Harm Reduction Needs to Start in Health Facilities

Now that PEPFAR (the US President's Emergency Plan for AIDS Relief) have revised their Bush era decision to refuse funding to harm reduction programs, the Kenyan government may also consider changing their policy towards intravenous drug users (IDU). According to the head of Kenya's National Aids Control Program, addiction will be treated as a health issue and needle exchange, methadone and condoms will provided for IDUs.

Although the contribution of intravenous drug use to Kenya's epidemic is currently estimated to stand at about 4%, this kind of exposure is a highly efficient transmitter of HIV. Heterosexual sex, on the other hand, is not such an efficient transmitter. In some countries, sex workers are only likely to die of Aids if they are also IDUs.

Commercial sex work can be one of the few ways to make enough money to feed a drug addiction. The drugs have to be paid for, but injecting equipment can be, and often is, shared. So a source of clean injecting equipment for IDUs could play a big part in reducing HIV transmission by this route. However, the decision to fund HIV programs that target HIV transmission among IDUs may also allow better estimates of their full contribution towards Kenya's epidemic. It may also allow a better evaluation of the part that commercial sex work plays in the epidemic.

Very few HIV positive IDUs are currently on antiretroviral treatment. Such treatment could significantly reduce sexual transmission of HIV, though it may not reduce non-sexual transmission so much. But giving IDUs better access to diagnosis and treatment should improve conditions for them and reduce further HIV transmission.

Sadly, the Kenyan police force may need more than a change in the law. As long as they and others can make money out of drug users, it's unlikely they will all turn into social workers overnight. Nor are NASCOP in a position to decriminalize drug use on their own. So let's hope decriminalization becomes a reality. If the administrators of PEPFAR can change their minds for ideological reasons, I'm sure the relevant people in the Kenyan government could change theirs for pragmatic reasons.

But any kind of re-evaluation of non-sexual modes of HIV transmission would be welcome in Kenya, in fact, in all African countries. If donors, governments, health professionals and other big players in the HIV scene start to think about highly efficient modes of transmission, as opposed to the low efficiency of most types of sexual behavior, ordinary academics, epidemiologists and others may eventually be allowed to research and publish data that currently appears to be deprecated (to put it mildly).

Those with the money, however they managed to get hold of it, decide how that money should be spent. There's little point in waving a lot of drug addicts in front of donors if those donors are opposed to working with drug addiction. With such restrictions lifted, who knows, drug addiction, and therefore HIV transmission among IDUs (and those they associate with), may turn out to be more common than previously assumed.

Perhaps donors and governments will eventually revise their attitude towards commercial sex work, especially in view of its interconnections with drug use. This could even lead to questions about exactly how much sex has to do with HIV when the far more likely transmitter is non-sexual.

And, it's a long shot, but if the HIV industry is willing to accept that some HIV is transmitted non-sexually, even among people who are said to have a lot of 'unsafe' sex, they may even wonder if ordinary people engaging in ordinary amounts of 'safe' sex are being infected non-sexually too.

Drug users are not the only people who use injecting equipment. More disturbingly, they are not the only people reusing injecting equipment. Some people get a lot of injections, because they are sick, pregnant, an infant, a sex worker, whatever. And in populations with high HIV prevalence, all of those people are at heightened risk of being infected with HIV, non-sexually.

Maybe we’ll live to see the day when sex is viewed once again as an aspect of health and life rather than as a spreader of disease. But first, we have to accept that poor health care can be a significant source of disease. Harm reduction programs, now that health care professionals and governments are allowed to talk about them again, need to start in health facilities.

You're Promiscuous, But in the most Non-Pejorative Sense Possible

Since mentioning the Vienna Declaration (on drug policy) yesterday, I have heard that Kenya is one of the countries that 'may' be funded to supply intravenous drug users with sterile injection equipment. The Declaration objects to current policy in many countries, which criminalizes intravenous drug use and does not permit 'harm reduction' programmes, such as injection equipment exchange.

For many years it has been known that harm reduction programs can help reduce a social problem such as intravenous drug use. These programs can also play a part in reducing transmission of viruses such as HIV and hepatitis. Despite the evidence, a lot of governments of countries with high levels of intravenous drug use refuse to allow harm reduction programs, some as a result of HIV funders banning this particular use of funds. These funders argue that distributing sterile injection equipment will give rise to increased intravenous drug use, although this has been shown to be untrue.

One of the biggest sources of HIV prevention funding is the US's PEPFAR Program (President's Emergency Plan for Aids Relief). This fund has been criticized since it began for having various clauses banning certain types of program, including supply of sterile equipment to intravenous drug users. Even when PEPFAR didn't specifically ban measures, things perceived to be deprecated were often avoided for fear of losing funding. Now, apparently, PEPFAR has relaxed some of its conditions. Let's hope perceptions also relax.

According to NASCOP (Kenya's National Aids Control Program) head, Dr Nicholas Muraguri, needle sharing is second only to blood transfusion when it comes to HIV transmission efficiency. Intravenous drug use with contaminated equipment is estimated to account for 3.8% of new HIV infections a year. Reducing this risk with an injection equipment exchange program could prevent hundreds of new infections every year. However, intravenous drug users are worried that police will still harass them, especially if they find them with injecting equipment.

But it is highly significant that Dr Muraguri acknowledges that injection equipment sharing is an important mode of HIV transmission. The WHO estimates that around 17% of HIV infections in Africa are due to unsafe injections. That's injections in healthcare settings, not injections relating to intravenous drug use. It's not just injections that can spread HIV, either. All sorts of medical procedures can carry a risk if adequate precautions are not taken to ensure blood safety and sterile conditions. I hope Dr Muraguri will get behind a program that takes measures to reduce medical transmission, given how efficient a transmitter of HIV it is.

Adding together injection safety for intravenous drug users and medical safety, this may account for around 30% of all HIV transmission. Almost all current HIV prevention programs in African countries assume that HIV is mainly transmitted sexually. However, changing sexual behavior will have no impact on non-sexual HIV transmission (sounds obvious, but try telling UNAIDS) and some programs, such as mass male circumcision, could increase non-sexual transmission.

It's time to move away from the rather atavistic attitude that people with HIV must have done something bad and should be punished accordingly. The effect of this attitude has been to punish people who are vulnerable, such as women, children or poor people, or who are already persecuted and discriminated against, such as intravenous drug users, men who have sex with men and sex workers. This sort of atavism has resulted in HIV continuing to spread, even in countries that have the wherewithal to avoid a serious epidemic. And it continues to be a barrier to reducing transmission in countries with serious epidemics.

But if you insist that most HIV in Africa is transmitted sexually, as the HIV industry does, you are thereby branding Africans as sexually promiscuous if they are found to be HIV positive. If you insist that Africans tend to be sexually promiscuous, it is pointless to then call for stigmatization of HIV positive people to be avoided, as the HIV industry does. Equating a HIV positive diagnosis with sexual promiscuity is what gives rise to HIV positive people being stigmatized.

People Need Protection from Harm, Not Punishment for Being Harmed

It has been revealed at a conference in Nairobi that 60% of all new sexually transmitted infections, including HIV, occur in those aged 15-24. These are the very people who should have received, and should still be receiving in the case of those in their mid teens, the latest HIV prevention programming. The authors of the report even suggest that there may be significant under-reporting of risky sexual behaviour.

The report calls for a 'more aggressive' educational approach, whatever that may mean. In a separate article on back street abortions in Kenya, there are some worrying remarks on sex education. Aside from concentrating on abstinence, often to the exclusion of anything else, teachers who are trained in teaching sex education are under no obligation to teach it. There is no specific time set aside for them to do so and many parents would prefer teachers not to teach their children anything about sex.

Kenya has spent over 20 years resisting the call to teach their children and adults about sex, safe sex, family planning, maternal health and health in general. In particular, they have resisted advice to promote the use of condoms to prevent HIV, other sexually transmitted infections and unplanned pregnancies. The multiple uses of condoms need to be stressed.

The repeated calls for abstinence, however dressed up in pointless slogans, are useless. Years of sexual transmission of HIV, other sexually transmitted infections and unplanned pregnancies show that these 'prevention' programmes have not worked. Unfortunately, the latest National Aids Strategic Plan has little new to suggest to prevent HIV from being transmitted and it still only allocates about 30% of HIV/Aids funding to prevention. But no amount of money will make a difference if abstinence is the best they can come up with.

Countries with high rates of HIV transmission seem to be obsessed with abstinence campaigns, which have had no impact and will continue to have no impact. Telling young people that it is worth their while waiting till they are married is simply lying in the face of evidence that many people become infected by their spouse. They need to be told about the dangers they face and given ways to avoid those dangers. If condom use is the best we've got right now, we owe it to people to promote the use of condoms.

Those who object to abortion, HIV, sexually transmitted infections, promiscuous sex, unsafe sex, sexual abuse and various other things that they rail about need to embrace comprehensive sex education for everyone, young and old. Denying the existence of risky practices, commercial sex work, men having sex with men, intravenous drug use and the rest is not going to make it go away. Moralising about it and saying how bad it all is will not make it go away either.

It's very hard to legislate over people's sexual behaviour. And even behaviour that is illegal will occur, despite the threat of punishment. The least the Kenyan government can do is to reduce the amount of harm people are currently being exposed to. Many Kenyans are now experiencing the consequences of not implementing harm reduction programmes, such as the widespread promotion of condoms, decriminalisation of commercial sex work and same sex relationships, needle exchange programmes and even family planning services that would support people who end up pregnant against their wishes. People need to be protected from harm, not punished for being harmed.