Punitive laws block access to health services for injecting drug users

The XIX International AIDS Conference (AIDS 2012) reminds us how punitive laws and criminalizing policies keep most affected communities disengaged. Due to the policy block in US, sex workers and injecting drug users (IDUs) weren't able to participate in AIDS 2012 from around the world. In their own countries, IDUs are struggling as well with policies that criminalize drug use and drive populations underground. There are an estimated 16 million Injecting Drug Users (IDUs) in 151 countries, and they are very often unable to access HIV and TB related services due to punitive policies and discriminatory attitudes. Many of them are infected with the Hepatitis C Virus (HCV) as well. 

As many as 60 countries report a prevalence rate of over 20% of HCV. In many settings HCV rates are higher than HIV rates in IDUs. In India, HCV is a major problem amongst IDUs in the North east Region, as also in countries of Central Asia and Eastern Europe.

According to Dr Chris Beyrer from Johns Hopkins University, “Drug use and drug policies are driving this population underground. A triple combination approach of (i) optimizing efficacy, (ii) having needle exchange coverage and (iii) opioid substitution therapy can save lives. With drug users having access to all the three elements in a safe environment we can tackle the dual problem of HIV-- HCV co-infection. Unfortunately this is not a reality in the real world. IDUs are often excluded from treatment due to presence of HCV and a variety of other reasons. An incredibly low proportion of IDUs are on substitution therapy. Out of the 1.8 million IDUs in Russia no one is on opioid substitution therapy as it is illegal there. China has 2.2 million IDUs but only 100,000 on substitution Therapy. Many IDUs are kept in state supported detention centres.”

Dr Beyrer shared the horrific experiences of a drug user Li Wei, who spent time in one of the detox centres in China. This is what Li had to say—‘Since the day I was sent there I was never given any medicines. I had to work for 16 hours a day and beaten and treated with violence. It was dubbed rehabilitation through labour but I never felt I was being rehabilitated. The only thing I felt was punishment and I believe that everyone else there felt the same. Detention is not treatment.’  

Giten Khwairakpam, Project Manager, Community and Policy, TREAT Asia/amfAR - The American Foundation for AIDS Research, also voices similar concerns. “If I go to a place where the medical government services are supposed to be provided to protect me from HIV or a blood borne infection and if I know that I will be caught, detained and beaten there, I will never come to that health care centre to get the things I am supposed to get that will protect me, my family, my friends and my peers from getting HIV or HBV or HCV or any other blood borne infection. So we have to create that environment and we have to ask from the law enforcers, police and the narcotics bureau that harm reduction facility is being provided. It is not about promotion of drug usage and it is not a point from where drug peddling is being conducted but it should be considered as a point where public health services are being provided for prevention from blood borne infection which the government has to prevent at a larger scale. Criminalization is not about a big thing but about a small thing where a person’s right to public health is basically addressed and protected.” 

The World Health Organization lists HCV as a major cause of acute hepatitis and chronic liver disease. Globally, 160 million persons are infected with HCV. Various blood bank studies indicate that an estimated 1% (12 million) of the Indian population is affected with this virus. But in the absence of proper data this could be an under estimate, especially where the number of IDUs is concerned, 80% of who reportedly suffer from HCV in India. There has to be some surveillance system through the delivery points of HIV treatment which can enable us to know the extent of the HCV epidemic. It would make sense to use the HIV mechanism to test for HCV, and vaccinate against HBV. Unless efforts are made to provide treatment for HCV, the gains made by putting PLHIV on Anti Retroviral Therapy will be greatly diluted. The key barriers, for those who need treatment for HCV (including the PLHIV and IDUs) but are currently unable to avail of it, include lack of knowledge about HCV, insufficient harm reduction services for IDUs, no clear action plan, inconsistent treatment protocols and of course, the high costs (around Rs 300,000 in India) of the treatment. Besides, the treatment is very long and fraught with many adverse effects—fever, haemoglobin drop, anaemia, WBC count fall, and depression. 

So what is the way out? Professor (Dr) Gourdas Choudhuri, former Head of the Gastro-enterelogy Department of Sanjay Gandhi Post Graduate Institute of Medical Sciences (SGPGIMS), Lucknow, feels that, ‘We need to create a lot of awareness about the disease as most people are unaware of it. High risk individuals must go for diagnosis much before symptoms appear. Manufacture of low cost generic medicines can also help. But the only issue is that while generics are well established for chemical compounds, where efficacy can be tested, HCV drugs have to be tested in terms of bio efficacy too, and not just by way of chemical structures. So there will need to be a little more reassurance from companies launching generic interferons about their effectiveness. Last, but not the least, there should be good hospital practices, more stringent testing for HCV in blood banks, use of disposable syringes/needles which are not reused, and very good management/control of intravenous drug use.”

"The 2012 Pipeline Report: HIV, HCV, and TB Drugs, Diagnostics, Vaccines, and Preventive Technologies in Development" which was released at the just concluded AIDS 2012 by HIV i-Base, a London-based HIV treatment activist organization, and Treatment Action Group (TAG) reveals the deepening gulf between new scientific advances that make it possible to prevent, treat, and in some cases cure people living with HIV, HCV, and TB and also provides an overview of the developments in HCV combination therapy and cure. Authors of the report, Tracy Swan and Karyn Kaplan caution that currently infrastructure and reimbursement mechanisms to cover treatment and care costs for people with HCV are lacking almost everywhere, and must be rapidly expanded to treat and cure the millions who are living with the HCV.

Shobha Shukla - CNS
(The author is the Managing Editor of Citizen News Service (CNS). She is a J2J Fellow of National Press Foundation (NPF) USA. She is supported by the Lilly MDR-TB Partnership to report on-site on TB related issues from XIX International AIDS Conference (AIDS 2012). She has worked earlier with State Planning Institute, UP and taught physics at India's prestigious Loreto Convent. She also authored a book on childhood TB (2012), co-authored a book (translated in three languages) "Voices from the field on childhood pneumonia" and a report on Hepatitis C and HIV treatment access issues in 2011. Email: shobha@citizen-news.org, website: http://www.citizen-news.org)