Supportig commuity actio o AIDS i developig coutries HIV ad drug use: Commuity resposes to ijectig drug use ad HIV
Good practice guide series This guide is oe i a series of good practice guides produced by the Iteratioal HIV/AIDS Alliace (the Alliace). This series brigs together expertise from our global commuity-level HIV programmig to defie ad guide good practice i a rage of techical areas, icludig: Huma rights ad GIPA HIV prevetio Sexual ad reproductive health ad rights ad HIV itegratio HIV ad tuberculosis HIV programmig for childre HIV ad drug use Plaig Alliace good practice guides are: user-friedly how to guides targetig HIV programmers workig i commuity settigs i developig ad trasitioal coutries helpig to defie what is good practice for commuity-level HIV programmes. To dowload Alliace publicatios, please visit www.aidsalliace.org/publicatios. Ackowledgemets This guide bega with a workshop i Bagkok, 2008, made up of Alliace HIV ad harm reductio programmers. This group created the first draft: Umesh Sharma, Iteratioal HIV/AIDS Alliace; Soal Mehta, Alliace Idia; Wag Jig, Alliace Chia; Vlodomir Chura, Alliace Ukraie; Choub Sok Chamreu, Khmer HIV/AIDS NGO Alliace (Khaa); A Fordham, Iteratioal HIV/AIDS Alliace; Susie McLea, Iteratioal HIV/AIDS Alliace. The process of developig ad refiig this guide was co-ordiated by Susie McLea, Iteratioal HIV/AIDS Alliace. The guide was field tested by colleagues i the followig Alliace Likig Orgaisatios: Alliace Chia; Khaa, Cambodia; Social Awareess Service Orgaizatio (SASO), Maipur, Idia; Alliace Ukraie. Ruth Birgi provided the techical review. Aette Verster from the World Health Orgaizatio ad the Alliace s Best Practice Uit reviewed ad provided commets ad suggestios. Published: Jue 2010 Iteratioal HIV/AIDS Alliace 2010 Iformatio cotaied i this publicatio may be freely reproduced, published or otherwise used for oprofit purposes without permissio from the Iteratioal HIV/AIDS Alliace. However, the Iteratioal HIV/AIDS Alliace requests that they be cited as the source of the iformatio. ISBN: 1-905055-69-4 Photos (from the top): Natalia Kravchuk for Alliace Ukraie. Outreach work with DARAT, Mombasa, Keya Nell Freema for the Alliace. Outreach work i Malaysia MAC.
Alliace good practice HIV programmig stadards HIV ad drug use alliace good practice hiv programmig stadards for hiv ad drug use Good practice stadard 1 Our orgaisatio uses a harm reductio approach to drug use ad HIV Good practice stadard 2 Good practice stadard 3 Good practice stadard 4 Good practice stadard 5 Good practice stadard 6 Good practice stadard 7 Good practice stadard 8 Our orgaisatio promotes ad/or provides access to clea ijectig equipmet, codoms, ad iformatio about safe ijectig ad safe sex for people who use drugs ad their sexual parters Our orgaisatio promotes ad/or provides access to atiretroviral treatmet, opportuistic ifectio prevetio, tuberculosis prevetio ad treatmet, opiate substitutio therapy, ad hepatitis C treatmet for people who use drugs ad their sexual parters Our orgaisatio promotes ad/or provides access to psychosocial support services to meet the priority eeds of people who use drugs ad their sexual parters People who use drugs participate i our programmig ad decisio-makig Our programmes targetig people who use drugs are geder-sesitive, ad icludig itervetios for the sexual parters of people who use drugs Our programmes targetig people who use drugs are part of a local etwork of services ad programmes Our programmes address stigma ad discrimiatio related to HIV ad drug use Each guide i the Alliace good practice series is accompaied by a set of programmig stadards. Implemetig these is oe of the ways that the Alliace, our parters ad other orgaisatios ca defie ad promote a uified ad quality-drive approach to HIV programmig. This Good Practice Guide cotais iformatio, strategies ad resources to help programme officers meet the good practice stadards of our HIV ad drug use programmes The full programmig stadards for HIV ad drug use ca be foud i Appedix 2 at the back of this guide. key resources For the full list of Alliace good practice programmig stadards, see: www.aidsalliace. org/publicatiosdetails. aspx?id=451 Frech versio www.aidsalliace.org/ Publicatiosdetails. aspx?id=452 Spaish versio www.aidsalliace.org/ Publicatiosdetails. aspx?id=453 good practice guide: hiv ad drug use 1
Cotets Abbreviatios ad acroyms 3 Itroductio What is this guide for? 4 Who is this guide for? 5 Makig it work o the groud 5 Good practice programmig stadards 6 Who developed this guide? 6 Laguage matters! People who use drugs 6 1. Drug use, HIV ad health what are the issues? Ijectig drug use ad HIV 8 Drugs ad their effects 10 Why do people take drugs? 12 How drugs are take 13 What is depedecy? 13 Why is drug use a health issue? 15 How do drugs affect peoples lives? 16 Drugs, crime ad the police 17 Co-ifectios hepatitis C ad tuberculosis 18 Other health issues for HIV-positive drug users 19 Drugs ad sex 21 2. Special populatios The eeds of specific groups Wome 24 Childre ad youg people 26 People i priso or detetio 27 3. What eeds to chage? The chage framework developig itervetios at differet levels 29 Risk ad vulerability 32 Behaviour chage, health promotio ad the Ottawa Charter 33 Buildig social capital for health 35 4. Approaches How huma rights, public health ad developmet shape our work 38 Demad reductio, supply reductio ad harm reductio 39 Why harm reductio programmig? 44 Low threshold services 46 2 good practice guide: hiv ad drug use
Commuity mobilisatio 49 Geder-sesitive programmig 50 5. Harm reductio itervetios Key harm reductio itervetios 53 Selectig ad plaig for itervetios 54 6. Ivolvig people who use drugs ad other stakeholders Ivolvig people who use drugs i programmig 78 Workig with stakeholders 83 Key characteristics of a effective HIV programme targetig 85 people who use drugs Appedices Appedix 1: Resources 86 Appedix 2: Alliace good practice HIV programmig stadards 87 HIV ad drug use abbreviatios ad acroyms ART ATS BBV BCC CBO GIPA HAV HBV HCV NSP OST MAC MMT PMTCT SRH SASO STI TB VCT WHO Ati-retroviral therapy Amphetimie-type substaces Blood-bore virus Behaviour chage commuicatio Commuity-based orgaisatio Greater ivolvemet of people livig with HIV Hepatitis A virus Hepatitis B virus Hepatitis C virus Needle ad syrige programme Opioid substitutio therapy Malaysia AIDS Coucil Methadoe maiteace therapy Prevetio of mother-to-child trasmissio Sexual ad reproductive health Social Awareess Service Orgaizatio Sexually trasmitted ifectio Tuberculosis Volutary cousellig ad testig World Health Orgaizatio good practice guide: hiv ad drug use 3
key to icos used i this guide Key resources Example Strategy Remember! Good practice stadard Itroductio What is this guide for? Ijectig drug use is oe of the major drivers of the global HIV epidemic. I may parts of Asia ad Easter Europe, the sharig of ijectig equipmet by ijectig drug users is a leadig cause of HIV trasmissio. 1 The sharig of ijectig equipmet also fuels the spread of hepatitis C (HCV), ad may people who iject drugs are particularly vulerable to tuberculosis (TB). I may parts of Africa ad Lati America, usafe ijectig drug use is icreasigly impactig o HIV trasmissio. 2 Approximately 80% of people who iject drugs live i developig ad trasitioal coutries, 3 yet much of the research ad documetatio of practice i respose to HIV ad ijectig drug use exists i developed or resource-rich coutries. This is chagig as HIV ad harm reductio research ad practice develops globally. This guide aims to support the scale up of commuity-based HIV ad harm reductio programmes i developig ad trasitioal coutries. It looks at practice ad research i developig ad trasitioal coutries ad the priciples uderlyig practice ad research i resource-rich coutries. It also sets out a approach to programmig at the commuity level, where commuities are fightig poverty, rapid social chage, iequality ad sometimes restrictive political cultures. People who use drugs especially those livig with HIV ad their families, frieds, eighbours ad commuities are most affected by drug use ad HIV. This is why they eed to be ivolved i their local respose. To participate i the respose, local people eed skills ad resources. They also eed opportuities to have their say ad to share their ideas ad experieces be part of the solutio whe drug use ad HIV is the problem. Support for a harm reductio approach to drug use ad HIV is buildig aroud the world. 4 New guides ad referece mauals are appearig all the time. May of these are iteded for atioal govermet programme maagers, primary care physicias or atioal public health plaers. Very few guides or tools exist to 1. UNAIDS (2008), 2008 report o the global AIDS epidemic. Available at: www.uaids.org/e/kowledgecetre/hivdata/globalreport/2008/2008_global_report.asp 2. Iteratioal Harm Reductio Associatio (2008), Global state of harm reductio 2008: mappig the respose to drug-related HIV ad hepatitis C epidemics. Available at: www.ihra.et/globalstate2008 3. Aceijas, C. et al. (2006), Estimates of ijectig drug users at the atioal ad local level i developig ad trasitioal coutries, ad geder ad age distributio, Sexually Trasmitted Ifectios, 82: 10 17. 4. See ote 2. 4 good practice guide: hiv ad drug use
support actio at a grassroots or commuity level. As a startig poit, this guide aims to assist local commuity orgaisatios who are respodig to drug use ad HIV. Who is this guide for? This good practice guide is aimed at people who are developig ad deliverig HIV ad harm reductio programmes or services at a commuity level i resource-poor settigs, or settigs where there are low levels of capacity or political support for harm reductio programmes. The guide is for: people with limited experiece of HIV ad harm reductio programmig i a commuity settig. It is ot a comprehesive maual cotaiig everythig that is kow about successful HIV ad harm reductio programmig. Istead, it aims to be a accessible ad user-friedly guide to thikig through what good practice meas for commuity orgaisatios workig with people who use drugs. It refers the reader to may other i-depth ad techical tools people workig i resource-poor settigs. HIV ad harm reductio programmes ad services are well established i Caada, Australia ad parts of Europe. But i may developig ad trasitioal coutries where HIV ad harm reductio programmig is urgetly eeded, there are added challeges of fewer resources ad fewer safety ets or state welfare systems for people who use drugs. This affects our defiitios of what are key services ad programmes. This guide is for people who are settig out to: prevet HIV trasmissio amog people who use drugs provide treatmet, care or support to people who use drugs, icludig people livig with HIV ad their parters ad families advocate for HIV ad harm reductio programmes ad services, ad for policy chage to support harm reductio programmig. Makig it work o the groud Very few of us start out as HIV ad harm reductio programmers with the resources or the opportuity to desig a comprehesive programme of itervetios or services. More commoly we are fuded or motivated to do oe or a small umber of thigs perhaps set up a drop-i service or desig a eedle ad syrige programme (NSP) i order to have a impact o HIV i our commuities of cocer. Moreover, the eviromets i which we work vary eormously. This guide aims to distil some of the elemets of good practice i differet settigs. It also aims to assist HIV programmers to thik through these elemets ad apply them to their ow settig. It ecourages a combiatio prevetio approach, 5 whereby 5. UNAIDS ad The Lacet (2008), The Lacet: series o HIV prevetio. Available at: www.uaids. org/e/kowledgecetre/resources/featurestories/archive/2008/20080806_lacet.asp good practice guide: hiv ad drug use 5
key resources There are a umber of more comprehesive ad techical mauals available i the field of HIV ad harm reductio programmig, otably the may techical guides provided by the World Health Orgaizatio (WHO). We will suggest ad refer to may of these guides for a more i-depth focus o a particular topic. programmers thik ot oly about service delivery but also about the structural ad social drivers that impact o behaviour, access to services ad HIV eeds. We aim to provide a tool that is adaptable to may differet eviromets ad coditios. Who developed this guide? This guide was developed i five stages: We reviewed existig tools ad resources o drug use, harm reductio ad HIV. The first draft was developed by people workig i civil society orgaisatios from the Alliace family of orgaisatios i Asia ad Easter Europe durig a workshop held i Chiag Mai i July 2008. This guide is shaped by their ideas, kowledge ad experieces. The draft guide was reviewed by iteratioal techical experts. The draft guide was field tested by HIV programmers workig i civil society orgaisatios, icludig people workig i grassroots commuity orgaisatios ad people who use drugs. Learig-from-the-field testig ad exteral expert review was the used to revise ad fialise the guide. Laguage matters! People who use drugs Throughout this guide we mostly use the term people who use drugs to describe the group of people our work cocers. Whe we use that term we mea both wome ad me, ad youg people who use drugs. We use this term, iflueced by the term people livig with HIV, to assert that people who use drugs are more tha just a risk group. They are people first ad foremost. Sometimes we use ijectig drug user, a commoly used term to refer to the particular subset of people who iject drugs. Ijectig is the behaviour that is the focus, ad so sometimes ijectig drug user is more specifically relevat. Sometimes, for brevity, we simply use drug user. We avoid terms like drug addict, drug abuser or jukie as they are stigmatisig ad have egative values attached to them. 6 good practice guide: hiv ad drug use
1 Drug use, HIV ad health what are the issues? I this chapter: Ijectig drug use ad HIV Drugs ad their effects Why do people take drugs? How drugs are take What is depedecy? Why is drug use a health issue? How do drugs affect peoples lives? Drugs, crime ad the police Co-ifectios hepatitis C ad tuberculosis Other health issues for HIV-positive drug users Drugs ad sex chapter 1: drug use, hiv ad health what are the issues? 7
Patters of illegal drug use The Referece Group to the Uited Natios o HIV ad Ijectig Drug Use estimates that 15.9 millio people iject drugs. 6 Approximately 200 millio people use illegal drugs, 7 but because of the particular risks associated with ijectig drugs, the figure of 15.9 millio is importat for global, atioal ad local efforts to prevet HIV trasmissio. 2008 158 coutries 1995 121 coutries 1992 80 coutries coutries reportig ijectig drug use 8 The Iteratioal Harm Reductio Associatio describes some importat treds i ijectig drug use: Ijectig as a practice ca spread rapidly it ca take oly a few years to develop. Drug trade routes ifluece local markets for drugs. Whe police ad drug cotrol officials close dow a drug traffickig route i oe coutry it ca move to a eighbourig coutry. Drug use patters are iflueced by political, cultural, ecoomic ad legal coditios; for example, icreased drug use ca be liked to rapid social chage or icreasig iequality, as i former Soviet Uio coutries. 9 key message I this guide we focus maily o illegal drugs that are liked to HIV trasmissio. These are drugs that are ijected (opiates ad amphetamies) or that ifluece sexual practice ad therefore sexual trasmissio of HIV (amphetamies). Both opiates ad amphetamies are widely used. Alcohol is also liked to icreased sexual trasmissio risk, but ot dealt with i detail i this guide. Ijectig drug use ad HIV Sharig ijectig equipmet is a very efficiet way to trasmit the HIV virus, alog with other blood-bore viruses (BBVs) such as HCV. Whe we share ijectig equipmet we dramatically icrease our risk of acquirig ad passig o HIV. Sharig ijectig equipmet has bee associated with the rapid expasio of HIV epidemics i Asia ad Easter Europe. Approximately 10% of all HIV ifectios occur through sharig ijectig equipmet. 10 Ijectig drug use is the mai driver of HIV trasmissio i Asia, Easter Europe, Cetral Asia, the Middle East ad North Africa. It is also a factor i regioal trasmissio treds i Lati America ad sub-sahara Africa. 11 The Referece Group to the Uited Natios o HIV ad Ijectig Drug Use estimates that 3 millio people who iject drugs might be HIV positive worldwide. 12 May of them do ot kow their HIV 6. Mathers, B. et al. (2008), Global epidemiology of ijectig drug use ad HIV amog people who iject drugs: a systematic review, The Lacet, 372. Available at: www.idurefgroup.usw.edu.au/idurgweb.sf/page/publicatios 7. Uited Natios Office o Drugs ad Crime (2007), 2007 world drug report. Available at: www.uodc.org/pdf/research/wdr07/wdr_2007.pdf 8. See ote 2 9. See ote 2 10. Aceijas, C. et al. (2004), Global overview of ijectig drug use ad HIV ifectio amog ijectig drug users, AIDS, 18: 2295 2303. Available at: www.ihra.et/ 11. See ote 1 12. See ote 6 8 good practice guide: hiv ad drug use
status. I may coutries, icludig Chia, Idia, Keya, Myamar, Nepal, Thailad ad Vietam, the prevalece of HIV amog people who iject is 50% or higher. 13 I may cities a large umber of people share ijectig equipmet; for example, 58% i Delhi, Idia, 55% i Dhaka, Bagladesh, ad 32% i Yago, Myamar. 14 Access to services for people who iject drugs is very poor. I 2003 UNAIDS estimated oly 5% coverage of basic HIV treatmet, care ad prevetio services for people who use drugs. Ba Ki-moo, the Uited Natios Secretary-Geeral, reported i 2007 that 92% of people who use drugs have o access to basic HIV services. 15 A review of coverage of prevetio ad treatmet services for ijectig drug users published i 2010 described that coverage as low. 16 I 2009 the World Health Orgaizatio estimated that fewer tha 5% of people who eed substitutio treatmet had access i may parts of South ad South-East Asia (3.5% i Idia, 1.5% i Idoesia, 0.7% i Nepal). 17 All of these factors large umbers of people ijectig, high rates of HIV amog people who iject, high rates of sharig ijectig equipmet, low access to services, icludig HIV prevetio services create the coditios for the rapid spread of HIV ad for reduced quality of life for drug users livig with HIV. 200 millio people use illegal drugs Nearly 16 millio people iject drugs 3 millio ijectig drug users may be HIV positive 92% of people who use illegal drugs have o access to HIV services 50% of ijectig drug users are HIV positive i Chia, Idia, Keya, Myamar, Nepal, Thailad ad Vietam 58% of ijectig drug users i Delhi share ijectig equiqmet 13. See ote 2 14. Sharma, M. et al. (2009), A situatio update o HIV epidemics amog people who iject drugs ad atioal resposes i South-East Asia regio, AIDS, 23(00). Available at: www.searo.who.it/likfiles/hiv-aids_pwid_i_sea.pdf 15. Declaratio of commitmet o HIV/AIDS ad political declaratio: focus o progress over the past 12 moths, Uited Natios Geeral Assembly, 20 March 2007. Available at: http://data.uaids.org/pub/report/2007/20070418_sg_%20progress_report e.pdf 16. Mathers, B. et al. (2010), HIV prevetio, treatmet, ad care services for people who iject drugs: a systematic review of global, regioal, ad atioal coverage, The Lacet, 375(9719). Available at: www.idurefgroup.usw.edu.au/idurgweb.sf/page/publicatios 17. See ote 14 chapter 1: drug use, hiv ad health what are the issues? 9
categories of drugs 18 stimulats Ecstasy Speed Base Ice Methamphetamie Amphetamie Dexamphetamie Phetermie Methylamphetamie Crystal methylamphetamie Paramethoxyamphetamie Cocaie Crack cocaie depressats Caabis GHB Ihalats Heroi Morphie Codeie Methadoe Bupreorphie Pethidie Dilaudid Kapaol MS Coti hallucioges LSD Magic mushrooms (psilocybi) PCP (phecyclidie) Ketamie Mescalie Drugs ad their effects It is importat if we are workig i drug user ad commuity orgaisatios that we have a basic scietific uderstadig of drugs, how they ca affect differet people, ad how ad why they are take. A drug is ay substace that alters our fuctio physical or psychological fuctioig. There are three mai categories: depressats, stimulats ad hallucioges. Depressats are drugs that slow dow the activity of the brai ad other body fuctios. They are ofte used to relieve pai, reduce axiety ad help us relax or sleep. They iclude opioids, caabis, bezodiazepies ad alcohol. Stimulats are drugs that speed up the impulses goig to ad from the brai. The use of stimulats icreases heart rate ad body metabolism, ad delays sleep. Some people who use stimulats experiece icreased alertess, eergy ad a feelig of power. Stimulats iclude amphetamies ad amphetamie-type substaces (ATS) (such as methamphetamie, dexamphetamie ad crystal methylamphetamie), ecstacy, cocaie, crack cocaie, tobacco, coffee ad some ihalats like amyl or butyl itrites. Hallucioges are both atural ad sythetic drugs that mix up impulses goig to ad from the brai, causig chages i our perceptio of reality. Hallucioges iclude LSD, cactus plats cotaiig mescalie, mushrooms cotaiig psilocybi, PCP (phecyclidie) ad ketamie. Lists of the potetial effects of differet drugs ca be both log ad misleadig i that they may ot be experieced by all users i the same way. The Ziberg model 19 provides a helpful framework for uderstadig the drug experiece by examiig the iteractios betwee the drug, the set (or the perso usig drugs) ad settig i which the drugs are used: Drug the type of drug ad its source, form, quality, quatity ad stregth. Set our curret metal ad physical health, ad level of experiece of ad tolerace to the drug (some people react badly to drugs that cause few problems for others). Settig i which drugs are used for example, the experiece of smokig caabis with frieds at home will be very differet if repeated i public ear a police statio. 18. Ceida: The three mai categories of drugs : Available at: www.ceida.et.au/drugs.asp 19. Ziberg, N. (1984), Drug, set, ad settig: the basis for cotrolled itoxicat use, Yale Uiversity Press. 10 good practice guide: hiv ad drug use
By examiig the drug, set ad settig i combiatio, the experiece of the drug ad the degree of potetial harm ca be better uderstood. Similarly, strategies to address harms associated with drug use should examie these three factors together. Our focus is maily o opiates ad amphetamies, so we will examie their potetial effects i more detail below. Opiates ad opioids Opiates are a group of drugs derived from opium, a extract of the poppy plat. Opiates iclude morphie ad its sythetic derivatives, such as heroi, morphie ad codeie. There are also sythetic opioids such as methadoe ad pethidie. Collectively, opiates ad opioids ca be termed opioids. key resources For more detail o drugs ad their effects, see The Cetre for Harm Reductio, Macfarlae Buret Cetre for Medical Research ad Asia Harm Reductio Network (2003), Maual for reducig drug related harm i Asia. Available at: www.buret. edu.au/freestyler/gui/files// Maual.pdf The effects of opioids ca iclude: depressig the cetral ervous system so our fuctios (icludig breathig ad bowel movemet) are slowed dow a feelig of euphoria ad a subsequet sese of profoud wellbeig pai relief drowsiess ad lethargy. Opiates ca be ijected, sorted, swallowed or smoked. Heroi is active i the body for aroud five hours. This meas that a sustaied effect requires aroud four doses a day. Amphetamies Amphetamie-type substaces (ATS) are cetral ervous system stimulats that quicke the heartbeat, breathig rate ad brai activity. ATS ca iduce feeligs of cofidece, eergy ad alertess. Sometimes they ca stimulate libido ad sexual activity. We ca become more outgoig ad talkative, but we may also feel tese ad axious. The effect usually lasts for three to six hours, after which withdrawal ca lead to tiredess, irritability ad depressio. Withdrawal symptoms for both opiates ad amphetamies are itese whe we are depedet o drugs (see page 15). Bezodiazepies Bezodiazepies are legal drugs usually prescribed to relieve axiety ad isomia, ad they have varied active duratio i the body. They iclude diazepam (Valium), itrazepam (Mogado), oxazepam (Serepax), fluitrazepam (Rohypol), temazepam (Normiso). Bezodiazepies are also importat for us to cosider as they are sometimes diverted to the black market ad ijected. They play a sigificat role i overdose risk, particularly whe we cosume additioal depressats such as alcohol or heroi. chapter 1: drug use, hiv ad health what are the issues? 11
key message Sharig ijectig equipmet is a highrisk practice Ijectig is a very high-risk activity i terms of HIV ad HCV trasmissio because BBVs ca spread whe ijectig equipmet is shared. If people fid it difficult to access sterile ijectig equipmet, or if they do ot kow about prevetig HIV ad HCV trasmissio, they ofte ed up sharig with their frieds. Why do people take drugs? People take drugs for may reasos, some persoal ad others related to the culture ad values of the commuities we live i. These ca iclude: to experiece a high to prevet withdrawal symptoms to escape daily realities to alleviate pai metal ad/or physical pai peer pressure or to belog to a group or friedship etwork because of setbacks or disappoitmet to medicate agaist depressio to temporarily escape family problems as a reactio to a sese of hopelessess, particularly about ecoomic ad social coditios to celebrate at special occasios ad festivals to feel relaxed to experimet out of curiosity to experiece reality i a differet way to improve creativity to ehace sex to sleep to stay awake to lose weight for fu. Although this is ot a exhaustive list, it does highlight that the reasos why people take drugs are may ad varied. key message Oly whe we uderstad the cotext ad practices ijectig ad sexual that put us at risk of HIV trasmissio do we really kow how best to itervee ad act. The reasos for takig drugs, the types of drugs ad ways of takig them are usually specific to our cotexts ad social coditios. Uderstadig the reasos why people take drugs, which drugs they use, what methods they use to take them ad the settig i which drugs are used is all essetial for the HIV programmer. Ask what, why ad how as this iformatio helps us to desig programmes. 12 good practice guide: hiv ad drug use
How drugs are take Drugs ca be ijected, swallowed, sorted or smoked. Some people prefer to iject as the effect is itese ad almost immediate. Ulike smokig, where some of the substace may blow away, ijectig may be see as a more ecoomical use of sometimes expesive drugs. For example, a perso might start out sortig amphetamies, but because of a police crackdow supplies might become scarce. So, i a attempt to get a strog effect from a smaller amout of amphetamies, they might try ijectig. Sortig ca also result i a direct ad powerful impact. Whe a drug is swallowed, the effects are ot as direct ad take loger to experiece. Sometimes people iject substaces that are ot made to be soluble for ijectio. For example, some bezodiazepies, available i tablet form, are crushed, mixed with water ad ijected. Because the particles do t break dow well, this practice ca put extra strai o the blood vessels ad lead to blood vessel damage. Drug use patters what drugs are used ad how they are take vary accordig to what drugs are available, treds ad orms amog peers i differet drug-usig commuities, ad chages i what people wat or eed. All of this iformatio is vitally importat to the HIV programmer. For example, i some commuities mixig heroi ito a solutio usig blood i the syrige is commo, but i other commuities the practice does ot occur. This has implicatios for BBV trasmissio, so it is importat iformatio. What is depedecy? Opiate depedecy Whe we use opiates cosistetly ad over time, adaptatio occurs i our body i order to ormalise to our usual opiate levels. The brai stops producig its ow opiates (called edorphies ) to regai the usual balace. The pleasure or reward systems i the brai adapt to higher cocetratios of edorphis from opiates, ad we eed more i order to feel ormal. This is called euro-adaptio. Neuroadaptio explais why opiate users report eedig to take icreasig doses to achieve the same effect. This is kow as tolerace. If a depedet perso suddely stops takig opiates, it takes their body a few days to retur to ormal edorphie productio. I the meatime, with o opiates or edorphis i the body, the perso will experiece a ucomfortable period of withdrawal. The degree of discomfort correlates with the degree of depedecy, or the size ad frequecy of a perso s usual dose. Opiates are a cetral ervous system depressat, so they slow dow our metabolic rate ad ucoscious muscle movemets like breathig ad itestie cotractios. A opiate overdose is sometimes chapter 1: drug use, hiv ad health what are the issues? 13
Descriptio of opiate depedece from the World Health Orgaizatio Opioid depedece develops after a period of regular use of opioids. The time required for depedece to occur i a perso varies accordig to the quatity, frequecy ad route of admiistratio, as well as factors such as idividual vulerability ad the cotext i which drug use occurs. Opioid depedece is ot just a heavy use of opioids, but a complex health coditio that has social, psychological ad biological determiats ad cosequeces. It is ot a weakess of character or will. World Health Orgaizatio, Uited Natios Office o Drugs ad Crime, Joit Uited Natios Programme o HIV/AIDS (2004), WHO/ UNODC/UNAIDS positio paper: substitutio maiteace therapy i the maagemet of opioid depedece ad HIV/AIDS prevetio. described as forgettig to breathe the dose has bee larger tha we ca tolerate ad the system has slowed dow to the poit where breathig has ceased. This is why first aid for overdose ivolves mouth-to-mouth resuscitatio. Cotrary to popular belief, if opiates are take i pure form ad measured doses, the oly potetial egative physical effects are costipatio, tooth decay (due to decreased saliva productio) ad depedece. The key elemets of opiate depedece are: a strog desire or sese of compulsio to take opiates difficulties i cotrollig opiate-takig behaviour a withdrawal state whe opiate use has stopped or bee reduced evidece of tolerace icreased doses are required to achieve effects similar to those origially produced. Treatmet Opiate depedecy is a chroic ad relapsig coditio typically ivolvig cycles of depedece, withdrawal ad relapse. 20 Treatmet is importat whe commuities are faced with a HIV epidemic amog people who iject opiates. Whe people who have a opiate depedece are ready to receive effective treatmet, they stop ijectig or reduce the amout of ijectig, ad this has a powerful effect o prevetig HIV trasmissio. There is o oe drug depedece treatmet that works for everyoe, ad some treatmets are more effective tha others. However, opioid substitutio therapy (OST) (methadoe or bupreorphie) has bee prove to be highly successful 21 i terms of HIV prevetio, as well as cost-effectiveess, supportig ati-retroviral treatmet (ART) adherece, reducig crime, health ad lifestyle improvemets, ad overdose prevetio. OST ca be very effective at: reducig trasmissio of HIV ad HCV helpig people to maage opiate depedecy improvig the health ad quality of life of people depedet o opiates supportig adherece for people livig with HIV who use drugs ad who eed ART. 20. World Health Orgaizatio/Uited Natios Office o Drugs ad Crime (2008), HIV/AIDS care ad treatmet for people who iject drugs i Asia ad the Pacific: a essetial practice guide. Available at: www.wpro.who.it/publicatios/pub_9789290613206.htm 21. World Health Orgaizatio (2005), Evidece for actio: effectiveess of drug depedece treatmet i prevetig HIV amog ijectig drug users. Available at: www.who.it/hiv/pub/advocacy/idupolicybriefs/e/ 14 good practice guide: hiv ad drug use
Amphetamie depedecy Amphetamie depedecy is differet to opiate depedecy. Although amphetamies have sigificat physical effects, the way they act o the physical chemistry of the brai makes them less physically addictive tha opiates. However, people ca experiece strog psychological depedecy. Frequecy of daily use is greater tha that of heroi because they act i the body for shorter periods. If they are also ijectig, this ca mea they are ijectig more regularly tha a perso who is depedet o opiates, ad therefore at higher risk of HIV/HCV trasmissio because of the frequecy of their ijectig. Amphetamies ca either be illegal substaces made privately i uregulated coditios, or ca also be pharmaceutical drugs. They ca also be mixed with other pharmaceutical drugs, although mixig i this way ca be risky. Treatmet There are very few effective treatmets for amphetamie depedecy, although differet itervetios are currelty beig tested. This is discussed i a review by the Cochrae Collaboratio. 22 Why is drug use a health issue? Drug use ca be a health ad HIV issue for five mai reasos: 1. Sharig ijectig equipmet dramatically icreases our risk of acquirig HIV ad HCV. People livig with a BBV ad who share ijectig equipmet are likely to trasmit ifectio. To prevet this we eed to promote safe ijectig ad offer sterile ijectig equipmet. Providig people with educatio about safe ijectig ad makig it easy for them to get ew ijectig equipmet is a priority itervetio, prove to prevet BBV trasmissio effectively. 23 2. Whe we take drugs our ability to make ratioal ad sesible judgmets about our health ad the health of others ca be compromised. Whe we are druk or high we might take more risks, icludig sexual risks. Sexual risk-takig ca icrease our vulerability to HIV or the likelihood of us passig o HIV sexually. 3. Whe we take drugs, ad i particular whe we mix differet types of drugs or whe we take drugs ad drik alcohol, we risk overdosig. Overdose rates ca be very high amog people 22. Srisurapaot, M., Jarusuraisi, N., Kittirattaapaiboo, P. (2001), Treatmet for amphetamie depedece ad abuse, Cochrae Database of Systematic Reviews 2001, Issue 4. Art. No. CD003022.DOI:10.1002/14651858.CD003022. Available at: www.cochrae.org/reviews/e/ab003022.html 23. World Health Orgaizatio (2005), Evidece for actio: effectiveess of sterile eedle ad syrige programmig i reducig HIV/AIDS amog ijectig drug users. Available at: www.who.it/hiv/pub/advocacy/idupolicybriefs/e/ chapter 1: drug use, hiv ad health what are the issues? 15
HIV ifectios i commuities of ijectig drug users HIV epidemics amog ijectig drug users ted to preset themselves very differetly from epidemics i which sexual trasmissio is the mai risk factor. Sexually trasmitted HIV may remai udetected for several years while associated health problems worse. However, drug-related epidemics spread more rapidly because sharig ijectio equipmet is a much more efficiet mode of trasmissio. Oce the virus is itroduced ito a commuity of ijectig drug users, tes of thousads of HIV ifectios may occur withi a short period. Ifectio levels amog ijectig drug users may rise from zero to 50 60% withi oe to two years, as we have see i cities as differet as St Petersburg (Russia Federatio), Imphal (Maipur, Idia) or Ruili (Yua Provice, Chia). WHO, UNODC, UNAIDS (2004), Advocacy guide: HIV/AIDS prevetio amog ijectig drug users. who use heroi. 24 Overdose is particularly liked to leavig drug treatmet or priso. 25 If a perso who has bee drug free or havig irregular access to opiates i priso or i treatmet takes the same dose of heroi whe they leave treatmet as they were used to before they wet i, the body ca o loger tolerate that amout, resultig i overdose. 4. Whe we take illegal drugs supplied i a uregulated market, quality caot be guarateed. So over the log term our geeral health ca be affected. Added to this, the cost of illegal drugs ca be high, leavig little moey for food, ret ad clothig. Ijectig drug users are ofte forced to use drugs quickly, sometimes i usaitary coditios, i order to escape the otice of police. They ca be malourished, more vulerable to TB or have problems with veis, ski, metal health or reproductive health. If they are also HCV positive, these geeral health problems ca become more serious. If co-ifected with HIV ad HCV, maitaiig geeral health is importat. 5. Whe we take illegal drugs we are more likely to be margialised or treated badly by authorities, families, eighbours, police ad health care staff. This ca lead to people who use drugs beig excluded from health care services, such as primary health care services, pharmacies, hospital services, family plaig or metal health services. Whe we are excluded from health services we are more vulerable to ill health. If we are livig with HIV we ca be further margialised or treated badly. How do drugs affect peoples lives? Whe a perso s drug use itesifies, the problems associated with drugs itesify too. If they are poor, their poverty is usually itesified by the expese of buyig illegal drugs. For those who have become depedet, their thoughts ad actios for most of the day may be related to esurig the ext dose. The other parts of life family, work, study may become less of a priority. This ca lead to icreased social isolatio, family ad health problems. May of these problems arise because drugs are illegal ad therefore expesive ad uregulated. Uregulated productio leads to ukow purity ad potetial cotamiats, with overdose ad other health implicatios. Problems with the police ca become a domiat part of drug users lives, as ca the pressures that may 24. Coffi, P. (2008), Overdose: a major cause of prevetable death i Cetral ad Easter Europe ad Cetral Asia. Recommedatios ad overview of the situatio i Latvia, Kyrgista, Romaia, Russia ad Tajikista, Eurasia Harm Reductio Network. Available at: www.harm-reductio.org/images/stories/library/od_report_2008_e.pdf 25. Curtis, M. ad Guterma, L. (2009), Overdose prevetio ad respose: a guide for people who use drugs ad harm reductio staff i Easter Europe ad Cetral Asia, Ope Society Istitute. Available at: www.soros.org/iitiatives/health/focus/ihrd/articles_publicatios/ publicatios/overdose_20090604/overdose_20090604.pdf 16 good practice guide: hiv ad drug use
result if they are desperate for moey to buy drugs. This ca lead to risky behaviour ad icreased HIV vulerability, ad the stigma that accompaies ijectig drug use ca lead to social exclusio, discrimiatio ad icarceratio. Some people i the geeral commuity ca be afraid of people who use drugs. Their fears may derive from prejudice or they may be axious about HIV ifectio. This is kow as scapegoatig of drug users. Therefore, educatig the geeral public especially those who most come ito most cotact with people who use drugs, such as police, drug treatmet workers ad other service providers about drug use ad drug depedecy is a importat part of a comprehesive respose. Not all of the effects of drugs are bad. A perso ca experiece euphoria, relief from pai, creative ispiratio, colourful dreams ad other pleasurable effects from opiates. People who use drugs ofte become part of a close-kit commuity ad value some of the social aspects of beig with other people who use drugs. With the help of peer educatio programmes, people who use drugs ca support ad care for each other, ad educate each other about health, HIV prevetio, prevetig ad maagig overdose ad how to use drugs safely. Stigma Blame ad scapegoatig Problems with the police Risky behaviour Drug depedecy Spiral of problems arisig from drug depedecy Family, work, housig problems Drug user scapegoatig I his article The political ecoomy of drug-user scapegoatig ad the philosophy ad politics of resistace Sam Friedma describes how drug users become scapegoats ; that is, they fuctio as a symbol of the may problems i society. Friedma argues that the fuctio of drug users as scapegoats is to distract attetio away from some of society s biggest problems globalisatio, ecoomic difficulties, iequality, lack of social cohesiveess ad to blame society s problems o youg, poor idividuals. Friedma, S. (1998), The political ecoomy of drug user scapegoatig ad the philosophy ad politics of resistace, Drugs: educatio, prevetio ad policy, 5(1). Crime Social isolatio Need moey Health problems Social exclusio chapter 1: drug use, hiv ad health what are the issues? 17
key resource Ope Society Istitute (2009), At what cost? HIV ad huma rights cosequeces of the global war o drugs, describes a rage of huma rights problems associated with the crimialisatio of drug use ad drug users. Oe of the mai problems they evidece is the icrease i HIV vulerability because of the war o drugs approach to drug use. Available at: www.soros.org/iitiatives/ health/focus/ihrd/articles_ publicatios/publicatios/ atwhatcost_20090302 key message We ca exted the impact ad relevace of our programmig by itegratig HCV prevetio efforts ad by workig to improve access to HCV treatmet. Drugs, crime ad the police I most coutries drug use is illegal. May of us would argue that keepig drugs illegal ad udergroud makes maagig the egative cosequeces of drug use ad depedecy more difficult. Because of the illegal ature of drug use, people who use drugs are ofte icarcerated, take away from their commuities ad families, ad ecouter high-risk ijectig-related ad sexual exposure to HIV i prisos. I some coutries they are beate, deied treatmet ad forced to pay bribes to local police or other officials. 26 27 People who use drugs are also forced to udergo urie tests carried out by the police, ad are stopped ad searched more tha other people. Experiecig fear, harassmet ad corruptio makes people take more risks with their drug use. They may iject i a rush, ad they are more likely to share ijectig equipmet ad iject i usafe, uhygieic coditios. The illegal ature of drug use creates challeges for HIV prevetio. 28 Fearig arrest, may people who use drugs are reluctat to carry ew or used syriges i case they are see as evidece of drug use. 29 Similarly, they may be reluctat to atted health services or to disclose their drug use to health professioals, fearig that health care workers will report them to the police. As a result, may people who use drugs have o access to iformatio about HIV prevetio, treatmet or care because their drug use is secret. Co-ifectios hepatitis C ad tuberculosis Ijectig drug users are at risk of two importat related ifectios: HCV ad TB. Hepatitis C HCV is a BBV ad ca be trasmitted by shared ijectig equipmet. May ijectig drug users are HCV positive, leadig i may cases to debilitatig symptoms arisig from poor liver fuctio. HCV is more ifectious tha HIV ad so is very commo amog people who use drugs. 30 As with other BBVs, HCV ca be trasmitted ot oly by sharig eedles ad syriges but also by sharig ijectig equipmet such as cotto swabs, water ad spoos, or cookers. Ulike HIV, it is 26. Ope Society Istitute (2009), At what cost? HIV ad huma rights cosequeces of the global war o drugs. Available at: www.soros.org/iitiatives/health/focus/ihrd/articles_publicatios/ publicatios/atwhatcost_20090302 27. Huma Rights Watch (2006), Rhetoric ad risk: huma rights abuses impedig Ukraie s fight agaist HIV/AIDS. Available at: www.hrw.org/e/reports/2006/03/01/rhetoric-ad-risk 28. Rhodes, T., Siger, M., Bourgois, P., Friedma, S., Strathdee, S. (2005), The social structural productio of HIV risk amog ijectig drug users, Social Sciece ad Medicie, 61. 29. Huma Rights Watch (2008), A ubreakable cycle: drug depedecy treatmet, madatory cofiemet, ad HIV/AIDS i Chia s Guagxi provice. Available at: www.hrw.org/e/ode/76256/sectio/1 30. Europea Moitorig Cetre for Drugs ad Drug Addictio, Hepatitis ad Ijectig Drug Use 18 good practice guide: hiv ad drug use
uusual for HCV to be trasmitted sexually. For more iformatio o HCV symptoms, progosis, maagemet ad treatmet see www.hepatitisaustralia.com/about_hepatitis/hep_c.html ad http://digestive. iddk.ih.gov/ddiseases/pubs/chroichepc/ May people who iject are co-ifected with both HIV ad HCV. Co-ifectio ca exacerbate health problems; for example, HCV disease progressio is accelerated ad HIV treatmet is compromised or complicated. 31 There is very poor access to HCV testig ad treatmet i most developig ad trasitioal coutries, so most people with HCV are uaware of their status. HCV ca lead to liver disease, ad i may coutries is a major cause of death amog people with HIV/HCV co-ifectio. 32 Tuberculosis I additio to high rates of HIV ad HCV, people i developig ad trasitioal coutries who use drugs also have high rates of TB. If they are also livig with HIV, this greatly icreases the risk of the TB ifectio becomig TB disease. Other factors, such as poverty, homelessess ad icarceratio, also icrease drug users vulerability to TB disease. Coutries with the highest rates of ijectig-drive HIV epidemics also have the highest rates of multidrug resistat TB. People with HIV ad TB, particularly those who use drugs, ofte get very poor or o treatmet for their ifectios because of stigma agaist drug users or because of a lack of capacity i health care systems. Ofte, TB doctors do ot kow how to treat HIV ad TB together, or HIV doctors do ot recogise or test for TB, ad HIV ad TB services are ofte ot itegrated. Other health issues for HIV-positive drug users People who use drugs ofte have a rage of other health cocers besides HIV ad other BBVs. WHO have developed a list of commo health problems (ot icludig overdose) associated with ijectig drug use (see page 20). People who use drugs may have limited access to primary health care because: there is a lack of health services i a district or regio health services are ot free ad people who use drugs are ofte poor key message Health problems associated with drug use are more commo i those who are most isolated ad socially excluded. 31. Collis, S. ad Swa, T. (2007), Hepatitis C for people livig with HIV: testig, coifectio, treatmet, support, HIV i-base. Available at: www.i-base.ifo/guides/hepc/idex.html 32. World Health Orgaizatio, Maagemet of hepatitis C ad HIV co ifectio: cliical protocol for the WHO Europea regio. Available at: www.euro.who.it/ data/assets/pdf_file/0007/91924/e90840_chapter_6.pdf chapter 1: drug use, hiv ad health what are the issues? 19
remember Commuity orgaisatios ca build capacity amog other service providers, icludig those providig HIV, hepatitis, TB ad sexually trasmitted ifectio (STI) testig ad treatmet, to improve access for drug users to these essetial health services. All these health problems uderlie the eed to provide access to primary health care services for people who use drugs, especially for people livig with HIV. health services discrimiate agaist people who use drugs ad treat them badly, if at all; for example, they may withhold medical treatmet util the perso stops usig drugs health services might report drug use to the authorities, or people who use drugs might fear that they will health services may require people to have official papers ad residecy rights may people who use drugs will ot have these people who use drugs might be youg, ad health services will require paretal coset i order to treat them people who use drugs might be pregat wome or mothers ad fear havig their childre take away from them by health officials. Improvig access to primary care services for people who use drugs is importat, alog with health iformatio ad educatio, home care services ad cousellig ad other metal health services. health problems associated with drug use ijectio-related ijuries ad ifectios Ijectio-related ijuries Bruisig Scarrig Swellig ad iflammatio, icludig urticaria Veous ijury Arterial ijury Ijectio-related ifectios Cellulitis ad abscess Thrombophlebitis Complicatios of ijectio-related ifectios Bacteraemia ad septicaemia Musculoskeletal ifectios Edovascular complicatios Tetaus ifectious diseases Sexually trasmitted ifectios Hepatitis B ad C Respiratory tract ifectios Tuberculosis o-ifectious disorders Psychiatric disorders Substace depedece other commo health problems Pai Costipatio Poor detal coditios World Health Orgaizatio Regioal Office for South-East Asia (2009), Maagemet of commo health problems of drug users. Available at: www.searo.who.it/likfiles/hiv-aids_primary_care_guidelies.pdf 20 good practice guide: hiv ad drug use
Remember! People who use drugs have sex. Wives ad other sexual parters of me who iject are particularly vulerable. Drugs ad sex Sometimes whe our focus is primarily o ijectig practice there is a tedecy to overlook the sexual trasmissio of HIV amog people who use drugs. It is importat to remember that people who use drugs, icludig people livig with HIV, have sex too. Some studies show that people who use drugs have very low rates of codom use, especially adolescets ad those livig ad workig o the street. 33 Therefore, the eed to prevet sexual trasmissio of HIV always applies. Strategies iclude: codom (male ad female) promotio iformatio, educatio, skills-buildig ad cousellig, as part of a behaviour chage commuicatio (BCC) strategy diagosis ad treatmet of STIs diagosis ad treatmet of HIV ad referrals to psycho-social care ad support services icreasig access to sexual ad reproductive health (SRH) services provisio of outreach ad low threshold services offerig psycho-social support, iformatio, educatio, cousellig ad skills-buildig, referrals ad advocacy. 34 Usig such strategies to miimise the risk of sexual trasmissio is a feature of good HIV programmig with people who use drugs. Uderpiig these differet strategies is a uderstadig that the people we work with will be HIV positive, HIV egative ad utested. Drugs ad sexual risk-takig Amphetamie use Amphetamie use is associated with icreased sexual risk-takig. Most of the research o this focuses o studies with me who have sex with me i Europe ad the USA. This work clearly eeds to expad to focus o the may amphetamie users i Asia ad Easter Europe, but i the meatime programmers eed to be aware of the greater likelihood of sexual ad HIV risk-takig whe people use amphetamies. The overlap betwee ijectig drug use ad sex work I our work with wome ad me who are ijectig drugs we ofte see the overlap betwee drug use ad sex work. May people who use drugs maily wome but also me report egagig i sex work to get moey to buy drugs, or sellig sex i direct paymet for 33. UNAIDS Iter-agecy Task Team o HIV ad Youg People: www.ufpa.org/public/iattyp/ 34. See ote 33 chapter 1: drug use, hiv ad health what are the issues? 21