The new era: Harm Reduction in the context of HIV

Author: Jimmy Dorabjee

The acceptance, development and expansion of harm reduction programs in countries that have traditionally employed deterrence and punishment as the primary response to the use of drugs is a remarkable achievement and a triumph for public health. What is striking is that in a few countries harm reduction has been driven by law enforcement agencies responsible for the administration of drug control. For example, while the Ministry of Health in Myanmar procrastinated for years, the Central Committee for Drug Abuse Control (CCDAC) recognized the serious consequences of not responding to the high HIV prevalence among Burmese PWID on the country’s future and supported the initiation of needle syringe programs and other harm reduction initiatives in Myanmar.

In spite of the continued growth and use of compulsory drug treatment centers, China has made some bold changes in laws and policies to facilitate the implementation and scale up of harm reduction. In response to the emergence and escalation of HIV among PWID as well as the high relapse rates from abstinence based treatment, China introduced NSP and methadone maintenance in 2004 Zou. 2002) and has since dramatically scaled up the number of methadone maintenance treatment (MMT) clinics and NSP outlets across the country. With its immense political and economic influence over other SE Asian countries, China presents a shining example of pragmatic public health by adopting harm reduction policies and scaling up interventions to manage the impact of HIV among drug users (Wu et al, 2007).

The vigorous scaling up of the methadone program in China is numerically stunning; from 34 MMT clinics at the end of 2004 (Zuo, 2002) to 500 MMT clinics by early 2008, and more than 680 clinics covering 27 provinces and serving some 242 000 heroin users by the end of 2009. The number of new HIV cases prevented due to the MMT programme during 2008 and 2009 is estimated at 3,377 and 3,900 respectively (UNGASS, 2010). Other benefits attributed to the national MMT programme include a reduction in consumption of heroin by an estimated 16.5 tons and 22.4 tons, respectively, and a reduction in the value of the drugs trade by an estimated 6.077 billion RMB and 8.3 billion RMB, respectively (UNGASS, 2010).

As a consequence, MMT is considered a crime reduction strategy that is strongly supported by the Public Security Bureau in China, and MMT has been incorporated into the AIDS Regulations as a treatment for heroin dependence Wu et al, 2007). Recognizing the role of law enforcement as a barrier to HIV prevention among drug users, a Training Module for Law Enforcement on Harm Reduction was developed and introduced by the AusAID funded Asia Regional HIV/AIDS Project in 2005-06, and is now an integral component of the training curriculum for police officers at the Yunnan and Guangxi Police Academies (Asia Regional HIV/AIDS Project,, 2005).

In Vietnam as in China, policy is now guided by pragmatism and evidence to support harm reduction for HIV prevention among drug users, despite the retention of otherwise severe policies towards drug users (Hammett et al, 2007). Under the legal framework of the Law on HIV, the national pilot MMT program began in Hai Phong and Ho Chi Minh City (HCMC) in May 2008 and in Ha Noi in 2009.Ministry of Health, Viet Nam, 2010) Currently methadone clinics are functioning in eleven centers and will be scaled-up to 245 MMT clinics by 2015 covering about 80,000 heroin users (IRIN, 2011). But these changes did not materialize overnight; they were the result of a combination of efforts over many years by different parties to showcase, sensitize and convince politicians, public health, and law enforcement agencies of the benefits of alternative approaches through workshops, study tours to other countries, conference attendance and initiation of pilot projects.

In Malaysia, drug control through strict legal sanctions and severe punishments was the predominant response to drug use. Recognizing that this approach failed to control HIV among people who inject drugs, the Malaysian government accepted harm reduction and started needle and syringe programs and opioid substitution therapy as a means to reduce HIV transmission among PWID. Buprenorphine has been available in private clinics since 2002 and methadone was first introduced in 2005 in government-sponsored healthcare settings. The pilot methadone maintenance therapy program in 2005 was under the Ministry of Health and government hospitals began methadone services as part of the program. The success of the program led to an expansion in the coverage in 2007 to 5,000 drug users. By June 2010, there were 211 free methadone service delivery outlets with 13,471 registered clients, while an additional 20,000 individuals were accessing fee-based substitution treatment through private practitioners. Over 18,000 PWID have accessed sterile injecting equipment through the 240 service delivery sites. Needle and syringe programs in Malaysia have mainly been the responsibility of civil society groups and this continues to be the case.

While the examples above have been showcased due to the immense impact the changes in government policy have had on the lives of millions of drug users, other initiatives owned by civil society and people who use drugs have also arisen.

Of particular noteworthiness is the Asian Consortium on Drugs, HIV, AIDS and Poverty (ACDHAP) whose Response Beyond Borders (RBB) consultations have brought grass roots workers, people who use drugs, politicians, civil society, UN and parliamentarians together on a platform to seek Asian solutions to Asian problems. The RBB consultations have provided the forum for the development of the Asian Network of People who Use Drugs, and seeded the Asian Parliamentarians for Harm Reduction, a group of Asian Parliamentarians who are supportive of harm reduction.

Another noteworthy development is the Asian Network of People who Use Drugs (ANPUD), the first registered regional network of people who use drugs was established by people who use drugs to unify the voices of their communities to advocate for changes in drug laws and policies that negatively affect their lives and for better access to prevention, treatment and care services across Asia. ANPUD currently has over 250 members in 11 countries throughout the Asian region.

In January 2008, the Response Beyond Borders “First Consultation on the Prevention of HIV Related to Drug Use” in Goa, India, provided a platform for Asian drug user activists to hold a regional consultation and develop the Goa Declaration, building on the Vancouver Declaration (talkingdrugs, 2011), that gave birth to ANPUD. Between 2008–2009 members of ANPUD, now an informal network, set up a Google group forum with the main purpose being to engage with membership to develop the constitution and governance structures.

A small group began to draft a formal constitution that would be necessary to register ANPUD as a non-profit entity. At the same time members met regularly and informally during key events such as the International Harm Reduction Conference in Bangkok in 2009, the Response Beyond Borders Workshops in Phnom Penh and Kathmandu and the International Congress on AIDS in Asia and the Pacific (ICAAP) in Bali.

Since its registration in Hong Kong in February 2010, ANPUD has made its presence strongly felt in the region. Members are involved in a broad range of activities and events in partnership with WHO, UNAIDS and UNODC and are currently conducting a study on the barriers faced by people who inject drugs in accessing hepatitis C diagnosis and treatment in four Asian countries. A hepatitis C regional advocacy strategy to pressurize ministries of health, the Global Fund and UN organisations to provide hepatitis treatment for PWID is being developed.

The formation of ANPUD is underpinned by the principle of “Meaningful Involvement of People who Use Drugs ” (MIPUD), with a strong belief in unity, support, equality, inclusiveness, collaboration and the will to change the current situation faced by people who use drugs in the Asian Region. ANPUD promotes the MIPUD principle in all aspects of the harm reduction response, and believes that people who use drugs must be actively involved and engaged in the design, implementation and evaluation of programs. ANPUD has vigorously campaigned against the detention of people who use drugs in compulsory treatment centers. ANPUD has been actively involved in the development of the new WHO Regional Strategy titled ‘A Strategy to halt and reverse the HIV epidemic among people who inject drugs in Asia and the Pacific, 2010 – 2015 (WHO, 2010).

In the past 18 months, ANPUD has established or strengthened National Networks of people who use drugs in India, Nepal, Indonesia and Malaysia. ANPUD continues to advocate for the harmonisation of policies, decriminalisation of drug use and reducing the stigma and discrimination faced by people who use drugs across the region. Further, ANPUD advocates for universal access to a range of diverse, evidence based, locally driven harm reduction approaches in conformity with the ‘WHO, UNODC, UNAIDS Technical Guidance'(WHO/UNODC/UNAIDS,2009) in the Asian region with a special focus on access to Hepatitis C diagnosis and treatment.