transmission of • counselling about maintaining good HIV it is important to gather relevant health during pregnancy through good information. This includes knowledge, nutrition and rest attitudes and practices in relation to sexual • counselling about use of condoms practices, the desire to have babies, • antiretroviral prophylaxis pregnancy, childbirth, the postpartum • elective caesarean section, if appropriate period, and infant feeding. • counselling about HIV and infant feeding • referral to a support group and follow-up care and support • information about contraception after the birth. In most settings in Asian countries the balance of risk for the baby of an HIV- infected mother will be in favour of exclusive breastfeeding for six months, then stopping breastfeeding if adequate weaning foods and a source of milk are available. HIV positive women need to be helped to reach their own decision about the most appropriate feeding method for their child. Section Two, Chapter Seven: HIV/AIDS: Preventing Transmission through Sex and between Parent and Child

For further information refer to WHO resources: Intervention Guide (ARV clinical) & Evidence for Action Papers. Refer to the following website: www.who.int/hiv (publications expected online from May 2003) The Centre for Harm Reduction

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CENTRE FOR HARM REDUCTION

▼▲ Risk factors for Sexual HIV Transmission

➤ Presence of any Sexually Transmittable Disease (STD) ➤ Sex and age of uninfected person ➤ Type of sexual act ➤ Stage of illness of infected person ➤ Virulence of HIV strain

Information for IDUs must be on Safer Injecting Practices AND Sexual Transmission of HIV

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CENTRE FOR HARM REDUCTION

▼▲ Strategies to Reduce Sexual Transmission of HIV

➤ Assess social & economic realities

➤ Education for all women

➤ Affordable technologies for women

➤ Encourage condom use

➤ Information/education on risks for men

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CENTRE FOR HARM REDUCTION

▼▲ Issues/dilemmas: Women’s position in society

➤ Sexual double standards ➤ Fertility ➤ Poverty, prostitution, sex tourism, migration ➤ HIV stigma and discrimination

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CENTRE FOR HARM REDUCTION

▼▲ Risk of HIV transmission from mother to child

Of 100 HIV-infected women, on average 35 of the babies will become infected with HIV

➤ 7 during the pregnancy ➤ 15 at the time of delivery ➤ 13 afterwards through breastfeeding.

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CENTRE FOR HARM REDUCTION

▼▲ Influences on risk of transmission from mother to child

Risk increased: ➤ among woman acquiring HIV infection during pregnancy or breastfeeding ➤ when an infected woman has HIV related signs and symptoms ➤ with any infection during pregnancy, especially a sexually transmitted infection ➤ with poor nutrition during pregnancy ➤ if child is born prematurely ➤ if membranes are ruptured (‘breaking the waters’) artificially ➤ if mother has mastitis or breast abscess while breastfeeding ➤ if child is not exclusively breastfed Manual for reducing drug related harm in Asia SECTION 2 • CHAPTER 7 • OVERHEAD 5

CENTRE FOR HARM REDUCTION

▼▲ Reducing parent-to-child transmission of HIV – Part A

Primary prevention especially during pregnancy and breastfeeding Secondary prevention General measures to: ➤ prevent unwanted pregnancies ➤ improve the health and nutrition of women during pregnancy ➤ strengthen men’s and women’s reproductive health services ➤ promote exclusive breastfeeding for all

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▼▲ Reducing parent to child transmission of HIV – Part B

Primary prevention especially during pregnancy and breastfeeding Measures for women known to be infected with HIV: ➤ good antenatal care including screening and treatment for STIs and other infections ➤ avoid invasive interventions during labour ➤ antiretroviral prophylaxis, if available ➤ elective caesarean section, if appropriate ➤ counselling about HIV and infant feeding ➤ advice about contraception ➤ follow-up care and support Manual for reducing drug related harm in Asia SECTION 2 • CHAPTER 7 • OVERHEAD 7

CENTRE FOR HARM REDUCTION

▼▲ Replacements for breast feeding

➤ commercial infant formula ➤ home-made animal milk formula ➤ expressing and boiling of the mother’s breast milk (or donated breastmilk) ➤ wetnursing

Cup feeding is safer than bottle feeding.

If no acceptable, feasible, affordable, sustainable and safe alternative is available HIV-infected women should be encouraged to exclusively breastfeed their baby for up to six months, and then cease breastfeeding if they can provide adequate weaning foods and replacement milk.

The Centre Manual for reducing drug related harm in Asia for Harm SECTION 2 • CHAPTER 7 • OVERHEAD 8 Reduction

272 Contents SECTION Section Two 2 Chapter Eight Voluntary HIV Counselling and Testing

What is VCT? The counselling process The HIV testing process Staff: burnout and stress

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Introduction

Voluntary counselling and testing (VCT) for HIV have become an integral Manual for part of HIV prevention and care programs in many countries. Knowledge reducing drug of serostatus through VCT can encourage both negative and positive related harm people alike to adopt safer practices to prevent HIV transmission. This in Asia intervention also facilitates access to care and support services for those who are HIV infected.

The fear and anxiety surrounding the idea of being tested, and the often incorrect information people have about HIV/AIDS, means that counselling is an essential part of the process.

This chapter examines: 1. What is VCT? 2. The counselling process 3. The HIV testing process 4. Staff: burnout and stress

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1.What is VCT? 2 HIV counselling is defined as: “Confidential • lack of immediate access to drug dialogue between a person and a care provider treatment and/or to clean injecting Chapter aimed at enabling the person to cope with stress, equipment and condoms to ensure safer Eight and make personal decisions related to practices. Voluntary HIV HIV/AIDS”. The counselling process • fears about how to tell partners and counselling includes an evaluation of personal risk of family if the result is positive and testing HIV transmission and facilitation of •fears about the future. preventive behaviour. For the person being tested, the Confidentiality is crucial in this scenario. procedure has consequences that reach It usually takes some time to come to terms beyond the diagnosis. Although there are with receiving an HIV positive test result many benefits to knowing one’s HIV status, and people feel especially vulnerable. It is a testing may have negative consequences in time when a person’s sense of power over communities where HIV-infected people are their life can evaporate: they at least need the stigmatised. No one should be coerced into power to determine who knows about their being tested. The decision to undergo HIV HIV infection. While widespread testing is entirely voluntary. discrimination against people with HIV/AIDS, and people who use drugs, Confidentiality continues to exist there is good reason for Trust is one of the most important factors in people not to broadcast their HIV status. the relationship between counsellor and Part of the pre- and post-test counselling client. It enhances the relationship and should be a discussion about confidentiality. improves the chances that an individual will A client should be told how their test results act on the information provided. Given the will be handled by the agency. For example: possibility of discrimination that an •whether the health department is notified individual with HIV may face, it is • who else in the agency would have access important that confidentiality be assured. to their file Confidentiality forbids any reference to or • how their result is recorded and filed. discussion about a client, except within a professional relationship, and only then with Any breach of this confidentiality will the consent of the client. damage whatever trust has been built People who inject drugs already between the counsellor and the client. experience discrimination, stigmatisation and rejection because of their drug use. In most societies, injecting drug users (IDUs) are viewed as criminals and outcasts and are often a target for society’s anger and fear. Add to this a diagnosis of HIV/AIDS and IDUs become one of the most marginalised groups in a society. When deciding whether or not to have a test, an IDU may question what benefits, if any, he or she may gain from knowing their HIV status. Concerns may centre around: •fear of further discrimination • lack of treatment for HIV-related illnesses The Centre for Harm Reduction

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2.The Counselling Process

• encouraging change in behaviours to “Non-judgemental, non-coercive and prevent transmission (i.e. safer using Manual for confidential.” practices and safer sex). reducing drug A motto of LALS (Lifegiving and Lifesaving related harm Society), Kathmandu, Nepal. in Asia What are the main goals of counselling? Who is counselling for? Who is counselling for? Counselling is for: Who should provide counselling? • people being tested for HIV (both pre- What is pre-test counselling? and post-test counselling) What is post-test counselling? • people who are infected and their What are the types of counselling? partners/families What is drug counselling? • people who are experiencing difficulties with issues such as employment, housing Counselling is an essential part of VCT. and finances because of HIV It should provide support for a person in • people who are seeking help because of making a decision about whether to be past or current risk behaviour. Remember tested or not and in receiving the result. confidentiality is important: a client Information about the test, and what the needs to be able to trust the counsellor results mean, will allow a person to make an and make his/her own decision about who informed decision about having the test. they will tell if they are infected with Counselling should also provide information HIV. The client has the right to decide if about HIV/AIDS and how it is transmitted other people are to be involved, such as and how to avoid acquiring and/or their family members, people from HIV transmitting the virus. support groups and other medical clinicians.

What are the main goals of Who should provide counselling? counselling? In reality, counselling forms a part of the The two main goals of counselling are to: workload of most people involved in an HIV 1 give psychosocial support to those people prevention program. Counselling, in the whose lives have been affected by most part, is not a one-time event. In the HIV/AIDS case of HIV testing, counselling should be 2 prevent HIV infection and its given to a client at least twice: certainly transmission to other people. before and after the HIV test. But counselling also happens on a day-to-day This is achieved by: basis: in the streets, in people’s homes, at •providing clients with information on clinics and so on. Situations arise where the HIV: what it is, how it is transmitted, opportunity to give some counselling occurs how it is prevented, what testing involves naturally. For example; a worker may be •helping people to handle their emotional tending to an IDU’s abscess, and together responses to an HIV positive result (i.e. they discuss why the person has developed an anger, fear, denial) abscess; this gives the worker an opportunity • discussing what action a client needs to to discuss safer using techniques and the take according to their situation and IDU a chance to ask questions. The Centre needs but not lecturing clients for Harm Reduction

276 SECTION Contents > Section 2-C hapter 8 2 To assess a client’s knowledge of What is pre test counselling? HIV/AIDS and ability to cope, a counsellor Chapter will need to look at these issues: HIV testing should only be offered when it is Eight •What does the client know about the Voluntary HIV accompanied by pre- and post-test test? Why is the test being requested? counselling. The counselling provides the counselling Has the client come willingly to and testing opportunity to give the client clear counselling? information about the test, to explain the • What particular behaviours or symptoms confidential nature of the test and to obtain are of concern to the client? informed consent. It also allows time to •Has the client considered how he or she build up rapport and trust between the would react to the results of the test counsellor and the client. (positive and negative)? Pre-test counselling should, ideally, take • What are the client’s beliefs and place in an environment where privacy is knowledge about HIV transmission and assured, for example, a room away from the its relationship to risky behaviours? centre of activity in an agency. Counselling is • If the test result is positive, who would a dialogue and not a lecture. The client provide emotional support for the client? should feel free to ask questions and discuss their fears and anxieties. Counselling Once a counsellor has assessed a client’s provides the chance for a counsellor to risk of being infected with HIV, their explain the HIV test and the implications of knowledge about the virus and their ability receiving an HIV positive result. This sort of to cope, the counsellor should give detailed discussion will help the client make their information about HIV/AIDS (what decision about whether or not they want to HIV/AIDS is, the difference between HIV proceed with the testing. and AIDS) and what a positive or negative The pre-test counselling should focus on: test result means. The counsellor should also •the client’s personal history and risk of inform the client that very occasionally false current or past exposure to HIV positive and negative results occur and •the client’s knowledge about HIV/AIDS explain what the ‘window period’ means. and their ability to cope with crisis. The counsellor should also discuss ways to prevent acquiring the virus and/or passing it To assess a client’s risk a counsellor will on to other people. He or she should also tell need to look at these issues: the client how long it will take before they • current or past high risk drug taking get the test results. If the client decides to go behaviour (i.e. sharing of needles and ahead with testing it is important to arrange syringes and other injecting equipment) post-test counselling. • current and past sexual behaviour, sex The WHO declared in 1987: ‘If testing work or sex with a sex worker is to be used to identify specific infected •use of condoms, practice of safer sex, individuals, voluntariness – free and frequency of unprotected vaginal and/or informed consent – was an indispensable anal sex precondition, and must to be accompanied • sex with multiple partners or known by counselling and protection of HIV-infected partners confidentiality.’ 2 •history of receiving a blood transfusion or organ transplant • exposure to non-sterile invasive procedures, such as injections, tattooing 1 The Centre and scarification. for Harm Reduction

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Informed consent means that the client Manual for understands the process and the implications What is post-test counselling? reducing drug of having an HIV test. Obtaining informed consent involves: Post-test counselling is primarily about related harm providing the results of an HIV test to a in Asia •educating the client about how the test is done and what the results will mean client. But it involves much more than •discussing the advantages and delivering test results and may require more disadvantages of having the test than one session. This may apply both to a • listening to the client’s concerns and fears person whose result is positive and a person • answering the client’s questions whose result is negative. The content of the • seeking the client’s permission to proceed post-test counselling will, of course, differ with the test. depending on the test result. Again, it is important that the counselling takes place A counsellor cannot presume that a in private and that, ideally, the counsellor client has consented to a test: the intention has a reasonable amount of time to spend to go ahead with the test must be clear and with the client. verbalised. Informed consent means the client is competent to make such a decision, Counselling after a negative result understands the purpose, risks, harms and It is just as important to counsel a person benefits of both being tested and not being who has received a negative HIV test result tested and that their decision is voluntary. If as it is to counsel a person who has received a a person does not consent to testing their positive test result. While it is reasons can be explored through further understandable that a client will be happy, if counselling but above all their decision must not euphoric, with the news that the test be respected. result was negative there is crucial information a counsellor must give the The reasons a client may not want to be client: tested include: •the counsellor should explain that the test • lack of information about the test and result may not be reliable because of the HIV/AIDS window period and that the client may • feeling unprepared emotionally to deal wish to have another test in three to six with the possibility of an HIV positive months, with no further risk exposures in result the meantime • lack of social support from family and •the counsellor must emphasise the friends importance of preventing further • fear that their HIV status will not remain exposure to HIV. Information about safer confidential sexual practices and safer using practices • fear that they will lose their job, house etc must be fully explained and discussed 3 • fear of losing their sexual partner. •the counsellor may wish to make a further appointment with the client to discuss in more detail how to make changes and negotiate safer behaviour (perhaps see the client’s partner at the next appointment).

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278 SECTION Contents > Section 2-C hapter 8 2 Counselling after a positive result • that it is impossible to tell from the test It is important that a client and counsellor results when a person was infected with Chapter are in a private place when the test result is HIV. This can be particularly important Eight given. The counsellor should reassure the for people who assume they have Voluntary HIV client that the discussion and the test results contracted HIV from their current sexual counselling are confidential. It will take some time for partner and therefore believe their partner and testing the client to absorb the news and the has been unfaithful. counsellor needs to be supportive and A person’s reaction to their positive HIV sensitive to the client’s shock and fear. The test result may differ according to a range of counsellor will then need to explain clearly factors; including their personality and their and simply, using language the client social environment. Other factors affecting understands, what the test result means. It is their ability to cope with the diagnosis may not the time to discuss how the disease will include: progress or to estimate the time left to live. • the person’s state of health at the time The counsellor should encourage positive • how well prepared the person is for the thinking (i.e. that the person may have many news of their HIV infection years without symptoms and that there are • how well they are supported in the treatments for some of the opportunistic community infections). Treatments with antiviral • how readily the person can ask for and medication should only be mentioned if they receive help from family and friends are available and affordable in that region. • the person’s personality and psychological The counsellor should arrange further condition appointments to see the client in order to •the cultural and spiritual values attached establish a supportive relationship but also to to HIV/AIDS, to illness and to death in repeat the information about HIV infection, their particular community. ways to improve the client’s health and information about preventing transmission of A client may also have concerns about the the virus. counselling and/or the counsellor. These The points which need to be emphasised concerns may centre around: constantly are: • discomfort in talking to a stranger • HIV infection is not AIDS • fear of what will be discovered •a person infected with HIV needs to look • fear of facing the infection after their health. The counsellor should •embarrassment at having to discuss stress the importance of avoiding intimate matters exposure to other diseases which may • concern that confidentiality will not be weaken the immune system respected •how HIV is transmitted and the ways to • difficulty in talking to a person of the make sure they do not infect someone opposite sex/different ethnic else: safer sex (use of condoms) and safer origin/linguistic group/age etc. using (not sharing needles and other injecting equipment)

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Manual for ARM EDUCTION EWS reducing drug H R N related harm in Asia “I ALMOST COLLAPSED”

HO CHI MINH CITY,VIETNAM things aside and I had my at that time his words just meals alone with my own flew from one ear to the n 1972, I was in the second bowl, chopsticks, glass etc. other. I was extremely con- Iyear of the University of After that my father asked fused and could not think Law and being a good guitar my younger brother to take straight. player, I played in a musical me to the Preventative I did not know what to band in a nightclub. Seeing Health Centre for a test. I do. I told the doctor that I the people smoke heroin and came back to get the result have done this so I have to breathing the smoke every- after three days. I was really bear the consequences. I day, I was tempted to use it. I nervous and praying on my begged the doctors to keep don’t remember when I way to the Centre with my this secret for me. What I was became addicted to heroin. brother. When the doctor really concerned about was informed me of the result I almost collapsed. I thought my life had ended. Thinking I begged the doctors …I was isolated“ in our of being discriminated “ house. against by my family and to keep this secret for having a fatal disease that I me. ” did not know much about, I In 1994, the HIV/AIDS intended to jump out the ” issue really exploded and balcony of the hospital. The that the doctor or hospital according to the original sta- doctor pulled me back. I was would reveal this to anyone tistics, the highest percent- standing still with mixed in the area where I lived. I age of overall cases were feelings, frightened, nervous was excessively anxious. Dr injecting drug users. My and desperate. I was afraid of Luyen promised to keep it father forced me to go for a my brother’s, then my par- confidential and advised me test. First I went to the ents’ and other family mem- to take care of my health. He Dermatology Hospital where ber’s reactions when they gently advised me to quit I got a negative result for knew the result. The doctor drugs if I wanted to prolong social diseases (STDs). My asked me to go and see Dr my life.” 4 family did not believe the Luyen in his office. Dr Luyen, Mr S. now works as a peer result and I was isolated in who was in charge of coun- educator with IDUs in Ho our house. They put my selling, talked to me a lot, but Chi Minh City, Vietnam.

be especially difficult and intense because What are the types of counsellors: counselling? •are forced to face their own mortality • have to deal regularly with loss Counsellors need to find a balance between •offer support to people in distressing and providing emotional support and care for the difficult circumstances, and client and maintaining an objective approach • at times, have to accept behaviour he or to the client’s problem. HIV counselling can she does not approve of or understand. The Centre for Harm Reduction

280 SECTION Contents > Section 2-C hapter 8 2 It is also wise for the counsellor to have and practices of drug use will be different someone to talk to; this will allow the from community to community. A counsellor Chapter counsellor an opportunity to express their will need to know: Eight feelings, sorrow and stress. • what sort of drugs are being used Voluntary HIV Counselling changes according to the • what ways people are taking the drugs counselling needs of the client and at different stages. (routes of administration) and testing The type of counselling needed will be • whether sterile injecting equipment is determined by: available •the client’s needs, circumstances and • the prevalence of HIV in the particular psychological state community •the types of problems they are •what the sharing practices are experiencing or facing • what treatment and other services are • the stage at which they seek counselling. available.6 Apart from dealing with the client’s needs Drug counsellors should be able to offer as productively as possible, the counsellor their clients lots of practical advice to reduce needs to know at what points the client the risks associated with their drug use. This should be referred on for other services (e.g. may include information about: medical care, financial assistance, social • cleaning needles and syringes support agencies). •rotating injection sites It is important that workers receive • where not to inject specific HIV counselling training as this •treatment for abscesses gives them the opportunity to explore the • information on HIV/AIDS and ways to broad range of reactions and problems a prevent contracting or passing on the client may experience. It also gives them the virus. chance to practise their counselling skills To do this successfully, counsellors must through role playing etc and to increase their not be judgemental about the client’s drug knowledge of HIV/AIDS. use. Most drug users have experienced judgement and discrimination from health professionals, family and the general What is drug counselling? community. The counsellor will not help by reinforcing these kinds of attitudes. Rather ‘The reality is that no counsellor can get their than imposing their attitudes and beliefs on clients off drugs. Clients have to want to the client, the counsellor should listen to come off for themselves and by themselves. what the client has to say: what is the most However, counsellors can assist, ease and important issue to the client? What support the process, provided they realize information do they want? that control has to rest with the drug using While the long term goal may be clients.’ 5 abstinence, both counsellors and clients need to be realistic. It is unusual for a person who Agencies may have a particular worker who decides to give up drugs to succeed the first focuses on dealing with clients’ drug use and time they try. If goals are unrealistically associated problems, but most workers, high, the sense of failure only increases a especially outreach workers, will be involved client’s feelings of hopelessness: that it is all in drug counselling regularly. The conditions too difficult to achieve.

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3.The HIV Testing Process

A counsellor, or outreach worker, can What is the test for HIV? What do the results mean? Manual for work with a client to make their drug using Who should have an HIV/AIDS test? reducing drug safer. Suggestions can include: What questions should you ask? related harm • taking the drugs another way, such as in Asia snorting, smoking or swallowing them • taking a substitute drug, such as methadone, where available What is the test for HIV? • continuing to inject but using sterile equipment each time The diagnosis of HIV has traditionally been • using a needle and syringe exchange made by detecting antibodies against HIV, program, if one exists not the virus itself. When a person becomes • not sharing their injecting equipment infected with HIV, their body produces with anyone else antibodies to the virus. Antibodies are • having their own needle and syringe and proteins the body makes to fight infections. cleaning it before use These antibodies do not protect a person • if having to share, because of lack of from HIV or AIDS. A wide range of HIV equipment, cleaning the needle and antibody tests are available today, including syringe between each person’s use. ELISA-based tests and many newer, simple and rapid HIV tests. For more information on safer using see ELISA testing: The most commonly used Chapter Five: Injecting Safely, for HIV-antibody testing method is the ELISA information about substitution drugs such as test (enzyme-linked immunosorbent assay, methadone and buprenorphine and issues also EIA), which is extremely sensitive in surrounding drug use see Chapter Six: Drug identifying HIV antibodies. Use and Substitution and for information Simple/rapid testing: More recent about drugs and how they work see advances in technology have led to the Appendix 2: Drugs and their Actions. development of various rapid tests. Most come in kit form and are simpler to use than ELISA. Furthermore, their diagnostic performance is comparable with traditional ELISAs. It is important to emphasise that although HIV antibody testing is highly sensitive and specific, all seropositive results from one test must be confirmed by an additional, different test. The western blot is still routine in developed countries but double-ELISA algorithms are more common in the developing world. After exposure to the virus it may take some time to develop antibodies to HIV/AIDS. This is called the ‘window period’ and may last between a few weeks to three months. During this time a person may receive a negative result from their HIV test when in fact they are HIV positive. The Centre for Harm Reduction

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Harm Reduction News Chapter Eight Voluntary HIV What Does Having HIV Mean? counselling and testing KATHMANDU, NEPAL pected bad news and that day and I told him he because he was sick. I said could come back and we n early 1993 we had our this is between you and I and would talk a little more. I Ifirst HIV positive case. He you may not want him here. spoke to his friend later was a young boy. We got the But he did, so I ended up about privacy and confiden- result – it was the first one telling him we had got his tiality and how he should try we’d had. It took us a while to test results and from the to support his friend and not catch up with him. When we results it looked like he was blurt it out to everyone. The did we asked him to come HIV positive. He didn’t react young guy came back a few back to the office. He came that much because I think he months later and he said: with a friend. He told us in was on his own trip but his “Do I really have HIV? I don’t retrospect he had suspected friend was pretty shocked feel so bad.” he might be positive. He did- and he said: “My god, are you n’t look very well, he might going to die?” It was a very “Do I really have HIV? I have had a bad hit. We were gut reaction: I don’t know don’t feel so bad.” thinking should we tell him whether it was shock or he while he’s feeling like this? was disgusted or he was It was early days for HIV But we couldn’t lose the scared for his friend. It was infection in Nepal – there opportunity because who hard to say: I think it was a were no TV programs or knew when we would see combination. information to say what him again? So I took him HIV/AIDS was, other than it upstairs, we had a big room “My god, are you going was a disease that affected where we did the training to die?” people who were bad. and so on, and I told him I Whereas if you had said ‘TB’ needed to sit down and talk So I sat him down and people had an image of what with him privately. said “I’ll talk to you after- TB does to people. If you say wards.” So he left and I talked to people you do this today “…should we tell him to the guy with HIV. I said and tomorrow you’ll get TB while he’s feeling like “Do you know what it they know to be scared but it means?” He said: “Does it wasn’t the same with HIV. this?” mean I’m going to die?” and People didn’t fully realise But he didn’t want his he started crying a little bit. I what being HIV positive 7 friend to go because he sus- don’t know if it really sunk in meant.” at that stage. We just let it go

Although tests may not be able to detect If someone has been exposed to the virus antibodies to HIV during the window recently and their test result is negative, it is period, the person can transmit the virus to recommended that they return for another other people through sharing needles and test in three months as they may be in the syringes (and other unsafe using practices), window period. During the three-month donating blood, and having sex. period before the second test, the person should be encouraged not to engage in any high-risk behaviors. The Centre for Harm Reduction

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Manual for ARM EDUCTION EWS reducing drug H R N related harm in Asia A CONVERSATION BETWEENA COUNSELLOR ANDA CLIENT

ANYWHERE,ASIA Counsellor: Do you have a regular sexual partner and do you use condoms? Client: I think I should have a test for Client: I have a girlfriend but we don’t use AIDS. condoms. Counsellor: Can you tell me why you think Counsellor: Do you have any other you need to have the test? girlfriends? Client: I’ve heard that you can get AIDS Client: Not for the past year. Tell me, do from sharing needles and I’ve shared you think I have AIDS , I mean HIV? needles a few times – you know – when Counsellor: It’s impossible for me to say if you can’t get clean ones what can you you have HIV but I must tell you that do? So I’ve shared friends’ needles after sharing needles and syringes does put they’ve injected themselves. you at a high risk. Do you understand Counsellor: Okay, well you’re right about the what HIV actually is? risk of transmitting HIV/AIDS by Client: Not really, but I’ve started to hear sharing needles and syringes. HIV is the people talking about it and they say it name of the virus that is transmitted makes you sick and you die from it. and AIDS is what you have once you get Counsellor: Well, HIV is a virus that enters sick. Anyway, sharing needles and the bloodstream and then circulates syringes is risky but sharing any of the around the body attacking certain cells injecting equipment you use is also a in the body which are part of the risk like spoons, filters, water and immune system. The immune system is tourniquets. We can do the test today if a general term that describes the way you like. But before we do, I’d just like the body defends itself from foreign to ask you a few questions about your substances that invade it to cause drug use and about sex. I know it can be infections or disease. Some people can hard to talk about these things so is it be infected with HIV for years and not okay with you if we talk about these look sick or feel sick. But AIDS is matters? different and it develops sometime after Client: Yes, that’s fine. you’ve contracted HIV. AIDS happens Counsellor: How long have you been sharing when the immune system has broken needles and syringes? down and the person becomes sick. Client: I think it is probably about six Does that make it a bit clearer? months. Client: Yes, I understand. Counsellor: When was the last time you Counsellor: To be sure that a person has HIV, shared needles and syringes? that the test is accurate, there is what is Client: Two nights ago. called a window period – what this

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ARM EDUCTION EWS Chapter H R N Eight Voluntary HIV counselling and testing means is that it can take some time for a want to tell anyone. How do you think person to develop a response to HIV you would react if you have HIV? that we will be able to see in the blood Client: Well, I’m not going to be happy test. This can take between three weeks about it but I’ve never had to have a test to six months. like this so I don’t really know how I’d Client: So how do you do the test? feel. Counsellor : We just take a little bit of your Counsellor: Are there people you think you blood and send it to the laboratory. could talk to if you did have HIV, like Client: So do you think I should have the your girlfriend or a good friend or your test? family? Counsellor: Well, the decision is really up to Client: I would tell my girlfriend but I you. But if you do know that you have don’t know if I could tell my parents. HIV you can take care of your health I’d have to think about it. and you will know how important it is Counsellor: If the tests show that you do that you are careful about not have HIV, it is a very common to feel transmitting it to other people injecting depressed. So I want you to know that drugs and to your girlfriend or anyone we do provide counselling here for all else you have sex with. But, even if you our clients and we are happy to talk to don’t have the test you need to be you about any of your concerns. We careful about not sharing needles and could also talk to your girlfriend if you syringes and having unprotected sex wanted. Now, if you have the test today because you could have the virus and be the results will be back in two weeks. passing it on to other people. Or you Client: Okay, I could come back – that’s not may not have it but pick it up from the a problem. people you share needles and syringes Counsellor: Do you have any questions? with or have sex with. It would be a Client: I can’t think of any at the moment. good idea to start using condoms too. It is not an easy decision for me, on the Client: How many other people, apart from one hand I think it is best to know if I you, would know about the test result? have HIV but on the other it really Counsellor: We believe that it is very scares me. important for the test results to remain Counsellor: Well, you can take some time to confidential so we have codes for all our think about it if you like. clients. Only the people working here Client: No, it’s okay I have made up my will know the results but they are not mind – I think I really should know one allowed to discuss them with anyone way or the other. So take the blood and else. It is up to you to decide if you let’s just hope for the best.

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Manual for What do the results mean? Who should have an HIV test? reducing drug If an HIV test result is positive it means that The focus of who should be tested for HIV related harm the person has developed antibodies to HIV: has largely been on groups of people thought in Asia in other words they are infected with the to be at risk, especially injecting drug users, human immunodeficiency virus (HIV). This sex workers and gay men. A problem with also means that they are able to infect other this is that it focuses on groups rather than people and will remain infectious for life. on specific risk behaviour. An HIV positive result does not mean the Many people may practise risky person has AIDS (Acquired behaviours but not identify themselves as Immunodeficiency Syndrome). Some people fitting into any of the above groups. For infected with HIV stay well for years while example, a married man may occasionally others become ill more quickly. An HIV have sex with other men but not consider positive person is diagnosed with AIDS when himself gay; a woman may have unprotected the immune system has broken down, sex with her partner but be unaware that he leading to infections or cancers. (For more occasionally injects drugs and shares information on HIV and AIDS see equipment; or a person may never share Appendix 1: Blood Borne Viruses). needles and syringes but will share all other If an HIV test is negative it can mean injecting equipment. that the person is not infected with HIV or A counsellor or worker in an HIV that he or she is infected with HIV but is prevention program may ask a series of still in the window period and has not questions to assess the risk of a person who produced enough antibodies to show up on requests an HIV test. These questions can be the test. used as a guideline, as most people feel A negative test result can only show that embarrassed and awkward discussing such a person was not infected with HIV up to private aspects of their lives. Several three months ago. If that person has shared meetings and conversations may be required injecting equipment or had unsafe sex in the before a level of trust exists whereby the last three months they could still be infected, person is willing to discuss these matters. but the test will not yet show it. The language used must be appropriate to the culture and religion of the region. If HIV testing facilities are not available or are too expensive, information should still be given about safer drug using and sex practices. (See Chapter Five: Safer Injecting and Chapter Seven: HIV/AIDS: Preventing Transmission: • Through Sex • Between Parent and Child.)

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4. Staff: Burnout and Stress 2

‘If the grief lingers on unresolved it can have a What questions should you ask? profoundly negative effect on a worker’s Chapter Counsellors may ask their client questions wellbeing and relationship to others.’10 Eight such as: Voluntary HIV •Has your partner, or anyone who has had What is burnout? counselling sex or used drugs with your partner, been What are some of the contributing issues and testing found to have HIV or AIDS? relating to stress and burnout in this •Do you engage in any sexual activities type of work? that could place you at risk? How do you avoid burnout? • Do you use condoms? How and when? • Do you have sex when you are using drugs and alcohol? What is burnout? •Have any of your partners had problems with drugs or alcohol? Burnout is a term used to describe the •Have you ever injected drugs? emotional and physical exhaustion which can •When was the last time you injected happen to people who work in the ‘caring’ drugs? professions. It is a response to the chronic •Have you ever injected drugs when you emotional strain which can occur when were under the influence of other drugs or working intensely with other human beings, alcohol? particularly when they have serious problems •Has someone ever injected you with and/or illness. The HIV/AIDS prevention drugs? area is especially difficult as workers are not • When was the last time you shared only dealing in areas which traditionally have needles and syringes, cookers or other been taboo (drug use and sex) but they also, injecting equipment? at times, have to tell people they have a •Have you ever had a sexually transmitted terminal illness. Burnout may manifest in: infection (STI)? • high levels of staff absenteeism •Have you ever had hepatitis or • high sickness levels tuberculosis? • fast staff turnover •Have you ever had surgery or a blood • expressions of job dissatisfaction transfusion?8 • conflicts between staff • ineffective delivery of services to the 11 ‘A youth with high risk practices (sharing clients. injecting equipment and having unprotected Workers who are suffering from burnout sex with multiple partners) had, on two may feel tired and drained of energy, with occasions, been treated for STIs.At pre-test limited emotional resources and a sense of counselling he volunteered that if he tested ‘compassion fatigue’. This can lead to a HIV positive he would seriously consider lowering of self-esteem as the worker feels he suicide. However, he came to see that or she is not working very well and is not behaviour change was essential for his own being of much use to the clients, and this in health and the health of his friends, turn can lead to depression. irrespective of the result of the test.As a Burnout can be categorised as a result he did not proceed to HIV testing, but progressive loss of idealism, energy and joined the Needle and Syringe Program and purpose. This can be identified in four 9 has had no further STIs.’ stages:12 The Centre for Harm Reduction

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Manual for Harm Reduction News reducing drug related harm in Asia HIV Testing and Counselling Go Hand in Hand

CHURACHANDPUR, INDIA situations two people have doing counselling in a hurry.” been involved. One of these All the HIV counselling is onfidential HIV antibody areas has been in jail where done by the same IDU coun- Ctesting is provided at one of the nurses has, at sellor who also works on pro- SHALOM for clients who times, given pre-test coun- viding the detoxification ser- wish to know their HIV sta- selling and then asked the vices. This has meant a tus. From January to IDU counsellor to come and steady stream of clients, and September 1996, 155 people tell the client the result and often frustratingly short peri- were tested for HIV. Using the give counselling at the same ods of time with each client. ELISA kits, 72.4 per cent test- time. This is particularly acute ed positive for HIV antibod- when trying to explain to the ies. The testing is voluntary “…we find ourselves clients the different factors and clients are assured that doing counselling in a involved with HIV testing. the result will be held in the hurry.” Given the limited time, it is strictest confidence. The not clear how much the samples are given to the lab- The heavy work-load of client has been able to oratory technician with only the counsellors means that understand about the possi- a code number as an identi- they are not always available ble six-month window peri- fying mark. All clients seeking to provide on-the-spot coun- od between their last risky confidential testing are given selling when clients present behaviour and knowing for counselling, before and after at the centre and want to sure that a possible negative the antibody test. These two have the test done. “The real result is really the absence of sets of counselling are usual- problem we have is with the HIV infection.13 ly performed by the same numbers of clients who member of staff but in some come: we find ourselves

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288 SECTION Contents > Section 2-C hapter 8 2 • Enthusiasm: initial period of high hopes, energy, unrealistic expectations; does not What are some of the Chapter yet understand the full scope of the job contributing issues relating to Eight but has high expectations stress and burnout in this type of Voluntary HIV • Stagnation: continuing with the job but work? counselling not finding it as stimulating; issues of and testing money, working hours and career • for some outreach workers this may be development become more important the first time in a long time that they • Frustration: beginning to question own have had structured work, so it takes effectiveness in doing the job and the some time to adjust to the change in value of the job itself, e.g. asking ‘What’s their lives the point?’; emotional, physical and • for ex-users there is the constant behavioural problems may start to confrontation with their old lifestyle and manifest at this stage the chance of relapsing into using drugs • Apathy: occurring when the worker feels • if the outreach worker is HIV positive he constantly frustrated in the job yet needs or she may be constantly reminded of the job to survive; may begin to put in a their HIV status through the work minimum of time, resist challenges, even • long working hours for not much pay avoid clients and distance him or herself • workers may not have much job security from co-workers. because their job is reliant on funding • workers have to deal with the social and Symptoms of burnout in individual workers political context, i.e. police harassment, may include: 14 arrest, antagonism from some members of •Physical: headaches, backaches, frequent the local community colds, exhaustion, lingering illnesses, • sense of loss and grief when clients die sleeplessness, gastrointestinal •constantly having to counter stereotypes disturbances about drug users and drugs • Emotional: irritability, frustration, anger, •having to go into battle time and again a rigid and inflexible approach to work, for clients increased use of drugs/alcohol/tobacco etc, • fighting feelings of futility and over-eating or under-eating, increased frustration conflict in marital or other relationships, • difficulties associated with forming closer depression and hopelessness. bonds with some clients than others • attempting to maintain compassion and solidarity with co-workers •a sense that their colleagues (e.g. those who do not work out on the streets) do not have a clear understanding of the pressures of the job •if the job consists of referring people on for further treatment, there may be frustration of not seeing the work through • being placed in positions of considerable personal risk •working anti-social hours 15 The Centre for Harm Reduction

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Manual for Harm Reduction News reducing drug related harm in Asia It’s worth the work

CHURACHANDPUR, INDIA and they’re going to die. And These guys are hopeless, use- when you think of the mag- less.” At times there is a lot of HERE are times when nitude of the problem it criticism. But I’ve decided I Tyou feel exhausted makes you very depressed want to work in this field. because you’re working in a and really tired. Initially it was very hard – I field where there is no easy Many times people tell felt so for them. answer to the problem. In me: “Why are you doing this I’d have sleepless nights, Manipur, 95 per cent of the work? It isn’t going to help, particularly watching people drug users are male, five per you’re wasting your time. die. But later on I became cent are female. more professional. I’m not Even if they want to give “I’m more mature now totally detached but I’m up they can’t and many of and I can handle more.” more mature now and I can them are already infected handle more.”16

Harm Reduction News

It Takes a Lot of Skills

CHARACHANDPUR, INDIA different situation. You’re But if someone is gasping working in crisis manage- for breath because they have ell, besides having to ment in a lot of cases. You tuberculosis, you have to Wwalk all day in all types have to know when your know when it’s above your of weather, you’re being an abilities are limited, when head. Then you have to educator, a counsellor, a pri- you have to call in somebody switch to referral mode, then mary health care worker, else. Obviously, if someone administration mode if they you’re working with clients, has an abscess that’s easy need to go to the TB clinic, or community, if you have to enough to lance, to bandage. you have to help a family take someone into drug bury someone because he or treatment then you’re having she has died of AIDS. Then to be an administrator – “Being acknowledged you have to write up reports you’re working in one situa- for your work is very on that day. Being acknowl- tion then five minutes later important.” edged for your work is very you’re working in a totally important.” 17

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ARM EDUCTION EWS Chapter H R N Eight Voluntary HIV IT PAYS TO TAKE BURNOUT SERIOUSLY counselling and testing KATHMANDU, NEPAL and behaving differently. But, people any longer: he said he after a couple of hours of talk had been having nightmares eebash started perform- and motivation, he said that every night. After a few hours Ding poorly during out- he was not willing to work of in-depth counselling he reach. He has been one of with IDUs and HIV positive was granted leave with pay our most innovative staff for five days to go and spend members but in the last cou- some time with his family ple of weeks he has been the outside the valley. He least active and interested. he said he“ had been returned last week as the Eventually management had having nightmares good and happy Deebash of to call him in to look at his every night old and is his jovial self once work performance. Initially more.” 18 he denied that he was feeling ”

There are several strategies that How to avoid burnout? managers/supervisors of programs need to be aware of for avoiding burnout among staff:19 It is important that agencies and programs 1 Supervision: organise regular de-briefing establish mechanisms to help workers to meetings with individual workers avoid burnout and to manage their stress. (perhaps every two to three weeks). Talk Burnout is often the result of anger, to the worker about how they are finding frustration and grief which has not been the job, what problems they are having, expressed. Supervisors need to assist what they are doing about those problems individual workers with their problems but and what they are aiming for. Provide also need support themselves. Burnout of clear guidelines on work roles and levels individuals can also, at times, highlight the of responsibility. Ensure the workers fact that there are problems in the know what is expected of them. The organisation. supervisor may like to accompany

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Summary

workers occasionally in their outreach Voluntary HIV counselling and testing Manual for work, to give them support and advice. (VCT) is the process by which an individual reducing drug 2 Team supervision: bring all workers undergoes counselling, enabling him or her related harm together every couple of weeks to discuss to make an informed choice about being in Asia the program, to offer each other support, tested for HIV, the virus that causes AIDS.. to air conflicts and to stimulate ideas. 3. Training: maintain ongoing training for staff, to give them a chance to develop Counselling Process skills, provide intellectual stimulation and give them a useful break from their daily work. Pre-test counselling 4 Recruitment of new staff: look at what •always to accompany antibody testing the team needs not only in terms of skills •a comprehensive assessment needs to be but race, gender and personality type. made of all the client’s risks Will this person fit into the team? Work • assess client’s knowledge of HIV/AIDS to integrate new staff members into the and ability to cope with crisis team. Involve and support volunteers. • comprehensive discussion about all 5 Evaluation and feedback: keep workers aspects of the test, issues of emotional up to date with what is going on in the support, and examining coping agency/program and what their work is mechanisms if the test result is positive achieving, e.g. how many people the • detailed information on HIV/AIDS, agency has reached, the quantity of issues of testing accuracy and the needles and syringes exchanged, condoms meaning of test results distributed, primary health care • appointment for follow-up for post-test delivered. Sharing this information can counselling help motivate workers and provide job satisfaction. Post-test counselling 6 Guidelines and protocols: establish •primarily involves giving the results of guidelines and agency protocols on: the HIV test to the client • occupational health and safety • type of counselling will depend on the regulations for the agency result and, as with the pre-test • grievance procedures counselling, privacy and sufficient time • strategies for dealing with abusive will be important so as to discuss the clients issues with the client. •procedures for handling crisis Comprehensive counselling is crucial even situations i.e. violence, overdose, if the test results are negative. When the death. tests are positive the counsellor needs to be supportive and sensitive to the client’s shock and fear. Explanations of the results need to be clear and simple and issues of disease progress and life expectancy are not appropriate for discussion at this time.

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292 SECTION Contents > Section 2-C hapter 8 2 Further appointments need to be arranged, Injecting drug users are an extremely not only to establish a supportive marginalised group in societies. The stigma Chapter relationship but to provide repeated wide of HIV/AIDS and the decision by IDUs to Eight ranging information about HIV infection. have a test, and the post-test implications, Voluntary HIV Reactions to a positive HIV test vary have highlighted the importance of counselling according to the client’s personality and their confidentiality. Informed consent is also and testing social environment. A client may have essential before an HIV test. Informed various concerns about counselling and/or the consent requires the client to be competent counsellor and these need to be addressed. in decision making, have full understanding of the purpose, risks, harms and benefits of being or not being tested, and aware that HIV Testing Process their decision must be voluntary. All clients should be provided with a The HIV test looks for antibodies to the comprehensive explanation about all matters virus, not for the virus itself. To confirm relating to an HIV positive test. A client infection by the virus a window period (three may not consent to a test because of a lack of weeks to three months) needs to occur before information on HIV/AIDS, feelings of the accuracy of an HIV/AIDS test can be emotional vulnerability in receiving a assessed. If the test result is positive, the positive result, lack of support by family and person has developed antibodies to HIV and friends, and a fear of any breach of is infected with HIV and capable of infecting confidentiality. others. A negative HIV test can indicate the Successful counselling can be achieved by person is not infected with HIV or that they combining various approaches. Information are still in the window period. AIDS about HIV needs to be comprehensive, develops when HIV has destroyed the people must be given emotional assistance to immune system. cope with a positive HIV test, and Determining which people should have encouragement must be given to adopt safe an HIV test has largely focused upon those behaviours to prevent transmission. groups whose behaviors put them at risk: Counselling is very often not a one-time • injecting drug users event and can occur formally or informally on • sex workers a regular basis. • gay men. However, many other people within the community may not associate or identify with these groups, continue practising risky behaviour and potentially become HIV infected. An HIV counsellor, keeping in mind cultural, religious and language sensitivities, can compile a series of questions to help identify those people at risk of HIV infection.

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Summary

Manual for Staff: Stress and Burnout reducing drug Within harm reduction programs, staff stress related harm and burnout have many manifestations in Asia ranging from high sickness levels to fast staff turnover. The progressive loss of idealism, energy and purpose can be identified through the following stages: 1Enthusiasm 2 Stagnation 3Frustration 4 Apathy Harm reduction work has an array of contributing issues that can both be stressful and can contribute to burnout for those involved in the program. Outreach workers often meet many difficulties that are linked to personal issues that have the potential to conflict with their assigned tasks. Other issues that may arise include fighting feelings of futility and frustration, political and social struggles, battling to protect their clients and a sense of loss and grief when a client dies. Mechanisms should be established to avoid burnout and manage stress. Strategies to avoid burnout include: •regular de-briefing meetings with individual workers to discuss various issues encountered on the job • team supervision to bring all workers together for open discussion, support and ongoing training • issues related to recruitment of new staff (i.e. skills, race, gender, personality types) • evaluation and regular feedback to staff Section Two, Chapter Eight: about any developments in the program, Voluntary HIV Counselling and which can not only motivate workers but Testing also promote job satisfaction. For further information refer to WHO resources: Evidence for Action Papers. Refer to the following website: www.who.int/hiv (publications expected online from May 2003) The Centre for Harm Reduction

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CENTRE FOR HARM REDUCTION

▼▲ HIV/AIDS test looks for antibodies to the virus not the virus itself. AIDS develops when HIV has destroyed the immune system.

Different modes of testing ➤ voluntary screening. e.g. blood donors ➤ compulsory ➤ sentinel surveillance ➤ anonymous and delinked

Pre and post HIV/AIDS testing requires strict confidentiality and informed consent.

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CENTRE FOR HARM REDUCTION

▼▲ Informed Consent Requirements From Client

➤ Competency in Decision Making ➤ Understanding Purpose, Risks, Harms & Benefits of being Tested or of not being Tested ➤ Must be completely Voluntary

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CENTRE FOR HARM REDUCTION

▼▲ Pre Test Counselling

➤ Antibody testing ➤ Comprehensive assessment of client ➤ Client’s HIV/AIDS knowledge & coping mechanisms ➤ Comprehensive discussions on all aspects of test, coping mechanisms and meaning of results ➤ Provision of information on HIV/AIDS ➤ Privacy

Manual for reducing drug related harm in Asia SECTION 2 • CHAPTER 8 • OVERHEAD 3

CENTRE FOR HARM REDUCTION

▼▲ Post Test Counselling

➤ Providing results of HIV test ➤ Counselling style depending on result (positive, negative, indeterminable) ➤ Privacy, complete confidentiality

Explain results in clear and simple language, particularly if test is positive. Supportive relationship needs to be nurtured.

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CENTRE FOR HARM REDUCTION

▼▲ Staff Stress and Burnout follow Stages

1 Enthusiasm 2 Stagnation 3 Frustration 4 Apathy

Manual for reducing drug related harm in Asia SECTION 2 • CHAPTER 8 • OVERHEAD 5

CENTRE FOR HARM REDUCTION

▼▲ Difficulties encountered by Outreach Workers

➤ Personal Issues

➤ Feelings of Futility and Frustration

➤ Political and Social Struggles

➤ Protection of Clients

➤ Loss and Grief

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CENTRE FOR HARM REDUCTION

▼▲ Strategies to Avoid Burnout

➤ Regular De-briefings

➤ Open Discussions & Ongoing Training

➤ Insightful Recruitment of New Staff

➤ Evaluations and Regular Feedbacks to Staff

Manual for reducing drug related harm in Asia SECTION 2 • CHAPTER 8 • OVERHEAD 7

The Centre for Harm Reduction

298 Contents SECTION

Section Two 2 Chapter Nine Specific Groups

Refugees Prisoners Sex workers Men who have sex with men Migrants (mobile populations)

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Introduction

Specific groups in the community have increased risks of contracting and Manual for transmitting HIV/AIDS. The reasons for the increased risk vary from reducing drug group to group but they all revolve around circumstances which lead related harm people to engage in risky sexual and/or drug taking behaviour. These in Asia groups require special targeting to ensure that their needs are recognised and met. Involving the specific group in the planning, establishment and running of the program will increase the chances that the program will be successful.

This chapter will look at: 1 Refugees 2 Prisoners 3 Sex workers 4 Men who have sex with men 5 Migrants (mobile populations)

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1. Refugees 2 Prostitution: “The destruction of families, deterioration of •the need for food is paramount in refugee Chapter social structures and unravelling of social situations, sex is used in exchange for Nine mores, the loss of homes and income, food and other essentials Specific overburdened health care resources, • fuelled by the fact that men and women groups crowding and the sex trade within refugee refugees often have no partners camps are just some of the factors leading • becomes established in and around the to increased risk-taking behaviour and camps susceptibility (to HIV/AIDS).Women and • inevitably involves the host community adolescent refugees, vulnerable to violence, • both sex worker and client at risk of HIV rape and coercive sex, are at especially if condoms are not used high risk.”1

“But what is of the utmost concern is the Why is HIV/AIDS a problem for forced, large-scale migration of people: refugees? displacement caused by ethnic feuds, leaving What can be done in these situations? whole villages torched, a large number of people dead, and the living without any It is estimated that there are 40 million visible means of livelihood.These displaced refugees in the world today with the majority people are given temporary shelter in being women and children.2 Refugees are crudely constructed refugee camps, where generally forced from their homes due to a conditions are usually degrading and natural disaster such as an earthquake or appalling.Women enjoy no privacy and flood or because of war or civil disruption. deprived of families and their livelihood they HIV/AIDS is often of little concern to are often forced into prostitution to survive refugees compared to their immediate needs or to provide for their remaining siblings, for food and shelter. However, HIV/AIDS has relatives etc.As the choice of prostitution as been found to be a real problem for refugees. a profession is not a free choice, they tend to shut off their minds and emotions from the work they are involved in and to do this, Why is HIV/AIDS a problem they usually need the help of alcohol, drugs forrefugees? or both.”3 Blood transfusions: many refugees need Injecting drug use: if the emergency occurs urgent blood transfusions due to injuries in an area where injecting drug use is from war and/or because of their poor common it may also begin in the refugee nutritional status. Transfusion with HIV- camps or refugees who were already IDUs infected blood is a highly efficient means of will continue injecting in the camps. It is transmitting the virus. highly likely that IDUs will be sharing Sexual contacts: fleeing populations are needles and syringes – this carries a great risk often made up of unaccompanied children for transmitting the virus where it is present. and many single women. In emergency Mixing of populations: some refugees situations people often lose their spouses and may have knowledge of HIV (e.g. urban families. Social ties break down leading to a people) while others may not. One group loosening of traditional values, rape occurs, may come from an area where HIV is prostitution becomes a way to earn money for prevalent, others from where it is not. basics such as food and condoms are often The Centre unavailable. for Harm Reduction

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Unprotected sex and the sharing of injecting •provision of condoms: make condoms Manual for equipment can lead to transmission of the available immediately and in sufficient reducing drug virus between these groups. The refugees also quantities even though other matters will related harm come in contact with the local host seem of greater urgency in Asia community where HIV may be prevalent. •provision of equipment to make injecting Health care: amid the chaos of an safer: provide supplies of household emergency, materials for HIV prevention, bleach (or other disinfectant) and teach especially condoms and new injecting IDUs how to clean their needles and equipment, are unlikely to be available. syringes and /or establish a needle and Health care services, including care for STDs syringe program and HIV/AIDS, most probably will not exist. •provision of information on HIV/AIDS: give refugees information about the transmission of HIV and how to prevent What can be done in it. The information should be given in these situations? the refugees’ language and designed in a way which is culturally appropriate and • make the blood supply safe: test all blood relevant to the target group for transfusion for HIV •provide supplies for ‘universal medical precautions’: adequate supplies will ensure health workers can follow the necessary precautions to prevent transmission of HIV. Universal medical precautions include: –Washing hands thoroughly with soap and water, especially after contact with wounds or body fluids. – Using protective gloves whenever there is contact with blood or potentially infected body fluids, and disposing of materials and sharp objects. – Using protective clothing when there is likely to be exposure to large amounts of blood. – Safely handling and disposing of needles and other sharp instruments. – Safely disposing of waste materials. –Properly cleaning and disinfecting medical instruments.

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ARM EDUCTION EWS Chapter H R N Nine Specific REDUCING HARM IN A REFUGEE CAMP groups

HONG KONG,CHINA health risks of injecting drugs syringe boxes, closed by a and to improve the overall tamper proof seal, were dis- illar Point refugee camp in quality of the lives of IDUs tributed and, when used, col- PHong Kong was primarily and their families. Their spe- lected by the doctor. opened as a transit camp for cific aims were to raise aware- A three month survey of Vietnamese people awaiting ness of the health related risks the program’s clients found departure to a country of asy- (e.g. HIV/AIDS), encourage that: lum. The camp is located in safer injecting practices and • 70 per cent of IDUs had an area well known for its safer sex, to encourage safer not shared needles and drug use and criminal activi- disposal of used needles and syringes syringes and to help IDUs gain access to methadone programs. (With) the“ sense of The field team was com- The camp“ has now helplessness and posed of one Vietnamese become free of hopelessness about drug counsellor and one discarded used needles the future… medical doctor: they mainly and syringes. worked in the evening and on the weekends as this was ” the best time to reach IDUs. • 30 per cent” of those who ty. The camp’s location, the difficult conditions within the The workers offered individ- had shared had cleaned camp, the sense of helpless- ual counselling where alter- the needle and syringe ness and hopelessness about natives of drug treatment before injecting the future, the pleasure from and safer injecting practices • 81 per cent always drugs and social acceptance would be discussed: all coun- cleaned their skin with a of drugs among the male selling was confidential. They swab before injecting refugees has led to a great also gave IDUs a needle pack • 30 per cent were using deal of heroin use in the service. This consisted of a sterile swabs camp. It is estimated that 90 – free set of: • 74 per cent used boiled or 95 per cent of Vietnamese •three needles and sterile water to mix up men in Pillar Point are depen- syringes their drug dent on heroin. They work •three sterile waters They also found that 75 per mainly as day labourers and •three sterile swabs cent of their clients were con- nearly all of them now have • one condom cerned about disposal issues criminal records which blocks •a leaflet with appropriate and understood the danger their chances of resettlement. information about STDs, discarded needles and In July 1996 Medecin Sans HIV/AIDS and condoms syringes could be to other Frontiers began a program Along with distributing the people, especially to the chil- among drug users in Pillar packs they would discuss dren in the camp. The camp Point camp. Their general methods of safer using and has now become free of dis- aims were to reduce the listen to the concerns of the carded used needles and IDUs. Individual needle and syringes.4

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2. Prisoners

•Drug use: many prisoners are in prison Manual for “ Many of those in prison are there because because of drug related offences and the reducing drug of drug use or trafficking and they often find experience of prison does not encourage related harm ways to continue drug use inside. Drug abstinence. Most prisoners cannot get in Asia injecting is shared – non-sterile equipment is access to sterile injecting equipment, but the factor probably accounting for the can get drugs, and what equipment exists greatest number of new HIV cases in prisons is usually shared between many people. worldwide.” 5 This is an extremely efficient way of passing on the virus. • Sex and Rape: sex between prisoners is Why is HIV/AIDS a problem for common and often includes anal sex. prisoners? Rape also happens in prison and What can programs do to stop the spread sometimes is part of an initiation to of HIV/AIDS in prisons? prison life: this can be gang rape. It is rare for prisoners to have access to condoms HIV/AIDS has been found among prisoners and lubricants to protect themselves from in most countries throughout the world. STDs including HIV/AIDS. HIV prevalence in many prisons in Asia is •Tattooing, skin piercing, blood high – often higher than among the general brother rituals: these practices are also population. Most prisoners return to the common in prison and the equipment is outside world and bring with them diseases usually shared and unsterilised, contracted inside the prison. A prison’s presenting a great risk of HIV population is constantly changing: prisoners transmission. are not permanently sealed off from the community. Prisoners are in a vulnerable position, at the mercy of the prison officials and often to the sexual, and other demands, What can programs do to stop of fellow prisoners. the spread of HIV/AIDS in prisons? • accept the reality that injecting drug use Why is HIV/AIDS a problem and sex takes place in prisons for prisoners? •provide bleach (or another appropriate disinfectant see Chapter Five: Injecting Many factors contribute to make prisons a Safely for more details) and instructions breeding ground for disease and infection for cleaning injecting equipment. It may including: be introduced into the prison as a means • Overcrowding: means prisons are of cleaning needles used for tattooing etc. usually unhygienic and makes the – this may be a more acceptable way of transmission of disease easier (e.g. convincing officials and getting a Tuberculosis) and it also leads to increased disinfectant to the prisoners tension between prisoners including • establish a needle and syringe program: sexual tension. establish a pilot program, this can be an •Violence: an atmosphere of violence and easier way to convince prison officials and fear is common in most prisons. This can governments of the benefits of the produce attacks, including sexual attacks. program. Evaluate it, for example, after one year The Centre for Harm Reduction

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Harm Reduction News Chapter Nine Specific Prison Spreads AIDS groups

YANGON, MYANMAR addicts. And the result – an properly trained but are pris- uncontrolled spread of the oners handpicked by the n the past few years , virus. Inside the prison hos- wardens to work in the hos- Iapproximately 100 political pital, there’s a small sign- pital. “And many of them are prisoners have died in Insein board at the entrance of the drug addicts infected with prison (in Myanmar) as a Out Patient Treatment (OPT) HIV,” Moe Aye said. result of dysentery and room which reads: ‘Today – Consequently, all severe torture. More recently, 15 needles are permitted for inmates, including political some political prisoners have use.’ prisoners, fear getting injec- died of AIDS. However, to tions at the prison hospital. date, the authorities are not “I’ve seen my friends die Their concern is genuine. A paying any serious attention in prison – the number of political prisoners to the worsening health situ- authorities paid no in Burma have died of AIDS. ation and the spread of the But those who suffer are not attention.” HIV virus among inmates of only Burmese. According to a Insein. According to Moe Aye, former Thai prisoner, at least Former political prisoner the OPT treats almost 200 one Thai dies each month of Moe Aye, who spent six years patients daily. Thus, if one HIV/AIDS – many of whom in Insein, said prisoners are needs an emergency injec- were fishermen arrested in afraid to go to the prison hos- tion, to ensure safety, the Burmese waters. pital. “Before, when we were patient has to bribe the med- “I’ve seen my (Thai) sick, we would go there, but ical officer to the tune of 300 friends die in prison – the not anymore,” he said. kyat for a new needle and authorities paid no atten- The reason: only one nee- syringe. tion,” Rashen Plengvithaya, dle is used a day for up to 200 In addition, the ‘medical who was in Insein prison for 6 patients. This includes drug workers’ at prison are not five years, said.

• train current prisoners to become peer • if possible try to persuade prison and educators: to teach other prisoners about government officials of the benefits of safer using and safer sex establishing a pilot drug substitution •provide condoms and lubricant to program (i.e. methadone, buprenorphine) prisoners through regular health visitors •try to persuade prison officials to allow to the prison outside doctors and health workers to •provide information on how HIV/AIDS is visit the prisoners transmitted through sharing injecting equipment and through unprotected sex

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3. Sex Workers

Inability to insist on condom use: Manual for “Sex work involves many more people than many women work as sex workers because of reducing drug sex workers, and supports local economies poverty: so that they can provide the basic related harm and the people who work in them, wherever necessities for their families. They often have in Asia it takes place.This includes the owners and little power to insist clients use condoms as staff of hotels, clubs, bars, brothels and escort the client may refuse to wear a condom and if agencies that employ sex workers, local they insist they will lose the business shops and food sellers; and taxi drivers, Violence: sex workers who insist on pimps, police, drug dealers and criminal condom use may face violence from clients elements who feed off the trade.”7 and/or brothel owners/pimps Youth: young women who are sold into sex work also have little power to insist on Why is HIV/AIDS a problem for condom use and/or are marketed as ‘unsoiled sex workers? goods’ What can programs do to stop the spread Trafficking: the trafficking of women of HIV/AIDS among sex workers? across borders and from remote areas means they may not speak the local language and Sex work is a reality in every country in the safer sex messages in that language may not world. Sex workers are at great risk of be understood by them contracting and transmitting HIV and other Injecting drug use: women who work as STIs if they do not use condoms. However, sex workers may also be injecting drugs and many clients of sex workers do not want to may contract HIV from sharing needles and use condoms and for various reasons (see syringes even if they use condoms in their below) sex workers are unable to insist. This work puts both the sex worker, the client and their Insufficient condoms: sex workers may partners and potential children at risk of not have access to sufficient numbers of HIV/AIDS. condoms Lack of health care: sex workers may not have access to health care to get Why is HIV/AIDS a problem for treatment for STIs which increase their risk sex workers? of contracting HIV/AIDS Work options: sex workers may have no Numbers of clients: unprotected sexual work options other than prostitution, they intercourse is a major risk factor for the may also not have access to land ownership or transmission of HIV/AIDS. Due to the use, money or credit amount of clients sex workers see, if they are not practising safer sex (i.e. using condoms), they increase their chances of contracting HIV from a client and they then can pass it on to other clients, their sexual partners and eventually their children

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306 SECTION Contents > Section 2-C hapter 9 2 HARM REDUCTION NEWS Chapter GETTING THE MESSAGE TO WHERE THE Nine CUSTOMERS ARE Specific groups BANGKOK,THAILAND •English speaking tourists In Bangkok 78 venues had Posters in both Thai and 343 signs placed in designat- he Thai TRAVEL SAFE English were displayed in a ed areas: English messages in Tpilot project was con- range of bars and nightclubs the client toilets and one ducted by Convenience in the Patpong area in Thai message in the sex Advertising in collaboration Bangkok and at the popular workers’ toilet. The sex work- with the Thai and Australian ers also requested European governments, NGOs, bar size condoms (52) be sup- owners, sex workers and plied. The messages were Sure, money is health officials. The broad “ designed by the Ministry for objectives of the project were precious; but if you Public Health in Thailand. to: reinforce the need for safe have to risk AIDS to An example of one of the behaviour in respect to sexu- get it, it ain’t worth it. signs: al contact when travelling, to LIFE IS VALUABLE. IT’S NOT increase the personal rele- ” WORTH GETTING AIDS. vance of the risks of HIV and resort Pattaya beach (a two DON’T FORGET; ALWAYS other STDs for men who and a half hour drive from USE A CONDOM. travel to South-East Asia for Bangkok). The largest group • Always protect yourself paid sex and to provide running bars in the Patpong and the one you love appropriate messages to Thai area is the King’s Group: they •Sure, money is precious; sex workers that would assist are reputed to have 1000 sex but if you have to risk in the negotiation of safer workers working for them in AIDS to get it, it ain’t sex. The project sought to the area. The company direc- worth it reach 20-40 year old: tor endorsed the TRAVEL • AIDS... incurable, but you •Australian male tourists SAFE project and ensured its can protect yourself 8 •Sex workers establishment in his venues.

What can programs do to stop • assure a consistent and adequate supply of condoms: there is no point in the spread of HIV/AIDS among encouraging sex workers and clients to sex workers? use condoms if there are none available • accept the reality that reducing the • discuss injecting drug use and provide number of clients a sex worker sees is an information on safer drug use including unrealistic strategy for most sex workers needle and syringe programs, cleaning • use peer educators to get the message techniques, substitution programs etc. across: educate sex workers who will be •provide links with health care facilities acceptable to other sex workers and encourage regular STI check-ups • involve sex workers in the design of for sex workers with guaranteed programs and IEC materials confidentiality • target owners and managers of brothels, •provide counselling and HIV testing for bars etc. to support safer sex practices those sex workers who request it. • target clients of sex workers and educate The Centre them on the risks of unprotected sex for Harm Reduction

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Manual for Harm Reduction News reducing drug related harm in Asia Peer Education Works for Sex Workers

CALCUTTA, INDIA fying themselves as sex work- three quarters of visits were ers. made by women. A second ver 5,000 women work Since the service started clinic, run during the Oas sex workers in in 1992, the number of peo- evening, is aimed at male Sonagachi, a ‘red-light’ area ple with STDs has fallen. HIV clients and sex workers who in one of India’s largest cities. prevalence, measured using travel to work in the area. Although most work from anonymous and unlinked brothels, some women, as testing, has remained the “The peer educators are well as male sex workers, same. Women reached by the proud of what they do travel into the area to work. project report that they use …” The male clients number condoms with more than more than half a million a half their clients while else- Over 65 former and cur- year. where in Calcutta female sex rent sex workers act as peer workers report condom use educators, after taking part in “The success of the with only about 20 per cent a six week training program service depends on of their clients. The success and passing an oral test. They community of the service depends on visit sex workers in their community participation. homes and talk with them participation.” This is made possible about their sexual health, An effective primary through continuing negotia- demonstrate and distribute health care service, with an tions with community power condoms and encourage emphasis on sexual health, groups, including leaders of them to visit the clinic. The has been developed by work- local political parties and peer educators are proud of ing with people in the area, gangs, youth groups, brothel what they do and feel they including sex workers, NGOs landlords and female man- have gained confidence and and local medical institu- agers, private practitioners dignity. The more experi- tions. Based in a building and sex workers. enced ones are involved in loaned by a local club, the During the first 15 training new peer educators service functions as a com- months of operation, more and other community mem- munity resource, with at least than 4,500 people visited the bers. 9 half of the clinic users identi- clinic for the first time. Over

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4. Men who have sex with men 2

“I live in a society which thinks that I am Why is HIV/AIDS a problem for Chapter abnormal. It will take a long time for the men who have sex with men?11 Nine society to accept me and they will not Specific understand me.All programs on Many factors contribute to make HIV/AIDS a groups homosexuality in the media are in English. risk for men who have sex with men (MSM) Are the English speaking ones the only ones including: entitled to be homosexuals? You should Sex: unprotected anal intercourse (i.e. provide more exposure in the mass media without using condoms and lubricants) is so that my parents will accept and a high risk activity for transmitting HIV 10 understand me.” and other STIs. Health care: lack of STI testing facilities for Why is HIV/AIDS a problem for men identifying and treating STIs and/or who have sex with men? failure to attend clinics for fear of being What can programs do to stop the spread identified as having sex with men. of HIV/AIDS among men who have sex Denial: in many countries the existence of with men? same sex intercourse is denied by the authorities and society. Men who have sex with men (MSM) are an Stigma: because of this denial and/or the often hidden group in many countries. While outrage of the community at MSM, many some men are open about their sexuality and MSM feel ashamed of their sexuality, belong to a gay community, many other men suffer from low self-esteem and attempt to are not. Many men who have sex with men do keep their sexuality a secret from their not see themselves as homosexual: they may families and the wider society. be married and have children and occasionally Tradition: pressure from family and society have sex with other men. These men may not to get married and have children, know of the risks they are taking in relation particularly a son, contributes to the to their own health and that of their families secrecy about MSM. If MSM marry and in terms of HIV/AIDS and other STIs. continue to have unprotected sex with other men, they also put their wives and children at risk of HIV.

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Manual for ARM EDUCTION EWS reducing drug H R N related harm in Asia FRIENDSHIP FIGHTS AIDS

HO CHI MINH CITY,VIETNAM homosexual in Ho Chi Minh meetings, activities and stud- City and 80,000 – 100,000 gay ies so that we can think GUYEN Friendship is a people in the provinces. about AIDS clearly. Nsociety working in Every month we ourselves Sometimes we also discuss HIV/AIDS prevention for the the gay way of life and hope gay community in Ho Chi to normalise relations with Minh City. As in many South other people and families, to East Asian countries, AIDS We need“ all of us to avoid despising and discrimi- has been the issue that gays unite in the spirit of nation. first organised around, creat- mutual help and However, for all our activi- ing, in addition, a place for friendship … ties, we still have problems. open discussion of gay, les- We are a small group who are bian, bisexual and transgen- ” usually despised by oriental der issues. issue hand-size leaflets to society. It is important that The Nguyen Friendship send to them. In those, most we haven’t been supported Society runs a group to dis- of the news is translated from yet by any associations or cuss these issues. In the foreign information, maga- personal support. We need all group there is a leader, a sec- zines etc. so we don’t have of us to unite in the spirit of retary, a cashier, the press very much. We also have the mutual help and friendship group, the musical group, money saving project to help with the purpose: don’t die of outreach team and volun- poor gays in their difficult ignorance and let’s have safer teers. lives. This project has raised sexuality.” 12 “Together we are part of $100 (US) or one million 10,000 people who are Vietnamese Dong. We hold

Lack of information: the mainstream media Police: many MSM have suffered police and program messages about HIV/AIDS harassment and have little knowledge of tend to revolve around heterosexual sex. their legal rights. Police have threatened MSM often do not have information about to expose MSM or have extorted money the dangers of unprotected sex with other from them. In some countries anal sex is men and therefore may be ignorant of illegal: this is a major hurdle to the risks. incorporating messages about anal sex into Injecting drug use: MSM may also be mainstream campaigns. injecting drugs and may contract HIV Condoms: MSM who are aware of the need from sharing needles and syringes even if to use condoms may be unable to get they use condoms. access to them. Some MSM are reluctant Sex work: some MSM work as sex workers to use them because of reduced pleasure. and are at great risk of contracting or transmitting HIV and other STIs if they have unprotected sex with their clients. The Centre for Harm Reduction

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5. Migrants (mobile populations) 2

What can programs do to stop “All throughout Asia political, ethnic and Chapter the spread of HIV/AIDS among religious conflicts are major causes of Nine men who have sex with men? migration. Because Asia is the region of Specific economic boom the so-called ‘push and pull’ groups • accept the reality that men do and will factors have also become major causes of continue to have sex with other men migration. Mass poverty exists side by side • establish STI clinics to deal specifically with the so-called economic miracle taking with MSM and/or educate existing clinic place in Asia. People from poor areas workers on the particular health risks for migrate to escape from poverty and hunger, MSM to find a better life elsewhere and to help • train and educate MSM for peer education the family back home.”13 on HIV/AIDS, sexual health, legal rights etc. Why is HIV/AIDS a problem for • set up a specific project to focus on MSM migrants? • set up informal discussion groups to What can programs do to stop the spread examine issues surrounding HIV/AIDS, of HIV/AIDS among migrants? sexuality, drug use, marriage, family etc. •provide adequate numbers of condoms There has always been a great deal of and lubricants migration in Asia and varying reasons for the • discuss injecting drug use and provide migration. People may migrate from areas of information on safer drug use including conflict to areas of relative peace and needle and syringe programs, cleaning stability, from poor to richer countries, from techniques, drug substitution programs rural to urban areas and so on.14 Migrant etc. workers often take up unskilled labour jobs •provide pre and post HIV test in construction, manufacturing, fishing, counselling, make testing voluntary domestic duties and the sex and •organise lawyers to come to a program entertainment industries. Illegal migrants and explain MSM’ legal rights find themselves outside of the law, without • work with government, police and other protection and often without a common authorities to sensitise them to MSM language. They are a vulnerable group and at issues risk for HIV/AIDS.

Why is HIV/AIDS a problem for migrants? Sex work: women are trafficked from rural to urban areas to work as sex workers, other female migrants are unable to find work or their work is so lowly paid that they have little option but to take up sex work, others have no option but to work as a sex worker because they are supporting their family back in their villages. (See section on sex work for more details of the risks sex workers face). The Centre for Harm Reduction

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Language: migrants may have no Local populations: can see migrants as a Manual for common language with their new country threat to local jobs and scarce resources, reducing drug and therefore don’t understand safer sex and migrants can feel stigmatised and related harm safer using messages. discriminated against, emphasising their in Asia Health Services: migrants often lack outsider status. access to health services where they could get treatment for STDs and receive information on HIV/AIDS. They may be unwilling to What can programs do to visit hospitals for fear of being caught by the stop the spread of HIV/AIDS authorities or simply because they have no among migrants? money. Law: illegal migrants often do not have •programs need to investigate who the any legal protection and so can easily be migrants are, why they have migrated and exploited through lower wages, forced into what their particular needs are sex work etc. • information needs to be targeted to the Traditional social environment: migrant group to ensure the messages are migrants are cut off from forms of control culturally appropriate, relevant and in that would normally affect their behaviour their own language. Involve migrants in (e.g. family and village pressure for sexual the planning of projects. Provide fidelity) and their anonymity and loneliness information on how HIV/AIDS is may mean they engage in behaviour they transmitted through unprotected sex and would not otherwise (i.e. sex with sex the sharing of injecting equipment workers and injecting drug use). •recruit migrants to work as peer educators Lack of knowledge: migrants may have as they are more likely to gain the trust of little knowledge and information, or have the community, especially given their misconceptions, about HIV/AIDS and how it outsider status in the general community is transmitted. •migrants need access to health services: Injecting drug use: migrants may come provide links to health care for primary into contact with injecting drug use in the health needs, STI check-ups and new country or they may already have been HIV/AIDS information injecting and continue the behaviour in the •provide sterile equipment to make new environment. They may come from areas injecting safer: provide supplies of where drugs, such as opium, are traditionally household bleach (or other disinfectant) smoked, to areas where heroin is injected. If and teach IDUs how to clean their they share injecting equipment they are at needles and syringes and/or establish a risk of HIV/AIDS. needle and syringe program Borders: migrants can often be found •provide condoms in sufficient quantity along border areas where trading towns and • work with the general community for ‘rest and recreation’ facilities exist. HIV greater understanding and acceptance of incidence is often higher in these places (e.g. the migrants Thai/Cambodian border and Thai/ Myanmar • inform migrants of their legal rights border). Men often outnumber women in border towns and therefore there is a demand for sex work outlets. Border towns on drug trafficking routes also have easy and regular access to drugs. The Centre for Harm Reduction

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Harm Reduction News Chapter Nine Specific Migration Increases Women’s HIV Risk groups

KUALA LUMPUR, MALAYSIA A study of Bangladeshi seemed to be present, not women in a community in only with maids, but women ecent years have wit- Malaysia showed that the working in factories that pay Rnessed a rapid feminisa- women not only enjoyed very low wages. There is tion of migration, originally their new found freedom but demand for sex work. And within the manufacturing threw away their social the very low wages leads to sector, now primarily norms. The move to Malaysia migrants seeking this alter- through the demand for led to anonymity. They are native. Demand for better domestic labour, and in the out of their social context wages would bring about the sex and entertainment and control. The anonymity risk of being dismissed from industry. In Malaysia there created an independence work. The need to survive are more than 60,000 maids and assisted them in devel- and hold on to work permits while in Saudi Arabia alone oping relationships. They makes the worker accept there are over 500,000 interacted freely with others. their situation. Indonesian maids. Some of them also had indis- criminate sexual behaviour “…for migrant women “…the unequal that included casual sex. the risks are even higher relationship that defines Gender power relations and more acute.” women’s lives in Asia and the unequal relationship that defines women’s lives in Women are indeed more raises issues related to Asia raises issues related to vulnerable to HIV infection. HIV vulnerability.” HIV vulnerability. As migrant But for migrant women the workers, these power rela- risks are even higher and The experiences and real- tionships seem to be much more acute. The environ- ities only show that women more evident especially ment, stigmatisation, anon- on the move have to deal when it comes to sexual rela- ymity, exploitation and dis- with multiple dangers and tionships. Though the crimination added with risks especially in terms of women found themselves to women’s subordination, spatial mobility and behav- be free to enter into relation- especially within sexual rela- iour, social networks, sexual ships, it was the male partner tionships, are all important behaviour and subordina- who made the decisions in to understand the connec- tion. There is a link between terms of safer sex practices. tion between migration, these factors, especially sexu- Observations of women women and HIV infection.”15 al activity and the creation of who earn very low wages networks, that can lead to show that they tend to sup- HIV infection. plement their wages. This

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Manual for HARM REDUCTION NEWS reducing drug related harm in Asia MIGRATION AND HIV – A MOBILE PROBLEM

BANGKOK,THAILAND Thailand. Away from home, believed to be Nepali. “They mobile groups are not bound are disadvantaged because here people move, so by social mores and tradi- they may not be able to Wdoes HIV. The disease tions and are often isolated speak the language. Laotian seems to follow any mobile and lonely. “Migrant workers or Burmese sex workers in group: workers migrating to live in difficult circumstances Thailand will not understand countries, fishermen, sailors, – overcrowded slums with lit- the media here, and so won’t traders, construction workers have access to HIV educa- and transport workers in tion. They cannot commu- general. In Malaysia there are nicate so they will have less We need all of us to an estimated 2 – 2.5 million “ bargaining power to use migrant workers, mostly ille- unite in the spirit condoms,” says Dr Shakti. gal and mostly from of mutual help Other mobile workers, Indonesia and Bangladesh. and friendship. such as fishermen and truck Thailand also has many drivers, have lifestyles that migrant workers, again most- ” include frequenting sex ly illegal, from Myanmar, tle recreation facilities. So sex workers. In Thailand, 15 to 20 Cambodia, Laos, China, is a mode for entertainment, per cent of fishermen are Nepal and Bangladesh. “ says Dr Shakti Paul, Health estimated to be infected with Migrant workers are also coordinator from the Asian HIV. High HIV prevalence has sizeable in Taiwan, South Research Centre for also been reported among Korea and Japan. Migration in Thailand. truck drivers in India and Some indigenous people In many countries, sex Thailand, where prostitutes also move between coun- workers may also originate are easily found at truck tries, for example, some hill- from foreign countries, for stops. In Africa, the spread of tribe people from Myanmar example, half the prostitutes HIV had a close parallel to and Laos have migrated to in Mumbai (Bombay) are major roads.16

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Summary 2

Refugees Prisoners Chapter Refugee numbers continue to increase HIV prevalence in many prisons in Asia Nine and one of the problems they encounter is high. Prisoners returning to the outside Specific is that of HIV/AIDS. Following the world will often bring with them groups turmoil that has led people to become diseases contracted inside the prison. refugees, various circumstances arise that Prisoner vulnerability can result in sexual increase their vulnerability towards and other demands of fellow prisoners HIV/AIDS. Some causative factors for leading to HIV infection. the development of HIV/AIDS are blood transfusion of HIV infected blood, Reasons for the HIV/AIDS problem loosening of traditional values and/or among prisoners economic instability leading to • overcrowding often leads to poor hygiene, prostitution, non availability of condoms, easier transmission of disease and mixing of refugee populations and all the potential for rising sexual tension disparities that exist within the various • atmosphere of violence that can include groups (i.e. knowledge of HIV and sexual attacks prevalence of HIV infection). • widespread drug use and the sharing of Additionally, health care information and unsterile injecting equipment related health services on HIV • sexual activities and rape between prevention usually do not exist and drug prisoners can be common. Access to injecting for those involved in such condoms and lubricants are rare practices before an emergency is likely to • tattooing, skin piercing and blood rituals continue. with shared unsterile utensils

Actions to be taken in refugee areas to Prison authorities need to accept the prevent HIV transmission reality that injecting drug use and sex •provide safe blood supply occurs in prison and that various •provide supplies for universal medical programs exist to prevent HIV/AIDS in precautions prisons. Education/information materials •provision of condoms on prevention of HIV from drug •provision of injecting equipment, related injecting and sexual acts, and the means supplies and education/information to prevent transmission, are very •provision of HIV/AIDS transmission and important (i.e. pilot programs on needle prevention education/information that is and syringe to promote validity of such both culturally appropriate and relevant actions, introduction of bleach for to the target group cleaning needles and syringes, provision of condoms and lubricants and the training of peer educators).

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Summary

Manual for Sex Workers Men who have Sex with Men reducing drug HIV/AIDS is a problem for sex workers In many countries men who have sex related harm due to some of the following factors: with men (MSM) are a hidden group and in Asia • unprotected sexual intercourse with the risks they encounter of HIV/AIDS various clients can increase risk of HIV and other STIs are great. Contributing transmission risk factors are numerous and range from • issues of poverty and diminished power unprotected anal intercourse and the lack enhances inability to insist on condom of appropriate education/information, to use issues of stigma and the inability to get •violent repercussions for those insisting condoms. on condom use • youth sold into sex work have little power Successful programs to protect MSM over their circumstances from HIV/AIDS have adopted various • lack of health care places sex workers at approaches that include: risk of STIs • accepting the continuing reality of MSM •sex workers may be involved in injecting • training and educating MSM as peer drug use and sharing injecting equipment educators •providing health clinic environments that Some programs to prevent spread of are accessible for the needs of MSM HIV/AIDS among sex workers include: •providing condoms and lubricants • use of peer educators to disseminate education/information • targeting both brothel owners and clients of sex workers to support safe sex practice •maintaining consistent and adequate supply of condoms • encouraging links with health services for regular STI check ups for sex workers

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Migrants (mobile populations) Chapter All throughout Asia various factors (i.e. Nine political, economic, religious) have Specific contributed to large migrations of people. groups Migrant workers, both legal and illegal, have often found themselves in circumstances that can increase their vulnerability and risk of HIV/AIDS. The HIV/AIDS problems they may encounter are numerous. Poverty can lead to sex work, language difficulties can exclude them from messages of safe sex, health services may be inaccessible, little knowledge of HIV may exist, and drug users from areas of opium smoking may encounter those who inject their drugs and soon adopt the various risks of this new technique (i.e. sharing injecting equipment).

Programs to stop the spread of HIV/AIDS among migrants: • investigations on who are the migrants, why they have migrated, and what needs they have • information needs to be culturally appropriate, relevant and understandable •migrants need to be involved in planning of projects • use of migrants as peer educators •provision of means to implement safer injecting techniques (i.e. sterile injecting equipment, bleach) Section Three, Chapter Nine: •provisions of sufficient condoms Specific Groups •promotion of greater understanding and acceptance of migrants among general For further information refer to community WHO resources: Policy and • issues of legal rights for migrants Programming Guide for HIV Prevention Among Injecting Drug Users & Evidence for Action Papers. Refer to following website: www.who.int/hiv (publications expected online from May 2003)

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CENTRE FOR HARM REDUCTION

▼▲ Preventing HIV transmission in refugees

➤ Safe blood supply ➤ Universal medical precautions ➤ Condoms provided ➤ Provision of injecting equipment, related supplies, education & information ➤ Education/information is culturally appropriate & relevant to target group

Manual for reducing drug related harm in Asia SECTION 2 • CHAPTER 9 • OVERHEAD 1

CENTRE FOR HARM REDUCTION

▼▲ HIV/AIDS among prisoners

➤ Overcrowding and potential for sexual tension ➤ Atmosphere of violence ➤ Drug use and sharing equipment ➤ Sexual activities ➤ Tattooing, skin piercing, blood rituals with shared equipment

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CENTRE FOR HARM REDUCTION

▼▲ Sex Workers and HIV/AIDS

➤ Unprotected sex with many clients ➤ Limited negotiation power over condom use ➤ Violent insistence towards no condom use ➤ Young sex workers have minimal power ➤ Restricted health services for STÎ checks ➤ Injecting drug use and shared equipment

Manual for reducing drug related harm in Asia SECTION 2 • CHAPTER 9 • OVERHEAD 3

CENTRE FOR HARM REDUCTION

▼▲ Preventing HIV/AIDS among Sex Workers

➤ Peer educators ➤ Brothel owners and clients supporting safer sex practices ➤ Consistent/adequate condom supply ➤ Encourage regular STIs checks

Manual for reducing drug related harm in Asia The Centre SECTION 2 • CHAPTER 9 • OVERHEAD 4 for Harm Reduction

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CENTRE FOR HARM REDUCTION

▼▲ Preventing HIV/AIDS among Men who have sex with Men (MSM)

➤ Accept reality of MSM ➤ MSM peer educators ➤ Accessible health clinics for MSM ➤ Provide condoms and lubricants

Manual for reducing drug related harm in Asia SECTION 2 • CHAPTER 9 • OVERHEAD 5

CENTRE FOR HARM REDUCTION

▼▲ Preventing HIV/AIDS among Migrants

➤ Comprehensive investigation about the migrants ➤ Information culturally appropriate, relevant and understandable ➤ Planning projects must involve migrants ➤ Peer educators ➤ Means for safer injecting techniques ➤ Provision of condoms ➤ Promote understanding among wider community about migrants ➤ Migrants’ legal rights

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Endnotes 2 Chapter Two Section 2 1 Dr Abul Abdul-Qader, HIV Prevention for People who Inject Drugs: Planning and Conducting local HIV intervention Activities Guide for local Chapter One field managers, draft November 1993 P.37 1 Stimson, G.V., Fitch, C. & Rhodes, T. (eds) The Unpublished. Guide on Rapid Assessment Methods for Drug 2 Aboagye-Kwarteng, T. & Moodie, R., Injecting World Health Organisation (draft, Community Action on HIV: Resource Manual for 1997) Chapter 5, p. 1 HIV Prevention and Care, Chapter Three: 2 Ibid., Chapter 5, p. 2-3 Riding the Project Cycle. Macfarlane Burnet 3 This section is based upon The Guide on Rapid Centre for Medical Research, International Assessment Methods for Drug Injecting Chapter 6: Health Unit, Victoria, Australia, 1995. Existing Information 3 Dallabetta, G., Laga, M. & Lamley, P., Control 4 UNDP/UNAIDS workshop, Warsaw, Poland, of Sexually Transmitted Diseases: A Handbook of 1997. the Design and Management of Programs. The 5 National AIDS Programme Management: Aids Control & Prevention (AIDSCAP) ATraining Course Chapter 9: Prevention of Project, Arlington, Virginia, U.S.A., Chapter HIV Transmission Through Injecting Drug Two, p. 35 Use, Global Programme on AIDS, WHO, 4 HIV Prevention for People Who Inject Drugs, 1993. p. 4 -5 WHO Global Program on AIDS, 1995, P.13 – 6 Ibid., p. 4 14 7 The Guide on Rapid Assessment Methods for Drug 5 Aboagye-Kwarteng et al, op.cit. Injecting Chapter 6: Existing Information 6 Abdul-Qader, op.cit., p. 72 op.cit., p. 5-6 7 Ibid., p.69 8 Balasegaram, M. Recovery Lies in the Hands of 8 Ibid., p.77 Addicts, The Sunday Star, Malaysia, 11 9 Training workshop to improve skills in prevention of February, 1996, p. 11 HIV transmission and acquisition among injecting 9 WHO Guide on RAM, op.cit., Chapter 6: drug users, workshop notes, Chiang Mai, Module 6.3, P.1 Thailand, September 22-25, 1995, p.29 10 Much of the interviewing section is 10 Adul–Qader, op.cit., p. 84 based on the WHO Ram Guide, ibid. 11 Lourdes D. Jereza, Harm Reduction Project, 11 Abridged from Bert Palto’s interview with an Cebu City, Philippines. (Unpublished) outreach worker from SHARAN, March, 1994. Unpublished. Chapter Three 12 WHO Guide on RAM, op.cit., Chapter 6: 1 Stimson, G.V. Drug Injecting and the Spread of Module 6.3, op.cit, p.8 HIV Infection in South-East Asia, 1996. 13 This section is based on WHO Guide on (Unpublished) RAM, Chapter 6:Module 6.5, op.cit., p.1 2 Interview with Palani Narayanan, Ikhlas 14 Ibid., p.1 Centre, Kuala Lumpar, Malaysia conducted in 15 Interview with Ching Hangzo (Manipur, Chiang Mai, Thailand, May, 1997. India), Chiang Mai, Thailand, May 1997. (Unpublished) 16 Costigan, G. Field visit to Hanoi shooting 3 Community Mobilisation and AIDS: UNAIDS galleries, May 1997. Unpublished. Technical Update, UNAIDS: Joint United 17 WHO RAM Guide, Chapter 6 : Module 6.3, Nations Program on HIV/AIDS. April 1997, p. 7 P. 2. 18 Oppenheimer, E. A Rapid Assessment of Drug 4 Shi Qing, Changes in Handeng Village, Director Use in Cambodia and Concomitant Risk of Ruili Project, Implementation Team, Conducted Sept/Oct 1995 March, 1996. 19 Dr Ba Thaung & Dr Khin Maung Gyee, Rapid 5 Information provided by the Project Director, Assessment Study of Drug Abuse in Myanmar: A Lourdes Jerez. Harm reduction project in Cebu National Report, June 1995. Unpublished. City, Philippines. 6 Narayanan interview, op.cit. 7 Prisons and AIDS, UNAIDS Point of View, April, 1997, P.4 The Centre for Harm Reduction

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8 Ibid., P.6 Chapter Five 9 Deutschmann, P., Aboagye-Kwarteng, T., 1 Navaratnam, V. & Foong, K., A study on Manual for Gifford, S., Living with the Epidemic: A intravenous drug use and AIDS knowledge reducing drug Community Responding to AIDS in among heroin addicts. Research Report Series, related harm Churachandpur, a review of SHALOM, No. 30, 1996, Malaysia. in Asia December, 1995. P.113. 2 Mulleady, G. Counselling Drug Users about HIV 10 Chen, J. & Stuart, P., 1996. and AIDS Blackwell Scientific Publications, Oxford, U.K., 1992 p.8 Chapter Four 3 Ibid., p.33 1Mann J, AIDS in the 1990s (Public lecture), 4 Ibid., p. 34 Prince of Wales Hospital, Sydney, Australia, 5 Ibid., p.35 1993. 6 Based on Gray J. Operating Needle Exchange 2 Des Jarlais & Friedman 1993, Mann 1993, Programmes in the Hills of Thailand, AIDS Burt & Stimson 1993 CARE, Vol. 7, No.4, 1995. 3 Rhodes,T. Risk, intervention and change: HIV 7 UNDCP in East Asia newsletter, Vol. 1, No. 2, prevention and drug use, Health Education Sept., 1997. p.8 Authority/National AIDS Trust, London, U.K., 8 Workshop on the Prevention of HIV Infection among 1994. Injecting Drug Users in Asia, Kathmandu, 4 Interview with Palani Narayanan (Iklas, Kuala Nepal, March 1994. (Lifesaving and Lifegiving Lumpar), Chiang Mai, Thailand, May 1997. Society, Kathmandu, Nepal, Macfarlane 5Zapka et al, Social network, support and Burnet Centre for Medical Research, influence: relationships with drug use and Melbourne, Australia, St. Vincent’s Hospital, protective AIDS behaviour, AIDS Education Sydney, Australia.) p. 33 and Prevention 5 (4): 1993, pp. 352-366 9 Reid, G. The Hidden Epidemic: A Situation 6Rhodes., op.cit., Assessment of Drug Use in South East Asia in the 7Trautmann, f. & Barendregt, C. The European context of HIV Vulnerability (prepared by the Peer Support Manual Netherlands Institute on Asian Harm Reduction Network for the alcohol and Drugs, Utrecht, Oct. 1994, p.3 UNAIDS/Asia Pacific Inter-Country Team, 8 McCalman, J. s peer education an effective November, 1997) and information from Shik- strategy for providing HIV education to young Ku Lin Chief, department of Addiction people? Thesis for Masters of Public Health, Science, Taipei City Psychiatric Centre, University of Sydney, 1994, p.128 Taiwan. 9 Information provided by the Harm Reduction 10 Peak, Aaron Mission Report on Injecting Drug use program in Cebu, Philippines. Program for Save the Children Fund, March – 10 Report from the Australian Intravenous League April, 1996 (AIVL) AGM and Peer Education conference, 11 Information provided by the Harm Reduction Sydney, May 1995. Program in Cebu City, Philippines. 11 Interview with Ching Hangzo, (Manipur, 12 Peak, Aaron Mission Report on Injecting Drug use India), Chiang Mai, Thailand, May 1997. Program for Save the Children Fund, March – 12 Prazuck, T. Myanmar: reaching out to drug April, 1996 users in the community, AIDS/STD Health 13 Living with the Epidemic: A community responding Promotion Exchange (2) 1997. to AIDS in Churachandpur (Project of 13 Li Jiahua, Li Xialiang, Zhu Hua, Preliminary Emmanuel Hospital Association, India, Discussion of Harm Reduction for Drug Users in Macfarlane Burnet Centre for Medical Yunnan, 1996, unpublished. Research, Melbourne, Australia, AusAID) 14 Prazuck., op.cit. 14 Knuckey, S. Developing Appropriate Messages 15 Interview with Sujata Rana (LALS, Nepal), for Injecting Drug Users in Vietnam AHRN Chiang Mai, Thailand, May 1997. Newsletter, No.4, Jan/Feb 1996, p.3 15 Trautmann, F. & Barendregt, C. The European Peer Support Manual, Netherlands Institute on alcohol and Drugs, Utrecht, 1994. 16 Interview (1998) with Dr Jennifer Gray re: establishment of needle exchanges in three The Centre remote hill tribes in Thailand. for Harm 17 Information provided by the Harm Reduction Reduction program in Cebu, Philippines.

322 SECTION Contents > Section 2-C hapter 9 2 Chapter Six 26 Ibid., p.4. 1Reynolds, A. Training on Drug Dependence and 27 Reid, G. The Hidden Epidemic: A Situation Methadone Maintenance Treatment in Vietnam, Assessment of Drug Use in South East and East July 1996 (unpublished draft report), p.61 Asia in the context of HIV Vulnerability (prepared 2Gossop, M., Grant, M. Preventing and by the Asian Harm Reduction Network for the Controlling Drug Abuse, WHO, Geneva, 1990. UNAIDS/Asia Pacific Inter- Country Team), p.19 November 1997. p.71. 3 Ibid., p.20 28 Interview (unpublished) with Jimmy Dorabjee 4 Ibid., pp. 2 -5 (SHARAN, New Delhi), Chiang Mai, May 5 NSW Needle and Syringe Exchange Policy and 1997. Procedures Manual, Sydney, NSW, 1996, 29 WHO Drug Substitution Project, op.cit., p. 26 Section 4, p. 5 30 Dorabjee, J., Samson, L., Dyalchand, R., A 6 Reynolds, A. op.cit., p. 51 Community Based Intervention for Injecting Drug 7 HIV Prevention Among Drug Users: A Resource Users (IDUs) in the New Delhi Slums, WHO Book for Community Planners and Program Drug Substitution Project Meeting on Opioid Managers, Academy For Educational Substitution Programs in Asia, Kathmandu, Development (Centers for Disease Control and February, 1997. Prevention), US, June 1997, p.10 8 The Lindesmith Center, Focus on Drug Chapter Seven Substitution and Maintenance Approaches, 1 Aboagye-Kwarteng, T. & Moodie R., http://www.lindesmith.org Community Action on HIV: Resource Manual for 9 Cheung, Y.W., Ch’ien J.M.N. Drug Policy and HIV Prevention and Care (Macfarlane Burnet Harm Reduction in Hong Kong, presented at the Centre for Medical Research, International 7th International Conference on the Reduction Health Unit, Victoria, Australia, 1995) of Drug Related Harm, Hobart, Australia, 2 Stewart,G. (Ed) Managing HIV (Australasian March, 1996. Medical Publishing Company Ltd., North 10 Reynolds, A. op.cit., p. 19 Sydney, Australia, 1997) p.20 11 Ibid., p.3 3 HIV Herald Dec/Jan 1997, Volume 7, Number 12 WHO Drug Substitution Project: Meeting on Opioid 1 (AFAO Australian Federation of AIDS Substitution Programs in Asia, Kathmandu, Organisations, Sydney, NSW, Australia) Nepal, February 1997, (unpublished meeting 4 Shreedar, J. & Colaco, A. Broadening the Front report) p. 24 ACTIONAID, The British Council, UNDP, 13 Ibid., p.16-18 New Delhi, July 1996. 14 Ibid., p.24 5 Aboagye-Kwarteng et al, p.133 15 Ibid., p.20 6 Lin O.C. Hong Kong: Integrating HIV/STD 16 Ibid., p.22 issues into women’s other concerns. AIDS/STD 17 Reynolds, op.cit., p. 28 Health Promotion Exchange, 1995,No.3, p.9. 18 Ibid., p.23 7 Shreedar et al, op.cit 19 Reynolds, A., op.cit., p. 33 8 Ibid., pp.54-58 20 Report from Aaron Peak on the Methadone 9 AIDS: Images of the Epidemic (World Health Maintenance Treatment program in Vietnam, Organisation, Geneva, Switzerland,1994) p.57 July 1997 (unpublished). 10 Ibid., p.56 21 Dunlop, A, Thornton, D, Lintzeris, N. et al, 11 NGO, Indian Health Organisation, April Coming Off Methadone, Turning Point Alcohol 1997. and Drug Centre Inc, Victoria, Australia, 12 AIDS: Images of the Epidemic, op. cit., p.56 September 1996. p. 26 13 Ibid., p.60 22 Reynolds, op.cit., p. 35 14 Ibid., p.59 23 Ibid., p.37 15 UNAIDS. Report on the Global HIV/AIDS 24 Newman, R.G, Peyser, N. Methadone Epidemic 2002. www.unaids.org Treatment: Experiment and Experience, 16 UNAIDS. Report on the Global HIV/AIDS Journal of Psychoactive Drugs, Vol.23 (2), Apr- Epidemic 2002. www.unaids.org Jun 1991, p.117. 17 de Cock K. Fowler M, Mercier E, de Vincenzi I 25 A Few Notes on Methadone Programmes, et al. Prevention of mother to child HIV Spotlight, The Hong Kong Council of Social transmission in resource-poor countries. The Centre Service, Vol. 25, April 1996, p. 4. Translating research into policy and practice. for Harm JAMA 2000;283:1175-1182 Reduction

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18 de Cock K. Fowler M, Mercier E, de Vincenzi I 27 WHO/UNAIDS: HIV and Infant Feeding: et al. Prevention of mother to child HIV Guidelines for decision makers, June 1998; Manual for transmission in resource-poor countries. and WHO/UNAIDS: HIV and Infant reducing drug Translating research into policy and practice. Feeding: A guide for health-care managers and related harm JAMA 2000;283:1175-1182 supervisor, June 1998. in Asia 19 Shaffer N, Chuachoowong R, Mock PA, Bhadrakom C, Siriwasin W, Young NL, Chapter Eight Chotpitayasunondh T, Chearskul S, 1 The counselling section is largely based on the Roongpisuthipong A, Chinayon P, Karon J, Guidelines for Counselling about HIV Mastro TD, Simonds RJ. Short course Infection and Disease (WHO, Geneva 1990) zidovudine for perinatal HIV-1 transmission in 2. Mann, Tarantola & Netter AIDS in the World: Bangkok, Thailand: a randomised controlled A Global Report (Harvard University Press, trial. Lancet 1999;353:773 -80 Cambridge, Massachusetts, USA, 1992 ) p551 20 Guay L.A., Musoke P., Fleming T., Bagenda 3 Canadian Counselling Guidelines for HIV D., et al. Intrapartum and neonatal single-dose Testing nevirapine compared with zidovudine for 4 My experience with; A document describing prevention of mother-to-child transmission of people’s experiences and perceptions about the HIV-1 in Kampala, Uganda: HIVNET 012 HIV/AIDS epidemic from Thailand, the randomised trial. Lancet 1999;354:795-802 Philippines and Vietnam. UNAIDS, Bangkok, 21 European Mode of Delivery Collaboration. Thailand, May 1997, pp82-83 Elective caesarean-section versus vaginal 5 Lockley, P., Counselling heroin and other drug delivery in prevention of vertical HIV-1 users Free Association Books Ltd, London, transmission: a randomised clinical trial Lancet U.K., 1995 1999;353:1409-14 6 Mulleady, G Counselling drug users about 22 Nduati R., John G., Mbori-Ngacha D., HIV and AIDS (Blackwell Scientific Richardson B., Overbaugh J., Mwatha A., Publications, Oxford, U.K., 1992) p.33 Ndinya-Achola J., Bwayo J., Onyango E., 7 Interview with Sujata Rana (The Lifesaving & Hughes J., Kreiss J. Effect of breastfeeding and Lifegiving Society LALS, Nepal) Chiang Mai, formula feeding on transmission of HIV-1, a Thailand, May 1997. randomized clinical trial. JAMA 2000; 8 Canadian Counselling Guidelines for HIV 283:1167-74 Testing 23 WHO Collaborative Study Team on the Role 9Living with the Epidemic: A community of Breastfeeding on the Prevention of Infant responding to AIDS in Churachandpur., Mortality. Effect of breastfeeding on infant Macfarlane Burnet Centre for Medical and child mortality due to infectious diseases Research, Melbourne, Australia, December, in less developed countries: a pooled analysis. 1995. Lancet 2000; 355:451-455 10 Majoor B., Burn Through in Harm Reduction 24 Coutsoudis, A., Pillay K., Kuhn L., Spooner, Coalition Newsletter, Oakland, Cal., U.S.A,. E., Tsai W-Y, Coovadia H.M. Method of This section is based on Majoor, op. cit., feeding and transmission of HIV-1 from Truatmann F., Barendregt, C., The European mothers to children by 15 months of age: Peer Support Manual, Utrecht, 1994., and The prospective cohort study from Durban, South NSW Needle and Syringe Exchange Policy Africa. AIDS 2001;15:379-387 and Procedures Manual, NSW, Australia, 25 Berer M. Reducing perinatal HIV 1996. transmission in developing countries through 11 Majoor, B., op.cit., p16 antenatal and delivery care, and breastfeeding: 12 NSW NSEP, op.cit., Section 3., p.2 supporting infant survival by supporting 13 Living with the Epidemic: A community women’s survival. WHO Bulletin responding to AIDS in Churachandpur., 1999;77:871-76 Macfarlane Burnet Centre for Medical 26 UNFPA/UNICEF/WHO/UNAIDS Inter- Research, Melbourne, Australia, December, Agency Task Team on Mother-to-Child 1995. Transmission of HIV. January 15 2001. 14 NSW NSEP, op.cit., Section 3., p.3 www.unaids.org/publications/documents/mtct/ 15 Majoor , B., op cit., pp. 14-16 and Mulleady, The Centre index.html op.cit., p. 45 for Harm Reduction

324 SECTION Contents > Section 2-C hapter 9 2 16 Interview with Ching Hangzo (Manipur, 15 Fernandez, I. The Gender Element in India) Chiang Mai, Thailand, May 1997. Migration and HIV/AIDS, CARAM News, 17 Interview with Aaron Peak, Chiang Mai, Caram Asia, Kuala Lumpur, (2), October Thailand, May 1997. 1997, pp.2-3 (This is an edited version of 18 Manisha Singh (LALS, Kathmandu, Nepal) Fernandez’s article). 19 Interview with Aaron Peak, Chiang Mai, 16 HIV and Vulnerability, a media-aids bulletin Thailand, May 1997. from UNAIDS Asia-Pacific Intercountry Team, November, 1997. Chapter Nine 1 Benjamin, J. AIDS Prevention for Refugees: the Case of Rwandans in Tanzania AIDScaptions 3 (2) July 1996. 2 This section is based on Refugees and AIDS: Point of View UNAIDS Best Practice Collection, April 1997. 3 Dr Salam Irene, Imphal, Manipur, India. 4 Nemayechi, G & Taveaux, T. Medecin Sans Frontiers HARP (Harm Reduction Program) for the Vietnamese drug users in Pillar Point refugee camp, July 1996- April 1997. Evaluation Report. 5 Prisons and AIDS: Point of View UNAIDS Best Practice Collection, April 1997. 6 Excerpt from Aung Zaw HIV scare in Burma’s Insein, The Sunday Nation, 19 October, 1997. 7 Berer, M., Ray, S. Women and HIV/AIDS: An International Resource Book Pandora/Harper Collins Publ., London, U.K., 1993, p. 195 8 Australia and Thailand unite to promote the Travel Safe message, Installation Report for the Travel Safe Thai Pilot Program, Convenience Advertising (Aust) Pty Ltd, March 1994. 9 All Part of the Service, AIDS Action, Asia- Pacific Edition, (26) January-March 1995, HAIN (Health Action Information Network Philippines), p.10 10 Quote from a Hindi-speaking boy who telephoned for counselling from the NAZ Foundation, India. 11 Most of the information in this section is based on information provided by Anjali Gopalan from The NAZ Foundation (India) Trust. An HIV/AIDS and Sexual Health Service for the South Asian, Turkish, Irani and Arabic communities. 12 This is taken from a letter sent to Utopia: South East Asian Gay and Lesbian Resources and then passed on to SEA-AIDS. 13 Ignacio, J.L. Migration and HIV/AIDS, Keynote speech at the first Northern South-East Asian Subregional Exchange: Migrant Populations and HIV/AIDS, Chiang Mai, Thailand, 8-12 December, 1996. 14 Ibid., p. 5. The Centre for Harm Reduction

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Section 3 Appendices

3327 Contents SECTION

Appendices 3 Appendix One Chapter Blood Borne Viruses: Three Rapid situation Hepatitis A, B, C and assessments HIV/AIDS

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Hepatitis

When the liver is inflamed, bile can also Manual for What is hepatitis? leak from the liver cells. If severe enough, reducing drug this can cause jaundice, a yellow related harm Hepatitis means inflammation of the liver. discolouration of the skin, eyes and urine, in Asia Inflammation is the body’s normal response which vary from being minor to quite to an injury, regardless of the cause of the dramatic, depending upon the severity of the injury. For example, an inflamed hand can be liver damage. caused by an infection, a chemical agent, by sunburn and by many other agents (though the type of inflammation may vary with the Viral Hepatitis cause). Similarly, hepatitis can be caused by Viral hepatitis causes a flu-like illness with infections, chemicals and many other fever, nausea, loss of appetite, loss of weight diseases. The hepatitis is then named after and may be accompanied by jaundice. The the cause of the inflammation (e.g. alcoholic severity of the symptoms can vary hepatitis, hepatitis B etc). considerably, as does the time involved to When the liver is inflamed soon after the recover from the illness. Hepatitis A, B and injury, this is called acute hepatitis. The C is a viral hepatitis. liver may recover completely, or develop long term mild inflammation called chronic hepatitis. In some situations this may lead Hepatitis A Virus Infection to scarring of the liver called cirrhosis, which can be fatal. This form of hepatitis, also known as The liver is a large organ of the epidemic hepatitis, was recognised long gastrointestinal system in the upper before the discovery of the hepatitis A virus, abdomen and has many functions. One of the as it was distinguished from serum main roles is the removal of toxic substances hepatitis, which was recognised to be from the body by the liver cells, including transmitted mainly by blood borne spread. bile, a yellow substance that is a normal Hepatitis A virus causes a non-fatal hepatitis breakdown product of red blood cells. of varying severity. A person will make a One effect of an inflamed liver is that the complete recovery from hepatitis A virus, liver cells can become slightly more “leaky”, and there will be no long-term carrier and proteins that are only found in the liver state. Any person who has been in recent can leak into the blood stream. This is not contact with someone infected with hepatitis dangerous, but it does enable some simple A (that is within the previous one to two blood tests to measure the amount of these weeks) should see a doctor, as there is proteins, called the liver function tests treatment available to prevent the further (LFTs). Liver function tests then give the development of hepatitis, even after someone doctor an opportunity to assess the type and has been exposed to the hepatitis A virus. severity of the inflammation. Liver function tests do not tell the cause of the hepatitis, so Transmission & Prevention that other tests are necessary to determine The virus is excreted in the faeces, and can the cause of the inflammation. therefore be transmitted through eating or drinking contaminated food and drink, sexually transmitted (oral-faeces contact) and by close social contact among children. The Centre Hepatitis A can be prevented by washing for Harm Reduction hands before handling food.

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Hepatitis B Virus Infection Hepatitis C Virus Infection Appendix One Hepatitis B virus can also cause an illness of History Blood borne varying severity, with two major differences After the discovery of the hepatitis B virus, viruses from hepatitis A: many cases of serum hepatitis (hepatitis • Hepatitis B virus infection tends to be acquired from blood transfusions and more severe, with a longer illness recovery contaminated needles) that were due to time than hepatitis A and may even cause hepatitis B virus infection were occurring death. and earned the resulting name of non-A non •A small but significant number of people B hepatitis. will develop long-term disease and may It has long been recognised that many become infectious carriers of the hepatitis people with haemophilia who had received B virus (for life) and may develop long- multiple transfusions of blood products often term liver disease. had abnormal liver function tests. Investigation revealed the presence of mild Transmission inflammation of the liver (chronic Hepatitis B is transmitted by contaminated hepatitis), and infectious agents were blood products, using needles contaminated thought to be one of the other possible with blood, needle sharing, sexual causes. transmission (unprotected vaginal and/or In 1989, the hepatitis C virus was anal sex) and from an infected mother to discovered using modern genetic engineering child at the time of birth. The virus can only techniques and is one of the major enter the bloodstream through broken skin achievements of molecular biology. The or a mucous membrane. hepatitis C virus has never been seen or cultured Prevention Hepatitis C is now recognised as the Hepatitis B infection is prevented by safe sex, major cause of non-A non-B hepatitis and safe needle use practices and vaccination. In occurs world-wide. the developed world the blood supply is screened effectively for the presence of Transmission hepatitis B , though this remains a problem Transmission of hepatitis C is entirely by in developing countries. blood to blood transmission. Sharing of any injecting drug equipment is the most Vaccination is highly effective in common way of becoming infected. All preventing hepatitis A and hepatitis B injecting equipment – syringes, spoons, infection filters, water, tourniquet and swabs are high risks. There is very little conclusive information currently available about sexual transmission, but it appears that sexual transmission is more likely to occur in the presence of acute hepatitis C infection, and that the total risk of sexual transmission of hepatitis C virus appears to be very low. The risk from household transmission also appears to be The Centre negligible. for Harm Reduction

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The risk of transmission of hepatitis C The diagnosis of active hepatitis C Manual for infection from mother to child is unknown, infection is a complicated medical process reducing drug but appears to be around 10 per cent. If the and special tests at research facilities are related harm mother has hepatitis C infection, around one required to detect the virus. in Asia in ten children may acquire hepatitis C. A person may need to be followed for two There is an increased chance of hepatitis C years before the final diagnosis of ongoing virus passing from the mother to child if the liver disease (chronic hepatitis) is made. mother has severe hepatitis C; the opposite Research indicates that the presence of occurs if the hepatitis is very mild in the hepatitis C antibody is not necessarily related mother. The risks from breastfeeding are to abnormal liver function test. The unknown, but currently research is occurring investigations for liver disease are usually into this area. made by an infectious disease physician or a gastroenterologist. Diagnosis The diagnosis of exposure to the hepatitis C Treatment virus is made by the detection of a protein in Currently there is no vaccine available for the blood that the immune system makes hepatitis C. Treatments consist of avoiding after exposure to the virus called the any further damage to the liver and for some hepatitis C antibody. Antibody tests people the drug interferon is used. indicate whether the body has been exposed to the virus and has produced antibodies to Consequences of hepatitis C: fight it. •Twenty to twenty five per cent of adults The hepatitis C antibody test usually does recover completely: the virus has left their not become positive for two to three months system and they are no longer infectious. after exposure. This antibody test identifies Hepatitis C antibodies are retained most people infected with the virus. providing immunity from further However, the antibody test does not infections determine if a person still has the virus and • Seventy five to eighty per cent retain the for how long they have been infected. virus, remaining infectious for life •Estimated that twenty five per cent of The presence of hepatitis C antibody chronic carriers are at risk of developing DOES NOT necessarily mean that there liver cirrhosis or liver cancer is current disease for hepatitis C virus • Carriers remain free of illness until onset of liver problems The hepatitis C antibody has “false •Continued alcohol use in the presence of positives” and “false negatives”. (That is active hepatitis C infection appears to some people who have antibodies to hepatitis make any chronic hepatitis worse C detected may not really have been exposed • An expensive drug called Interferon is to hepatitis C infection, and also, that some currently being trialled as treatment, people who do not have hepatitis C with approximately half responding to antibodies may have been exposed to the drug. Following the discontinuation hepatitis C virus infection). of Interferon drug treatment, only half will continue to remain free of the virus.

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HIV/AIDS 3 aged 15-24 years, most live in the History developing world and mosr are not aware Appendix they carry the virus. At the beginning of the One The spread of Human Immunodeficiency HIV/AIDS epidemic, in the developed Blood borne Virus (HIV) commenced in the mid to late world, practically all HIV infections occurred viruses 1970s but is believed to have existed in in men. This is no longer the case as women Africa for many years. The first cases were are increasingly infected by HIV. recognised in central Africa but their deaths were blamed upon tuberculosis and other diseases. Epidemiological studies of HIV What is HIV ? disease began in 1981 following the first outbreaks in several US cities of a rare form HIV stands for Human Immunodeficiency of cancer, Kaposi’s sarcoma and Pneumocystis Virus. It is the name given to the virus that carinii pneumonia in homosexual men. By can cause AIDS. 1982, the Centre for Disease Control and As with all viruses, HIV depends on the Prevention (CDC), in Atlanta, US, defined cells it infects to multiply. However, unlike the new complexes of cancers and infectious many other viruses, HIV can remain conditions as Acquired Immune Deficiency permanently in the infected person as the Syndrome (AIDS): as the evolving genetic material of HIV integrates with the understanding of the advance manifestations genetic material of the host cell. HIV enters of HIV infection and diagnostic changes have and integrates itself with the control centre occurred, the CDCs AIDS definition has had of the CD4 cell resulting in a process that a few revisions. In 1983, the virus leads to the destruction of the CD4 cell. responsible for AIDS was identified in HIV is actively infecting and destroying France: originally named HTLV-III or LAV cells of the immune system and the obvious and then renamed HIV. Tests to check for effect is the decline in the blood levels of serological antibodies to HIV were developed CD4 and T4 cells: the immune system’s in 1984, allowing epidemiological principal infection fighters. During the investigations on people with AIDS or those initial stages, HIV destroys these cells with symptomatic or asymptomatic forms of without causing symptoms. As the immune HIV disease. system deteriorates complications begin to Global experience has shown that surface. For a brief period, HIV can survive although geography may delay the arrival of outside of the body and this is dependant HIV, it is not protective. The HIV/AIDS upon the fluid around the virus and the epidemic has, within the last two decades, temperature (HIV is destroyed at 56º Celsius). spread to over 190 countries in all continents. Five million people became newly infected with HIV in the year 2001. By the end of that year an estimated 40 million people world-wide were living with HIV; AIDS deaths in 2001 numbered 3 million. Since the beginning of the epidemic, more than 60 million people have been infected and globally it has become the world’s fourth biggest killer. It is estimated that most people living with HIV/AIDS are The Centre for Harm Reduction

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In the developing world TB, in Manual for Primary HIV infection association with HIV, is one of the most reducing drug important life threatening opportunistic related harm Following first exposure to HIV, viral infections. The WHO projects by the year in Asia reproduction is very high. Generally within 3 2000 the worldwide number of those months the body’s immune system is infected with HIV and TB will reach 4 activated, producing antibodies to HIV. This million. process is called sero conversion and some It was thought that for a while that the typical clinical symptoms can include fever, natural history of HIV infection was different enlarged lymph nodes, skin rash and in the developed as opposed to the headaches which usually last for 10-14 days. developing world, but this is largely The latency period occurs when the HIV discounted now. Of those with HIV infection infected person has no symptoms for months (untreated), after ten years 25 per cent will or years: an asymptomatic stage of HIV have developed AIDS and died; 25 per cent disease of 4-5 years is common. Although will be living with AIDS; 25 per cent will asymptomatic, HIV is actively infecting and have developed HIV disease but be short of killing cells of the immune system. Before progressing onto AIDS and 25 per cent will the onset of AIDS, some typical symptoms have no HIV/AIDS disease. can include lack of energy, weight loss, The period between exposure to HIV and frequent fevers and sweats and persistent skin signs of illness and the length of survival rashes. time for those with AIDS in the developing The rate of the HIV progression is world, is shorter. This is largely due to the dependent on the individual’s immune lack of antiviral drugs to treat HIV and other system to contain the virus and the confounding factors such as poverty, diet, replicating ability of the viral strain in the environment, lack of medical services, and infected individual. In time there is a prevalence of other infectious diseases decrease in the number of CD4 -T4 cells, the immunity system is damaged and vulnerability to infections occurs. Testing for HIV infection Tests for HIV infection are widely available. AIDS As early HIV infection often causes no symptoms, blood is tested for the presence of AIDS applies to the most advanced, serious antibodies (disease fighting proteins) to the stages of HIV infection. The majority of virus, not for the virus itself. HIV antibodies AIDS defining conditions are opportunistic are generally detectable within 1- 3 months infections, that rarely cause any harm to (window period) following infection. HIV those with good immunity. Opportunistic ‘antibody positive’ indicates that antibodies infections commonly occurring with AIDS to the virus have been found in the blood and cases are Tuberculosis, Pneumocystis carinii the person has become HIV infected. HIV pneumonia and cryptococcal meningitis. testing should be accompanied by Various cancers can develop such as Kaposi’s counselling, confidentiality and informed sarcoma or cancers of the immune system consent. (see Chapter 8: Voluntary HIV known as lymphomas. Counselling and Testing)

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Transmission Prevention of HIV/AIDS Appendix One • The most common transmission route is As no vaccine is available for HIV, the Blood borne by sexual contact with an infected principal way of preventing HIV infection is viruses partner. The virus found in semen, blood to avoid behaviours that place a person at or vaginal fluids enters the body through risk: e.g. sharing injecting equipment and the lining of the vagina, vulva, penis, having unprotected sex. rectum or mouth during unprotected sex. It is recommended that people use •Before the screening of blood for evidence condoms whenever having anal, vaginal or of HIV infection, and introduction of oral sex (when either partner has herpes, heat treating techniques to destroy HIV ulcers or bleeding gums) with someone they in blood products, HIV was transmitted are not certain is free of HIV or other through transfusions of contaminated sexually transmitted diseases. Condoms must blood or blood products. It is still a be used correctly and with water based common problem for those that do not lubricant. have blood donations screened before HIV transmission from mother to child is transfusion. significantly reduced if she takes the anti- • HIV is commonly spread among viral drug AZT (zidovudine) during injecting drug users by the sharing of pregnancy, labour and delivery and that the injecting equipment (needles, syringes, baby takes AZT for first six week of life. tourniquets, spoons, water, filters and (For injecting drug users see Chapter 4: surfaces) with someone infected by the Education) virus. HIV transmission from accidental needle stick injury from a patient to health worker with contaminated needles or medical instruments is rare. •Transmission from infected mother to baby during pregnancy or birth can occur. Risk of transmission ranges from 15 per cent to 50 per cent. Studies have shown HIV can spread to babies through the breast milk of a mother infected with the virus. • The presence of sexually transmitted diseases such as syphilis, herpes, chlamydia or gonorrhoea increase the susceptibility of someone to HIV infection during sex with an infected person. (see Chapter 7: HIV/AIDS: Preventing Transmission: • Through sex • Between Parent and Child)

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Bibliography

Aboagye-Kwarteng T and Moodie R (ed) Mullis KB. 1990. The unusual origin of the Manual for 1995. Community Action on HIV: A Resource polymerase chain reaction. Scientific reducing drug Manual for HIV Prevention and Care. American. April: 36-43. related harm Fairfield: Macfarlane Burnet Centre for Shilts R. 1987. And The Band Played On: in Asia Medical Research International Health Politics, people and the AIDS epidemic. Unit. London: Penguin Books. AIDS action Asia-Pacific edition. 1996. Stewart G (ed) 1997. Managing HIV. Sydney. Tackling HIV and TB. Issue 30 Jan- Australasian Medical Publishing. March. London: Health Action Watson K. 1991. Hepatitis C infection in Information Network Australia. Modern Medicine. July:18-31. Philippines/Appropriate Health Victorian Government Department of Resources & Technologies Action Group. Human Services. 1996. Management, Aegis: AIDS Educational Global Information Control and Prevention of Hepatitis C: System [ http://www.aegis.com ] Guidelines for Medical Practitioners. Australian Gastroenterology Institute. 1991. Melbourne: Victorian Government Hepatitis C: an information brochure for Department of Human Services. health care providers. September 1991. Victorian Government Department of Health Dixon P. 1994. The truth about AIDS. and Community Services. 1995. The ABC Eastborne: Kingsway Publication. of Hepatitis. Melbourne: AIDS/STD Unit, Fairley CK, Leslie DE, Nicholson S, Gust ID. Victorian Government Department of 1990. Epidemiology and hepatitis C in Health and Community Services Victoria. Medical Journal of Australia. 153:271-273. Gold J, Penny R, Ross M, Morey S Stewart G et al . 1994 (3rd edition). The AIDS Manual: Albion Street (AIDS) Centre. Sydney: Maclennan and Petty. Health and Community Services. 1995. AIDS: Your Questions Answered. Melbourne: Victorian Government, Department of Health and Community Services. Kaslow RA and Francis DP (ed). 1989. The Epidemiology of AIDS: Expression, Occurrence, and Control of HIV Type 1 Infection. New York: Oxford University Press. Mackay IR. 1990. The new hepatitis virus: hepatitis C virus. Medical Journal of Australia. 153:247-8. Mann J, Tarantola DJM and Netter T (ed). 1992. AIDS in the World: A Global Report. Cambridge: Harvard University Press. Mertens TE and Low-Beer D. 1996. HIV and AIDS: where is the epidemic going? Bulletin of the World Health Organization 74(2): 121-129. The Centre for Harm Reduction

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Appendices 3 Appendix Two Drugs and their Actions

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Heroin – Opium – Characteristics and Effects Characteristics and Effects

• First discovered by a British chemist in • The sole source of opium is the opium Manual for 1874, heroin or diacetylmorphine is a bond- poppy (Papaver somniferum). The reducing drug ing of opium’s active ingredient, mor- psychological and healing effects of related harm phine (obtained from the opium poppy), opium have been known for around 4,000 in Asia with a common industrial acid, acetic years. anhydride. By the end of the 19th century • By incising the head of the opium poppy, it was being mass produced as a broad farmers can extract its sticky brown sap spectrum pain killer. It was previously from the egg shaped bulb. The raw believed to be a “safe, non addictive” sub- opium sap contains 7-15 per cent stitute for morphine. morphine, which easily can be • Induces high physical addiction and precipitated from the poppy sap after lasting psychological dependence. simple boiling. Raw opium has a •Administered by injection, sniffing characteristic odour which is strong and (snorting), or smoking. pungent. • Depending on availability of drug and • Opiate receptors in the brain induce high finances of user, drug is commonly physiological addiction and lasting injected about three times a day (every psychological dependence. Regular use eight hours). results in increased tolerance and the need •Effects last from three to six hours. for greater quantities of the drug. •Common behaviour following adminis- • Use of opium in Western countries has tration include an intense feeling of decreased substantially but it is still euphoria and sleepiness soon after injec- widely used among highland ethnic tion, lethargy, docile appearance and pos- minorities in China, Laos, Cambodia, sibly a shuffling gait. Myanmar, Thailand and Vietnam both for • Acute withdrawal symptoms commence recreational and medical purposes. within 8 to 12 hours after last dose. • Can produce intense euphoria, a •Withdrawal symptoms are generally not heightened state of wellbeing, enhanced life threatening but they can be very imagination and speech. Soon after, distressing. Symptoms include respiration slows down, imagination gastrointestinal discomfort, muscle diminishes and the thinking process cramps, and flu- like symptoms. becomes confused. Lethargy, relaxation Withdrawal symptoms can be severe and deep sleep usually follow. enough that when the users obtain • Administration is usually by smoking but heroin, they may inject as rapidly as it can also be chewed and cooked with possible, sometimes without concern for food for digestion. Particularly in possible HIV, hepatitis B (HBV) and countries of origin, it can be drunk as an hepatitis C (HBC) risks. infusion. • Associated health problems of long term • An opium pipe has a long thick stem heroin use can be collapsed veins, with a bowl at one end. The opium abscesses, tetanus, HIV/AIDS, hepatitis B ‘pellet’ is placed into the bowl , heated (HBV), hepatitis C (HBC), heart, chest and the smoke is inhaled. and bronchial problems and constipation. Possible overdose can occur with or without long term use.

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Cocaine – Characteristics and Effects 3 • Sediment or the ‘dross’ left in smoking • Inhabitants of South America have a implements can contain up to 8 per cent history of chewing of the coca leaf for Appendix morphine, is often used again and is thousands of years but it has only been Two known as blackwater opium. This form of known to the Europeans since the 19th Drugs and opium still remains popular in particular century. The coca leaf effects a number of their actions Asian countries i.e. Vietnam, Cambodia. neuro-transmitter systems in the brain •Smoking puts more of the active and is active on various anatomical sites ingredients of opium into the blood within the central nervous system. stream faster, by the way of the lungs, so • Cocaine is produced by chemical the drug begins to reach the brain in processing and treatment of the coca about 7 seconds. plant which transforms the leaves into • Long term use results in decreased mental coca paste. Paste is treated with and physical capacities with loss of hydrochloric acid to remove impurities appetite and body wasting. and results in white, crystalline substance, •Withdrawal symptoms, similar to those cocaine hydrochloride. of morphine, include agitation, • It is the most potent of the stimulants. irritability, anxiety, restlessness, insomnia, •In the form of leaf chewing or brewed tea and abdominal and muscle pain. the drug is believed to be virtually harmless but it is rarely available in this form outside of South America. •Disagreements exist among authorities and researchers as to the addictive nature of cocaine. While some state there is a high risk of developing physical and psychological dependence, many researchers suggest that cocaine does not produce physical dependence. • Methods of administration include snorting by intranasal inhalation (onset of effects 2-4 minutes); smoking or “freebasing” (burning the crystals and smoking the vapours; onset of effect 10- 15 seconds); and injection (onset of effect 15-20 seconds). •Effects can last from 10 to 40 minutes depending on the purity and the route of the administration. •Typical behaviours during the effect include hyperactivity, exhilaration, increased energy, alertness, confidence and sexual activity. The user may also have unpredictable behaviour, feel invincible and be both quarrelsome and aggressive. •A fatal condition can result from high sensitivity to the drug or massive overdose. The Centre for Harm Reduction

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Cannabis – Characteristics and Effects

• Several hours after last use, feelings of • Cannabis is a psychotropic product from Manual for agitation and depression can occur. the plant Cannabis sativa. It is believed to reducing drug • High risk of HIV transmission through have been used for thousands of years for related harm multiple injections with previously used medical, religious and social reasons. The in Asia injecting equipment and through stem of the plant (non potent form of unprotected, prolonged sexual cannabis) is used in the manufacture of intercourse. hemp rope, string, paper, textiles and clothing. • There are male and female plants. The strongest concentration of the psychoactive chemical, Tetrahydrocannabinol or THC, is found in the flowering shoots of the female plant. •Awidely used drug with a relatively low potential for harm when compared to heroin, alcohol and tobacco. • Differing views by authorities on physical dependency of cannabis. Psychological dependency can be associated with frequent cannabis use. • Three forms of cannabis exist: marijuana, hashish and hashish oil. Marijuana is the dried leaves and flowers of the plant and is usually the least potent of the three. Hashish forms as a sticky oil coating on the flowering tops of the plant which is collected and made into small blocks of dried resin. The concentration of THC is greater thus producing a stronger effect. Hashish oil is the extraction from the resin of the cannabis plant and is the most powerful of all the cannabis forms. •Marijuana is usually smoked in hand rolled cigarettes or in a pipe. The concentrated form of hashish, or hashish oil, is often smoked with ordinary cigarettes or incorporated into food substances such as cakes and biscuits and ingested.

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Amphetamine – Characteristics and Effects 3 •Effects vary due to a number of factors in • Originally synthesised in Germany in the relation to the person, method of late 19th century amphetamines were not Appendix administration, cannabis form and patented until the 1930s. In the 1940s Two frequency and period of use. Some effects the drug came into therapeutic use for a Drugs and can include euphoria, relaxation, relief variety of medical conditions such as their actions from stress and pain, increased appetite, epilepsy, depression and hyperkinetic impaired motor skills, confusion, loss of children. Following World War II, concentration and decreased motivation. amphetamines were promoted quite •Effects normally reach their peak within readily. 30 minutes and can last up to 3 hours. • Amphetamines have a stimulant action •Withdrawal following long term use can similar to the naturally occurring include headaches, anxiety, depression, hormone adrenalin which stimulates the and sleep disturbance. activity of the central nervous system and • Like other burnt inhalations cannabis increases the activity of the brain. contains carcinogens, tar and carbon • Amphetamines appear in a number of monoxide. This can result in respiratory forms and when manufactured illegally complications, cardiovascular effects and can be found in powder, tablet, capsules cancer. A single cannabis cigarette or liquid. contains the same amount of tar and other • Administration is by ingestion, injection, noxious substances as approximately 14- inhaled through the nose and smoked 16 filtered cigarettes. when in the form of methamphetamine hydrochloride. • Most common illicit manufacturing of amphetamine is in the form of methylamphetamine. The most common starting material for methylamphetamine is ephedrine, which is a legal substance, is readily available in tablets or capsules and is sold as a decongestant. •Self medication with amphetamine is common among truck drivers, students, fishermen, and businessmen to stave off normal fatigue, enabling them to work for days with little sleep or food. •Effects usually wear off after 3 to 6 hours and the user can become suddenly tired, irritable, depressed and unable to concentrate. Methylamphethatamine ‘ice’ when smoked can have an effect of between 2 to 16 hours depending on the amount taken. •Effects from amphetamines vary and depend on dosage, mode of administration, the individual, and the circumstances in which the drug is taken. The Centre for Harm Reduction

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Ecstasy or Methylenedioxymeth- ampthamine (MDMA) – • Low doses can result in a sensation of Characteristics and Effects Manual for euphoria, heightened alertness, increased reducing drug energy and activity, reduced appetite and •Although first patented in Germany in related harm self confidence. Long term use can lead to 1914 as an appetite suppressant, it was in Asia malnutrition, exhaustion, depression and never marketed. In the 1970s it was used psychosis. Death from stimulant use is by psychiatrists in the USA as a valuable rare but is more likely to occur with and safe aid to counselling and therapy, intravenous injection. until it was banned in the mid 1980s. In •Tolerance can be pronounced where a the 1990s it is commonly associated with long time user may need 20 times the dance parties and other social activities. initial dose to produce the same effect. •Closely related to both amphetamines and •Has a reputation for facilitating social and hallucinogens it is often described as a sexual interactions which has implications psychedelic drug with stimulant for potential HIV risks as enhanced properties. sexuality may not be accompanied by • Appears as tablet (most frequently seen), safer sexual practices. capsule and powder form. •Withdrawal symptoms during the initial •Preferred administration is by swallowing period may be acute exhaustion, and for a although there are reports of regular user, it may be followed by experimentation by injection and irritability, lethargy, deep depression, inhalation. anxiety attacks and episodic craving. •Taken orally the effect will commence between 30 to 60 minutes and may last for several hours. • The immediate effects can be a ‘rush’ of euphoria, followed by a general sense of peacefulness and heightened sensual awareness. Inhibition can disappear, there is increased self esteem and confidence, and improved trust and communication between friends can occur. Adverse effects can include dry mouth and throat, jaw clenching, increased heart rate and blood pressure. • Overdose can result from very high blood pressure, increased heart beat and body temperature (overheating). Deaths have been reported from fluid imbalance either by dehydration or water overloading. •A ‘high’ can be followed with fatigue, anxiety and a depression which may last several days. •Tolerance can develop with continued use and some dependence is thought to occur. Little is known about long term effects but it has been suggested that it may damage some type of brain cells. The Centre for Harm Reduction

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Hallucinogens – Characteristics and Effects 3 • First synthetically produced in the 1940s feelings of being invincible resulting in a to remove obstructive inhibitions in person physically placing themselves in Appendix psychiatric cases. Those derived from danger. Two plants, such as the peyote cactus, have • Long term use can result in flashbacks of Drugs and been used by indigenous groups of hallucinogenic effects, days, weeks or their actions Mexico for hundreds of years for months after using the drug. recreation and religious observations. • There is no evidence of physical •Hallucinogens also known as dependence and no withdrawal symptoms psychedelics, act on the central nervous have been observed even after prolonged system to produce significant, often use. However, psychological dependence radical, changes to the user’s state of can occur. consciousness; can distort the user’s sense •Tolerance to LSD can develop rapidly but of reality, time and emotions. tolerance can also disappear after 5-6 days •Lysergic acid diethylamide (LSD) is the when not used on a regular basis. best known of hallucinogens. It is a • Other hallucinogens include mescaline synthetic drug based on an ergot which (natural product from the peyote cactus) has been extracted from a dry fungus that nutmeg, particular mushrooms grows on rye grass. The manufacturing of (containing the drugs psilocin and LSD from precursor drugs requires a high psilocybin) dimethyltryptamine (DPT), level of technical knowledge and phencyclidine (PCP) and ketamine expertise. hydrochloride. • LSD is an odourless, colourless and tasteless liquid which is often absorbed into any suitable substance such as blotting paper and sugar cubes or can be incorporated into a tablet, capsule or occasionally confectionery. Its most popular form is on absorbent sheets of paper which are then divided into squares and taken orally. •Unlike many other drugs, LSD users can have little idea of what they are embarking on and the effects can vary from person to person, from occasion to occasion and the dose. •Effects can begin within an hour of the dose, build up between 2 – 8 hours and slowly fade after about 12 hours. • For many LSD users the effect can be extremely enjoyable, relaxing and promote a sense of wellbeing. There are often changes in perception, of sight, sound, touch, smell, taste and space. Negative effects can include loss of emotional control, disorientation, depression, dizziness, acute panic and The Centre for Harm Reduction

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Nicotine /Tobacco – Characteristics and Effects

•Known to be used by Native Americans •Withdrawal, after long term use can Manual for in religious and social occasions 1,000 result in headaches, severe irritability, reducing drug years ago. Introduced to Europe in the inability to concentrate, nervousness and related harm 17th century where it was used for sleep disturbance. Nicotine craving may in Asia recreation and medicinal purposes. last a lifetime after withdrawal. Tobacco consumption expanded with the • For the very physically dependent, introduction of milder forms of tobacco, nicotine patches are provided in a automatic cigarette rolling machines, relatively harmless form avoiding the massive advertising campaigns and when injurious affects of tobacco smoke such as governments saw its potency as a source carbon monoxide, tar, soot and other by- of revenue. products. •Nicotine, found in tobacco, is one of the most addictive substances known. Nicotine is a central nervous stimulant that disrupts neuro transmitter balance. Physical dependence on nicotine and more importantly, psychological dependence on cigarettes, develops quickly. •Tobacco inhalation results in nicotine affecting the central nervous system (CNS) in about 10 seconds. With the chewing of tobacco, it takes about 3 to 5 minutes to affect the CNS. • The effect of nicotine when tobacco is consumed in the form of smoking, chewing or as snuff is the constriction of blood vessels, raising of the heart rate, and blood pressure, decreased appetite, producing mild emphysema, partially deadens sensation of taste and smell and irritates the lungs. Prolonged use of tobacco can cause lung, heart, blood vessel damage and cancer. • The World Health Organization estimates that smoking is responsible for 1 out of 5 deaths, or 3 million per year. Research has shown that over 50 per cent of smokers will die prematurely as a direct result of tobacco induced illnesses. •Tolerance to the effects of nicotine develops rapidly, faster than that of heroin and cocaine.

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Solvents, Inhalants and Alcohol – Volatile Substances – Characteristics and Effects 3 Characteristics and Effects • The most commonly used psychoactive • Since ancient times people have inhaled drug in the world and the oldest known. Appendix the vapours of perfumes, ointment and Historical references abound in literature, Two burning spices as part of their religious religion and science about alcohol, its Drugs and ceremonies. Solvent misuse, as we know effects and its consequences. their actions it, emerged during the 1950s in the USA • The production of alcohol results from a and has since spread to most parts of the process of fermentation, in which water world. and yeast act on the various sugars of • Three main types of inhalant are organic various types of grains, vegetables and solvents, volatile nitrates and nitrous fruit. The psychoactive drug that is oxide. produced is ethyl alcohol. • Some of the most common inhalants • As a depressant drug, alcohol slows down include glue, aerosol spray cans, paint the activity of the central nervous system thinner, petroleum products, chrome and in small doses can result in people based paint, felt pens. being relaxed with inhibitions being • Inhalation is either through the mouth or lowered. As the depressant effect takes nose. Often the product can be sprayed over, it can slow reflexes, depress into a plastic bag or soaked onto a rag and respiration and heart rate and disrupt then inhaled or it is inhaled directly from reasoning and judgement. the container. •Heavy drinkers usually develop a • Inhalants are absorbed through the lungs tolerance to alcohol and need to drink into the blood stream, which then carries more to experience the same effect. the chemicals rapidly to the brain. They • The long term effects of alcohol on the slow down the activity of the brain and body, following heavy drinking over a central nervous system. long period of time, are extensive. These • Intoxicating effects are often quick acting can include higher blood pressure, (7 to 10 seconds), intense and short lived enlarged heart, cirrhosis of the liver, liver lasting no more than 30 to 60 minutes swelling and pain, skin bruising, stomach (some inhalants only last 2 minutes). and intestinal ulcers, muscle weakness, •Effects can include excitement, dizziness, loss of memory, loss of sensation in feet stupor, disorientated and uncoordinated, and hands and foetal damage if pregnant. visual disturbance and slurred speech. • Behavioural problems are commonly Prolonged use, particularly leaded linked to alcohol. Some problems can petroleum products, can lead to brain, include family violence, work liver, kidney, and especially lung damage. absenteeism, motor accidents, legal Death can arise from respiratory arrest problems and fines associated with and cardiac irregularities. violent assaults and financial difficulties. •Organic solvents are often readily • Regular drinking can result in available, inexpensive and are commonly psychological and physical dependency. used by young people in their first few •A physically dependent person will suffer years of secondary schooling. withdrawal symptoms that can include loss of appetite, irritability, confusion, inability to sleep, cramps, tremors, hallucinations and even death due to seizures. The Centre for Harm Reduction

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Benzodiazepines – Characteristics and Effects

• Addiction to alcohol is a chronic • This class of synthetically based drugs Manual for progressive disease that is distinguished was developed in the late 1940s and reducing drug by lack of control over drinking, 1950s as an alternative to barbiturates. In related harm preoccupation with alcohol use despite the West they came into wide clinical use in Asia adverse consequences and denial. If not in the 1960s and the 1970s. The drugs controlled it can be fatal. While were looked upon as an innovation in the alcoholism can take years to develop the treatment of anxiety disorders and recovery period can take a lifetime. sleeping problems. •Benzodiazepines is a chemical group term which are classified as sedatives or tranquillisers. This ever increasing number of drugs include Temazepam, Diazepam, Nitrazepam, Oxazepam, Clonazepam and Flunitrazepam. •Benzodiazepines combine with certain parts of the nerve cells in the brain to enhance inhibitory mechanisms. They induce a state of calmness, slowing down physical, mental and emotional responses. When given in large doses they will induce sleep. • Administration is usually in tablet, capsule or liquid form. It is usually taken orally or by injection. The calming effect is evident in about 45 minutes and some degree of sedation can persist for 24 hours. • Adverse side effects can include lethargy, confusion, mood swings, nausea, dizziness, disturbing dreams, and slurred speech. The over prescribing or individual misuse of such drugs can result in increased anxiety, irritability and hostility. Mixed with other drugs they can reduce judgement of time, space and distance and combined with alcohol can result in death. •After a high dose continued for about 2 months or a low dose taken for a year or more, withdrawal can be extremely severe and prolonged. Feelings of craving for the drug, anxiety, sleep disturbance and possible hallucinations can occur. Withdrawal symptoms can erratically come and go in cycles separated by 2 to 10 days and may persist for several The Centre for Harm months after the drug has been stopped. Reduction

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Anabolic Steroids – Characteristics and Effects 3 •Performance enhancing drugs have been • Physical addiction is not believed to occur documented throughout human history. but some users do become psychologically Appendix In the 1920s, testosterone (male hormone) dependent, believing their physical and Two was isolated and by World War 11 it was sporting achievements will be reduced Drugs and being administered to troops to overcome without them. their actionss fatigue and injuries. Since the 1950s, •Withdrawal symptoms can include severe testosterone has been synthetically depression, insomnia, lethargy, loss of produced and its use was soon associated appetite, headaches and craving for with athletic performance. anabolic steroids. • Anabolic steroids are a group of synthetic compounds which are structurally related to the natural male hormone testosterone. They produce anabolic activity (greater muscular bulk resulting in increased muscular strength) by increasing protein synthesis and androgenic activity (enhanced secondary sexual characteristics). •Administration is by intravenous or intramuscular injection and by the oral route. • Injectable forms are designed to be longer acting than orals and are released slowly over time. The high rate of administration via injection has raised the concern and risk of HIV, hepatitis B and hepatitis C. •Primarily taken to increase muscle mass, they can also allow a user to train harder, promote a quicker recuperation phase and increase the healing process for some types of injuries. • Early effects can include increased confidence, energy, enhance motivation and enthusiasm, increased aggression and sexual appetite. Larger doses can result in a loss of inhibition, lack of judgement and mood swings. Prolonged users frequently become quarrelsome and aggressive. Severe prolonged use can result in heart disease, liver damage, mental disorders and violence.

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Methadone – Characteristics and Effects

• German chemists first produced • Methadone can lead to dependence but it Manual for methadone in the early 20th century and is generally considered less serious than reducing drug it has been used clinically since the end of heroin and morphine dependence and is related harm World War 1. easier to treat. People can come off using in Asia • It is a powerful synthetic opiate like methadone by reducing their dose heroin and morphine but without the gradually, by not setting a time to achieve strong sedative effect. It can substitute for this goal, and by consulting the heroin and is widely used by doctors in counsellor /doctor involved in the the treatment of heroin addiction. methadone program about what is • In its basic form it is a white crystalline involved. powder. It is generally administered as a •Sudden withdrawal is not recommended syrup, mixed with cordial or fruit juice as the discomfort encountered can result and taken orally. Methadone is also in people using heroin again regularly. available in an injectable form. Users have been known to inject the syrup often resulting in health problems. •Effects are felt within 1 hour of a dose, with the peak effect felt at 4 to 8 hours after the dose. The effects of methadone last longer (usually up to 24 hours) than heroin and therefore administration is usually once a day. •Doses vary for different people and from the commencement of treatment the dose is gradually increased while observing the level of tolerance and avoiding the onset of heroin withdrawal. Once treatment has stabilised, daily dosages can vary from 40mg to >100mg of methadone. •If the dose is too low opiate withdrawal can occur resulting in symptoms such as abdominal cramps, nausea and vomiting, irritability and back and joint ache. Too high a dose can be indicated by such symptoms of drowsiness, nodding off, shallow breathing and pinpoint pupils. •Other side effects that can occur but are unrelated to the dose can include, sweating, constipation, aching muscles and joints, decreased sex drive, fluid retention, loss of appetite and tooth decay.

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References 3 Miller S N (ed). 1991. Comprehensive Handbook Australian Bureau of Criminal Intelligence. of Drug and Alcohol Addiction. New York: 1996. Australian Illicit Drug Report 1995- Appendix Marcel Dekker Publications. 96. Canberra: Australian Bureau of Two Marnell T (ed). 1995. Drug Identification Bible. Criminal Intelligence. Drugs and Denver: Drug Identification Bible Health and Community Services. 1995. their actions Publications. Methadone Treatment in Victoria: User Stockly D. 1992. Drug Warning: Illustrated Information Booklet. Victoria: A Public Guide for Parents, Teachers and Employers. Health Branch Publication. London: Optima Books. Stafford P. 1992. Psychedelic Encyclopedia. Berkley: Ronin Publishing. Inaba D S and Cohen W. 1993. Uppers, Downers, All Arounders: Physical and Mental Effects of Psychoactive Drugs. Oregan. CNS Publishing. Commonwealth Department of Health, Housing, Local Government and Community Services. 1993. Handbook for Medical Practitioners and other Health Care Workers on Alcohol and other Drug Problems. Canberra: Australian Government Publishing Service. Gossop M and Grant M (ed). 1990. Preventing and Controlling Drug Abuse. Geneva: World Health Organization. Australian Drug Foundation. 1995. How Drugs Affect You: Alcohol (pamphlet). North Melbourne: Australian Drug Foundation. Australian Drug Foundation. 1995. How Drugs Affect You: Amphetamines (pamphlet). North Melbourne: Australian Drug Foundation. Australian Drug Foundation. 1995. How Drugs Affect You: Inhalants (pamphlet). North Melbourne: Australian Drug Foundation. Australian Drug Foundation. 1995. How Drugs Affect You: Hallucinogens (pamphlet). North Melbourne: Australian Drug Foundation. Australian Drug Foundation. 1995. How Drugs Affect You: Cannabis (pamphlet). North Melbourne: Australian Drug Foundation.

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Appendices 3 Appendix 3 Sexually transmitted infections

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Introduction

Manual for reducing drug STIs are a serious public health problem across Asia. Unless treated early, related harm they can lead to serious complications and sequelae, including male and in Asia female infertility, sudden life-threatening internal bleeding (e.g. ectopic pregnancy), damage to the brain and other internal organs, stillbirth, and an increased risk for HIV transmission.

In most developing countries, the World Health Organization has recom- mended that STIs be managed by using a ‘syndromic approach’. This means that the diagnosis and management is based on the symptoms and signs that commonly cause people with STIs to seek care from a clinic.

The most common symptoms and signs can be grouped into ‘syndromes’ for which the most common causes are already well known from previous research. Since many presenting syndromes are caused by more than one infection at a time, more than one drug is often required to manage the common causes of each syndrome. Additionally, the best drugs for treat- ing the STIs are also known from research - this makes sure that STI germs that are resistant to some antibiotics are treated with drugs that still work well.

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352 SECTION Contents > Section 3-Appendix 3 3 The most common syndromes are: There are also some disadvantages of the •urethral discharge approach, including: Appendix • vaginal discharge •Many people will receive drugs that they Three • genital ulcers did not really need (over-treatment). This Sexually • lower abdominal pain in women adds to costs and can cause possible drug transmitted • inguinal swelling (or bubo) reactions. infections • scrotal swelling • Low-risk women with vaginal discharge • neonatal conjunctivitis (Ophthalmia are unlikely to have an STI but since neonatorum). there is no simple way to diagnose whether they have one, many are over- Most countries in Asia have national treated. guidelines for managing STIs and, generally, • Contact tracing can be challenging when they follow the syndromic approach and the diagnosis is uncertain. provide simple flowcharts and clinic wall •Most STIs in women and many men do charts to help health workers follow the not cause symptoms and thus are not guidelines. addressed by the syndromic approach.

Advantages of the syndromic approach include: • It focuses on common STIs of public health importance. • It does not depend on laboratory support. • It allows for standardised clinical management, including drug selection, patient education to ensure adherence (compliance), counselling, contact tracing (also called partner notification or management) and demonstration and provision of male and female condoms and water-based lubricant. • It allows for STIs to be managed at first visit in a primary health care setting. • Multiple infections are treated at the same time. • Different types of health workers (i.e. doctors, nurses and others) can all follow a standard and effective system - this also helps standardise training and supervision.

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Gonorrhoea

If it is not treated early, it can develop Manual for Epidemiology into a scrotal swelling in men or lower reducing drug abdominal pain in women. related harm Caused by infection with Neisseria gonorrhoea, Transmission from a mother to her baby in Asia occurs worldwide, affecting both sexes and can present as neonatal conjunctivitis. practically all ages, especially younger adult groups. Drug resistant strains are now common worldwide. Untreated patients may be infectious to others for several months. Chlamydia Infected with chlamydia at the same time is (non-gonoccal urethritis) not uncommon.

Epidemiology Symptoms and signs Between 35 per cent and 5o per cent of cases The infection can be asymptomatic in both of non-gonococcal urethritis are thought to sexes. In males, a thick white or yellow be caused by Chlamydia trachomatis, which discharge from the urethra occurs 2-10 days occurs commonly worldwide. In women it after infection. There is usually pain during can cause mucopurulent cervicitis but urination. In people who practise anal sex, infection is more commonly asymptomatic. there may be a rectal discharge. Repeated infections of chlamydia are a very In females, the symptoms are often mild common cause of chronic pelvic and may pass unnoticed. There may be inflammatory disease and infertility. discomfort on urination, a mild discharge, Transmission is by sexual intercourse, and some irritation in the vagina. Chronic occurring in both sexes and all ages, infection is common and may lead to especially young adults. infertility. Newborn children infected with gonorrhoea have red and swollen eyes, with a Symptoms and signs thick discharge, within 1-5 days after birth. Quite similar to gonorrhoea; however, many Blindness may occur if specific treatment is infected women may be asymptomatic. not given promptly. Complications of infertility in women are Diagnosis is by direct microscopic also common. Eye infections may occur in infection examination of a gram-stained babies born to infected women. Diagnosis is smear taken from the discharge, or by usually based on failure to demonstrate the culture. presence of gonococci in a cervical or urethral smear or culture. It may be confirmed by examination of smear material with test for Which syndrome? chlamydial antigen. Remember that co-infection with chlamydia is common. In men, gonorrhoea is a common cause of urethral discharge, and a less Which syndrome? common cause of vaginal discharge in Remember that co-infection with gonorrhoea women. is common. In men, chlamydia is a common The Centre cause of urethral discharge, and a less for Harm Reduction

354 SECTION Contents > Section 3-Appendix 3 3 common cause of vaginal discharge in may include severe central nervous or women. cardiovascular system disease, causing Appendix If it is not treated early, it can develop disability and premature death. The Three into a scrotal swelling in men or lower laboratory diagnosis is usually made by Sexually abdominal pain in women. seriologic tests of blood or cerebrospinal transmitted Transmission from a mother to her baby fluid. infections can present as neonatal conjunctivitis.

Which syndrome? Syphilis Early syphilis usually presents as a genital ulcer. Remember that co-infection with other STIs (e.g. herpes and chancroid) is common.

Epidemiology

Caused by Treponema pallidum which is a Chancroid spirochete (bacteria); occurs worldwide, primarily in young adults 20-25 years of age. More prevalent in urban areas; there has been a recent increase in incidence in some Epidemiology industrialised countries associated with Caused by Haemophilus ducreyi, a bacterium. illegal drug use and prostitution. Most prevalent in tropical and sub-tropical Transmission occurs through direct contact regions of the world; more frequently seen in with early lesions (ulcers) of skin and mucous men. Chancroid lesions are highly infectious. membranes or with body fluids (semen, blood, vaginal discharge) during sexual contact. Transmission may occur by blood transfusion if the donor is in the early stage Symptoms and signs of infection. Infection may be transmitted Characterised by acute, painful genital ulcers, from an infected mother to the unborn child usually single, <-1cm in diameter. They – an important cause of still birth in endemic usually appear 3-5 days after exposure, with areas. painful swelling of local lymph nodes. Chancroid is more commonly asymptomatic in women. Diagnosis may be confirmed by Symptoms and signs culture of fluid from a lesion. A primary lesion occurs a few weeks after exposure; this is a painless ulcer at the site of original contact (penis, cervix, rectum, Which syndrome? pharynx). The organism enters the Chancroid usually presents as a genital ulcer, bloodstream and a secondary stage occurs often with an inguinal swelling (bubo). within 1-3 months, consisting of a Remember that co-infection with other STIs widespread rash and enlarged lymph nodes. (e.g. herpes and syphilis) is common. After a latency period of 5-20 years with few or no symptoms, the tertiary stage of syphilis The Centre for Harm Reduction

355 Contents > Section 3-Appendix 3

Lymphogranuloma Trichomonad Infections Venereum

Manual for Epidemiology Epidemiology reducing drug Caused by different variants of Chlamydia A common, persistent infection of the female related harm trachomatis from those that cause urethritis genito-urinary tract, caused by the protozoa in Asia and cervicitis: occurs world wide but more Trichomonas vaginalis. Occurs worldwide, common in tropical and subtropical regions. mainly diagnosed in women 16-35 years of Less commonly diagnosed in women; age. however, this may be due to a higher rate of asymptomatic infections in women. Symptoms and signs Symptoms and signs In women, causes inflammation of the vagina with a profuse, yellow, foul smelling A small painless lesion on the genitalia (often discharge; however, the infection is often not noticed) is followed by severe, painful asymptomatic. The majority of infected men swelling of the lymph nodes and surrounding have no symptoms; in a small number, there tissues between 5-30 days after initial are symptoms of urethritis. Diagnosis is exposure. Diagnosis is made by culture of made by microscopic examination of fluid from a lesion or demonstration of the discharge and identification of the parasite. organism by an antigen test.

Which syndrome? Which syndrome? Trichomoniasis usually presents as a vaginal LGV sometimes presents as a genital ulcer discharge. Remember that other causes of but more commonly as an inguinal swelling vaginal discharge are sometimes difficult to (bubo). Remember that co-infection with distinguish from trichomoniasis (e.g. other STIs (e.g. syphilis, herpes and bacterial vaginosis and candida) and that chancroid) is common. cervicitis caused by gonorrhoea or chlamydia is also a cause of vaginal discharge.

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356 Contents > Section 3-Appendix 3 SECTION

Genital Herpes Anogenital Warts 3

Epidemiology Epidemiology Appendix Usually caused by herpes simplex virus type These warts are found in the genital area or Three 2 (HSV-2); occurs worldwide and type 2 in and around the anus, and occur Sexually antibody is found in 20 per cent-90 per cent worldwide. As with other STDs they may be transmitted of adults. The frequency is strongly associated with increased risk of HIV infections associated with age at first intercourse and infection (e.g., a recent study in Thailand has lifetime number of sexual partners. Primary shown up to 16 fold increase in female-to- infection usually occurs in adolescence or male transmission of HIV in the presence of soon after sexual activity commences; anogenital warts). They are caused by the recurrences are common. Vaginal delivery in human papillomavirus. pregnant women with active (especially primary) genital infection carries a high risk of severe infection to the newborn. Which syndrome? While warts are a common problem, they are Symptoms and signs not usually part of the syndromic approach - since the diagnosis and management is Primary and recurrent skin blisters, often generally straightforward. They are painful , in the anogenital area. In women, sometimes confused with condylomata lata often in the cervix, vulva, perineal skin, legs (wart-like lesions caused by syphilis). and buttocks. In men, usually on the penis; and in the anus and rectum in men and women who practise anal sex. May occur on Which syndrome? the mouth in both sexes, depending on sexual practices. Diagnosis is usually clinical. Donovanosis usually presents as a genital ulcer. Remember that co-infection with other STIs (e.g. herpes, syphilis and chancroid) is Which syndrome? possible. In most countries, donovanosis is rare and is not routinely included as part of Herpes usually presents as a genital ulcer. the genital ulcer syndrome. Remember that co-infection with other infections (e.g. syphilis and chancroid) is common. In many countries, herpes has not been included as part of the genital ulcer syndrome because of the costs of antiviral therapy and the fact that treatment is palliative rather than curative. Additionally, herpes is often a recurrent condition - meaning that the treatment costs will often also be ongoing. Since the cost of the most commonly used drug for herpes in developing countries (acyclovir) is declining and since herpes is also a major co-factor for HIV transmission, many countries are reviewing the situation and considering the The Centre inclusion of herpes treatment in their for Harm national guidelines. Reduction 357 Contents > Section 3-Appendix 3

Granuloma Inguinale References (Donovanosis) Chin JE. 2000. Control of Communicable Diseases Manual (17th edition) American Manual for Epidemiology Public Health Association; ISBN: reducing drug This infection is rare in industrialised 0875531822. related harm countries, but endemic in many tropical and Centers for Disease Control and Prevention. in Asia sub-tropical countries (especially southern Sexually transmitted diseases treatment India, Papua New Guinea, central, eastern guidelines 2002. MMWR 2002;51 (No. and southern Africa, the Caribbean, South RR-6). Acrobat version can be America, and central and northern Australia). downloaded from web-site: Probably caused by Donovania granulomatis. www.cdc.gov/STD/treatment/rr5106.pdf or browsable at: www.cdc.gov/STD/treatment/TOC2002T Symptoms and signs G.htm . Holmes KK et al. (eds). 1998, Sexually A small lesion on the skin in the genital area Transmitted Diseases (third edition). New spreads, gradually forming a granuomatous York: McGraw Hill. ISBN: mass which may result in extensive 007029688X. destruction of genital organs. Laboratory WHO Guidelines for the Management of diagnosis is usually made by identification of Sexually Transmitted Infections. Geneva, “Donovan bodies” in Giemsa-stained smears. 2001. [WHO/HIV_AIDS/2001.01 and WHO/RHR/01.10]. Acrobat version can be downloaded from web-site: www.who.int/HIV_AIDS/STIGlobalRep ort/who_hiv_aids_2001.01.pdf . World Health Organization. 1997. STD Case Management: The Syndromic Approach for Primary Health Care Settings. Manila: World Health Organization, Regional Office for the Western Pacific.

Treatment of Sexually Transmitted Infections National guidelines should be sought from your national health department since the local situation might require different approaches in the management of specific conditions when compared with global recommendations from organizations such as World Health Organization and/or Center for Disease Control, United States. The updated references and web-sites provided can be reviewed and assessed for appropriateness.

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358 Contents > Section 3-Appendix 3 SECTION Glossary of Terms 3 Abstinence Going without. In relation to into communities and 3) community drug treatment the complete cessation of development that address issues of Glossary drug use. poverty, economic opportunities and of terms AIDS Acquired Immunodeficiency integration of people into meaningful Syndrome. It is a disease caused by the social structures. Human Immunodeficiency Virus (HIV). Detoxification Medically supervised AIDS is the end stage of HIV infection. programs for drug users being weaned The body’s immune system is seriously from their physical dependence on drugs. damaged and the infected person is Can be run in an institute, as an in- vulnerable to common infections that can patient, in the community and in the result in death. home. Burnout A period of emotional and physical Drug Substitution Replacing the drugs a exhaustion in response to an intensity of drug user is taking with a similar drug work with other human beings, (i.e. methadone, buprenorphine). The particularly those who have serious goal is to reduce the health, social, and problems and/or illness. economic harms to the individual and the Chasing the dragon A popular way to community. administer heroin. A portion of heroin is Epidemic Any disease, infectious or placed on aluminium foil. The underside chronic, occurring at a greater frequency of the foil is heated with a flame and as than usually expected. the heroin melts vapours are released and Evaluation Process of collecting and the fumes are inhaled. Inhalation is often analysing information at regular intervals through a little tube which is held in the about the effectiveness and impact of the mouth. project. Community Group of people who have Golden Triangle The geographical region something in common and will act that includes the countries of Myanmar, together in their common interest i.e. Thailand and Laos. This region produces neighbourhood, drug users. 80% of the opium and heroin in Asia. Counselling Involves providing advice, Harm Reduction A generally accepted support, education, information, aid and definition has yet to emerge. However, a assistance, referral and prevention principal common element is reducing strategies, for example on health related the harmful consequences of drug use issues i.e. HIV/AIDS. without necessarily reducing the drug Demand Reduction Refers to the use. Emphasis is on short term pragmatic prevention of illicit drug use. Various goals over long term idealistic goals. prevention approaches include 1) Various programs to foster harm providing education and information reduction are, for example, needle and targeted at the general community, the syringe programs, education of drug youth (school based programs) and drug users and drug treatment and users in order for people to make substitution programs. informed decisions about healthy HIV Human Immunodeficiency Virus. It is lifestyles 2) treatment for drug users the virus that causes AIDS. HIV infects include detoxification (where appropriate cells of the immune system, which over under medical supervision), methadone time become damaged. This results in the maintenance treatment and social immune system no longer resisting rehabilitation of drug users by promoting common illnesses. The Centre employment prospects and re-integration for Harm Reduction

359 Contents > Section 3-Appendix 3

HIV/AIDS Test A blood test which looks Peer Education Program Educational Manual for for the antibodies to the virus, not for the strategies created and implemented by reducing drug virus itself. A HIV/AIDS infected person members of a particular group of people related harm will produce antibodies, which are made for their peers, for example, drug users. in Asia to fight germs, but do not protect a The desired outcome is to effect and person from HIV or AIDS. sustain a change in behaviour by HIV Positive Antibodies to HIV have provision of relevant information from an been detected by a blood test and the acceptable source. A group of related person has been infected with HIV. They projects or services directed towards the are now able to infect other people and accomplishment of specific (usually will remain infectious for life. It does not similar or related) objectives. Projects mean they have AIDS. that are long term can be viewed as a HIV Negative Either a person is not program. infected with HIV or they remain in the Rapid Situation Assessments Involve both window period (3 weeks to 3 months) and an assessment of the problem and the therefore production of antibodies are not resources available that may be required enough to be indicated by a blood test. to address the problem. The research tools Methadone A synthetic opiate, like heroin, are adapted from anthropological and which is used to limit discomforts other social sciences to examine a associated with heroin withdrawal. particular subject. These can be Methadone Maintenance Treatment undertaken within a short timeframe and (MMT) Programs that provide at low cost. outpatient services for those addicted to Relapse When a person dependant upon opiates, such as heroin, by offering drugs stops using them for a period of methadone in combination with time but eventually starts using them counselling. Methadone is provided in again. Initial attempts to stop using various dosages and its long-acting effect drugs often prove unsuccessful and alleviates withdrawal symptoms. relapses can be frequent. Methadone is not a cure for opiate Sharing of Injecting Equipment addiction but it does offer people a chance When a person uses injecting equipment to stabilise their lives and lessen the risks which includes a needle, syringe, filter, associated with illegal drug use. water, glasses, tourniquet and surface and Maintenance means long term. is then followed by another person re- Monitoring Continuous process of using the same injecting equipment. This collecting and analysing information action can result in the transfer of HIV, about the implementation of the project. Hepatitis B and C; needles and syringes Needle and Syringe Program (NSP) A are the most important pieces of program allowing injecting drug users equipment for transfer of these viruses. access to sterile injecting equipment, Shooting gallery A name given to an area providing for needle and syringe disposal in which individuals gather to inject and for the provision of advice and drugs, to be injected by a ‘professional’ information. NSP may be a fixed site or a injector and/or to buy drugs. It can be in mobile outreach service. an abandoned building, shack, hut or Opioids Natural and synthetic someone’s house. (manufactured) opiate drugs, with the Stimulants Drugs classified as stimulants same actions on the body as opium and include amphetamines, cocaine, ecstasy The Centre for Harm heroin. and hallucinogens. Reduction

360 Contents > Section 3-Appendix 3 SECTION Abbreviations 3 Supply reduction Various steps are HIV Human Immunodeficiency implemented to prevent illicit drugs from Virus Glossary reaching the consumer. These steps of terms include 1) eradicating the cultivation of AIDS Acquired Immunodeficiency illicit drugs 2) crop substitution to Syndrome decrease the cultivation of illicit crops 3) interdiction of precursor chemicals that IDUs Injecting Drug Users are used for the processing of illicit drugs 4) interdiction of the various means of RSA Rapid Situation Assessment transporting drugs 5) limiting distribution in the chain of trafficking NSPs Needle and Syringe Programs 6) control and/or legislation on money laundering and 7) the War on Drugs. STIs Sexually Transmitted Infections STI Sexually Transmitted Infections. A variety of sexually transmitted SWs Sex Workers infections can be contracted following various forms of unprotected sex with MSM Men who have Sex with Men someone who is infected. HIV is one such sexually transmitted infection. Others TB Tuberculosis include gonorrhoea, syphilis and chlamydia. MMT Methadone Maintenance Viral load The amount of HIV in a person’s Treatment blood at a particular time. This can go up and down and will depend on the person’s Mg Milligram general health and the state of their immune system. WHO World Health Organization Withdrawal Signs and symptoms commonly experienced when a person CHOWs Community Health Outreach stops using a drug which they are Workers dependent upon. Withdrawal symptoms can vary from being unpleasant to life NGO Non-Government Organisation threatening and can include irritability, shakiness and nausea. MBCMR Macfarlane Burnet Centre for Medical Research

AHRN Asian Harm Reduction Network

ELISA Enzyme-Linked Immunosorbent Assay (test)

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361 Contents > Section 3-Appendix 3

Internet Resources List

Asian Harm Reduction Network: Centre for Harm Reduction: A global information and support Established at The Macfarlane Burnet Manual for network. The four key activities are Institute for Medical Research & Public reducing drug advocacy, information sharing, Health it is the lead technical agency in related harm networking and training. the Asian region for developing responses in Asia http://www.ahrn.net/ for the reduction of drug-related harm. http://www.chr.asn.au Australian Department of Health and Ageing - Population Health: Centre for Drug Research, University of A 2002 report that examines the return Amsterdam: on investment in needle and syringe Its goal is the determination of various programs in Australia. aspects of the drug problem from a http://www.health.gov.au/pubhlth/ socio-scientific angle. publicat/hac.htm http://www.cedro-uva.org/ Australian Drug Foundation: Centers for Disease Control and An independent non-profit organisation Prevention – HIV Prevention Among to prevent and reduce alcohol and other Injection Drug Users: drug problems. The focus is on research, This web site provides access to materials information, community development, and resources developed to assist HIV education and advocacy. prevention providers working with IDUs http://www.adf.org.au/ and their sex partners. http://www.cdc.gov/idu/default.htm Australian Drug Information Network: Provides a central point of access to DRCNet Online Drug Policy Library: quality internet-based alcohol and drug A US national network working for drug information provided by prominent policy reform from a variety of organisations in Australia and perspectives ranging from harm reduction internationally. http://www.adin.com.au/ to a more open debate on drug prohibition. http://www.druglibrary.org/ Australian National Council on Drugs: The principal advisory body to the Drug Policy Alliance: Australian Government on drug-related The leading organisation working to policies and strategies. broaden the public debate on drug policy http://www.ancd.org.au/ and to promote realistic alternatives to the war on drugs based on science Australian National Council on AIDS, compassion, public health and human Hepatitis C & Related Diseases: rights. http://www.drugpolicy.org/ The peak advisory body on the Australian response to and the management of these Drugscope: diseases. http://www.ancahrd.org/ The UK’s leading independent centre of expertise on drugs. To inform policy Bureau for International Narcotics & development and reduce drug-related Law Enforcement Affairs: risk. Provides quality drug information, A unit of the US State Department, they promotes effective responses to drug produce an annual report on all countries taking, undertakes research at local, of the world, examining issues of drug national and international levels, advise trafficking, supply and demand and the son policy-making and encourages use of drugs. informed debate. http://www.state.gov/g/inl/narc/ http://www.drugscope.org.uk/ Canadian Harm Reduction Network: Drug Misuse Information: The nexus for individuals and Substance Misuse Information pages are organisations across Canada dedicated to operated by UK Department of Health. reducing the social, health and economic Intended primarily as a resource for a harms associated with drugs and drug wide range of professionals and managers policies. to help in the delivery of drug prevention The Centre http://www.canadianharmreduction.com/ for Harm and treatmentservices. Reduction http://www.doh.gov.uk/drugs/

362 SECTION Contents > Section 3-Appendix 3 3 Drugtext: HIV Insite (University of California): This foundation is for the dissemination Source for comprehensive, in-depth and production of information on HIV/AIDS information and knowledge. Internet substance use, addiction, harm reduction, Extensive collection of original material, Resources and international and national drug including the HIV InSite Knowledge List policy. Base, a complete textbook with extensive http://drugtext.org/ references and related links organized by topic. http://hivinsite.ucsf.edu/cgi- Family Health International: msql/world_db1.pl Works to improve reproductive and family health around the world through HIV/AIDS Information Centre (Journal biomedical and social science research, of the American Medical Association): innovative health service delivery Designed as a resource for physicians and interventions, training and information other health professionals. The site is programs. Work in partnership with produced and maintained by JAMA universities, ministries of health and non- editors and staff. governmental organizations, conducting http://www.ama-assn.org/special/hiv/ ongoing projects in the US and more than International Crisis Group: 40 developing countries. A private, multinational organisation, http://www.fhi.org with staff on five continents, working Francois Xavier-Bagnoud Centre: through field-based analysis and high- The first academic centre to focus level advocacy to prevent and contain exclusively on health and human rights, conflict (also examines HIV/AIDS). combines the academic strengths of http://www.crisisweb.org/ research and teaching with a strong International Harm Reduction commitment to service and advocacy. Association: http://www.hsph.harvard.edu/fxbcenter/ Working with local, national, regional Global HIV-AIDS & STD Surveillance: and international organisations to assist A joint effort of WHO and UNAIDS, individuals and communities in public Primary objective is to strengthen health advocacy, collaboration and national, regional and global structures communication, best practice on various and networks for improved monitoring issues related to harm reduction, and and surveillance of HIV/AIDS and STIs. education, training and research. http://www.who.int/emc-hiv/ http://www.ihra.net/ Harm Reduction Coalition, New York: International Narcotics Control Board: Committed to reducing drug-related An independent and quasi-judicial harm among individuals and control organ for the implementation of communities by initiating and promoting the United Nations drug conventions, local, regional, and national harm established in 1968 by the Single reduction education, interventions, and Convention on Narcotic Drugs of 1961. community organising. http://www.incb.org/e/index.htm http://www.harmreduction.org Mainliners: Hepatitis C Council of New South Wales: On-line advice and information service An independent, charitable, community- for people affected by drug use, HIV and base membership organisation offering hepatitis. http://www.mliners.org/ assistance to people affected by the hepatitis C virus (HCV) and providing online, up to date information about hepatitis C. http://www.hepatitisc.org.au

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363 Contents > Section 3-Appendix 3

National Institute on Drug Abuse: United Nations Drug Control Program Researches on the health aspects of drug (Regional Centre for East Asia & the Manual for abuse and addiction and works towards Pacific): reducing drug the rapid and effective transfer of Responsibility for drug control in East related harm scientific data to policy makers, drug Asia and the Pacific covering over in Asia abuse practitioners, other health care 30 countries/areas. practitioners and the general public. http://www.undcp.un.or.th/ http://www.drugabuse.gov/NIDAHome. United Nations Development html Programme, Regional Programs on Open Society Institute, International HIV/AIDS in Asia/Pacific: Harm Reduction Development: Deals with various tasks associated with Aims to diminish the individual and advocacy, sharing best practices and social harms associated with drug use mobilizing resources it also addresses through innovative measures based on the issues linked to HIV/AIDS. philosophy of harm reduction. Currently http://www.hivundp.apdip.net/ supports more than 180 projects in over World Health Organization, Department 20 countries in Eastern Europe and the of Mental Health and Substance former Soviet Union. Dependence: http://www.soros.org/harm-reduction Deals with all psychoactive substances, RARarchives: regardless of their legal status. The WHO Site aims to provide general information mandate is to: prevent and reduce the and resources on rapid assessment which negative health and social consequences of aim to prevent HIV and other infectious psychoactive substance use; reduce the diseases among IDUs. demand for non-medical use of http://www.rararchives.org/ psychoactive substances; and assess psychoactive substances so as to advise the Trimbos Institute (Netherlands) of United Nations with regard to their Mental Health and Addiction: regulatory control. Aims to promote mental health in the http://www.who.int/substance_abuse/ broadest sense of the term. The Institute index.html is an independent national centre of expertise that, on scientific grounds, World Health Organization, Department provides services in the field of mental of HIV/AIDS: health care, substance use and the care of As a co-sponsor of UNAIDS the WHO addicts. mandate is to head the health sector http://www.trimbos.nl/indexuk.html response to HIV/AIDS. This sitemap exams issues of surveillance, monitoring UNAIDS Joint United Nations and evaluation, care, prevention, technical Programme on HIV/AIDS: support and HIV/AIDS in emergency The leading advocate for worldwide settings. action against HIV/AIDS, the global http://www.who.int/hiv mission of UNAIDS is to lead, strengthen and support an expanded response to the epidemic. http://www.unaids.org/ United Nations Office for Drug Control and Crime Prevention: Works to educate the world about the dangers of drug abuse. Aims to strengthen international efforts against drug production, trafficking and drug related crime. http://undcp.or.at/index.html

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364 Contents > Section 3-Appendix 3 SECTION Useful Publications on the Internet 3 AIDSCAP Making prevention work: Preston A. Methadone Briefing HIT Liverpool Global lessons learned from the AIDS Control 1997. Available direct from HIT Cavern Internet and Prevention (AIDSCAP) Project 1991- Walks, Mathew Street, Liverpool L2 6RE. 1997. Chapter 4: Policy development and Website:http://www.drugtext.org/books/ Resources HIV/AIDS prevention: creating a methadone/ default.htm List supportive environment for behaviour. Sharma RR. An Introduction to Advocacy: 1998 Website: http://www.fhi.org/en/aids Training Guide. Support for Analysis and /aidscap/aidspubs/special/lessons/chap4. Research in Africa, USAID Africa Bureau html Office of Sustainable Development. Ball A and Crofts N. HIV risk reduction in Washington DC 1997. Also in Spanish injecting drug users. In: Lamptey PR and French. and Gayle H (Eds) HIV/AIDS Prevention http://sara.aed.org/sara_pubs_list_sara_5. and Care in Resource-Constrained Settings. htm Arlington, Virginia: Family Health Stimson G, Fitch C and Rhodes T (Eds). International 2002 http://www.fhi.org Rapid Assessment and Response Guide on Burrows D. Starting and Managing Needle and Injecting Drug Use. World Health Syringe Programs: A guide for Central and Organisation/UNAIDS Geneva 1997. Eastern Europe and the newly independent From WHO/UNAIDS, 20 avenue Appia, states of the former Soviet Union Open CH-1211 Geneva 27, Switzerland. Society Institute, International Harm Available in English and Russian. Reduction Development (OSI/IHRD) Website: http://www.who.int/home/ NY 2000. From OSI/IHRD 400 West UNAIDS/UNDCP Drug use and HIV 59th St, New York NY 10019 USA. Vulnerability: Policies in Seven Asian In English, Russian and Slovakian. Countries UNAIDS APICT. Bangkok Website:http://www.soros.org/ 2001. Website: http://unaids.org/ harm-reduction/ publications/documents/health/access/ Chapman S. Advocacy in public health: roles Drug.pdf and challenges International Journal of UNAIDS Drug use and HIV/AIDS Epidemiology 2001: 30: 1226-1232. UNAIDS Statement presented at the UN Website: http://www.health.usyd.edu.au/ General Assembly Special Session on tobacco/worddocs/IJE.pdf Drugs June 1998 Geneva. Also in Costigan G, Crofts N and Reid G. Manual Spanish, French and Russian Website: for reducing drug-related harm in Asia. The http://www.unaids.org/publications/docu Centre for Harm Reduction, Macfarlane ments/specific/injecting/una99e1.pdf Burnet Centre for Medical Research and UNAIDS/ODCCP Drug Abuse and Public Health Ltd and Asian Harm HIV/AIDS: Lessons Learned Case studies Reduction Network, Melbourne/ Chiang Booklet: Central and Eastern Europe and the Mai 2003. http://www.chr. asn.au Central Asian States 2001 Website:http:// Derricot J, Preston A and Hunt N. The Safer www.unaids.org/publications/ Injecting Briefing. HIT Liverpool 1999. documents/specific/injecting/JC673-Drug English only. Available direct from HIT Abuse-E.pdf Cavern Walks, Mathew Street, Liverpool UNAIDS Best Practice Collection Six best L2 6RE also on the HIT Website: practice studies on HIV/AIDS and http://www.drugtext.org/books/needle/ injecting drug use in China, Bangladesh, Johns Hopkins Centre for Communications Nepal, Belarus, Southern Cone countries Programs “A” frame for Advocacy. Set of (Latin America), Asia. Website: http:// nine web pages providing short www.unaids.org/bestpractice/digest/table. descriptions of steps in advocacy for html#inj public health. No date. Accessed 7 May WHO (World Health Organisation) The 2002. Index and introduction: Ottawa Charter on Health Promotion Geneva. http://www.jhuccp.org/pr/advocacy/index. 1986 Website:http://www.who. stm int/hpr/archive/docs/ottawa.html

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365 Contents > Section 3-Appendix 3

International Contact List

Afghanistan Cambodia Manual for UNDCP (for Afghanistan) UNODCP Country Office 11th Floor Saudi-Pak Tower No4 Mao Tse-Tung Boulevard, Sangkat reducing drug P.O Box 1051 Boeung Keng Kang, Khan Chamcarmon, related harm Islamabad Phnom Penh in Asia Tele: +92 51 279088 Tel: (855-23) 726-035 Fax: +92 51 279085 Fax: (855-23) 216-257 Email: [email protected] Email: [email protected] Website: www.undcp.org/pakistan/index.html UNAIDS Cambodia PO Box 877, Phnom Penh, Cambodia Tel: (855) 23 721 153 Bangladesh Fax: (855) 23 721 153 HIV Program Email [email protected] CARE International Bangladesh House 66, Road 7/A Dhanmondi Residential area China Dhaka-1209 Guangxi Centre for HIV/AIDS Prevention Bangladesh and Control Tel: 88-02-8114195, 88-02-8114198 80 Taoyuan Road, Nanning, Guangxi Fax: 88-02-8114183 530021 Email: [email protected] Tel: 86 771 5327110 Fax: 86 771 5316432 HIV program Email: [email protected] CARE Dhaka Field Office 49/1 Babar Road Yunnan Provincial Bureau of Health Mohammadpur Housing State 166 Wuyi Road, Kunming, 650021 Block-B, Dhaka -1207 Tel: 86 871 3629527 Tel: 88-02-8123364, 88-02-8114311 Fax: 86 871 3620353 Fax: 88-02-8114183 Email: [email protected], Yunnan Institute for Drug Abuse [email protected] Xi-hua-yuan, Kunming, 650228 Yunnan Province Bandu Social Welfare Society and HIV/AIDS Tel: 86-871-4624423 and STDs Prevention Project Fax: 86-871-4624356 106, Kakrail Email: [email protected] Dhaka-1000 Tel: 88-02-9339898 National Center for AIDS/STD Prevention Email: [email protected] and Control Add: 27 Nanweilu, Beijing 100050, China HIV/AIDS STD Alliance Bangladesh Tel: 010-63174322 (HASAB) Fax: 010-63179516 4/1 Iqbal road, Mohammadpur Email:[email protected] Dhaka-1207 Tel: 88-02-8123021, 88-02-9132644 Chinese AIDS Network Fax: 88-02-8122786 Peking Union Medical College Email: [email protected] Add: 5 Dongdansantiao, Beijing 100005, China Concern Bangladesh Tel: 010-65296973/65296971 House 61, Road 15/A Fax: 010-65288170/64812781 Dhanmondi Residential Area Email: [email protected] Dhaka-1209

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366 SECTION Contents > Section 3-Appendix 3 3 Health Education and Behaviour Macau (Special Administrative Region, Interventions Office (a focus on IDUs) China) National Center for AIDS/STD Prevention International Department for Prevention and Treatment of Contact List and Control Drug Dependence -Social Welfare Institute Add: 27 Nanweilu, Beijing 100050, China Rua Sanches de Miranda, No.5, MACAU Tel.: 010-63152573 (South of China) Fax: 010-63131081 Tel: (853)781718 Email: [email protected] Fax no.(853)781720 Email: [email protected] China-UK HIV/AIDS Prevention and Care Website: www.ias.gov.mo Project 27 Nanweilu Beijing 100050 China Ph: 8610-6313-1047/ 6313-1174 India Fax: 8610-6313-1366 The Calcutta Samaritans Rev. Vijayan Pavamani Mahesh Nathan Hong Kong (Special Administrative 48 Ripon Street, Calcutta-16 Region, China) Tel: 033-2295920/2299731 Red Ribbon Centre Fax: 033-2268097 2/F, 200 Juntion Road East, Email: [email protected] Kowloon, Hong Kong Email: Tel: (852) 2304 6268 Fax: (852) 2338 0534 Society for Community Intervention & Email: [email protected] Research (SCIR) Website: www.rrc-hk.com Sunjoy Bhattacharya Mr. MM Rahaman (President) Methadone Clinic (Narcotics & Drug 37, Alimuddin Street, Administration) Calcutta - 700 016. 8/F Southorn Centre Tel: 033-2290484 130 Hennessy Road, Hong Kong Email: [email protected] Tel: (852) 2835 1831 Fax: (852) 2572 6072 Sahai Trust Website: www.harmreduction-hk.com Fr. Desmond Daniels Chubby Rehab Centre: 04114-74321 Phoenix Project (The Society for the Aid and Clinic: 044-434-5668/4843836/4332285 Rehabilitation of Drug Abusers. SARDA) Office: 044-4953644 fax: 044-4958302 3/F, Duke of Windsor Social Service Office: 15, Rosary Church Rd, Santhome Building, Chennai-600004 15 Hennessy Road, Wanchai, Hong Kong Rehab: Mount Carmel Mission, Kovalam Tel: (852) 2527 7726 PO Pin: 603112 Fax: (852) 2865 5455 Email: [email protected] Email: [email protected] Website: www.sarda.org.hk TTK Hospital Shanti Ranganathan Pui Hong Self Help Association TT Ranganathan Clinical Research Found. Flat C, 4/F, Haven Building, IV Main Road, Indira Nagar 128-138, Leighton Road, Hong Kong Chennai - 600 020. Tel: (852) 2576 2356 Tel: 91-44-827 5841/493 8584 Fax: (852) 2882 3534 Emai: [email protected] Email: [email protected]

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367 Contents > Section 3-Appendix 3

TTK Drop in centre Indonesia Dr. S. Srivatsan Manual for Aksi Stop AIDS (ASA)/ Family Health 20, II Cross Street International reducing drug Kodambakkam, Chennai-600024 Ditjen PPM & PL Depkes Rl related harm Tel: 044-3726356 Jl. Percetakan Negara 29 in Asia Jakarta 10560 SASO - (Social Awareness Service Indonesia Organisation) Tel: 62 21 422 3463 Khwai Lalambung - Makhong Fax: 62 21 422 3455 RMC Road, Imphal - 795 001 Email: [email protected] MANIPUR Tele: 0385- 310011/411408 Yayasan Pelita Ilmu Fax: 0385-411409 Jl. Tebet Timur Dalam VIII Q/6 Email: [email protected] Jakarta 12820 Email: [email protected] Tel: 62 21 794 6040 Fax: 62 21 799 5847 North East India Harm reduction Network Email: [email protected] (NEIHRN) R.Raju Yayasan Hatihati Address/telephone: same as SASO Jl. Pulau Batam I/9 Email: [email protected] Denpasar 80114, Bali Email: [email protected] Indonesia Tel:62 36 122 1271 MUKTI Sadan Fax: 62 36 122 1271 Shoba Kapoor Email: [email protected] Praful Sali Plot No.49 Yayasan Bahtera Parsee Panchayat Road, Andheri (E) Jl. Jatihandap Gg. iv / 210 Bombay - 400 069. Desa Mandalajati Tel: 022-8325184 / fax: 022-837-6428 Cicaheum Bandung Tel/Fax: 022-727-9320 Family Health International Email: [email protected] Kathleen Kay Ground Floor (opp. Convention Centre) Yakita (Yayasan Harapan Permata Hati Kita) Ashok Hotel Jl Ciasin no.21 Chanakyapuri, New Delhi 110 021 Desa Bendungan India Ciawi, Bogor Tel: 91-11-6873950-53 Tel/Fax: 0251-335-875 Fax: 91-11-6873954 Email: [email protected] Email: [email protected] Website: www.yakita.or.id UNDCP-ROSA Renate Ehmer Iran EP 16/17, Chandragupta Marg United Nations Drug Control Programme Chanakyapuri, New Delhi-110021 45 Pardis Str. Mola Sadra Str. Vanak Sq., Tel: 4104970-73 199195-3471, Tehran. Fax: 4104962 Tel: +98-21-879 5031/2 Email: [email protected] Fax: + 98-21-877 6661 Email: [email protected] Sharan - Society for service to urban poverty Luke Samson Drug Control Head Quarters (DCHQ) C-43, Neeti Bagh, 143, Baharan Sq., Vozara St., Tehran, Iran New Delhi-110049, India Tel: +98-21-877 02 35 Fax: +98-21-877 02 35 The Centre Tel:91-11-8642311/8642322 for Harm Email: [email protected] Website: www.dchqiran.org Reduction

368 SECTION Contents > Section 3-Appendix 3 3 State Welfare Organization Malaysia No. 32, Ghaem Magham St. Opposite Malaysian AIDS Council International Mashahir St., Haft-Tir Sq., Tehran 12, Jalan 13/48A, The Boulevard Shop Contact List Tel & Fax: +98-21- 830 61 10 Office off Jalan Sentul, 51000 Kuala Lumpur Ministry of Health Tel: 603 4045 1033 South Iranshar, Opposite Iranshahr Hotel, Fax:603 4042 6133 No. 68, Tehran Homepage:http://www.mac.org.my Tel: +98-21-882 06 78 Persatuan Pengasih Malaysia Prisons Organization Rumah pengasih Shariati St., Istgah Yakhchal, 4th Floor, 3201-A jalan Syers off Langgak Tunku Tehran 50480 Kuala Lumpur Tel: +98-21- 266 172 Tel: 03-6201 3179/0287 Fax: +98-21- 267 930 Fax: 03-6201 3013 Email: [email protected] Japan Japanese Foundation for AIDS Prevention Ikhlas Drop-In-Centre Terayama Pacific Building. 4F Pink Triangle Foundation Toranomon 1-23-11, 7C-1, 1st Floor Minato-ku, Tokyo, 105-0001 Jalan Ipoh Kecil Tel: +81-3-3592-1181 off Jalan Raja laut Fax: +81-3-3592-1182 50350 Kuala Lumpur Email: [email protected] Laos Malaysian Care UNDCP Country Office Lot389, 8.8km Jalan Hulu Kelang Route Phone Kheng, Vietiane 68000 Ampang, Selangor Postal address P.O Box 345 Tel; 03-7785 4627 Tele: (00856-21) 413-204, 416-427 Fax:03-7981 2954Email: Fax: (00856-21) 413-203 Email: [email protected] [email protected] Website: www.undcp.org/laoPDR Youth With a Mission (YWAM) UNAIDS 7B jalan Kenari 10 P.O. Box 345 Bandar Puchong Jaya Phon Kheng Road 47100 Puchong Vientiane Lao PDR Selangor Tel: (856-21) 213395-97 Tel: 03 8070 0301 Fax: (856-21) 241742 Fax:03 8076 4116 Email: [email protected] Email:[email protected]

Lao-German Project ‘Promotion of Drug Mongolia Control’ National Aids Foundation: P.O.Box 9233, Vientiane, Lao PDR Executive Director. Kh. Enkhjargal Tel/Fax: +856-21-351978 Central Post Office, E-mail: [email protected] Ulaanbaatar-13, box-117 Tel: 976-11-318016 NCCA Bureau Fax: 976-11-321659 Km 3, Thadeua Road Email: [email protected] Vientiane Municipality, Vientiane Website: www.naf .org.mn Tel / Fax: (856-21) 315500 Email: [email protected] The Centre for Harm Reduction

369 Contents > Section 3-Appendix 3

Myanmar Family Health International- Nepal (FHI) Addrss:Gha-2-789, Tangal Manual for UNDCP, PO Box 650, 11A Malikha Road, Ward 7, G.P.O: 8803, Kathmandu reducing drug Mayangone Township, Yangon Tel: 977-1-427540 related harm Tel: (951) 666 903, 660 538, 660 398 Fax: 977-1-414063 in Asia Fax (951) 651 334 Email: [email protected] Email: [email protected] Website: http//www.nepalinitiative.org.np

CCDAC, Corner of Set-hmu and Saya San Lifesaving and Lifegiving Society (LALS) Roads, Bahan Township, Yangon Address: P.O. Box 7151, Kathmandu Tel: (951) 549 642 Tel: 977-1-413576 Fax : (951)549 284 Fax: 977-1-413976 Email: [email protected] MANA, Room 101-102, Bldg 3, Myaing Hay-wun Estate near Junction 8, 8th Mile, International Nepal Fellowship (INF) Naulo Kyaik-waing pagoda Road, Mayangone Ghumti Program Township, Yangon Address: P.O. Box: 28, Pokhara, Kaski Tel: (951) 667 270 district, Nepal Fax: (951) 660 266 Tel: 977-61-24515 / 061-23350 Email: [email protected] Fax: 977-61-30940 Email: [email protected] CARE International in Myanmar, 98A Kaba Aye Pagoda Road, Bahan Township, Yangon Pakistan Tel: (951) 544 289, 544 805, 549 152 Nai Zindagi Fax: (951) 549 338 # 37-38, Beverly Center, Blue Area, Email: [email protected] Islamabad Tel: +92 51 2874120 Medecins du Monde, 10 (A) Thar Tha Na Fax: +92 51 2874121 Yeik Street, Mahasi, off Kaba Aye Pagoda Email: [email protected] Road, Bahan Township, Yangon Tel: (951) 548 294 Pakistan Society Fax: (951) 544 557 C-15, Block 12, Federal B Area, Karachi Email: [email protected] 75950 Tel: +92 21 6344644 Nepal Fax: +92 21 6343810 Centre for Harm Reduction Email: [email protected] Nepal Country Office CHA 2/173, Ward#2, Gairidhara, Al Rehman Kathmandu 155 A Bank Road, Rawalpindi GPO Box. 19688 Tel: +92 51 5515272 Tel: +977 1 410701 Fax: +92 51 5515274 Fax: +977 1 410601 Email: [email protected] Email: [email protected] UNDCP (also for Afghanistan) Government: National Centre for AIDS and 11th Floor Saudi-Pak Tower STD Control (NCASC) P.O Box 1051 Dr. Shyam Sundar Mishra- Director Islamabad Address: Teku Hospital, Kathmandu Nepal Tele: +92 51 279088 Tel: 977-1-261653 or 258219 Fax: +92 51 279085 Fax: 977-1-261406 Email: [email protected] Email: [email protected] Website: www.undcp.org/pakistan/index.html

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370 SECTION Contents > Section 3-Appendix 3 3 Philippines South Korea Metsa Foundation Korea Drinking Culture and Alcohol International Anita Morales - Project Coordinator Research Foundation (Alcohol) Contact List Km. 20 Los Amigos 13-8, Noryangjin-Dong, Dongjal-Gu, Seoul, Tugbok Street, Davao City Korea 156-050 Tel.: (0 82) 2930219 Tel: 822 817 6812(501) Email: [email protected] Fax: 822 817 6844 Email: [email protected] Higala Association www.kodcar.or.kr Onesimo Tabaco - Executive Director Purok 14 Sta. Cruz Korea Anti-Drug Campaign Center (Drug) Bugac, Ma-a Road, Davao City 238, Dangsan-Dong 6 Ga, Youngdeungpo- Telefax: (0 82) 2441753 Gu, Seoul, Korea 150-809 Email: [email protected] Tel: 822 677 2245 Fax: 822 677 2247 Kaugmaon Center for Children’s Concerns www.drugfree.or.kr Faustina carreon - Executive Director 59 Vinzon Street corner Cervantes Street Korean Alliance to Deft AIDS (HIV/AIDS) Barrio Obrero, Davao City 307, sEMI BUILDING, 57, Youngdeungpo- Tele/fax.: (0 82) 2216669 8Ga, Youngdeungpo-Gu, Seoul Korea, 150- Email: [email protected] 038 Tel: 822 675 4111-4 Shed Foundation Fax: 822 675 2114 Domingo Non - Executive Director Email: [email protected] Mindanao State University Campus www.aids.or.kr Fatima, General Santos City Tel.: (0 83) 3807149 Korea\n Anti-AIDS Federation, Inc. Tele/fax: (0 83) 5538979 (HIV/AIDS) Email: [email protected] 201, BOSUK BILAT, 2-15 Dongsung-Dong, Jongro-Gu, Seoul, Korea Philippine HIV/AIDS NGO Support Tel: 822 747 4071 Program (PHANSup) www.aidskorea.org.kr Mezzanine, Brickville Condominium 28 N. Domingo Street Singapore New Manila, Quezon City 1112 Action for AIDS Tel.: (6 32) 7266921 to -22 c/o DCS Clinic #02-16 Fax: (6 32) 4154381 31 Kelantan Lane Email: [email protected] Singapore, 200031 Tele: 2509495 Remedios AIDS Foundation (Cebu Youth Fax: 2994335 Zone) Email: [email protected] 1066 Remedios cor. Singalong Sts. Malate, Manila 1004 Central Narcotics Bureau Tel. Nos.: (6 32) 5240924/ (6 32) 5244831 393 New Bridge Road, Singapore, 088763 Fax: (6 32) 5223431 Tel:1800 3256666 Email: [email protected] Fax: 6227 3978 Website: http://www.remedios.com.ph Website: http://www.cnb.gov.sg http://www.youthzone.com.ph

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371 Contents > Section 3-Appendix 3

Sri Lanka Drug Dependence Research Centre, Institute of Health Research, Chulalong Manual for UNDP 202 & 204, Bauddhaloka Mawatha, Colombo University. Institue Building II, reducing drug 7, Sri Lanka or P.O. Box 1505, Colombo 7 Chula Soi 62, related harm Tel: 580691-7. Phyathai Road, Bangkok in Asia Fax: 00 94 01 581116/501396 Tel: (662) 218 8200 Email: [email protected] Fax: (662) 255 2177 Website: http://www.undp.lk/ Email: [email protected]

National STD/AIDS Control Programme, Family Health International P.O. Box 567, Colombo 10 Asian Regional Office Tel: 695183, 667163, 667029, 696433 Arwan Building, 8th Floor Fax: 075 336873 1339 Pracharaj 1 Road Bangkok 10800 National Dangerous Drugs Control Board, Tel: (662) 587 4750 383, Kotte Road, Rajagiriya, Fax: (662) 587 4758 Tel: 868794, 868795, 868796 Email: [email protected] Fax: 868792 Website: http://www.fhi.org/en/cntr/ asia/asiaro/asiaaro.html Police Narcotics Bureau 3rd Floor, New Secretariat, Colombo 1. AIDS Network Development Foundation Tel: 324626, 447943, 447946, 332985 (AIDSNet) Fax: 440584, 332985 48/1 Anantasiri Tennis Court) Moo 3, Chang Puek Taiwan Chiang Mai -Lampang Road Chiang Mai, 50300 Dept. Humanities and Social Science Tel: 6653 222417 National Defense Medical Center Szu-Hsien Tony Lee, Ph.D. Northern Drug Research Centre No 161 Sec. 6 Min-Chuan E. Road, Taipei, Chiang Mai University Taiwan 00114 110 Intavaros Road, Chiang Mai 50202 Tel: 02- 87923100~18588 Tel: 053 942505 ext 107 Email: [email protected]

Department of Addiction Science Vietnam Taipei City Psychiatric Center GTZ HIV/AIDS/STI Control, 309 Sung-Te Road, Taiepi Room 402, 4th floor, Tel: 886-2-2728-5791 4 Tran Hung Dao Street, Fax: 886-2-2726-7246 HANOI. Email: [email protected] Tel: (84-4) 933 1379/80/81 Website: www.tcpc.gov.tw Email:[email protected] Website: http://www.gtz.de/vietnam/ Thailand UNDCP UNDCP 25-29 phan boi chau Regional Centre for East Asia and the Pacific Tel: 84 4 9421495 United Nations Building, 14th Floor, Email: [email protected] Rajadamnern Nok Ave, Bangkok 10200 Website: Tel: (0066-2) 288-2091 http://www.undcp.org/vietnam/index.html Fax: (0066-2) 281-2129 Email: [email protected] World Health Organisation Website: www.undcp.un.or.th 63 Tran Hung Dao Tel: (84-4) 843-3734, Fax: (84-4) 843-3740 The Centre E-mail: [email protected] for Harm Website: www.un.org Reduction

372 SECTION Contents > Section 3-Appendix 3 3 Ministry of Health - AIDS Division World Health Organization Dr. Trinh Quan Huan Avenue Appia 20 Director of Preventive Medicine 1211 Geneva 27, Switzerland Chairman, AIDS Division Tele: +41 22 791 2111 International Ministry of Health Fax: +41 22 791 3111 Contact List 138 Giang Vo, Hanoi Email: [email protected] Tel. No.: (84 4) 846 2364 Website: www.who.int/en Fax No.: (84 4) 840 507 Email: [email protected] UNAIDS - Joint United Nations Programme on HIV/AIDS Family Health International 20, Avenue Appia Thomas Kane, Country representative CH- 1211, Geneva 27, Switzerland Suit 201 , 30 nguyen du, Hanoi Tel: +4122 791 3666 Tel: 84 4 9431 828 Fax: +4122 791 4187 Email: [email protected] Medecins du Monde France (MDMF): Website: www.unaids.org/index.html Dr. Nguyen Quang Ngoc (Hanoi) Toserco Building, room 504 The International HIV/AIDS Alliance 269 Kim Ma Street, Hanoi Queensbury House Tel. 8464688 Fax 8464689 104-106 Queens Road Email: [email protected] Brighton, BN1 3XF, United Kingdom Tel: +44 1273 718 900 MDMF: HCMC Fax: +44 1273 718 901 Dr. Nguyen Dinh Tuan Email: [email protected] 11/5A Dang Van Ngu, Ward 10 Website: www.aidsalliance.org Phu Nhuan District Ho Chi Minh City Trimbos Institute - Netherlands Insitute of Tel: 08- 844 22 63 Mental Health and Addiction, Unit Fax: 08- 844 80 04 International Affairs. P.O Box 725 Email: [email protected] 3500 AS Utrect, The Netherlands Tele: +31 (0) 30 297 1100 General International Fax: +31 (0) 30 297 1111 International Harm Reduction Development Email: [email protected] Open Society Institute Website: www.trimbos 400 West 59th Street New York, NY, 10019 United States Imperial College of Science, Technology and Tel: 212 548 0677 Medicine. Fax: 212 428 4617 Centre for Research on Drugs and Health Email: [email protected] Behaviour, Imperial College Website: www.soros.org/harm-reduction Exhibition Road, London SW7 2AZ Tel: +44 (0)20 7589 5111 United Nations Office for Drug Control and E-mail: [email protected] Crime Prevention. Website: http://www.ic.ac.uk Vienna International Centre PO Box 500, A-1400 Vienna, Austria Johns Hopkins University, Tel: +43 1 26060 0 Bloomberg School Public Health Fax: +43 1 26060 5866 Department of Epidemiology, Email: [email protected] 615 N Wolfe Street, Website: www.odccp.org/odccp/index.html Baltimore, MD 21205, USA Email: [email protected] Website: www.jhu.edu

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373 Contents > Section 3-Appendix 3

WHO List of Appropriate Publications

Recommended Publications Evidence for Action Papers produced by The following publications are accessible WHO for Policy Makers on HIV/AIDS Manual for Prevention among Injecting Drug Users reducing drug through the following WHO website (www.who.int/hiv) These are expected online related harm from May 2003. It is recommended to check Topics of papers include the following: in Asia the web address for any new publications. • Nature and extent of HIV/AIDS among Burnet Institute. 2003. Policy and IDUs Programming Guide for HIV Prevention • Methods for assessing and monitoring Among Injecting Drug Users. Geneva, HIV risk among IDUs, its World Health Organization. health/social/economic impact and Burrows D. 2003. Advocacy Guide for effectiveness of interventions Effective HIV Prevention among Injecting Drug Users Geneva, World •Effectiveness of HIV information, Health Organization. education and communication Burrows D. 2003. Training Guide for HIV interventions for IDUs Prevention Outreach to Injecting Drug •Effectiveness of community-based HIV Users. Geneva. World Health interventions for IDUs Organization. •Effectiveness of sterile needle and syringe World Health Organization. 2003. Technical Guide to Rapid Assessment and programming (including other injecting Response. Geneva. World Health paraphernalia) Organization. (Various RAR guides are •Effectiveness of drug dependence available refer to: www.RARarchives.org). treatment in prevention of HIV among IDUs •Effectiveness of interventions for preventing sexual transmission of HIV among IDUs •Effectiveness of STI and HIV/AIDS treatment in HIV prevention among IDUs •Effectiveness of structural and environmental interventions for HIV prevention among IDUs •Effectiveness of interventions for young and new injectors •Effectiveness of interventions for marginalized and particularly vulnerable IDUs

The Centre for Harm Reduction

374 SECTION Contents > Section 3-Appendix 3 3 Other useful publications: Burrows D. 2000. Starting and managing WHO List of needle and syringe programs: a guide for Appropriate Central and East Europe and the Newly Publications Independent States of the former Soviet Union. New York. International Harm Reduction Development. [www.soros.org/harm- reduction/frame_publications.htm] UNAIDS. 2000. National AIDS Programmes: A Guide to Monitoring and Evaluation. Geneva. UNAIDS (refer to: www.unaids.org) UNAIDS/World Bank. 2002. National AIDS Councils: Monitoring and Evaluations Operations Manual. Geneva. UNAIDS (refer to: www.unaids.org) UNAIDS/WHO. 2000. Guidelines for Second Generation HIV Surveillance. Geneva. UNAIDS/WHO (refer to: www.unaids.org)

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375 Contents > Section 3-Appendix 3

Index

abstinence 359 circumstantial drug use 226 cocaine 225 Manual for Acquired Immunodeficiency Syndrome characteristics and effects 339-40 reducing drug see AIDS adequacy, of information 96 use, in Brazil 21 related harm AIDS 334, 359 community in Asia and HIV tests 282 definition 147, 359 incidence 333 support for harm reduction programs AIDS virus see HIV 146-52, 161 alcohol community development, defence against characteristics and effects 345-6 drug use 53 as a disinfectant 215 community networks, and drug user amphetamines 225 education 173 characteristics and effects 341-2 compulsive drug use 226 use in Australia 20 confidentiality, and HIV testing 275, 284-5 see also ecstasy constraints, and information gathering 95 anabolic steroids, characteristics and effects consultation 347 in planning education programs 183-4 anogenital warts 357 in mobilising community support 150-2 Asia core questions 106 HIV and IDUs 21-26 corruption, and the drug trade 47 audience, and information gathering 95 counselling 40, 359 Australia, HIV and IDUs 20 and HIV tests 276-9, 292-3 coverage, of information 95 benzodiazepines, characteristics and effects crop substitution 44 346 cultivation, of crops from which illicit drugs Beyond Appearances (newsletter) 180 derived 44-5 bleach, as a disinfectant 213, 215 blood borne viruses 195, 330-35 demand reduction 50, 54, 359 boiling, as a method of disinfecting 213, integration with other approaches 54-5 216 depressants 239, 255 Brazil detoxification 52, 230-2, 240, 359 cocaine use 21 diacetylmorphine see heroin HIV and IDUs 21 dish-washing detergent, as a disinfectant breastfeeding, and transmission of HIV 215 260-1 disinfecting, of used injecting equipment budgets 127 211-6, 219 buprenorphine 237-8, 241 disposal of unsterile equipment 216-7, 219 burnout 285, 289-92, 294 distribution see drug trafficking dosage, methadone 230-5 cannabis, characteristics and effects 340-1 drug counselling 281-2 chancroid 355 drug substitution 38, 229, 339, 359 chasing the dragon 359 see also buprenorphine; methadone children drug trade, magnitude 47 and HIV infection 17, 18, 19 drug trafficking 46, 47 China development 13,14 HIV and IDUs 25-6 routes 14, 21, 25 incidence of HIV among IDUs 25 and spread of HIV 16-17 opium addiction in 13 drug treatment programs 38, 52-3 chlamydia 354-5 as source of information for RSA 94 The Centre for Harm Reduction

376 SECTION Contents > Section 3-Appendix 3 3 drug use 225-8, 239 health risks, for injecting drug users 195, trends 15-16 199 Index drug users hepatitis 330-2 education 36, 170-83, 186-7 heroin 225 involvement in harm reduction programs characteristics and effects 338 36 seizure 46 see also injecting drug users heroin use drugs, seizure 46-7 growth 12 see also injecting drug users Eastern Europe, HIV and IDUs 27 hidden populations 172, 186 ecstasy, characteristics and effects 342 HIV 333-5, 359 education and breastfeeding 260-1 about drugs 50-1 death rate, in the US 20 for drug users 171-83, 186-7 epidemics in Asia 17 on safe injecting 36, 210-1 prevalence among IDUs 21-8 epidemics 17, 359 pregnancy-related transmission 259-66 ethnic minorities, and HIV infection 40 and reproduction 259-66, 267-8 evaluation 359 sexual transmission 249-57 of programs 130-5, 136 spread in Asia 16-17 experimental drug use 226 tests 40, 282-85, 293, 334, 360 transmission 335 feedback 135 between mother and child 259-61, finance, drug trade 47-8 viral load 252 focus group discussions 101 homosexual men follow-on questions 107-10 see men who have sex with men funding, of programs 126 Human Immunodeficiency Virus see HIV genital herpes 357 impact evaluation 131 Golden Crescent 13 indicators 132 Golden Triangle 13, 14, 359 implementation indicators 132 opium production 45 India and trafficking routes 13, 25 drug use 48 gonorrhea 354 HIV and IDUs 22 governments, policy responses to drug use indicators, use in evaluation 130-1 158-61, 163 information analysis granuloma inguinale (Donovanosis) 358 for program evaluation 133-4 group education 176-9, 187 for RSAs 96-7 information gathering hallucinogens 226, 239 for program evaluation 131-33 characteristics and effects 343 for RSAs 94-6, 113 harm reduction 54, 359 information management, for RSAs 96 defined 35 information analysis, for program evaluation goals 35-36 136 integration with other approaches 54-5 informed consent, and HIV testing 277-8, rationale 34-40 284-5 health care facilities, as source of information inhalants, characteristics and effects 345 for RSA 94

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377 Contents > Section 3-Appendix 3

injecting drug users monitoring 360 growth in numbers 12 of program 130-4, Manual for and HIV infection 17-28 of programs 137-8 reducing drug key resource in program planning 148-9 morphine 225 related harm men who have sex with men 309-11 MSM see men who have sex with men in Asia migrants 311-2 mobilisation 150 Needle and Syringe Programs 37, 199-202, need for information on sexual 216-7, 218, 360 transmission 252-4 needles in prisons 155-7 distribution through retail outlets 203 refugees 301-3 sale and purchase 39, 195 injecting equipment Nepal, HIV and IDUs 26 disinfecting 211-16, 219 NGOs sharing 195-7, 360 and program establishment 123-4 see also needles; syringes as source of information for RSA 95 injecting safely 194-221 support for harm reduction programs International Conference on Drug Abuse and 160 Illicit Trafficking, Vienna (1987) 50 nicotine, characteristics and effects 344 interventions non-government organisations see NGOs modifying 135, 138 NSPs see Needle and Syringe Programs planning 123-25, 137 interviews, conduct 99-105, 113 observation, information gathering technique 102-5, 113 law enforcement see police official corruption see corruption local government, support for harm one-to-one education 173-5, 187 reduction programs 160 one-to-one key informant interviews 101 LSD 226 opium 225 lymphogranuloma venereum 356 characteristics and effects 338-9 lysergic acid diethylamide 226 seizure 46 opium production 46 Malaysia, HIV and IDUs 23 opium use Manipur see India change to injecting heroin 12, 34 mass media, monitoring 97-8 in China 25 mass media education 182-83, 187 outreach 174, 203 MDMA see ecstasy men who have sex with men, risk of HIV peer education programs 38-9, 360 infection 17-18, 309-311, 310 performance targets 129 methadone 230-6, 240, 360 pharmacists, as source of information for characteristics and effects 348 RSA 95 methadone maintenance programs 38, 53, police 232-5, 240-1, 360 education 183-4, 187 Australia 20 and outreach workers 207, 209 methylenedioxymeth-amphetamine as source of information for RSA 95 see ecstasy and support for harm reduction programs migrants, risk of HIV infection 311-4, 317 153-5 mobile populations see migrants policy makers, education 183-4, 187 mobility, among IDUs 196 post-test counselling 278-9 pre-test counselling 277-8 pregnancy-related transmission, HIV The Centre 259-62 for Harm Reduction

378 SECTION Contents > Section 3-Appendix 3 3 primary health care 39 sexual transmission, HIV 25, 249-59, prisoners sexually transmitted infections 351-8 Index and HIV infection 40 sharing of injecting equipment 195-7, 360 risk of HIV infection 304-5, 315 shooting galleries 19, 24, 196-7, 205, 207, prisons 155-7, 162, 196 208, 360 processing, of opium into heroin 45 shopkeepers, as source of information for profit margins 47 RSA 95 programs social drug use 226 establishing and sustaining 122-44 social networks, and drug user education management 127-8 173 projects solvents, characteristics and effects 345 development plans 125-6 staff 128 management 127-8 see also burnout plans 125-9, 136-7 statistics, interpretation 96-7 prostitution, among refugees 301 STI clinics, as source of information for RSA 94 questions, in interviews 105-10, 114 stimulants 225, 239, 360 structured questions 105-6 rapid situation assessments 92-120, 183, supplementary questions 107-10 360 supply reduction 153, 361 recidivism 52 integration with other strategies 54-5 recreational drug use 226 supply routes see drug trafficking, routes refugees, risk of HIV infection 301-3, 315 syphilis 355 rehabilitation 53 syringes relapse 360 distribution through retail outlets 203 relevance, of information 95 exchange programs see Needle and religious groups, support for harm reduction Syringe Programs programs 152-3, 162 sale and purchase 39, 195 reproduction, and HIV 259-263, 267-8 round table discussions 102 target groups, identification 123 RSA see rapid situation assessments targeted education 179-81, 187 tests, for HIV 40, 282-5, 293, 334, 360 safe injecting Thailand, HIV and IDUs 21-2 education programs 36 time, and information gathering 95 removal of barriers 40 tobacco see nicotine safe injection 194-222 transport of drugs see drug trafficking school based education 51 treatment programs see drug treatment seizure of drugs 46, 47 programs semi-structured questions 105 treatment programs, see also drug serum hepatitis 331 substitution; methadone maintenance sex workers trichomonad infections 356 and HIV infection 40 tuberculosis, incidence in Asia 17 men who have sex with men 310 migrants 311 United Kingdom, HIV and IDUs 17-18 risk of HIV infection 306-8, 316 United States, HIV and IDUs 19-20 see also prostitution unsterile equipment, disposal 216-7, 219 used equipment, disinfecting 213-6, 219

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379 Contents > Section 3-Appendix 3

Vietnam, HIV and IDUs 23-4 viral hepatitis 330-2 Manual for viral load 252, 361 reducing drug viruses, blood borne 195, 329-35 related harm volatile substances, characteristics and effects in Asia 345

war on drugs, expenditure by US 48 window period, in HIV testing 284, 293, 334 withdrawal 361 women, position in society 257-9

youth education 187 education programs 184-6

The Centre for Harm Reduction

380 Contents

This publication was made possible through support provided by the Office of Strategic Planning, Operations, and Technical Support, Bureau for Asia and the Near East, U.S.Agency for International Development, under the terms of Award No. HRN-A-00-97-00017-00 to Family Health International.The opinions expressed herein are those of the author(s) and do not necessarily reflect the views of Family Health International or the U.S.Agency for International Development.

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