HIV, HCV, TB, laws and funding
Vietnam has made remarkable progress over the last
decade in not only making harm reduction and HIV services available and
accessible for people who use drugs but also reforming laws for supportive
health policies on the ground.
Khuat Thi Hai Oanh who leads Vietnam’s Center for
Supportive Community Development Initiatives, was a plenary speaker at 20th
International AIDS Conference (AIDS 2014) in Melbourne. Inn 2003, Oanh said,
Vietnam had criminalizing laws related to drug use and compulsory drug
dependence treatment of those using drugs. Being caught even once with illicit
drugs meant being sanctioned and criminalized.
Oanh met an Australian harm reduction advocate in
2003, she said, who motivated her to lead the process of changing the scenario
for drugs users and HIV in Vietnam. She realized that harm reduction is a
pragmatic approach to keep people who use drugs safe, healthy and be a part of
the community. She saw that that harm reduction effectively prevents the
transmission of HIV and other blood-borne infections among drug users in
Australia. People who have drug dependence can still live a healthy life. Oanh
said that laws and social perceptions are very critical. “These laws are made
by human beings, so human beings can change them too.”
Laws and policies can either be critical barriers or
critical enablers. Before 2003, harm reduction was illegal in Vietnam.
Distribution of clean needles was equated with promoting drug use. It was
written in the Vietnam’s constitution that people who use drugs would be
subjected to compulsory treatment.
No wonder when the first round of grant came from the
Global Fund to fight AIDS, Tuberculosis and Malaria, there was not a penny for
harm reduction. But soon after, in 2003, British government stepped in and
initiated a harm reduction initiative in Vietnam which was not called ‘harm
reduction’ since it was illegal in Vietnam. So this initiative was referred to
as HIV prevention work, which it truly was. 1000 clean needles were provided to
an estimated 200,000 drug users in Vietnam – a humble beginning but a positive
start in the desired direction!
By 2004, Vietnam was targeting to provide 100 percent
clean needles for all drug users. In 2006, the National Assembly passed the HIV
law and harm reduction was included (such as needle exchange programs, etc) and
opioid substitution therapy was legalized. 17,000 drug users were provided
substitutes such as Methadone in 32 provinces. By the end of the following
year, 80,000 drug users were on such substitutes. Most significantly drug use
was decriminalized in in 2009 with revision of penal code. In 2013, the
national assembly revised the law and removed compulsory drug dependence
treatment for drug users.
Oanh said that globally too, significant progress was
made in harm reduction by 2012: 77 countries were providing some substitution
therapy, 86 countries had instituted needle and syringe exchange programs, 97
had policies that support harm reduction and 158 countries were reported to
have drug users.
“Sometimes we forget, HIV is not the only killer.”
Oanh said. “People who use drugs are 14 times more likely to die than
non-usersof the same age groups. Drug overdose kills 500 people every day
according to the UNODC. But no one needs to die of drug overdose. Overdoses can
be reversed especially with naloxone. The WHO is supporting community
distribution of naloxone and developing guidelines and I hope countries will
implement these guidelines effectively.”
At least 60-80 percent of drug users are infected with
the hepatitis C virus and 85 percent of them become chronically infected.
One-third of those develop liver cirrhosis or liver cancer, Oanh said. said
Oanh. HCV treatment is effective as combination therapy for 12 weeks works with
90 percent effectiveness.
“But the price of medicine kills the people, not HCV.
Medicines do not have to be that expensive,” she continued. “A 12-week course
of these drugs could be manufactured for US$78-166 per person if methods of
mass-producing generic drugs were applied (according to the research done by
Hill A Cooke in 2014)” remarked Oanh.
TB is among the top killers of drug users. TB is the
leading cause of deaths among people living with HIV, of whom many are drug
users. Regardless of HIV status drug users, are many times more likely to get
TB than others. If drug users get TB, then they are more likely to die of TB
too. But the good news is that TB treatment works effectively among drug users
as well.
Annabel Baddeley of the WHO Global Tuberculosis
Programme agreed with Oanh's call to stop neglecting TB among drug users.
Annabel said: "drug users are at a higher risk of TB regardless of their
HIV status. They suffer from other co-morbidities as well and also from massive
stigma and discrimination even from the medical staff. All this makes the issue
more complex. If services are not integrated they will have to approach a lot
many services separately
In Chennai, Baddely said, a study of HIV negative drug
users found that in them TB was the second-biggest cause of death after
overdose. So awareness about TB is lacking in them even though they are more at
risk of it. Imprisonment also impedes services."
“Good intention is not always matched with good
intervention. 235,000 people are in 1,000 compulsory detention and rehabilitation
centers in East and Southeast Asia,” Since 2012 in Vietnam, pre-conditions and
a court process is required before sending any person to compulsory
rehabilitation center.
Vietnam recognizes drug dependence as a chronic health
problem and calls for scaling down compulsory rehabilitation centers and aims
to reduce the number of drug users in these centers from 63 percent in 2013 to
6 percent in 2020.
“This is not perfect but we are making progress” said
Oanh.
A new ceiling on the Global Fund grants means harm
reduction has to come along with other interventions. Funding to middle income
countries has been reduced but that is where majority of drug users live. 99
percent of drug users live in middle income countries which are among the 15
priority countries identified by UNAIDS, with only 1 percent in low-income
countries.
“The funding gap in harm reduction is 93 percent,”
Oanh said. “The excuse is always that there is not enough money but how come
there is never a shortage of money to do drug control?”
Australia has been a good example to support harm
reduction initiatives for drug users which have had profound public health
impact.
“Australia works with governments in our region to
implement proven, cost-effective interventions which respond to the particular
needs of countries,” said Australian Deputy High Commissioner to India, Bernard
Philip. “This includes advocacy for evidence-based programs targeted at key
populations, including people who use injecting drugs. In many countries
Australia has supported harm reduction: needle and syringe programs; methadone
maintenance therapy care support and treatment for people who inject drugs.”
In Indonesia in 2011, 87 percent of people who inject
drugs reported using sterile equipment, Philip said. The decrease in sharing is
likely to have contributed to declines in HIV infection rates in this
population from 52.4 per cent in 2007 to 42.4 per cent in 2011. In Vietnam
close to 60 percent of users have access to harm reduction services.
“These harm reduction interventions are increasingly
being integrated within national health programs and funded by the
governments,” Philip said. “In Indonesia 83 MMT clinics are now run and funded
by the government as part of the health system. In future, all harm reduction initiatives
in Indonesia will be fully integrated within the health services.”
Oanh ended her plenary with a remark that perhaps
sends a strong message for supportive policy and legal framework for health and
rights: “I put on hold my medical practice for policy advocacy. Doctors save
lives one at a time. Bad policies kills at a massive scale. Good policies save
lives."
Shobha Shukla
Shobha Shukla is Managing Editor of Citizen News Service
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