Journal of Drug Abuse Open Access

Introduction

Concentrated HIV epidemics have already occurred in IDUs in the neighbouring India, Myanmar and Nepal (WHO, Regional Office South-East Asia, 2008). Due to porous borders with India and Myanmar and central geographical situation between ‘Golden Triangle’(Myanmar, Thailand and Laos) and ‘Golden Crescent’ (Pakistan, Afghanistan and Iran), Bangladesh is a potential route of international drugs trafficking, which makes drugs easy available in the country (Department of Narcotics Control (DNC), Ministry of Home Affairs (MHA), 2006); (National AIDS and STIs Programme (NASP), Ministry of Health and Family Welfare (MOHFW), 2005 [1].

A concentrated epidemic in male IDUs in central Bangladesh has been confirmed. High prevalence of hepatitis C virus infection and syphilis indicate sharing of needles and unsafe sexual practices. The wide network between IDUs with other high risk groups and bridging population endangers the country with risk of generalised epidemic (International Centre for Diarrhoeal Diseases Research, Bangladesh (ICDDR,B), 2009; NASP, MOHFW, 2008).

An amendment to the Narcotics Control Act-1990 was realized the needs of providing supports and services to the drug users. But due to incompatibility between the original Narcotics Control Act and its amendment, narcotic control activities often target drug users rather than suppliers. Moreover, there is social stigma and discrimination of the IDUs. Legal pressures and social exclusion factors are the key barriers to effective implementation of harm reduction services to IDUs, which threats further HIV spread in the country [2]. According to the International Harm Reduction Association, harm reduction refers to policies, programmes and practices that aim to reduce the harms associated with the use of psychoactive drugs in people unable or unwilling to stop. The defining features are the focus on the prevention of harm, rather than on the prevention of drug use itself and the focus on people who continue to use drugs.

To prevent further spread of HIV within and from IDUs community and to secure human rights of IDUs, it is crucial to identify the loopholes of the present legal environment and HIV control programme for adapting and implementing evidence and human right based policy actions urgently. This policy brief aims for formulating such one.

Methods

For the purpose of framing an evidence-based policy brief on harm reduction of IDUs, the following two databases- Cochrane collaboration and Medline, were searched during July 2015. Searches were limited to journal articles, published and unpublished national serological and behavioural survey reports, national daily newspaper articles, and international conference proceedings in English language. WHO, UNODC, UNAIDS, MHA, Bangladesh National AIDS and STIs Programme (BDNASP) and ICDDR,B websites were searched. PubMed, Google and Google Scholar were used as search engines.

Findings

Structural and social factors of drug addiction

The structural and social factors influence individuals towards proximity of drugs and then drug addiction. Due to geographical situation and strong networks between national and international drug dwellers, various illegal drugs are entering into Bangladesh. There is evidence that corrupted members in the law enforcement department are also involved in illegal drug trafficking and establishing drug markets; thereby, easy availability of those drugs [3].

The Narcotics Control Act of many countries including Bangladesh is the response to international community since Bangladesh is a signatory of all three conventions of United Nation on drug abuse and trafficking, namely the Single Convention on Narcotic Drugs 1961, the Convention on Psychotropic Substances 1971 and the United Nations Convention Against Illicit Trafficking in Narcotic Drugs and psychotropic Substances 1988 (UNODC, 2005). As an international commitment, the Narcotic Control Act of Bangladesh was enacted in 1990 that prohibits import, export, sale, purchase, transport, manufacture, processing, possession, use or any other kinds of the operations except for medicinal, scientific or legitimate industrial purposes under licence, permit or pass and according to the severity of crime the punishment ranges from death sentence to imprisonment of varying duration [4]. Thus, if a drug addict is arrested with illicit drug, s/he is burdened to double charge of keeping and using drugs.

In 2000, for treatment and rehabilitation purpose, an amendment was done to the Narcotic Control Act, which defines that the drug users facing trials can have opportunity of treatment instead of imprisonment. The Director General of the Department of Narcotic Control (DAC), a state body under the jurisdiction of the Ministry of Home Affairs, is empowered to notice/allow drug addicts for treatment. The incompatibility between Narcotic Control Act - 1990 and its amendments - 2000 disrupts the human rights of the IDUs’ access to the harm reduction services. It is informed that the major providers of services to IDUs often are facing difficulties from members of the law enforcement due to legal criminal status of IDUs. Survey shows that about 70% of IDUs and heroine smokers have been locked up by police at least once [4].

Drug users often suffer from social stigma and exclusion in Bangladesh. The major underlying factors that coincide with drug use are unemployment, frustration, depression, broken family, parental negligence, parent-child conflict, isolation, broken love affairs and easy access to drugs [5]. When the drug addicts need social support on humanitarian and human rights ground, they face social exclusion and legal threats [2, 6]. The situation extends from individual to societal dimension when the drug addicted people are affected with HIV, hepatitis C virus (HCV) and various sexually transmitted infections (STIs), which have already been appeared as crucial public health burden for Bangladesh. As Sidibe, the formal UNAIDS Executive Director, said “…we must stop criminalization of drug users. Addiction is an illness which needs treatment, not a crime in need of punishment” [7] is the human right-based approach of responding to IDUs.

IDUs: risk behavioural practices and consequences

The estimated number of IDUs in Bangladesh is about 20,000- 40,000 [8]. The number is gradually increasing. The commonly injecting drugs in Bangladesh are buprenorphine and pethidine [4, 8]. The number of HIV positive cases in IDUs is increasing in the country. The 8th national HIV serological surveillance reports have confirmed concentrated epidemic in male IDUs in the central Bangladesh, which was about 7% and one site near Dhaka city the prevalence was about 11%.

HCV infection and active syphilis in IDUs are increasing which indicate sharing of needle-syringes and unprotected sex practices in IDUs. The 8th national HIV survey-2007 shows that the average prevalence of HCV infection in 28 sample cities was 26.43% with the maximum (84.3%) at Kansat, a north-western border area of Bangladesh. Active syphilis in female IDUs in Dhaka and Chittagong cities was 14.6% and 11.1% respectively [9, 10].

IDUs move frequently in different regions and there are wide networks between IDUs and other most-at-risk-populations such as female sex workers (FSW), men having sex with men (MSM), male sex workers and bridging populations, e.g. transport and factory workers [11]. According to the fifth national behavioural surveillance report, it is known that high proportion of IDUs practice sex with commercial and non-commercial sex partners and many of them are married. About (3-20)% IDUs engage in group sex. Consistent condom use is low and varies from (6- 35)% in regular sex partner to (10-44)% in sex with FSW. Overall, knowledge about HIV transmission is low in IDUs. Moreover, there are gaps between knowledge and practices [12].\

Unprotected sex, sharing of needle-syringe and lack of knowledge about HIV transmission among IDUs are increasing the risk of wider spread of HIV in the country.

Prohibition versus harm reduction: lessons for Bangladesh

Sidibé said “…Laws which prevent drug users from access to harm reduction measures are counterproductive to the AIDS response”. Prohibitive law against drug crimes such as trafficking and underground drug business is essential; however, the IDUs should have legal identity and rights similar to general citizen of the country. The Reasons to support harm reduction are remarkable, it preserves the human rights of IDUs, serves the purpose of reducing HIV spread and cost-effective as well. The success of harm reduction needs good partnership between legal and public health sectors of the country. There are successful examples of partnership between law enforcement and public health departments in Britain and Australia where police fights against drug crimes and refers the drug users to health and welfare services [9].

Global examples of success of harm reduction

The Netherlands is the pioneer of the successful harm reduction in IDUs since 1984 [13]. Similar success has also modelled in Australia and Switzerland. China and Indonesia are convinced by the success of their own harm minimization approach and increasing the programmes and coverages enormously. To prevent HIV spread in IDUS, the impact of harm minimization approach is unanimous globally [7].

Harm reduction and Bangladesh

Following gradual increase of HIV prevalence in IDUs, the harm reduction strategy was included in the National Strategic Plan for HIV/AIDS 2004-2010.The components of the harm reduction strategy are: needle-syringe exchange programme, condom distribution, substitution of injection drugs with oral methadone, peer education, health education and rehabilitation. Reduction of HIV, HCV and STIs prevalence among IDUs at some target areas proves the effectiveness of harm reduction strategy [10].

Loopholes in implementing harm reduction strategy

Dealing with lack of coordination between harm reduction service provider and law enforcement department is the key challenge to reach IDUs. As Methadone is defined as illegal drug, no oral substitution therapy is still possible to use. There is no financial allocation for IDUs issue in the national budget. Coverage of the harm reduction is. Inadequate skilled health worker, treatment and rehabilitative facilities for IDUS are also barrier to harm reduction approach [4].

Evidence-based policy options

Harm reduction approach has been proved balanced and acceptable option to preserve human rights of IDUs and prevention of HIV spread. Based on the finding, decriminalization of IDUs with prohibition of drug crimes is essential for successful harm reduction programme in Bangladesh and it needs to be institutionalized.

Advantages

• Easy to reach IDUs for harm reduction services that will reduce spread of HIV and other infectious diseases, e.g. HCV and STIs.

• IDUs will be open to receive harm reduction services.

• Easy to control drug addicts and rehabilitate them.

• Reduction of social stigma and discrimination towards drug addicted people.

• Reduction of in-coordination between service providers and law enforcement agency.

Disadvantages

• Decriminalization may encourage drug abuse.

• Resistance from extremist groups.

Conclusion and Recommendation

In Bangladesh, IDUs overdrives all HIV related public health concerns. Legal prohibition and social exclusion of drug addicted people are aggravating the adverse consequences rather solving the crisis. IDUs are the integral part of society having equal human rights. If we want to preserve their rights of health and humanity; thereby, prevention of further HIV spread in the country harm minimization approach is a far better option than prohibition.

For the strategic implementation of the harm reduction option the following recommendations are addressed to the policymakers-

• Country-wide social mobilization should be done for primary prevention of drug abuse and removal of social exclusion to IDUs.

• Drug Addicts should be socially rehabilitated on human rights ground and to control further HIV spread in the country, all evidence-based harm reduction programmes, especially needle-syringe exchange, oral drug substitution with Methadone, condom distribution and health education to IDUs should be implemented countrywide.

• Public-private partnership for harm reduction services and advocacy between service provider and law enforcement agency should be done in wider scales.

• Adequate financial allocation in the annual national budget with partnerships to the international donor agencies should be done to develop skilled manpower to serve drug addicts, material supply, oral drug substitution and infrastructures.

• Entrance of illicit drugs and underground drug business in the country should be prohibited by good governance.

References

1. Alam MK (2009)Trafficking & HIV/AIDS is inter-related.
2. Khosla (2009) HIV/AIDS Interventions in Bangladesh: What can application of a social exclusion framework tell us? J Health PopulNutr 27: 587-597.
3. Akhter F (2008) Drug addiction on rise, The Financial Express, Dhaka.
4. UNODC (2007) Legal and policy concerns related to IDU harm reduction in SAARC countries.
5. Sussman S, Ames SL (2008) Drug abuse: Concepts, prevention and cessation. Cambridge Press; ISBN 978-0-521-85892-2.
6. Rawshan AF (2010) Drug abuse in Bangladesh, The Daily Independent Bangladesh.
7. Sidibe M (2009) Why we need harm reduction to reach universal access goals. In: Donor Conference Harm Reduction, Amsterdam, Netherlands.
8. WHO (2009) HIV/AIDS in the South-East Asia region.
9. ICDDR B (2009) Injecting drug use and HIV: A call to action for Bangladesh.
10. NASP, MOHFW (2008) National HIV serological surveillance, 2007, Bangladesh (8th Round Technical Report), Dhaka: The Stationery Office.
11. Haider M, Ahmed SN, Jaha NK (2008) Bangladesh HIV/AIDS communication challenges and strategies, Bangladesh Medical Research Council Bulletin 34:54-61.
12. NASP, MOHFW (2007) National HIV serological and behavioural surveillance, 2003-2004, Bangladesh (5th Round Technical Report).
13. vanLaar M, van Ooyen-Houben MMJ, Meijer RF, Croes EA, et al. (2015) Netherlands National Drug Monitor, Annual Report 2014. Trimbos Utrecht.