Sun, 02 Feb 2003

Harm reduction is safe and effective: WHO

I Wayan Juniartha, The Jakarta Post, Jakarta

The controversial harm reduction approach, whose introduction has met with strong opposition abroad, is gradually gaining ground in several countries as a true complement for two previous drug eradication approaches: remand reduction and supply reduction.

Tom Moore of the World Health Organization (WHO) said here earlier this week that the harm reduction approach had gained support in several countries because, contrary to popular belief, this program was not only safe, but also effective and cost- effective in addressing the HIV/AIDS epidemic.

"By 2000, the needle and syringe program in 103 cities across Australia had prevented 25,000 HIV infections and 21,000 HCV (Hepatitis C) infections. By 2010, it will have prevented 5,000 HIV-related deaths," he said.

Moreover, from 1991 to 2000, the Australian program, which cost US$75 million, had saved about $1.3 billion, which would have otherwise been spent on HIV/AIDS-related costs, such as medical treatment.

"An international review has reported the decrease of HIV prevalence by 5.8 percent in 29 cities with the program, and an increase of HIV prevalence by 5.9 percent in 52 cities without the program," he said.

The harm reduction approach has been implemented in various degrees in areas throughout Europe, Latin America, India, Southeast Asia and Australia.

In Indonesia, two pilot projects of hospital-based methadone maintenance treatment have been introduced in Jakarta and Bali. In addition, two small-scale needle and syringe programs have also been launched in these two areas.

Currently, over 20 non-governmental organizations (NGOs) across the country are working hard to promote the harm reduction approach.

The introduction of the harm reduction approach was driven by the failure of the two other approaches -- demand reduction and supply reduction -- to address the real problems of drug-users.

Demand reduction is mainly achieved through education, drug treatment and community development. Meanwhile, supply reduction is conducted mainly through law enforcement activities aimed at destroying the ability of drug syndicates to produce, process and distribute illicit drugs.

With the advent of the HIV/AIDS epidemic among Asian injecting drug-users in the middle of the 1980s, it became evident that the demand reduction and supply reduction approaches could not cope with the epidemic's deadly speed.

Data from Myanmar, India, China, Thailand and Vietnam showed how the prevalence of HIV/AIDS among injecting drug-users skyrocketed by 60 percent to 90 percent in just six months after the first case was reported.

In several areas, 60 percent of the drug-users had reportedly contracted HIV in the first two years of injecting, providing the evidence for the explosive nature of the epidemic.

The epidemic's spread is at an immense speed because of the rising population of drug-users. These drug-users are involved in various high-risk activities, particularly needle-sharing and unprotected sex, according to harm reduction expert Dave Burrows.

"This population can then transmit the disease to other groups of people through their sexual partners, or in the case of drug- users, who are also sex workers, via their clients," said Burrows during a workshop on harm reduction here earlier this week.

Unlike the demand reduction and supply reduction approaches, the harm reduction approach focuses its efforts on short-term strategies to reduce various adverse health and social impacts caused by dangerous drug-using practices.

In the words of Jimmy Doorabjee, a leading and pioneering figure in India's harm reduction program, harm reduction aims at "keeping the drug-users alive and healthy as long as possible before they make the final choice of quitting or continuing their drug habit".

"There is no point in devising an abstinence-oriented long- term program when the drug-users die in the process."

The approach relies on two things: the hierarchy of means and the active involvement of drug-users.

Hierarchy of means involves urging drug-users to stop using drugs. Second, if a drug-user insists on using drugs then they are urged not to inject them.

Third, if a drug-user insists on injecting, then they are urged not to use needles or other injecting equipment. Last, if needle-sharing does occur, then the drug-users are advised and trained in sterilizing their injecting equipment.

The harm reduction program mainly consists of a primary health care program, peer education, peer outreach, counseling, HIV testing, drug treatment and substitution -- using Methadone or Buprenorphine pills -- and a sterile needle exchange.

The needle exchange is also known as the needle and syringe program, and is aimed at reducing the dangerous needle-sharing habit by providing drug-users with either sterile injecting equipment or better and sufficient access to the equipment.

The needle and syringe program is perhaps the most criticized component of the harm reduction approach, as it has been accused of condoning drug use, increasing the number of new drug-users, interfering with the law enforcement's clampdown on drug-users and wasting taxpayers' money.