A powerful overview of all the issues associated with harm reduction was given by Dr Adeeba Kamarulzaman as a plenary lecture in a session that packed the vast main session hall.

A summary of the transcription from the talk is included below – but better still, get to a broadband internet connection and watch it first-hand.

Plenery Session, Day 2:
http://www.aids2008.org/Pag/PSession.aspx?s=32

Adeeba Kamarulzaman

I started life as an AIDS physician, and I still am, and every day I am confronted with patients such as this.

This is an x-ray of a 35-year old man with extensive TB who presented to me approximately three months ago, in severe respiratory failure and metabolic derangement. We were unable to do anything for him, and within two days of admission, he passed away.

This is just one example of a patient who succumbed who, because of the failure of the Malaysian government to implement harm reduction measures 20 years ago.

Many of you see similar patients daily because at the recent estimation, there are approximately 11 million injecting drug users around the world, of whom more than 3.3 million are infected with HIV, and even more infected with hepatitis C virus. We know that outside the sub-Saharan Africa, 30% of HIV infections are due to injecting drug use and in Asia, the region I live, and in Central and in Eastern Europe, injecting drug use is the main drivers of the HIV epidemic.

The situation is even worse in prisons where the prevalence of HIV is more than 4 to 10 times the general community. And we know that prisons are an incubator that makes transmission of HIV and other infectious diseases, particularly tuberculosis, a lot worse. In the words of my colleague, Rick Altice, prison is like a semi-permeable membrane which with prisoners going in and out to the community, the HIV and other infections that occur within prison, then go out into the community and back into the prisons as the prisoners come back into the system.

Drug users do not live in isolation. This complex diagram from Bangladesh showing the social and sexual network of injecting drug users shows how injecting drug use can quickly fuel the HIV epidemic within the HIV community and eventually into the general community.

Now, we know that drug use is a chronic and relapsing disease for many years, the argument for or against harm reduction to prevent HIV transmission should be long over.

Extensive, scientific evidence for the effectiveness of opiate substitution therapy and needle exchange therapy have been done over the last 20 years. Review after review, including two reviews by the Institute of Medicine in the U.S. have shown the effectiveness of harm reduction measures. Immediate action needs to be taken to slow the spread of HIV amongst injection drug users using multiple approaches, as was the conclusion of the review by the Institute of Medicine in 2006.

WHO and UNAIDS have also endorsed harm reduction in their policy briefs since 2005. Yet, out of the 158 countries that have injecting drug use, only 77 countries have implemented needle exchange. Even fewer countries have opiate substitution treatment with less than a million people globally receiving opiate substitution therapy.

So what is stopping us? Unfortunately, in the last few decades, criminalisation of drug use and law enforcement have taken over the health issues of drug use. Dominance of law enforcement over health takes over harm reduction, and moral and religious frameworks are linked to prohibition. Treatment, when it is available, is often geared towards abstinence and a drug-free environment.

Conflicting policies coming from the UN organisations often sends countries confused messages. The UNGASS on AIDS in 2005 emphasised the importance of “ensuring wide-range prevention programs and commodities, including condoms and sterile injecting equipment, and harm reduction, if it is related to drug use”. However, in Vienna, the UNGASS on drugs has said, since the Vienna Convention in 1988, to “establish stricter obligations to criminalise all aspects of cultivation and production, distribution and possession of illicit drugs”. No wonder many countries are confused.

A large percentage of countries report laws, regulations and policies that present obstacles to services for injecting. Recent reports for UNAIDS show that, especially in countries that need it most, there are many, many countries with laws that prohibit harm reduction.

The presence of laws that criminalise drug use, not only prevent access to much needed harm reduction measures, but most often, also leads to outright abuse of human rights. A recent raid in Cambodia led to many people, including non-drug users and children, being behind bars.

Funding for effective HIV prevention including harm reduction measures is abysmal, highlighted by a recent UNAIDS report from the recent Global AIDS update. Even in countries that have embraced harm reduction, the National Drug Policy funding goes mostly towards enforcement. In the Canadian Federal National Anti-drug strategy, funding for harm reduction is a mere 2% compared to 70% for enforcement.

I am moving on to treatment—opiate substitution treatment. The WHO says that medicines that satisfy the priority of healthcare needs of the population are criteria for medicines to be included into the essential medicines list. And they are selected with due regard to disease prevalence, evidence on efficacy and safety and comparative cost effectiveness. They are intended to be available at all times in adequate amounts.

Methadone and buprenorphine were listed in this list in 2005. However, in many countries, these two drugs, which are essential components of the harm reduction program, remain illegal, or unavailable. A report in the New York Times (on 22 July 2008) describes how Russia, up until now, does not make methadone available for its severe heroin problem.

In most instances, evidence-based treatment is put aside for treatment based on incarceration and punitive actions (which have no evidence base), as can be seen in pictures here from Malaysia, Russia, and Myanmar.

All is not bad. There has been progress, including in my own country where the government allowed for the implementation of harm reduction programs, including opiate substitution therapy and needle exchange. Since 2005, we have more than 22,000 drug users on opiate substitution therapy, 11 needle exchange sites (including seven that are funded by the government) with more than a million needles and syringes distributed up to June 2008. More recently, we have also introduced pre-release prison methadone programmes in our prison system.

In China, the roll-out for harm reduction is very fast, as only the Chinese could do, with 88,000 people on methadone maintenance therapy, and 50,000 injecting drug users receiving needle syringe services, as of October 2007.

In the Islamic Republic of Iran, there are now 600 addiction clinics including 132 methadone clinics. Between 100,000 to 130,000 people are on methadone maintenance therapy, including a very large number of prisoners. More recently, they have even introduced automatic vending machines offering sterile syringes and condoms.

At this point I would like to take a minute of my presentation to appeal to the Government of the Islamic Republic of Iran to release Arash and Kamiar Alaei from custody and the charges that have been brought upon them.

I have met the brothers on many occasions and had the opportunity to visit your beautiful country as a Faculty member of the HIV/TB training course for the region that they organised. It was through the inspiration that was gained by the visit to your country that the Malaysian Prison Department has implemented opiate substitution therapy in the Malaysian prison system. As a fellow Muslim, I appeal to the leaders of the Islamic Republic of Iran, in the name of Allah the Most Merciful and Compassionate, to release these brothers immediately.

If access to opiate substitution therapy and needle syringe programs is problematic, excess to antiretroviral therapy is equally abysmal. A review conducted by the WHO European region, showed, for example, that 83% of the HIV reported cases in Eastern Europe are injecting drug users, but only 24% of people on HAART are injecting drug users. These kinds of statistics are seen in many, many regions of the world, including Asia.

Why is this? Barriers to access can be sociopolitical, social marginalisation and the continued criminalisation and stigma and discrimination of drug users. Individual barriers including fear of side effects, psychiatric illness, homelessness, lack of trust, addiction and addiction related instability and ask the medical community equally at fault with our own perceptions and prejudice against drug users.

In an ideal world, we would like to see the integration of HIV treatment with opiate substitution therapy, tuberculosis, hepatitis C, and mental illness. Unfortunately, these kinds of services only occur in very, very select sites around the world.

If we continue to reject harm reduction it will be at a huge cost. For instance, in the US, where harm reduction is widely rejected at home, but also in countries where it financially supports health programmes.

In the US, 25-33% of injecting drug users are HIV-positive. In contrast, in Australia, where harm reduction was adopted in the early 80’s, this figure is only 3-6%.

We need to stop arguing about the merits of harm reduction and just do it. We need to expand coverage in countries where this is currently not a priority. We need to raise funding for health measures at the same level as law enforcement. We need to harmonise public security and health policies, and lastly we need to integrate prevention and treatment services. We need to do all this based on science, public health and human rights.

Now ladies and gentlemen, while we sit here and argue, and while we sit here and collect statistics of drug users becoming infected with HIV and hepatitis C, I would like to share with you something that I think brings home to all of us that drug users are people like you and me. They are somebody’s son, somebody’s brother, somebody’s daughter. This is a documentary that was done by the BBC more than 15 years ago, but the messages that it brings, I think is relevant until today.

The video shows the anguish of this mother over her son’s drug addiction. Thank you.