Mukta Sharma

Women and Substance Use in India and Bangladesh

Given the feminization of the HIV epidemic in India and Bangladesh, understanding substance-use-related concerns among women is important for effective HIV prevention. This review is based on published research, reports (2000–2005), and primary data from treatment centers for drug-using women. We identify four main themes: (a) opioid use and injecting drug use in women, (b) alcohol use in sex work settings, (c) sexual transmission of HIV from male-injecting drug users (IDUs) to their regular female sex partners, and (d) sexual violence among female partners of substance-using men. We urge for focused HIV prevention interventions targeting substance-using women and female sex partners of male substance users to reduce vulnerability.

Five years of needle syringe exchange in Manipur, India: programme and contextual issues

Abstract This paper reviews the performance of the syringe exchange programmes (SEPs) in Manipur, northeast India, with the objective of identifying good practice, and areas that require improvement. The paper also examines contextual and structural factors in Manipur that inhibit optimal functioning of SEPs and hinder behaviour change, and argues that these factors need to be addressed as part of any endeavour aimed at improving services and programme coverage in the future.

Partnering with law enforcement to deliver good public health: The experience of the HIV/AIDS Asia regional program.

In the South-East Asia region, the drug control and supply reduction agenda is of high political importance. A multitude of law enforcement agencies are engaged in this work. Nationwide campaigns such as the “Strike- Hard” campaign in China or the “war on drugs” in Thailand dominate the landscape. Viet Nam’s response to drug use has historically focused on deterrence through punishment and supply-side measures. This policy environment is further complicated by lack of evidence-based drug dependence treatment in several settings. The public health consequences of this approach have been extremely serious, with some of the highest documented prevalence of preventable blood-borne viral infections, including HIV, and hepatitis B and C. The wider socioeconomic consequences of this have been borne by families, communities and the governments themselves.The HIV/AIDS Asia Regional Program (HAARP) aims to stop the spread of HIV associated with drug use in South-East Asia and parts of southern China. HAARP works across five countries (Cambodia, China Burma, Laos, Viet Nam) chiefly through the Ministries of Health and Social Affairs, National Drug Control Agencies, and Public Security sectors, including prisons. HAARP has also engaged with UN agencies and a wide range of civil society organisations, including organisations of people who use drugs, to ensure their meaningful involvement in matters that directly affect them. We describe the experience of HAARP in implementing a large-scale harm reduction programme in the Sub-Mekong Region. HAARP chose to direct its efforts in three main areas: supporting an enabling environment for effective harm reduction policies, building core capacity among national health and law enforcement agencies, and supporting “universal access” goals by making effective, high-coverage services available to injecting drug users and their partners.The activities supported by HAARP are humble yet important steps. However, a much higher political-level dialogue is needed. The current huge gap of human rights standards in drug control practices also needs to be bridged immediately. Public health that embraces a rights-based approach must be given its fair share of policy space, budget and influence.

Needle Syringe Acquisition and HIV Prevention Among Injecting Drug Users: A Treatise on the “Good” and “Not So Good” Public Health Practices in South Asia

This article describes the prevalence of HIV/AIDS and other bloodborne infections is well established among injection drug user (IDU) populations in South Asia (SA). IDU populations in SA are diverse and display different demographic and socioeconomic profiles. The current provision of sterile injecting equipment as part of public health initiatives is suboptimal. Although some needle and syringe exchange programs (NSEPs) operate in the region, pharmacies and “friends” continue to be a major source of syringe acquisition. It is suggested that the cost of syringes in the region is significantly higher in real terms than in several other countries and negatively impacts on the ability of IDUs to acquire needles and syringes. In addition, existing NSEPs offer poor coverage both at the population and individual level. Their effective functioning is hampered by resource constraints, ambivalent policy positions, little attention to quality, and environmental factors. Secondary syringe exchange is a nascent phenomenon in SA that needs to be adequately documented and evaluated. Urgent attention needs to be given to developing alternative models of needle syringe delivery to scale-up HIV prevention interventions for IDUs. This study was conducted in the first quarter of 2004 and updated in 2006. We used key informants, previously unpublished and published data from research studies, and interventions programs, service statistics, and primary data to inform this study.

How much will it cost? Estimation of resource needs and availability for HIV prevention, treatment and care for people who inject drugs in Asia

As countries in Asia strive to meet their universal access targets, harm-reduction programmes are yet to be scaled up to reach effective levels of coverage. Resource tracking and estimation of resource needs and gaps is critical to inform the financing decisions of major donors of harm-reduction programmes in the region. This study aimed at estimating the financial resource needs and gaps for scaling-up harm reduction in the region, building on previous research conducted by the Independent Commission on AIDS in Asia. The overall resource need for achieving universal access in the target population in 2009 was US

Moving from a project to programmatic response: scaling up harm reduction in Asia.

0.5 billion, with NSP and OST accounting for nearly 70% of the overall regional resource need. A significant resource gap, approximately 90%, of the resource need in 2009, was identified for harm reduction in the region, representing less than 2% of the overall global resource need to address AIDS. Additional resources will be required to support the introduction and scaling-up of integrated, comprehensive harm-reduction programmes that provide a full range of services to reduce HIV transmission among people who inject drugs.

Substance Dependence Treatment Interventions: Why We Continue to Fail People Who Use Drugs in Asia

The response to the HIV epidemics among people who inject drugs in Asia began to emerge in the early to mid 1990s, with the rather hesitant implementation of small-scale needle syringe programmes and community care initiatives aiming to support those who were already living with the virus. Since then Asia has seen a significant scaling up of harm reduction, despite very limited resources and difficult policy and legislative environments. One of the major reasons this has happened, is the utilisation of programme based approaches and the firm entrenchment of harm reduction thinking within national HIV/AIDS programmes and strategic plans--in most cases aided by multilateral and bilateral donors. Several models of scale up have been noted in Asia. The transition away from project based approaches, while on the whole positive, can also have a negative impact if the involvement of civil society and a client focussed approach is not protected. Also there are implications for which models of capacity building can be systematised for ongoing scale up. Most crucially, the tensions between drug policy, human rights and public health policies need to be resolved if harm reduction services are to be made available to the millions in Asia who are still unable to access these services.

Mukta Sharma on Julia Dickson-Gómez's “Substance Abuse Disorders Treatment in El Salvador: Analysis of Policy-Making-Related Failure”

Introduction: Substance use disorders contribute to a large number of preventable deaths in Asia; a majority of the negative health consequences are associated with opioid use. User friendly and effective drug dependence treatment is limited. Scope: Factors mediating drug user treatment outcomes in Asia are explored, with a focus on opioid use. Individual, programmatic, and legal/political issues which reduce the impact of drug user treatment are noted. Discussion: Criminalization of drug users, inadequate insurance, chronic underinvestment, and an overall lack of therapeutic options create structural barriers for treatment for users and providers. The practice of detention as drug treatment serves to fracture the treatment alliance. At the individual level, extreme poverty and the lack of a social protection network mediate against the achievement of treatment goals. Conclusions: A range of factors has a bearing on processes and outcomes of drug user treatment. Acknowledging and addressing them, at each level, is fundamental to delivering useful interventions for people who use drugs.

Mukta Sharma on Bruce K. Alexander's “Addiction: The Urgent Need for a Paradigm Shift”

Dickson-Gómez’s use of El Salvador as a case study to examine the failures of policy making in developing countries to support drug demand and harm reduction measures, will strike a cord with many readers who work and live in these settings. The failure of policy making is explained in terms of a “lack of political will” on behalf of the El Salvador government to “effectively monitor, supervise, and subsidize” treatment of substance users. The lack of resources allocated to reducing demand for drugs, compared to what is spent on supply reduction and law enforcement is also a theme which is familiar in many settings, including the United States and across the spectrum of high and middle income countries. While the lack of political will, and optimal allocation of resources for humane and evidence based drug user treatment options is an issue commonly seen in many settings, one is forced to ask whether these are the symptoms of other multiple failures, which underpin the symptom of “lack of political will.” A whole range of factors including lack of consumer advocacy, donor attitudes, societal and religious attitudes, political systems, and the failure of governments and non-governmental organizations to work together collaboratively etc. influence how “political will” is played out. Are there differences in systems that make it easier for some countries to make it easier for human beings to “fail” other human beings compared to others—by looking the other way, by marginalizing, and stigmatizing them, by seeing them as a “homogenized” “the other”? The exploration of these issues

Drug users as social change agents in Asia: the diversity of experience and challenges.

Bruce K. Alexander’s politically irreverent and intuitively appealing diagnosis of the causes of “addiction” in the modern world urges the reader to look beyond individual-level factors in explaining increases in substance use globally and indeed, in the failure of current drug user treatment approaches to provide “treatment.” Alexander challenges the reader to come away from traditional explanations, and locates “addiction” as an adaptive mechanism that individuals resort to, when free market imperatives crush “psychologically sustaining” cultures. His diagnostic framework is grounded in the work of Karl Polanyi, which emphasizes the role of psychological and physical dislocation in explaining the historical evolution of the levels of drug dependence globally, post sixteenth century to the times that we live in. The argument that dislocated people compensate for their lack of psychological integration by clinging to various types of “addiction implies that medical, psychological, faith-based, and law-enforcement interventions cannot check drug dependence on the local and global levels.” He argues that a different paradigm is needed to address this—not deficiencies in the brain reward system, neural sensitization to the reinforcing effect of substances, or some other similar explanation. But what that paradigm is, and whether such a paradigm is possible, remains elusive. Alexander’s thesis needs further examination to stand up to theweight of evidence and needs to explain better the vast variation seen globally in the prevalence of substance use. While societal-level dislocation creates a demand at the individual level for a coping mechanism (drugs), what