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Harm reduction history, response, and current trends in Asia Nicholas Thomson a,b,* a b

Johns Hopkins School of Public Health, Baltimore, USA Nossal Institute for Global health, University of Melbourne, Carlton, Victoria, Australia

abstract Keywords:

Human immunodeficiency virus (HIV) epidemics in Asia have been initially driven through

Harm reduction

injection drug use and the use of shared needles and syringes. Molecular epidemiological

HIV prevention

work has shown that where there is heroin trafficking and use, there is also HIV. Given the

Opiate substitution programs

often strict enforcement of national antinarcotic laws, harm reduction responses to HIV infections driven by injection drug use have been historically slow. As it became clear that preventing HIV meant embracing harm reduction, many countries in the region have adopted harm reduction as part of their national acquired immunodeficiency syndrome (AIDS) strategy and increasingly as part of their national drug strategy. Initial successes have proven that harm reduction, as it pertains to HIV among injection drug users (IDUs), can and does work in Asia. These initial successes have led to more comprehensive scaleup of other essential components of HIV prevention among IDUs, including increased availability of opiate substitution programs. Still, multiple challenges remain because overall coverage of services in the region remains poor. Changes in the availability and patterns of use of drugs, including the exponential increase in the use of amphetaminetype stimulants, are providing ongoing challenges to both the law enforcement and public health sectors. This paper reflects on the history of harm reduction in Asia and the shifting trends forcing policy makers to adapt and expand harm reduction strategies to include an ever widening approach to criminal justice, policing, public health, and human rights. Copyright ª 2013, Food and Drug Administration, Taiwan. Published by Elsevier Taiwan LLC. All rights reserved.



Harm reduction responses to drug use and human immunodeficiency virus (HIV) infection in Asia began over 20 years ago. This paper describes the evolution of harm reduction through a historical analysis of four interconnected themes:

harm reduction programs, research, policy, and advocacy. This paper then describes the need for an expanded definition and construction of harm reduction in order to meet the challenges posed by changing trends in drug availability and use, particularly regarding methamphetamine. In this expanded definition, multisectoral partnerships across law

* Corresponding author. Johns Hopkins School of Public Health, Baltimore, Maryland, USA; Nossal Institute for Global Health, University of Melbourne, 161 Barry Street, Carlton 3053, Victoria, Australia. E-mail address: [email protected] (N. Thomson). 1021-9498/$ e see front matter Copyright ª 2013, Food and Drug Administration, Taiwan. Published by Elsevier Taiwan LLC. All rights reserved. http://dx.doi.org/10.1016/j.jfda.2013.09.047


j o u r n a l o f f o o d a n d d r u g a n a l y s i s 2 1 ( 2 0 1 3 ) s 1 1 3 es 1 1 6

enforcement, criminal justice, the health sector, and civil society organizations would work toward reducing all harms associated with drug use, including the widespread arrest and incarceration of drug users. Only a comprehensive revision and expansion of how we implement harm reduction in Asia will allow harm reduction to remain the cornerstone element in the reduction of drug-related harm for the next 20 years.

2. Asia

Harm reduction projects and programs in

In response to widespread needle sharing among injection drug users (IDUs), the first needle exchange project in Asia was set up in Nepal’s Kathmandu Valley in 1991 by the Life Saving and Life Giving Organization [1]. Since then, there has been tremendous expansion, progress, and innovation in the delivery of harm reduction projects and programs in a variety of complex settings across Asia. The Mae Chan Clinic in northern Thailand set up the first multisite needle and syringe exchange project at three sites in 1992, and The Society for Service to Urban Poverty (SHARAN) established the first sublingual buprenorphine project in 1993 in India. The acquired immunodeficiency syndrome (AIDS) Surveillance and Education Project began distributing needles to methamphetamine injectors in the Philippines in 1995. SHALOM began delivering needles and conducting outreach to respond to the devastating epidemic in Manipur, in conflict-riddled northeastern India, in 1995. The Pink Triangle (forerunner to the Malaysian AIDS Council) began street outreach in a red light area in Chow Kit (in Kuala Lumpur) in 1995 [2]. Almost all of these early harm reduction projects shared a similar set of characteristics. The projects were initiated and driven by nongovernment organizations (NGOs) and operated in isolation from, and often in conflict with, mainstream government approaches to drug use. This led to a constant state of tension between public security, public health, and the community. The projects were often underfunded or at risk of funding gaps, and this perilous existence relied upon extensive and exhausting advocacy. This situation began to change during the late 1990s when harm reduction concepts began to become entrenched in national HIV/AIDS programs and strategic planning in some Asian countries. Assisting this change were the donor agencies’ support and funding for government agencies to adopt harm reduction programs. As momentum for harm reduction grew, the United Nations (UN) formed its first iteration of the UN Regional Task Force on Injecting Drug Use and HIV in 1997 [3]. The first of the AusAID regional projects concentrating on policy and advocacy began working across three countries in Asia [4], and donors supported the first national-level program scaling up coverage of needles and syringes in Nepal [5].

3. Influence of research on harm reduction in Asia The early harm reduction projects led by NGOs in Asia also led to the earliest research efforts investigating HIV and drug use in Asia. Partnerships between NGOs and international

research institutes led the first studies determining HIV prevalence among IDUs. These papers formed comparative baselines for research to show that harm reduction projects implemented by NGOs led to a reduction in HIV risk behavior among IDUs and confirmed that harm reduction could work in the Asian context. A growing research interest in the HIV epidemic among drug users in Asia led to an increasing number of United States (US) National Institute on Drug Abuse/National Institutes of Health (NIDA/NIH) meetings taking place in Asia, as well as an increase in the number of grants given to research collaborations between Asian and US research institutes. The HIV Prevention Trial Network and the HIV Vaccine Trial Network funded several of these initial collaborations, which included peer-based behavioral intervention/control HIV prevention studies [6], as well as a large study examining the role of Suboxone in HIV prevention among injecting opiate users [7]. The growth of national research networks, such as the Thai Academic Substance Abuse Network, highlighted that national governments were increasingly interested in drug use and its implications for individual and public health as well as for public security. Molecular epidemiology studies began proving that HIV epidemics followed heroin trafficking routes across Asia. This research highlighted the role of complex political environments and porous borders on the mixing of HIV viral subtypes. It also indicated that for harm reduction programs to grow in complex environments they would need to be supported by key stakeholders across the political, security, and health sectors. Research efforts began focusing on showing how harm reduction projects could be delivered across borders between two countries [8]. These efforts led to the programming of broader regional cross-border harm reduction across the Greater Mekong Subregion [9].

4. The rise of methamphetamine use and the implications for harm reduction and its research While harm reduction programs and research continued to predominately focus on injecting drug use and HIV, patterns of drug use in Asia were drastically changing. Across Asia, the availability and use of methamphetamine exponentially increased beginning in 1996, and by 2009, rates of methamphetamine use had overtaken the use of heroin in many countries across Asia [10]. Because most methamphetamine use was through noninjecting methods, the links between the drug’s use and HIV were less clear than with injecting drug use. The implications for individual and public health as well as public security, however, extended beyond just HIV risk and highlighted the need for an expanded definition of harm reduction and, indeed, the research agenda [11]. Specific harm reduction research in the context of methamphetamine use in Asia only began after nationwide household surveys described its widespread use [12]. Some clinical studies followed examining methamphetamine withdrawal and the role of cognitive behavioral therapy in promoting cessation of use and prevention of relapse [13]. Given the lack of substitution therapy for methamphetamine

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use, researchers needed to design and explore a harm reduction approach to methamphetamine in the Asian context. A large peer-based behavioral intervention/control trial conducted in northern Thailand showed that reductions in methamphetamine use and uptake in condom use could be influenced by peer-based methods [14]. This study has led to a larger community mobilization study exploring how the root structural causes of methamphetamine availability and use could be identified and addressed to reduce methamphetamine use [15].


only prevent HIV but can have major benefits for the criminal justice system as well as the community. Evidence that harm reduction can decrease crime as well as improve a variety of health outcomes makes a strong argument. HIV can no longer remain our only harm reduction research endpoint. In Asia, we need to explore the science of the enabling environment so that an expanded harm reduction approach results in an expanded number of multisectoral key stakeholders engaged and committed to its implementation.



Harm reduction policy and advocacy

Across Asia, harm reduction is mentioned in the National HIV and/or National Drug Strategic Documents in Afghanistan, Bangladesh, Burma, Cambodia, China, Indonesia, Laos, Malaysia, Nepal, Pakistan, Philippines, Taiwan, Thailand, and Vietnam. Common in the language describing national harm reduction policy in these countries is the specific shift away from constructing the response to drug use through a criminal justice framework to a health-orientated model. Despite this shift in policy rhetoric, drug users continue to be commonly arrested for drug use [16] and overrepresented in the prisons and the growing number of compulsory detention centers of Asia [17]. Historical advocacy for harm reduction in Asia was originally taken up by the NGOs providing harm reduction services to IDUs in Asia. These efforts were supported by the UN and the donors but have remained fixed on advocating for expanding country ownership and implementation of a comprehensive range of services to prevent HIV among and from IDUs. Given the large number of noninjecting methamphetamine users experiencing harm from both their drug use and their subsequent deleterious interactions with law enforcement and criminal justice, advocacy for an expanded definition of harm reduction needs to be a major priority of all the aforementioned key stakeholders.


The future of harm reduction in Asia

While an expanded definition of harm reduction is required to respond to changing drug trends, it will only assist in scaling up coverage and impact of programs if multisectoral partnerships are prioritized. In the context of HIV among key affected populations, these partnerships are endorsed by UN Economic and Social Commission for Asia and the Pacific (ESCAP) Resolutions 66/10 and 67/9. Both of these resolutions call for the scaling up of partnerships between law enforcement, criminal justice, public health, and civil society in the context of the provision of universal access to harm reduction programs for all key affected populations [18,19]. In the context of harm reduction, partnerships between law enforcement, criminal justice, public health, and civil society are critical if we are to meet the challenges of responding to drug use in Asia in the next 20 years. Some researchers have begun documenting how harm reduction programs can more effectively engage with police [20]. We need to show that in an expanded definition of harm reduction, partnerships cannot

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[16] Thomson N. ATS and sexual risk in Cambodia, Thailand and Laos. In: Presentation at the 11th International Harm Reduction Conference, Bangkok 2009. [17] Thomson N. Detention as treatment: detention of methamphetamine users in Cambodia, Laos, and Thailand. New York: Open Society Institute; 2010. [18] United Nations Economic and Social Commission for Asia and the Pacific (UNESCAP). ESCAP resolution 66/10: regional call for action to achieve universal access to HIV prevention, treatment, care and support in Asia and the Pacific. Available at: http://www.unescap.org/sdd/issues/hiv_aids/Resolution66-10-on-HIV.pdf; 2010 [accessed 12.12.11].

[19] United Nations Economic and Social Commission for Asia and the Pacific (UNESCAP). ESCAP resolution 67/9: AsiaPacific regional review of the progress achieved in realizing the Declaration of Commitment on HIV/AIDS and the Political Declaration on HIV/AIDS. Available at: http://www. unescap.org/sdd/meetings/hiv/hlm/English/HIV_IGM1_INF5. pdf; 2011 [accessed 10.01.12]. [20] Thomson N, Moore T, Crofts N. Assessing the impact of harm reduction programs on law enforcement in SE Asia: a description of a regional research methodology. Harm Reduct J 2012;9:23.

Harm reduction history, response, and current trends in Asia.

HIV epidemics in Asia have been initially driven through injecting drug use and the use of shared needles and syringes. Molecular epidemiological work...
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