Harm reduction a medical and political approach based on public health and human rights by Médecins du Monde

Harm

Reduction A medical and political approach based on public health and human rights ÂŠ Serbia, Benoit GuĂŠnot

HARM REDUCTION (HR) MÉDECINS DU MONDE

MÉDECINS DU MONDE AND HARM REDUCTION

WHY TAKE

édecins du Monde (MdM) is an international aid organisation caring for the most vulnerable populations, for victims of armed conflicts and natural disasters and for those who are gradually being forgotten about by the rest of the world. As an independent organisation, its actions go beyond medical care. It openly condemns attacks on human dignity and rights and fights to improve the situation of these populations.

ACTION?

MdM has long been committed to delivering programmes to the general population for the prevention and treatment of HIV/AIDS and, in the process, has noted that some sections of the population either affected by or suffering from HIV/AIDS do not have access to such programmes: people who use drugs (PWUD), sex workers (SW) and people who are homosexual are just some of the many who are excluded because of what they are or what they do. This is what makes them more vulnerable and more at risk than others: not because the virus is different or is transmitted differently but

because their social and legal status distances them from the prevention and treatment programmes and, as a result, is what exposes them, more than others, to the risk of infection by HIV/ AIDS and viral hepatitis. Their ostracizing sometimes goes as far as imprisonment, torture and even death. MdM has therefore decided to redirect its activities to combat HIV/ AIDS and viral hepatitis towards these individuals. This involves working with them and close to them to offer health services that are adapted to their needs, at the same time as seeking to develop their social and legal status. This action is referred to as Harm Reduction (HR).

Tanzania, © Agnès Varraine-Leca

WHAT IS IT ABOUT? 5

Afghanistan, © Sandra Calligaro b

WHICH CONTEXT OF INTERVENTION? 7

WHAT ARE THE BATTLE LINES? 8

Marseille, © Christina Modolo b

FROM FOCUSING ON FRANCE TO WORKING INTERNATIONALLY

PROGRAMMES IN FRANCE 11

INTERNATIONAL PROGRAMMES 15

Burma, © Sophie Brändström b

HARM REDUCTION (HR) MÉDECINS DU MONDE

WHAT

IS IT ABOUT? b

In Tanzania, a mobile unit surveys the streets of Dar-es-Salaam on a daily basis, raising awareness of drug users to the risks associated with injecting. Tanzania, © Agnès Varraine-Leca

A GLOBAL APPROACH BASED ON UNDERSTANDING THE RISKS The risks are not limited to increased exposure to HIV (Human Immunodeficiency Virus) or viral hepatitis. They are viewed in global terms of their adverse health, social and economic consequences and take into account the impact of the illness on the individuals as well as their communities and society as a whole1. Applying such a definition involves not only public health interventions but also advocacy work to change the political and legal environment in which these people live.

AND FOUNDED ON PRINCIPLES Harm reduction is intended to be pragmatic and humane, based on a non-judgmental approach to others and an acceptance of the different practices and lifestyles of the people encountered. Moreover, harm reduction within MdM relies on the principle of adopting a low (or unconditional) threshold2 as one of the main means of establishing links with the most marginalised individuals.

HARM REDUCTION (HR) MÉDECINS DU MONDE

Since 2006, local stakeholders involved in the fight against HIV/AIDS have been going out to meet drug users in Kabul to pass on health prevention messages. Afghanistan, © Sandra Calligaro

WHICH CONTEXT OF

INTERVENTION? A PUBLIC HEALTH RESPONSE As a humanitarian medical aid organisation, MdM uses its expertise in health matters to create programmes for accessing prevention and treatment provision that is adapted to the needs of these individuals. The HR approach is recognised at a global level as being the most effective method for reducing HIV transmission among these most at-risk groups. MdM is promoting an HR approach that is based on scientific evidence which has also demonstrated its added value in terms of cost-effectiveness. The HR activities mean that those benefiting from programmes can be offered the tools (prevention methods, counselling and testing and care and treatment) and knowledge to increase their capacity to protect themselves and others.

A COMMUNITY RESPONSE FOR SOCIAL CHANGE In addition to their relevance to public health, HR programmes at MdM are aimed at helping develop a community response. That is to say, they are aimed at empowering via the active participation of beneficiary groups, as a way of identifying health-related solutions and of combating the stigmatising and exclusion of these groups. MdM supports the creation of self-support groups as a way of strengthening civil society and recognising experience-based expertise. HR activities can, in this way, lead to social change. b

1. This definition draws on the HR definition put forward by the global NGO Harm Reduction International (HRI) 2. A programme with a low or unconditional threshold is based on there being few or no criteria for accessing the services offered. This principle makes the programme accessible to the most vulnerable people.

While referring to the comprehensive package of 9 core interventions of the UN agencies3 in the field of HIV prevention and treatment aimed at injecting drug users (IDUs), MdM puts forward a broader, multidisciplinary framework of intervention. This framework, which is based on 12 areas, is equally valid for interventions targeting sex workers and lesbian, gay, bisexual and transgender people (LGBTs). w Antiretroviral treatment and care for HIV/AIDS w Counselling and testing of HIV/AIDS and viral hepatitis w Targeted* information, education and communication w Condom and needle and syringe programming w Prevention, diagnosis and treatment of sexually transmitted infections w Prevention, diagnosis and treatment of viral hepatitis w Prevention, diagnosis and treatment of tuberculosis w Socioeconomic reintegration w Promotion of human rights, fighting criminalization and preventing violence w Mental health care interventions w Opioid substitution therapy w Preventing and managing overdoses

*By ‘targeted’, we mean activities such as educating users about the risks associated with injecting, or maintaining and encouraging the use of noninjection methods (e.g. chasing), drugs analysis or self defense guidelines for sex workers. b 3. WHO, UNODC, UNAIDS, 2009. Technical Guide for countries to set targets for universal access to HIV prevention, treatment and care for injecting drug users.

HARM REDUCTION (HR) MÉDECINS DU MONDE

MAP OF PROJETCTS as off 1st of June, 2012

WHAT ARE THE

BATTLE

LINES? In addition to providing a health-related response, MdM is drawing up battle lines along 4 political fronts

Advocating access to testing, treatment and care for viral hepatitis: There are 180 million carriers of HCV and 70% of new infections occur in injecting drug users. Access to affordable treatment is therefore now an urgent priority.

Reforming national laws and regulations, as well as international policies which criminalise, are repressive or controlling and which penalise the practices and lifestyles of these people, in favour of approaches based on public health and human rights.

Promoting the concept and practices of HR in Africa, where care and treatment of these population groups is virtually non-existent and, as a result, less than 1% of drug users in that continent benefit from health services.

Developing the definition and practice of HR across the world: HR is still far too focused on HIV/AIDS prevention and injecting drug use: It must be viewed from a more global perspective, going beyond the technical framework of reference used by international agencies. b

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FROM FOCUSING

ON FRANCE TO

WORKING INTERNATIONALLY MdM’s HR programmes were first developed with drug users in France in 1989 and then with sex workers in Paris. Today, MdM remains a key player in HR in France and recently put in place a programme of operational research into educating people about the risks associated with intravenous drug use, and is pursuing its HR work with female sex workers. In addition, MdM has developed HR programmes in other countries, the initial trial being conducted in the Russian Federation in 1997. MdM is currently operating in Asia, Latin America, Eastern Europe and Africa, where it offers a holistic approach to HR, working mainly with drug users but also sex workers and LGBTs. As a humanitarian medical aid organisation, MdM is capable of designing and leading HR programmes in various contexts, including in countries where there are severe constraints. Over the past few years, MdM has, in particular, introduced HR principles to Afghanistan and has made a huge contribution to the introduction of substitution therapies both there and in Myanmar (Burma). Similarly, MdM is currently involved in innovative work to introduce HR to and among drug users in subSaharan Africa, notably by developing a model programme in Tanzania. MdM is therefore a key global HR player, exploiting its expertise to develop concrete, quality solutions and, at the same time, to strengthen the capacities of national players. b

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CURRENT PROJECTS

Mexico 1 State of Chiapas 2010 Spain (MdM Spain) 2 14 Harm Reduction projects with drug users and sex workers in 13 Spanish cities France 3 9 Harm Reduction projects with drug users and 5 with sex workers Georgia 4 Tbilisi 2011 Afghanistan 5 Kabul 2006 Burma/Myanmar 6 Kachin Province 1996 7 Rangoon 1999 Democratic Republic of Congo 8 Kinshasa 2009 Tanzania 9 Dar es Salaam 2010 Kenya 10 Nairobi 2012

FUTURE PROSPECTS

Egypt 11 Republic of Cote d’Ivoire 12 Mozambique Senegal (MdM Spain) 15 Angola (MdM Spain) 16

Vietnam

PAST PROJECTS 11

w Vietnam: Hanoi, 2005-2010, Ho chi Minh City, 2005-2010 w China: Chengdu, 1999-2010 w Serbia: Belgrade, 2002-2011 w Russia: St Petersburg, 1997-2003

FRANCE 1987 b

1994 b

2000 b

First MdM HIV counselling and testing centre (voluntary, anonymous and free) opened

First ‘low threshold’ methadone distribution centre opened

First drugs analysis undertaken at MdM

First programme aimed Several needle exchange at sex workers in Nantes set up (Funambus) programmes in Lyon, 1989 b Bordeaux, Nice, 2007 b Strasbourg, etc. opened First needle exchange Opening of the 1997 b programme in Paris Mediterranean Harm operating outside the law Prevention programmes Reduction project (interventions in rave and 1992 b for rave parties in Paris, free parties in the south Lyon and Montpellier Prevention Kit of France) set up (2 syringes, sterile water, 2010 b 1998 b condom and health prevention message) Pilot project on First methadone bus in introduced Drug-Injection Risk France established Education (ERLI) in Paris

HARM REDUCTION (HR) MÉDECINS DU MONDE

Afghanistan, © Maxime Couturier

b b

Burma, © Sophie Bränsdtröm

Serbia, © Benoit Guénot

Afghanistan, © Maxime Couturier

HARM REDUCTION (HR) MÉDECINS DU MONDE

PROGRAMMES IN

FRANCE ERLI PROGRAMME— (DRUG-INJECTION RISK— EDUCATION)— w Designing a tailored solution for preventing hepatitis C transmission

The HR mechanisms currently in place in France are not suitable for dealing with the risks of hepatitis C transmission, as they take little account of the specific determinants of HCV exposure present in the methods by which users take drugs and the situations in which they do so. In many areas, patients’ therapeutic education has long demonstrated the value of promoting practical education to compensate for a lack of theoretical education. Why should the same not apply in the area of drug use where users are unable or do not wish to give up intravenous drug use? From a health perspective and as a way of responding to the needs expressed by users, MdM has instigated an innovative programme – drug-injection risk education (ERLI) – in Ile-de-France, which offers injecting drug users health education sessions that are both theoretical

The HR programme in Marseille gives young people hanging out on the alternative party scene and in squats the possibility of accessing healthcare and rights. Marseille, © Christina Modolo

HARM REDUCTION (HR) MÉDECINS DU MONDE

Lotus-bus © Diane Grimonet

and practical. During these sessions, which are held at a site specifically for this purpose, users can take their drugs in the presence of MdM health workers, providing an opportunity for a dialogue about the risks associated with the users’ own methods. Other MdM programmes offer supported drug injection with an HR objective.

LOTUS-BUS (PARIS)— AND FUNAMBUS (NANTES)— w Undertaking HR interventions with sex workers

Since the end of the 1990s, hundreds of women of Chinese origin in Paris have been driven to selling sexual services. As the majority of them do not have the right to work, selling these services is a survival strategy and one of their only means of subsistence. As a result of inadequate responses to this issue, lack of care provided by the social welfare and health services, and the complex needs of this population in terms of harm reduction and access to care, the Lotus Bus has been working with these women for over ten years in Paris. The Funambus resulted from a needle exchange programme in Nantes used by people working in the sex industry. Both programmes rely on a mobile unit which goes out to meet people where they are working and on a drop-in-centre. MdM’s 5 projects in France with female sex workers (Paris, Nantes, Montpellier, Rouen and Poitiers) offer harm reduction services which make no judgement of the women’s activity. MdM thus supports women working as prostitutes as a way of empowering them. This outreach work enables MdM to witness these people’s situation – living in the shadows because they are on the margins of society, which stigmatises them, and because they are on the fringes of the law, which penalises them. Speaking out on behalf of this group and transmitting their demands to improve their access to healthcare and rights underlines the conflict that exists between security and public health issues.

WORKING IN SQUATS— w Introducing innovative intervention methods At the end of the 1990s, MdM began to intervene in places where raves and free parties were being held, bringing the NGO into contact with drug users who had also opted for alternative lifestyles that broke with traditional ways of life which rely, among other things, on having a job and a fixed address. Living in a squat is just one such alternative lifestyle. MdM teams thus established links with groups of users and the communities living in these premises. The squatters concerned – whether or not they were using psychoactive products – voiced certain health and social needs. In this way, interventions in squats were identified and carried out at the request of the people involved and in partnership with self-support organisations.

The object of these interventions is to set up HR activities which form part of the healthcare and access to rights strategies and which are tailored to suit the practices and living conditions of these individuals. Like the Parisian project, the Marseille team has started working in the squats in 2011, adding to his project a self-support approach.

XBT MISSION— w Developing new HR tools “What is the quality of the illicit substances I’m using?” is a frequent concern of users. Answering this question forms part of an HR approach based on information targeting the needs of drug users. MdM therefore developed drugs analysis. The approach is the same as for HIV consultations, which are based on counselling: discussing

In Paris, the Lotus bus heads for places where Chinese women involved in prostitution work to provide them with health prevention materials and to offer them a space where they are listened to. © Damien Roudeau

a person’s practices freely and in a non-judgmental way so that the individual becomes more aware of the risks taken and how to manage them. Entering into dialogue about the practices and levels of drug use, using information about the quality of the product as a starting point, provides an opportunity for counselling these drug users. The technique used by the MdM teams involves thin-layer chromatography (TLC), a colorimetric reaction caused following the separation of substances contained in a sample and providing a qualitative result. TLC analysis takes one hour and advantage is taken of this time to talk with the user. The XBT (Xenobiotrope) project, created in May 2000, provides technical support to MdM’s rave/party, squat and ERLI interventions, as well as to those at drug-injection sites. b

INPUD’s (International Network of People Who Use Drugs) motto, poster done by the Afghan project team.

PROGRAMMES AFGHANISTAN — w Introducing Harm Reduction to a country

For twenty years Afghanistan has shown record levels of opium and heroin production (90% of global production of opium) and of domestic consumption, with 1.5 million drug users recorded in 2009, a figure that is equivalent to 8% of the adult population. The number of those injecting heroin – a major route for transmitting HIV/AIDS and viral hepatitis – is rapidly rising. This challenge to public health is compounded by the issue of human rights in a situation where drug users are harshly repressed and severely discriminated against. Since 2006, MdM has been running a programme in Kabul offering drug users a global package of care based on the 12 aspects of HR that MdM is seeking to promote. Since 2010, this care has included the provision of methadone. Drug users and patients on methadone are involved in designing the services and tools and hold key positions in the team; among other things, they take part in national and international advocacy work for the scaling up of the methadone programme across the country. In addition to helping those who benefit directly, the programme is also intended to serve as a model of HR intervention for Afghanistan. For this

reason, a training and resources centre is designing and leading HR training for Afghan professionals and partners in the form of theoretical and practical training delivered at the healthcare centre. The good practice established as part of the Kabul model programme is being copied and disseminated.

BURMA/MYANMAR — w Taking action aimed at more vulnerable individuals Since 1996 MdM has been working in the country with those populations who have a high risk of exposure to infection: sex workers, men who have sexual relations with other men (Rangoon) and drug users (Kachin State). Both sites are designed along the same lines: a global package of psychosocial-medical care at the clinic and ‘outside’ via the mobile teams. The care provided comprises MdM’s package of services. As

INTERNATIONAL

In addition to a needle exchange – an essential health prevention tool – drug users receive advice on risk-free injecting. Burma, © Sophie Brändström

in Afghanistan, the community dimension is very much to the fore and MdM introduced methadone substitution therapy into Kachin in 2006. In Rangoon, the programme in particular offers a hotline and website devoted to men who have sex with other men. Many links have been forged with civil society stakeholders by means of information sessions on HIV/AIDS and by promoting the programme’s activities in communities, universities, police stations and prisons. The project also incorporates an advocacy initiative in support of the rights of these stigmatised populations..

GEORGIA— w Supporting HR against a backgroundof repression The HR programme which opened in Tbilisi in Georgia in 2011 mainly targets injecting drug users and focuses, in particular, on the hepatitis C virus, as 70% of drug users there are carriers. The law and police in this country are extremely repressive and this translates into taking those benefiting from needle supply programmes in for questioning and requiring doctors and emergency services to report instances of overdoses, for example. This situation does not allow for good HR practice to be implemented and has the immediate effect of distancing those people who use drugs

HARM REDUCTION (HR) MÉDECINS DU MONDE

from the health and social services. Severe penalties for simply using drugs also force users to turn to dangerous, homemade substances such as ‘krokodil’ (desomorphine) with disastrous consequences. In this country, MdM has opted to strengthen the capacities of two local, self-support NGOs. The first partnership is aimed at promoting good HR practice and its mission is to facilitate improved access to basic services by setting up a model centre. It is also putting together the elements needed to advocate reform of the law. The second partnership is using a self-support initiative for hepatitis C sufferers to advocate easier access to screening, diagnosis and treatment of this illness.

DEMOCRATIC REPUBLIC— OF CONGO— w Integrating the concept of HR into sexual health programmes Sexual harm reduction (SHR) is incorporated into the health promotion programme for teenage girls living on the streets of Kinshasa, a marginalised and vulnerable population both because of their gender and their living conditions. As with health education, this approach is based on an analysis of the social and legal determinants of these individuals’ state of health. In this programme, SHR involves providing psychosocial-medical and educational services. These services are aimed at reducing the risk of infection from HIV/AIDS that is associated with the girls’ risky sexual behaviour with their regular partners or their clients on the one hand and with mother-to-child transmission on the other. The programme also includes advocacy initiatives in favour of access to contraception for minors. Particular attention is paid to the situation of young teenage girls who are pregnant or the victims of rape. The programme relies on those benefitting being extensively involved. The teenage girls take part in prevention activities, in discussions and in advocacy initiatives. The issue of prostitution among minors (girls and boys) is discussed as part of the programme with partner organisations and with the teenagers, with a view to designing a package of care that is appropriate to the local culture and the specific needs of teenagers. self-support groups are involved in delivering psychosocial support.

Slogan worn by Raheem, member of the MdM team and director of the Kabul self-support group in Afghanistan (ADUG). © Maxime Couturier

TANZANIA— w Launching HR in a region The situation regarding HIV/AIDS in Tanzania is typical of the changes taking place in the continent as a whole: while the HIV/AIDS epidemic was stabilising in the general population, the MdM teams were noticing that prevalence among injecting drug users was reaching alarming levels: 30% among men and 67% among women. MdM therefore put forward a proposal for a pilot project in Dar es Salaam in 2010 in order to demonstrate that HIV programmes destined for at-risk populations offered effective prevention strategies. The first programme ever to distribute sterile syringes in East Africa, its mission, more broadly, is to offer the full MdM package of services. Special attention is being paid to female drug users who are more exposed and vulnerable to HIV transmission, particularly as most of them are sex workers. Once a week, they are received at the MdM centre with their children at a time set aside for them. The mission of this HR programme is to bring out of the shadows a population which is vilified and often abused and which is also overlooked by the continent’s anti-AIDS programmes. The intention is to offer a training platform for Tanzanian stakeholders, and those from other countries in the region, as part of efforts to promote the concept of HR in Africa. b

Women drug users are seriously affected by the AIDS epidemic – 67% among them are HIV positive. MdM goes out to where they are living to meet them. Tanzanie, © Chien Chi Chang/Magnum

HARM REDUCTION IS COLORFUL! Targeted information, education & communication

Counselling and testing of HIV/AIDS & viral hepatitis

Condom and needle & syringe programming

Prevention, diagnosis & treatment of sexually transmitted infections

Prevention, diagnosis & treatment of viral hepatitis

Prevention, diagnosis & treatment of tuberculosis

Antiretroviral treatment & care for HIV/AIDS

Opioid substitution therapy

Promotion of human rights, fighting criminalization & preventing violence

Mental health care interventions

Socioeconomic reintegration

Preventing & managing overdoses

Médecins du Monde 62 rue Marcadet 75018 Paris, France Tél: +33 (0)1 44 92 15 15 www.medecinsdumonde.org

This brochure has been made thanks to the the financial support of the French Development Agency (AFD). The ideas and opinions here presented are Médecsins du Monde’s and do not necessarily correspond to those of the AFD’s