Toespraak aidsambassadeur bij the First Asian Consultation on the Prevention of HIV related to Drug Use (Engels)
Gelegenheid: First Asian Consultation on the Prevention of HIV related to Drug UseHon. Ministers, Excellencies, Members of Parlement,
I would like to talk to you about the need to reach vulnerable groups. Because they are human beings entitled to human rights and because it is a matter of public health. I will try to show that successes can be achieved through the right interventions, including the active involvement of vulnerable groups. I will argue that harm reduction is a good and valid strategy, but that it only works is applied in a good legal environment. Finally, I will talk about the situation in my own country, the Netherlands.
I am honoured to be part of this First Asian Consultation on the Prevention of HIV related to Drug Use. This consultation creates an opportunity for empowerment of present and future leaders: politicians, professionals, policy makers and activists. I am confident that our work during these days will contribute to stronger leadership and greater commitment to balanced and evidence-based policy-making ass well as to feasible and sustained solutions. Let me therefore extend my sincere compliments to the organizers of this important meeting: the Asian Consortium on Drug Use, HIV, AIDS and Poverty.
The subject of this meeting is not an easy one; it is sensitive, difficult, it relates to moral views and it is political. As Dr. Peter Piot, executive director of UNAIDS, once told me: “Sex is a difficult subject but drugs is even more.”
We have a shared responsibility to book results and therefore of the need to constantly rethink what to do and how to do it. As Gary Lewis argued yesterday, “we know what to do; we need to deliver a comprehensive prevention package of services”.
We are united here in the desire to learn from each other and to join forces in the fight against poverty, disease and preventable death. Let us be careful and not allow the debate about what works and what doesn’t to end in deadlock as a result of convictions about what is deemed morally desirable. Of course, we all have our moral beliefs and convictions. I do. That is what makes us human! But let’s look beyond that and let us instead be guided by evidence. The opportunity cost of the failure to act now and to act effectively is counted in human lives!
The theme of this consultation could not have been chosen better: the prevention of HIV related to drug use in the context of poverty. The links between poverty, exclusion, widening inequalities and drug use are well known. I quote Dr. Margaret Chan, the Director General of the WHO, who said that “Our greatest concern must always rest with disadvantaged and vulnerable groups. These groups are often hidden, live in remote rural areas or shanty towns and have little political voice.’
And Dr. Chan is very right. The big problem is that these groups, these people lack access to services, to information, to counselling and to sexual health services.
In spite of hugely increased efforts, worldwide still between 55 and 80% of injecting drugs, share syringes. According to UNAIDS, in this region, only 1% of men who have sex with men have access to prevention services, only 8% of injecting drug users, and less than 20% of sex workers are able to access sexual health services, preventive methods, information on how to protect themselves etc.
These statistics are alarming, ladies and gentlemen, because together, drug injecting and HIV/AIDS and other infectious diseases form an explosive combination. The consequences are disastrous, not only for drug users themselves but also for their sexual partners, their children and the wider community. Therefore the failure to attend to the needs of marginalized groups is a violation of their dignity and their human rights and it will not prevent the spread of the HIV epidemic to the general public.
Successes
But there is good news also. There are successes to report. Successes from which we can learn.
In spite of daunting challenges, countries throughout the world have expanded access to life-saving interventions, among which harm reduction and HIV treatment. Faced with problems on the ground, faced with reality these countries acted, based on available evidence, and with success.
Allow me to give some examples here in Asia
Vietnam has recently adopted its national harm reduction action program.
Iran — The hon. Minister and his delegation will confirm that home to an estimated 137,000 injecting drug users, one in four of whom may be HIV-infected —has established a network of clinics to provide comprehensive HIV preven¬tion, treatment, and care to injection drug users. HIV clinics were operating in one-third of all prisons in Iran by the end of 2006, and methadone substitution therapy was reaching 55% of all prisoners in need.
Other accounts of successful interventions come from Pakistan.
Bangladesh and other countries of the region. Mr Zafar mentioned some.
Vulnerable groups
The key to success in all these cases is the fact that all these programs target the needs of specific vulnerable groups, be they injecting drug users, commercial sex workers, children living in the streets, prison inmates, men who have sex with men, transgenders or mobile and migrant workers. In order for these approaches to become sustainable however, they need the protective umbrella of the law.
And here we touch upon another problem: Usually out of a justifiable motivation to protect their citizens, governments apply restrictive legislation. The problem is they leave it at that, with the result that –perhaps unwillingly- they have created an environment that con¬dones discrimination against drug users and other populations most vulner¬able to HIV. The preference for law enforcement over public health approaches in addressing drug use, discourages utilization of services, and makes such programs vulnerable to official harass¬ ment or closure.
Some examples:
According to UNAIDS 45% of countries have laws on books that deal with the delivery of prevention services to marginalized popula¬tions. Where needle possession is against the law, individuals run the risk of arrest merely by participat¬ing in a needle-exchange project. Similarly, both sex work and sex between men are criminalized throughout much of the world, complicating efforts to deliver life-saving HIV prevention services.
Another example:
Although most countries have developed written HIV prevention poli¬cies for correctional institutions, experts in the field report that, in practice, few prison inmates have access to proven prevention strategies such as condoms and safe injecting equipment. As a result, as you are aware HIV infection rates are much higher among pris¬oners than in the general population.
So, a mere concentration on repressive legislation alone leads to a situation in which populations at higher risk for HIV exposure are invisible, even to HIV prevention planners and that is exactly what we all tried to prevent.
One more remark on vulnerable groups, if I may, members of vulnerable populations tend to be viewed as passive beneficiaries of our interventions. In order for these interventions to succeed however, we should see our target groups as a pool of human resources and involve them in program planning, delivery and monitoring. That isn’t easy, as drug users are not the easiest people to deal with, depending on how they cope with their addiction. Outreach and peer-based services have proven especially effective in reaching marginalized groups, as many present here in the audience will confirm. Outreach work may be done by professionals and volunteers but the involvement of peers is of critical value to build a relation of trust with the target groups. Their aim and motivation is to stand beside the people in need, and to help them to seek solutions to their problems, rather than deciding behind their desks what is best for them. This is a pragmatic approach based on acceptance of drug-taking as a social reality. The goal is to prevent any further marginalisation and to encourage social integration. NGOs are particularly well placed to do this kind of work and to facilitate collaboration among the different sectors involved.
Netherlands policy
Hon. Minister Excellencies, ladies and gentlemen, allow me to now turn to the approach the Netherlands adopted to contain what we -back in the 1980s when AIDS hit the community of drug users in our cities- saw as an imminent disaster. At that time, alarmist articles in the media called for repressive measures against drug users, a reflex inspired by fear and moral condemnation. Since that time, we have learnt a lot about responding effectively to drug-related problems.
Some background; like everyone else we distinguish between the simple economics, the supply side and the demand side.
The fight against the supply side is a continuous national concern. In the case of the Netherlands, this struggle is complicated by the fact that our economy depends mainly on trade and transport; with one of the largest seaports in the world (Rotterdam) and the airport of Amsterdam which handles close to 50 million travellers per year, our country is very vulnerable to supply of drugs. We have had to accept that a drug-free society is not a realistic option for a quite a while to come. In spite of our efforts, drugs continue to come into the country.
On the demand side, our answer is a pragmatic and flexible policy in which the leading perspective is health. Consequently, the law makes a distinction between hard drugs and soft drugs, that is to say, between acceptable and unacceptable health risks.
Following international conventions, using drugs is not a criminal offence under Dutch law.
Possession of cannabis (up to 30 grams) is treated as a misdemeanour, not as a criminal offence. By allowing the use of soft drugs, our policy aims to separate the markets for soft and hard drugs, thereby diminishing the chances that cannabis users are approached by dealers in illegal hard drugs.
In the Netherlands we have developed a policy that is based on the following 3 principles: (1) prevention – preventing people, especially kids from taking drugs – takes priority; (2) treatment of drug users is geared towards getting them off their habit; (3) acknowledge that this cannot be done overnight and meanwhile alleviating the harmful effects of injecting drug use. It is important to limit the associated risks in the interest of the individual drug user and of public health. Those are the 3 principles that form the basis of our policy.
In addition to sustained prevention campaigns this harm reduction policy is continuously being adapted to changing circumstances. Already in the 1960s we started substitution treatment with methadone. Since the 1970s, a number of city councils have established user rooms for injecting drug users. Needle exchange programs are in place since the early 1980s, heroin treatment since the late 1990s and cour-ordered compulsory treatment of addicted offenders since the year 2000.
Treatment provided by authorized addiction care centres is part of our health care system and paid for by public health insurance. The local government is responsible for social care like resettlement, drug consumption rooms and day shelters with the budget made available by the national government.
Where has this brought us: Let facts and figures speak for themselves. Evidence shows that the Netherlands are way more successful than countries with a restrictive policy on drugs. Contrary to general belief the Netherlands had the lowest prevalence of problematic hard drug use in all of the European Union.
Instead of being treated as criminals, drug users in the Netherlands are seen as individuals who have a right to care and treatment. This resulted in a drop in HIV infections among this group from 180 new diagnoses in 2002 to 30 in 2005. A drop of 600%.
The lessons that we have learned and that we like to share with others are:
1. However much we invest in fighting drugs, a completely drugs-free society is an illusion.
2. The drug problem is dynamic and therefore requires a flexible and pragmatic policy. Interventions have to be designed and tested in response to concrete problems. An innovative attitude is important.
Our approach is not a panacea, nor do we pretend to have the ideal policy. However, the facts speak for themselves and I believe that it can be adapted to a diversity of contexts, societies andd cultures. And it is clear that effective interventions save lives and protect public health!
One of our Ministers recently said that “The scientific discussion has been concluded years ago; unfortunately the political discussion still goes on”. This ongoing discussion is not always informed by scientific findings; unfortunately some countries feel the need to resort to unorthodox methods.
Ladies and gentlemen, I will conclude, as an individual country, a member of the European Union and of the United Nations we work to broaden the acceptance of evidence-based policies and programs throughout the world. We are convinced that this can not be achieved without a clear division of labour and an unambiguous harmonisation of policies. It is our goal to promote equal access to prevention, support, treatment and care for all people who use drugs. Indeed, universal access for all people who need it. It is our ambition to ensure that drug users and their families are free from stigmatization, marginalization and discrimination and that they can enjoy the full range of human rights and protections as enshrined in the Universal Declaration of Human Rights.
In addition, several Dutch NGOs specialized in harm reduction are working internationally in Eastern Europe and Asia, with support from the Dutch Government. NGO’s like Asian Harm Reduction Network, Mainline, Aids Foundation East-West work to empower and strengthen political, community and business leadership, adopting a consultative and participatory approach.
Ladies and gentlemen, as was stated by the International Federation of Red Cross and Red Crescent Societies in 2003: “It is time to be guided by the light of science, not by the darkness of ignorance and fear.”
And finally, ladies and gentlemen, it is my pleasure to present to you this brochure (toont brochure) “Out of the Margin. Harm Reduction and HIV prevention ” which addresses harm reduction in a summary fashion. It contains a CD with reference documents. Is available here. From today it will be accessible on the website of the Asian Harm Reduction Network, in English and soon also in Russian. I look forward to discussing the issue with you further.
Thank you.