Harm reduction

1. Welcome to I-TECH India
National Distance Learning Seminar Series
Date: 14-Aug-2019
Time: 2 PM - 3 PM
Title: Transforming lives and empowering communities: Harm
reduction a holistic approach to people who use drugs
Speaker: Mr. G. Charanjit Sharma
Technical Advisor: Drug Use & Harm Reduction, Alliance India

3. India - Drug use and Harm Reduction - National Response to HIV
(WHO recommended comprehensive package of health services for people who use drugs*)
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Particular
Size estimation for PWID
177000 (2009-10 revalidation exercise of NACO)
(10,000 – 30,000 FIDU/WUD)
850000 (MoSJE - conducted by NDDTC, AIIMS - 2019)
HIV prevalence
9.9% (IBBS 2014-15)
6.26% ( HSS 2016-17)
Profile of PWID
The median age of respondents was 30 years nationally and ranged between 24 and 35 years across
different states.
Nationally, 42% of IDUs reported they were currently married and 48% unmarried
Prédominant Drug use pattern
etc.
Most of the states had similar pattern of age at initiation of injecting drug use, with IDUs in the 18-21 year
age group being the predominant age for initiation into injecting drug use.
Injecting Practices: The median number of times drugs were injected, on last injecting day, was 2 times;
around two thirds of IDUs had injected once or twice and close to one fourth (24%) injected three times or
more times on the last day they injected.
Nationally 15% of IDUs had shared needles / syringes at the time of last injecting episode and 20% had
shared needle/syringes in last 3 months

4. India - Drug use and Harm Reduction
National Response to HIV
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Coverage of the Existing Harm Reduction programs and interventions in India
Total number of sites where needles and syringes services are available
529 TI sites (247 exclusive and remaining core
composite)
Number of syringes distributed per person who injects drugs per year by needle and
syringe program
212
Program coverage of NSP at the national level 1,30,800
Percentage of people who inject drugs reporting using sterile injecting equipment the
last time they injected
85.5% of PWID (MTR 2016)
Number of people who inject drugs receiving opioid substitution therapy 23,077
Percentage of Individuals receiving maintenance OST continuously for at least 6 months 62% of 23,077
Number of sites providing OST services (Buprenorphine) 212
Number of sites providing OST services (Methadone) 15+
Percentage of PWID ever tested for HIV 57.2% of 1.8 lakhs ((MTR 2016)

5. • Adopted by NACO towards prevention of HIV among PWID population in India
during NACP Phase IV
– Targeted Intervention (TI) programme service component for PWID:
1. Community led outreach services to Male & Female IDU
2. Drop in centre
3. OST (Buprenorphine)
4. BCC/IEC
5. NSEP
6. Condoms
7. Static clinic providing STI/abscess management
8. Community mobilisation
9. Referrals to HIV services
# OD initiated in Manipur, soon to be in other NE states, Delhi)
# OST (Methadone in 15 government hospital across India.
National Harm Reduction Strategy

6. WHAT IS ‘HARM REDUCTION’?
Policies and programmes that are aimed at
reducing the harms from drugs but drug use per
se
Reducing harms from drugs more important that
reducing drug consumption
More effective as it seeks to achieve realistic
objectives – 80% of something is better than
100% of nothing

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HARM REDUCTION: KEY CONCEPTS
• Some drug use in society is normal; reduce the immediate
harms
A Practical Approach
• Let us reduce harms not necessarily the drug use
Focus on Harms, not drug use
• Let us set immediate and realizable goals, though
eventual goal may be abstinence
Prioritization: Deal with more severe harms first
• Each drug user is different; let us provide a range of
options
Flexibility; Maximum options
• Let us respect the drug user's decision and choice
Autonomy

8. PRINCIPLES OF HARM REDUCTION
• The intrinsic value and dignity of human
beings
Recognizes
• Maximize social and health assistance
• Minimize repressive and penalizing measures
Seeks to
• Drugs and drug use as good or bad, rather it
emphasizes the reduction of drug-related harm
Does not judge
• Safer drug use
Encourages
• Competency of users to make choices and
change their lives
Recognizes the
• Conventional drug policies and their
consequences
Challenges

9. HARM REDUCTION FOR HIV PREVENTION
 Harm reduction is a framework in which effective HIV
prevention can be carried out for IDUs and their sexual
partners.
 The focus of harm reduction strategies remains on
immediate and easily preventable harms rather than on
setting unrealistic goals such as complete abstinence.
 Harm reduction aims to prevent the transmission of HIV
by reducing the harm associated with high risk
behaviours such as sharing needles, syringes and other
equipment for preparing and injecting drugs, and unsafe
sexual behaviours.
 Harm reduction is not limited to HIV prevention alone.
 Other interventions such a abscess prevention, safer

10. HARM REDUCTION STRATEGIES
in national program

11. METHODS TO REDUCE DRUG-RELATED
HARMS
Educational Interventions
• How to reduce risk
• Safer methods of drug use
Needle syringe exchange programmes
Opioid Substitution Therapy e.g. methadone, buprenorphine
Peer based information on safer injecting and safer sex practices (including
condom demonstration and safer injecting practice demonstration
This entire package = ‘Harm Reduction’

12. VARIOUS HARM REDUCTION
STRATEGIES
 Needle Syringe Exchange Programme
 Agonist Substitution Treatment
 Other Strategies
 Outreach Services
 Safe Injection Facility
 Drop-In Centres

13. NEEDLE SYRINGE EXCHANGE
PROGRAMMES

14. FEATURES OF NSEP
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More readily associated with the harm reduction
approach than any other type of intervention
Involves supplying new, clean needles and syringes to
IDUs, in exchange of old used, needles and syringes.
Incorporate a variety of other preventive strategies
such as outreach, risk reduction education, referrals to
other health and social services, etc.

15. • Unclean
• Infected
• Previously
used by
others
• Risk of HIV
transmission
• Clean
• Uninfected
• For use by
client only
(expected)
• No risk of
HIV
transmission
PHILOSOPHY OF NSEP

16. OPIOID SUBSTITUTION TREATMENT

17. PHILOSOPHY OF AGONIST
SUBSTITUTION
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18. BENEFITS AND LIMITATIONS
Benefits
• Reduces drug consumption, promotes abstinence
• Reduces risky behaviours, risk of HIV transmission
• Reductions in lethal overdose – decrease use and high
tolerance
• Reductions in sex work
• Reduction in crime
Limitations
• Patient still chemically dependent on opioids
• Limited availability, due to cost and logistic reasons
• Risk of diversion to unregistered drug users

19. 1. OUTREACH SERVICES
2. SAFE INJECTION FACILITY
3. DROP-IN CENTRES
OTHER STRATEGIES

20. OUTREACH SERVICES
 Reaches out to hidden drug users
 Within own communities, closer home
Finding drug users
Observing them
Establishing contact and rapport with
them in their natural environments
Providing information about risk
behaviours
Promoting and supporting safe
behaviours

21. SAFE INJECTION FACILITY
 Also known as ‘injection rooms’
 Provides not only clean syringes or needles, but a
safe injection facility
 Provides opportunity to IDUs to inject pre-obtained
illicit drugs under the supervision of and/or by the
medical staff
Controversial strategy, used in few
countries till date

22. DROP-IN CENTRE (DIC)
 Also known as DIC
 Provides clean Needles and Syringes (N/S)
 Collects used N/S from IDUs for disposal
 Is a safe ‘hang-out’ for recreational purposes
 Provides risk reduction education
 Provides abscess identification and treatment
services
Other Services
• Overdose management
• Condom distribution
• Referral for medical complications
• STI treatment and other general illness

23. Drugs: The Vicious Cycle
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Presence makes you
feel good… (euphoria)
Absence makes you
feel miserable… (withdrawal)
Contd…

24. Taking drugs…
NOT
Taking drugs…
..makes one
feel good… (euphoria)
likely that one
will continue..
..makes one
feel miserable… (withdrawal)
..to avoid which one
will continue..
Drugs: The Vicious Cycle
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25. CONCLUSIONS
Harms associated with drug use can be dealt with in a number
of ways
Harm reduction strategy provides the most practical and
flexible approach to reduce these harms
Focus is on immediate and easily preventable harms rather
than setting unrealistic goals such as complete abstinence
NSEPs and Agonist substitution treatment are the most
common and effective strategies
Combination of strategies and individualization of intervention
are important aspects of a harm reduction approach

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