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 The Centre for Harm Reduction 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. The Centre for Harm Reduction 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 The Centre for Harm Reduction 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. The Centre for Harm Reduction 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.