Pubdate: Wed, 31 Oct 2001
Source: Jakarta Post (Indonesia)
Copyright: The Jakarta Post
Contact:  http://www.thejakartapost.com
Details: http://www.mapinc.org/media/645
Authors: Alex Wodak, Joyce Djaelani Gordon
Note: Dr. Alex Wodak, Director of Alcohol and Drug Service, St Vincent's
Hospital, Sydney, Australia, and President of The International Harm
Reduction Association. Joyce Djaelani Gordon, Chairperson, Yayasan Kita
Addiction Treatment and Community Recovery Center, Cipayung, West Java, Jakarta

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".
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MAP posted-by: Lou King