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Exploring new ways to fight AIDS

WHEN Datin Paduka Marina Mahathir starts talking about harm reduction, one gets the impression that she is almost at her wits’ end trying to convince people why it can be a way to reduce the rate of HIV infection among injecting drug users (IDUs) in the country.
The issue, she said, has been at a stalemate between the government and NGOs for the past seven years, when stakeholders like the police had understood what was needed and agreed to back the programme although they could not be seen to be supporting it publicly.
However, she lamented, after that “encouraging start”, “certain people” came into positions of authority and were adamantly against it. The result is that harm reduction has ceased to be considered as a viable option.
The Manual for Reducing Drug Related Harm in Asia released by The Centre for Harm Reduction, Macfarlane Burnet for Medical Research and Asian Harm Reduction Network, defines harm reduction as “the prevention of adverse consequences of illicit drug use without necessarily reducing their consumption”. Which does not involve dealing with the drug problem but seeks to reduce the harm in terms of HIV infection, said Marina.
Besides needle exchange, harm reduction includes counselling, education and rehabilitation.

Among the reasons given for rejecting harm reduction are that it would promote drug use since there would be a needle and syringe exchange programme; it goes against the culture of being a Muslim and Asian country; and it is not in tandem with the government’s policy of having a drug-free nation by 2015.

“As a result, the incidences of infection among drug users remains high. Sure, there may be a bias towards them but they still figure highly in our statistics and we cannot just look at those numbers and do nothing about it,” Marina argued.

To date, and officially, the number of people living with HIV/AIDS in Malaysia stands at 47,000. This has far outstripped initial predictions when the virus first surfaced.

There were about 5,000 HIV/AIDS cases in the early 1990s and it was predicted that there would be 30,000 infections by 2000. However, in that year the infection number was 38,000.

And last year, there were 6,000 new cases – the largest number ever for any year while the latest United Nations Programme on HIV/AIDS (UNAIDS) report says 14,000 children in Malaysia have been orphaned by the virus.

The prevalence rate is 0.4%.

However, Dr Sandro Calvani, a representative from the United National Drug Control Programme Regional Centre for East Asia and the Pacific, warned that the country could face an HIV/AIDS epidemic if steps were not taken to remedy the situation, which concerns a high infection rate among IDUs.

Speaking at the recent meeting of the UN Regional Task Force on Drugs and HIV/AIDS Vulnerability, Dr Calvani had said that the virus could spill over to the general population faster than anticipated because the main group was the IDUs where rate of transmission was higher than other causes such as sexual intercourse.

Marina, meanwhile, stressed the importance of harm reduction in cutting down the HIV infection rate as one could not wait until a person was free from drugs before anything was done about the virus.

“That can take two or 10 years, God knows, or never. HIV infection takes all of one second to occur between two people who are sharing the same needle. How do you beat the odds of that?”

Marina also claimed that efforts so far were limited to reaching out to drug users and HIV had therefore not been stopped from “circulating”.

“The drug using community is not always an isolated one. They have links with the non-drug using community and the possibility of HIV transmission going further is there and it is happening,” she said.

She also did not mince her words when she said that the incredible resistance to harm reduction is due to ignorance of the authorities in Malaysia.

“All everyone sees is needle exchange and that is very emotive. When we have been on this track of zero tolerance for drug use, the idea that you might tolerate a little bit for a larger good is very hard to get over,” she said.

“People get fuzzy over the word “exchange”. Exchange is exchange. You give me one dirty needle, I will give you a clean one. The total sum of needles out there doesn’t increase,” she said.

“The other thing is they have to come to a certain place to get it and when they come in, you can provide information, counselling and everything. You can encourage them to get off drugs in the first place. And that is one of the major benefits,” she added.

Countries in Asia that have implemented harm reduction include Nepal, India and Bangladesh while pilot programmes are being carried out in Indonesia.

“Bangladesh is a Muslim country, so is Indonesia. All these barriers can be brought down if you have the will and if you know what is important. If it is a public health issue, you have to do it,” argued Marina.

She also lamented the fact that there was a lack of co-ordination between ministries in tackling the problem. A typical mindset, she said, was putting all the responsibility on the Health Ministry although there was a clear link between drug users and HIV infection that needed intervention from other ministries.

“People on the ground who actually have to deal with the situation know. The police know of the problem. But the police’s role is very limited. They clean up the streets but they are not dealing with HIV prevention either,” she said.

The first step to starting up harm reduction is to educate the different stakeholders such as Pemadam, National Drug Agency and police so they will understand what it is and its importance, Marina said.

“People who oppose harm reduction never come up with very good reasons why it won’t work, apart from ‘it won’t work’ and that’s all!” she exclaimed.

“Secondly, they don’t have any alternatives for prevention of HIV among drug users. We need to get the discussion to a more sophisticated level than that. Otherwise, it’s like children in the playground. We need to recognise the issue in the first place,” she curtly said.

Accepting that successes from using harm reduction in other countries were mainly localised, Marina said: “It depends on the local community accepting it and for them to support it. Even the United States has strong anti harm reduction (sentiments) but some communities have been able to do it successfully.”

It is also impossible for NGOs to go at it alone and start up harm reduction programmes as there are laws prohibiting the possession of needles and syringes.

“We need an amendment from the authorities to allow us to at least carry out pilot tests. And we can’t do a good job if one gets arrested. So how can our workers go around explaining or showing clean needles to someone and run the risk of being arrested?” she questioned.

All the NGOs want, she said, is for the government to acknowledge that harm reduction needs to be done and to provide the right environment for them to carry out the programme.

“Besides, do you think the drug users want the government to do it? They don’t want the government to do it. They are not interested in having government officials come and see them and hand them needles.”

And as harm reduction is a preventive method, she said, it is an uphill task making people realise that HIV/AIDS is a problem that can affect them.

“In the meantime, you are talking about theories about an invisible problem and people want to see evidence. You look at other countries and try to take the lessons learnt there to apply here before it happens.

“And because it has not happened yet, people find it hard to believe. You are waiting for it to happen, and by that time it will be too late,” she stressed.

In the end, Marina said that statements like harm reduction advocating drug use was simply pass?.

“Prove it. I have heard that for the past 10 years. Again it is the case of tak ada modal (no more excuses). Why would we want to promote drug use when it contributes to the HIV problem? What have we got to lose?” she said.

The Star, 25 Aug 2002

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