UNDP HIV and
Development Programme HIV and
Injecting Drug Use: December 2000 Paul Deany Contents Preface The current situation Understanding the problem Policy issues Programming issues Actions for UNDP to consider Conclusion Endnotes Appendix I: A Framework for Understanding and Responding to the Development Challenges posed by HIV and Drug Use
Preface The HIV epidemic is a new, complex phenomenon in the world today. It is challenging accepted ways of understanding health and human development, and is demanding new forms of expertise and a more integrated and collaborative development practice. It is raising significant conceptual, ethical and programmatic issues. From the beginning, the HIV and Development Programme has drawn attention to the complex and dynamic relationship which exists between the HIV/AIDS epidemic and development. Many of the commonly acknowledged impediments to development, such as social and economic inequality, environmental degradation, political instability, civil disorder and the absence of good governance are also key driving forces behind the spread and unfolding of the HIV epidemic. Through its extensive range of publications, and in particular through its series of Issues Papers, the Programme has encouraged consideration of the epidemic in relation to critical (and sometimes neglected) aspects of development. This tradition is continued here in a paper which explores different aspects of the relationships between HIV, injecting drug use and development. This paper is the result of extensive review of available documentation and dialogue with a range of partners in the field. It is neither exhaustive nor definitive, nor is it intended to be so. As an Issues Paper, it is most appropriately considered a 'working draft': the distillation of experience, reflection and observation from the perspective of an experienced, engaged practitioner. The paper has been reviewed and revised several times over, with each new version generating further questions and discussion: providing some indication of its success as a trigger for discussion and as a tool towards enhanced understanding of UNDP's role in relation to them. As with all Issues Papers, the views expressed in this paper are those of the author and they do not necessarily reflect those of the United Nations Development Programme. We encourage reproduction of the material and welcome acknowledgement, comment and feedback. Mina
Mauerstein-Bail
Acknowledgements The author would like to thank the following people for their time and comments: Mina Mauerstein-Bail, Benjamin Brown, Desmond Cohen, Peter Gordon, Catherine Hankins, Bruce Harland, Nick Crofts, Jean Wyldbore, Penny Martin, Peter Deutschmann, Bruce Parnell, Gary Reid, Christina Gynna Oguz, Juana Tomas-Rosello and Chris van der Burgh.
Executive Summary
A needle-syringe
exchange programme and drop-in centre run by New Delhi agency,
SHARAN.
Injecting drug use (IDU) is well known as a way to spread HIV, as are ways to prevent HIV transmission among injecting drug users (IDUs). But the growing number of developing countries experiencing new and uncontrolled HIV spread among drug users demonstrates that many communities currently lack the capacity to control these epidemics. Economic, political and social changes are compounding this situation and increasing peoples’ susceptibility and vulnerability. Fear, denial and discrimination are also making HIV prevention among injecting drug users a low national and global priority, despite the huge threat this problem poses to development. A growing number of countries urgently need assistance to develop the policies, strategies and programmes required to deal adequately with this significant development problem. What is lacking most is an understanding of the particular challenges that injecting drug use and HIV pose for achieving sustainable human development (Brown, 1999). To respond to this challenge, this report has been prepared in collaboration with UNDP’s global HIV and Development Programme and the UNDP Asia-Pacific Regional Programme on HIV and Development. This report was developed with advice from UNDCP and UNAIDS, and through in-depth consultations during late 1999 in Asia (Pakistan, India, Thailand and Vietnam) and Central and Eastern Europe (Russia, Ukraine, Lithuania, Poland and Romania). Drawing on these consultations, this report presents a basic framework for understanding both the challenges injecting drug use presents to sustainable development and the clear actions that can now be considered by relevant UN agencies, governments and other development partners. Acknowledging that HIV epidemics among injecting drug users are much easier to prevent than control, this report stresses the need for urgent action. But the report also acknowledges that injecting drug use is a highly complex and evolving development issue. Ongoing analysis, consultation and policy dialogue continue to be needed in order to understand and respond more effectively.
Particular Relevance to UNDP Since its inception, the UNDP HIV and Development Programme has drawn attention to the complex and dynamic relationship which exists between the HIV epidemic and development. (Mauerstein-Bail, 1999). But our understanding of the specific challenges to development posed by HIV epidemics among IDUs is still far from adequate. The spread of HIV among IDUs highlights many development issues. It is notable that some of the countries and communities most at risk from HIV and injecting drug use are often some of the least developed. Drug use and HIV affect the most vulnerable and marginalised groups within communities: from slum populations in New Delhi and hill tribes in Northern Thailand, to disadvantaged young people in Central and Eastern Europe. When IDUs are women, the stigma and vulnerability they face is even worse. Development problems foster drug problems. Communities in remote areas, which are marginalised and have little control over their economic and social development, are natural habitats for the cultivation, trafficking and consumption of narcotic drugs. Drug production leads to economic dependence on drug traffickers, not to social and economic development. Increased drug use also leads to increased health problems in producer countries, especially where the use and sharing of needles for injecting drugs facilitates the spread of HIV (Ahmed, 1988). Risk behaviours leading to HIV transmission through shared needles and syringes are closely linked to development problems such as poverty and lack of sustainable livelihoods, exploitation, inadequate education and political repression. The exact nature of the links between risk behaviours and specific development problems remains unclear. Exploring these links, potentially, could make a significant contribution to increasing understanding of both development and the epidemic. Injecting drug use destroys social cohesion and erodes social capital. Through the cumulative loss of potentially important contributors to society, ultimately, injecting drug use undermines sustainable human development. Injecting drug use poses an enormous threat to sustainable human development. In countries such as Russia (which has as many as 700,000 IDUs), Ukraine (200,000+ IDUs), Pakistan (180,000+ IDUs), and India (400,000+ IDUs) the current scale of injecting drug use creates a potentially massive group of susceptible individuals for the further spread of HIV. Experience from other countries demonstrates that, once HIV enters the injecting population, countries can expect large and sustained HIV epidemics. This is now the case in China, Malaysia, Vietnam, Russia and Ukraine, countries where injecting drug use accounts for more than 60% of all HIV infections. The impact this will have on the Human Development Index (table 1, page 12) in these countries will be considerable. New patterns of drug use appear, influenced by the interplay of macro social, economic and political factors. In the Newly Independent States in Eastern Europe (NIS), for example, it seems to be no coincidence that rapid spread of drug use and drug injecting has occurred since 1990, paralleled by major social dislocation and change. Shifts to private economic production have occurred in the context of sharp declines in gross domestic product and have led to dramatic unemployment, increased income differentials and poverty, and the rapid expansion of criminal economies. Further suggestions of the link between social conditions and ill-health are indicated by the parallel increases in alcohol consumption and morbidity (Rhodes et al, 1999). In Asia, economic, social and political instability is similarly paving the way for increases in drug production, injecting drug use, sex work and cross border migration - all recognised factors in the spread of HIV. Shifts in trade, transportation and communication networks across Asia are also facilitating the spread of drug injecting, needle-sharing and consequently, of HIV (Rhodes et al, 1999). Social and Ethical Issues As is the case with drug use in general, injecting drug use often provokes moralistic or judgmental attitudes and responses. Perceiving (and treating) drug users as a ‘species apart’ may reinforce a sense of moral superiority, but it is unproductive and indefensible. Potentially, anyone could become an injecting drug user or find themselves the parent, partner, child, sibling, colleague or friend of a user. Stigmatising and marginalising injecting drug users are likely to leave them alienated, fearful, and out of touch with the support and services they may most need. Legal and ethical factors are also creating challenges to the enabling environment. For example, the illegal nature of drug use can lead young people to hide their drug consumption, preferring to inject rather than risk detection through the smell of smoking. This is despite the risk that injecting poses for HIV transmission through clandestine sharing of injecting equipment (Parnell and Benton, 1999). Current responses In the face of these difficulties, there is a growing body of experience in the development and implementation of effective HIV prevention responses among IDUs and willingness on the part of many policy and programme designers to consider the various strategies that could be tried. These include drug and HIV/AIDS policy reform, methods for involving affected communities in developing responses, outreach and peer education, needle and syringe exchange, and drug substitution programmes to decrease injecting. Countries experiencing these epidemics may lack the capacity to develop policy and programmatic responses which deal appropriately with injecting drug use. Where responses are developed, they mainly target the long-term goals of eradication of drug supply and drug use, rather than the more pressing problem of HIV transmission. Redressing this imbalance is a major challenge for the development community. The relationship between IDU and HIV transmission is also different in each location. Changes to policies and programmes must therefore be developed separately through a process of ongoing analysis, policy dialogue and monitoring of responses. Challenges to development Despite recent expansion of responses, within individual countries, these tend to be several years behind the pace and scale of the actual epidemic. This appears to be the result of a range of factors closely linked to development and including:
The challenge then, is twofold. Firstly, new ways need to be found to build the capacity of communities to understand and respond more effectively to this emerging development problem. At the same time, donors, governments and the international community need to be persuaded to make HIV prevention among injecting drug users a much more urgent global priority, as well as a local reality.
How can UNDP respond to the challenge? UNDP and partner agencies, especially UNAIDS and UNDCP, are in a unique and appropriate position to take the lead in the planning and implementation of responses in the following areas:
These strategies should reflect the broader development framework within which UNDP operates. UNDP and its partners should be encouraged to work towards integrating understanding and appropriate policies on IDU and HIV within overall development objectives. This report supports this integration through the identification of a number of practical actions that UNDP can take.
This report at a glance HIV and injecting drug use: the situation
Gaps in responses: We know how to stop HIV transmission among injecting drug users but are struggling to do so in most developing countries. Reasons for this include:
Current responses: Whilst current responses lag years behind the epidemic, there is increasing evidence to show that HIV can be prevented among IDUs. Proven approaches include:
Responding to the challenge: UN agencies need to expand their action on HIV among IDUs. Key areas for possible action by UNDP include:
1. The Current Situation Drug use Methodological note on different types of drug use and HIV transmission. Various forms of drug use contribute to the spread of HIV. Alcohol consumption and marijuana smoking, for example, influence sexual behaviour. But this paper focuses primarily on injecting drug use, especially needle and syringe sharing, as this poses the most direct and immediate risk for drug-related HIV transmission in developing countries. n the wake of economic, social and political changes over the last decade, a growing number of countries have experienced increases in illicit drug trafficking together with consequent increases in drug-injecting, needle-sharing and HIV transmission. Today, more than 200 million people use illicit drugs - from glue-sniffing street children to teenage Ecstasy users to "hard-core" heroin addicts. Injecting illicit drugs is increasing around the world and is currently estimated to involve 20 million people in 134 countries (Crofts, 1999). The drug problem is multidimensional. It spans political, economic, geographic, social, legal, health, and cultural spheres and affects all sectors of the community. Drug use is responsible for lost wages, soaring health care costs, broken families and disintegrating communities. Countries world wide, both industrialised and developing, spend large sums of money to strengthen their police forces, border patrols, judicial systems, addiction treatment and health care programmes. The social costs are equally staggering, though more difficult to measure (UNDCP, 1999: www.undcp.org).
From drug trade to drug use With increasing law enforcement, refinement of drugs has moved closer to production areas. As a result, there has been a sharp increase in the use of developing countries for trafficking and transit of illicit crop-based and synthetic drugs. Some producer countries have become consumer countries also and some consumer countries have become producers of illegal drugs (UNDCP, 2000). These changes in production and distribution patterns are exposing new populations to injectable opiates (heroin) and amphetamine-type stimulants, both for their consumption and their trade. Together with increases in drug consumption, the pattern of drug use is also changing radically. Probably the most common shift has been from smoking of opium to the injecting of heroin and other injectable drugs, as a result of law enforcement. The injecting equipment used is often un-sterilised, and sharing of equipment is common, for reasons explored below. From a public health perspective, this shift is disastrous, as injecting drug use fuels the rapid spread of injection-related diseases such as HIV and hepatitis. World wide, the commonest injected drugs are heroin, amphetamines and cocaine, though many other drugs are also injected, including tranquillisers and other pharmaceuticals. The particular drug injected depends on availability and cost (which, in turn, often depend on geographic proximity to production areas or trafficking routes), personality traits and peer group norms, among other - poorly understood - factors.
Another feature of the growth in drug trafficking has been the close relationship between the spread of HIV infection among injecting drug users and the routes of drug trafficking. These trafficking routes have become more unstable over time as intense efforts by law enforcement to control drug supplies have resulted in the movement of these routes to new areas where there are temporarily lower risks. Unfortunately this instability of drug trafficking routes exposes additional large populations to the risk of HIV infection among injecting drug users. The growth in illicit drug use
Injecting drug use and HIV transmission The global spread of injecting drug use since the 1960s has set the scene for massive outbreaks of HIV infection among injecting drug users, their sexual partners and children. According to recent estimates by the United Nations International Drug Control Programme and the World Health Organisation, 114 countries are now experiencing HIV transmission among IDUs (Ball, 1999): more than double the number in 1992. It is now estimated that the cumulative number of HIV infections among injecting drug users could have risen to a figure as high as 3.3 million (UNDCP, 2000). Stimulated by changing economic and social conditions, the rise of drug injecting is adding another dimension to the vulnerability of people to HIV. Injecting a substance contaminated with HIV directly into the blood stream is a particularly efficient means of transmission than occurs for example through sexual activity. Injecting drug use can play a critical role in determining how and when the epidemic begins within a region together with the ways in which it unfolds (Cowal, 1998). The most rapid increases in HIV among IDUs, have been in developing countries and in countries in transition. In some countries - such as Kazakhstan, the Russian Federation, Ukraine, Malaysia, Vietnam and China - drug injecting is the major cause of HIV infection.
Table 1: Countries consulted by UNDP involvement in illicit drugs and HIV-risk*
Code: DU = Drug users; IDU = injecting drug users; N/A = not available, PLWH - Person Living with HIV *Methodological note: These figures and comments are based on estimates and opinions gathered and then triangulated from expert key informants, WHO, UNAIDS and UNDCP surveillance reports.**The Human Development Index was developed by UNDP and is published every year in The Human Development Report. The HDI measures a country's achievements in terms of life expectancy, educational attainment and adjusted real income.
In many other regions, including South and South East Asia, Northern Africa, Eastern Europe, and increasingly West Africa and Latin America, drug injecting is proving to be a major factor behind sustained and often explosive HIV epidemics. In addition to being among the most populous parts in the world, these countries are also experiencing dramatic economic and social change. The regions witnessing the most rapid spread of HIV among IDUs, almost a decade apart, are south East Asia (since 1986) and the NIS (since 1995). (Rhodes et al, 1999). Injecting drug use: fuelling national HIV epidemics In South East Asia, injecting drug use has been a major factor in initiating and sustaining widespread HIV epidemics since the 1980s (Crofts et al, 1998, Reid 1998). The impact of these early HIV and IDU epidemics has been well documented:
This pattern of explosive localised epidemics among IDUs followed by sustained national epidemics appears set to repeat itself in South Asia:
In Central and Eastern Europe, injecting drug use has been the major cause of new HIV infections. Since 1995, there has been evidence of rapid HIV spread in Belarus, Kazakhstan, Moldova, Russia, and Ukraine, with estimates suggesting that between 50% and 90% of new HIV infections are occurring among IDUs:
The evidence is now overwhelming that when HIV is spread through injecting drug use, the epidemic can accelerate rapidly. The prevalence of HIV among people who inject drugs has risen from zero to 30 percent within 12 months, in many cities including New York, Edinburgh, Bangkok, Ho Chi Minh City, Manipur, Riuli, Kaliningrad, Svetlogorsk, Odessa and Nikolayav (Stimson et al, 1998). This pattern of explosive infection rates is very common where injecting drug use is the mode of transmission. The social and behavioural factors behind this spread are complex and have been inadequately explored in the context of developing regions. Injecting drug users are widespread, mobile and sexually active (Stimson, Unpub). In many places, transmission through sharing of injecting equipment has soon been followed by extensive sexual transmission as the sexual partners of drug users interact with others through prisons, the sex industry and committed relationships.
Injecting drug use and HIV infection
2. Understanding the problem Why are most developing countries failing to respond adequately to the development challenges posed by HIV among injecting drug users? Why are a small number of countries succeeding? What are the reasons behind successful and unsuccessful responses? And what are the particular challenges to development posed by injecting drug use and HIV? This section provides a framework for analysing some of the social, cultural, political and economic factors surrounding injecting drug use and HIV transmission. In many developing countries injecting is a relatively new way of transmitting infectious disease. It is also behaviour about which relatively little is known. HIV infection among injecting drug users is a new phenomenon in many places and current policies and programmes may be insufficiently relevant to the specific challenges posed by contemporary drug use. The factors precipitating these new epidemics are multiple, but most are directly linked to sustainable human development. The wider social, economic and policy environment surrounding illicit drug use probably has more impact on HIV transmission and illicit drug use than any other factor. Syringe sharing, for example, is not merely a product of individual risk ‘calculus’ and immediate setting, but is also contextually determined by:
To understand more fully why drug injecting and needle-sharing behaviour are increasing in developing countries and why these countries are failing to respond appropriately to the associated health and development threats, it is necessary to explore some of the contextual and development factors which affect drug use and HIV.
Drug use and developing countries Developing countries suffer far more, both numerically and socially, from the consequences of drug misuse in comparison with developed countries. While developed countries have structures and mechanisms to deal with drug addiction, developing countries may lack necessary "know-how", infrastructure and resources to address adverse social and health consequences associated with drug addiction. At the same time, disintegrating social conditions in urban areas often provide fertile ground for the spread of substance use among young people and the economically disadvantaged (DOH International, undated). An understanding of the micro and macro risk environments in which HIV epidemics occur is an important element of developing effective responses. Key macro factors which create the environmental conditions for new and continuing epidemics include:
It has become increasingly apparent that developing countries are more seriously affected by the problems of drug use, drug trafficking and organised crime than was previously imagined. This is especially the case in communities in poverty stricken areas - such as those dependent on cash crops to forge an existence – and those in slum areas of cities where desperate, unemployed individuals become drug dealers and users in order to survive (Ahmed, 1998). People who produce drugs often inhabit remote areas, living on the margins, socially, geographically and economically. For example, countries such as Myanmar, in and around the golden triangle drug production region are experiencing widespread HIV epidemics among IDUs. In many locations, increases in drug use are directly associated with lack of development and may even be an indicator of this. Efforts to eradicate drug production and trafficking can easily lead to increased poverty in these areas, as it is may prove difficult to generate income from alternative activities. Problems associated with drug use contribute to development problems. The cost of drugs, reduced productivity from drug use, unemployment and associated crime all contribute to poverty and social dislocation. The consumption of drugs places street-children in a downward spiral of poverty and exploitation. In many countries the combination of involvement in illicit drugs, crime, violence and prostitution has adverse effects on families and the social situation of women (Ahmed, 1998). The causes and consequences of the HIV epidemic among drug injectors are similarly linked to other barriers to development including poverty, migration, gender inequity and governance. For example, women carry a disproportionate share of the burden of social disruption and destabilisation. This has resulted in increasing numbers of single parents, alcohol and drug use and rising delinquency among young people, all of which disproportionately affect women (UNDP, 1999).
Drug users: high risk, but low priority Drug users face widespread stigma and discrimination which, coupled with the fact that they may be living under extremely disadvantaged conditions, render them particularly vulnerable to HIV infection. Injecting drug users are not a homogenous group: people inject drugs in all countries, among many different ethnic groups, in both rural and urban areas. Nonetheless, common to many IDUs in developing regions is a set of socio-economic conditions which combine to make drug users highly vulnerable to HIV. These conditions include:
In urban settings, drug users are often uneducated, homeless or living in slum conditions. In rural areas, they are located in remote regions where drugs are produced and trafficked. In both instances, drug users have little access to the support, information and services necessary to protect them from becoming infected with HIV. Why are more people using drugs? Increases in the numbers of drug users in Asia and Central and Eastern Europe have been closely linked to situations of massive unemployment, high demand for drugs together with expansion of informal economies including drug trafficking. Drug use increases with social and economic dislocation, rising unemployment, psychological stress, and inadequate health care. The behaviour which places IDUs at risk of HIV infection is the consequence of specific social and political factors. These are exacerbated by the social, economic and political changes occurring in Asia and Central Eastern Europe. Shifts in trade, communication and migration, for example, facilitate the transfer of knowledge about techniques of drug consumption, encouraging new routes of drug administration such as injecting. Why do people inject drugs? Several factors contribute to the trend toward injecting drugs. These include the presence of other forms of drug taking, the influence of migrating drug users, the custom of injecting for self-medication, involvement in the cultivation and manufacture of drugs, proximity to drug trafficking routes and the availability of drugs which are easy to inject (UNDCP, 1998). Socio-psychological factors contributing to the appeal of injecting may include the illicit, rebellious and potentially dangerous nature of the activity, together with the pleasure and pain which may result from it. Economic factors also influence drug use patterns. People inject because it is cheaper and faster-acting than other methods. When illicit drugs become more scarce as a result of drug control efforts, it becomes uneconomical for the drug user to smoke or inhale the drug, as much of it is lost in smoke. Injectable forms of drugs are also more easily concealed. Why do people share needles? Reasons for sharing injecting equipment include scarcity or cost (of needles and syringes), lack of information and awareness about the risks associated with sharing, cultural practices, and legal or policing barriers to availability or use of equipment. Sharing of injecting equipment is embedded within the social context in which drug use takes place. For example, the sharing of contaminated injecting equipment may arise because IDUs fear that, while carrying needles and syringes, they will be stopped by police who will use possession of drug paraphernalia as evidence of a drug-related crime. Instead of purchasing or obtaining a new needle and syringe, users prefer to use the specific needle and syringe in use where the drugs are purchased or consumed and be able to leave the scene without carrying any equipment on their person. These situations give rise to ‘shooting galleries’: locations where the needles and syringes provided by a dealer are used in rapid succession, without adequate (if any) sterilisation between use, by a number of different users. For a fee, professional injectors administer to ‘clients’ the drugs which they have purchased, and in so doing, provide a potential hazard for transmitting HIV and other blood-borne viruses. Reasons for needle sharing
However, increasing the availability and accessibility of sterile injecting equipment, while fundamentally important, may be insufficient in itself to control the spread of HIV among drug users in the absence of action to address contextual factors which impact upon the health and well-being of drug users. IDU is embedded in specific social and cultural contexts. Its most salient feature is its illegality. Because they participate in one illegal activity, IDUs are generally stigmatised, discriminated against or excluded from access to health services. They are subject to human rights violations, and despite their numbers and vulnerability, constitute a low priority in terms of their health and welfare. Why does sexual transmission of HIV occur among injecting drug users? A high correlation has been noted between injecting drug use and other risk behaviours; virtually all studies of risk behaviour among injecting drug users, in both developed and developing countries, find that they are sexually active with both injecting and non-injecting partners and that they use condoms infrequently (UNDP, 1999B). The following factors link injecting drug use to sexual transmission of HIV:
Gender issues Drug use is a gendered phenomenon. Gender roles and inequality have significant influence on the ways in which men and women are differently affected by drugs, whether as users, suppliers, traffickers, carers and supporters, and breadwinners. The gender dimensions of drug use are also likely to be affected in turn, to varying degrees, by other factors such as age, race, class, ethnicity and geographical location. Since these factors may also have critical roles in determining patterns of drug use, their causes and consequences, it is important that a sufficiently complex, social and gender-sensitive perspective be adopted. Consider some of the ways in which women may be implicated in drug use. Women are centrally involved as sexual partners of male IDUs, as carers of people with HIV/AIDS and as people who may be vulnerable, in their own right, to the risk of HIV through drug injecting. The links between drug use, HIV and gender in developing regions are not yet well understood and need further exploration. It is clear however that the problems surrounding HIV and gender are greatly compounded when drug use is an added factor. The relationships between sexual behaviour and IDU are quite complex. Women IDUs, who are dependent on men, may fear rejection by their partners if they do not inject drugs. Some people use drugs because they believe the drugs will increase pleasure during sex. Others engage in sex in order to obtain drugs or money to purchase them (Des Jarlais 1997). Factors placing women drug users at high HIV risk
Women have increasingly become involved in all forms of drug-related problems and are likely to suffer more severe consequences than men as a result of this involvement. Women IDUs are at increased risk of HIV infection over male IDUs for several reasons, but principally because of their generally subordinate status in society. When drug-using women are also involved in sex work, the risk of acquiring HIV infection through unprotected sex, compounds the existing risk of transmission through the reuse of needles and syringes. Women may also be introduced to drug use by sexual partners who inject their drugs for them. If the sexual partner becomes ill or is imprisoned, these women are at risk for overdose if they are unaware of the dosage they have been injecting, and at risk for HIV, if they must rely on others to inject them. There is less documentation about women drug users than their male counterparts. In most literature specific attention is not devoted to female drug users as a distinct group; consequently in the perception of the general public, female drug users are mostly invisible.As a result of these gender-specific perceptions of drug users, female and male users may differ with regard to their backgrounds, reasons for using drugs, psycho-social problems and resulting needs. Although the ratio of female to male drug users is still low, it has been steadily increasing. This phenomenon coincides with the rise of population mobility, broken families, and collapsing communities. While society in general does not look kindly on drug users, it is even more harsh in viewing women who use drugs. A woman who uses drugs for whatever reason and who is infected by HIV seldom receives the sympathy and support that she needs (Duongsaa, 1998).
Women who use illicit drugs are likely to be more stigmatised than men because their activities are regarded as more deviant, both from the general norms of society but also from traditional expectations of women as wife, mother and nurturer. Many countries, for example, do not have drug-treatment facilities for pregnant or HIV positive women, nor do they make provisions for child care, even though many women who use drugs are single, separated or divorced. Women who use drugs are often hidden from public view. However, women who are partners of drug users and girls who are daughters of drug users are even less visible and accessible. Non-using women with drug-using partners have different problems, especially if their partners are so heavily addicted as to be unable to function normally. Women often endure verbal, physical and sexual abuse, poverty and deprivation of material comfort and facilities, lack of emotional and social security, concern about the future not only for themselves but also for their children. Some women eventually turn to using drugs as a way of escaping from the harsh realities of their lives. Many women are forced into begging or prostitution to earn money to buy drugs for their partners. Of course, through these activities their risk of HIV infection may rise still further. The children of drug users are often forced to share the burden of the impact of parental (particularly paternal) drug use, and both boys and girls may be forced into child labour or prostitution in order to support parental drug use. The needs of such children are seldom taken into consideration in programme planning or policy formulation (Duongsaa 1998).
Other risk groups: mobile populations, young people and prisoners Mobile and migrant populations Mobility and injecting drugs are also closely associated. Migrant workers, seafarers, refugees and other highly mobile populations are also increasingly becoming involved in injecting drug use and have all been identified as being at high risk for HIV infection. People who travel for work may be exposed to drug use, and may even become involved in the transport of drugs. In several locations where IDU has been occurring recently, drug-injecting was introduced by drug users who had acquired their injecting habits (and possible HIV infection) in other locations, then brought the practice home with them. Migrant and border populations are therefore potentially very important to the spread of HIV infection, both among drug-using populations and within the wider community. Drug use also occurs along border regions and transport routes, where drug trafficking, commercial sex and other HIV risk factors have been well documented. Ethnic minorities along these borders are often particularly vulnerable to HIV infection through injecting, because of proximity to drug supply routes and the fact that non-injecting drug use may already be an established indigenous practice. These groups often have poor access to health care and employment. They are therefore often the first group to be at risk of HIV, once illicit drugs and HIV enter a country. Prisoners Drug use and injecting takes place in most prisons world wide, usually with much more risk of blood-borne infections because of the unavailability of needles and syringes. The majority of IDUs experience prison at some time. Prisons bring together IDUs from a wide range of social and geographic backgrounds, potentially facilitating transmission of blood-borne viruses across social groups which may not otherwise have had such intimate contact. Programmes to decrease risk in prison, such as diversionary sentencing, peer education, provision of bleach or other means of disinfecting equipment, drug treatment and substitution programmes, and even the consideration of needle-syringe exchange programmes, are important in controlling HIV epidemics in prisons and in surrounding communities. Prisons embody many of the development challenges of HIV and injecting drug use. Prisons allow the collection and mixing of diverse and often disadvantaged groups of people. In prison, inmates can become infected through drug injecting and male-to-male sex before returning to their own communities. Prisoners are sometimes held without formal charges simply because they are drug users: their families, court systems or local treatment programmes can find no alternate ways to help them. This represents a fundamental abuse of human rights. Once in prison drug users are highly vulnerable to the risk of HIV infection. Inmates are likely to adopt high-risk practices whilst in prison, given the clandestine methods required for administering drugs, the fact that many other prisoners may have a history of drug use and the high premium placed on mind-altering substances in closed environments. Compounding these problems is the fact that few governments openly acknowledge that drug use or sex occurs in prisons. Consequently, interventions to target these complex and inter-related problems can be very difficult to initiate. Young People Young people are particularly vulnerable to the risks posed by drugs and HIV. Children aged 10 and younger are using illicit drugs in many cities and communities around the world. These young people may live on the streets where risks to health are high and welfare support critically low, or in households where information about HIV and illicit drugs is taboo. Young people may be initiated into injecting by more experienced drug users in a greater position of power or trust and who may already have been exposed to HIV. Given these and other related problems facing young people, specialised programmes are needed for young people at risk from drug use and HIV.
Personal Story from Thailand "My Name is Alor. I am the oldest son of my mother. I have a little brother who is two and a little sister who is eight. I love my mother, but she could not afford to keep me any more. My friends had told me of the place they live where a boy can make a living selling flowers. I hoped to make enough to send some home to my mother sometimes, but I have not been able to do that. After I had lived in the city for half a year, I met a new friend. There were many kids like me there. We all had no family except for each other, and no way to eat except selling flowers. Some of the older boys also sold themselves, sometimes, and when they did they had a lot of money, and we all had plenty to eat. One night my friend had a new customer. The man gave him 1000 baht (about $27 USD) for 2 hours. When my friend came back he had with him a little silver package and a needle and syringe. He did something with the stuff in the package, then heated it up. He put some of the stuff in the needle and then put it into his arm. His eyes went funny after a minute and then he relaxed. He asked if I wanted some too. He looked at my arm but it was very thin. He stuck the needle in my hand, and then I felt very good. I wasn’t worried about where I was going to get food tomorrow, or whether I was going to sell flowers in the market. I was relaxed and being with my friend made me happy. Over the next few months, my friend and I shared the silver package many times. This went on for five months, the needle at night, then at 6 o’clock the next evening I would go to the night market, pick up flowers and sell them. Always there was a needle to go home to share. A week later I went to get my flowers. I was very sick. I remember coughing a lot. I remember my chest and tummy hurt a lot. I went home. My friend was still there. He was not moving. His face was cold. Another friend and I spoke to a man who lived in a shack nearby. He came with his friend and they moved my friend out to the riverbank. There were men with cameras as well as the police. They took picture of my friend then carried him to a truck and took him away." Alor was only 10-11 years old when he became infected with HIV. Adapted from the Newsletter of the Asian Harm Reduction Network, Vol. 15 Jan-Jun, 1999.
3. Policy issues he lack of a supportive policy environment is perhaps the greatest obstacle and challenge for controlling HIV among injecting drug users. Despite the fact that drug use drives the HIV epidemic in many countries, the relationship between HIV and drug use is particularly neglected in terms of national policies on both HIV and drugs. Policy dialogue and policy reform are generally lacking with respect to injecting drug use and HIV. This lack of supportive policies makes it extremely difficult for programmes to implement the activities necessary to reduce drug-related harm, especially HIV. While some progress is being made, national responses are generally inadequate and are not integrated into national development strategies, poverty reduction strategies and other key areas of development policy and planning. This has particular relevance to UNDP and other agencies looking to integrate concepts of sustainable human development into policy making processes, thus building the institutional capacity of governments for policy development and implementation. Drugs and HIV policy frameworks often develop at different times through different processes, so it is no surprise that they have often evolved with different goals and approaches. Drug policies in many countries do not focus on public health issues such as HIV. Conversely, HIV policies often do not address injecting drug use (Burrows, 1999). Instead, governments and development agencies place priority on finding long-term solutions to problem, rather than addressing the more immediate harm caused by drug use, most notably, HIV. It seems the international community cannot reach consensus on how to deal with the problem of illicit drugs, arguing about the relative merits of demand reduction, supply reduction and harm reduction approaches, while the HIV epidemic among drug injectors continues unabated. By adopting the (DDR) Drug Demand
Reduction Declaration Member States have committed themselves
"to promote in a balanced way, interregional and
international co-operation in order to control supply and reduce
demand". There are several references to comprehensive
policies in In the absence of effective national policies and programmes to prevent HIV among IDU, community-based organisations are often the only agencies to implement responses. However the development of effective programmes is often inhibited by government policies which prevent the implementation of interventions that have been proven successful elsewhere, such as needle exchange programmes and drug substitution. This situation is changing, but often not until HIV has already begun to spread among IDUs. The challenge therefore is to identify ways of engaging governments, local programmes and policy makers to develop policies that will support prompt implementation of effective responses to the epidemic among IDUs. To do this, governments and development agencies need better understanding of the nature and extent of the HIV epidemic among IDUs, exposure to different strategies, and examples of programmatic and policy responses for consideration.
Current approaches to HIV among IDUs Efforts to control illicit drug supply and demand have been considerable over the past half-century, with the United Nations International Drug Control Programme (UNDCP) combining with national governments and law enforcement agencies in massive drug control activities. However, these efforts have not been intended to prevent the spread of HIV among drug injectors (UNDCP, 2000). The advent of HIV among drugs users is however leading to more contemporary approaches to reducing the supply and demand for drugs, acknowledging also the need to reduce the harm associated with drug use in order to achieve a more balanced response to the drug problem. Demand reduction strategies include education and other prevention strategies, drug treatment and rehabilitation, and a range of educational measures including mass campaigns, school campaigns and programmes directed at established drug users and others involved in risk situations. Few drug treatment programmes, however, have as a goal, protecting people from HIV infection. Concepts such as ‘safe drug use’ are not encouraged because they are perceived to condone continued drug use. This leaves drug users at high risk of HIV infection once they re-enter the community since relapse rates are often in excess of 70% once people leave drug treatment. Supply reduction involves attempts to reduce crop production, drug production, drug transport from countries of origin to countries of destination (interdiction), drug entry to the country of destination (customs), drug distribution (police) and money laundering (financial surveillance). Attempts to reduce the supply of drugs for which there is a persistent demand are of limited effectiveness. Moreover, harsh application of supply control strategies, such as restriction of syringe availability or imprisonment of drug users, often creates favourable conditions for the spread of HIV by driving drug use underground or to other geographical areas. Harm reduction refers to various strategies and approaches for reducing the harms associated with drug use, especially HIV, without requiring abstinence or a reduction in drug use itself (Heather et al, 1993, Strang, 1993). The principles of harm reduction are increasingly being applied in developing countries, through a range of different activities designed to decrease needle-sharing and unsafe injecting behaviour (Piot 1999, Crofts 1999, Deany 2000). Common to these programmes is an approach which is fundamentally different from that of demand and supply reduction in that reduction in the use of drugs is not the primary goal. Nonetheless, these differing approaches should and can be complementary (Crofts, 1999). Harm reduction can also be applied to other practices for which abstinence is not a realistic option. The promotion of ‘safer sex’ and condom use are good examples of harm reduction, as is the use of seat belts in cars. Where harm reduction programmes have been introduced among IDUs, there has been an overwhelmingly positive effect in slowing the rate of HIV transmission. Yet introduction of these programmes is often controversial, and presents challenges to both local communities and governments. Balancing harm, supply and demand reduction International drug policy is gradually accepting the need for balance between supply and demand reduction, preventive education, health programmes and the treatment and rehabilitation of drug users which will facilitate their social and economic re-integration (Ahmed, 1998). Harm reduction should be seen as complementary to and part of the overall demand and supply reduction approach. The ultimate way to prevent harm from drug use is to stop completely the demand for drugs. However, just as it is unrealistic to expect people to stop having sex, it is important to be realistic about the likelihood of the global eradication of drug use in the near future.
Prevention of transmission of HIV among IDUs must therefore occur in a context of overall attempts to reduce the use of illicit drugs, through demand and supply reduction. Strategies for each should be as consistent as possible in terms of the relative emphasis placed on demand and supply reduction, and on HIV prevention, so as to minimise the harm associated with injecting drug use. The World Bank writes the following on this topic in their recent policy research report: Confronting AIDS, Public Priorities in a Global Epidemic (Oxford University Press, 1999) "The most politically popular way to deal with the problem of drug use has been to reduce the availability of drugs. However, drug interdiction may simply rearrange the problem or make it worse. For example:
If restricting the supply of injectable drugs does not effectively reduce risky injecting behaviour and may actually increase it, what about attempts to reduce demand? Because most injecting drug users are chemically dependent, prohibition and threat of punishment are notoriously ineffective in reducing their demand for drugs. A survey of 450 injecting drug users in Manipur State in India, where addicts are imprisoned, found that only 2 percent regarded the threat of imprisonment as a reason to stop injecting. And far from reducing HIV transmission, imprisonment may have the opposite effect. Unable to obtain syringes, prisoners frequently resort to shared, improvised equipment, such as ballpoint pens, which would be very difficult to sterilise, even if bleach were available. Mandatory drug testing is likely to be even less successful in ending drug use than voluntary treatment, since patients presumably have very little desire to change behaviour. In summary, efforts to raise the cost of injecting drugs through drug interdiction or the punishment of injecting drug users may increase rather than decrease risky injection behaviour. Although the data on the impact of such efforts on HIV incidence are fragmentary, the available evidence suggests that harm reduction programmes, including information about HIV, provision of sterile injection equipment or bleach kits, and referral for voluntary treatment programmes will be more effective and less costly in reducing risky injection behaviour than interdiction or incarceration of addicts." HIV can spread with extraordinary rapidity when drug injecting is the key route of transmission. Therefore an early imperative for policy makers must be to prevent the spread of HIV through drug injecting, because it is so devastating in its effects and much more difficult to control once it has begun to spread. Finding a balance between the long-term development goals of demand and supply reduction, and the more pressing goal of HIV prevention is a development challenge that policy makers and the development community in general have failed to meet effectively. It requires commitment and urgent action not only from national policy makers but also from international agencies. UNDCP has already taken initiatives in this direction - initiatives which need to be further strengthened together with other UN agencies, particularly UNAIDS, and with bilateral donors (Moerkirk, 1998).
Issues of Governance To engage successfully with the problem in all facets requires a new, concerted and more enlightened approach to governance. Drug use and the HIV epidemic are both new to many places but current policies and programmes are often designed for past situations and do not take account of the specific dangers presented by the epidemic. Illicit drug use is a very difficult issue for governments to deal with. For example, is heroin usage a legal issue, a public health issue, or both? How heroin and other injectable drugs are dealt with by governments will have a large bearing on the extent of HIV spread among drug users and the broader population. Yet policy decisions are often made in response to community fears about drugs instead of on the basis of empirical evidence. Furthermore, patterns of illicit drugs use are becoming globalised and standardised with complex global production and distribution networks, diversified marketing, new and emerging markets and a highly dynamic and thriving scene. The drug industry is based within local communities but operates internationally. Attempts to control the industry are most often organised by national governments in response to international pressure. For example, decisions about how to control the drug industry, through governance or other means, have a significant impact on the spread of the HIV epidemic. Where heroin is made or transported, people inject and HIV spreads rapidly. This represents an important challenge for improving governance in the global economy. Attempts to reduce the production of drugs without taking into account the development consequences have proven to be unsuccessful. Instead, the drug problem needs to be strongly linked with development policies and strategies to address HIV. Giving governments options Experience indicates that meaningful policy changes come about through:
Governments and communities therefore need to be provided with options for dealing with the drug problem and fora in which these options can be considered. Integrating different sectors of government How drug use and HIV are viewed may also depend on the sector of government concerned with the issue:
The fact that injecting drug use can fall within so many different areas of government illustrates in part the difficulty which governments and others often have in dealing with the broad implications of illicit drug use. Uncoordinated policies may lead to a clash between the goals of different agencies involved in combating drug use and HIV. Drug use needs to be recognised both as a health and as a legal problem. Governments must strike a balance between the need to curb illicit drug use on the one hand and the reality that drug use cannot be eradicated overnight (if at all) on the other, so it must be made safer.
Whatever approaches governments and other policy making agencies take towards illicit drug use, it is important that they carefully consider the full implications of their decisions. Declaring stringent bans on drug use, or advocating imprisonment for all offenders may sound like strong leadership, but in isolation from other public health measures, may simply result in more harm.
Legal, ethical and human rights issues The legal and social context can make it very difficult for an HIV prevention programme or agency to make contact with at-risk IDUs in an effort to educate them about HIV and its prevention. The social and legal situations around drug use can drive drug users underground and make them difficult to reach. It has been found many times that when a group of people in a community are driven underground in this manner, HIV transmission is enhanced. There may also be legal barriers, aimed at enhancing drug control but unintentionally promoting the risks of HIV transmission. An example is the so-called ‘paraphernalia laws’, under which possession of injecting equipment is criminalised. Rather than deterring IDUs from injecting, such laws simply promote the use and reuse of common injecting equipment (and therefore of HIV transmission) so that individuals will not be charged with crimes relating to possession of needles and syringes. Experience in developed countries shows that abolishing paraphernalia laws does not increase participation in drug use, but does remove a barrier to safer use for the current drug use. At the societal level, imprisoning drug users on the sole grounds of using drugs does not diminish demand for drugs and potentially causes major harm to users who are exposed to further harm in prison (including a higher risk of HIV infection) while typically unable to access drug treatment. Acknowledgement of these factors can assist the police and other law enforcement officers to assume important roles in HIV prevention. For example, in some countries, the police actively participate in harm reduction by referring drug users to treatment (rather than arresting them), and even by providing them with clean needles and syringes. Stigma and discrimination The frequent lack of effective responses to HIV infection among IDU, despite the simultaneous presence of active national HIV programmes, stems from a combination of lack of concern for the human rights of drug users together with perceptions that drug users are too ‘difficult’ or ‘unworthy to work with’. Injecting drug users are a hidden and stigmatised group because their behaviour is illegal. They may engage in criminal activities to support their drug habit and may engage in other risk behaviours for HIV, such as sex work or paid blood donation, because of the cycle of poverty and the cost of drugs. Because of the illegality of drug use and because they have had multiple bad experiences with police and other social agencies, including health care agencies, many drug users are extremely scared of contact with any authority or agency associated (in reality or perception) with government. They are also extremely distrustful of advice which they perceive as associated with these agencies. People who choose to use drugs that are not socially sanctioned are usually treated as if they were ‘beyond society’, sometimes even as ‘enemies’ of the social structure. What does this mean for HIV and drug use? For the majority of injecting drug users, it means that lip-service is paid to the principles which supposedly have been learned through the course of the epidemic. Issues such as human rights, peer education, community participation, and legal and social change are mostly unachieved fictions. Legal, ethical and human rights policies concerning drug use can therefore directly influence the spread of the epidemic. Stigmatising drug users does not help them to change their activities nor reintegrate within society. Nor does it help families, communities and society to accept and support them. Barriers to the health and human rights of injecting drug users
Costs from lack of action In most countries in Asia and Central and Eastern Europe, HIV epidemics among IDUs are still at a relatively early phase. Evidence from other countries indicates that this will soon pass and the opportunity to make a significant difference will be lost. The personal, social and economic costs associated with HIV and drug use can be devastating for individuals, families and society as a whole. With countries such as Russia, expecting to have 800,000 people living with HIV by the year 2000, the consequences of ineffective action will be devastating. Introducing harm reduction measures before HIV enters It is difficult, but nonetheless crucially important, to stimulate effective political action on drug use and HIV when HIV prevalence is still low or close to zero. Unfortunately, this is also likely to be the time when appreciation among policy-makers of the potential scale and dimensions of the problem is at its lowest. The necessary measures demand political leadership from an early stage. Experience from many countries has shown that it is exceedingly difficult to contain the epidemic among IDU once a prevalence rate of 10% has been reached. The common scenario, wherein concern is raised only after HIV has begun to spread widely among IDUs, means that responses have to be developed within a context which includes the provision of care for many people who have HIV-related disease. This reduces the availability of resources for prevention and places significant demands upon community capacity to respond. It is a mistake to think that HIV will remain confined to the drug using populations in any country. The history of the epidemic demonstrates that the virus can spread from country to country and from specific populations (such as IDU) to wider communities, with frightening rapidity. It is essential that injecting drug use be taken into consideration in the development of responses to the epidemic. For example, in Thailand, few programmes or policies have evolved with specific reference to IDUs. Despite Thailand’s record of success in preventing HIV through sexual transmission, rising rates of HIV among injecting drug users are eradicating many of the gains made elsewhere. Consequences of HIV epidemic among IDUs:
Given that HIV infection is one of the most serious possible consequences of injecting drugs, the approach must therefore be to reduce the harm to individuals and communities by advocating for and strengthening effective HIV prevention programmes among drug users.
4. Programming issues IV has been consistently acknowledged as a major threat to sustainable human development. In response, significant efforts have been made by different UN agencies, including UNAIDS and its co-sponsors, to enhance awareness and understanding of the epidemic and to strengthen local capacity to respond. However, except in a limited number of countries, these efforts have not as yet focused specifically upon HIV and injecting drug use. Current responses There is a growing body of evidence which demonstrates that HIV transmission among injecting drug users can be prevented, and even reversed, through a combination of programmatic and policy responses. A recent World Health Organisation study of cities with stable and low HIV prevalence among IDUs concluded that several factors were associated with these low rates:
Measures implemented in these cities included needle and syringe exchange programmes, drug substitution, sale of clean injecting equipment through pharmacies and other outlets, peer support and outreach, as well as policy advocacy and skills building to support the above. Where these types of programmes have been introduced, there has been an overwhelmingly positive effect on slowing down the spread of HIV among IDUs. In collaboration with a range of partner agencies, UNDP has been involved in piloting and supporting a range of HIV prevention initiatives with injecting drug users. Examples include the following:
Involvement of UNDCP Recognising the links between drug use and HIV, the United Nations International Drug Control Programme (UNDCP) has increasingly been involved in HIV prevention initiatives. These initiatives link to its work on demand reduction. UNDCP has now formalised its commitment to collaboration in fighting the global epidemic by becoming a cosponsor of UNAIDS, joining the six existing cosponsors: UNICEF, UNDP, UNFPA, UNESCO, WHO and the World Bank. UNDCP actively supports HIV prevention initiatives linked to its own programmes to reduce the demand for illicit drugs. These include the following:
Key principles identified in the success of these and similar programmes include:
Creating a supportive environment There is now ample evidence to show that HIV transmission among IDUs can be prevented through a range of approaches often described as ‘harm reduction’ programmes. By improving the health of IDUs and enabling them to participate in community activities including productive work, harm reduction programmes reduce the association between drug use, poverty and HIV risk. But the introduction of harm reduction measures is often controversial and seems possible only within an enabling environment comprised of the following:
Harm Reduction Networks: building a better enabling environment In many developing countries, a supportive environment for harm reduction activities simply doesn’t exist. It has to be created. To achieve this, community-based programmes are forming into regional and national networks to stimulate the policy and programme environment necessary to prevent HIV among IDUs. Often called ‘harm reduction networks’ these coalitions of like-minded programmes have become effective mechanisms for strengthening and catalysing national responses to HIV and drug use. These networks can assist with building local technical capacity; national and regional advocacy; sharing information; peer support and facilitating collective action. By improving knowledge, providing support, developing capacity and sharing evidence-based approaches, these networks have strengthened prevention efforts on the ground and influenced policy development at regional and national levels (Deany et al, 1999). Networking can also foster development of programmes in regions or countries where a response has yet to materialise or is in its infancy. Networking can also provide expertise, models and examples to assist in overcoming barriers to the implementation of harm reduction programmes. Through their activities, these networks have identified and advocated for some of the major elements necessary for a more effective enabling environment for HIV prevention among injecting drug users. These elements include:
Barriers and challenges Removing the barriers to safer injecting, which include political, economic, cultural and physical dimensions, is proving difficult in developing regions. Indeed, the fact that both HIV rates among IDUs and the numbers of injecting drug users are increasing rapidly in many developing countries clearly illustrates that we are failing to understand and respond adequately to these inter-linked development problems. This is the result of a range of gaps and barriers including:
Identifying these gaps in action and knowledge leads to the following questions:
5. Actions for UNDP to consider Many countries are experiencing unprecedented increases in drug injecting and consequent HIV epidemics among injecting drug users. These countries are struggling to understand and respond to the broad contextual and developmental factors associated with injecting drug use and need assistance in developing strategies for reducing HIV transmission among injecting drug users. UNDP action in this area should be consistent both with the principles of sustainable human development and with the organisation’s emphasis on policy dialogue, building institutional capacity for policy development and implementation. Activities also need to be based upon a premise of partnership within and beyond the UN system, in particular with the UNAIDS secretariat and co-sponsors. UNDP could play an important role in promoting enabling environments which support reduction of HIV transmission, particularly by facilitating strategies which address underlying causes of the HIV epidemic among injecting drug users and introducing policy makers to new conceptual frameworks. Ways of achieving this include:
Suggested activities match UNDP goals of strengthening regional co-operation, emphasising multi-sectoral and participatory methodologies, promoting networking and partnerships, supporting national and regional capacity building and giving special attention to gender issues and inclusion of people affected by the epidemic. The activities suggested here are also consistent with UNDP’s role within the UN Joint and Co-sponsored Programme on AIDS (UNAIDS), and with the objectives of the UNDP Regional Projects on HIV and Development.
Policy and programme development It should come as no surprise that HIV and injecting drug use is increasing in many developing countries, given the lack of policies, policy dialogue and programming responses to the specific needs of IDUs. This failure to recognise IDU as a factor in national HIV epidemics stems from less than optimum capacity in the following areas:
While progress is being made, nonetheless, national responses are generally inadequate and unintegrated with national development strategies, poverty reduction strategies and other key areas of development policy and planning. Non-governmental and community-based programmes are left to fill the gap both in terms of policy advocacy and responses, often acting in multiple roles as researchers, programme designers, implementers, trainers, fundraisers and advocates. As well as the need to replicate and scale- up programmes to the national level (supported by appropriate HIV and drug policies), there is also a need to build the capacity of existing programmes. Possible actions
Strengthening community capacity HIV prevention among IDUs has proven to be difficult in any circumstance. However when resources, skills and community capacity are critically low, as is the case in many developing countries, translating perceived needs into effective programmes and policies can be almost impossible. Core competencies that need to be developed and strengthened include:
Additionally, understanding and acceptance of the need to prevent HIV among IDUs is generally lacking, with community concern usually only arising once the HIV epidemic has taken off. This highlights the need to develop ways for communities to explore, understand and respond to the development implications of injecting drug use and the HIV epidemic.
Possible actions
A harm reduction programme in Hanoi, Vietnam.
Awareness raising and advocacy Community awareness and understanding of the drug use problem is determined largely by two factors:
On the first point, it is clear that a lack of information on the nature, scale and trends of drug use and HIV transmission is significantly hampering community and government responses. On the second point, it is also clear that a failure to understand the development dimensions of the drug problem is an impediment to the capacity of communities to respond appropriately. Despite differing perspectives, most people and agencies concerned about the drug problem seek the same goal - diminishing the harms (social, criminal, health, etc) associated with drug use. But, while there are many different approaches to achieving this goal, most are currently failing. Effective responses to the problems of drug use and HIV require new and enlightened thinking, more sophisticated analysis of the problem and a greater understanding of the development implications of drug use within the context of HIV. Possible actions
Regional co-operation and networking Injecting drug use is an issue that cuts across borders and affects different sectors of the community, but responses generally take place in an uncoordinated and chaotic manner. Co-operation and networking between sectors and across borders is also lacking. We therefore need to look for ways that people and organisations in all sectors (government, NGOs, the private sector, health and development agencies, religious organisations, and others) can work co-operatively and communicate with each other about problem definition as well as resolution. These processes should be directed towards consensus building and decision making around difficult issues, facilitating the creation of critical links between people and organisations within and between countries and enhancing their capacity to act. Possible actions
Gender Gender, drug use and HIV combine to create multiple risk and stigma for women, but current responses and understanding do not reflect the differing needs of women and men. This is particularly acute in the case of women, a situation compounded by lack of research and action on the relationships between women, IDU and HIV. Programmes for female drug users and female partners and carers of drug users are absent, as are programmes for girl-children of drug users. There is therefore a demonstrable need to develop a more comprehensive understanding of the special needs of women with respect to drug use and HIV, and a corresponding need to develop programmes and policies addressing gender considerations. Possible actions
Legal, ethical and human rights issues A range of ethical, human rights and legal barriers are making drug users especially vulnerable to the HIV epidemic. Drug users also experience marginalisation and exclusion from the very processes and services that should protect them from HIV. Current anti-drug and anti-paraphernalia laws drive drug users underground and precipitate risky drug injecting and needle sharing behaviour, and thus facilitate the spread of HIV through IDU. Yet there is little recognition of either the importance of legal, ethical and human rights issues in proliferating HIV transmission among IDUs or the need to investigate possible solutions. Possible actions
6. Conclusion Injecting drug use is a critical and rapidly evolving development issue and no single report can adequately cover all the issues which need to be considered. The impact of injecting drug use on national HIV epidemics, and thus upon human development, looms large in many countries. But responses are hampered by the failure of policy makers and decision makers to recognise the scale of the problem together with a lack of understanding and community capacity to respond. The HIV epidemic is immensely complex and involves a mix of social, political, economic, ethical and legal factors that are specific to each location. When injecting drug use is added, the complexities are further multiplied. Ongoing analysis and consultation is needed to understand and respond more effectively to this new development challenge. The problem is as large as it is complex but with both time and resources often limited. Responses to other aspects of the epidemic demonstrate that people, communities and nations can work together to make a difference. UNDP and partner agencies should continue to mobilise resources, to strengthen political and donor support and to support the capacity of countries to respond effectively to the growing threats of HIV and injecting drug use. The drug problem is complex and touches on many other issues apart from drugs, dealers and users. We need to understand the connections between these issues in order to see the whole picture rather than a single piece of the jigsaw. Instead of stigmatising drug users and focusing mainly upon supply reduction, we need to work towards a better balance between the goals of demand, supply and harm reduction. Finally, we need to change the social and economic environments that help create the demand for drugs in the first place. We need to reconsider, and change if necessary, our development paradigm to one which restores respect for human dignity and equality of human rights regardless of race, religion, gender, and economic, social or health status (Duongsaa 1998).
7. Endnotes
Appendix I:
Framework for understanding and responding to
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