Wake up Call
Speech on behalf of the International Aids Day 2005
Spoken by Ilona van de Braak (AIDS Foundation East-West) and John-Peter Kools, Mainline
Just one year ago, Mainline protested at this very conference. Mainline members climbed onto the stage, rolled a giant globe onto the stage and into the spotlight, to draw attention to the millions of injecting drug users worldwide who are at risk of getting HIV. The protest stated that:
Injecting drug users all over the world are locked away, marginalised and not talked about. Even at this conference they do not have a place, a voice or a face This is unacceptable.
Today, an entire year later, we regret to report that not much has changed. We, Mainline and AIDS Foundation East-West (or AFEW for short), know each other from the field in Russia and have worked for years on AIDS prevention among injecting drug users. It is thanks to our hands-on-experience that we feel it is our responsibility to sound the alarm, and we do so under the slogan: ‘This is your wake up call. Your last wake up call.’
Mainline is, at its core, an organization that is engaged in AIDS prevention and health promotion among injecting drug users. Its origins are in the Netherlands, but by 1996 it had expanded into Eastern Europe and Russia and, as of last year also operates in Asia.
AFEW came at the same issue from a completely different angle. As a Dutch AIDSorganization, AFEW focuses already for 7 years on HIV/AIDS in the countries of the former Soviet Union. It is no surprise then that AFEW began working with injecting drug users, as they act as a driver in the spread of the epidemic in those countries – although not only in those countries.
My name is Ilona van de Braak from AFEW. Today I would like to share with you some information that will give you a better idea about the HIV/AIDS epidemic among drug users. After that John-Peter Kools from Mainline will than give you some more background information on this hidden epidemic.
We know that many people might think that injecting drug use is unique to the West. Well, this is not true. On this map we have marked the countries with large populations of injecting drug users. We have marked any country that has at least 50 000 injecting drug users. First and second place go to Russia and China, which boast a combined total of approximately 4 million. In comparison, the so-called ‘drugs paradise’ the Netherlands, has ‘only’ 4 000, which doesn’t even place it on our map. Now I know what you’re thinking: How can you compare the Netherlands, such a small country, with Russia or China? Well, we also have the relative sizes of these populations.
On this map we have marked the countries where, at a minimum, half a percent of the adult population injects drugs. Surprisingly, Bermuda has the highest rate, with almost 5 percent. Estonia and Russia follow not too far behind with 2 percent.
The Netherlands does not make it onto this map either, with only 0.04 percent of the adult population using injecting drugs. This is more than 10 times lower than the minimum rate set for this map.
Most AIDS prevention programs focus all their efforts on sexual transmission. For instance, in the West the focus is on unsafe homosexual contacts, and in Africa on unsafe heterosexual contacts. Unsafe injecting drug use is a severely underestimated mode of transmission, although in many parts of the world, the contaminated syringe has become the main vessel for transmitting AIDS.
On this third map, marked in red are the countries where more than half the HIV-cases are attributed to injecting drug use. Keep in mind that this map is incomplete: many countries don’t have information on HIV-transmission via unsafe drug use. We know of at least 19 countries where contaminated injection equipment is the main source of HIV-infection. Among them are huge countries like Russia and China. Although exact figures for India are not available, UNAIDS reported last week that unsafe injecting drug use is fuelling the epidemic there too.
UNAIDS also released information about where the epidemic is growing the fastest. The top 3 regions on this list are Eastern Europe and Central Asia, with an increase of 20 percent, East Asia, with 19 percent an South and Southeast Asia with over 15 percent. It is in these parts of the world that unsafe injecting drug use is the main source of HIV-transmission.
Why should you care about these drug users After all, they live in remote areas. A cynic would say that we should not get involved with such a small, isolated group. But even a cynic, which we know you are not, understands the hidden danger. Drug users do not live on an island, and the epidemic will not stop with them. Via unsafe sex, the epidemic can spread like wildfire to the rest of the population. The scary thing is that more than half of the world’s population lives in countries where contaminated syringes are the leading cause of HIV/AIDS.
I will now hand over the stage to John-Peter Kools of Mainline who will shed some light on who these drug users are and what we could and should do for them.
The images that you are about to see are from the countries in which our organizations work. Many people are surprised to learn that injecting drug users do not look like stereotypical junkies like Herman Brood and Keith Richards. But these are people who use drugs. Young people, old people, children without a home, people in slums, homeless in urban areas. People from all layers of society: students, shoe shiners, street vendors, middleclass-people with a good job. People from Vietnam, Ukraine, Russia, Iran, Kazakhstan and Pakistan. All these people, at this very moment, run a very high risk of HIV-infection or are already infected.
These photographs were taken by leading photographers and fieldworkers.
UNAIDS announced last week that, right now, Eastern Europe and Asia have the fastest growing incidence of HIV in the world. This growth didn’t come out of nowhere: quite the contrary. At the bi-annual World AIDS Conference in Barcelona in 2002, the message of the closing session was: ‘In Africa, large-scale death has already begun – the next continent will be Asia’. But while the international focus should have massively turned to Eastern Europe and Asia it has not. In fact, the international response has been eerily silent. Meanwhile, the virus is spreading, quietly, out of sight of the media and mainstream society. Ignored by politicians. And so, it is left at underground parties, at the edges of society, in the margins of illegality, shame, stigma and discrimination.
It is tempting to believe that, if left alone, things will not spin out of control. But the example in Russia proves that it only takes a couple of years for the situation to do just that. This epidemic can easily paralyse an entire society, both socially and economically.
The first registered case of HIV in the Soviet Union was in 1986. This sparked the beginning of massive testing programs. 140 million people were tested and the results were relieving: in 10 years only 1 100 cases of HIV were detected. AIDS came to be seen as an alien disease, reserved for black people, Americans and other foreigners.
The fall of the ‘iron curtain’ brought on a time of experimentation, sex, drugs and rock n’ roll. Drugs were cheap, and a major drug route made its way across Russia. People knew how to make drugs at home, using cheap medications, and these injectable drugs were already being used during Soviet times. Sharing of needles became commonplace, opening the door for the spread of HIV among injecting drug users. In the late 1990s, in a matter of months, entire communities of drug injecting youths became infected. It all began in the western part of the country: Kaliningrad, St. Petersburg and Moscow and soon thereafter, spread to the cities behind the Urals.
Today there are more than 315 000 officially registered cases of HIV in Russia, and a vast majority of them are under the age of 30. Specialists from Russia, the World Health Organisation and UNAIDS believe that the real figure is much higher: estimates vary from 1 to 1.5 million. For years, more than 90 percent of these infections were attributed to drug use. Last year this figure fell to 75 percent, but it’s not because fewer drug users were infected, but because there was an increase in sexual transmission of the virus.
With that, the epidemic in Russia moved into the second phase, facilitated by untreated STDs. If things continue at this rate, 5 to 8 million Russians will be infected by 2010. In other words, 1 out of every 10 Russian adults will be infected.
This is how it started in Russia, and a similar fate may await China, Iran, Vietnam, Pakistan and Indonesia. In all these countries two thirds of all HIV-infections are among injecting drug users.
At first glance, young people experimenting with injecting drugs in urban industrial towns in Russia don’t seem to have anything in common with the street children or urban poor living in the raw conditions of shanty towns in Teheran or Ho Chi Min City. But in reality, they have a lot in common: a lack of future, no social and health structures, and sheer poverty. There isn’t much difference between the perspective on life and future prospects in an unheated flat in Siberia and a slum in New Delhi. Poverty and marginalisation are the main fuel for drug use today.
Tackling the HIV-problem among injecting drug users is both extremely difficult and simple at the same time. Difficult because it deals with the deepest human lusts and longings. Of course stopping drug use all together would be most ideal, but unfortunately, abstinence is not feasible for many drug users. Therefore, we must face this reality with simple effective tools that can prevent HIV-transmission: needle-exchange, methadone distribution, targeted information on safe drug use, peer-education, condom distribution and training of healthcare workers. Altogether these interventions are know under the name Harm Reduction.
Harm Reduction aims to assists drug users to minimize health risks in the period in their lives that they are using drugs. Most drug users want to stop using drugs and will, and Harm Reduction methods ensure, that if they do, they remain healthy, or as healthy as possible, especially if they are already HIV-positive.
Even though they live on the fringes of society, injecting drug users still deserve to have equal access to public healthcare. Care is a fundamental human right.
Keeping drug users healthy is a goal in itself, but it also serves a wider purpose. Harm Reduction works to keep the people close to drug users healthy, in order to reduce their chances of becoming infected. In this way, Harm Reduction can make a major contribution to stopping the HIV-epidemic. Therefore targeting vulnerable groups should be a very high public health priority.
Harm Reduction has been proven to be effective in the western world. The Netherlands already have extensive experience with this pragmatic public health approach. This exportable approach is taken by us, beyond the Dutch borders, to the regions where we work; to our projects involving needle exchange in Iran, AIDS prevention training for prisoners in Russia, outreach workers educating sex-workers in Kazakhstan, and healthcare workers contacting children who sniff glue in the slums in Pakistan.
These pictures may be shocking and unsettling, but also provide examples of our work – our steps to reach drug users and to reverse this epidemic. What these Harm Reduction efforts lack is massive scale that would be needed in all facets of life. Roll out is now key.
In order to accomplish this, it needs financial and political support from these affected countries.
Furthermore it will take money, support and advocacy from European countries to stand strong for the still controversial and unconventional methods of Harm Reduction as an integral part of a comprehensive HIV-response worldwide.
We also want to make an appeal to those of you in the audience today, and ask you to mobilize your organizations, contacts and expertise and give this matter the highest priority.
We call upon you today to look at your projects into the problem of injecting drug use and HIV/AIDS.
To provide assistance to people at an individual level and by doing so to contribute to stopping the biggest driver behind the HIV/AIDS epidemic at this moment.
Do something now, before it is too late. Because we know what the problem is, we know how to respond and we know that it works.
Thank you for your attention