1. 1 Scaling up an Essential Harm Reduction Package: overcoming the barriers in South Asia World Bank Inter-Country Consultation on Prevention of HIV among IDUs Scaling Up: From Evidence to Action 9–13 April, 2007, Kolkata, India Dr. Alex Wodak, St. Vincent's Hospital, Sydney, Australia awodak@stvincents.com.au

2. 2 Outline: 1.Recognising national HIV problem 2.Recognising need for harm reduction 3.Planning implementation 4.Ensuring sustainability

3. 3 1 Recognising HIV/IDUs problem: Will, or is, HIV a problem in my country? Will, or is, HIV/IDUs a problem in my country? –Power of national immunity myths –Power of denial Can HIV/IDUs be controlled? –Pervasive nihilism about drugs –Nothing works, nothing effective or acceptable

4. 4 Recognition HIV/IDUs problem: Why bother trying to save IDUs? –‘AIDS and drugs are problems that will solve each other’ Does my country have to adopt harm reduction? What is harm reduction? Is harm reduction acceptable politically, legally? –Entrenched support drug law enforcement major obstacle to harm reduction

5. 5 Overcoming barriers: 1 Assessment of risk: Is HIV a problem in my country? Is HIV/IDUs a problem in my country? Isn’t my country immune? –Surveys HIV/IDUs: power of local data –Rapid assessment –Modelling health, social, economic impact –Comparing costs action vs. costs inaction –Reviews of international experience

6. 6 Overcoming barriers: 2 2 Assessment of response: Can HIV/IDUs be controlled? –Reviews of international experience –Harm reduction is effective, safe, cost-effective Why bother trying to save IDUs? –Altruistic arguments ‘It’s the right thing to do’ –Self-interest arguments ‘What if it was your own son/daughter?’ ‘You will go down in history’ ‘You might not like them but the general population will suffer’

7. 7 Overcoming barriers: 3 Does my country have to adopt harm reduction? –Review of options What is harm reduction? –Explaining harm reduction –Primary focus on harm –Includes promotion abstinence –Use of same approach in other policies

8. 8 Overcoming barriers: 4 Is harm reduction acceptable politically, legally? –Documentation support in UN system –WHO, UNAIDS, UNODC –Acceptance by other countries –Legal status UNODC report –Relationship to drug law reform? Indulgence? Essential?

9. 9 Overcoming barriers: 5 Critical importance political leadership –HIV control only achieved where strong leadership e.g. Thailand, Uganda, Australia –What’s popular doesn’t work –What works, isn’t popular –Need highest level leadership Raise, maintain high level awareness Belief efficacy, safety of prevention Mobilise funding

10. 10 2 Accepting harm reduction: Is harm reduction accepted nationally? Will harm reduction be implemented by all government departments? Is harm reduction morally acceptable?

11. 11 Overcoming barriers: Is harm reduction accepted nationally? –Arranging demonstration of national acceptance Will harm reduction be implemented by all government departments? –Developing partnerships: Religious leaders Government officials Law enforcement –Guidelines, training, international collaboration Injecting drug users Researchers, clinicians

12. 12 Overcoming barriers: 2 Is harm reduction morally acceptable? –Contrast with morality condemning unborn generations HIV despite known effective prevention

13. 13 3 Planning implementation: How many IDUs are there? What kinds of interventions needed? How much each intervention is needed? Goals and targets? Should prisons be included? Vulnerable and bridge populations? Should ‘pre-IDUs’ be included?

14. 14 Planning implementation: 2 How many, what kind staff needed? Buildings? Materials procured? Vehicles, computers? Training? Administration? Funding? Research?

15. 15 Overcoming barriers: How many IDUs are there? –Capture-recapture –Multiplier –Triangulation –Back calculation, modelling What kinds of interventions needed? –Reviews international experience –Education, NSPs, drug treatment, community development –Manuals

16. 16 Overcoming barriers: 2 How much each intervention is needed? –UNAIDS guidelines –Modelling –Current reviews Goals and targets? –History + x%? –5 year plan?

17. 17 Overcoming barriers: 3 Should prisons be included? –Community first, then prisons? –Important but too difficult? Vulnerable and bridge populations –Ethnic minorities –Severely disadvantaged groups –MSM IDUs –CSW IDUs –Certain drugs e.g. amphetamine, cocaine

18. 18 Overcoming barriers: 4 Should ‘pre-IDUs’ be included? –High risk youth –Non injecting drug users How many, what kind staff? –Doctors –Other healthcare –Administration –Researchers

19. 19 Overcoming barriers: 5 Buildings? –Needle syringe programme outlets –Drop In Centres –Drug treatment clinics Materials? –Methadone, buprenorphine –Needles, syringes –Environmental policies

20. 20 Overcoming barriers: 6 Vehicles, computers? –Coordination –Generating, compiling data Training? –Manuals –Train the trainer –National centre?

21. 21 Overcoming barriers: 7 Administration? –Central control? –Devolve states/provinces? –National guidelines? Funding? –Are national resources available? If not now, when? –Can GFATM resources secured? –Other Multilateral Bilateral

22. 22 Overcoming barriers: 8 Research? –Hasn’t there been enough research? –Local data much more powerful –Local researchers Understand language, culture, history Always there, critical advocacy role How to train? Help defend sensitive programmes

23. 23 4 Ensuring sustainability: How monitor, evaluate? Defending ‘controversial programmes for unpopular populations’

24. 24 Overcoming barriers: How monitor, evaluate? –Simple –Timely –Inexpensive –Un-intrusive –Meaningful –Benefits of small, frequent vs. large, infrequent

25. 25 Overcoming barriers: Defending controversial programmes for unpopular populations –Strategic, creative, national –Monitor opposition carefully –Commission research –Attend promptly to problems of prevention

26. 26 Conclusions: 1.Raise, maintain high level awareness of HIV 2.Promote effectiveness, safety, cost effectiveness of harm reduction 3.Explain, maintain advocacy harm reduction 4.Importance high level political leadership

27. 27 Conclusions: 2 5.Entrenched support drug law enforcement major obstacle to harm reduction 6.Counter moral arguments against harm reduction by appeal to protection unborn generations 7.Develop structures encourage partnerships

28. 28 Conclusions: 3 8.Plan strategy implementation –Which strategies? –How much? –Goals, targets? –Estimate staff, materials, support, training, funding 9.Ensuring sustainability –Monitoring, evaluation –Supporting valuable, vulnerable programs