Beyond Punishment: A Conversation about the Government of India’s Support for Drug Users

Rajesh Nandan Srivastava (right) in conversation with Francis Joseph in Vienna, Austria. (Photo: India HIV/AIDS Alliance)

Rajesh Nandan Srivastava (right) in conversation with Francis Joseph in Vienna, Austria. (Photo: India HIV/AIDS Alliance)

Rajesh Nandan Srivastava, India’s Director of Narcotics Control, was in Vienna last month to attend the High-Level Segment of the 57th Session of the UN Commission on Narcotic Drugs (CND). Francis Joseph, Alliance India’s Programme Officer for Harm Reduction & HIV, caught up with him there to discuss issues facing people who use drugs in India. Edited excerpts of the interview follow.

 Francis: There are estimated to be two million people dependent on various drugs in India, but only 400 drug treatment centres? Is that adequate?

Rajesh: In addition to the 400 centres run by civil society organisations with support from Union Ministry of Social Justice, there are also 120 de-addiction centres being run in various government hospitals with support from Union Ministry of Health & Family Welfare. It is the responsibility of these two ministries to establish such centres. Civil society should advocate with these ministries and ask for more drug treatment centres at district hospitals and more trained doctors. As far as our department is concerned, we are already supporting the National Drug Dependence Treatment Centre (NDDTC), and the All India Institute of Medical Sciences (AIIMS) in New Delhi is training 500 doctors on issues concerning drug use in the country.

Francis: Section 64A of the Narcotic Drugs & Psychotropic Substances (NDPS) Act allows people arrested for using drugs to be exempted from prosecution if they volunteer for treatment, yet we still see many unlawful detentions.

Rajesh: The problem is lack of awareness among both people who use drugs (PWUD) and policemen about this provision (Section 64A). Civil society organisations need to sensitise both PWUD and police personnel on this provision at national, state and district-level.

Francis: An important step to ensure proper implementation of section 64A is getting accurate numbers on how many people are imprisoned in India for drug use. Some NGOs have tried to get data, but what they receive from government is highly disaggregated, unclear and incomplete?

Rajesh: It is necessary to have data on the types of drug offences for which people are imprisoned, and the Narcotics Control Bureau (NCB), the coordinating agency on drug matters under the Ministry of Home Affairs, should be able to provide this informations. NGOs can even approach National Crime Records Bureau and request such data. If gathering accurate data on the number of PWUD in prisons requires additional money, a proposal to fund the same could be made under National Fund for Control of Drug Abuse (under section 7A of the NDPS Act).

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.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.

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The Pain of Being ‘the Other’: How Stigma Fuels HIV/AIDS among People Who Inject Drugs in India

People who inject drugs face widespread discrimination, physical violence, hostility and harassment that limits their access to lifesaving health services. (Photo by Prashant Panjiar for India HIV/AIDS Alliance)

People who inject drugs face widespread discrimination, physical violence, hostility and harassment that limits their access to lifesaving health services. (Photo by Prashant Panjiar for India HIV/AIDS Alliance)

Born in a poor family in a remote district of Haryana, Paul (name changed) learnt from childhood to be by himself. He was dragged to work at the age of 10. It was here, copying older boys, he got into the habit of smoking ganja (cannabis). Soon his peers influenced him enough to experiment with stronger substances like smack (a heroin derivative). As his cravings increased, he was soon hooked on injecting pharmaceutical drugs, unaware that sharing needles and syringes could make him vulnerable to HIV.

Paul’s story is shared by many people who inject drugs (PWID) in India. There are thousands in India, who feel helpless because drugs control their bodies and minds. Addiction compels them to keep ‘using’ despite horrendous physical and mental consequences and unaware of their increased risk for HIV. It is estimated that the HIV prevalence amongst 180,000 PWID in India is approximately 7.1%.

Their vulnerability is further fuelled by the fact that society perceives drug users as criminals and a threat to society. This makes it difficult for people who want to reach out to them to build rapport and trust. This demonization further fuel the HIV epidemic in the country.

PWIDs are often assumed to be HIV-positive and refused treatment when clinical care is needed. There have been many instances of PWID being denied services at public healthcare facilities and instead getting arrested and suffering police brutality.

“When I tested HIV-positive, hell broke on me. Going for treatment was scary as there was so much stigma attached with being a PWID,” recalls Paul.

Sensitization efforts by India HIV/AIDS Alliance’s Hridaya programme with healthcare facilities and psychosocial interventions with PWID have helped community members living with HIV avail stigma-free antiretroviral treatment. Hridaya follows a harm reduction approach, which – as the name suggests – aims to reduce the harm associated with injecting drug use, such as vulnerability to HIV and Hepatitis C infection, rather than trying to eliminate drug use per se.

“Thanks to Hridaya, I am now comfortable with myself, comfortable with the fact that I am positive,” says Paul.

This year the global theme of World AIDS Day is “Getting to Zero”: zero new infections; zero AIDS-related deaths; and zero discrimination. For the first two to happen, eliminating discrimination is essential. Building rapport with PWID and gaining their trust are essential in harm reduction programming and are the first steps towards getting to zero with PWID.

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The author of this post, Francis Joseph, is Programme Officer: Drug Use & Harm Reduction at India HIV/AIDS Alliance 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 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.

This blog was published on The Alternative on 2nd December 2013. 

Realising ART Adherence among People Who Inject Drugs in India

Hridaya educates PWID living with HIV about positive prevention, emphasizing the importance of adhering to ART treatment regimens. (Photo by Prashant Panjiar for India HIV/AIDS Alliance)

Hridaya educates PWID living with HIV about positive prevention, emphasizing the importance of adhering to ART treatment regimens. (Photo by Prashant Panjiar for India HIV/AIDS Alliance)

Adherence to antiretroviral therapy (ART) is strongly correlated with HIV viral suppression, reduced rates of resistance, an increase in survival, and improved quality of life. Yet there are numerous cases in India of people living with HIV who exist in co-morbid conditions: dependent on substances but dropping their ART regime due to societal stigma and discrimination or to a lack of understanding about the need to adhere to treatment.

Lamyanba (name changed) from Imphal has been injecting drugs since 1989. When he tested positive for HIV recently, he had a dangerously low CD4 count of 19 and was immediately put on ART. He responded favourably to treatment, and his CD4 count increased to 600 in a span of six months. When his health improved, he decided to stop the treatment without consulting a doctor or service provider. Lamyanba’s decision is unfortunately too common.

Recognizing that people who inject drugs (PWID) living with HIV frequently drop out from ART treatment, the Hridaya programme is undertaking active monitoring to address this problem. A tracking tool has been developed to monitor a client’s routine diagnostics. The tool indicates the dates for ART follow-ups, and an outreach worker contacts clients to remind them of their follow-up appointments. Outreach workers also keep a check on client CD4 counts.

Supported by Government of Netherlands, Hridaya works in the states of Bihar, Haryana, Uttarakhand, Jammu and Manipur to strengthen harm reduction interventions at state and district levels. Aiming to cover all PWID in these states, the programme focuses on the unmet harm reduction needs of vulnerable drug-using populations and complements HIV prevention activities in each state under India’s National AIDS Control Programme.

Hridaya routinely educates PWID living with HIV about positive prevention focusing on the value of adhering to ART treatment. The programme team works with clients to identify barriers to accessing ART treatment and advises on the need for strict adherence to the treatment regime. In Imphal, Hridaya aims to keep 95 percent of clients on treatment and minimize loss-to-follow-up. With this support, Lamyanba is back on ART, leading a healthy positive life.

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The author of this blog, Roshan Ningthoujam, is programme manager for Hridaya at Social Awareness Service Organisation (SASO) in Manipur, India.

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.

“11 for ICAAP 11”: A Selection of Alliance India Posters at ICAAP (November 17-22, 2013, Bangkok, Thailand)

Alliance India is presenting a total of 31 posters at the 11th International Congress on AIDS in Asia and the Pacific (ICAAP 11) in Bangkok, Thailand, 17-22 November 2013. To mark the 11th ICAAP, below are a selection of 11 of our posters displayed in Bangkok that detail our work supporting community-based programming for people living with HIV (PLHIV), men who have sex with men (MSM), transgenders, hijras, sex workers and people who inject drugs (PWID), all key priorities to addressing India’s complex epidemic.

Paving the Pathway: PLHIV community consultations enhance national care and support programme in India

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Factors Influencing SRH Service Uptake by PLHIV: Findings from the Koshish baseline study in India  

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An Emergent Crisis: Addressing the Hepatitis C Epidemic in People Who Inject Drugs (PWID) in India

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By the Community, For the Community: Involving PWID in Assessment of Drug-using Patterns Assessments

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Identifying Access Barriers for Transgenders Seeking Gender Transition Services in India

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Community-led Advocacy to Address SRH Needs of PLHIV: Experience from the Koshish programme in India

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Service without a Smile: Pehchan study of the friendliness of HIV services to sexual minorities in India

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Positive Rights and Sexual Health: A review of SRH laws and policies for PLHIV in India

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Tracking Organisational Development of Sexual Minority CBOs in India Using Pehchan’s ‘CBO CyclePoster_Page_10

Power in Our Hands: Increasing involvement by sexual minorities in HIV programme oversight in India 

Poster_Page_11

Promoting Entrepreneurship among Sex Workers to Reduce HIV Vulnerability in Andhra Pradesh

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Alliance India at ICAAP 11 (November 17-22, 2013, Bangkok, Thailand)

Blog2India HIV/AIDS Alliance is excited to be part of ICAAP 11. You are warmly invited to attend our sessions and learn more about our work in India to improve the AIDS response for communities most affected by the epidemic, including MSM, transgenders and hijras; female sex workers; people who inject drugs, and PLHV from all demographics.

Alliance India staff, board members and representatives from our partner organisations will participate in a range of sessions including pre-conference meetings, skills building workshops, oral presentations, poster exhibits and press conferences.

Please download our roadmap of sessions at ICAAP that include Alliance India team members or discussions of our work. It includes a full list of our 31 posters describing our responses to a range of key priorities in India’s epidemic. Please also visit our Community Booth (#C3) to learn more about our work.

The conference takes place at the Queen Sirikit National Convention Centre (QSNCC) from November 17-22 in Bangkok, Thailand.

APCOM Pre-Conference on MSM and Transgender Issues in Asia and the Pacific

– FOREPLAY: The Final Push Toward the Three Zeroes: Nov. 17, 8.30am–5.30pm, QSNCC

Community Forum

 – Nov. 18, 8.30am–5.00pm, QSNCC

Community Booth & Marketplace

 – Alliance India Community Booth (#C3): Nov. 19: 4-7pm; Nov. 20-21: 9 am-9pm; Nov. 22: 9am-3pm. Zone CG

Oral Presentations

– Reaching the Hard-to-Reach: Engagement & Facilitation as Research Strategies with Sexual Minorities: Nov. 20, 3:45-5:15pm, Hall H

– Building Capacity of MSM & TG CBOs to Partner with Government HIV Prevention Interventions in India: Nov. 20, 3:45-5:15pm, Hall H

Poster Discussion

 – Cervical Cancer Awareness in Women Living with HIV: Findings from the Koshish Baseline in India: Nov. 22, 12:45-1:45pm, Plaza

Skills Building Workshops

– Me and My Partner’ – A Community-Based Skill Building Training on Positive Prevention for Key Populations: Nov. 20, 1:15-4:15pm, Hall P

– Equal Access/Equal Rights: Empowering transgender communities through advocacy, mobilization, and capacity building under the Pehchan program: Nov. 20, 4:15-7:15 pm, Hall K

– Strengthening Community Systems for MSM, Transgender and Hijra Populations in India: The Pehchan Training Curriculum in Action: Nov. 21, 4:15-7:15pm, Hall O

– Beyond My Infection: A workshop to build capacities of PLHIV and Key Populations as advocates on Sexual and Reproductive Health and Rights (SRHR): Nov. 22, 10am-1pm, Hall O

 Press Conferences

 – Engagement & Facilitation as Research Strategies with Sexual Minorities: Nov. 20, 2-3pm, Press Conference Room

– Building capacity of MSM & TG CBOs to partner with Government HIV prevention interventions in India: Nov. 22, 2-3pm, Press Conference Room

We’ll update Facebook, Twitter and our blog every day with details of our activities, including documents to view online or download. We look forward to connecting with you at ICAAP in Bangkok!

If you have any questions, please contact us at info@allianceindia.org. For more information, please visit:

Facebook: https://www.facebook.com/indiahivaidsalliance

Twitter: https://twitter.com/AllianceinIndia

Blog: https://indiahivaidsalliance.wordpress.com/

Website: http://www.allianceindia.org/

Protecting Rights to Ensure Health: International Drug Users Day 2013

India is lagging behind in efforts to reach people who inject drugs with oral substitution therapy. (Photo by Prashant Panjiar for India HIV/AIDS Alliance)

India is lagging behind in efforts to reach people who inject drugs with oral substitution therapy. (Photo by Prashant Panjiar for India HIV/AIDS Alliance)

November 1st is International Drug Users Day. Initiated in 1995 by the Dutch drug user organization, Landelijk Steunpunt Druggebruikers (LSD), the day aims to raise awareness and increase action to address the needs of people who use drugs.

In India, networks of people who inject drugs (PWID) and people living with HIV (PLHIV) mark the day by advocating with stakeholders for action to create an enabling environment for PWID and expand access to a full range of harm reduction services.

The PWID response in India has primarily used a health services-based approach. Though mitigating aspects of PWID vulnerability, this approach fails to address the central role that rights protections play in ensuring the overall wellbeing of PWID nor does it deal with related issues like stigma, discrimination, harassment, violence, alienation and destitution. There can be no doubt that India needs a comprehensive, rights-based harm reduction approach.

PWID need to be afforded choices to seek addiction treatment but also to avail services that best suit their needs. Alliance India programme teams frequently meet PWID during field visits who rue the high costs of addiction treatment in India. While there are more than a hundred de-addiction centres in district hospitals and medical colleges across the country, most are not functional. In any case, few PWID are keen to be treated in government facilities due to fear of criminal sanctions.

There are an additional 400 centres run under the aegis of Ministry of Social Justice and Empowerment that are operated by non-profit organisations but charge PWID for services. Not only are they heavy on the pocket, most function with little or no real regulation. A recent article in the Mumbai Mirror highlighted the case of a de-addiction centre in Alibaug, Maharashtra, but this is just one of many examples of exploitation of PWID seeking services they need.

India is also lagging behind on oral substitution therapy (OST) for PWID, an essential tool for managing addiction and mitigating the risk of HIV infection from injecting. According to a recent report by India’s Department of AIDS Control (DAC), although more than 143,000 PWID were reached through Targeted Interventions for HIV prevention in 2012, only 11,500 were covered by OST. The figure is not even close to the national target to put 20% on OST.

To the public at large, drug use remains a “menace”. There is little understanding of the issues, and scant political will to make the changes needed. The biggest barriers to a rights-based approach remain the laws that criminalise the use of narcotic substances except for medical purposes. Some argue that criminalisation is directly responsible for the stigma and discrimination faced by PWID every day. Until India rationalizes its policies toward drug use and improves services, PWID here will continue to face grim prospects.

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

With funding from European Union, 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.

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.

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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.