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Indian Journal of Community Medicine

Reducing HIV-Related Risk Behaviour Among Injecting Drug Users: The Harm Reduction Model in Bangladesh

Author(s): S.E. Habib

Vol. 29, No. 4 (2004-10 - 2004-12)

Abstract

Background: Injecting drug users (IDU's) are one of the primary groups who are at risk for acquiring an HIV infection. The extent of their high risk behaviour is reflected in the alarming incidence of HIV (2.5%) among IDU's in Dhaka City.

Objectives: To reduce HIV related risk behaviour among injecting drug users through the harm reduction model in Bangladesh.

Design: Scientific review of the different programmes related to needle & syring distribution in Bangladesh.

Study setting: IV drug users of Bangladesh.

Results: The paper focusses on various public health strategies in form of a harm reduction model and their efficacy in dealing with problems associated with injecting drug use and spread of HIV.

Conclusion: There is a need for harm reducation model in Bangladesh and to examine the efficacy of the model in reducing the risks and acceptability of the program in large society.

Key Words: Harm reduction, Injecting drug user, HIV/AIDS, Bangladesh.

Introduction

The sharing of needles and syringes while injecting illicit drugs is becoming an increasingly important part of the epidemic of HIV/AIDS throughout the world1. The recent explosion of HIV among injecting drug users (IDU's) in the South2,3 and Southeast4,5. Asian countries has documented that sharing of needles and syringes play a major role in HIV transmission in some regions. For example, in India and Myanmar, the sharing of drug injection equipment has become the single most common mode of transmission among recent cases of HIV6,7. Infection of HIV among IDU's has also emerged as a major public-health problem in Nepal and Thailand8,9.

In almost all Asian countries where HIV infection among IDU's has emerged as a potential problem, the primary public-health approach to preventing further transmission of the virus among IDU's has been providing legal access to sterile injection equipment9-13. The rationale for this strategy is relatively simple : since it is the sharing of drug injection equipment that actually transmits HIV, reducing multi-person use of the equipment can reduce the transmission of the virus.

Like the neighbouring countries, Bangaldesh has also documented an incidence of HIV associated with injecting drug use14-16. Consequently, there have been concerns with developing harm reduction policies to reduce risks of HIV infection and AIDS in Bangaldesh17-18. One aspect of these concerns has focused on providing protection to injecting drug users. This has resulted in increasing health promotion programs to increase awareness of HIV/AIDS and to provide IDU's with easier access to sterile needles and syringes19,20.

The present paper is an attempt to address the harm reduction issue and its benefits in controlling HIV/AIDS and other blood-borne viruses with special reference to Bangladesh. It also highlights the approaches of harm reduction in some neighbouring countries where it has been found to be the most feasible approach to stem the epidemic at both population and individual levels.

Drug use and HIV/AIDS situation in Bangladesh

In recent years there has been a large increase in the number of people regularly using drugs in Bangaldesh, many of them having turned from smoking or inhaling opium to injecting heroin.21,22 While most users mainly inject in moderate quantities, some inject frequently, inappropriately, with adverse and sometimes tragic results. Drug-related problems constitute major concerns, including ill-health, injuries, abscesses, premature mortality, social, family and economic difficulties, public order offences, and a host of behavioural consequences.

The number of drug users is increasing not only in urban areas but also in rural areas, and the number of injecting drug users is on the rise.23

While reliable data on this topic is lacking, the evidence from a few studies suggests that several thousand people regularly use illicit psychoactive substances both orally and intravenously.21,22 According to a baseline survey carried out by CARE-Bangldesh in 1997, the estimated number of IDU population in Dhaka City was 7,650.23 Another rapid assessment study conducted in six major cities, documented the number of IDU's as 7,500 to 12,500 with the greatest concentration outside of Dhaka found in Rajshahi City.25

Up until now there has been limited information on HIV seroprevalence among different target groups in Bangladesh. At the end of 2000, Bangladesh had an estimated 13,000 thousands HIV/AIDS carriers.1 Although the country now has a low prevalence of HIV it is considered to be at high risk for an epidemic due to behavioural risk factors26-29.

Sentinel surveillance for HIV/STD was introduced in Bangladesh in 1998 among different high-risk groups, including IDU's.16,17 The first sentinel surveillance found a HIV prevalence of 2.5 percent among a sample of 402 in-treatment IDU's from Dhaka City.14 This suggests that Bangladesh is at the beginning of an HIV epidemic - which has the potential of spreading the virus rapidly via IDU's and their sharing partners.24,27 Isolated data coming from drug treatment centres also provides evidence that needle sharing puts IDU's at risk of HIV infections.30 Although recent government initiatives are evident in the National Policy on HIV and STDs31, only a few strategies in response to the rapid transmission of this virus have been developed for IDU's who are a hidden part of the AIDS epidemic.

Needle and syringe distribution program in Bangladesh The SHAKTI (Stopping HIV/AIDS through Knowledge and Training Initiative) Project initiated by CARE-Bangladesh grew out of Dhaka and Tangail in 1995 with funding from international donor agencies. Its goal is to focus on behaviour change among selected high-risk population, in order to reduce the transmission of HIV/AIDS in Bangladesh. The project operates in brothel sex worker intervention in Tangail, Street sex worker intervention in Dhaka, Injecting drug user intervention in Dhaka, and Scaling up intervention among IDU's at Rajshahi City in partnership with local NGOs.19

A major component of the SHAKTI Project is to make contact with members of the drug-using community, prioritising a significant reduction in drug problems.17 By the end of 1998, with funding from the Department of International Development (UK), the project had begun AIDS education for IDU's and a needle and syringe exchange program in several areas of Dhaka City). The main aim is to encourage IDU's to stop sharing injecting equipment and thereby reduce the spread of HIV by making clean equipment accessible. The program also includes a number of activities-such as information on issues like safe injecting practices, safer sex, general health care, STD and absces treatment, and condom distribution. Apart from that, IDU's suffering greater health hazards and needing greater care are referred to the government drug treatment hospital at Tejgaon and other health services.

The primary function of SHAKTI's NSEP program is to provide a comprehensive HIV prevention service offering a range of information, advice and referral. The service is provided at several Drop-in-Centres staffed by outreach workers and are specifically designed to provide needle distribution and exchange and some related health services (management of minor abscesses) for IDU's. By July 1999 there were seven Drop-in-Centres in Dhaka for IDU's to socialise and seek general health and STD treatment19. The program is operating in 40 wards of Dhaka City, where around 3,000 IDU's are reached every alternate day through a needle exchange program. These approaches are coordinated by an outreach worker who assists an STD doctor in managing STD clients once a week. The program focuses on the exchange of sterile syringes in return for used ones. As of July 1999, the IDU intervention of SHAKTI has covered a significant number of IDU's across many wards of Dhaka City with a syringe exchange rate of 81%.19

The SHAKTI Project has been expanded to Rajshahi City where injecting drug use is a serious problem21,24. The harm reduction program has grown in this area since August 1999, in direct partnership with a local NGO, ASHEKE, who has been working on a demand reduction program over the past years. The future strategy of this project is to encourage IDU's to help themselves by forming self help groups and partnership with other NGOs and/or governmental organisations working in this field.

Harm Reduction intervention components

The term harm reduction - also called harm minimisation - has more commonly been applied in recent years to programs which were developed to deal with problems associated with illicit drug use, particularly the spread of HIV and hepatitis C (HCV) infection from the sharing of injecting equipment by intravenous drug users. Examples of harm minimisation strategies include the provision of sterile needles and syringes for injecting drug users, the prescribing of methadone for opiate users and the dispensing of free condoms to sexually active prople, such as those working in the sex industry. Whilst emphasis is placed on preventing the spread of HIV, harm reduction strategies also aim to raise awareness and provide education within the IDU community about HIV and other communicable diseases32.

Needle and Syringe Exchange Program (NSEP) is a significant element of the HIV/AIDS education and prevention strategies. It has been one of the most rapidly expanding and developing areas of work which has major significance to help drug users reduce their risk of HIV/HCV infection or of transmitting it to others. Targeted at IDU's, the NSEP aims to minimise the spread of HIV within this section of the community by developing awareness of the need for safe injecting and safe sexual behaviour, facilitating access to sterile injecting equipment, safe disposal of used needles and syringes and distribution of safe sex equipment (e.g. condom).

Challenges for harm reduction program in Bangladesh While the Bangladesh government harm reduction programs at the National AIDS Policy in early 1997, there have been challenges to much of the project's intervention areas19. One is that some strategies, such as the operation of NSEP, imply condoning illicit drug use, or potentially health-damaging forms of behaviour. Another is that by focusing on reducing harm among established 'heavy' users leaves a substantial number of people who are currently non-users or moderate users at risk.

Another common barrier to harm reduction programs, particularly NSEP's, is that they are western models33 culturally inappropriate to a Muslim society. In recent times this has been an increasingly difficult position to maintain given the range of indigenous harm reduction programs successfully operating in other parts of Asia. Moreover, many policy makers in Bangladesh concern that extremely repressive laws have had little effect other than to further disenfranchise drug users, driving them underground. More amendments designed to decriminalise possession of injecting equipment, and to enable authorised workers to legally supply such equipment in certain areas. Furthermore, it is unrealistic to arrange treatment for several thousands IDU's for a short time, given the fact that drug treatment is costly. An additional problem with this strategy is that many IDU's do not want to enter treatment, often leaving before they are ready while others relapse. More importantly, anecdotal evidence suggests that many police in Bangladesh are involved in drug trafficking. These contextual factors provide a framework within which specific harm reduction intervention can be planned, implemented, evaluated and, if necessary, modified.

One of the major factors hindering NSEP from operating more effectively, is a lack of appropriate government support for NSEP programs. This is largely manifested in a reticence to defend NSEP programs and workers when they are attacked by police, residents, media and politicians. It is manifested in insufficient funding for education programs, and in the legal uncertainties belying NSEP's operating in this country. This lack of support has reduced NSEP workers vulnerable, and increased stress. Political and bureaucratic support must be increased if NSEP programs are to succeed. At the same time, legal uncertainties and obstacles to effective NSEP must be addressed.

Suggested public health strategies

Reducing stigmatisation of IDU's. Firstly, in our society IDU's have always been labelled as 'diseased' and are often discriminated against because of their illness. This is because, IDU's have been positioned in society an lazy, untrustworthy, and potential sources of HIV/AIDS infection. All of which adds to the notion that their injecting practices are antisocial, unhygienic and irresponsible. Therefore, education campaigns are needed to address 'userphobia' - specifically among health care and law enforcement workers, the media and general community.

Developing practical strategies

There is a need for immediate attention in designing, implementing and evaluating practical strategies for reducing the risks of HIV infection among IDU's. Peer education is universally regarded as successful in promoting the use of new needle and other equipment, and providing appropriate health education. Needle supply has proven ineffective as an infection prevention strategy without appropriate education. Furthemore, an important part of evaluating harm reduction programs would be to conduct cross-sectional surveys among IDU's who are not the clients of needle and syringe exchange programs, and compare these with a sample of needle and syringe attenders.

Promoting non-injecting routes of drug administration The promotion of transitions to non-injecting routes of administration of illicit drugs among IDU's could be a feasible strategy for controlling HIV/HCV. Since illicit drug use seems unlikely to be eradicated, it might be possible to significantly reduce IDU by persuading current drug users to adopt non-injecting routes of administration. This issue merits further research in order to provide an increased understanding of the epidemiology.

Transforming the role of the police

The role of police in hindering effective NSEP programs has been mentioned by NGO health workers21. Police have the ability to destroy a NSEP program's reputation and credibility with its client group : as most jurisdictions of CARE-Bangladesh have witnessed examples of this type of police hindrance in the past. Police carrying out drugs-related law enforcement tasks should not be allowed to impede infection prevention measures. Clear legal and procedural guidelines for both police and NSEP are needed in all jurisdictions.

Modifying high risk behaviour

Although absolute abstinence through prevention and treatment is emphasised in the disease model of addiction as the only acceptable goal, drug abuse treatment or attendance at drug dependency centres in Bangladesh have the additional drawback of being very costly. Despite this drawback, there is a need to identify ways of improving access to detoxification at drug treatment centres, to ensure that poor or disadvantaged IDU's retain free access to the full range of treatment.

Promoting programs in prisons

As prisons remain a high-risk environment for HIV and hepatitis C transmission, immediate attention is needed to prevent further transmissions among people who inject drugs whilst incarcerated.

Broadening the role of NSEP

And lastly, NSEP needs to be re-conceptualised as a public health activity which assists in preventing a range of infections, as well as helping injecting drug users to improve their overall health by improving their health knowledge and their injection technique. Funding for NSEP and associated education should be increased from dedicated funding attached to international donor agencies, to meet these new challenges.

Conclusions

A meticulous scientific review has now proven that NSEP programs can reduce the transmission of HIV and save lives withut losing ground in the battle against illegal drugs. In the Asia region several countries led the way creating several NSEP programs and found these programs successful in slowing the rate of infection among intravenous drug users and decreasing the risk behaviours of HIV infection. In sum, IDU's in Bangladesh need to be protected from health hazards but this argument should not lead to their being relegated to continued drug use as the only option.

Acknowlegement

The present paper has benefited much from extensive materials held in the library of the National Centre in HIV Epidemiology & Clinical Research at the University of New South Wales, Sydney, Australia. No institutional affiliation is implied to the opinions expressed in this article.

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School of Sociology,
The Universities of New South Wales,
Sydney 2052, Australia.
E-mail: [email protected]

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