From Addiction to Action

Photo: Francis Joseph ( in middle) during a meeting of Alliance India members. Francis is the Programme Officer for Hridaya, an HIV and harm reduction programme supported by the Community Action on Harm Reduction (CAHR), Netherlands and implemented by Alliance India. Photographer: G Charanjit Sharma

Francis Joseph (center) with Alliance India colleagues. [Photo by G. Charanjit Sharma]

Francis Joseph is Programme Officer for Hridaya, our HIV and harm reduction programme in India supported through the five-country Community Action on Harm Reduction (CAHR) programme with funding from the Government of the Netherlands. Hridaya works in partnership with SASO, Sharan, a number of community-based harm reduction organisations, and the Indian Drug User Forum (IDUF), a national network of people who use drugs.‎

In this interview, Francis discusses the National AIDS Control Organisation’s approach to prevent HIV among people who inject drugs (PWID) and the work that Hridaya does to provide an additional package of services to this community, their spouses, children and families. Francis offers us a glimpse into the personal and programmatic consequences of social and self-stigma against people who inject drugs, and opens up about his personal connection to the PWID community which inspires his work every day.

Q: Why is a programme like Hridaya important especially in a country like India?

Francis Joseph (FJ): The National AIDS Control Organisation has adopted harm reduction strategy under the National AIDS Control Programme Phase three (NACP III) to prevent HIV amongst people who inject drugs (PWID), and has scaled up services through targeted interventions implemented by NGOs. The primary objective under the NACP III was to halt and reverse the spread of the HIV epidemic by 2012 and to cover 80% of the overall population of PWIDs through targeted interventions. By reaching out to a significant proportion of the estimated injecting drug users (IDU) population, the NACP III laid the foundation for an effective and evidence-based comprehensive response to halt and reverse the HIV epidemic among IDUs.

While considerable progress was made under NACP III with respect to the scale-up of interventions for IDUs as well as quality assurance in the country there were areas that were identified as emerging areas of concern. Some of these services include sexual and reproductive health services for spouses/sexual partners of male PWID, inadequate regulated drug treatment services and active engagement of PWID within the programme. The country lacks leaders from this community and especially lacks networks of drug users.

Any successful harm reduction approach requires greater involvement of PWID. Hridaya aims to empower drug users, identify individuals and build them as leaders from this community so that they are informed, educated and can voice for their basic human rights. Hridaya’s overall aim is to empower the drug using community in each of its focus states so that they can strengthen the harm reduction approach at the state and district level, and develop a local resource pool for capacity building initiatives.

Q: There are so many preconceived notions about IDUs. How does this affect their ability to seek treatment? Can you talk a bit about stigma?

FJ: Generally, people perceive drug users as criminals, social outcasts, and a threat to society. This makes it difficult for people who want to reach out to them to even contact them, or to build rapport and trust with them, and this is incredibly important since these factors further fuel the HIV epidemic in the country.

PWIDs are generally assumed to be HIV positive and are, hence, refused treatment when care and treatment is required. There have been many instances of PWID being denied treatment at public health care facilities, getting arrested and being treated with police brutality, and experiencing community hostility.

All of this leads to a complete lack of access to treatment and other essential services. The shabbily dressed appearance and unhygienic conditions of a number of PWIDs leads to them being denied access to any service. This has led to a sense of mistrust and has fuelled stigma and discrimination.

There was an incident in Delhi where a PWID burst his femoral vein due to injecting and was rushed to a nearby hospital. He was bleeding profusely and needed immediate critical care. The doctor on duty refused to help this man before an HIV test had been done on him. All through this, the man continued to be in incredible pain and was near death, but no one would help him.

Q: What motivates you about your job? Are there people you’ve met who inspire you to continue working in this area?

FJ: I come from the same community of PWID and have also experienced the pain of rejection, isolation, denial from family, friends, relatives and society at large. I know exactly what it feels like being socially rejected and ostracized, denied for many social entitlements and disowned by my family. I have lived a life full of negativity and have seen the inside of treatment centres and incarceration.

There are millions of people like me and very few have been fortunate enough to have come out of their dependence. I feel that I have a special calling that has motivated me to do something for my community. I began my new life of sobriety from the very basics, taking one day at a time, and I painstakingly built it up to where I am now. Today, I’m at a level where my voice is heard and I can speak up for the needs of the people who share a common background with me.

Q: What do you wish more people in general society understood about harm reduction and IDUs?

FJ: There are three approaches to any drug treatment programme: Drug demand reduction, drug supply reduction and harm reduction. The first two approaches see the solutions to this problem as generating awareness in reducing the desire to use drugs and prevent and delay the onset of drugs use to disrupt the supply of drugs through the implementation of draconian laws. Both these approaches focus on abstinence, which has constantly proven to result in a very poor outcome.

We at Hridaya follow the harm reduction approach, which-as the name suggests–aims to reduce the harm associated with injecting drugs use, such as HIV and Hepatitis C, and not eliminate the drug use per se. General society perceives that the only option to treat drug users is for them to follow the route of abstinence, which is practically impossible since there may be a certain segment of people who would never be able to give up drugs completely. Hence, the harm reduction approach advocates for drug users to stay safe and healthy regardless of whether they are still doing drugs or of the conditions that they live in.

Q: Are there any resources that you would recommend for people who want to learn more about harm reduction in relation to injection drug use?

FJ: I urge people to read more about this topic. To break the stigma against IDUs, we need more informed people. For those who are interested in learning more, there are some very good resources available on www.unodc.org/India/harmreduction,   www.nacoonline.org/publications/harmreduction and www.aivl.org

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The subject of this post, Francis Joseph, is Programme Officer for Alliance India’s Drug Use & Harm Reduction programmes and is based in New Delhi.

Spanning five countries (India, China, Indonesia, Kenya, and Malaysia), Community Action on Harm Reduction (CAHR) expands harm reduction services to more than 180,000 injecting drug users (IDUs), their partners and children. The programme protects and promotes the rights of these groups by fostering an enabling environment for HIV and harm reduction programming in these five countries. CAHR is supported by the Ministry of Foreign Affairs, Government of Netherlands.

CAHR in India is called ‘Hridaya’ and is implemented by India HIV/AIDS Alliance in partnership with SASO, Sharan, and a number of community-based harm reduction organisations and networks. This project helps build the capacity of service providers, makes harm reduction programmes more gender-responsive, improves access to services and advocates for the rights of PWIDs. In addition to providing services, Hridaya has a strong capacity building component to support advocacy, knowledge management and improved services for PWIDs.

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The Other Epidemic: Gender-based Violence in India

Highly visible, India’s hijras manage the threat of violence as a routine and dehumanizing part of their daily lives. (Photo © 2012 Peter Caton for India HIV/AIDS Alliance)

Highly visible, India’s hijras manage the threat of violence as a routine and dehumanizing part of their daily lives.
(Photo © 2012 Peter Caton for India HIV/AIDS Alliance)

The world has watched over the past weeks as India has struggled to address the causes and consequences of sexual violence, an all too common part of life in this country. The horror of the December 16th rape and murder in New Delhi has not diminished, its brutality a reminder in extremis of our collective failure to respond to male violence in its myriad manifestations.

If there is any good that can come out of this grim demonstration of humanity’s darkness, it is the emerging movement to speak publicly about the culture of rape, harassment and discrimination that limits and destroys the lives of too many Indians. The government’s response so far has done little to build confidence that change will come quickly.

In the past, the standard and accepted reaction of the government and its institutions responsible for public safety and security has been inaction or worse. Of the more than 600 reported rapes in Delhi during 2012, only one so far has been successfully prosecuted. In Punjab, the police response to a young woman’s efforts to report her rape so diminished her that she ended her life rather than face further humiliation.

While tempting and indisputably true, we must do more than simply blame men. Men must change, of this there can be no doubt, but if we really seek transform society, we need to make peace with the complexity of gender and sexuality. Too often gender and sexuality are framed in a static male-female binary. Few if any of us can honestly say that we don’t routinely encounter variations. Yet these variations are ridiculed and criminalized for failing to adhere to the established norm.

Consequently, far too many lesbian, gay, bisexual and transgender (LGBT) people in India live lives of secrecy and shame. Those who reveal their sexual identities or who deviate from gender norms face social rejection, economic marginalization, and physical violence—by now a familiar litany of consequences for not being a heterosexual male.

If we are to address sexism in India and the violence against women and girls that it generates, we cannot ignore its connection to homophobia and transphobia. Though not identical, they are fellow travelers. Misguided ideas about male heterosexual power and privilege allow men and boys to claim control over the lives of those whose sexuality and gender are different from theirs.

Gender-based violence is an epidemic facing India and the world, and like AIDS, it will require a sustained and committed effort to overcome. Attitudes must change. We must never tolerate violence against women and girls. We must never be blind to gender’s diversity. We must never excuse or accept any violence based on gender or sexuality, and we must never step away from our responsibility to speak, to act and to end this epidemic.

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The author of this post, James Robertson, is Country Director of India HIV/AIDS Alliance in New Delhi.