Harm reduction: A necessary solution to IDU/HIV dilemma

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.