ACCEPTING DRUG REALITIES TO SAVE LIVES

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".