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Scaling up an Essential Harm Reduction Package: overcoming

the barriers in South Asia

World Bank Inter-Country Consultation on Prevention of HIV among IDUs

Scaling Up: From Evidence to Action9–13 April, 2007, Kolkata, India

Dr. Alex Wodak,St. Vincent's Hospital,

Sydney, Australiaawodak@stvincents.com.au

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Outline:

1. Recognising national HIV problem

2. Recognising need for harm reduction

3. Planning implementation

4. Ensuring sustainability

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1 Recognising HIV/IDUs problem:

• Will, or is, HIV a problem in my country? • Will, or is, HIV/IDUs a problem in my

country?– Power of national immunity myths– Power of denial

• Can HIV/IDUs be controlled?– Pervasive nihilism about drugs– Nothing works, nothing effective or acceptable

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Recognition HIV/IDUs problem:

• Why bother trying to save IDUs?– ‘AIDS and drugs are problems that will solve each

other’

• Does my country have to adopt harm reduction?

• What is harm reduction?• Is harm reduction acceptable politically,

legally?– Entrenched support drug law enforcement major

obstacle to harm reduction

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Overcoming barriers:

1 Assessment of risk:• Is HIV a problem in my country?• Is HIV/IDUs a problem in my country?• Isn’t my country immune?

– Surveys HIV/IDUs: power of local data – Rapid assessment– Modelling health, social, economic impact– Comparing costs action vs. costs inaction– Reviews of international experience

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Overcoming barriers: 2

2 Assessment of response:• Can HIV/IDUs be controlled?

– Reviews of international experience– Harm reduction is effective, safe, cost-effective

• Why bother trying to save IDUs?– Altruistic arguments

• ‘It’s the right thing to do’– Self-interest arguments

• ‘What if it was your own son/daughter?’• ‘You will go down in history’• ‘You might not like them but the general population will

suffer’

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Overcoming barriers: 3

• Does my country have to adopt harm reduction?– Review of options

• What is harm reduction?– Explaining harm reduction– Primary focus on harm– Includes promotion abstinence – Use of same approach in other policies

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Overcoming barriers: 4

• Is harm reduction acceptable politically, legally?– Documentation support in UN system– WHO, UNAIDS, UNODC– Acceptance by other countries– Legal status UNODC report– Relationship to drug law reform?

• Indulgence?• Essential?

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Overcoming barriers: 5

• Critical importance political leadership– HIV control only achieved where strong

leadership e.g. Thailand, Uganda, Australia– What’s popular doesn’t work– What works, isn’t popular– Need highest level leadership

• Raise, maintain high level awareness• Belief efficacy, safety of prevention• Mobilise funding

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2 Accepting harm reduction:

• Is harm reduction accepted nationally?

• Will harm reduction be implemented by all government departments?

• Is harm reduction morally acceptable?

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Overcoming barriers:

• Is harm reduction accepted nationally?– Arranging demonstration of national acceptance

• Will harm reduction be implemented by all government departments?– Developing partnerships:

• Religious leaders• Government officials • Law enforcement

– Guidelines, training, international collaboration

• Injecting drug users• Researchers, clinicians

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Overcoming barriers: 2

• Is harm reduction morally acceptable?– Contrast with morality condemning unborn

generations HIV despite known effective prevention

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3 Planning implementation:

• How many IDUs are there?• What kinds of interventions needed?• How much each intervention is

needed?• Goals and targets?• Should prisons be included?• Vulnerable and bridge populations?• Should ‘pre-IDUs’ be included?

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Planning implementation: 2

• How many, what kind staff needed?• Buildings?• Materials procured?• Vehicles, computers?• Training?• Administration? • Funding?• Research?

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Overcoming barriers:

• How many IDUs are there?– Capture-recapture– Multiplier– Triangulation– Back calculation, modelling

• What kinds of interventions needed?– Reviews international experience– Education, NSPs, drug treatment,

community development– Manuals

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Overcoming barriers: 2

• How much each intervention is needed?– UNAIDS guidelines– Modelling – Current reviews

• Goals and targets?– History + x%?– 5 year plan?

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Overcoming barriers: 3

• Should prisons be included?– Community first, then prisons?– Important but too difficult?

• Vulnerable and bridge populations– Ethnic minorities– Severely disadvantaged groups– MSM IDUs– CSW IDUs– Certain drugs e.g. amphetamine, cocaine

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Overcoming barriers: 4

• Should ‘pre-IDUs’ be included?– High risk youth– Non injecting drug users

• How many, what kind staff?– Doctors– Other healthcare– Administration– Researchers

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Overcoming barriers: 5

• Buildings?– Needle syringe programme outlets– Drop In Centres– Drug treatment clinics

• Materials?– Methadone, buprenorphine– Needles, syringes– Environmental policies

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Overcoming barriers: 6

• Vehicles, computers?– Coordination– Generating, compiling data

• Training?– Manuals– Train the trainer– National centre?

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Overcoming barriers: 7

• Administration?– Central control?– Devolve states/provinces?– National guidelines?

• Funding?– Are national resources available?

• If not now, when?

– Can GFATM resources secured?– Other

• Multilateral• Bilateral

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Overcoming barriers: 8

• Research?– Hasn’t there been enough research?– Local data much more powerful– Local researchers

• Understand language, culture, history• Always there, critical advocacy role• How to train?• Help defend sensitive programmes

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4 Ensuring sustainability:

• How monitor, evaluate?

• Defending ‘controversial programmes for unpopular populations’

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Overcoming barriers:

• How monitor, evaluate?– Simple– Timely– Inexpensive– Un-intrusive– Meaningful– Benefits of small, frequent vs. large,

infrequent

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Overcoming barriers:

• Defending controversial programmes for unpopular populations– Strategic, creative, national– Monitor opposition carefully– Commission research– Attend promptly to problems of prevention

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Conclusions:

1. Raise, maintain high level awareness of HIV

2. Promote effectiveness, safety, cost effectiveness of harm reduction

3. Explain, maintain advocacy harm reduction

4. Importance high level political leadership

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Conclusions: 2

5. Entrenched support drug law enforcement major obstacle to harm reduction

6. Counter moral arguments against harm reduction by appeal to protection unborn generations

7. Develop structures encourage partnerships

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Conclusions: 3

8. Plan strategy implementation– Which strategies?– How much?– Goals, targets?– Estimate staff, materials, support,

training, funding

9. Ensuring sustainability– Monitoring, evaluation– Supporting valuable, vulnerable programs