tag:theconversation.com,2011:/es/topics/needle-exchange-3600/articlesNeedle exchange – The Conversation2023-12-11T04:27:58Ztag:theconversation.com,2011:article/2164392023-12-11T04:27:58Z2023-12-11T04:27:58ZWe’re on track to eliminate hepatitis C, but stigma remains and reinfection is a risk<figure><img src="https://images.theconversation.com/files/564715/original/file-20231211-21-yubjnt.jpg?ixlib=rb-1.1.0&rect=244%2C325%2C5794%2C3630&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/back-view-man-standing-looking-through-2136042105">Shutterstock</a></span></figcaption></figure><p>Hepatitis C is a preventable but potentially life-threatening blood-borne virus. It primarily affects the liver and, if untreated, can lead to <a href="https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/cirrhosis-of-the-liver">cirrhosis</a> (scar damage) and cancer. </p>
<p>When direct-acting antivirals for hepatitis C arrived in 2016, they were described as a <a href="https://www.smh.com.au/politics/federal/turnbull-government-to-spend-1-billion-on-hepatitis-c-miracle-cures-for-all-20151219-glrib0.html">game changer</a>. They <a href="https://www.penington.org.au/wp-content/uploads/2022/07/The-Bulletin-April-2021.pdf">cured</a> chronic hepatitis C in <a href="https://www.nature.com/articles/510043a">more than 95% of cases</a>. So Australia adopted the World Health Organization’s target to <a href="https://www.nature.com/articles/510043a">eliminate hepatitis C</a> by 2030.</p>
<p>More than <a href="https://www.abc.net.au/news/2016-12-05/hep-c-drugs-australias-most-expensive/8094188">a billion dollars</a> has been invested in adding direct-acting antivirals to the Pharmaceutical Benefits Scheme, making treatment accessible to anyone covered by Medicare. By the end of 2022, <a href="https://unsw-primo.hosted.exlibrisgroup.com/primo-explore/fulldisplay?vid=UNSWORKS&docid=unsworks_modsunsworks_84935&context=L">about 60%</a> of people living with hepatitis C had been treated. </p>
<p>That’s a remarkable public health achievement. Life-changing for many and for some, literally life-saving. But what is life like for this growing group of people after they’ve been cured? And where are we still lagging in our efforts to combat hepatitis C?</p>
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Read more:
<a href="https://theconversation.com/explainer-the-a-b-c-d-and-e-of-hepatitis-54739">Explainer: the A, B, C, D and E of hepatitis</a>
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<h2>Cure doesn’t always eliminate stigma</h2>
<p>The most common way of picking up hepatitis C in Australia is by sharing injecting equipment. As injecting drugs is widely disapproved of, and illegal in most parts of Australia, this has huge implications for people with hepatitis C. </p>
<p>The <a href="https://journals.sagepub.com/doi/10.1177/1357034X09347221">stigma associated with injecting drugs</a> means people with hepatitis C can experience persistent discrimination – in relationships, at work, and other settings. Research suggests <a href="https://www.unsw.edu.au/content/dam/pdfs/unsw-adobe-websites/arts-design-architecture/ada-faculty/csrh/2021-06-Stigma_Indicators_Monitoring_Project_Summary_Report.pdf">more than half</a> of people with hepatitis C experienced discrimination in a 12-month period. </p>
<p>Such discrimination happens <a href="https://academic.oup.com/cid/article/57/suppl_2/S51/394838">most commonly in health care</a>, when doctors, nurses and others health-care professionals become aware of someone’s hepatitis C status. This <a href="https://www.sciencedirect.com/science/article/pii/S1326020023001784?via%3Dihub">can include</a> withholding treatment, <a href="https://theconversation.com/mental-distress-is-much-worse-for-people-with-disabilities-and-many-health-professionals-dont-know-how-to-help-187078">diagnostic overshadowing</a> (when workers attribute physical symptoms of illness to mental health issues), rude or unwelcoming behaviour, and excessive infection control like double-gloving. This may lead some people to avoid seeking medical care entirely.</p>
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<img alt="GP talks to female patient" src="https://images.theconversation.com/files/564712/original/file-20231211-21-7k618h.jpg?ixlib=rb-1.1.0&rect=27%2C9%2C6132%2C4091&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/564712/original/file-20231211-21-7k618h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/564712/original/file-20231211-21-7k618h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/564712/original/file-20231211-21-7k618h.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/564712/original/file-20231211-21-7k618h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/564712/original/file-20231211-21-7k618h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/564712/original/file-20231211-21-7k618h.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Some health providers act differently when finding out about a patient’s history of hepatitis C.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/close-young-female-general-practitioner-gesturing-1917303137">Shutterstock</a></span>
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<p>Our recent research <a href="https://mh.bmj.com/content/early/2023/07/13/medhum-2023-012653">found</a> direct-acting antivirals do not necessarily cure these forms of stigma and discrimination. If medical records show a person has a history of hepatitis C, some health-care workers change the way they treat that person. </p>
<p>Their manner can change. The treatments they offer might change – for example, whether they will provide access to painkillers. Sometimes people are treated as if they are infectious, or as if they still have the virus when they don’t.</p>
<h2>The law can reinforce stigma and discrimination</h2>
<p>Laws and legal practices have been slow to respond to new treatments.</p>
<p>In insurance law, for instance, having once had hepatitis C has been considered a risk to insurance providers. This means affected people <a href="https://opal.latrobe.edu.au/articles/journal_contribution/Insurance_discrimination_and_hepatitis_C_Recent_developments_and_the_need_for_reforms/22091411">may not be</a> approved for travel, health or life insurance. Or, their premiums may be much higher, potentially pricing them out of the market and limiting their ability to travel, access health care or plan for their financial futures. </p>
<p>We would expect to see practices change with more effective treatments. But insurance practices and the actuarial data that insurers use is <a href="https://opal.latrobe.edu.au/articles/journal_contribution/Insurance_discrimination_and_hepatitis_C_Recent_developments_and_the_need_for_reforms/22091411">lagging</a> behind medical developments. </p>
<p>This is just one example of how laws and legal practices can exacerbate stigma and discrimination for people with a history of hepatitis C. Our <a href="https://opal.latrobe.edu.au/articles/report/Hepatitis_C-related_stigma_and_discrimination_in_a_post-cure_world_Summary_report_of_project_findings_and_recommendations/23909613/1">research found</a> this also occurs in <a href="https://journals.sagepub.com/doi/full/10.1177/09646639221115698">criminal law</a>, privacy law, <a href="https://www.tandfonline.com/doi/full/10.1080/1535685X.2023.2221950">social security and migration law</a>.</p>
<h2>People in prison are being left behind</h2>
<p>Prisons have high rates of injecting and <a href="https://theconversation.com/direct-acting-antivirals-can-cure-hepatitis-c-and-prisons-are-now-leading-efforts-to-eliminate-the-virus-182854">hepatitis C transmission</a> has historically been high. </p>
<p>While Australia has had <a href="https://www.sydneycriminallawyers.com.au/blog/australia-pioneered-drug-harm-reduction-and-must-continue/">a good track record</a> on reducing some harms associated with drug use in prisons, there is at least one <a href="https://www.hepatitisaustralia.com/news/renewed-calls-for-needle-syringe-programs-in-prisons-ahead-of-international-drug-users-day">glaring omission</a>: prisons don’t have access to a needle and syringe programs to ensure that people who use drugs can access sterile equipment. This means it’s much harder to prevent the transmission of hepatitis C and other blood-borne viruses in prisons.</p>
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Read more:
<a href="https://theconversation.com/sterile-needles-can-stop-the-spread-of-disease-in-prisons-heres-how-3644">Sterile needles can stop the spread of disease in prisons – here's how</a>
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<p>Yet <a href="https://www.health.gov.au/resources/collections/national-strategies-for-bloodborne-viruses-and-sexually-transmissible-infections?utm_source=health.gov.au&utm_medium=callout-auto-custom&utm_campaign=digital_transformation">current national hepatitis C policy</a> says harm reduction should be available in prisons. And the <a href="https://www.penalreform.org/resource/standard-minimum-rules-treatment-prisoners-smr/">Mandela Rules</a> – which are a set of international human rights principles – state that prisoners should receive the same standard of health care as those in the wider community.</p>
<p>Without sterile injecting equipment for people in prisons, people who have been cured of hepatitis C are at risk of reinfection. And Australia is less likely to eliminate hepatitis C. </p>
<h2>Elimination demands more than just treatment</h2>
<p>The world is watching as Australia tries to be one of the first countries in the world to <a href="https://www.health.gov.au/sites/default/files/documents/2022/06/fifth-national-hepatitis-c-strategy-2018-2022.pdf">eliminate hepatitis C</a>. The final national hepatitis C health strategy is expected to be released before the end of 2023. </p>
<p>But the number of people coming forward for treatment has <a href="https://unsw-primo.hosted.exlibrisgroup.com/primo-explore/fulldisplay?vid=UNSWORKS&docid=unsworks_modsunsworks_84935&context=L">dropped significantly</a>. Resources are being marshalled into <a href="https://pubmed.ncbi.nlm.nih.gov/34448668/">finding people</a>, and keeping the momentum going on elimination. </p>
<p>It is increasingly clear that we also need to direct resources to what happens “post-cure”, assuring people that stigma-free health care is available to them. We also need to tackle the laws, policies and practices that allow stigma and discrimination to linger in people’s lives. </p>
<p>Finally, we need to ensure people in prisons have access to sterile injecting equipment so they aren’t reinfected.</p><img src="https://counter.theconversation.com/content/216439/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kate Seear receives funding from the Australian Research Council's Discovery Scheme (DP200100941) and the Future Fellowship Scheme (FT200100099).</span></em></p><p class="fine-print"><em><span>Dion Kagan, Emily Lenton, and Sean Mulcahy do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Around 60% of Australians with hepatitis C have accessed treatment which usually cures the condition. But to eliminate the disease, we need to prevent re-infection and tackle stigma.Dion Kagan, Research Officer, Gender, Law and Drugs program, La Trobe UniversityEmily Lenton, Research officer, La Trobe UniversityKate Seear, Associate professor, La Trobe UniversitySean Mulcahy, Research Officer, La Trobe UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1718692021-11-18T14:00:09Z2021-11-18T14:00:09ZAfrican countries perform badly when it comes to drug policies: a new index shows how<figure><img src="https://images.theconversation.com/files/431977/original/file-20211115-15-1gk0kki.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Kenyan police officers display bags of heroin seized in 2011. </span> <span class="attribution"><span class="source">Tony Karumba/AFP via Getty Images</span></span></figcaption></figure><p>Awukye received a 10-year prison sentence in Ghana for cannabis possession. The experience, he <a href="https://globaldrugpolicyindex.net/stories/using-cannabis-to-relax-after-work-landed-me-10-years-in-prison-awukyes-story/">said</a>, shattered his family’s dreams. Michael Anami, a Kenyan, <a href="https://globaldrugpolicyindex.net/stories/my-lived-experience-motivates-me-to-challenge-punitive-and-harmful-policies-anamis-story/">recalled</a> the “multiple arrests, beatings, incarcerations, and untimely deaths” he had witnessed as a drug policy activist and former user.</p>
<p>These were just some of the harrowing stories we heard while developing the recently launched <a href="https://globaldrugpolicyindex.net/">Global Drug Policy Index</a>, a way of comparing countries’ policies on drugs. Such stories suggest that drug policy all too often blights lives. But there are also inspiring individuals and communities working to help people who use drugs. They provide medicine to combat overdoses, needle and syringe exchange programmes to prevent the spread of blood borne diseases, and drug checking services to inform people about the potency and quality of drugs that they might ingest.</p>
<p>It has long been clear that some countries have policies that cause harm and violate human rights, while others have more rational, evidence based and humane policies. But it has been difficult to assess and compare them. </p>
<p>The Global Drug Policy Index aims to fill this gap. It is designed to provide rigorous, transparent and comparative evidence about the quality of countries’ drug policies. It’s a tool to hold governments accountable and ensure that policies are based on health, human rights and development.</p>
<h2>Measure, compare, guide</h2>
<p>The United Nations’ <a href="http://hdr.undp.org/en/content/human-development-index-hdi">Human Development Index</a>, Transparency International’s <a href="https://www.transparency.org/en/cpi/2020/index/nzl">Corruption Perception Index</a> and Freedom House’s <a href="https://freedomhouse.org/countries/freedom-world/scores">Global Freedom Index</a> are just three examples of projects that measure and compare countries in complex areas of policy. Such indices are useful because they crystallise the performance of states and offer clear guidance on how to improve.</p>
<p>The Global Drug Policy Index was driven by <a href="https://idpc.net/policy-advocacy/partnerships/the-harm-reduction-consortium#:%7E:text=The%20Harm%20Reduction%20Consortium%20brings%20together%20seven%20of,European%20Network%20of%20People%20who%20Use%20Drugs%20%28EuroNPUD%29.">the Harm Reduction Consortium</a> and developed by academics at <a href="https://www.swansea.ac.uk/gdpo/">Swansea University’s Global Drug Policy Observatory</a>.</p>
<p>In the sphere of drug policy, academics often collaborate with policymakers, activists and people who use drugs. For the 30 countries covered in this first version of the Global Drug Policy Index, we consulted widely with organisations rooted within the communities affected by drug policies. We also surveyed 371 individuals with “on the ground” knowledge of each state’s drug policy. </p>
<p>The index specifies 75 policy indicators. These are derived from a recent <a href="https://www.unodc.org/documents/commissions/CND/2019/Contributions/UN_Entities/What_we_have_learned_over_the_last_ten_years_-_14_March_2019_-_w_signature.pdf">UN report</a> on best practice in state drug policy.</p>
<p>Based on how they perform on these indicators, states get a score from 0 to 100. One hundred would represent a full implementation of recommended policies across five areas. </p>
<p>The first area is the absence of extreme response, like the death penalty and extrajudicial killing. </p>
<p>Second is the proportionality of the criminal justice response. This looks at levels of violence, discrimination and human rights abuse in states’ policing of drug policy. </p>
<p>Health and harm reduction is the third. This focuses on the funding, availability and accessibility of interventions that reduce the harms arising from problematic drug use. </p>
<p>Access to controlled medicines is fourth. It looks at states’ provision of medicines for pain relief and palliative care. </p>
<p>Finally, there’s development: programmes designed to provide alternative livelihoods to people who grow illicit crops. </p>
<h2>Drug policies in African countries</h2>
<p>Even a quick glance at the <a href="https://globaldrugpolicyindex.net/ranking/">index results</a> for states in Africa reveals a grim truth: African states are among the worst performers in the world in terms of drug policy. </p>
<p><a href="https://globaldrugpolicyindex.net/ranking/">Uganda</a> scores just 28 in the overall index. The country has a perfect storm of punitive, highly violent drug law enforcement combined with minimal availability of basic medical interventions to reduce the harms caused by drug use.</p>
<p>In Kenya, which scores only 32 overall, access to harm reduction interventions is better, although still patchy. Our expert respondents in Kenya described frequent use of violence and torture by police, as well as arbitrary arrest. They said drug law enforcement was particularly harsh on women, certain ethnic groups, and the less wealthy. Such features are common in all low-ranked states in the Global Drug Policy Index.</p>
<p>In other African states evaluated in the index (such as South Africa, Mozambique and Senegal), the picture was more mixed. There were areas of good practice, including less “extreme” responses to drug crimes such as the death sentence. And there were some promising developments in harm reduction. But access to essential medicines is very limited across the continent. And most states are exercising disproportionate force in delivering their drug policies.</p>
<p>These problems aren’t separate. Money spent on police, courts and prisons is money that could be spent on healthcare and harm reduction. Sadly, it seems that Africa’s states are still largely operating from an outdated and discredited “<a href="https://www.bloomsburycollections.com/book/africa-and-the-war-on-drugs/?clearSearch">War on Drugs</a>” perspective. Even South Africa, a <a href="https://www.talkingdrugs.org/drug-decriminalisation">regional leader</a> in decriminalisation policy, has implemented it in a cautious, limited way. Our expert respondents collectively judged that South African decriminalisation has so far been ineffective in reducing contacts between people who use drugs and the criminal justice system. </p>
<p>We hope the information contained in this index will help to develop constructive debates that will lead to more humane and evidenced based policies in the region. To achieve this, states should reorient their approaches to focus on the health and human rights implications of drug use. The index provides a clear guide to the types of policies and actions that will move them towards this goal.</p><img src="https://counter.theconversation.com/content/171869/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Matt Wall receives funding from the Robert Carr foundation for his work as a specialist in social science methodolgy on the Global Drug Policy Index project. </span></em></p><p class="fine-print"><em><span>David Bewley-Taylor received funding from the Robert Carr Fund for his work on the Global Drug Policy Index project. He is a Senior Associate of the International Drug Policy Consortium. </span></em></p>It has long been clear that some countries have drug policies that cause harm and violate human rights.Matt Wall, Associate Professor, Political and Cultural Studies, Swansea UniversityDavid Bewley-Taylor, Personal Chair, Politics, Philosophy and International Relations, Swansea UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/773432017-05-15T20:07:49Z2017-05-15T20:07:49ZAustralia should stop beefing up its steroid laws – that won’t help users<figure><img src="https://images.theconversation.com/files/168686/original/file-20170510-7904-9futrr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">There has been a dramatic increase in the amount of steroids seized at the Australian border over time.</span> <span class="attribution"><span class="source">AAP</span></span></figcaption></figure><p>The use of image and performance enhancing drugs – in particular steroids – is a growing area of concern <a href="https://www.ncbi.nlm.nih.gov/pubmed/24582699">globally</a>. </p>
<p>The use of these drugs has traditionally been limited to elite athletes and professional bodybuilders. But now their use is becoming normalised as part of a <a href="http://onlinelibrary.wiley.com/doi/10.1111/hsc.12326/pdf">fitness and beauty regime</a> for people who want to gain muscle, become leaner, and improve their appearance.</p>
<p>Several <a href="http://www.tandfonline.com/doi/abs/10.3109/09687637.2015.1061975">population studies</a> have shown the use of image and performance enhancing drugs in Australia is relatively low. However, the dramatic increase of <a href="https://www.acic.gov.au/sites/g/files/net1491/f/2016/08/acic-iddr-2014-15.pdf?v=1470178813">steroids detected</a> at the country’s borders, and the number of users <a href="https://www.ncbi.nlm.nih.gov/pubmed/26644363">accessing needle and syringe programs</a>, seem to indicate otherwise. </p>
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<a href="https://images.theconversation.com/files/168825/original/file-20170510-21593-cled6x.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/168825/original/file-20170510-21593-cled6x.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/168825/original/file-20170510-21593-cled6x.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=273&fit=crop&dpr=1 600w, https://images.theconversation.com/files/168825/original/file-20170510-21593-cled6x.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=273&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/168825/original/file-20170510-21593-cled6x.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=273&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/168825/original/file-20170510-21593-cled6x.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=344&fit=crop&dpr=1 754w, https://images.theconversation.com/files/168825/original/file-20170510-21593-cled6x.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=344&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/168825/original/file-20170510-21593-cled6x.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=344&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Number of performance- and image-enhancing drug detections at the Australian border, 2005–06 to 2014–15.</span>
<span class="attribution"><span class="source">DIBP</span></span>
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<p>If Australia is to respond to image and performance enhancing drug use effectively, we need to improve our prevention and harm-reduction strategies – and not merely further criminalise users.</p>
<h2>Potential health harms</h2>
<p>The most-researched (and targeted) image and performance enhancing drugs are steroids. But other examples include <a href="https://theconversation.com/health-warning-about-body-sculpting-drug-clenbuterol-23815">clenbuterol</a> (to lose weight) and <a href="http://www.news.com.au/lifestyle/health/health-problems/melanotan-ii-sold-illegally-online-to-people-desperate-for-a-tan/news-story/878a895097e72cfe6b723e5d9f4234ed">melanotan II</a> (a tanning agent).</p>
<p>The inappropriate and excessive use of these drugs has been associated with a range of negative <a href="http://www.sciencedirect.com/science/article/pii/S0376871608001919">physical</a> and <a href="https://www.ncbi.nlm.nih.gov/pubmed/19769977">psychological</a> health consequences. Steroid use, for example, has been linked to high blood pressure, heart attack, stroke, acne and skin infections, liver damage, tendon rupture, premature baldness and stunted bone growth in adolescents. There are also psychological implications such as addiction, mood syndromes, and body image disorders. </p>
<p>Another issue is that the widespread use of <a href="https://www.ncbi.nlm.nih.gov/pubmed/20355210">illicitly manufactured products</a> sourced through the black market puts drug users at risk of adverse reactions to tainted products.</p>
<p>In addition, as many of these substances are injected, there are potential harms from unsafe injecting practices. For example, <a href="http://www.tandfonline.com/doi/abs/10.1080/09595230802392568">research</a> has found that 41% of Australian men who injected steroids reported an injection-related health problem such as such as fevers, scarring and abscesses. </p>
<h2>Beefing up steroid laws</h2>
<p>In Australia, increases in the detection of these drugs at the border, coupled with <a href="https://theconversation.com/why-organised-crime-should-not-be-used-to-shape-anti-doping-policy-42385">contested concerns</a> about <a href="http://www.tandfonline.com/doi/abs/10.1080/09595230802392568">links to organised crime</a>, has led to greater levels of law enforcement. </p>
<p><a href="https://www.legislation.qld.gov.au/Bills/54PDF/2014/SafeNightOutLAB14E.pdf">Queensland</a>, Australia’s steroid capital, reclassified steroids a <a href="https://www.tga.gov.au/scheduling-basics">schedule-one drug</a> in 2014. This means they are now classed alongside heroin, cocaine and ice in the highest category of dangerous illicit drugs. </p>
<p>Under this legislation, the maximum penalty for possession or supply of steroids is 25 years’ imprisonment. Similar tough penalties apply in <a href="http://www.criminallawyers.net.au/reclassification-of-steroids-as-narcotics/">New South Wales</a> and <a href="https://www.sentencingcouncil.vic.gov.au/sites/default/files/publication-documents/Major%20Drug%20Offences%20Current%20Sentencing%20Practices.pdf">Victoria</a>. </p>
<p>However, there is little evidence that tougher penalties have resulted in reductions in steroid availability. The total number of seizures at the border fell in 2013-14. But <a href="https://www.acic.gov.au/sites/g/files/net1491/f/2016/08/acic-iddr-2014-15.pdf?v=1470178813.">there is evidence</a> of increases in recent years. </p>
<p>The <a href="https://www.acic.gov.au/sites/g/files/net1491/f/2016/06/oca2015.pdf">Australian Crime Commission</a> suggested in 2015 that any decrease in border interceptions could be the result of an increase in domestic production, coupled with increasingly easy access to drugs over the internet. </p>
<p>Despite having the toughest legislation, Queensland accounts for the greatest proportion of <a href="https://www.acic.gov.au/sites/g/files/net1491/f/2016/08/acic-iddr-2014-15.pdf?v=1470178813">national steroid arrests</a> (58% in 2014-15). But the greatest proportion of those arrested are steroid consumers – not suppliers. This suggests the current criminal justice approach may have limited capacity to limit distribution. </p>
<p>That growth in steroid use is most apparent in jurisdictions where recent legal changes have increased penalties suggests enhancing law enforcement measures may be an ineffective response to steroid use. <a href="https://theconversation.com/australias-recreational-drug-policies-arent-working-so-what-are-the-options-for-reform-55493">Other research</a> on the impact of drug policies on other illicit substances have reached similar conclusions. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/168826/original/file-20170510-21620-1c28tgl.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/168826/original/file-20170510-21620-1c28tgl.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/168826/original/file-20170510-21620-1c28tgl.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=324&fit=crop&dpr=1 600w, https://images.theconversation.com/files/168826/original/file-20170510-21620-1c28tgl.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=324&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/168826/original/file-20170510-21620-1c28tgl.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=324&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/168826/original/file-20170510-21620-1c28tgl.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=407&fit=crop&dpr=1 754w, https://images.theconversation.com/files/168826/original/file-20170510-21620-1c28tgl.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=407&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/168826/original/file-20170510-21620-1c28tgl.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=407&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Number of national steroid arrests, 2005-06 to 2014-15.</span>
<span class="attribution"><span class="source">ACIC</span></span>
</figcaption>
</figure>
<h2>Consequences of a tough law enforcement approach</h2>
<p>As is the case with drug use broadly, users of enhancement drugs can be considered rational consumers who make a deliberate choice to use steroids to achieve a desired outcome.</p>
<p>But social and cultural factors are also very influential in the decision to use drugs. <a href="http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=10737421139&libID=10737421138">Research</a> suggests people considering drug use rarely take the illegality of a particular substance into consideration. </p>
<p>Increasing penalties associated with the use and possession of image and performance enhancing drugs are unlikely to prevent uptake or encourage users to stop. Instead, this may result in several unintended negative consequences. For one, it can hinder <a href="https://link.springer.com/article/10.1007%2Fs12117-014-9235-7">access to medical services</a> and information by discouraging both users and healthcare practitioners from talking about drug use.</p>
<p>Tougher penalties can also distract from key harm-minimisation measures, such as safe injecting practices. </p>
<p>Other unintended negative consequences of criminal justice responses to such drug use include:</p>
<ul>
<li><p><a href="http://www.springer.com/gb/book/9781461482406">a growing black market</a>;</p></li>
<li><p><a href="http://www.sciencedirect.com/science/article/pii/S2211266915300086">geographical displacement</a> of users and suppliers; and </p></li>
<li><p><a href="https://www.ncbi.nlm.nih.gov/pubmed/20355187">increased risk of bad-quality drugs</a>. </p></li>
</ul>
<h2>What about harm-reduction strategies?</h2>
<p>Victoria’s existing harm-reduction initiative, the <a href="http://www.publish.csiro.au/py/pdf/PY02022">Steroid Education Project</a>, lags far behind services for alcohol and other illicit drugs in its funding and resources. It provides face-to-face and over-the-phone counselling to steroid users, and delivers training to needle and syringe program staff. </p>
<p>Greater resourcing is required to extend this program to allow for training in needle and syringe programs across Australia, and to deliver training to GPs. Given the reluctance of users to engage <a href="https://harmreductionjournal.biomedcentral.com/articles/10.1186/1477-7517-11-19">with traditional drug services</a>, GPs may be an <a href="https://www.youtube.com/watch?v=IQiZ4gGflKo">important avenue</a> for providing harm-minimisation messages to this group.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/IQiZ4gGflKo?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
</figure>
<p>There is an urgent need to reconsider steroid use as a public health issue, as opposed to a criminal justice concern. Harsher penalties will do nothing to tackle misinformation about steroids or underlying issues of body image dissatisfaction, depression and mental health concerns among users.</p><img src="https://counter.theconversation.com/content/77343/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>There is an urgent need to reconsider steroid use as a public health issue as opposed to a criminal justice concern.Katinka van de Ven, Research Fellow, National Drug and Alcohol Research Centre, UNSW SydneyRenee Zahnow, Postdoctoral Research Fellow, Faculty of Humanities and Social Sciences, The University of QueenslandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/649722016-09-09T10:26:46Z2016-09-09T10:26:46ZDrugs fatalities overtake car fatalities for the first time<figure><img src="https://images.theconversation.com/files/137080/original/image-20160908-25249-1ct7wc5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-276472910/stock-photo-man-injecting-himself-with-a-small-hypodermic-needle-possibly-administering-medication-for-a-disease-such-as-diabetes.html?src=NLK3gv9RXwwEBCFGAW-lgA-1-0">NAS CREATIVES/Shutterstock.com</a></span></figcaption></figure><p>Seven years ago, <a href="http://articles.latimes.com/2011/sep/17/local/la-me-drugs-epidemic-20110918">fatalities from opiates</a> overtook fatalities due to road accidents in the US. Sadly, the same phenomenon is now playing out in England. The latest figures from the Office for National Statistics (ONS), show that last year, 1,732 people died in <a href="https://www.gov.uk/government/statistics/reported-road-casualties-in-great-britain-main-results-2015">traffic accidents in the UK</a> compared with <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsrelatedtodrugpoisoninginenglandandwales/2015registrations">1,989</a> who died due to opiates in England alone.</p>
<p>New psychoactive substances, referred to as “legal highs”, have <a href="https://theconversation.com/stories-about-legal-high-deaths-are-bound-up-in-media-hysteria-24360">received significant media attention</a>, and deaths due to these drugs have risen by 40%, but opiate deaths now outnumber legal-high deaths by 19 to 1, despite a <a href="https://www.gov.uk/government/statistics/drug-misuse-findings-from-the-2015-to-2016-csew">steady decline</a> in opiate use in England and Wales over the last decade.</p>
<p>Of course, opiates are not the only problem – deaths due to cocaine have reached the highest on record at 320, increasing by nearly 30% since last year – but opiates are what we should really be focusing on. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/137200/original/image-20160909-13363-1uib24s.PNG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/137200/original/image-20160909-13363-1uib24s.PNG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=377&fit=crop&dpr=1 600w, https://images.theconversation.com/files/137200/original/image-20160909-13363-1uib24s.PNG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=377&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/137200/original/image-20160909-13363-1uib24s.PNG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=377&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/137200/original/image-20160909-13363-1uib24s.PNG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=474&fit=crop&dpr=1 754w, https://images.theconversation.com/files/137200/original/image-20160909-13363-1uib24s.PNG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=474&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/137200/original/image-20160909-13363-1uib24s.PNG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=474&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Drug deaths.</span>
<span class="attribution"><span class="source">Office for National Statistics</span></span>
</figcaption>
</figure>
<h2>Premature and preventable</h2>
<p>Drug-related deaths of males outnumber those of females by three to one and 60% of deaths occur in 30- to 49-year-olds – compared with an <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/lifeexpectancies/bulletins/lifeexpectancyatbirthandatage65bylocalareasinenglandandwales/2015-11-04">average life expectancy</a> for the rest of the population of 80. </p>
<p>Health complications resulting from drug use do not entirely explain this inequality in life span. A range of factors are likely to be involved. Purity and quality of heroin are not as critical, borne out by <a href="http://onlinelibrary.wiley.com/doi/10.1111/add.13516/full">decades of research</a>. Rather it is the risk of accidental overdose by more experienced and tolerant heroin users. Equally, combining heroin with alcohol and or a benzodiazapine such as diazepam <a href="http://www.sciencedirect.com/science/article/pii/S0376871612002785">increases the risk of death</a>. In 1993, one in four deaths were attributed to combining alcohol with opiates; this has now reached one in two. </p>
<p>In 2010, the newly elected Conservative government introduced a <a href="https://www.gov.uk/government/publications/drug-strategy-2010">new treatment strategy</a>. The policy emphasised the importance of achieving abstinence from drugs rather than merely reducing the harm they can cause. This recovery agenda may have inadvertently contributed to the rise in drug deaths. Unfortunately, even if abstinence is achieved, the <a href="http://bit.ly/2cbURiS">odds of relapsing</a> are high. Abstinence <a href="http://www.bjmp.org/files/2013-6-1/bjmp-2013-6-1-a601.pdf">reduces the ability</a> to tolerate previously manageable doses of heroin, resulting in an overdose for some. </p>
<h2>Treatment risk</h2>
<p>Treatment does reduce mortality. A <a href="http://www.nta.nhs.uk/uploads/trendsdrugmisusedeaths1999to2014.pdf">recent report</a> showed that most opiate deaths were of people not in treatment. Treatment usually involves providing a substitute drug with the aim of weaning the individual off heroin. Methadone and buprenorphine are commonly used to do this. But there are two critical factors, retaining people in treatment and what happens when treatment finishes. The month following treatment is particularly important as a person’s tolerance to opiates will have reduced, increasing the risk of overdose <a href="http://onlinelibrary.wiley.com/doi/10.1111/add.13087/full">if the person relapses</a>. Following up people at this critical stage could help reduce the risk of fatality. </p>
<p>But the challenge is how to engage those who are not in treatment. Attracting this group requires a more radical approach. <a href="https://theconversation.com/why-australia-needs-drug-consumption-rooms-53215">Drug consumption rooms</a> provide a safe place for people to use their drugs, providing clean syringes for those who inject heroin. These facilities have an impressive record of reducing fatalities due to drug use. And, just as important, they are the first step towards engaging a marginalised group into health and social care. We don’t need any more evidence as to their value – we need what politicians crave: <a href="http://www.tandfonline.com/doi/abs/10.3109/14659891.2016.1143049">public support</a>.</p>
<p>Naloxone can also temporarily reverse the effects of an opiate overdose. Making this drug available to opiate users and their families offers the potential to reduce fatalities. Scotland has pioneered this by implementing a <a href="http://onlinelibrary.wiley.com/doi/10.1111/add.13265/pdf">national naloxone policy</a> and new regulations in England have <a href="https://www.gov.uk/government/publications/widening-the-availability-of-naloxone/widening-the-availability-of-naloxone">allowed this approach to be mirrored</a>. This development gives workers and heroin users access and permission to administer naloxone when an overdose occurs.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/137083/original/image-20160908-25260-hhapzw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/137083/original/image-20160908-25260-hhapzw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/137083/original/image-20160908-25260-hhapzw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/137083/original/image-20160908-25260-hhapzw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/137083/original/image-20160908-25260-hhapzw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/137083/original/image-20160908-25260-hhapzw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/137083/original/image-20160908-25260-hhapzw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Naloxone can reverse the effects of an opiate overdose.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-418417357/stock-photo-layton-utah-march-11-2016-vial-of-naloxone-drug-which-is-used-for-opiate-drug-overdose-it-is-now-available-to-patients-without-a-prescription-or-over-the-counter.html?src=HeShWLVmobUTJtghilzrNw-1-0">PureRadiancePhoto/Shutterstock.com</a></span>
</figcaption>
</figure>
<h2>A glimpse into the future?</h2>
<p>The US has witnessed a 200% rise in prescription-opiate deaths since the millennium, driven by <a href="http://onlinelibrary.wiley.com/doi/10.1111/ajt.13776/full">increasing availability and lower costs</a>. The regulatory and marketing environments differ in the US and the UK. In the UK, open marketing of opiates is prohibited and there are stricter controls and monitoring of prescribing. But current drug control measures are outdated and <a href="http://www.tandfonline.com/doi/abs/10.3109/14659891.2014.980861">easily circumvented by the internet</a>.</p>
<p>So we need to carefully monitor the use and misuse of a range of prescription drugs such as tramadol. Tramadol is an analgesic used for moderate to severe pain. Prescriptions for tramadol rose dramatically over the <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsrelatedtodrugpoisoninginenglandandwales/2015registrations">last decade</a>, as did deaths thought to be the result of misusing the drug. This prompted new regulations which came into force last year with the aim of curbing tramadol-related deaths. This year’s ONS data shows that one year after the introduction of these regulations deaths have reduced, but we will need to see if this trend continues.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/137202/original/image-20160909-13345-2cdpp9.PNG?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/137202/original/image-20160909-13345-2cdpp9.PNG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/137202/original/image-20160909-13345-2cdpp9.PNG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=366&fit=crop&dpr=1 600w, https://images.theconversation.com/files/137202/original/image-20160909-13345-2cdpp9.PNG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=366&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/137202/original/image-20160909-13345-2cdpp9.PNG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=366&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/137202/original/image-20160909-13345-2cdpp9.PNG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=460&fit=crop&dpr=1 754w, https://images.theconversation.com/files/137202/original/image-20160909-13345-2cdpp9.PNG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=460&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/137202/original/image-20160909-13345-2cdpp9.PNG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=460&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Tramadol deaths.</span>
<span class="attribution"><span class="source">Office for National Statistics</span></span>
</figcaption>
</figure>
<p>A clear measure of the UK government’s ambition to reduce inequality is <a href="http://www.huffingtonpost.co.uk/clare-bambra/theresa-may-health-inequalities_b_11716312.html">halting the rise in drug overdoses</a>. Avoidable fatalities due to drugs serve as a barometer of how equal our society is and how we respond to individual vulnerability. We all lose out when an individual dies this way.</p>
<p>Public Health England has responded to the trend in drug fatalities, publishing <a href="http://www.nta.nhs.uk/uploads/phe-understanding-preventing-drds.pdf">several recommendations</a>. There are some welcome aims but they could be bolder. The time has come to introduce drug consumption rooms – it’s a life or death decision.</p><img src="https://counter.theconversation.com/content/64972/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ian Hamilton is affiliated with Alcohol Research UK.. </span></em></p><p class="fine-print"><em><span>Mark Monaghan does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Opiates have emerged as a significant threat to public health in the UK.Ian Hamilton, Lecturer in Mental Health, University of YorkMark Monaghan, Lecturer in Crimimology and Social Policy, Loughborough UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/431842015-07-02T01:40:43Z2015-07-02T01:40:43ZForced rehabilitation of drug users in Indonesia not a solution<figure><img src="https://images.theconversation.com/files/86817/original/image-20150630-5864-1q3pbut.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Indonesia is forcing people with drug dependence problems to go into rehab. </span> <span class="attribution"><span class="source">joloei/www.shutterstock.com</span></span></figcaption></figure><p>Earlier this year, Indonesia <a href="https://theconversation.com/bali-nine-duo-executed-the-view-from-indonesia-38392">executed</a> 14 people, including Bali Nine duo Andrew Chan and Myuran Sukumaran, for drug offences. President Joko Widodo <a href="http://www.aljazeera.com/programmes/talktojazeera/2015/03/joko-widodo-strong-message-drug-smugglers-150305131413414.html">portrayed</a> the executions as the ultimate weapon in an expansive “war on drugs” deployed to protect the country’s young generation from an <a href="https://theconversation.com/indonesia-uses-faulty-stats-on-drug-crisis-to-justify-death-penalty-36512"> alleged “national drug emergency”</a>.</p>
<p>But his policy is harming the very people he claims he wishes to protect. </p>
<h2>A problematic approach</h2>
<p>Widodo’s tough approach does not only apply to drug traffickers. The Indonesian government, through its anti-drug agency, the National Narcotics Board (BNN), is <a href="http://www.republika.co.id/berita/nasional/hukum/15/05/23/norwnd-bnn-pecandu-narkoba-wajib-jalani-rehabilitasi">pushing compulsory treatment</a> for people with drug dependence. This coercive approach is jeopardising health gains made by existing harm reduction programs and is fertile ground for corruption and abuse.</p>
<p>BNN pledges to rehabilitate 100,000 drug users in 2015. They aim to double the numbers every year – to 200,000 in 2016 and 400,000 in the year after that. </p>
<p>But there aren’t enough problematic drug users in Indonesia to meet these targets. According to estimates by the Ministry of Health, Indonesia is home to about 74,000 injecting drug users. Only a fraction may choose drug treatment at any given time. </p>
<p>Some civil society groups working on the ground consider even this an overestimation. National Narcotics Board statistics claim a large number of crystal meth and cannabis users, but Indonesian academics argue these numbers have been derived using <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)61058-3/fulltext">questionable methods</a>. </p>
<p>There is a strong movement in Indonesia opposing the government’s tough approach. Activists in 15 cities in Indonesia last week joined a <a href="http://supportdontpunish.org/day-of-action-2015/">worldwide</a> call for governments to end the counterproductive war on drugs. </p>
<h2>Mandatory rehab = incarceration</h2>
<p>Last year, seven government bodies in Indonesia, including BNN, the police, the Ministry of Health, and the Ministry of Social Affairs, <a href="http://www.thejakartapost.com/news/2014/03/12/rehab-better-can-drug-users.html">signed a Memorandum of Understanding</a> promoting rehabilitation for drug users. The memorandum appears to promote a more lenient approach to addressing drug use, calling for drug users to be “rehabilitated rather than incarcerated”. </p>
<p>But, in practice, BNN’s special drug eradication squad often seek out and forcibly detain suspected drug users; few people with drug dependence voluntarily choose treatment under the agency’s programs. </p>
<p>Indonesia currently has more than 400 addiction treatment facilities in hospitals, government narcotics clinics, and privately-run centres. But the country lacks formalised national best practice standards for addiction treatment. Options range from medical detox in hospitals and 12-step programs, to religious or spiritual centres that boast “curing” drug dependence using magic, prayer, beatings, and shackling drug users in cages with a ball and chain. </p>
<p>Most share the same goal: abstinence from drugs. And few independently evaluate the effectiveness of their programs. </p>
<p>To meet the 2015 target, the government is establishing <a href="http://slank.com/potlot/tempat-pendaftaran-pelaporan-rehabilitasi-narkoba-gratis/">additional drug rehabilitation centres inside</a> 60 prisons and 30 police and military training academies.</p>
<p>It is hard to imagine how the <a href="http://www.insideindonesia.org/overcrowding-crisis">substandard, overcrowded conditions</a> and limited health facilities of existing prisons in Indonesia can address the nation’s drug woes. <a href="http://www.justiceaction.net/2015/05/surat-terbuka-kepada-slank-tolak-tempat.html">Critics claim</a> sending people to rehabilitation centres in prison is simply another form of imprisonment or involuntary detention. </p>
<h2>Corruption and abuse</h2>
<p>When Indonesia amended its narcotics law in 2009, there was hope for a more balanced response to drugs. The revised law effectively decriminalised possession of small amounts of drugs for personal use by providing judges with the discretion to divert drug users to treatment programs instead of prison. But, in practice, the criminalisation of drug use continued. </p>
<p>Some authorities use the new legal provisions to extract heftier prices from well-off drug users, and downgrade the offence they were charged with. As of May 2015, 36% of prisoners in the country’s 427 overcrowded detention facilities are serving time for drug use.</p>
<p>Working together with the <a href="http://www.pkni.org">Indonesian Drug Users Network</a>, I am documenting a host of coercive and abusive measures carried out by law enforcement in the name of rehabilitation. </p>
<p>Health workers in Jakarta have reported an increase in the number of drug raids since January 2015 in known drug-use hot spots, but also in apartment buildings, schools, and community health clinics. </p>
<p>We found cases of forced urine testing, corruption, extortion, intimidation, and confidentiality breaches. Officers photograph suspected drug users against their will. They offer money in exchange for snitching on friends and family members who may use drugs. They demand access to private client records at methadone substitution clinics and other organisations working with drug users.</p>
<p>The government should seriously reconsider this approach, as <a href="https://www.unodc.org/documents/ungass2016//contributions/civil/count-the-costs-initiative/awdr.pdf">studies have shown</a> that criminalisation and punitive law enforcement approaches can lead to higher drug-related criminality and increased risk of contracting HIV and hepatitis C, among other unintended social and economic costs.</p>
<h2>Compulsory treatment is ineffective</h2>
<p>Indonesia’s coercive measures are at odds with <a href="http://www.unodc.org/southeastasiaandpacific/en/2012/10/ccdus/story.html">a broader tendency</a> in Asia to move away from compulsory treatment and transition toward voluntary, <a href="http://apps.who.int/iris/bitstream/10665/77969/1/9789241504379_eng.pdf">scientifically and medically appropriate approaches</a> to managing drug use. </p>
<p>Compulsory treatment and rehabilitation is costly and ineffective in addressing drug issues; relapse rates are high. There is no evidence that compulsory treatment leads to positive health outcomes among drug users or that it has any effect on drug use rates. </p>
<p>Instead, <a href="http://www.ijdp.org/article/s0955-3959(14)00335-1/fulltext">compulsory treatment</a> in countries such as Cambodia, China, Malaysia, Myanmar, Philippines, Thailand and Vietnam has led to increased HIV risks, added stigma and discrimination against drug users, and <a href="http://www.countthecosts.org/sites/default/files/ihra_compulsory_treatment.pdf">human rights violations</a>.</p>
<p>In July 2012, the United Nations issued a <a href="http://www.unaids.org/en/media/unaids/contentassets/documents/document/2012/jc2310_joint%20statement6march12final_en.pdf">Joint Statement</a> calling for the closure of compulsory drug detention and rehabilitation centres. They called governments to adopt “voluntary, evidence-informed and rights-based health and social services in the community”. </p>
<h2>Alternatives to compulsory treatment</h2>
<p>Harm reduction interventions such as <a href="http://www.who.int/hiv/topics/idu/needles/en/">needle syringe programs</a> and <a href="https://en.wikipedia.org/wiki/Methadone_maintenance">methadone maintenance therapy</a> are some of the world’s most effective and affordable treatments available. If President Widodo is serious about managing Indonesia’s drug problem, he should urgently scale up these proven strategies.</p>
<p>Methadone maintenance therapy reduces heroin use, HIV transmission, criminal activity and risk of drug-related death. The expansion of such programs in Indonesia has helped reduce HIV rates among injectors from 42% in 2011 to 36% in 2013, bringing thousands of drug users closer to health and support services. </p>
<p>Indonesia is also home to some of Asia’s most successful voluntary, community-based treatment programs for drug users. These include <a href="http://rumahcemara.org/en/about-us/">Rumah Cemara</a> and <a href="http://rumahpeka.org/">Rumah Singgah PEKA</a>, which are currently in the process of being documented as best practice treatment models by the United Nations Office on Drugs and Crime (UNODC). </p>
<p>These and more than a dozen programs like them are based in non-government organisations, often run by former drug users and offering a menu of evidence-based harm reduction and treatment options from which clients can choose. </p>
<p>The outcome isn’t always abstinence from drugs, but an improvement in the client’s social function, overall health, productivity, reduction in risky drug use patterns, and personal goals. </p>
<p>From a public health perspective, drug use is best portrayed as existing on a spectrum from beneficial to problematic. The majority of people who try drugs or use them occasionally <a href="https://www.scribd.com/doc/270054187/James-C-Anthony-2002-C109-1557-1574">never develop dependence or problematic use patterns</a>. </p>
<p>Leaders who want to support those dealing with drug dependence should listen to their needs and support them with strategies that work, rather than instituting policies that punish them.</p><img src="https://counter.theconversation.com/content/43184/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Claudia Stoicescu is affiliated with Persaudaraan Korban Napza Indonesia (PKNI)/Indonesian Drug Users Network, with whom she is currently collaborating on joint research.</span></em></p>Indonesia’s war on drugs aims to protect the country’s young generation from an alleged “national drug emergency.” But the government’s coercive approach is harming the people it wishes to protect.Claudia Stoicescu, Associate Professor, Public Health, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/406312015-05-13T06:45:15Z2015-05-13T06:45:15ZAwareness campaigns need to target the real victims of ice<figure><img src="https://images.theconversation.com/files/81491/original/image-20150513-25052-m9o97p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Instead, we need to adopt a harm-minimisation approach. </span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-193975568/stock-photo-man-slumped-on-sofa-with-drug-paraphernalia-in-foreground.html?src=2rYBphv_c167L_RK3of-3g-1-4">Monkey Business Images/Shutterstock</a></span></figcaption></figure><p>This week the <a href="http://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel-yr2015-nash015.htm">federal government launched</a> a television advertising campaign to warn young people and their families about the harms of using crystal methamphetamine, also known as “ice.” The first ad in the A$9 million campaign, depicting ice-fuelled violence in the home and a hospital emergency department, will run for four weeks on television and six weeks online. </p>
<p>The government also set aside <a href="http://www.budget.gov.au/2015-16/content/bp2/html/bp2_expense-14.htm">A$20 million in Tuesday’s budget</a> for ice awareness campaigns over the next two years. This comes as the Commonwealth government prepares its interim <a href="http://www.dpmc.gov.au/taskforces/national-ice-taskforce">National Ice Taskforce</a> report, which aims to develop a collaborative federal-state response to the drug.</p>
<p>But international evidence suggests such “awareness” campaigns are not the most appropriate way to address harmful methamphetamine use. In fact, fear-based approaches can increase stigma which possibly drives people away from, rather than towards, treatment.</p>
<h2>No methamphetamine epidemic</h2>
<p>Australian media outlets and politicians claim we’re facing a nationwide “ice <a href="http://www.abc.net.au/news/2015-05-05/governor-youthie/6446546">epidemic</a>”. But ice is just one – albeit typically very pure – form of methamphetamine and the most up-to-date <a href="http://www.ncbi.nlm.nih.gov/pubmed/25559677">research</a> estimates that the proportion of Australians who have used any type of methamphetamine (ice, “speed” powder) in the previous year has remained relatively stable for at least the last <a href="http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129549848">decade</a>.</p>
<p>Nevertheless, the government and media’s continued use of hyperbolic language – in addition to a tendency to ignore and sometimes <a href="http://www.dailytelegraph.com.au/news/nsw/ice-scourge-needs-a-strong-response/story-fni0cx12-1227296149027">dismiss</a> public health experts’ advice on ice – has the potential to incite unnecessary fear and misinform the public about this supposed “<a href="http://www.governmentnews.com.au/2015/04/abbott-goes-cold-on-ice-menace/%22">menace</a>”. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/GIh6Tb0O9sA?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">The government’s TV ad campaign started this week.</span></figcaption>
</figure>
<p>Victorian premier Daniel Andrews, for instance, <a href="http://www.abc.net.au/news/2015-03-05/victoria-unveils-455m-plan-to-tackle-ice-problem/6282258">recently claimed</a> 80,000 Victorians had used the “evil” drug ice in the previous year. ABC Fact Check subsequently <a href="http://www.abc.net.au/news/2015-04-07/ice-users-in-victoria/6346708">investigated</a> the accuracy of this figure and, based on the most recent National Drug Strategy Household <a href="http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129549848">Survey</a> (NDSHS) and expert advice, concluded that the statement was not supported by data. </p>
<h2>Use and harm</h2>
<p>According to the NDSHS, in 2013 around 2% of the Australian population used any methamphetamine (speed powder, ice or “base”) in the previous 12 months. Only about 16% of these “recent” methamphetamine users reported using the drug once a week or more. </p>
<p>Regardless, using methamphetamine – particularly frequent and heavy use – <a href="http://www.ncbi.nlm.nih.gov/pubmed/18368606">is associated with</a> serious psychological, physical, social and financial harms.</p>
<p>The risk of experiencing such effects is likely to have increased due to the dramatic <a href="http://www.ncbi.nlm.nih.gov/pubmed/25220170">rise in purity</a> of methamphetamine in recent years. The average purity of speed powder and crystal methamphetamine seizures in Victoria increased from 12% to 37% and 21% to 64% respectively in the four years up to 2013. </p>
<p>It’s therefore crucial we that don’t undermine the experiences of individuals, families and communities impacted by the harmful use of the drug. </p>
<p>Rather, we need to accurately define the issue, including the nature and extent of methamphetamine use and related harms in rural and regional areas, to allow the development and implementation of cost-effective, evidence-based and timely responses. </p>
<h2>Awareness campaigns</h2>
<p>Numerous studies have indicated “what works” with regard to public awareness, education and prevention strategies which aim to reduce harms related to licit substances, such as <a href="http://www.tobaccoinaustralia.org.au/14-4-examining-effectiveness-of-public-education-c#x21.">tobacco use</a> and <a href="http://www.aic.gov.au/media_library/publications/tandi_pdf/tandi472.pdf">drink driving</a>. But there is little evidence that similar initiatives targeting illegal drugs are effective. </p>
<p>The limited available research suggests that the well-known, graphic <a href="http://www.google.com.au/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=0CB4QFjAA&url=http%3A%2F%2Fwww.montanameth.org%2F&ei=H79JVfmZPOSgmwXBs4CIBA&usg=AFQjCNGsCkgtUZNS9CQJN-mXvwVZocT6zw&bvm=bv.92291466,d.dGY">Montana Meth Project</a> and <a href="http://www.facesofmeth.us/">Faces of Meth</a> advertising campaigns in the United States are costly, ineffective and possibly even counterproductive. </p>
<figure>
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<figcaption><span class="caption">Faces of Meth campaign.</span></figcaption>
</figure>
<p>The findings of one study suggest that the Montana Meth Project might actually increase acceptability and decrease perceptions of risk relating to using methamphetamine.</p>
<p><a href="http://www.ncbi.nlm.nih.gov/pubmed/20638737%20study">Another</a> noted that:</p>
<blockquote>
<p>“When accounting for a pre-existing downward trend in meth use… [the campaign’s] effects on meth use are statistically indistinguishable from zero.”</p>
</blockquote>
<p>Concerns about the efficacy of such initiatives are reflected in the HIV <a href="http://wsuengdoctors.pbworks.com/w/file/fetch/60398594/Fear%20apeals.pdf">literature</a>, which suggests that fear-based approaches can lead to stigma and poor health outcomes, such as from reduced treatment-seeking.</p>
<h2>Reducing the harms from meth use</h2>
<p>Many of the evidence-based suggestions put forward by leading experts are not – at least currently – politically palatable and are therefore unlikely to be implemented anytime soon. </p>
<p>Extensive international <a href="http://www.druginfo.adf.org.au/topics/supervised-injecting-facilities">research</a>, for example, shows safe-injecting facilities such as the one in Sydney’s Kings Cross can have enormous public health benefits. These include preventing blood-borne virus transmission, freeing-up health-care resources and improving drug treatment pathways. However, we are yet to see a comparable service implemented in any of Australia’s other drug use “hot spots.” </p>
<p>It is also unlikely that Australia will soon follow the lead of nations and jurisdictions that have decriminalised, legalised or “controlled” previously illicit substances. These include Portugal and the United States, with Ecuador’s government <a href="http://panampost.com/rebeca-morla/2015/04/14/ecuador-breaks-the-ice-on-drug-legalization-in-landmark-bill/">currently</a> debating the issue.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/81496/original/image-20150513-20475-qit2e4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/81496/original/image-20150513-20475-qit2e4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/81496/original/image-20150513-20475-qit2e4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/81496/original/image-20150513-20475-qit2e4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/81496/original/image-20150513-20475-qit2e4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/81496/original/image-20150513-20475-qit2e4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/81496/original/image-20150513-20475-qit2e4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The average purity of speed powder and crystal methamphetamine seizures in Victoria increased in recent years.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-97440071/stock-photo-female-hand-retrieving-drug-packet-our-of-her-blue-jean-pocket-with-copy-space-on-black.html?src=pp-photo-755829-NeJk99chI1rL5pBu_mip7A-7&ws=1">Sylvie Bouchard/Shutterstock</a></span>
</figcaption>
</figure>
<p>As many have said before, drug policies in Australia need to ubiquitously incorporate the proven approach of harm-minimisation. </p>
<p>Although our <a href="http://www.nationaldrugstrategy.gov.au/internet/drugstrategy/publishing.nsf/Content/national-drug-strategic-framework-lp">National Drug Strategic Framework</a> is underpinned by this principle, failure to adopt evidence-based techniques that reduce drug-related harms, such as more safe-injecting facilities and <a href="https://ndarc.med.unsw.edu.au/resource/prison-based-syringe-exchange-review-international-research-and-program-development">prison-based needle exchanges</a>, indicates a discrepancy between policy and practice. </p>
<p>Because people will choose to engage in drug use (both licit and illicit) regardless of the policies and programs in place, we need to encourage them to do so as safely as possible. We also must continue to inform the public about options for managing drug-related consequences and appropriate and available means for professional support, such as telephone and internet counselling <a href="http://www.health.vic.gov.au/aod/directline.htm">DirectLine</a> and <a href="https://www.counsellingonline.org.au/">Counselling Online</a>. </p>
<p>Addressing barriers to drug treatment and ensuring that such services are adequately resourced is vital to meeting the needs of methamphetamine and other drug users at the “pointy end” of the spectrum. </p>
<p>But providing targeted and relevant harm reduction education and ensuring that support is available to individuals who aren’t yet ready – or who <a href="http://www.ncbi.nlm.nih.gov/pubmed/23867050">don’t see a need</a> – to use drug treatment is just as important for preventing the transition to more harmful use patterns.</p><img src="https://counter.theconversation.com/content/40631/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Brendan Quinn has worked on research projects funded by the National Health and Medical Research Council to study methamphetamine use and related issues.</span></em></p><p class="fine-print"><em><span>Paul Dietze has received funding from the National Health and Medical Research Council, the Australian Research Council, the Commonwealth Department of Health and Ageing and the National Drug Law Enforcement Research Fund to study methamphetamine use and harms.</span></em></p>International evidence suggests “awareness” campaigns are not the best way to address harmful methamphetamine use. Fear-based approaches can increase stigma and drive people from treatment.Brendan Quinn, Research Officer (drug and alcohol epidemiology), Burnet InstitutePaul Dietze, Head of Alcohol and other Drug Research, Centre for Population Health; Burnet Principal for Alcohol, other drugs and harm reduction, Burnet InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/405502015-04-28T09:58:20Z2015-04-28T09:58:20ZSyringe exchange in southern Indiana to respond to an increase in HIV cases: better late than never?<p>The recent <a href="http://www.nytimes.com/2015/04/19/us/indiana-says-hiv-outbreak-is-worsening.html">upsurge in HIV cases</a> linked to injection drug use in southern Indiana has thrust the issue of syringe exchange programs (SEPs) into the headlines. While authorities are linking these cases of HIV infection directly to injecting drugs, it is unknown how many are caused by sexual activity with an infected drug user.</p>
<p>Nearly all states prohibit possession of syringes other than for medical need through their drug paraphernalia laws. Syringe access laws that require ID and proof of medical need to purchase them from pharmacies also exist in the majority of states, including Indiana. Federal funding of <a href="http://www.publichealthlaw.net/Research/PDF/syringe.pdf">syringe exchange programs</a> is banned as well. </p>
<p>To respond to the current outbreak, Indiana Governor <a href="http://www.in.gov/gov/">Mike Pence</a> <a href="http://cbs4indy.com/2015/04/20/pence-extends-hiv-emergency-order-in-scott-co-lawmakers-debate-expanding-needle-exchanges/">signed a 30-day exception</a> to the state’s restriction on needle exchange programs. The governor has extended the exception <a href="http://www.usatoday.com/story/news/nation/2015/04/21/ind-needle-exchange/26114799/">for another 30 days</a>, as the state’s legislature considers legalizing needle exchanges in some areas. The Centers for Disease Control and Prevention as well as other federal and state personnel are working to <a href="http://www.indystar.com/story/news/2015/04/21/beyond-needle-exchange-containing-hiv-outbreak/26145339/">contain the outbreak</a>. </p>
<p>This upsurge in HIV cases in Indiana hasn’t exactly come out of nowhere. An increase in Hepatitis C cases (which can also be spread through re-used syringes) began nearly <a href="http://www.indystar.com/story/news/2015/04/21/beyond-needle-exchange-containing-hiv-outbreak/26145339/">fifteen years ago</a> in Scott County, so officials should not have been surprised that a corresponding rise in HIV cases would eventually follow. </p>
<h2>Injection drug use and HIV</h2>
<p>Injection drug use (IDU) is a well known <a href="http://www.cdc.gov/hiv/pdf/statistics_2009_HIV_Surveillance_Report_vol_21.pdf">risk factor for HIV</a>, as well as Hepatitis B and C infections. The fact is that injection drug use accounts for about <a href="http://www.drugabuse.gov/publications/addiction-science/hivaids/injection-drug-use-has-contributed-to-nearly-one-third-cases-hiv">one-third of HIV infections in the country</a> since the beginning of the epidemic. </p>
<p>Transmission of HIV occurs through an exchange of bodily fluids. In the case of injection drug use, transmission can occur not only by sharing needles, but by sharing any of the materials used to <a href="https://www.aids.gov/hiv-aids-basics/prevention/reduce-your-risk/substance-abuse-use/">prepare and inject the drug</a>, such as water or cotton used to filter the solution. </p>
<p>Women are <a href="http://www.cdc.gov/hiv/risk/gender/women/facts/index.html">particularly vulnerable</a>, either from injecting drugs themselves, or from having unprotected sex with injection drug users, and women account for about twenty percent of new HIV infections yearly. </p>
<h2>Why do people reuse syringes?</h2>
<p>In most states, access to syringes is <a href="http://www.publichealthlaw.net/Research/PDF/syringe.pdf">severely restricted</a>. This forces injection drug users to reuse or borrow syringes. </p>
<p>These laws intending to prevent illegal injection drug use, while perhaps well-intentioned, do not prevent it. Drug users do not quit because they don’t have access to new syringes. Not having access to a clean glass doesn’t keep me from being thirsty. Glass or no, I will find a way to get a drink of water. </p>
<p>Being forced to re-use dirty syringes places not only the drug user at risk of greater harm, but the public as well. </p>
<p>In my twenty years of work in the HIV field, I have seen patients who borrowed family members’ insulin syringes, migrant workers who shared syringes used to inject liquid vitamins, hospital workers who recovered used syringes from the trash. These syringes are used repeatedly until the needle is too dull to pierce skin. One HIV-positive person places the entire needle-sharing network at risk.</p>
<p>For example, a 73-year-old grandmother was referred to our HIV clinic after her grandson, a 29-year-old addict, had infected her by using and returning her insulin syringes. </p>
<p>We saw groups of migrant workers who had shared needles to inject the liquid vitamins needed to withstand the hard labor, and who were all now HIV positive. We also saw diabetics who shared insulin syringes to save the expense of new ones. The substance being used doesn’t matter – only the syringe.</p>
<h2>Injection drugs and poverty: a few hours of escape</h2>
<p>Research also shows an association between <a href="http://www.cdc.gov/hiv/risk/other/poverty.html">poverty and both illegal drug use and HIV infection</a>. The stresses of living in poverty are well known, and often people feel the only ways to relieve the stress include escaping through drug use. </p>
<p>In research conducted in 2011, at Indiana University-Purdue University Fort Wayne (IPFW), located in the center of northeast Indiana counties similar to Scott County, the epicenter of the latest outbreak, we interviewed fifty injection drug users about their drug use. Of the people we interviewed, only one was employed and the rest were living in impoverished situations. Some of the women survived by trading sex for drugs, others in the sample sold drugs – either illegal drugs or legal prescription medications. </p>
<p>They all agreed that getting high was one of the only times they felt good, and while they felt guilty about using drugs, they couldn’t give up those few hours of escape that the drugs gave them. Becoming addicted, they then couldn’t quit.</p>
<p>None of the people in our sample used drugs alone; they were accompanied by at least one other person, and everyone shared needles at least “several times.” Frequent unprotected sex was reported, and only one person reported knowing their HIV status. </p>
<p>Frequently, as the CDC <a href="http://www.cdc.gov/mmwr/preview/mmwrhtml/mm64e0424a1.htm?s_cid=mm64e0424a1_x">has reported</a> for Scott County, families use drugs together, making it a multigenerational issue.
In this case some cases also involve pregnant women who, in a resource-poor area, may or may not have access to treatments that would prevent transmission to their unborn child.</p>
<p>That isn’t unusual. Many people with HIV don’t know about their positive status. According to the Centers for Disease Control and Prevention, about <a href="http://www.cdc.gov/hiv/statistics/basics/ataglance.html">14% of 1.2 million HIV positive persons</a> in the US do not know they are HIV positive. </p>
<h2>Syringe exchanges can also provide medical services and drug treatment information</h2>
<p>Given the incidence of HIV infection in rural, impoverished areas, plus the transmission routes of shared injection syringes and unprotected sex, the situation in southern Indiana is not surprising, and a syringe exchange program (SEP) is a logical response. These programs have been around nearly as long as we have known how HIV is transmitted. </p>
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<a href="https://images.theconversation.com/files/79329/original/image-20150426-14558-79pokx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/79329/original/image-20150426-14558-79pokx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/79329/original/image-20150426-14558-79pokx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=899&fit=crop&dpr=1 600w, https://images.theconversation.com/files/79329/original/image-20150426-14558-79pokx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=899&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/79329/original/image-20150426-14558-79pokx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=899&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/79329/original/image-20150426-14558-79pokx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1130&fit=crop&dpr=1 754w, https://images.theconversation.com/files/79329/original/image-20150426-14558-79pokx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1130&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/79329/original/image-20150426-14558-79pokx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1130&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Syringe exchanges are about more than syringes.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/riekhavoc/6858609934">Kaytee Riek</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-sa/4.0/">CC BY-NC-SA</a></span>
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<p>I worked with one such program. A typical SEP trades one sterile syringe for each used syringe. This approach does not put additional syringes on the street. Many programs also include bleach kits and instructions for properly cleaning syringes when clean ones are not available. They also provide condoms and information about safer sexual practices and includes the opportunity for HIV testing. </p>
<p>Research has consistently shown that SEPs <a href="http://www.cdc.gov/idu/facts/aed_idu_syr.pdf">do not increase drug use</a> or the number of used syringes discarded in streets and playgrounds. Further, SEPs provide <a href="http://www.cdc.gov/idu/facts/aed_idu_syr.pdf">a point of contact</a> for obtaining HIV testing, substance abuse counseling, screening for tuberculosis (TB), hepatitis B, hepatitis C, and other infections as well as referral for medical services. </p>
<p>When I handed out a sterile syringe, bleach kit, and condoms, I also included information about drug rehabilitation, jobs, housing, and my business card. More than once, I received phone calls months later from drug users I had contacted through the SEP who then wanted help with recovery.</p>
<h2>Syringe exchanges should be the rule, not the exception</h2>
<p>The response to the Scott County situation <a href="http://www.indystar.com/story/news/2015/04/21/beyond-needle-exchange-containing-hiv-outbreak/26145339/">seems reasonable</a>. However, given the predictability of this current outbreak based on the Hepatitis C increase beginning 15 years ago,the Scott County response comes late in the game. </p>
<p>Any HIV statistics are likely underestimates of the true numbers, and given the percentage of persons who are positive and do not know it, the incidence of known HIV cases in Scott and other Indiana counties is quite likely to increase. </p>
<p>Officials would have served the population better with preventative services in place. Governor Pence and the Indiana State Legislature would do well to put establishment of syringe exchange programs on a fast-track to-do list so there is a way to stem the tide of new HIV infections.</p><img src="https://counter.theconversation.com/content/40550/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jeannie D. DiClementi does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Officials in Indiana would have served the population better if syringe exchanges had been in place before the upsurge in HIV cases began.Jeannie D. DiClementi, Associate Professor of Psychology, Indiana UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/283862014-06-24T20:26:42Z2014-06-24T20:26:42ZHIV in Australia: we’ve come a long way but there’s more to do<figure><img src="https://images.theconversation.com/files/52031/original/t834mst7-1403589139.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Prevention messages and consistent condom use have broken the nexus between sex work and HIV transmission in Australia. </span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/publik16/2532824517">publik16/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-sa/4.0/">CC BY-NC-SA</a></span></figcaption></figure><p>In the three decades since the virus was identified, Australia has done well by international standards in keeping HIV infection rates down. But certain aspects of our national approach continue to risk the national prevention strategy, and stigmatise people with HIV.</p>
<p>The last <a href="http://www.som.uq.edu.au/media/345623/10_australian_hiv_timeline.pdf">32 years have seen numerous advances</a> in HIV, from the early deaths in 1983, including the deaths of four Queensland babies who received blood transfusions, which led to the blood-screening program; through to the introduction of early combination therapy in 1992 and the reduction in people dying from AIDS-related illnesses after the introduction of combination therapy in 1996. </p>
<p>Since 1999, there has been a small but significant yearly increase in the number of people newly diagnosed with HIV; more people living relatively well with HIV increases the risk of exposure through unsafe sex. </p>
<p>Today, there are <a href="http://www.kirby.unsw.edu.au/surveillance/2013-annual-surveillance-report-hiv-viral-hepatitis-stis">an estimated 25,708 people</a> living with HIV infection in Australia, the majority of whom are gay men.</p>
<h2>The good and the bad</h2>
<p>One of the testaments to the medical successes in dealing with the virus is the significant number of <a href="http://www.latrobe.edu.au/__data/assets/pdf_file/0007/546037/HIV-Futures-Seven-Report.pdf">HIV-positive people living into old age</a>. They are coping with the same crises that beset us all as we get older, but with the additional burden of a chronic condition that interacts unpredictably with other diseases. </p>
<p>Despite the downsides of ageing, the fact that HIV-positive men and women are growing old is an outcome that far exceeds what we anticipated 30 years ago. Back then, most people infected with the virus could not expect to still be alive after five years.</p>
<p>Sitting alongside these celebrated advances is the necessity of a pragmatic public health approach to HIV and the frequent challenges posed by the need to regulate or legislate on HIV-related matters. </p>
<p>And there’s some good news here too: a strategic and policy-driven approach has been the most consistent feature of Australia’s response to HIV. The brave steps taken by the <a href="https://www.youtube.com/watch?v=REv6oC1jYUE">then-health minister Neal Blewett</a>, and others in successive governments were critical to HIV prevention. </p>
<p>Fundamental to this success was respect for the views of affected communities. A genuinely national approach in the early days, encapsulated in the first and subsequent national strategies, also ensured local – and sometimes parochial – views did not hold sway.</p>
<p>Nonetheless, there remains a conflicted relationship between government and HIV, particularly in the area of criminal law, reflecting society’s double standards with regard to sex and drugs. </p>
<h2>Drugs and prison</h2>
<p>Perhaps the best evidence of a successful public health initiative to prevent HIV transmission was the establishment and maintenance of needle and syringe exchange programs, early in the epidemic. These contributed to keeping HIV rates among injecting drug users very low indeed. </p>
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<img alt="" src="https://images.theconversation.com/files/52032/original/dy526ddn-1403589425.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/52032/original/dy526ddn-1403589425.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/52032/original/dy526ddn-1403589425.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/52032/original/dy526ddn-1403589425.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/52032/original/dy526ddn-1403589425.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/52032/original/dy526ddn-1403589425.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/52032/original/dy526ddn-1403589425.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">The criminalisation and prosecution of illicit drug use still exposes people to risks of blood-borne viruses within the prison system.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/yewenyi/2886512483">Brian Yap/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-sa/4.0/">CC BY-NC-SA</a></span>
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<p><a href="http://www.kirby.unsw.edu.au/surveillance/2013-annual-surveillance-report-hiv-viral-hepatitis-stis">Only 1.9% of newly-acquired HIV infections</a> in Australia are attributable to injecting drug use and the rate has been around 3% for the past decade. In contrast, an average of one in ten new HIV infections internationally is caused by injecting drug use and, in parts of Eastern Europe and Central Asia, that figure is over 80%. </p>
<p>Despite its clear success, Australia’s well-resourced needle and syringe exchange program is constantly under threat, always at risk of de-funding by a disapproving public (and media). But it remains the single most effective public health measure in Australia to reduce the harms of HIV and other blood-borne viruses.</p>
<p>Unfortunately, the criminalisation and prosecution of illicit drug use still exposes people to risks of blood-borne viruses within the prison system. </p>
<p>The recent introduction of a trial of safe injecting equipment in an ACT prison is a step in the right direction, and there’s a chance other jurisdictions may follow suit. Similarly, the confirmation of a <a href="http://www.sydneymsic.com/">safe injecting facility in Sydney</a> is a leap forward for public health, despite constant attacks from conservative forces. </p>
<h2>Sex, crime and stigma</h2>
<p>Internationally, sex work has been closely linked with HIV transmission but, in Australia, HIV-prevention messages and consistent condom use have broken this nexus, and rates of HIV remain very low among sex workers. </p>
<p>Still, the regulation of sex work has an even more chequered history. The various states and territories <a href="http://www.scarletalliance.org.au/laws/">criminalise different elements of sex work</a>, and there are plans in both Western Australia and South Australia to increase the legal attention on it. </p>
<p>But there’s very little hard evidence that a punitive approach improves the health and welfare of sex workers and their clients. Consider the hundreds of charges of soliciting or selling sex (or both) that go through the courts with little obvious deterrent or protective value.</p>
<p>Criminal law has also been used to prosecute potential exposure and transmission of HIV transmission. As with sex work, regulation varies across Australian jurisdictions. </p>
<p>One of the most striking state differences is that Victoria, South Australia and the Northern Territory criminalise HIV exposure (where there’s no transmission) while other states do not. This connection between HIV and the law <a href="http://napwa.org.au/files/napwa%20monograph%2009.pdf">exacerbates the stigma and discrimination</a> associated with living with the virus. </p>
<p>So when we welcome international HIV communities to Melbourne next month, we must be prepared for not only the praise and celebration of Australia’s long-standing effective HIV response, but also some criticism of our laws and regulations. They continue to support stigma and discrimination and run counter to efforts to make HIV a virus of the past.</p>
<p><br>
<strong><em>This article launches our coverage of the <a href="http://www.aids2014.org/">20th International AIDS Conference</a>, to be held in Melbourne from July 20 to 25. Look out for more pieces in the following weeks and full coverage during the conference.</em></strong></p><img src="https://counter.theconversation.com/content/28386/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Marian Pitts receives funding from the National Health and Medical Research Council and the Australian Research Council.</span></em></p>In the three decades since the virus was identified, Australia has done well by international standards in keeping HIV infection rates down. But certain aspects of our national approach continue to risk…Marian Pitts, Emeritus Professor, Australian Research Centre in Sex, Health and Society, La Trobe UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/88572012-08-15T20:43:29Z2012-08-15T20:43:29ZConviction politics: needle exchange established in ACT prison<figure><img src="https://images.theconversation.com/files/14283/original/thtryy86-1345011644.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Katy Gallagher and the ACT government have acted in the best interests of the community.</span> <span class="attribution"><span class="source">AAP/Alan Porritt</span></span></figcaption></figure><p>The announcement yesterday by Chief Minister Katy Gallagher to establish a needle exchange in the ACT’s Alexander Maconochie Prison is historic. Politicians need votes like the rest of us need oxygen. And they know that there are no votes in prisons. But prisoners are a major concern for public health and human rights.</p>
<p>Despite prison authorities all over the world doing everything in their power to stop drugs entering prisons, they still get in. And they always will. Charles Manson, the most closely-guarded prisoner in the Western world, was still able to obtain illicit drugs behind bars. </p>
<p>But why do prison inmates take drugs despite the huge risks they run? A prisoner once explained to me that “a day off your face is a day off your sentence”. Last year, an inmate in a Jakarta jail told me that drugs were sometimes cheaper in his prison than in the community.</p>
<p>Less than 1% of the community injects drugs. But those who do inject about two to three times a day (or about 60 to 100 times a month). These days people injecting in the community are likely to share needles and syringes with about half a dozen close friends each year. Most of the time, they inject using brand new sterile needles and syringes. Other harm reduction measures are generally readily available. In the community HIV infections, but not hepatitis C infections, are rare.</p>
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<span class="caption">A prisoner once said to the author that – a day off your face is a day off your sentence.</span>
<span class="attribution"><span class="source">Todd Huffman</span></span>
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<p>That’s quite a contrast with the situation in prisons. Up to 25% of prisoners will inject drugs while they are behind bars. Prisoners who inject drugs do so much less frequently than their counterparts in the community – perhaps only half a dozen times a month. But they will often share each needle and syringe with between six and ten other inmates. The needles and syringes used in prison are cut down and will have been used previously, perhaps hundreds of times. They are perfect and efficient vehicles for transmitting viral infections. </p>
<p>Most HIV and hepatitis C infections that occur in prisons are only detected when the former inmate is back in the community. By then it’s almost impossible to prove where the infection was contracted. People who use drugs often serve frequent but short prison sentences and so often move between the community and prison.</p>
<p>It’s difficult explaining this situation to the community. More draconian approaches to prison are always expensive, rarely effective and often have severe unintended negative consequences. But draconian approaches are political viagra while pragmatic and effective approaches are often considered politically suicidal.</p>
<p>That’s why it’s taken more than 20 years before any politician in the English-speaking world has done what Katy Gallagher has had the courage to do. Politicians who stand up for important principles deserve to be strongly supported. Katy Gallagher will be greatly admired for the rest of her life by people who understand that protecting public health and human rights is critical.</p>
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<img alt="" src="https://images.theconversation.com/files/14281/original/2y7spy6y-1345011414.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/14281/original/2y7spy6y-1345011414.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/14281/original/2y7spy6y-1345011414.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/14281/original/2y7spy6y-1345011414.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/14281/original/2y7spy6y-1345011414.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/14281/original/2y7spy6y-1345011414.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/14281/original/2y7spy6y-1345011414.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">A needle exchange kit.</span>
<span class="attribution"><span class="source">Todd Huffman</span></span>
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<p>Sooner or later, a prisoner or former prisoner who can prove that they acquired HIV or hepatitis C in a correctional system elsewhere in Australia will sue the prison authority for failure to provide duty of care to the level provided in the community for the last quarter century.</p>
<p>A court will then award them a large sum of money. One by one, correctional authorities in other jurisdictions will act either before or after such a court case. But the experience with the introduction of community needle syringe programs in Australia in the late 1980s suggests that it will still be a difficult and protracted battle extending this decision to the rest of the country.</p>
<p>This is a great moment for public health and human rights. The ACT government’s decision reminds us that offenders get sent to prison as punishment, not for punishment. They’re certainly not sent to prison to acquire dangerous infections and then spread them to their loved ones and friends in the community.</p>
<p>Those who like to demonise all politicians should think about Katy Gallagher and the ACT government courageously acting in the best interests of the community. We should remember with gratitude how politicians from all parties in the early years of HIV excelled themselves by ranking the national interest above their short-term political interests. Katy Gallagher is following in this great tradition.</p><img src="https://counter.theconversation.com/content/8857/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alex Wodak is the president of the Australian Drug Law Reform Foundation. He has been involved with prison health meetings with UN Office Drugs and Crime.</span></em></p>The announcement yesterday by Chief Minister Katy Gallagher to establish a needle exchange in the ACT’s Alexander Maconochie Prison is historic. Politicians need votes like the rest of us need oxygen…Alex Wodak, Emeritus Consultant, St Vincent's Hospital, DarlinghurstLicensed as Creative Commons – attribution, no derivatives.