Accepting drug realities to save lives

Dr. Alex Wodak, Director of Alcohol and Drug Service, St Vincent's Hospital, Sydney, Australia, and President of The International Harm Reduction Association. Joyce Djaelani Gordon Chairperson, Yayasan Kita Addiction Treatment and Community Recovery Center, Cipayung, West Java, Jakarta

Indonesia now faces a serious threat from HIV among its rapidly increasing number of injecting drug users (IDUs). A recent report from Monitoring the AIDS Pandemic (MAP) Network notes a stark increase of HIV levels among Indonesian IDUs from 15 percent in 1999 to 40 percent in 2000, followed by an equivalent increase of HIV levels among sex workers.

It will soon be followed by an increase of HIV among the general population, including pregnant women, just like in Thailand.

In 1987, HIV in Thailand grew from less than 1 percent to more than 40 percent of IDUs in just 10 months. Within five to six years in the northeast of Thailand, one in six male military recruits and one in eight pregnant women had become infected. Now, almost 2 percent of the Thai population is infected.

Similar epidemics have occurred in other parts of the world. Yet countries which adopted harm reduction approaches such as Australia, New Zealand and the Netherlands have managed to either avoid these epidemics altogether or bring small epidemics quickly back under control.

In contrast, countries that focused on eliminating illicit drug use, such as the U.S., have not only failed to create drug- free nations, but have also seen HIV spread rapidly among IDUs and their general populations. More than a quarter of the 40,000 new HIV infections in the U.S. each year involves IDUs.

Harm reduction refers to policies and programs that primarily aim to reduce complications of mood altering drugs; be healthy, socially or economically. Most often, it is used to ensure that HIV does not spread rapidly among the IDU communities, and from them to the general population.

Harm reduction approaches started becoming established in the developing world from early 1990s. Nepal, India, Bangladesh, Vietnam and some other Asian countries have now established harm reduction programs to control HIV among IDUs. The problem is that they are not established fast enough to control the spread of HIV.

As a pragmatic way to respond to illicit drug use, harm reduction recognizes that we do not know how to ensure that IDUs would stop injecting immediately. Some drug users do not want to stop, while others badly want to, but are unable to.

Harm reduction deals with those who are unable or unwilling to stop. It includes explicit education about the risks of sharing needles and syringes, preferably with active involvement of drug users in designing and implementing education campaigns.

Also, sterile needle and syringe utilization programs are required to try and ensure that as many injecting episodes as possible involve the use of sterile injecting equipment. Needle and syringe exchange or distribution programs are at the center of this work.

Drug treatment is required which is attractive, readily available and based on evidence of effectiveness. While a diverse range of options work best, methadone programs for heroin users have been shown to be most effective in attracting and keeping large numbers in treatment and slowing the spread of HIV.

Finally, community development among drug users is needed to ensure that they become part of the solution rather than part of the problem.

There are many parallels between a harm reduction approach to injecting drug use and traditional public health responses to many common health problems. Attempts to control sexually transmitted infections cannot be based on efforts to achieve total abstinence from sexual activity. That is unachievable.

Use of the term "harm reduction" and interest in the philosophy increased substantially in the early 1980s, following recognition of the AIDS epidemic and the realization that the sharing of injection equipment was a major risk for the transmission of HIV. When attempts to reduce risk episodes have been pursued to their maximum, sensible public policy requires that attempts are also made to reduce the hazardousness of each remaining risk episode.

The defining characteristic of the major alternative approach to harm reduction is an overriding emphasis on reducing or even eliminating consumption. The level of adverse consequences then becomes very much a secondary consideration. However, reducing the consumption of drugs does not necessarily reduce harm and has often inadvertently exacerbated it.

The well-intentioned closure of opium dens throughout Asia one or two generations ago saw opium smoking in elderly men disappear, only to be replaced by heroin injecting among young and sexually active men. This has prepared the fertile soil for a public health catastrophe of unimaginable proportions.

Some mistakenly regard harm reduction and abstinence as mutually exclusive options. True, abstinence is the most complete form of harm reduction, however, abstinence is often the least feasible and sustainable option. Relapse is very common, accompanied by increased risk of adverse outcomes.

The single-minded pursuit of abstinence can have serious unintended negative consequences and exacerbate harm.

Attempts to reduce the demand or supply of drugs are not incompatible with harm reduction, provided that the overriding objective remains the reduction of harm, rather than the reduction of consumption per se.

The way Indonesia responds to the threat of HIV infection among IDUs will affect the health and well being of several future generations.

If Indonesia responds by attempting to create a drug-free nation, there will be many unnecessary deaths, much misery, occupied hospital beds and extremely high social and economic costs. A burden Indonesia can do without in the light of its current economic and financial condition.

If Indonesia is to avoid such high costs, it must adopt harm reduction strategies immediately. If we respond pragmatically, acknowledging that injecting drug use cannot be eliminated, many of the serious adverse effects of drug use can be minimized.

Dave Purchase, who founded the first needle syringe program in the U.S., said "we may not be able to stop young people being silly, but we can stop them being dead".