ASIA. The state of emergency

by Isabelle Célérier
©Swaps

The 12th International Conference on the Reduction of Drug related Harm was held in April 2001 in New Delhi.
According to Pat O'Hare, Chairman of the International Harm Reduction Association (IHRA) which staged the conference, "the epicentre of the HIV epidemic looks as if it will soon shift from Africa to Asia, where drug injection is now one of the main causes of the spread of the infection". Taking stock of the situation and the harm reduction policies.

1. INDIA
The high rates of buprenorphine injection recorded have surprised many observers from Europe, where this product is mainly used as a substitute for drugs in the treatment of addicts.

India, the host country for the 12th Interna tional Conference on the Reduction of Drug related Harm, is currently the country with the second highest estimated number of people infected with HIV (between 3 and 8 million), and 89% of all the declared cases of AIDS in this country are between 15 and 45 years of age. The first case of HIV infection among drug users was recorded in 1989 in Manipur, but the results of various studies have shown that the prevalence of the infection in this sector of the population is more than 70 %. in some regions of the north-eastern states. The rate of infection among drug users was found to vary from 2% in Kolkata to 10% in Mumbai (Bombay), and from 20% in Chennai (Madras) to as much as 80% in Imphal.

In the eighties, the traditional use of opium gradually gave way to the use of heroin (brown sugar), a practice which was first adopted by urban youths but spread to rural areas. Opiates, especially raw opium, heroin and, to a lesser extent, buprenorphine, dextropropoxyphene and codeine are now commonly used by adults. Besides the use of heroin, the latest trend consists in fact of injecting pharmaceutical products. After first appearing in the northeast of the country and spreading throughout south-eastern Asia, this epidemic of intravenous abuse of pharmaceuticals, especially buprenorphine, has been facilitated by the great availability of injectable preparations. The high rates of consumption of injected buprenorphine have surprised a number of observers from Europe, where the drug is used as a substitute for oral heroin, especially in France, where it can be prescribed by general practitioners. Buprenorphine, which was discovered in 1973, was first used for its antalgic properties before being earmarked for the treatment of drug dependency: it induces moderate, heroin-like euphoria without any of the sedative, dysphoric and hallucinatory effects which accompany the use of heroin.

Several Indian studies have noted in this context that the recent increase in buprenorphine abuse has been paralleled by a decrease in heroin addiction. After extending the possibilities available for treatment to be provided in special centres in the framework of general hospitals and placing the management of these centres in the hands of the Ministry of Health, the Indian government, since 1998, has supported a number of pilot schemes in this field, such as those designed to set up SEP's (syringe exchange programmes). These initiatives are concentrated for the moment, concentrated in the north-east of the country.

There are more than 25,000 intravenous drug users (IVDUs) living in Delhi, the capital, where heroin is widely used. However, those who inject are usually the least well-off of all the opiate users, and they therefore tend to favour the less costly cocktails of easily obtainable pharmaceutical products.

John Francis at the Sharan mutual-aid association, an organisation that runs an HIV and STD prevention programme in Delhi and 4 other Indian towns, has made an important point, "It isn't easy to create an association to aid the drug users in India because the first priority is food and shelter".

As David Thapa at the same association has pointed out, the drug users are good communicators, however. "They have never heard of AIDS before the start of the programme but they have passed the message on, and it has even spread to areas outside Delhi. Many come in to the centre every day wanting to help the others. Many of them can't read, but those who can read the brochures to the others". Information written in Hindi might seem essential, but very little backup material is currently available in that language. "Everyone is afraid of dying, he continues. Why shouldn't they be too? When someone is feeling ill in the neighbourhood, they come and tell us. They should be encouraged and we should thank them for helping."

2. BANGLADESH
Most of the drug injectors in this country are in Dhaka and North Bengal. According to the survey carried out on 1,300 or so users, the incidence of needle sharing used to be extremely high (93% in Dhaka and 96% in North Bengal). However, in the year 2000, most of Dhaka's 7,000 injectors and a quarter of those in North Bengal were targeted by a Syringe Exchange Programme (SEP). As a result, the proportion of those shooting "safely" in North Bengal rose from 4% in 1998 to 45% in 2000. Never theless, 86% of the users continue to share syringes when no such programme is available, as against 32% when a SEP has been set up.

In Dhaka, in the wake of a comprehensive programme (designed to approach people living on the streets to reduce the occurrence of abscesses, treat STDs and change sexual behaviour by encouraging safe sex) a high rate of syringe exchange (82 %), was observed between October 1997 and April 2000, along with a significant decrease in needle sharing (which fell from 81 % to 25%), as well as a decrease in the number of cases of syphilis (from 28% to 13 %) and no significant increase in the incidence of HIV (from 1 % to 2.5%).

The practice of injecting cocktails of pharmaceutical compounds increased sharply, however, on the streets of Dhaka during the first six months of the year 2000. This sudden change was due to the disappearance of the "favourite drug", buprenorphine, when its production by an Indian pharmaceutical firm came to a standstill.

The price of buprenorphine, which is marketed under the various names Hydrabad, Madras and Tidigesic, increased 4 to 7 fold. The outcome was that users began injecting cocktails of sedatives and antihistamines, intravenous injection increased (previously, half of all the users practised intra-muscular injection), abscesses became more common and there was an increase in petty crime.

For associations such as the "Shakti Project of Care", this is a new challenge which requires new strategies such as peer education, checking the quality of the buprenorphine in the hands of users, dealing with the problem of overdoses resulting from the injection of cocktails of pharmaceutical products, and possibly teaching safer methods of injecting the aforementioned drug cocktails.

But, as one a project worker asked, "How do you make Harm reduction an acceptable strategy? Hard drug users are discriminated against, stigmatised and marginalised. The only drugs which are socially acceptable are raw opium, alcohol and cannabis for smoking purposes".

In order to respond to the demand among users wishing to overcome their addiction, the Shakti Project has established lowcost, short-term (two-week) "treatment camps". During their stay, staff members accompany each user night and day to help the person overcome "withdrawal symptoms that can be very difficult to handle during the first 2-3 days". About 60% of those who have frequented these camps have gone back to using drugs, especially those receiving little family support. The remaining 40% are still "clean" after 6 months and seem to have resumed a normal life.

Other programmes set up in 1999 in two other towns in the north-west likewise confirmed that the "favourite drug" is now buprenorphine and that 90% of the users share needles. However, once an SEP is operating, the rate of syringe exchange and the return of used syringes can be as high as 95%, which shows that real awareness of the risks has arisen among the users. But here again, as the directors of the Shakti Project have pointed out, one has to "deal with political decisions to clean up the streets and close down the shooting galleries as well as addressing public hostility".

3. INDONESIA
Indonesia has around 1.5 to 2 million drug users (out of 203 million inhabitants), the majority of whom live in the big cities, particularly in the shantytowns of Djakarta. During the last two years, there has been an exponential increase in the number of recorded cases of HIV among the country's drug users, and this number increased twelve and a half fold between 1999 and 2000.

A study carried out in eight towns shows that the majority of the users are aged between 16 and 24, and that 80% of them inject heroin (of a low purity, cheap, and increasingly available grade), while the rest use crystal -methamphetamine. 70% share their syringe with at least two or three other people, while only 5% use clean equipment. 65% are sexually active, but less than 10% use condoms.

Previous studies carried out in two areas of Jakarta also showed that 60% to 70% of the young men between 15 and 25 years of age used narcotics and other "dangerous substances", and 60% injected their drugs. 70% of the latter had shared their syringes in the course of the previous month, and half of them had done so two or three times that very week. 75% had had sexual intercourse, but only 41 % used condoms. Practically none of them had heard of HIV or AIDS. The authors of these studies expressed the view that "Harm reduction programmes continue to come up against numerous obstacles, mainly due to the law which makes it necessary to have a prescription in order to obtain a syringe. People still think that providing free syringes might encourage the use of drugs".

4. VIETNAM
The first case of HIV was reported in Vietnam in 1990. Ten years later, the epidemic had spread to all 61 of the country's provinces. In the year 2000, 26,333 cases of infection were registered, most of which involved drug users (65% of the total number) and sex workers (4% of the total number). The first aid projects (which were financed by the UNDCP) were set up between 1997 and 2000 at five pilot sites providing needle exchange and free condoms -"after solving a few problems linked to the refusal of the police force to co-operate". As stated by a representative of the UNDCP, "The government's recognition that Harm reduction measures are an important part of the national anti-AIDS campaign has been an important step, and the acceptance of these measures on a smaller scale at family and local community level has also helped to create an environment which is favourable to achieving changes of behaviour".

5. CHINA

The first case of HIV infection in an IDU was officially diagnosed in Peking in 1996. A high rate of needle sharing (65%) and the lack of availability of condoms led to an increase in the infection rates among these same users, which had risen to 22% by the end of 1997. In Peking, thanks to a peer education programme, where a "trained" user can reach and teach 10 others on average, safe sex and safe injection practices have become more widespread and the rate of needle sharing has decreased conspicuously. As the spokesman for the project has said, "peer education is feasible in China and seems to be a good way of educating the community. Some initial data have been obtained which suggest that this approach may have reduced the incidence of HIV among the drug users".

1 *Contact:sharanindia@vsni.com

2 From Tareque Golam et Greg Monica. SAKTI Project, CARE-Bangladesh. Contact : Tareque@carebangladesch.org

3 From Surahya P., Sragin F., Sari K. Center of Health Research University og Indonesia. Contact : phitunk@yahoo.com

4.From the United Nations International of Drug Control Programme (UNDCP), 25-29 phan Boi Chou Street, Hanoi. Contact : huongthu@un.org.vn

5.From Wei L., Chen J., Li Z., Li R., Liang Q., Zhu Q., Razak MIT. Beyrer C., Yr X., Lai S. Guangxi AIDS Surveillance and Testing Centre. Contact : gastc@public.nn.gx.cn

Source: PEDDRO december 2001