Middle East Kick Off Harm Reduction

Nov 2009 saw the first ever international harm reduction conference held in the Middle East, and I must say, as one who thought she could never be impressed by a drug conference again: I was wrong!

A key factor that left me feeling that way was that I didn’t feel that the people were arrogant about the work they were doing, and the challenges they faced. It was fresh, new and they were eager to get everybody on board to help out – including politicians and religious leaders, which is impressive for any of our conferences, never mind firsts.

One of the first speakers, director of the conference, Elie Aaraj of MENAHRA (Middle East and North African Harm Reduction Network), said that a key issue that had to be addressed first was Stigma; that in order to do this, we must encourage IDUs to adopt safer behaviours and first, drugs must be decriminalised. Good, I knew I was in the right place!
This event was a historic cornerstone in the young life of the international harm reduction movement, and the Lebanese President has supported the event, not to mention many young people who ought to be thanked for their input.

Gerry Stimson (IHRA’s Executive Director) gave a summary of the present global picture:

1)There are roughly 16 million IDUs in the world.
2)In 158 countries all over the world
3)10% of all HIV infections are IDU-related
4)There is some level of harm reduction work going on in 84 countries, supported by the IFRCRC (International Federation of Red Cross and Red Crescent)
5)And in 66 countries, the OSI (Open Society Institute) support the work

Later Pat O’Hare added that 25% of all IDUs are already living with HIV infection. He also mentioned that we now have 34 countries in the world, where we know drug user groups are functioning. I would add, 34 that we know of that is. And actually harm reduction was endorsed by the WHO as far back as 1974

The bad news is that in 80 of the 158 countries, there are no harm reduction interventions whatsoever, and in general, only 5-8% of those with interventions have access to this support, so there is a huge amount of work left undone. In economic terms, current spend is only 5% of what it needs to be…………

Generally, “we are often still working in hostile environments,” said Dr Tobias Lengsfeid, of the DROSOS Foundation, another major funder of this conference, (along with WHO and the IHRA.)
Dr. Hussein Gezairi, working for the East Mediterranean region of the WHO, began “ in the name of God, the most merciful Allah” a dialectic rarely heard at harm reduction events. He spoke of the impact of war, trauma, the breakdown of the extended family networks, stress therefore and the the increase of drug supplies to the region as causative factors for the rapid increase of drug use in this area of the world. “It is estimated that only 10% of drugs are interdicted in this part of the world” he added..

Later Joummana Hermez, who works for the Lebanese wing of WHO noted that there are already over half a million people living with HIV in the region, and a million IDUs. Various countries in the region that have reported HIV among IDUs include Oman, Afghanistan, Djibouti and Somalia.

That 11% of the regions IDUs are living with HIV, but in Iran this figure is more like 23% and in Pakistan it is almost 21%, according to current available data. Also Afghanistan has a 37% rate for IDUs living with HCV. Libya has the highest (known) rate of HIV in the Nth African region. Surveillance has been carried out in Jordan also, as well as Algeria, but it is not thought to be totally reliable yet, according to Dr Emran Razagh.

Syria has an HIV incidence of 20% right now and in Somalia, Methadone is only used as a detox medication.

In Afghanistan, it is the larger NGOs like Medicines Du Monde who carry out Needle Exchange, and in this part of the world: not enough of course, but at least there is some. There is also a small number of IDUs who can now access methadone since Feb 2010 (in the community that is.)

In ten short years, countries with IDUs went from 80 to 130 by 2004. According to some research, there are now but 77 countries of the 158 (that we know of) which carry out some level of NSP (Needle and Syringe Program.

However the prison situation is much bleaker as you would expect. That we are aware of only ten countries have NSPs in prison settings. NSPs are often more than just works provision, but also HBV vaccine and provision of other paraphernalia.

By 2007, the UNODC, WHO and UNAIDS begin to write publicly about the effectiveness of NSPs in prison, according to Wodak and Cooney. Their research speaks to the effectiveness of NSPs in preventing or slowing down the spread of BBDs (Blood Borne Diseases) and that there are no unintended consequences, apparently feared by so many, i.e. giving free clean works to injectors has not increased the numbers of people who inject illegal drugs. Indeed, Australian research shows that for every $1 spent on NSPs, $4 are saved in the long term in terms of need for anti-HIV meds in the future.

Since 2003, the IFRC&RC have also been spreading the light of science on these issues which has been great for the IHR movement; that is to have increasing numbers of larger generic NGOs supporting our cause. In one ecological study, carried out in 99 cities globally, the 63% of cities that did not have NSPs had an 80% in Hep C cases, whereas in the 36 cities that did have, HIV rates fell by 18.6%

According to Professor Rudolph Ingold, drug users should be the first partners in this struggle

Challenges to the development of Harm Reduction

1)Abstinence oriented rehab programs that either don’t understand harm reduction, or don’t care: funding competitions…
2)Stigma and discrimination
3)Where systems are based on religion or moral codes, resistance can be an issue (not always – Iran and Texas!)
4)Some Law Enforcers have previously been obstructive and thus enabled an increase in BBDs
5)The bureaucracy of larger organisations.
6)Political and/or security issues: where other priorities are paramount, harm reduction can be overlooked or seen to be unimportant

One of the impressive sessions of this conference was the one sat on by parliamentarians and religious leaders. Social affairs MP, Dr Alef Majdalam said, “ We are seeing the dismantling of the family as internet, radio, and TV take over the ‘communication’ within our families, so most of our kids do not even talk to one and other.” He felt this had contributed to the increased use of drugs among young people.

Dounja Aziz of Pakistan’s National Assembly, who admitted she had only just become aware of what harm reduction is said “ it is imperative to decriminalise drugs.” She also mentioned that we do not do ourselves any favours by omitting the lobbying of parliamentarians and legislators in addressing these issues adequately. She was referring to the IHRC in Bangkok. She then proceeded to give us a short one-on-one lesson about lobbying legislators!

She also said that Pakistan had given tentative approval to OST (Opiate Substitution Treatment) Nov 2009:-)

We then heard from an Islamic researcher, Fadlallah, who said a lot of interesting things, much of which appeared to upset several of the audience members. Frankly I thought it was great that he was there, and though he was probably trying hard not to offend us; implying that drug users are sinners and “must repent” is likely to get some folks backs up no? I had already asked to address what I thought might come up, so when I got 100 seconds, I simply said “Speaking as a drug user: when I was a kid, frankly I’m not sure that I knew what I was doing. As an adult, I was simply seeking comfort, and I do not see where the sin is in that.” I added “ God could be an important part of our recoveries, but not if s/he is used to beat us over the head further” to which I received an applause. Later, through his translator, I was told, I had not understood what he was saying, so I arranged to interview him when the conference finished:-)

The same Mullah, Fadlallah, said that though we should not accept drug use, it is not helpful to criminalise drug users: we still have human value. In summary his message was that we love the sinner but not the sin, and ultimately a little bit of coercion is not so bad…

DAY 2

The second day kicked off with a session on Human Rights. This session included Rick Lines (now Deputy Director of IHRA) and Ms Katib, regional director of UNAIDS in the North African area and Dr Elie Abouaoun (director of the conference)

It was pointed out that the High Commissioner for UNAIDS has already said that:
“drug users do not forfeit their human rights…and should receive the highest attainable level of physical and mental health care.”

Also, within the International Covenant on Economic, Social and Cultural Rights of 1966, Article 12 states “everyone has the right to health rights and states are responsible for making sure these rights are fulfilled.“

The question was then raised…”what does it mean to have these rights on paper?..” In other words, how to make sure they are actually implemented is another story too often. Lines said this is where the issue of interpretation enters the fray, and that the job of advocates is to ensure this is done in line with assisting drug users where necessary.

Even within Shari’ah Law, Article 17 says that everybody has the right to health: there is the CAIRO declaration on Harm Reduction in Islam, which refers to this, and the majority of states in the region have ratifies these articles, though Gaza/West Bank cannot as it is not recognised as a State…And 16 out of 21 states in the region have ratified the International Covenant on Economic, Social and Cultural. Algeria in Article 54. Therefore there are already some opportunities to ensure the development of harm reduction in the region.

Elie Abou Aoun (DDS Lebanon): this presentation largely reiterated the need to mainstream harm reduction into the social policies of country states and make sure that human rights law and rights are adhered to. Abou Aoun mentioned that drug users are “victims of greedy corporations” and “corrupt politicians and policies.” He said it is essential Not to address the drug issue exclusively as a criminal one, and that drug users should receive the highest attainable standard of health.

This session recommended increased

1)Training on the human rights issue within harm reduction organisation
2)That all policies should take into account of users and non-users
3)That (for the time being at least) better to refer to IDUs as victims not criminals…(something hotly debated by a few drug users in the international user movement)
4)Participation of drug users at all phases of policy development
5)Advocacy to promote a rights based drug policies.

Ghassan Moukheiber, a Lebanese MP raised the fact that there is no reference to drugs[users]in the development of the national Human Rights Plan for 2010, though it was said to be a fully inclusive process consultatively. He stressed that everybody should be involved in promoting the policies we advocate including government, MPs, Civil Society (especially all the different human rights organisations), Trade Unions, professional organisations and relevant international NGOs.

Dr Ahmed Mohit: he listed the rights we need as users:

1)Right to protection of self esteem,
2)Right of confidential diagnosis
3)Right to receive information on prevention and reducing harms
4)Right to being respected with equal rights under the Law
5)Right to treatment of all illnesses
6)Right to selection of different treatment modalities
7)Right to Education, Employment and Housing

He also referred to the right of “unborn children to be protected from the illness…” His key point was that what works today may not work tomorrow policy and practise-wise and we therefore need to be able to make quick change where necessary, and in the meantime be flexible.

Oliver, a consultant to Medicines Du Monde (MDM) presented a paper about the rolling out of methadone in Afghanistan:

The process was began in April 2007. There was a National OST Conference in Nov 2007, a methadone protocol by 2008. Between Feb 2008 and Oct 2009, there were administrative processes to go through in order to get methadone imported to Afghanistan. He pointed out that it is dangerous to implement large programs without economic and social interventions, that if “we are to implement methadone programs in Kabul, we must socially market” responsibly. However, methadone is not The solution to drug users plights, therefore we need drug user organisations.

It costs $8m to treat half a million drug users.. Money came from the World Bank, the national AIDS program, the IMF (International Monetary Fund) and NAHRA (their national harm reduction association.)

DAY 3

Tariq Zafar of the Nai Zindagi Association in Pakistan presented on preventing HIV among street-based IDUs, through provision of comprehensive package of harm reduction and HIV prevention in four cities of the country: Lahore, Faisalabad, Sarghoda and Sialkot. There are approximately half a million opiate users, who sniff, smoke and inject opiates including synthetic ones. The vast (known) majority are males between 24 and 35

100,000 IDUs (50%) are married with 4 kids. Over 80% share works… and over 80% have been imprisoned, with the highest rate of HIV being recorded in this group up to 51%

Kids of these families are often stigmatised in school.

In the development of these comprehensive packages, both ex-users and government representatives had to learn their weaknesses and compromise on strategy. The final cover was something like 80% having access to clean needles, ARVs and employment..of those reached, which was something like 20-24%, and there is still the need to include methadone as part of the overall strategy
The good news was that there was definitely a reduction in the transmission of HIV, e.g. in Sarghoda, it has gone down from 51% to 22.8%

Drug Users Workshop

From what I heard, it seemed that almost all the panelists were ex IDUs living with HIV. They came from Libya, Bahrain, Beirut, Oman and Syria.

Speakers spoke to the issue of many IDUs not being aware of their HIV status in communities where women did not have equal rights in marriage and so the men often infected their partners but didn’t know, or tell their wives that they were living with HIV. In Syria, people used to be arrested for this and therefore there was no real support around the issue

A Lebanese -X-IDU, who referred to himself as a former drug addict and field activist, began to work at SIDC in May 2009. “This program does not have government approval so we do not know whether we will be arrested for carrying out street outreach, “ he said. He described the street using scene as dangerous and risky in that are frequently verbally tortured and or robbed. Many have no shelter, so are in constant danger of arrest for possession. He thinks the cops and the rehabs collaborate against street IDUs
Most rehabs only address 5% of the IDUs needs, and very few ‘addicts’ know their legal and /or civil rights.

Hassan, an activist from Bahrain introduced himself as an HIV+ ex addict, started using as an adolescent beginning with “inhalants” and progressing to heroin. In 1990, he was arrested for drug addiction….and submitted to ‘treatment.’

Recently USAID funded a workshop for PLWHIV of people from Egypt, Lebanon and Bahrain.

Later, I gathered peers and suggested we ensure we have a voice in the final plenary of the conference. Conference Director told me only if the local users have said they want it! They did! And an outreach worker from Oman spoke well on our behalves..including addressing the fact that we must ‘positivise the image of drug users in society’ and of course work hard on legislative change. It was also pointed out that crucial for IDUs is access to ARVs (Anti-retroviral therapies), counselling and rehab too

In the Final Plenary of the conference, some awards were given out and everybody clearly felt gratified by this, the first harm Reduction conference in the region, And the fact that it had gone so well
So….it was then announced by Gerry Stimson where the 2011 IHRC would be held…………………..BEIRUT

They deserve it

Andria Efthimiou-Mordaunt
2010

Financial gain from Drug Users pain?

A few pharmaceutical companies are set to reap huge rewards from treatments and tests for hepatitis C. Grant McNally, from the UK Assembly on Hepatitis C looks at the fact that despite their still being no clear cure, this is not holding back phenomenal profit margins.

It is 15 years since the US biotech company Chiron Corp first identified the HCV virus, and engaged in certain dubious practices in an attempt to wholly own it and any spin off. In that time the virus has went through a metamorphosis, from a being believed to be a benign infection that was thought to have little consequence for long term health, to the serious global health concern it is now known as today. For their efforts Chiron Corp have benefited to the tune of a hundred million dollars or so in patent royalties payments (as I said , they even tried to patent the virus itself!).

The LA times recently reported that:

Chiron, (a Californian firm), has introduced a new policy for companies wishing to license its HCV patents. Chiron holds over 100 patents related to the HCV genome, which won’t expire until 2015. Any company that develops a new drug targeting hepatitis C (such as a protease inhibitor), or a diagnostic test to detect and measure HCV (viral load; tests for screening the blood supply), needs to license Chiron’s patents, typically by negotiating a licensing fee and royalties on product sales. Chiron typically charges each company millions of dollars in licensing fees during research and development alone, and makes millions more each year in royalties from HCV tests.

This went beyond the realms of ethical science and their were a number of litigations, before Chiron brought in their new policy which is tied to future sales, so potentially allowing them to make even more money for themselves.

This obviously annoys the companies presently at the forefront of treatment products, who are having to divert large chunks of their profits, but the fact is that it is not only the financial gains that upset’s people in the HCV field, but also, scientists have complained for years that Chiron Corp has hindered the fight against hepatitis by creating a virtual commercial monopoly over drug research.

Now, federal health officials are reviewing the 14-year-old government agreement that gave Chiron so much control over research that seeks to help the millions of people afflicted with the disease. It is this that has led to Chiron introducing the new royalty payment method reported above, a sort of buy now pay later.

Chiron currently hold 100 patents in 20 countries related to hepatitis C. Competitors had complained they’ had abandoned plans to enter the field because Chiron demanded too much money to access its technology. (Chiron successfully sued many companies for infringing its patents related to the virus).

Those patents credit Chiron scientists with discovering the hepatitis C virus — despite the fact that a scientist from the Centres for Disease Control and Prevention contributed much to the original research.

But the CDC signed away to Chiron most of the commercial control of the virus for a little more than $2.2 million in 1990.

There are, however, now over 50 medications in clinical trials for potential use relating to hepatitis C. In 15 years hep C has moved from an insignificant virus, akin to EBV, to being a mass cash cow for the pharmaceutical industry. For instance if the UK prevalence was low, say 200,000 with viral RNA, then based on current statistical models around 60% could be eligible for treatment, which would work out at 120,000 at £6000 per 24 wk treatment cycle, would be £720,000,000. Their would obviously be drop outs, non responders, etc, however, if factoring a percentage that will require 48 weeks treatment, £720 million, would not be far of the mark. This is only considering the current available treatments of Peggylated Interferon Alfa and Ribavirin, which has less than 50% success rates! So in the UK alone this a multi million pound industry, and this is just treatment, the economic costs of lost working years, other hospital treatments for the disease and it’s many associated conditions, then there is the costs of benefits, mental health care and areas in drug rehabilitation failures I will address later.

Meantime there is still concern and tension between the U.S. patent system and free scientific inquiry.

The CDC now, for instance, claims ownership of the SARS virus and its entire genetic content after its researchers helped map the bug’s genome. Rather than try to profit from it, the CDC wants to prevent others from monopolizing the field the way Chiron does with hepatitis C.

It certainly raises some questions about the morality of so much profit at the expense of those affected, not that this is anything new.