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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
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