A policy to be consolidated
by Bernard Kouchner
Minister of Health, France

The urgent need to fight the HIV epidemic has led most of the industrialised countries, especially the European ones, to set up strategies for reducing the risks of contamination to which drug abusers are particularly exposed. These policies have proved to be highly effective, since they have rapidly decreased the rate of HIV infection among this population: these efforts need to be sustained, however, as well as being adapted to fight the hepatitis C epidemic, another urgent issue, and extended to cover all the problems facing drug abusers, which have serious implications in terms of public health and damage to society.
In France, it was estimated that the HIV epidemic affected 40% of all the drug abusers in 1987, and the Ministry of Health therefore decided in 1989 to authorise the prescription-free sale of syringes to adults at chemists' shops. In 1993, a voluntaristic overall policy came into force, in which provision was made for the following:
• more extensive health care coverage for drug users in the framework of the general health care system (hospital care, city hospital and general practitioners' networks),
• Harm reduction initiatives,
• and setting up structures providing substitutive treatment.
As in most countries where policies of this kind have been adopted, a set of action principles was defined and applied, as follows:

Finding responses to the underlying public health and social problems
Taking steps to prevent contamination by the AIDS and hepatitis viruses as well as to avoid the complications resulting from drug addiction and abuse: those due, for example, to injecting products under unsuitable conditions, or to the social problems caused by isolation, nomadism and the various emotional, family and occupational rifts with which the history of drug addicts is beset. Taking steps to accompany drug users who have not yet decided to give up taking drugs. Reaching out inclusively in this way means paving the way to help even the most socially excluded drug abusers.

Providing drug abusers with the means of preventing contamination:
• authorising the prescription-free sale of syringes (in single units) and preventive kits ("Steriboxes" and other kits) at chemists' shops,
• installing 270 vending machines and/or kit vending and/or exchange machines in 60 communes,
• setting up 100 syringe replacement schemes (mobile units, fixed points, street workers) with the help of associations and the participation of former addicts, drug prevention workers, educators and nurses providing sterile equipment, information and advice and giving drug users a hearing.
• access to substitutive maintenance programmes (using methadone and Subutex®*)

Opening special meeting places
The first meeting places for active drug users were opened in June 1993 in Marseille and Paris. By the end of the year 2000, 42 "drug boutiques" had been created. These pioneering points of contact involved a whole range of different projects, practices, beneficiaries and field workers, but they were all based on similar outreach and care provision strategies.
Syringe exchanges were basic to all these points of contact. Thanks to the spirit of warm, open hospitality in which these places are run, they serve several functions: they restore the body by providing simple medical aid, access to showers, washing equipment and food supplements; they create or restore social links by giving people an opportunity of chatting over a cup of coffee and exchanging syringes; they are educational establishments where there is a set of rules which have to be either obeyed or discussed: within this solid framework, drug abusers can re-discover what it means to respect and be respected by other people; and they are a place of guidance, since the workers act as mediators and facilitate the users' access to the health care and social services to which they are entitled.
These places are not intended to deal with drug addiction itself. The broader networks to which these groups of workers belong therefore play a vital role: drug users can be accompanied to hospital outpatient consultations, medical centres and social services by people who will help them to open the doors.
These meeting places are the first step towards a system capable of helping those excluded from all existing social spheres. Some of the people targeted at these centres will obviously either not be willing to join the health care system, or will not yet be able to do so. These "last resort" places of refuge must be non-intrusive, otherwise the drug abusers might reject them and go back on the streets. By accepting and respecting people as they are with no questions asked, it is hoped to possibly help them to communicate and then to start moving in the right direction.

Developing outreach initiatives
Most drug abusers have benefited from none of these schemes so far, of course: those living on the farthest fringes of society under highly precarious conditions and the youngest members of these communities, who are also the most vulnerable, can be reached only by associative initiatives where the workers go out to meet them in their squats or on the streets, where self-support is a decisive factor. These associations have to fit in with local policies.
Developing peer education and self-support systems with the help of former drug addicts is central to all these schemes, but it is necessary to recognise the role of the peers who participate and to give them a proper status.
These policies are having concrete, measurable effects everywhere: In France, fewer new cases of contamination by the HIV virus are now occurring among drug abusers (who accounted for 14% of all the new cases in 2000, as compared with 22% in 1994). Although the prevalence has been reduced (by 20%, according to the 2000 survey on syringe exchange programmes), drug abusers are still the group in which the rate of HIV infection is the highest. These efforts must therefore be sustained, especially as the prevalence of hepatitis C in this population has been reported to be as high as 70%. Harm reduction policies of this kind have often been rather shaky, especially in France, because public opinion ignores and fails to recognise them. They therefore need to be consolidated and extended by political and public health decision-makers, who should make strong commitments on these lines as well as promoting concerted co-operative efforts between countries.

Source: PEDDRO december 2001