The beginnings of Harm Reduction

Author: Jimmy Dorabjee

The beginnings of harm reduction in the context of drug use is difficult to clearly define, as harm reduction is now equated with HIV prevention for PWID and not as drug treatment. This is mainly the outcome of many years of concerted advocacy efforts promoting needle syringe exchange and methadone or buprenorphine substitution, much after the HIV epidemic had swept through PWID in many Asian countries. In South Asian countries, harm reduction services, particularly opioid substitution therapy, are only provided to drug injectors as an HIV prevention strategy. It is still debated whether non injectors should be eligible to receive methadone or buprenorphine substitution.

The earliest methadone program began in Hong Kong much before HIV infection entered the consciousness. The Hong Kong Methadone Treatment Program is operated by the Department of Health of the Government of the Hong Kong Special Administrative Region. The methadone program started in 1972 as a pilot serving primarily as a crime prevention initiative. In 1976, it was formally launched and currently there are 20 clinics across the region. Today, the program is well accepted and broadly recognized and has continued to provide services at easily accessible centers suited to the schedules of working PWID. One of the outcomes of the methadone program in Hong Kong is that it maintained low HIV prevalence among MMT participants through the years, averaging 0.3 to 0.4 per cent during 2004-2008 (UNODC and UNAIDS, 2009).

Hong Kong’s methadone clinics have provided an important link between marginalized people and health and social services. Apart from medical assessments by doctors, services provided at the clinics include counselling by doctors, social workers and peer counsellors, referral services including the referral of HIV positive methadone users to the Department of Health HIV clinic and tetanus vaccination.

Nepal is bordered by countries with extensive HIV epidemics among PWID, including Myanmar and North East India. The Lifesaving and Life giving Society (LALS), a community based NGO established in 1991, began outreach services with needle syringe exchange to PWID in Kathmandu, Nepal. The outreach teams included ex-drug users, nurses and social workers. LALS is widely recognized as the first known harm reduction program in Asia. A year later in 1992, Sharan an NGO in Delhi with community health clinics and drug treatment programs for marginalized communities, began a small scale pilot buprenorphine substitution program for heroin users from the slum colonies in Delhi, India. The pilot was evaluated by the Indian Council for Medical Research in 1996 who reported the program had established the efficacy of buprenorphine treatment, was acceptable to heroin users, appeared to induce a low level of physical dependence and significantly diminished the self-administration of heroin. In 1999, Sharan initiated partnerships with 6 NGOs in the cities of Chennai, Imphal, Kolkata and Mumbai to provide a range of harm reduction initiatives including OST, NSP, wound and abscess management and treatment for STI among 1500 PWID and their sexual partners. When the project ended in 2002, over 20,000 drug users had received harm reduction services and set the stage for government acceptance and endorsement for harm reduction.

Like many of its neighbours in the region, Bangladesh had witnessed a rapid shift from oral use to injecting of drugs, along with a surge in risk related behaviours among the drug users. Bangladesh is surrounded by countries with significant HIV epidemics among PWID. In 1998, CARE Bangladesh began a needle exchange program in Dhaka City that was later expanded to other major cities. The high coverage of the needle exchange program in Bangladesh has successfully maintained low HIV prevalence among the estimated 20,000 to 40,000 PWID.

In Kuala Lumpur, Malaysia the IKHLAS Centre began providing drop in health facilities for drug users on the streets of Chow Kit, also giving out needles and syringes in 1994. In Mae Chan district of Northern Thailand bordering Myanmar, a community based needle exchange for the Akha tribals from 3 villages began in 1992. As a result of opium eradication and easy availability of cheap heroin, the Akha had switched from traditional opium use to the easily available high quality Burmese heroin. The village committee in each village undertook the responsibility for distributing clean needles and syringes and disposing of old ones.

All these were small scale harm reduction programs that proved valuable in demonstrating that harm reduction was not only a western concept and could be done in Asia, but they were too few and small in scale to have any measurable impact.
The early history of the development of harm reduction in Asia would be incomplete without mention of some important initiatives that played a catalytic role and set the stage for what followed. In 1994 Dr Nick Crofts from the Macfarlane Burnet Centre for Medical Research, Melbourne and Dr Alex Wodak from St. Vincent’s Hospital, Sydney, in collaboration with Aaron Peak and Sujata Rana from the Lifesaving and Lifegiving Society, organized the first workshop on harm reduction in Asia in Kathmandu, Nepal. The workshop was attended by many Asians who went on to become leaders in the Asian harm reduction movement.

In 1995, an article published in the journal AIDS by Nick Crofts and colleagues described the few harm reduction programs in Asia and concluded that the “prevention of HIV infection among PWID is possible and occurring in Asia on a small scale and that the urgent challenge is to increase the scale of what is now a demonstratedly effective response to meet the scale of the epidemic (Crofts et al, 1995)”.
In 1996, the Indian State of Manipur in North East India, struggling to cope with high levels of drug injecting and extremely high HIV prevalence rates, became the first in Asia to adopt Harm Reduction as the official State Policy to address HIV amongst PWID. With 80% of PWID infected with HIV, Manipur had the dubious distinction of being called the AIDS capital of Asia.

In 1996, at a satellite workshop held just after the International Conference on the Reduction of Drug related Harm in Hobart, Australia, representatives of the few Asian harm reduction programs met to share their experiences for development of a manual on harm reduction in Asia. Authored by Nick Crofts, Genevieve Costigan and Gary Reid from the Centre for Harm Reduction, Burnet Institute, Melbourne, the Manual for Reducing Drug Related Harm in Asia was published in 1999 and became a seminal publication that was one of the main resources available to Asian audiences.

The participants at the satellite workshop in 1996 decided to form the Asian Harm Reduction Network to nurture and support harm reduction in the Asian region. The network soon became instrumental in advocating and promoting harm reduction and linking the few isolated programs in the region and a forum for disseminating information on good practices in Asia through newsletters and a website, exposing harm reduction to a much wider audience. Initially based at the Macfarlane Burnet Institute for Medical Research in Melbourne, Australia, the Secreteriat moved to an office at the Centre for Disease Control, Region 10, Chiang Mai, Thailand in 1997. At the same time, UNAIDS and WHO began to endorse and promote harm reduction principles and methodology to prevent and control the rapid diffusion of HIV epidemics among PWID across the region.

Another significant development in the regions response to drug use and HIV came from the UN. Co-chaired by UNAIDS and UNODC, the United Nations Regional Task Force on Drug Use and HIV/AIDS Vulnerability in Asia and the Pacific was established in 1997 to support the United Nations System identify priorities and propose strategies, guidelines and options for collaborative activities on HIV vulnerability and drug use in the Asia Pacific region.(United Nations, 2006) The Task Force went through two distinct phases, starting with a period of confrontation between the public security and public health authorities. However, drug control and HIV prevention activities implemented on the ground catalyzed an environment more conducive to the second phase, one of advocacy and dialogue.

Holding regular meetings, the Task Force was a forum for collaboration between a wide range of stakeholders. Regional meetings held in China, Indonesia, Myanmar and Thailand between 1999 and 2001 were an important forum for moving the agenda at the country level. The Task Force generated better communication, especially on sensitive issues such as HIV risk in prisons, between different agencies in countries with assistance from international experts. The regional meetings allowed the host countries as well as the participants and observers to share information and discuss plans to implement HIV prevention programs for drug users and their families. In 2005, the Task Force was reconstituted and renamed the United Nations Regional Task Force on Injecting Drug Use and HIV/AIDS for Asia and the Pacific and continued to lobby for policy change to enable harm reduction in the region.
Technical assistance, capacity building and training programs were organized by UN organisations, academic and medical research organizations, funders and INGOs targeted at government, law enforcement and public health authorities. These workshops introduced evidence of the effectiveness, health benefits and cost effectiveness of harm reduction, and created the enabling environment that resulted in changes to laws and policies legitimizing harm reduction. The substantial funding made available for HIV prevention among PWID by development agencies, notably the Australian AusAID, United Kingdom’s DfID and the United States USAID, significantly contributed to the piloting, initiation and establishment of harm reduction in countries across the region.

By the early 2000s, many Asian countries began to embrace harm reduction principles and initiate HIV prevention programs for people who inject drugs, followed by the expansion and scale up of programs. At the end of 2010, out of twenty five Asian countries reporting the injecting of drugs, sixteen countries had endorsed harm reduction in their national policies and introduced needle and syringe programs, while twelve countries had begun opioid substitution therapy, mainly with methadone and buprenorphine (IHRA, 2010).