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Popularising harm reduction strategies

Drug users are the most neglected of those groups considered at high risk of contracting and transmitting HIV/AIDS. Freny Manecksha spends time at one centre in Mumbai that offers injecting drug users exchange needle programmes, and other harm reduction facilities

It’s a small single-storied tenement on a bustling street in the heart of Mumbai. Several men are milling around. Some are eating, some are waiting to speak to the nurse, and others just chat among themselves.  

We are at one of the five drop-in centres (DICs) of the Sankalp Rehabilitation Trust where Mumbai’s “nowhere” people, the marginalised population of drug-using street-dwellers, receive the support they need to reduce the risk of HIV transmission.  

Sankalp works among drug users many of whom are at increased risk because infected needles shared among injecting drug users (IDU) spreads HIV. In 1992, Eldred Tellis became aware of this problem after being sent to document and study the prevalence of HIV infections in the north-eastern states by SHARAN, a civil society organisation working in Delhi, and the international aid agency Oxfam.  

It was evident from the study that contaminated equipment like needles and syringes was a major driving force for HIV and hepatitis-C transmission. On his return to Mumbai, Tellis found that needles and syringes were being freely exchanged by drug users on the streets of Mumbai. Drug users were not covered under any AIDS awareness programme and many of them had little or no access to rehabilitation centres, which were either unaffordable or had criteria for admission that they could not meet. 

The Sankalp (meaning ‘resolve’ or ‘determination’) Rehabilitation Trust was formed in 1995 with Tellis, A V Krishnan, a retired director-general of police, B N Bhagawat, a retired civil service officer, and Sujata Ganega, director of SUPPORT, an organisation for street children. Today, it is a member of NACO’s Technical Resource Group for harm reduction programmes and a leading advocate for more such programmes in the country. 

Sankalp believes that no matter what their degree of dependency, drug users can make decisions to change their lives if they are treated with respect. Its experience in working with drug users showed that while it is obvious that abstinence is most desirable, it cannot always be achieved. So, the next best thing is to adopt the harm reduction approach – that is, provide the means to reduce the risks of HIV transmission for those who continue to inject drugs or those who stopped but have relapsed.   

The concept of ‘harm reduction’ first emerged in HIV/AIDS prevention programmes with the promotion of condoms for interventions linked to sex workers. Since sex work was seen as a profession, it was important to promote the idea of ‘safe sex’ and condoms were an acceptable way of controlling sexually transmitted infections and HIV. The idea is that even if one cannot provide the perfect solution, at least the damage can be controlled. 

The same principle of damage control is applied to the practice of injecting drug use and the risk of HIV. Since drug users often shared needles and syringes whilst injecting, which could spread HIV, giving them clean needles and syringes in exchange for the used ones, and putting them on opioid substitution treatment was a risk containment strategy.  

Opioids are powerful – and potentially addictive – painkillers. In opioid substitution programmes IDUs are provided the means to switch from an injected to a non-injected substance (so, for example, switching from injecting buprenorphine to the opioid sublingual buprenorphine).  

The concept of substitution pharmacotherapy (sometimes called maintenance treatment) was part of drug treatment even before the advent of HIV/AIDS. But today, opioid substitution is seen as an efficacious, safe and cost-effective way of preventing HIV among IDUs.  

However, a debate has continued to rage around the harm reduction versus the abstinence oriented approach. The USA, for example, accepts methadone maintenance as part of treatment but does not endorse the needle/syringe exchange programme. Funds from US donors are not permitted to be used for harm reduction activities, creating hurdles for civil society organisations in implementing their prevention programmes. 

Eldred Tellis says the debate is not meaningfully directed. “Harm reduction and abstinence approaches are not mutually exclusive but complementary.” He points out how the drug user begins to feel accepted through a harm reduction programme and this helps build trust. In Sankalp’s drop-in centres, a rapport is built with drug users who have little or no access to other rehabilitation measures. “The low threshold nature of the drop-in centre allows the drug user to understand the various options available to him/her and make choices when ‘ready’,” Tellis says. 

The twin pillars of the harm reduction approach are public health as well as upholding human rights. In its interventions, Sankalp lays equal stress on both. 

Thomas George, project manager of Sankalp’s drop-in centres (a project that comes under Mumbai’s District AIDS Control Society), explains the difficulties of reaching out to IDUs. “Our aim is to reach out to IDUs. But these are people literally on the streets. Society has not accepted them and they have no family support. There is little incentive for them to go off drugs and go clean.” 

Initially, he says, there was little concern among drug users about contracting HIV. But over the years IDUs have become aware of the risk of infected needles. “Through our peer educators who fan out to different parts of the city, we encourage them to exchange their old needles and syringes for new ones. Through the needle exchange programme and the opioid substitution programme we try to spread the message of how to prevent HIV/AIDS,” George explains. Condoms are also handed out to promote safe sex. “This is how a rapport is built up and they are encouraged to visit the drop-in centres where they know they are always welcome. At the centre we give them food and clothes, a cup of tea. We provide the supportive care of the family.”   

Sankalp has drop-in centres in Mumbai Central, Govandi, Kalyan, Bhiwandi and Kurla. There is also one for women at Mumbai Central as some five to ten per cent of the city’s IDUs are women. The centres function from 9 am to 5 pm.  

George is careful to point out that the support Sankalp offers goes beyond the needle/ syringe exchange programme. “The drop-in centre is the place where IDUs can avail of the services of a counsellor or learn about abscess management brought on by injecting, or about the importance of nutrition in AIDS prevention. The team at the centre includes peer educators, two peer counsellors, a part-time doctor and nurse. Group counselling is provided daily and also services for referral to HIV or TB testing and medical facilities. Counselling is provided before recommending HIV testing.”  

The links between poverty and injecting drug use are evident. The majority of IDUs in a city like Mumbai, for example, are rag-pickers between the ages of 25 and 40. They are largely runaways, youths who, on their arrival in a big city, find they have no home or shelter and so gravitate towards similar youths clustered around railway stations. The rag-picking business generates enough money to buy dugs, which sometimes makes it difficult for those who have kicked the habit to continue to stay clean.  

However, the harm reduction approach seems to be yielding results with HIV infection rates among IDUs decreasing. It is the experience of Sankalp’s workers that many drug users are making great efforts to move from “fixing” (injecting the drug) to “chasing” (a form of inhaling). 

Sankalp has also established a community care centre where drug addicts and IDUs can be admitted for treatment of opportunistic infections related to HIV. Dr Sachin Khaire, who is attached to the community care centre known as Nivara, explains the need for such facilities: “Hospitals are reluctant to admit drug users who are on the streets. Besides, there are practical difficulties because the drug users have no relatives or family members who can stay with them in the hospital. We admit them to the community care centre and provide the necessary treatment. We can facilitate the investigations for TB or the CD4 test. In some cases patients are admitted so that they can be given symptomatic treatment for withdrawal symptoms, or so that the substitution therapy can be monitored.”  

The community care centre is in Thakurdwar in Mumbai and provides 24-hour medical treatment with a nurse on duty at all times, doctors on call and its own ambulance. 

Sankalp also works with drug users in prisons. It began doing this after it realised that many drug users who had opted for the opioid substitution treatment and who would come regularly to the drop-in centres as part of the direct observation therapy, seemed to have suddenly disappeared. Inquiries revealed that they were in jail having been rounded up by the police along with others drug addicts.  

In jail, their situation was extremely vulnerable. They were lodged with convicted criminals and were often abused physically. Moreover, their substitution treatment was abruptly stopped and there was no access to risk-reduction services.  

Sankalp began drug treatment therapy in Arthur Road jail in Mumbai. Besides the needle/syringe exchange and substitution treatment, doctors from Sankalp run an out-patient medical service in the jail, arrange for check-ups or referrals, and even provide antiretroviral treatment (ART) to those who need it. Even jail inmates who are not drug users have approached Sankalp for help as they had tested positive but had not been helped by the jail system.  

Sankalp is firm in advocating that harm reduction strategies be legalised and be widely adopted with the backing of law enforcement agencies. It is also essential to create jobs and provide social support for drug users. This will create the incentive to stay off drugs. One programme on the cards is to train drug users in computer skills for specific jobs. The programme was created for mentally challenged people by a Bangalore based IT company and can be adapted for drug users, Tellis says.  “The idea of working with computers gives them immense self-esteem. Just putting their fingers on a keyboard provides enough motivation to stay clean.”  

The ultimate goal, he adds, is setting up a community based organisation. Sankalp would provide stipends but the drug users would manage affairs for themselves.    

(Freny Manecksha is a freelance journalist based in Mumbai)

InfoChange News & Features, April 2009