Friends, please allow me to join my distinguished colleagues in welcoming you all to Goa. This greeting goes out to all our friends and colleagues gathered in this room - many of whom have traveled endless miles and many hours to be with us here at this, the very first "Asian Consultation on the Prevention of HIV related to Drug Use".
Mr. Gary Lewis, Representative, UN Office on Drugs and Crime, Regional Office for South Asia In South Asia - as elsewhere in Asia - the need of the hour is to scale-up interventions in order to reach out to populations who are at risk, and, in doing so, to save lives. Please therefore allow me to dispense with some of the statements which reiterate - in numbers and opinions - the extent and scale of the problem. These can be found on UNAIDS's website. And on ours. We know the right thing to do, we need to do it right, and we need to do more of it.
A consistent body of evidence has established the following fact. Comprehensive HIV prevention programmes - which include oral substitution programmes (which I shall refer to henceforth as OST) and needle syringe programmes - when included as part of a comprehensive package of services - reduce drug-related HIV risk behavior such as needle sharing, unsafe injecting, and frequency of injecting. There is also strong evidence that substitution treatment reduces criminal behavior as well as illicit opioid use. We know that it increases retention in treatment and improves the overall health status of drug users infected with HIV. These are outcomes which we all seek to promote. Tomorrow, we will share with you even more evidence - as if this were required - of how this has worked in South Asia.
What I would like to assure you is that you can count on the United Nations as a whole to support - to the best extent that we can -inclusive, country-led efforts which try to contain and reverse this epidemic. Our goal is to reach Universal Access to treatment by 2010. A tall order indeed.
As I see it, UNODC's role - and what we feel we can contribute to this Consultation - lies in the area of preventing the spread of HIV among two broad categories of people who are at risk of contracting HIV. The first is drug users - especially injecting drug users and female drug users. The second is prisoners. I would like to speak about what we can do to help people who fall into both of these two broad categories.
Challenges for comprehensive HIV programming for IDUs
In respect of IDUs, what is the situation which confronts us on the ground in Asia - especially South Asia? First of all, and often, the main elements of a comprehensive approach are simply missing in many countries in the region. This includes access to affordable treatment for STI infections. It includes access to HIV-related health care - including ARV - as well as voluntary HIV counseling and testing.
Sometimes we also encounter difficulties in the relationship between harm reduction programmes and law enforcement.
What we know - and have known for some time - is this. Global evidence indicates that if there is a delay in scaling-up substitution treatment and needle-syringe exchange programmes as a core component of harm reduction programmes, this delay will result in a human cost. This is why
UNODC has been assisting countries in South Asia (especially Nepal, India, Maldives, Bangladesh and Pakistan) to set up demonstration sites and provide technical assistance in developing costed national workplans for scaling-up coverage OST and needle-syring exchange programmes as part of a comprehensive package.
But even while demonstration work is getting off the ground we continue encounter other problems. Sustained funding for scaling-up is often not available.
It seems that we are also constantly having to be reminded - in all our busy planning exercises and logical frameworks - to link up with the very people we are supposed to be helping - those who are living positively or at risk of doing so through their drug use habit. The maxim of "
Nothing for us without us" seems difficult for us to learn. Thus, ensuring the participation of drug users to the maximum degree - especially in the OST delivery programme - remains a challenge. One dimension of this has emerged recently in our thinking about whether to charge a fee for OST treatment. I believe that this question - which is currently under review in parts of South Asia - merits the attention of participants at this Consultation, because, should we get our approach wrong, we risk excluding users from access to the treatment they need - either by charging fees - or by charging fees that are too high. We have no room for error.
The Way Forward for scaling up OST & NSEP
As we showed in April last year in Kolkata when we released the assessment of "Legal and Policy Concerns Related to IDU Harm Reduction in SAARC Countries", there is sometimes a need to amend the laws and regulations - where necessary - to allow access to both buprenorphine and methadone (each of which is pre-qualified by WHO as essential medicines) as part of an OST regime. Usually not much is required. But sometimes this is not needed. All that is required is a little creativity in working within the existing regulations. UNODC will thus continue to support efforts to obtain provisional marketing approval to and access, prior to full registration by national drug regulatory authorities - to roll out OST programmes.
We must also remove the barriers which exist in
regulatory policy on the procurement of methadone and buprenorphine. More than this, we must find the financial resources to speed up access to affordable, quality OST and clean needles for all the drug users who wish to avail themselves of such services.
And even while we do demonstration work, let us not be sitting on our hands. We should not use the demonstration phases to avoid rapid scaling-up. Learnings in the South Asian context can be retro-fitted onto existing interventions. Such retro-fitting is not likely to require dramatic changes. We know this from other regions. And time is not on our side. We have lost enough time already.
What we need is for countries to set up national goals to speed the expansion of OST interventions. In some respects, we take special note of the achievements of China which started its methadone roll-out in only 5 provinces in 2004. However, by 2006, the programme encompassed 320 clinics covering 27,000 drug users in 22 provinces.
Tomorrow, we will share with you some of the efforts which the United Nations is undertaking to help countries in South Asia attain their plans to scale-up for universal access.
Gender Issues in IDU programming
While speaking of drug use and IDU, I would like to turn to another aspect of what we should be considering at this Consultation: the issue of gender. No one can deny that there is - at present - a low level of participation by female injecting drug users in most programmes. Not only are there few facilities for female users to access, but the "double stigma" faced by drug users and their partners who are HIV positive also impedes them from seeking access to HIV treatment and care programmes. We need to change this. Everyone knows that it is a challenge to reach out to the hidden population of female IDUs. Making services accessible and affordable to our sisters is indeed a huge gap. But we must simply make the effort. I am pleased to say that - to some extent - the groundwork is already being laid for this. Tomorrow, UNODC would like - in all humility - to share with you, some of the work we have been doing in South Asia in recent months which we hope will pave a path in making this change.
The bottom line is that the only way forward is to develop low-cost gender sensitive services - test them - and then deliver them.
OST in Prisons
Prisons. In many parts of Asia, opioid-dependent people can constitute up to one-third of the entire prison population. This figure rises to 80% in some Central Asian countries. We believe there is an urgent need to provide OST treatment for opioid-dependent drug users in prisons in Asia.
For this, a lot of groundwork needs to be done first. The environment in prison settings must be properly prepared for such interventions. Prisons are extremely sensitive zones. Producing change here is enormously complicated.We must therefore seek to build trust and credibility first.Then, we must forge strong links between the OST interventions being managed by prison health care services and those which are being run in the wider community at large.We have been working in this area for about two years now in South Asia.And I daresay that some of our friends have wondered about the seemingly slow pace at which we have been moving.But I believe our work will have paid off when we get the buy-in - as is happening in parts of South Asia, specifically, Sri Lanka, the Maldives and India - to run OST in prisons.
Friends, in conclusion, this Consultation should aim to take us one step closer to the central objective of achieving universal access for people injecting drugs. Along the way, there are other related constituencies who need our help as well.The United Nations is extremely happy to support this form of regional collaboration on HIV prevention and treatment. We have a unique opportunity to produce lasting solutions to HIV and AIDS based on what we know at the moment. As I said at the beginning. We know what is the right thing to do. Let us do it right. And let us do enough of it. I have been to similar meetings for the past four years in Asia. And when all is said and done, more is said than done so let us do.