Introduction
HIV, a virus that was first detected in the Democratic Republic of Congo in Africa (Kirchner, 2019), has led to the death of approximately 32 million people globally, between the time it was detected 2018. Up until 2018, the estimated population of people living with the virus globally was 37.9 million. Among these, 36.2 million were adults, while 1.7 million were children below the age of 15 years. And of these, only 79% were aware of their HIV status, according to Global HIV & AIDS statistics (2019).
The nature and rate of the spread of HIV
The rate of spread of HIV can be said to have declined by a significant 40% when compared to 1997, when the epidemic was at its peak. Consequently, the AIDS-related deaths also reduced significantly since 2004, when the mortality rates were very high. HIV is spread in several ways; body fluids from a person who has HIV, blood, semen, pre-seminal fluids, rectal fluids, vaginal fluids, and breast milk (World Health Organization HIV/AIDS Online Q&A, 2017). Having unprotected intercourse, vaginal sex, with an infected person without using protection or sharing injection drug equipment, with someone who is infected, can also spread HIV.
In Australia, there was once an outbreak of the spread of HIV through the sharing of injections. It therefore mostly affected People Who Inject Drugs, and a solution was necessary to curb the spread. There was a need for a suitable means besides the usual prevention means such as; use of condoms and drugs. This led to the harm minimization policy and peer-based organization, composed of people who inject drugs in Australia. In 2017, approximately 27,545 people were living with HIV.63% was attributable to sexual contact between men, 25% to heterosexual sex, 5% to a combination of sexual contact between men and injecting drug use, 3% to injecting drug use and 3% to other (Australian Federation of Aids Organization, 2017).
The historical development of the harm minimization policy/needle syringe program.
Australia prides itself on the lowest rates of infections among people who inject drugs. These efforts can be greatly traced back to the 1980s, where there were partnerships between the governments, health care stakeholders, affected communities, and researchers. These partnerships were the beginning of the fight against the spread of HIV in Australia (Miller, 1993). The political sphere at the time was very instrumental in the development of the harm reduction policy.
The Commonwealth AIDS Prevention and Education (CAPE) program was put in place to make available monetary support for public awareness of HIV and its prevention (Madden & Wodak, 2014). This was a move made in 1984, which had been influenced by the Federal Health Minister at the time. The program made it possible to conduct education on prevention and to cater for the affected population. NACAIDS, The National Advisory Committee on Aids, was also instituted by the federal government around the same time as a watchdog of the money being allocated and as a public advisor regarding the rising curiosity and questions regarding HIV/AIDS.
The major plus by NACAIDS was its inclusion of the members from the target population and affected communities. The research teams included a representative of people who injected drugs, defying the assumption and bias that such people are not fit to conduct any solid research due to the effect of the drugs. This inclusion had a very positive impact on the agenda of the minimization of the spread of HIV since the target population did not feel stigmatized or attacked by the policy. Instead, they felt included and embraced to make their contribution, which was valid (Bowtell, 2005). Consequently, funding from the CAPE program became annual funding aimed at HIV awareness and prevention. Peer groups of people who inject drugs, AIDS Council, and sex workers groups gradually came to be, to join up in the conversation, and to air their views.
The big break for harm minimization as a national drug policy began in late 1984 after the daughter of a minister was reported to be a ‘heroin addict.' This stirred a lot of conversation and public debate, with the significant one being, The Special Premiers' Conference, also known as the Drug Summit on April 2, 1985. It was at this summit that harm minimization was pronounced as the official national drug policy (Wodak & Cooney, 2006).
At around the same time, there was an outbreak of HIV among gay men in Eastern Sydney, a place famous for Australia's largest drug market and inhabited by the highest population of people who inject drugs (Mindel & Kippax,2013). The outbreak had to be curbed in time as it posed a real threat to the community at large if it continued. It was quite evident that the epidemic of new infections of HIV was directly linked to drug use, specifically the injections.
Still, in 1985,a petition was filed requesting a formal system through which the public could participate in the comprehensive national from the health sector. The Consumers Health Forum of Australia emerged as a result of public involvement. The discussions that followed, including the Ottawa Charter for Health Promotion, 2013, led to a focus shift, from treatment to prevention and a desire to have a collective approach towards health matters.
Harm minimization, defined as "the combination of supply reduction, demand reduction, and harm reduction" in the late 1990s, was adopted to curb the outbreak of the new infections. The Needle and Syringe Program later came to be, as a result of the Harm Minimization (Bowtell, 2005). The then Federal government adopted a "Tough on Drugs" slogan, and this saw direct funding to the Needle and Syringe Program combined with an extension of harm reduction initiatives.
The Needle and Syringe Program was aimed at making sterile injecting equipment available to the public. Before this, people who inject drugs had limited access to sterile needles and syringes, if any. The condition was such that, in some states, injecting equipment was only available through prescription by a medical practitioner, and this was owing to a medical condition, for example, diabetes. The result of this was that there was a full sharing of the equipment, even by the health workers. Loxley (2000) stated that a pilot needle syringe program conducted in defiance of the NSW Drugs Misuse and Trafficking Act, 1985, exposed this situation and can be attributed to the government's concerted efforts to establish the Needle and Syringe Program throughout NSW in 1987. A national Needle and Syringe Program had been put in place throughout Australia by late 1988 (Australian National Council on Drugs, 2006).
Social, political and economic factors that influenced the development of harm minimization/ needle syringe program.
The success of the harm minimization policy can be significantly attributed to the inclusion of drug users. The power of the drug users cannot go unnoticed in Australia's successful prevention of a would-be massive wave of HIV infection. The drug user was allowed to be human again and regarded as an intellectual person who could have a say in the implementation and making of government policies (Crofts and Herkt, 1995). The drug users were even employed through the system.
Before the outbreak of the HIV infections, there existed local peer groups mainly based on drug treatment. After the explosion, however, peer groups of drug users emerged nationwide, and this led to the need to establish one national organization to collectively represent their needs and air their views (Crofts and Herkt, 1995). The Australian Intravenous (IV) League or AIVL was established in 1992, and it later its name to the Australian Injecting & Illicit Drug Users League in 2003. This reduced the stigma and discrimination of the people who injected drugs and recognized them as people with a right to representation. Information regarding HIV was provided to them through this national organization, as well as availing the sterile-injecting equipment without judgment.
One of the terms for the funding agreements was that peer education had to be provided to those high-risk exposed populations (Mindel & Kippax, 2013). Peer education involved training of HIV prevention mechanisms by fellow peers. This was important because people felt free to talk about their drug use, sexuality, among others, without fear of judgment. The training would continue formally and informally at the grass-root level (Plummer and Irwin, 2006). It is during these peer training that resources like condoms, pamphlets, lubricants, and sterile injection equipment were made available to the locals. The peer training's success can be mainly attributed to the lack of power difference between the teacher and the student. There was an equal risk and equal knowledge. The peer education did not take place at formal places, because this would require on to ‘come out' as a drug user. It was successful because it happened at the easy setups where they would meet to buy, sell, and use drugs.
Parties involved in advocating for the policy development.
There are very many actors involved in advocating for and influencing the harm minimization policy. First and foremost, the success of the plan would not have been save for the significant partnership that was emerged when the HIV infection broke out.
All levels of government, people living with and affected by HIV/AIDS, medical communities, research and scientific communities, people who inject drugs, and the healthcare community, all teamed up with the same goal to curb the spread of HIV (The World Bank's global HIV/AIDS program of action, 2006). Ordinarily, it would be expected that due to the diverse interests represented by these actors, they would never see eye to eye or that the achievement of the goal was impossible. The reverse was witnessed in Australia because it is this partnership and inclusivity that led to the massive success of low HIV infection rates, especially among drug users.
Several organizations came up as a result of these partnerships, and they joined up in the overall objective of curbing the spread. The National Advisory Council on Aids (NACAIDS) and the AIDS Task Force are two national advisory structures that were established y the health ministers. NACAIDS was tasked with government advisory on the treatment and care of those living with HIV/AIDS, the prevention of education, and the social policy of the high-risk community. NACAIDS received funding for the tasks and negotiated on behalf of the government with the various interest groups and civil society organizations. The Aids Task Force was tasked with consolidating clinical and scientific expertise, as well as making a recommendation on the allocations of the budget for the research (Luetjens, Mintrom, and Hart, 2019).
The Parliament also played a significant role in stirring the conversation on HIV/AIDS after the outbreak. Following alarming, confusing, and contradictory claims made concerning the epidemic, parliament needed to hold structured and useful discussions concerning the matter. Parliamentary Liaison Group on AIDS was constituted, bringing together politicians who were interested in HIV/AIDS policy (Bowtell, 2005). They were briefed on the likely plans for consideration and the evolutions of the epidemic. The PLGAIDS was a means through which the people who inject drugs and all other concerned organizations could lobby members of the federal parliament and exchange views and concerns (The World Bank's global HIV/AIDS program of action, 2006).
Implementation and challenges encountered during the implementation of the harm minimization policy/needle syringe program.
All these efforts have not been without scrutiny and criticism from the media, politicians, as well as members of the community. The idea that the government would avail equipment to facilitate the safe use of illicit drugs among its citizens is unthinkable to many. This explains why the collaboration between the government, non-governmental organizations, and the target groups had to be in exclusion of representation from the NCADA. NCADA is tasked with oversight of the use of drugs, which entails the prevention of the use of illicit drugs. The approach of the NCADA towards providing safe injecting equipment to people who inject drugs was differential. NCADA saw NSP as a way of promoting the use of illicit drugs, an act that waters down its efforts as an organization (Bull, Denham, Trevaskes, and Coomber, 2016). As a way of addressing NCADA’s concern regarding the encouragement of illicit drug use, the HIV prevention campaigns would adopt a hierarchy of safety messages, though it was later done with due to effectiveness concerns on the method prescribed.
- “Do not use drugs.
- If you do use drugs, don’t inject them.
- If you do inject drugs, don’t share injecting equipment.
- If you cannot avoid sharing injecting equipment, then clean syringes between uses, using the 2*2*2 method (rinse twice in water, twice in bleach, then twice in water).”
These criticisms, among others, were barriers to setting up new initiatives and establishments. However, the benefits of harm minimization and NSP among people who inject drugs went beyond the prevention of HIV. First and foremost, NSP entailed more than just exchanging a used syringe for a sterile one. There was education involved; opportunities were made available, without discrimination of the injection drug users. Being a part of the Needle and Syringe Program enabled one to become a part of the global community working towards the prevention of HIV.
The monetary support that was being channeled towards the policy made it possible for the IDU peer educators to advance and expand not only their education but also their self-advocacy and to better support themselves (Newland & Treloar, 2012). This was made possible by the existent social networking whose potential in the reduction of HIV spread has not been realized before (Madden, Byrne, & Bath, 2002). There was a significant decline in the rate of discarding used syringes due to the return policy, and this meant that the streets were a little safer for the vulnerable population.
The harm minimization policy prompted a different outlook and perspective towards the act of injecting drugs and the people who inject drugs. It required a level of acceptance of the bill and the people, in a new dimension. It is this acceptance that made the entire policy possible in the first place. It was a paradigm shift in the Australian drug policy and the health sector in general (McDonald, 1987). In the beginning, it was opposed by the drug and alcohol treatment sector since it seemed to conflict with their objectives of preventing illicit drug use.
Needle Syringe Program combined with Injection Drug Users' peers' groups considerably favored the reduction of the spread of HIV (Wodak & Cooney, 2006; World Health Organization, 2012) The inclusion of the people who inject drugs in the design and implementation of the policies towards the reduction of the spread of HIV proved to be a very major positive move. The NCADA also expanded Methadone Maintenance Treatment in a very unprecedented move since they believed that NSP encouraged the use of illicit drugs. This treatment indirectly reduces the risk of spread and infection of HIV.
Conclusion
Currently, there are more than 3000 NSP outlets throughout Australia, located in diverse settings. The distribution of needle and syringes annually is now at over 30 million, and these numbers are sourced from the Australian Government, Department of Health. Compared to an annual allocation of 6.3 million needles and syringes in 1991(Burrows, 1998).
The harm minimization policy/ needle syringe program has been adopted in very many other countries over the years (Jürgens, 2008). The people who inject drugs in Australia proudly boast of decades of being “Still Out Loud and Proud”. The aim being to keep up with the funding of the organizations involved in the policy. There is still more room for achievement of the rights of the people who inject drugs and provision of better-quality healthcare. Reduction of the funding towards these initiatives would lead to a rapid increase in the rate of spread of HIV through injections and drug use in Australia, especially among the vulnerable populations.
The impact of the success of the harm minimization policy has been immense, and can be felt even in the economy (Kwon, et al., 2012). The high rate of prevention of spread of HIV leads to saving up of resources that would have been used in the treatment plan of the HIV. The working population is also preserved and the economy of the country grows. Social structures and relations are also spared the pain and anguish of having sick loved ones. They are also saved of the resources they would have to spend on the treatment. Cumulatively, those resources are utilized to better the living standards. Prevention of the spread of HIV has endless benefits and should be worked at, by all means; as has been demonstrated in Australia through the adoption of the harm minimization policy, to cater for the people who inject drugs.
References
Australian Federation of AIDS Organisations, (2017) Global
Bowtell W. (2005). Australia’s Response to HIV/AIDS 1982-2005. Lowly Institute for International Policy. Retrieved 21th October 2019 from https://archive.lowyinstitute.org/sites/default/files/pubfiles/Bowtell%2C_Australia%27s_Response_to_HIV_AIDS_logo_1.pdf
Bull, M., Denham, G., Trevaskes, S., & Coomber, R. (2016). From punishment to pragmatism: sharing the burden of reducing drug-related harm. The Chinese Journal of Comparative Law, 4(2), 300-316.
Burrows, D. (1998). Injecting equipment provision in Australia: The state of play. Substance use & misuse, 33(5), 1113-1127.
Crofts, N., & Herkt, D. (1995). A history of peer-based drug-user groups in Australia. Journal of Drug Issues, 25(3), 599-616.
Global HIV & AIDS statistics — 2019 fact sheet. (2019). Unaids.org. Retrieved 21 October 2019, from https://www.unaids.org/en/resources/fact-sheet
HIV Statistics - Australian Federation of AIDS Organisations. Retrieved 21 October 2019, from https://www.afao.org.au/about-hiv/hiv-statistics/
Jürgens, R. (2005). " Nothing about us without us"-greater, meaningful involvement of people who use illegal drugs: a public health, ethical, and human rights imperative. Canadian HIV/AIDS Legal Network.
Kirchner, J. T. (2019). The Origin, Evolution, and Epidemiology of HIV-1 and HIV-2. Fundamentals of HIV Medicine 2019, 14.
Kwon, J. A., Anderson, J., Kerr, C. C., Thein, H. H., Zhang, L., Iversen, J., ... & Wilson, D. P. (2012). Estimating the cost-effectiveness of needle-syringe programs in Australia. Aids, 26(17), 2201-2210.
Loxley, W. (2000). Doing the possible: harm reduction, injecting drug use and blood borne viral infections in Australia. International Journal of Drug Policy, 11(6), 407-416.
Luetjens, J. C., Mintrom, M., & t Hart, P. (2019). Public Policy Success: Lessons From Australia and New Zealand. ANU Press.
Madden, A., & Wodak, A. (2014). Australia's response to HIV among people who inject drugs. AIDS Education and Prevention, 26(3), 234-244.
Madden, A., Byrne, J., & Bath, N. (2002).' Who's peering at who?' Junkmail, 4,8-13.
McDonald D. (1987). Australia’s national campaign against drug abuse. Taylor & Francis.
Miller PG. (2001). A critical review of the harm minimization ideology in Australia. Critical Public Health. Taylor & Francis.
Mindel, A., & Kippax, S. (2013). A national strategic approach to improving the health of gay and bisexual men: Experience in Australia. The new, public health and STD/HIV AIDS Prevention: Personal, general, and health system approaches (pp.339-360). New York: Springer
Newland, J., & Treloar, C. (2012). Evaluation of a hepatitis C prevention peer education project for people who inject drugs in New South Wales, Australia, Sydney, Australia: National Centre in HIV Social Research, the University of New South Wales.
Plummer D, Irwin L. (2006). Grassroots activities, national initiatives, national initiatives, and HIV prevention: clues to explain Australia's dramatic early success in controlling the HIV epidemic. International Journal of STD & AIDS.
The World Bank's global HIV/AIDS program of action (2006). Documents.worldbank.org. Retrieved 21 October 2019, from https://documents.worldbank.org/curated/en/448121468780608451/The-World-Banks-global-HIV-AIDS-program-of-action
Wodak, A., & Cooney, A.(2006).Do needle syringe programs reduce HIV infection among injecting drug users ?: A comprehensive review of international evidence. Substance use & misuse, 41, 777-813
World Health Organization (WHO) (2012). Guidance on the prevention of viral Hepatitis B and C among people who inject drugs. Geneva, Switzerland: WHO. Retrieved 21 October 2019 from https://www.who.int/hiv/pub/guidelines/hepatitis/en/
World Health Organization HIV/AIDS Online Q&A (2017). Retrieved 21 October 2019 from https://www.who.int/features/qa/71/en/
