healthmedicinet

More than two decades ago, attention was called to the uncontrolled spread of injecting
drug use in many Asian countries and the virtually unnoticed but rapid spread of HIV
among those who were injecting 1]. It was pointed out that constantly changing trafficking routes from the Golden Triangle
were exposing new populations to the use and subsequent injecting of heroin, that
these populations were forming the fertile ground for explosive but largely silent
epidemics of HIV and that there were structural and other reasons why these epidemics
would prove difficult to control. It was called an evolving public health crisis;
the authors concluded that

Vigorous efforts are urgently required at both a national and international level
to raise awareness of the consequences of an uncontrolled epidemic of HIV among IDUs
in Asian and other countries, and to support the implementation of policies which
are likely to reduce the spread of HIV 1].

The initial challenge to the public health community was to gain acknowledgment of
the existence of both epidemics—of drug injecting and of HIV among people who were
injecting. Many original national medium-term AIDS plans from countries in the Asian
region did not even mention injecting drug use as a component of the national epidemic,
despite evidence from early in the course of the epidemic of explosive spread, high
prevalences and the central role of epidemics of HIV among people who inject drugs
(PWID) in driving national epidemics.

The second challenge was to gain recognition that these epidemics of HIV among and
from PWID mattered and that it was necessary to control HIV spread among PWID to stop the national HIV
epidemic. This challenge was increasingly taken up by the growing NGO sector, with
harm reduction programs springing up in most countries in the region, most often in
very adverse circumstances. In 1997, these programs came together at the International
Harm Reduction Conference in Hobart to form the Asian Harm Reduction Network, which
became the lead advocacy body for harm reduction responses in Asia.

These early harm reductionists also took on the next challenge, that of convincing
authorities that something could be done to address and control these HIV epidemics
and that it was worth doing. Official points of view, on the part of both national
health and criminal justice sectors, were generally opposed to these positions: that
there was nothing to be done about HIV among PWID (a view held for various and mostly
spurious reasons) and that anyway, it did not matter because the epidemic would remain
confined to populations of PWID, a group seen universally as socially undesirable,
if not worse. Allied with the deeply felt desire to stamp out drug use, which was
seen as a threat to Asian societies, this stance militated strongly against the adoption
of effective measures—measures for the effectiveness and safety of which there was
by then a large body of international evidence 2].

Increased attention to the issue followed high-profile epidemics of HIV among and
increasingly from PWID, which occurred around the Burmese borders, following heroin trafficking routes
3], especially in the southwest of China, in Ruili county and in the northeast of India,
in Manipur State. By 2000, one study found that of young PWID in Manipur, 75 % were
infected with HIV and 98 % had been exposed to the hepatitis C virus (HCV)—this despite
the fact that Manipur was the first jurisdiction in the Asian regions to explicitly
adopt harm reduction as policy 4]. The scale of the response was manifestly insufficient to match the scale of the
epidemic, and in most places, what response there was came well after the epidemic
was established. For instance, Bangladesh, which responded early, has maintained low
HIV prevalence among PWID 5]; Pakistan, where the response was much later, has seen continuing epidemics 6]. It is a truism in the field of control of blood-borne viral infections that much
greater prevention efforts are required when prevalences are high 7].

The evolution of drug production and consumption patterns, of social and geographic
focuses of drug use and injection, and of viral epidemics associated with drug use
has been rapid, constant and varied. New populations exposed by new trafficking routes
and methods; new vulnerabilities created by social and economic development, with
the appearance of irreversible structural unemployment associated with urbanisation;
and new drugs appealing to hitherto uninvolved segments of society—all these factors
have contributed to a constantly shifting and complex set of challenges to HIV control.
The increasing use of amphetamines, originally largely occupational use in the region
but rapidly becoming recreational among large communities of young people, has been
described as a ‘flood’ across the region 8]. Increasing crossover of risks—especially between injecting drug use and sex work—and
continued incarceration and reincarceration of these populations have amplified spread
of HIV and ensured it has affected whole communities—ot just those who use drugs.

Has the public health response, in the form of harm reduction interventions, kept
pace with these changes and reached the scale necessary to stop HIV among PWID in
Asia? Certainly, there is an increasing number of programs providing sterile needles
and syringes to an increasing number of clients 9] and an increasing number of countries are implementing opiate substitution programs,
led by a startling volte face by China in relation to methadone maintenance in the early part of this century 10], 11]. But is it enough?

And beyond HIV, have harm reduction policies and programs brought substantial gains
in access to effective drug treatment, in recognition of the human rights of people
who use drugs and in elimination of prejudice, stigma and discrimination against people
who use drugs? And where there have been successes, are they integrated into social
systems and structures so as to become sustainable 12]?

This special issue of the Harm Reduction Journal brings together current research
evidence to address these questions.

Harm reduction responses have indeed grown in the region over the last two decades,
but what has been achieved in most countries has been the introduction of small programs
reaching few people in need. Katie Stone’s report from the HR Global State of Harm
Reduction survey in 2014 illustrates this: of 23 countries in south and SE Asia, 17
countries have needle and syringe program (NSP) provision and 15 opioid substitution
therapy (OST); coverage, however, remained low, with the numbers reached with OST
in the few thousands and less than 20 % of those infected with HIV on antiretroviral
treatment (ART) 9]. An example is Pakistan where HIV prevalence in this population is above 40 % in
several cities, including Faisalabad (52.5 %), D.G. Khan (49.6 %), Gujrat (46.2 %),
Karachi (42.2 %) and Sargodha (40.6 %) 6]. Current coverage of the needle and syringe program, HIV testing and counselling
and ART among PWID remains insufficient: of an estimated 430,000 PWID in Pakistan,
around one tenth are registered with harm reduction programs and less than 10 % of
those in need of ART are receiving treatment 6].

As well as inadequate attempts to address these needs, there are huge gaps yet to
be addressed: most PWID are infected with HCV, for instance, but treatment remains
beyond the reach of virtually all. In Kabul, a conflict-affected area, Todd et al.
show a high HCV incidence and high numbers of reported deaths among male PWID despite
relatively consistent levels of harm reduction program use 13]. The case is similar for those PWID with combined TB and HIV infection, for very
few of whom is there available treatment 14].

Although the needle syringe program has been adopted in many countries in the region,
sharing of used needles syringes continues to remain an issue 10]. WHO recommends the use of low dead space syringes (LDSS) with permanently attached
needles in NSPs as these are better at preventing HIV and HCV transmission 15]. However, the acceptability of LDSS by PWID has been problematic as shown in the
qualitative study conducted with PWID in Tajikistan by Zule et al., which shows that
the size of the syringe as well as being able to detach the needle from the syringe
are important aspects to injection practices 16]. Such barriers may be overcome through social marketing interventions as demonstrated
in the paper by Huong et al., where such an intervention in Vietnam was found to play
an important role in widening access to and the use of LDSS for PWID 17].

HIV in PWID in the Asia Pacific region is a mixed picture with declining trends but
emerging pockets 18]. The need to better understand the epidemic is highlighted in the paper by Todd et
al. that summarises the discussions of a consultative meeting reviewing what is known,
what needs to be known and how to move forward so that the universal goal of 90-90-90
can be achieved by engaging communities for reaching those most hidden, enhancing
HTC coverage and ensuring adherence for ART 19]. Similarly, from the Pacific region where information is limited on drug use behaviours,
Power et al. stress the need for a better understanding of the local situation in
order to ensure more appropriate programming—especially recognising the diversity
of situations, summarised in the phrase ‘know your epidemic’ 20].

It is encouraging to see that OST is gaining acceptance in most countries in the region
although coverage is far from adequate. Three papers presented in this issue discuss
beneficial effects of methadone maintenance treatment (MMT) on clients as well as
factors that could improve uptake of methadone. Hoang et al. show that in Vietnam,
a successful pilot of MMT has led to considerable expansion; they have gone further
to show that being on ART or being co-infected with TB may act as barriers to adherence,
factors which need to be addressed in the MMT programs 21]. Similar findings have been reported from Taiwan by Chang et al. where the quality
of life of MMT clients improved but co-infections such as with HCV were predictors
of non-adherence 22]. In Hong Kong, where MMT has been in place for about 40 years, Kwan et al. have analysed
records of MMT clients since 2008 and shown that optimal frequency of attendance at
MMT program is dependent on an adequate dosage and that the connectivity of methadone
users among themselves could impact harm reduction intensity 23].

There is a cruel irony in the fact that methadone is becoming established just as
Amphetamine-type stimulants (ATS) take over as dominant drug 8]. The four papers in this issue on women who use drugs all report ATS as the dominant
drug used.

A recently published meta-analysis on the number of females who inject drugs (FWID)
showed that of people who inject drugs, around 21.5 % are women, which would correspond
to approximately 3.5 million FWID globally 24], 25]. Women who use drugs are highly stigmatised and suffer from multiple risks related
to drug use, unsafe sex and violence 26]. In this issue, four papers present different dimensions of women using drugs from
China, Vietnam, Cambodia and Malaysia. In Yunnan, China, Zhang et al. highlight the
special needs of young women who often sell sex to support their ATS use and the risky
sexual practices associated with ATS alongside a lack of knowledge and understanding
of those risks and access to services 27]. Similarly, the paper from Vietnam by Morrow et al. reveals the vulnerabilities of
women who use drugs in Hanoi and Ho Chi Min City both in terms of their individual
behaviours (unsafe injecting and unsafe sex) as well as high levels of stigma 28]. The study from Cambodia by Dixon et al. on female entertainment sex workers (FESW)
presents a different dimension of women’s vulnerabilities associated with ATS use,
where ATS is used for occupational performance—to stay awake longer and to work more
hours, enabling FESW to see more clients and also in some cases to be “happy” and
to forget about their problems 29]. Present harm reduction services are geared towards individual behaviour change but
fail to recognise these structural issues that make it difficult for individuals to
adopt safer behaviours, such as condom negotiation when both FESW and their clients
are using ATS. The role of familial instability as a gateway to drug use is presented
in the qualitative study from Malaysia by Rahman et al. on a small group of women
who mainly smoke heroin or ATS; with a lack of appropriate services and interventions,
these women were condemned to recreate the unstable backgrounds from which they came
30].

As has been found in other places, the role of the at-risk communities is a critical
one in building successful responses to HIV epidemics. Le et al. highlight the efforts
that are underway in Vietnam for CBOs and the government to work together, as there
is increasing recognition that community-based organisations (CBOs) have greater access
to the marginalised communities of people who use drugs and/or sell sex 31]. Building partnerships with police, in particular, is critically important for effective
responses 32]. And it is becoming very clearly recognised that unidimensional law enforcement approaches
to illicit drug use, and a reliance on arbitrary detention, based on administrative
regulation and masquerading as ‘drug treatment’, is not only ineffective but also
extremely deleterious, both to the individual and to their communities 33], that the death penalty for drug-related offences that continues to be used is unconscionable
34].

What is the future of harm reduction in the Asian and Pacific regions in the face
of shrinking resources and the rise of competing priorities?

A very real and ever-present danger is that with apparent control of the epidemic,
attention will shift away from PWID and gains in human rights, rule of law and effective
approaches to treatment achieved at great cost will be wound back. A further irony
is that without an HIV epidemic, it is very unlikely that the human rights of people
who inject drugs would ever have become a topic for international discussion and funding.
If the HIV epidemic is perceived to be over, will countries return to their previous
unconcern and inhumanity towards these people? Or have we actually learnt something
from the struggle against HIV?