Side event: Progress in Asia in reducing HIV among people who inject drugs

Organized by the International Federation of Non-Governmental Organizations for the Prevention of Drug and Substance
Abuse, Association of Rehabilitation of Drug Abusers of Macau and Rumah Cemara.

 

Chair: Augusto has been working with people who use drugs for many years now, and given an award to recognise his work by the government of Macau.

Association of Rehabilitation of Drug Abusers of Macao (ARTM): Macao’s harm reduction approach combines methadone maintenance treatment (MMT), NSP and counselling, and its implementation is supported by a multi-stakeholder group comprising government and non-government agencies. Macao is a very small place, with a population of 600,000 people, and in 2004 many people were sharing needles as part of their injecting drug use. In 2003, 1 injecting drug user was infected with HIV, but in 2004 there were 18 IDU infected. This was considered an outbreak of HIV amongst people who inject drugs. At the time, there was no methadone, only buprenorphine treatment. Under the Anti-Drug Law (No. 5/91/M), there was no big conflict with the methadone maintenance treatment programme that was introduced, but there was with needle/syringe programmes and people were afraid to carry needles. There was a study visit to Australia and in 2006 there was a first meeting of the Macao AIDS Prevention and Control Commission, and six subgroups were proposed involving both governments and civil society. I am a part of the working group on the HIV response towards people who inject drugs. The pilot study for the methadone maintenance programme was started in 2005 and formally adopted in 2007.

In 2009, a new anti-drug law was announced that permitted needle/syringe programmes. The Commission took steps to have legal barriers removed and for special services to be delivered, including an inpatient center, infectious disease prevention centers, needle/syringe programmes and methadone maintenance treatment programmes which started in 2007, and is quite new compared with Hong Kong. Since 2008, the government also supported provision of anti-retroviral therapy and needle/syringe programmes. We also run a day care service, where people can stay there and feel safe. There is also a nurse on site. One of the problems is the relationship with the neighbours. In the beginning they were not happy with the services being there. The social affairs agency helped us with organising meetings with the neighbourhood to explain what we were doing. The crime rate in the area reduced. Last year we celebrated 10 years of the site’s operation, and invited the UNODC and government agencies to join in the anniversary event.

We also have a public housing safety campaign, where syringe collection services are offered. We have an important cooperation with the law enforcement as well, and they have safe syringe collection facilities.

Since 2008, 325, 252 used syringes have been recovered. The average attendance rate of the methadone maintenance programme is very high, at 80% from 2006 to 2018. The number of new infections resulting from injecting drug use in Macao has now fallen from 18 in 2004 (accounting for 60% of the total) to 0 in 2018 (0% in total). Access to treatment was very low and the likelihood of sharing needle/syringes was high given the smaller community of people who inject drugs. Since 2016, we have managed to achieve 0 new HIV infections amongst people who inject drugs. This success is due to strong multi-sectoral collaboration involving government and civil society. With the help of the law enforcement, corrections service (allowing harm reduction services to be implemented in prisons) and civil society, we managed to achieve a good result. Not all developments are negative in Asia and I hope Macao can be seen as a good role model. There are a lot of NGOs working in the harm reduction sector in Macao. The majority of funding for these operations is from the government. Strong communication, mutual respect and acceptance between the civil society and the Government was the key for the successful results in reducing the HIV among the PWID. Finally I would like to say thank you to Loretta Lei from the Social Welfare Bureau for preparing this presentation. I also thank other members of the government, and after many years of working together, we have managed to achieve something, that governments in the region can see as an example. Good results are only possible if we work together instead of opposing each other. It worked well in Macao because we did not impose our ideologies on each other.

Subhan Panjaitan, Rumah Cemara, Indonesia: Usually I talk about people who use drugs and legal problems. Today I will talk about alternative strategies in relation to people who use drugs and living with HIV. Rumah Cemara was founded by five (former) illegal drug consumers in 2003. This community organisation goals is to improve the quality of life of people with HIV/AIDS, people who use drugs, and other marginal people in Indonesia through a peer support approach. Rumah Cemara’s Vision is ‘Indonesia without stigma’ and discrimination where all humans people living with HIV, people who use drugs and other marginalised groups) can be a part of society. We have 5 areas of work in Rumah Cemara, including peer support for PLHIV, sport and advocacy. Why do we choose sport as an entry point for reducing stigma and discrimination amongst PLHIV and people who use drugs? Because it is acceptable, accessible, and it is a universal language. Some people respond by not believing that people living with HIV or using drugs could competently play sports.  We participated in the Indonesian football team in the Homeless World Cup, boxing, and will start joining marathons.

In our advocacy work, we carry out advocacy in relation to the narcotic law amendment, penal code amendment, presidential regulation about national health coverage, and the review carried out by the Ministry of Health Regulation about harm reduction, as well as in relating to health services and financial sustainability. We work with governments agencies, national NGOs and international partners. Our progress so far is having community involvement in the processes for amending the national narcotic law and penal code, developing guidelines for drug treatment and rehabilitation, and research on the quality of HIV and harm reduction services. I will now show a video on the work of Rumah Cemara, including provision of rehabilitation services, campaigns to reduce stigma and discrimination of people who use drugs and people living with HIV, services for people and children living on the street and community outreach programmes including sport events. Ginan was one of the founders of Rumah Cemara and initiated the sport programmes – he passed away last year and we pay tribute to his long-lasting legacy.

Chair: how is Macao able to influence the wider policy of China? Is it seeing the success of Macao?

ARTM: Macao is a part of China, and so what is happening there is taken account of. I don’t think we are able to influence China. A delegation came to visit us recently, and one of them said that the services they saw are need in Yunnan. They have a much larger population. We are co-hosting a conference there with CADAPT.

Chair: with the oppressive policies in ASEAN, how do you spread the good work you are doing so that other countries might consider adopting them instead of the punitive approaches they are taking?

Rumah Cemara: on stigma and discrimination, we just established an index so we don’t have data on our success in reducing stigma and discrimination. In terms of harm reduction, we started implementation in 2007. Since 2013, the number of harm reduction facilities has increased, including in prisons. The problem today is that in 2017, the President dismissed the National HIV Commission and merged their function under the Ministry of Health. We can say that the Ministry of Health has reduced their focus on HIV issues. On drug policy, I also can’t say that we have succeeded in achieving decriminalisation, but we have progress in our collaboration with government. Today, we have a director and deputy director from BNN here with me to see the perspective of people who use drugs. For police to say that we should see drug use as a health issue is already progress. We still hope that the narcotic law and penal code amendment process will see people who use drugs from a health and not criminal perspective.

Prof. Adeeba: are you also having issues in the rise of methamphetamine use instead of heroin, as in Malaysia and Thailand, where the harm reduction approach needs to expand to behavioural treatment instead? And how is hepatitis C treatment?

Rumah Cemara: based on our quarterly report from the HIV agency, the new cases of HIV amongst people who inject drugs is only 1% so this has decreased. Now we are in the process of reviewing the Ministry of Health regulation on harm reduction, and hoping that they will incorporate guidelines on harm reduction for people who use methamphetamine. Based on a BNN survey in 2017, the harms caused by drug use in relation to HIV are reduced. So we are recommending to the government for comprehensive approaches to harm reduction to be reduced. For hepatitis C, the government will provide free treatment to a limited number of people. We advocate for data on the rate of hepatitis C amongst people who inject drugs, so that the risk environment can be understood. On ARV, the change in type of treatment provided has had a significant impact and we are also trying to advocate for reductions in the price.

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