NDARC Technical Report No. 291 (2008)
INTRODUCTION
Injecting drug use and HIV transmission
Injecting drug use (IDU) is a global concern. Over 130 countries have reported drug injection within their borders and there are an estimated 13.2 million IDUs worldwide, 80% of whom live in developing countries (Aceijas, Stimson, Hickman, & Rhodes, 2004; Wodak, Ali, & Farrell, 2004). Harms associated with IDU include involvement in criminal activity, imprisonment, overdose and mortality (WHO/UNODC/UNAIDS, 2004). However, one of the most prominent harms associated with IDU is HIV infection, which can be spread via sharing of injecting equipment. In many countries, particularly in South and South-East Asia, IDU is the leading mode of HIV transmission (UNAIDS, 2005). IDU accounts for half of new HIV cases reported in China (Ministry of Health China, 2006) and as much as 90% of new cases in Indonesia (Ford, Wirawan, Sumantera, Sawitri, & Stahre, 2004). IDUs have the highest HIV prevalence of all risk groups in Viet Nam, with one-third of all IDU infected (Ministry of Health Vietnam, 2005).
The potential for HIV to spread from IDUs to the wider community is great. IDUs are usually sexually active and may have multiple sex partners (Pisani, Dadun, Sucahya, Kamil, & Jazant, 2003; M. Zhao, Wang, Lu, Xu, & McCoy, 2005). Furthermore, many IDUs engage in sex work (UNAIDS, 2006). Infected sexual partners of IDUs and sex workers may then further transmit the virus to other sexual partners. Mother-to-child transmission of HIV can also occur. Addressing injecting drug use with effective interventions is vital for stemming HIV transmission and other drug-related harms among both IDUs and the general community.
Harm minimisation: Supply, demand and harm reduction
Harm minimisation comprises three categories of interventions to address drug use: supply reduction, demand reduction and harm reduction. Each category of harm minimisation targets a different aspect of drug use, from production and distribution of drugs, to preventing drug use and treating dependent users, to reducing the negative outcomes associated with drug use (see table 1.1).
Table 1.1: The harm minimisation approach to drug use
| HARM MINIMISATION | |||
| Supply Reduction | Demand Reduction | Harm Reduction | |
| Goal | To reduce the availability of drugs | To prevent initiation to drug use and treat dependent drug users | To prevent or reduce the harms associated with drug use |
| Typical Strategies |
- Crop eradication -Maintaining border controls - Legal sanctions against the sale and distribution of drugs |
- Drug education in schools - Drug dependency treatment |
- HIV education for drug users - Outreach services - Needle and syringe programs |
Supply reduction has traditionally been the avenue through which governments have attempted to control drug use (Morin & Collins, 2000; Wodak, Ali, & Farrell, 2004). However, supply reduction is expensive and there is little to no evidence to suggest it results in reduced drug use (Morin & Collins, 2000). Demand reduction strategies such as drug treatment have been shown to be effective in reducing drug use and related HIV transmission and are a cost-effective adjunct to supply and harm reduction strategies (World Health Organization, 2005a).
Demand reduction in institutional settings
Drug users are over-represented in prisons and other criminal justice settings throughout the world (Dolan, Kite, Black, Aceijas, & Stimson, 2007; UNAIDS, 1997). For example, a 2003 survey of prisoners in Indonesia found that just over half (54%) were drug users (UNODC Regional Centre for East Asia and the Pacific, 2005), compared to an annual prevalence of drug use among students of 3.9% (UNODC Regional Centre for East Asia and the Pacific, 2006). With large numbers of drug users, closed institutions such as prisons and compulsory drug treatment centres provide an opportunity for delivering demand reduction strategies.
A wide variety of demand reduction strategies are found in prisons throughout the world (Larney, Mathers, & Dolan, 2007). Drug and HIV education is provided to prisoners in most developed and many developing nations. Education usually focuses on topics such as the effects of drugs, how drug dependence develops and HIV transmission and prevention. Some programs employ principles of peer education, in which a member of the group being targeted by the education program (a peer) delivers the educational material. The World Health Organization has produced a comprehensive HIV education manual specifically for use in closed settings (World Health Organization Western Pacific Regional Office, 2007).
More intensive than HIV and drug education are treatment programs such as therapeutic communities and methadone maintenance treatment. Therapeutic communities (TCs) are common in prisons in Australia, the United States and the United Kingdom. Evaluations of prison-based TCs often find positive effects on subsequent drug use and offending. A five-year follow-up of inmates who participated in the Amity program, a prison-based TC in California, found that participants were less likely than non-participants to be re-incarcerated (Prendergast, Hall, Wexler, Melnick, & Cao, 2004). Another study found that TC participants were significantly more likely than non-participants to be abstinent from drug use at five-year follow-up (Inciardi, Martin, & Butzin, 2004).
Methadone maintenance treatment (MMT) is also available in prisons in a number of countries, including Australia, Canada, Spain and Germany. In a randomised controlled trial of the prison methadone program in New South Wales, Australia, treated inmates had lower levels of drug use and syringe sharing than non-treated inmates (Dolan et al., 2003). A four-year follow-up of this study found that, compared to non-treated inmates, inmates who remained on MMT for a minimum of eight months were less likely to be reincarcerated, less likely to contract hepatitis C and less likely to die (Dolan et al., 2005).
The above research demonstrates that implementing demand reduction strategies in institutional settings can benefit both detainees and the communities they return to on release. Despite the large numbers of drug users currently in prisons and compulsory drug treatment settings in various countries throughout South and South-East Asia, little is known about what treatments and other demand reduction strategies are in use in these countries. This study aims to collate data to produce a coherent picture of the availability of demand reduction strategies in prisons and compulsory treatment settings in China, Indonesia and Vietnam.
Citation: Larney, S. & Dolan, K. (2008) Demand reduction strategies in closed settings in China, Indonesia and Vietnam. Sydney: National Drug and Alcohol Research Centre.