Pol­icy must recog­nise link be­tween drugs and de­vel­op­ment

The Weekend Australian - Travel - - Health -

THE no­tion of har­mon­is­ing re­gional drug pol­icy to in­te­grate drug de­mand, sup­ply and harm re­duc­tion ap­proaches is piv­otal to eco­nomic sta­bil­ity and growth within the Asia-Pa­cific re­gion. While many coun­tries have de­vel­oped na­tional drug plans, the op­por­tu­nity to dis­cuss the link­age be­tween this pol­icy of gov­ern­ment and eco­nomic de­vel­op­ment has been over­looked.

How­ever, the dis­cus­sion is im­por­tant to avert the po­ten­tial threat of gov­ern­ments im­ple­ment­ing harsher pol­icy re­forms through a mis­guided be­lief that puni­tive le­gal sanc­tions against drug users will aid de­vel­op­ment.

The links be­tween drugs and de­vel­op­ment, par­tic­u­larly poverty era­di­a­tion, are clear. While the quan­tifi­ca­tion of the size of eco­nomic im­pacts of sub­stance use in the re­gion is not as clear, this is work that could and should be un­der­taken to im­prove gov­ern­ment sup­port for broad­en­ing the re­sponse to sub­stance use.

Harm re­duc­tion has been in­tro­duced suc­cess­fully into the re­gion be­cause it was, and still is, right­fully per­ceived as an emer­gency re­sponse to an HIV cri­sis. How­ever this should not be the end of the story, but rather the first plank of a suc­cess­ful re­sponse which then in­cor­po­rates drug de­mand and sup­ply re­duc­tion ap­proaches. This will al­low links into an eco­nomic and so­cial de­vel­op­ment agenda which pro­vides sus­tain­able and mean­ing­ful ca­pac­ity-build­ing re­sponses to prob­lems caused by sub­stance mis­use.

Aus­tralia has shown a lead­er­ship role in the re­gion on HIV. This is a role we can be proud of; how­ever, there is ca­pac­ity to work more with in­ter­na­tional agen­cies such as the United Na­tions and the World Health Or­gan­i­sa­tion to en­sure we de­velop lo­cal in­sti­tu­tional ca­pac­ity to ad­dress drug use is­sues be­yond HIV in the re­gion. Mov­ing be­yond pilot stud­ies is crit­i­cal and re­quires com­mit­ment.

The Aus­tralian Gov­ern­ment’s an­nounce­ment of $1 bil­lion to be spent on HIV/AIDS by 2010 recog­nised the im­por­tance of work­ing with the gov­ern­ments of China, In­done­sia, In­dia, Pa­pua New Guinea, the Philip­pines and Viet­nam. All of th­ese coun­tries are im­por­tant to mov­ing HIV pre­ven­tion for­ward. Other key coun­tries that need to be in­volved are Myan­mar and Cam­bo­dia. As for Thai­land, In­dia and Viet­nam, th­ese coun­tries have had spikes in HIV, which rep­re­sents a real threat to the eco­nomic pros­per­ity of those coun­tries.

In many parts of Asia, HIV epi­demics have been largely driven by in­jec­tion drug use. HIV rates of greater than 40 per cent among in­ject­ing drug users have been recorded in many coun­tries, in­clud­ing In­done­sia, Malaysia, Myan­mar, Thai­land, and Viet­nam. Given that HIV trans­mis­sion has firmly taken root in many parts of Asia through in­ject­ing drug use, it is no sur­prise that in­ject­ing drug users ac­count for a large num­ber of those in­fected.

In In­done­sia, for ex­am­ple, 51 per cent of all newly re­ported HIV in­fec­tions up to March 2006 oc­curred among in­jec­tors, while in China, it is es­ti­mated that over half of new HIV in­fec­tions are oc­cur­ring among the coun­try’s es­ti­mated 1.14 mil­lion reg­is­tered drug users. In Malaysia up to De­cem­ber 2006, users ac­counted for 65 per cent of re­ported HIV cases.

In re­sponse to the es­ca­lat­ing epi­demic, sev­eral coun­tries in the re­gion have re­cently em­barked on harm re­duc­tion ef­forts for in­ject­ing drug users that in­clude opi­ate sub­sti­tu­tion ther­apy, such as methadone pro­grams. How­ever, in Asia, in­ad­e­quate health in­fra­struc­ture and a lack of peo­ple with rel­e­vant skills and train­ing to pro­vide ad­dic­tion treat­ment are a ma­jor ob­sta­cle to ac­cess­ing ther­apy.

The health ex­pen­di­ture as a pro­por­tion of GDP is telling. Myan­mar, for in­stance, only spends 2.2 per cent of its GDP on health care, which equates to $A6 per per­son. In­deed, health care ac­counts for just un­der 13 per cent of to­tal gov­ern­ment ex­pen­di­ture. By con­trast, Aus­tralia ex­pends 8.8 per cent of GDP, which equates to just un­der $4000 per per­son, or 67 per cent of to­tal gov­ern­ment ex­pen­di­ture.

De­spite the re­cent global ini­tia­tive that has in­creased the num­ber of peo­ple re­ceiv­ing HIV an­tiretro­vi­ral ther­apy in the re­gion, in­ject­ing drug users re­main dis­pro­por­tion­ately less likely to have ac­cess to th­ese med­i­ca­tions. Some of the ma­jor ob­sta­cles to ac­cess in­clude le­gal poli­cies around drug use, in­ad­e­quate health in­fra­struc­ture, and the per­va­sive stigma and dis­crim­i­na­tion as­so­ci­ated with HIV. Ad­e­quate train­ing needs to also be pro­vided about the pos­si­ble in­ter­ac­tions be­tween opi­ate sub­sti­tu­tion treat­ment, HIV treat­ments and other drugs fre­quently used by in­jec­tors.

In­te­grated treat­ment for sub­stance abuse, gen­eral med­i­cal care, HIV and psy­chi­atric treat­ment and psy­choso­cial sup­port is a model of care that should be ex­ten­sively de­vel­oped in the re­gion. Mod­els of care that need fur­ther in­ves­ti­ga­tion in­clude com­mu­nity based opi­ate sub­sti­tu­tion ther­apy. Al­ter­na­tively, in­te­grat­ing drug ad­dic­tion treat­ment into ex­ist­ing pri­mary health care fa­cil­i­ties along with HIV treat­ment and other in­fec­tious dis­ease treat­ment may pro­vide a one-stop cen­tre that could sub­stan­tially im­prove HIV pre­ven­tion and treat­ment ef­forts.

A ma­jor po­ten­tial bur­den of harm in the com­mu­nity is the un­der-recog­nised prob­lem of sub­stance use and harms as­so­ci­ated with women, which is a hu­man rights is­sue. They are a marginalised stig­ma­tised group who rarely finds op­por­tu­ni­ties for ef­fec­tive in­ter- ven­tions that are cul­tur­ally spe­cific and gen­der ap­pro­pri­ate for their needs. Fi­nally, scal­ing up opi­ate sub­sti­tu­tion treat­ment must be ac­com­pa­nied by a com­mit­ment to im­prove so­cial sup­port ser­vices, in or­der to help in­te­grate peo­ple back into so­ci­ety through job train­ing and place­ments. Build­ing the ca­pac­ity of health care pro­fes­sion­als alone will not be ad­e­quate. Peer sup­port, pa­tient ad­vo­cacy, case man­age­ment and so­cial ser­vices are other cru­cial ser­vices that must be de­vel­oped for a com­pre­hen­sive and suc­cess­ful man­age­ment of drug users. One op­por­tu­nity that has also been missed is a mech­a­nism for fam­i­lies to make a con­tri­bu­tion to the ef­fec­tive im­ple­men­ta­tion of safe and ef­fec­tive drug treat­ment pro­grams.

This sub­stan­tial re­source has been un­der­utilised in the Asian re­gion and could prove of ben­e­fit for both com­pli­ance and treat­ment for drug ad­dic­tion treat­ment as well as HIV pre­ven­tion, treat­ment and care. As­so­ci­ate Pro­fes­sor Robert Ali is an ex­ec­u­tive mem­ber of the Aus­tralian Na­tional Coun­cil on Drugs and chair­man of its Asia Pa­cific Drug Is­sues com­mit­tee

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