Too Little, Too Late is Not Enough: International Overdose Awareness Day 2013

The right medical help at the right time can help avert overdose-related deaths. (Photo by Prashant Panjiar for India HIV/AIDS Alliance)

The right medical help at the right time can help avert overdose-related deaths. (Photo by Prashant Panjiar for India HIV/AIDS Alliance)

In the past few years, a number of famous celebrities including Michael Jackson have died due to fatal drug overdose. The media is quick to target the lifestyles of these stars, paying little heed to the grieving families and fans. Some of these deaths have left us surprised, while others we saw coming.

For people who inject drugs (PWID), a fatal drug overdose is an occupational hazard. In India, overdose deaths are particularly common among street-based drug users in bigger cities. Often, these deaths are not reported or even recorded for fear of legal consequences. Like most countries, Indian law criminalises illicit drug use. When someone overdoses, they seek medical help as the last resort, not wanting to deal with the possibility that the police might be called to the hospital.

Anyone who has witnessed an overdose will tell you about frustration and helplessness. The extent of the problem in India is unknown, as there is little reliable data on the annual number of drug overdose deaths. Estimations by NGOs working in the field indicate that in areas with high levels of injecting drug use, hundreds of people die from overdose each year. These cases are mainly due to mixing drugs or use of drugs of poor or unknown quality. Those of us who use drugs or know people who do always need to be aware of the underlying dangers of using drugs in combination. People who have been trying to quit or have been abstinent for a while — such as after a treatment programme or incarceration— are more prone to overdose than those who regularly use drugs.

Preventing overdose-related deaths can require just a few simple steps. A Naloxone injection in time can save a person’s life. What is needed is to ensure that Naloxone — a drug included in India’s National List of Essential Medicines — is readily available at all public healthcare facilities. Unfortunately this is not yet the case. In a number of recent cases, the emergency ward has had no Naloxone available. Relatives or friends of the overdosing PWID have had to rush to procure Naloxone from nearby pharmacies, where they are charged 10- to 20-times the actual price by staff who exploit the urgency of the situation.

Naloxone is an integral and necessary part of effective programming for PWID, but it still needs to be fully integrated into India’s national programme. Alliance India has incorporated overdose prevention and management into the harm reduction services provided to PWID under our Hridaya programme. Our Asia Action programme complements these efforts by supporting advocacy for expanded access to Naloxone and other interventions to reduce overdose-related deaths.

International Overdose Awareness Day is an opportunity to raise awareness about drug overdose, reduce stigma, and advocate for expanded access to overdose-related services. Join Alliance India in solidarity with friends from all over the world as we remember those who have died and recommit to our efforts to end the epidemic of overdose-related deaths.


The author of this post, Simon W. Beddoe, is Advocacy Officer: Drug Use & Harm Reduction at Alliance India.

With funding from European Commission, the Asia Action on Harm Reduction programme supports advocacy to increase access by people who inject drugs (PWID) to comprehensive harm reduction services and reduce stigma, discrimination and abuse towards this vulnerable population. In India, the three-year programme will initially engage with PWID and local partners in Bihar, Haryana, Uttarakhand, Delhi and Manipur. 

Spanning five countries (India, China, Indonesia, Kenya, and Malaysia), Community Action on Harm Reduction (CAHR) expands harm reduction services to more than 180,000 people who inject drugs (PWID), 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. 

In India, CAHR 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 programme 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.

Strengthening STI Services for Key Populations: Alliance India’s Mythri Mainstreaming Model

Mythri Clinics provided counseling and treatment services for sexually transmitted infections (STIs) to female sex workers, men who have sex with men, and transgender individuals in 13 districts of Andhra Pradesh, India. (Photo by Peter Caton for India HIV/AIDS Alliance)

Mythri Clinics provided counseling and treatment services for sexually transmitted infections (STIs) to female sex workers, men who have sex with men, and transgender individuals in 13 districts of Andhra Pradesh, India. (Photo by Peter Caton for India HIV/AIDS Alliance)

Providing STI/HIV services in rural areas with fewer and scattered key populations (female sex workers, men who have sex with men, transgenders) is a challenge for HIV prevention programmes in India. In such scenarios, project-supported static clinics are not a sustainable option because of the limited availability of skilled health professionals and operational costs involved. Realising this need for sustainable approaches for providing STI services to key populations, India HIV/AIDS Alliance in collaboration with Andhra Pradesh State AIDS Control Society (APSACS) conceptualized the Mythri Mainstreaming Model in March 2007 as part of programming it supported under the Bill & Melinda Gates Foundation-funded Avahan India AIDS Initiative.

Alliance India initiated the model through a public-private partnership (PPP).The model used infrastructure and personnel of existing government healthcare facilities. Capacity building of staff, provision of STI drugs, and syphilis screening kits were provided by Alliance India to enable the provision of an essential package of STI services. STI services were provided after regular outpatient hours to female sex workers, men who have sex with men, and transgender communities. To address stigma and discrimination in accessing government facilities, doctors and staff were trained on issues faced by these clients.

The Mythri Mainstreaming Model achieved notable success. It resulted in improved utilisation of public healthcare facilities. Within the first year of initiating these clinics, more than 60% of targeted key populations had accessed these STI services. It successfully brought these groups to mainstream healthcare services. The Mythri model serves as a ‘one-stop’ centre for HIV/STI as well as other health care needs of key populations. Considerably greater understanding on health issues of key populations developed among medical staff, and these groups reported less stigma and discrimination while accessing services. Additionally, government healthcare facilities enjoyed improved infrastructure and staff capacities.

A study done by Alliance India to identify the most effective healthcare model for the delivery of STI services found that of the three models studied—project-owned clinics, private clinics, public private partnership (Mythri) clinics—the Mythri model was the most cost-effective. The model was also found to be the most effective in leveraging the strengths of the public and private sector and was the most sustainable of the three.

Due to lower operational costs and with better performance indicators, the Mythri Mainstreaming Model offers characteristics that make it preferable to other models of HIV/STI service delivery for scattered key population groups in rural areas. Similar models should be promoted in other resource-poor settings to improve HIV prevention and overall healthcare for vulnerable populations, such as female sex workers, men who have sex with men and transgenders.


The author this post, Dr. M. Ravikanth, was Documentation & Communication Specialist with India HIV/AIDS Alliance in Andhra Pradesh.

The Avahan India AIDS Initiative (2003-2013) is funded by the Bill & Melinda Gates Foundation. The programme aims to reduce HIV transmission and the prevalence of STIs in vulnerable high-risk populations, specifically female sex workers, MSM, and transgenders, through prevention education and services such as condom promotion, STI management, behavior change communication, community mobilization, and advocacy. Avahan works in six states, and Alliance India is a state lead partner in Andhra Pradesh.

More or Less Equal: Reflections on Freedom

In India, there is a need to make sexuality more visible and to voice issues around sexuality more publicly, without stigma and shame. (Photo by Peter Caton for India HIV/AIDS Alliance.)

In India, there is a need to make sexuality more visible and to voice issues around sexuality more publicly, without stigma and shame. (Photo by Peter Caton for India HIV/AIDS Alliance.)

The Indian Constitution declares that all Indians are granted the Right to Freedom of Speech and Expression. On Independence Day, Shaleen Rakesh explores what freedom means for young Indians struggling to express their sexuality:

I am at the barber’s shop, and reflecting on the sensual quality of something as practical as having a haircut in Delhi. The guy is massaging my scalp, it is highly tactile, and I am instantly aware of it. In India, there seems to be an unconsciousness around the body – you don’t have personal space, people do not think it wrong to crowd close together, to touch one another. In buses and the metro, you become aware of a very close and mostly unselfconscious proximity.

This unconsciousness of certain aspects of anatomy and gender and the way you are in public is a paradox – in some ways India is a tolerant society, since it recognizes homo-affective and homosocial relationships. As far as sexual behaviour is concerned, India can be very accommodating, but it becomes very intolerant and homophobic when it comes to a question of identity.

It seems like a constant partition of freedoms. You are free to do what you want but not express freely who you are.

There is a need to make sexuality more visible and to voice issues around sexuality more publicly without stigma and shame. People who are straight also feel sexuality is silenced in India: they are victims of a similar oppression. The objective of breaking silence is to look at the issue from a cultural point of view.

When I’m still waiting for my shampoo, three or four young guys walk in. One of them is dark-complexioned and is looking at himself very intently in the mirror. His friends start pulling his leg: “Dude, what a fabulous complexion you have! How come you don’t have a girlfriend?” The boy was obviously embarrassed about being dark and being teased publicly but couldn’t find the words to retaliate and offered an embarrassed smile. His friends were laughing.

Soon the friendly banter started recounting failed sexual overtures with girls. I thought the young guys, in their talking and making fun of their own sexual feats – or lack of them – there was a great irony at the core, and a certain sadness also. I felt sorry for them for a moment, thinking, why do they need to be in this place where the only way they can articulate some of their frustrations is in the form of a joke? I identified with it. At 19, I felt oppressed about my own sexuality. Of course, I couldn’t even talk about it in barber shops. I still can’t actually. Invisibility and silence are the problem we share.

As I walk out of the barber shop, I realize how conflicted and bottled up most Indians are when it comes to talking about sexuality. It’s a cultural prison most of us find difficult to step out of.


The author, Shaleen Rakesh, is Director: Technical Support, India HIV/AIDS Alliance.

India HIV/AIDS Alliance (Alliance India) is a diverse partnership that brings together committed organisations and communities to support sustained responses to HIV in India. Complementing the Indian national programme, Alliance India works through capacity building, knowledge sharing, technical support and advocacy. Through our network of partners, Alliance India supports the delivery of effective, innovative, community-based HIV programmes to key populations affected by the epidemic.

International Youth Day 2013: Putting Youth Living with HIV in the Mix

With information and support from Alliance India's Action Project, youth have gained capacity and confidence to advocate for improved sexual and reproductive health policies and services for their peers. (Photo by Prashant Panjiar for India HIV/AIDS Alliance)

With information and support from Alliance India’s Action Project, youth have gained capacity and confidence to advocate for improved sexual and reproductive health policies and services for their peers. (Photo by Prashant Panjiar for India HIV/AIDS Alliance)

Fifty percent of India’s population is below 25 years of age. As they mature sexually, adolescents—especially those from high-risk groups—face vulnerability to HIV and experience a range of unmet sexual & reproductive health (SRH) needs. The SRH needs of too many of India’s adolescents continue to be underserved. Sexuality education in schools is limited, and social norms typically silence discussions of adolescent sexuality and act as barriers to creating responsive services. As adolescents become sexually active, they have limited access to the information and services they need. Adolescents show low levels of knowledge about puberty, menstruation, contraception, safer sex and sexually transmitted infections (STIs), including HIV.

According to an Alliance India study conducted by our CHAHA programme with 72 girls and boys living with HIV and 95 girls and boys affected by HIV (aged 12-18 years), the support needed by these groups was intense, particularly among those who had lost one or both parents to HIV and whose remaining family members struggled to provide the needed level of ongoing support and supervision. In cases of orphaned adolescents, distant relationships with caregivers resulted in reluctance among adolescents to discuss issues and concerns about SRH openly and made them feel more isolated and lonely.

Moreover, the HIV status of adolescents themselves also influenced their level of engagement with their peers and the community. In the same study, adolescent girls living with HIV in Andhra Pradesh appeared to be isolating themselves from their peers due to self-stigma and feared discrimination, which seemed to be more common among girls than boys. As with older girls living with HIV, they appeared to be spending most of their time home alone since many lived in widow-headed households in which their mothers worked all day and were less available for support and conversation.

Boys living with HIV reported being teased by their peers for their stunted growth, delayed development and sexual inactivity often related to HIV status. Many of the adolescent boys living with HIV explained that they did not want to engage in any sexual relationships because they were afraid of ‘spoiling other people’s lives with HIV.’

For young people living with HIV, concerns about physical development, sexuality and reproduction, including getting married and having children, are immediate and profound. They feel pressure to control their desires and limit their aspirations because they are living with HIV. Little effort has been made to give them guidance on their choices, and youth-friendly counseling services are rarely if ever available to them.

Under our European Union-supported Action Project, Alliance India made some progress in efforts to empower youth, including those living with HIV, by educating them about SRH issues that are important to them—contraception, HIV prevention and care, STIs, hygiene, and pregnancy—and by discussing subjects that no one had ever talked to them about before. With this support, youth grew confident to advocate through the Youth Partnership Platforms formed under the project to encourage government to enact policies and offer services that respond more effectively to the SRH needs of young people like themselves.

There is a long journey ahead. This International Youth Day, let’s commit to shaping SRH services and policies that recognize the distinct challenges youth face, that reflect their diversity (including issues around gender identity and same-sex desire), and that address the stigma and discrimination that poisons the lives of adolescents living with HIV.


The author of this post, Sonal Mehta, is Director: Policy and Programme of India HIV/AIDS Alliance in New Delhi.

The Action Project (2010-13) was funded by the European Union and strengthened and empowered civil society organisations and youth groups to advocate for more responsive policies addressing the sexual and reproductive health and rights (SRHR) of young people. The project focused on the most marginalised young people—MSM and transgender community members, drug users, sex workers and those living with HIV. The project was implemented in partnership with MAMTA and SASO in India and by HASAB in Bangladesh. Over its life, the Action Project contributed to shaping SRHR policies and their implementation in India and Bangladesh by supporting the meaningful participation of young people in relevant processes and programmes.

Ignorance is Not Bliss: Why HIV-Hepatitis C Co-infection among People Who Inject Drugs is a Crisis in India

Umesh (3)HIV-Hepatitis C co-infection is emerging a complex and urgent problem. Umesh Sharma, executive member of the Asian Network of People who Use Drugs (ANPUD), has been working for many years to reduce HIV and drug-related stigma and discrimination. Infected with both HIV and Hepatitis C, he is known nationally and internationally for his advocacy on behalf of people who inject drugs (PWID). In the following interview with Alliance India’s Francis Joseph, Umesh shares his perspective on the problems with HIV-Hepatitis C co-infection and explores options for an improved and more impactful response to this challenge.

Q: What is your perspective on the increasing Hepatitis C problem in India?

Umesh: The situation is very alarming. One of the major factors that compounds the problem and encourages its spread is the lack of knowledge about Hepatitis C among people who inject drugs. For example, during a focus group discussion in 2011, we heard a belief in the community that “even if a person is injecting drugs without sharing for six months, the person will still get Hepatitis C.” So you can imagine how low information levels really are among community members.

Q: What are the major problems that a person living with HIV-Hepatitis C co-infection faces?

Umesh: Well, things become more challenging with co-infection. In case of a mono-infection, for example, with HIV, chances of a person getting better and improving his quality of life with ART medication is high. But with Hepatitis C co-infection, the improvement slows down.

Q: How much does the Hepatitis C treatment cost? Can the community afford it? What needs to be done to make it accessible?

Umesh: We surveyed Delhi, Manipur and three other countries in 2011 to check the prices. At the time, the price for Hepatitis C treatment for 48 weeks ranged from USD 14,000 to USD 20,000, which is obviously quite expensive. Accessible treatment depends on governments. We have seen in a country like Egypt where they have a high burden of Hepatitis C, the government has come up with a plan to get more people treated, including children.

My suggestion is to integrate Hepatitis C treatment into the HIV programme. This integration has to be not just in terms of treatment but also education so that the right messages and information go to the community. Moreover, service providers at the grassroot-level also need to be educated. One of our studies found that peer leaders inform the community about Hepatitis C, and most of their information is wrong. Working only with the national HIV programme, they’re still not aware of the basics of HIV-Hepatitis C co-infection.

Q: What can be the role of civil society organisations in this entire endeavour?

Umesh: Civil society needs to create demand and keep pushing the government for an integrated policy and for affordable treatment. Civil society is the frontrunner in this initiative, as currently we are the only ones advocating for it. We also don’t have national numbers on the prevalence of Hepatitis C in India, and getting these data are a priority.