Harm reduction: A necessary solution to IDU/HIV dilemma

Chris Green, AIDS Activist and advocate, Jakarta

Nowhere in the world is the practice of harm reduction, as explained in the accompanying article, uncontroversial. For a start, even those among us who understand the basics of drug use and abuse often find it difficult to appreciate the logic of providing substitute drugs or clean needles to drug addicts.

Surely we are trying to cure them of their addiction, not sustain them in their habit?

But the fact is, even the best-run drug treatment centers have a very low success rate. Some may claim that they "cure" a large percentage of those they accept, although such figures are often questionable. But even if correct, that leaves at least half with their habit, continuing to use drugs. Should we ignore them?

It is generally accepted that a large proportion of addicts can conquer their addiction -- in time. It may take five years or 10 years or even longer, and countless attempts, before they finally become "clean". And they can then return to being productive and profitable members of society -- but only if they are still alive and healthy.

If they have become infected by life-threatening diseases, such as HIV or hepatitis C, they'll remain a burden on society. The investment that society has made in their upbringing and education will have been lost.

Thus, our objective must be to allow them to pass through their drug-using phase, however long that may be, and come out at the end with their health unaffected. This is one of the main aims of harm reduction.

Illicit drug use places many burdens upon society. The fact that it is illegal increases the cost of the drugs, with the result that addicts often must steal or commit other crimes to support their habit, a harm that we all feel and fear.

Jailing drug users costs society much more than treating them. The corruption that accompanies drug trafficking -- that allows it to continue to exist, despite expensive law enforcement efforts -- is also a huge burden upon society.

There is often a misconception that equates harm reduction with distribution of clean needles or substitute drugs to drug users. While these are indeed components of a comprehensive harm reduction program, such programs cannot succeed without other elements.

Perhaps the most important of these, as identified in a recent report by the UN body responsible for drug control, is that of reaching out to drug users.

Drug users are frequently isolated from society, and excluded from the very support that will help them to overcome their addiction. Thus outreach, encouraging them to accept that society cares about them, must often be the first step in addressing their problems. This is often best done by peer support, using active drug users or ex-users to talk to them -- such marginalized groups will often trust their peers far more than others, however good their intent.

Peer educators can inform them about the risks they are taking and how to minimize these risks. Outreach workers can encourage them to seek treatment for their addiction or other problems.

Such outreach programs should therefore be supported by other services that form part of the harm reduction continuum. Drug users must have access to primary health care: Too often community health centers are less than welcoming of drug users.

They must also be able to access voluntary counseling, testing and treatment for HIV and hepatitis C, infections that so often accompany the sharing of needles, which is commonly the practice among uninformed or poor drug users. Outreach must also extend to other populations at risk, particularly those in prison or in refugee camps.

What progress has so far been made in Indonesia? We know a little about the negative progress -- a huge explosion of infection by HIV and hepatitis among injecting drug users that is only now becoming apparent as it spreads into the general population. We can only guess at the size of this epidemic; some experts believe that we cannot avoid more than one million Indonesians becoming infected, although we may prevent the second and third million if we take urgent action.

On the positive side, a greater appreciation of the importance and urgent need for harm reduction programs is becoming apparent -- the fact that these articles are being published is evidence of this. Many in the Ministry of Health are extremely concerned and are encouraging responses. The visit by the Minister of Health to an outreach center in Melbourne during his current visit to Australia demonstrates a new level of determination to find solutions.

Yayasan Pelita Ilmu in Jakarta and Yayasan Hati-hati in Bali both have embryo harm reduction programs in place, reaching out to the poorest drug users. Plans are advanced for maintenance programs in both cities, to replace heroin use with methadone or buprenorphine. These drugs, which are taken orally, may be considered as similar to the insulin that diabetics must take every day or the medicines that those with chronic heart conditions must take continually to stay healthy.

Most of us find it difficult to understand what drives addicts to continue using drugs, often in a manner that they know is injurious to their health.

But there is much evidence from around the world and in Southeast Asia that the application of harm reduction principles can be a first step along the road to treatment for these addicts and a return to productive life. With perhaps as many as five percent of our future generation at risk, surely it behooves us to take a pragmatic approach to save them.