Rapid spread of HIV among drug users calls for action

Rapid spread of HIV among drug users calls for action

Joyce Djaelani Gordon, Chairperson, Kita Foundation, Addiction
Treatment and Community, Recovery Center in West Java, Jakarta

The latest, most up-to-date report on the spread of HIV in
Asia released by the Monitoring the AIDS Pandemic (MAP) Network
shows how Indonesia, Iran, Japan, Nepal and Vietnam have
registered a marked increases in HIV infection.

Two years ago, these countries reported a fairly slow spread
of Human Immunodeficiency Virus (HIV).

The report, which was released on the eve of the 6th
International Congress on AIDS in Asia and the Pacific (ICAAP) in
Melbourne last month, highlights specific examples of the rapid
HIV spread among specific sub-populations, such as among
injecting drug users (IDUs) in Indonesia, where HIV levels have
increased from around 15 percent in 1999 to 40 percent in 2000.

The increase of HIV prevalence among IDUs in Vietnam and Nepal
have also been similarly dramatic in recent years.

According to the MAP Network, the interface between sexual and
drug-using behavior indicates that the spread of HIV between
population groups is more widespread than previously thought.
"Most drug users are sexually active men. Many have steady
partners, are sex work clients and some finance their drug habit
by selling sex. A recent phenomenon is that many sex workers are
turning to intravenous drugs." Translated into simple terms,
reducing harm among IDUs will rapidly reduce HIV among the
general population.

In a special session titled "Scaling Up Harm Reduction in
Asia", which was co-sponsored by the World Health Organization
(WHO) and the Asian Harm Reduction Network during the AIDS
Congress in Melbourne, WHO's director Gundo Weiler emphasized the
role of harm reduction as a crucial element of comprehensive
HIV/AIDS strategies.

It is clear that WHO is now advocating harm reduction
strategies in the region. Therefore, the Indonesian government is
likely to follow future regional guidelines on this issue and
prepare to undertake harm reduction work with IDUs. The drug-for-
drug strategy the government is now slating is a simple beginning
to more comprehensive harm reduction strategies.

The dramatic increase of HIV infection among IDUs in Indonesia
is worrying. We are not fully prepared to face an epidemic when
we are already burdened with various other issues. That is why
effective and proven prevention strategies should be carried out
immediately.

Yet, although support to move in this direction is beginning
to increase, there are still some who are against these
strategies, either because they are misinformed, do not
understand addiction, or because they are even less aware about
HIV, drug-related harm and how this affects the country on a
national scale.

In confronting drug problems, there are groups who can be
categorized as "supply reductionists" -- those who believe that
focus should be given to finding ways to cut supplies of illicit
drugs and using the full strength of law enforcement. Another
group, "demand reductionists", are those who believe we should
focus on finding ways to prevent drug use and to rehabilitate
those with drug problems. With HIV in mind, we now have "harm
reductionists" who are more concerned about cutting down the
amount of harm that is related to drugs. There is a place for
each of these approaches and there are places where supply
reduction, demand reduction and harm reduction overlap.

Those focused on supply reduction strategies - feeling that
demand reduction programs are a waste of money - often make calls
for tougher laws as the panacea for drug problems in the country.
Demand reductionists on the other hand, often think that we can
cure every single case. The reality is, putting people in prison
not only places a financial burden on the government but it is
also not much of a solution because many prisons do not have
programs to deal with drug abuse.

News of rampant drug dealing in prison is still fresh in our
minds. IDUs, who have been through prison, report a very high
incidence of needle sharing, leading to the rampant spread of HIV
and Hepatitis C Virus (HCV) in prison, which in turn leads to an
added health cost to be carried by the government in later years.
Even countries with stringent laws continue to fail to keep their
countries free of drugs.

On the other hand, demand reductionists who call for
prevention and rehabilitation often forget that most are not
going to listen to prevention messages, even if the messages are
accurate, comprehensive and widespread, like what we find in
developed countries. And those who do become addicted will only
find themselves admitted to a rehabilitation center after years
of use.

Imprisonment, death by overdose or driving accidents under the
influence of alcohol and drugs, drug-induced mental damage and
finally infection of incurable blood-borne viruses such as HIV
and hepatitis, are just some of the costs we must look at. And if
we are to rehabilitate all cases of drug abuse and addiction, we
must remember that we are dealing with close to four million drug
users. Indonesia simply does not have the resources, manpower and
the finances necessary to do this on a national level. However,
if we wait for more resources and manpower, many lives will
already have been lost.

Demand reductionists hope that drug abusers will achieve
sustained abstinence. There is nothing wrong with that, because
sustained change or abstinence is ideal, so ideal that it is
parallel to achieving a gold medal in sports. Yet, we know that
winning a gold medal takes learning and practice. In other words
it is a process.

From the perspective of harm reduction, would it be acceptable
to teach a person how to swim if the conditions for learning puts
them in real danger of losing their life? If a person cannot
swim, do we take them to the deep end of a pool for their first
lesson and leave them there? If we know that a person may
relapse, as most addicts do, is it acceptable for us to risk
their life by withholding lifesaving information and tools to
protect them and others around them from ever getting infected by
HIV and HCV? Would that not be parallel to shooting them on the
spot, along with their sexual partners and those they have shared
risky behavior with?

Tools to reduce harm can be applied in all situations, be it
on the street level, where resources are low and hamper
treatment-seeking behavior, in prison, or in counseling centers
or any other service points where the drug abuser or addict may
show up. Its simple objective, which is to reduce harm for anyone
using drugs, decreases potential harm and cost to those around
them. It has also been shown that harm reduction approaches often
motivate people to ultimately stop using drugs.

Are you sure your loved ones are not using drugs? Or perhaps,
that your child is not using drugs, or dating and having sex with
an IDU? If you are a typical parent, like many parents of addicts
who come to Yayasan Kita recovery center in Cipayung, you
probably don't know. Most parents find out that their children
use drugs only a year or so after they have first started. You
cannot always tell an addict from their appearance and you cannot
tell who has HIV or HCV from how they look. And if your loved
ones are in fact using drugs, would it not be better if you could
get them off drugs before they get HIV or HCV from needle
sharing? Would it not be great if someone out there told them the
facts and gave them lifesaving tools while you yourself were
sleeping?