Are harm reduction strategies working?

Harm reduction services need to be amplified and customised based on community needs.

Harm reduction services need to be amplified and customised based on community needs.

Observed every year on 26th June, International Day Against Drug Abuse and Illicit Trafficking remains focused largely on protecting society from the evils of drugs. There is however a burning need to consider the situation of people who use drugs. To what extent are we as a society enabling drug users either to quit taking drugs or – failing that – to minimize the harmful consequences of their drug use? This is where ‘harm reduction’ comes into play.

In India, harm reduction has generally meant helping people who inject drugs (PWID) reduce the harmful consequences of their injecting practices – notably the risk of HIV infection. Harm reduction has been adopted as the official policy of Government of India, though there has been criticism about the manner in which it has been done. Under the National AIDS Control Programme, preventing HIV among PWID  is accomplished by delivering a package of services to them that include, access to clean needles and syringes (Needle Syringe Exchange Programmes, or NSEP), Opioid Substitution Therapy (OST), peer-education for adopting safer behaviours, primary medical care and referral for other health-care needs. This package of interventions, collectively called ‘Targeted Interventions’ (TIs) is typically delivered by NGOs working with PWID. The NGOs are financially and technically supported by the Government, and it is estimated that more than 80% of estimated 186,000 PWID in India are covered by such TIs.

However, we need to consider the variations in the injecting patterns of PWID in a vast and heterogeneous country like India. PWID from north-east India would have very different needs as compared to PWID from say, Punjab, who would need different services as compared to PWID from, say, Kerala.

Indeed, nationwide research studies have been able to document the variations and similarities in the drug use patterns of PWID in different parts of India. One such study looked at behaviours and practices of about 1,000 PWID from 11 different states of India. Another soon to be released study, by the same author in collaboration with India HIV/AIDS Alliance, involved specifically interviewing PWID from four states – Bihar, Haryana¸ Jammu and Uttarakhand titled ‘Drug Use Patterns among Clients Receiving Services from Targeted Interventions for People Who Inject Drugs.’

Such studies reveal very important facts about the situation of PWID in India. One clear, unambiguous finding has been that across the country, the injecting pattern in India is characterized by injecting ‘opioid’ group of drugs. There may be variations in the choice of opioid drug injected by PWID – from D-propoxyphene or pure heroin in the north-eastern states, to buprenorphine or pentazocine or street heroin (‘brown sugar’ or ‘smack’) in other states of the country. But in medical terms, almost all the PWID can be diagnosed as having suffering from ‘opioid dependence disorder,’ and intervention strategies must take this fact into account.

Another issue of concern which emerges from this available data is the progression and continuation of risky practices by PWID. On an average a typical person who injects drugs in this country begins his/her drug use career by using legal and common substance like tobacco or alcohol in the early teen years. By late teen years, he/she begins using illegal drugs, though through a non-injecting route (orally or through smoking). It is only after spending about five to six years as a non-injecting drug user, he/she begins injecting the drugs – often under the persuasion and influence of his peers. Soon as he/she begins injecting, he/she starts sharing needles and syringes, putting himself/herself and his/her peers at the risk of HIV. And here comes the interesting part. Only after having spent about four to five years as a person who injects drugs does he/she begin receiving harm reduction services from the TI. Thus, for many crucial years in their drug use careers, PWIDs remain out of the network of any services. Clearly, we are not ‘catching them young’!

A Hypothetical time-line of Drug Use Career of a typical IDU in India sdp blog insert 1Adopted from Ambekar (2012)

Our data also show that even after coming in contact of harm reduction services, a certain proportion of PWID continue to share their injections. In a nationwide study, almost a quarter of PWIDs reported sharing their injections in last three months, despite receiving services for an average of about two years.

Thus two crucial issues which emerge are (a) we are reaching the population quite late, when a behavioural pattern appears to have been well established putting them at risk; and (b) our services are probably not geared to ensure zero sharing of injections. No wonder then, that recent research studies show that there is practically no reduction in HIV or HBV or HCV infection among people who inject drugs, despite provision of harm reduction services.

Does this mean we need a course correction? Do we need to think of innovative approaches and alternate models of service delivery? Do we need to enhance and intensify the existing programmes? A combination of all of the above? Worth thinking about on this year’s International Day Against Drug Abuse and Illicit Trafficking which is also the Global Day of Action for the Support. Don’t Punish campaign which promotes the human rights of people who use drugs and advocates against the harms of criminalising drug use.

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The author of this Post, Dr. Atul Ambekar is Additional Professor of Psychiatry at the National Drug Dependence Treatment Centre (NDDTC), AIIMS, New Delhi. He is also member of the Strategic Advisory Group to United Nations of HIV and IDU and a member of the Technical Resource Group on IDU for the Department of AIDS Control, Government of India. Views expressed are his own.

Alliance India 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.