Special Report: Syringe scrimmage (When drugs and Aids collide)

Giving syringes to drug users to stop spread of HIV prickly issue

IN EARLY 2014, Dr. Alice Utlang started work at the Cebu City Office for Substance Abuse Prevention (Cosap) at the Cebu City Health Department building.

A curious sight immediately met Cosap’s new executive director: the long line of people outside the CebuPlus Association Inc. office close by.

CebuPlus works with the City Health Department to prevent the spread of the human immunodeficiency virus (HIV).

“Since 2010, the City Health Department has been giving syringes to drug users. I knew some of those lining up, private butchers from Barangay Lorega,” said Utlang, a former city veterinarian. “I asked them, ‘You have no plan to stop (using drugs)?’ I interviewed them one by one. Some of those lining up were not even users. They would just sell the syringes for P20 to drug users.”

She raised her complaint to the Cebu City Anti-Drug Abuse Council (Cadac).

“Di ko kampante. (I’m concerned.) My office is here preventing drug use, while it’s as if the other office is encouraging drug use,” Utlang said of the Cebu City Health Department’s (CHD) program to give clean needles and syringes to injecting drug users for free to prevent the spread of HIV.

HIV is transmitted through sexual contact, needle sharing among injecting drug users, transfusion of infected blood products, and mother-to-child transmission.

In 2010, more than half of Cebu City’s injecting drug users (IDUs) were found to be infected with HIV, the virus that causes Acquired Immunodeficiency Syndrome (Aids).

This, amid the high rate of syringe- needle sharing, with up to 10 people sharing a syringe to save on costs.

Following Cadac’s objection, “City Health temporarily stopped the distribution—but only because they transferred it. They opened a distribution center in Kamagayan. It was in the barangay hall,” Utlang said.

Haven

Barangay Kamagayan is a haven for drug users. In Cebu Province, 81 percent of male IDUs used a shooting gallery in Kamagayan as their usual venue for injection. Ten percent used their own house; five percent, a hangout in Mandaue City; three percent, another IDU’s house, the Department of Health’s

(DOH) 2013 Integrated HIV Behavioral and Serologic Surveillance (IHBSS) found.

For Cebu City residents, 85 percent of male IDUs and 73 percent of female IDUs frequented the Kamagayan shooting gallery.

Research

The Kamagayan project was to have been a two-year operations research of the DOH, Philippine National Aids Council, the Cebu City government and Population Services International. Among the aims of the free syringe distribution program in Kamagayan was to reduce the number of blood-borne diseases like hepatitis C and HIV.

On Oct. 8, 2014, the Dangerous Drugs Board (DDB), through Board Resolution 298, approved the “scientific and medical study” funded by the World Bank and Asian Development Bank. Aside from needle and syringe distribution, the study components included counseling on HIV, counseling on drug abuse, medical services and psycho-social care.

But on hearing of the project, Sen. Vicente Sotto III in a privilege speech last May 11 said the DDB resolution was in conflict with Section 12 of Republic Act 9165, the Comprehensive Dangerous Drugs Act of 2002, that prohibits possession of paraphernalia for dangerous drugs.

The DDB had declared the village a safe zone from arrests in relation to Section 12 insofar as IDU participants and village health personnel in the needle-syringe exchange program were concerned.
Sotto said the DDB also could not allow any agency to conduct studies for HIV/Aids prevention, as it is empowered to conduct or support studies for “drug prevention and control” only, which the DOH’s research was not, as it even “sabotages the government’s campaign for drug prevention.”

Senior Supt. Pablo Labra II, Police Regional Office 7 intelligence division chief, agreed that syringe distribution could worsen the drug problem and opposed it as well.

“We stopped the needle and syringe distribution in the Kamagayan barangay hall last May,” said Dr. Ilya Tac-an, head of the CHD’s Social Hygiene Clinic. “But HIV and drug counseling continue there.”

On non-drug users getting the syringes, she said the stigma of being a drug user prevented some from showing up to get the free needles, so “there’s a chance that in the early days we arranged with those living there so we could have access (to the drug users). But we discourage selling of the needles.”

“When we gave needles, we got blood samples also when we registered them, so we know that some of those resellers were also users,” she added.

Rehab better

Cosap’s Utlang said the money spent for the syringes should have been used to rehabilitate the addicts instead.

She said rehab at a government facility costs just P6,000 a month. Or it could be just P3,000, as the other P3,000 is just “a deposit at the canteen if you buy something there.”

CebuPlus executive director Jerson See said some P6 million worth of syringes was bought for the program.

The DOH undertook the harm reduction program after the Cebu City HIV/Aids Registry showed that the main mode of HIV transmission in Cebu City had shifted from sexual contact in 2008 to injecting drug use in 2010.

From January 1984 to August 2015, 99 percent of the 1,247 people who got HIV through injecting drug use in the country were from Central Visayas, the bulk of them from Cebu City.

Many users

There are an estimated 2,500 injecting drug users in Cebu City.

After testing 2,000 IDUs, the CHD found 1,050 positive for HIV.

“But some of these are from outside Cebu City. They just came to Cebu City because in the past, there was no testing in their cities,” said Tac-an. Only recently has HIV testing been made available in Talisay, Danao, Mandaue and Lapu-Lapu cities.

Metro Cebu (Mandaue, Lapu-Lapu, Talisay, Cebu cities and Consolacion town) is estimated to have 5,000 IDUs, she said.

For the entire Cebu province, See said the estimate was 6,000 IDUs in 2013.

Asked why practically all who got HIV by injecting drugs were from Central Visayas, Tac-an said, “Other sites in the country did not access their IDUs.”

She said Cebu and Quezon cities started surveillance of IDUs in 1993. Thereafter, only three sites consistently reached the 300 target sample size needed.

“Only Cebu, General Santos and Zamboanga continued their surveillance of IDUs,” she said.

More than 90 percent of IDUs in Cebu City use Nalbuphine (generic name of Nubain).

Mobile

Recognizing that clients are mobile, the DOH supported a tri-city program targeted at IDUs in Cebu and males having sex with males (MSM) in Quezon City.

The “HIV/Aids Prevention in the Philippines: Reaching Out to Most-at-Risk Populations,” a three-year project of the United States Agency for International Development, ended in September. It aimed to provide services for IDUs in the social hygiene clinics of Cebu, Lapu-Lapu and Mandaue cities, and to reach 80 percent of the key MSM and IDU populations.

It strengthened peer education to motivate HIV counseling and testing, and the use of prevention commodities (meaning it distributed syringes/needles, condoms and lubricants). It also improved case management to increase treatment initiation, retention and adherence.

The goal was to maintain national HIV prevalence in the general population at less than one percent, in accordance with the 2011-2016 Aids Medium-Term Plan, and to keep the HIV prevalence among IDUs in the tri-city area below 58 percent in 2015.

The target was met, its March 2015 report said. HIV prevalence was at 51.5 percent among male IDUs in Cebu City, 32.4 percent among female IDUs in Cebu City, and 35 percent for male IDUs in Mandaue City, using the 2013 IHBSS figure as the accomplishment figure.

The 2011 IHBSS figures were 53.8 percent for Cebu City and 3.6 percent for Mandaue, meaning the cases in Mandaue grew. No figures were given for Lapu-Lapu.

The report said “needle-syringe distribution was halted periodically because of legal issues,” and that the Mandaue City Health Office had had “reservations about implementing a needle-syringe program.”

Even the innocent

Harm reduction helps not just the IDUs.

“Some females have partners who are HIV-positive IDUs, so they were infected by their IDU partners,” said See of CebuPlus. “Their babies may be HIV positive.”

“In Cebu City, there’s already a two-year-old and a nine-year-old born with HIV. If we don’t respond to this, more women and children will become HIV positive,” he said.

“The problem is more of the sex partners of the IDUs since we don’t see them,” Tac-an said. “Most likely, the other IDUs already have HIV, so we have been able to reach them. But the sex partners appear only when they are pregnant because there is a pre-natal checkup. That’s the time we encourage them to go for testing for HIV, hepatitis B and syphilis. This is free.”

But logistical limitations hamper testing. “We have satellite laboratories in only six barangays. We encourage that at the first pre-natal they get tested for HIV. But if there is no lab, they are referred to another barangay for the blood test,” she said.

Long before

Unknown to many, syringe distribution in Cebu City began not in 2010 but in 1993.

“Since the 1990s, one non-government organization had been giving syringes to IDUs in partnership with the Cebu City Health Department. All the projects ended in 2009,” Tac-an said. “In late 2009, the CHD saw a spike in HIV cases among IDUs. That’s why the department stepped in to continue syringe distribution in 2010.”

From 1996 to 2009, the HIV prevalence among Cebu City IDUs was less than one percent. This jumped to 53 percent in 2010, then 53.3 percent in 2011.

She said the low HIV prevalence in the years syringes were distributed shows that harm reduction prevents the spread of HIV.

Malaria outbreak

What first alerted health officials to the risks injecting drug use posed on public health was a 1992 malaria outbreak among IDUs in Cebu, a non-malarial area, Tac-an said in an interview with the World Health Organization (WHO) Representative Office-Philippines. They later discovered that it was not mosquitoes, but needle sharing by drug users, that spread the malaria.

Another blood-borne disease, hepatitis C, was also rampant in the IDUs, showing the risks needle sharing posed on the spread of other blood-borne diseases like HIV.

Tac-an told the WHO that almost 95 percent of Cebu City’s IDUs have hepatitis C, not a surprise considering “needle-sharing is so common but safe needle exchange is not widely practiced, plus it is criminalized.”

To show how widespread HIV is among the city’s IDUs, she told Sun.Star: “The Kamagayan study was approved by the DDB in October 2014. The research required a sample size of 400 HIV negative people so we could see if with intervention, we could maintain their negative status. But it took us a long time to find 400 HIV negative IDUs because so many of the IDUs were positive. We got the 400 in January 2015 only. Because so many were HIV positive, we had to test a lot of people.”

Rehab blues

In Kamagayan, part of the study was to give six slots for free for rehabilitation at the New Horizon Treatment and Rehabilitation Center in Argao town.

“In less than a year, we already got six people to agree to go to rehab,” Tac-an said. “There is also counseling on the harmful effects of drugs.”

Cosap’s Utlang was not impressed. She said, “Since the (drug users) were already there, they should have rehabilitated them.”

Tac-an, however, said: “Some (IDUs) say, ‘We have no money’ for rehab. Others say they’ve gone to rehab three times already—meaning rehab won’t work, especially if you did not go there voluntarily.”
While there have been cases of successful rehabilitation, she said some people would also say “there is no cure for drug addiction. You just say you have been drug-free for (this number of) days or years.”

Most of the time, those who succeeded were those who left the place they lived, the place that enabled their addiction, she said.

A long-time volunteer in Kamagayan’s efforts to rid itself of the drug haven tag, who asked not to be named, said many parents of the more well-off drug addicts had sent the police to Kamagayan multiple times to arrest their children when they went there to buy drugs. But six months later, after their stint in rehab, the addicts usually returned to Kamagayan to get their fix again.

Not free

“The problem with drug rehabilitation is that Cebu doesn’t have free treatment,” See of CebuPlus said.

“It will cost more than P50,000 per person. And all rehab centers are already full. There are 2,500 IDUs in Cebu City alone. How will you (accommodate) all these in the facilities? We need a multi-sectoral solution.”

Utlang admitted that 60 addicts are still waiting to get into the government-run Argao facility. She also said treatment in a private drug rehabilitation center will cost P18,000 to P45,000 a month. “It’s expensive because it includes accommodation and aircon. And depending on the assessment of your case, they might give you (medication to help you withdraw from your addiction).”

Education

CebuPlus does not condone drug abuse.

“It’s not like we’re tolerating drug use. But if we don’t give it (syringe) to them, they will still buy it. The cost of syringes is (only) P10-P15. The drug is P20-P30. It’s like giving condoms. Whether you give these or not, people will still have sex,” See said.

He said there is also more to the Kamagayan project than needle and syringe distribution. “Education includes disposal of needles. They should bring their (used needles) to the center” for proper disposal.

He said this way drug users would not just throw their needles anywhere, where children could pick them up and get pricked.

The 2013 IHBSS found that half of Cebu and Mandaue IDUs threw their needles and syringes in public trash bins, where in theory they could be found and reused by others.
From January 2016, CebuPlus will sustain the Kamagayan Comprehensive Care Center on the fourth and fifth floors of the Kamagayan Barangay Hall.

“The center provides testing, education, counseling and health services, even for regular diseases, even wound care only, not only HIV,” See said. It is focused on IDUs.

The long-time volunteer said village officials also did not support drug use.
In fact, he said, some drug users got angry on going to the barangay hall for the free syringes when they were arrested for carrying ampules or syringes that still had small amounts of illegal drugs inside. The syringes should have been empty because possession of dangerous drugs is illegal. The users are checked before they go up to the center.

Global state

According to the 2014 Global State of Harm Reduction (GSHR), 90 countries and territories had needle and syringe exchange programs (NSP), among them Brazil, Australia, Germany, China, Indonesia, Malaysia, Thailand and Vietnam. It said NSP was available in prisons in eight countries.

In its 2007 “Guide to starting and managing needle and syringe programs,” the WHO said a punitive approach “based overly on criminal justice measures succeeds only in driving underground those people most in need of prevention and care services.”

Last year, the WHO recommended “decriminalizing drug use to enable a supportive environment for key (at-risk) populations,” the GSHR said.

To allay fears that harm reduction will encourage intravenous drug use, the 2012 policy brief “Unsafe injecting drug use, a growing source of HIV transmission in the Philippines: Implications to policy” cited studies in the United States in 2002, Asia in 2007, and Europe in 2012 showing that making clean syringes and needles available to IDUs “does not lead to an increase in drug use in general, nor to intravenous injection, in particular.”

The programs also brought drug dependents into contact with helping agencies, “often resulting in better monitoring, care and treatment,” it said.

The Kamagayan volunteer confirmed that the giving of syringes did not result in the drug users shooting drugs more often than their usual five to eight times a day. But he said that sometimes, after using the clean needles, the poorer drug users, like jeepney dispatchers, passed these on to others. The educated and more affluent addicts, however, kept their needles to themselves.

Out of reach

CHD’s Tac-an showed the difficulty of reaching and maintaining contact with IDUs. For instance, only half of male IDUs tested for HIV in Cebu City got their results, the 2013 IHBSS showed.

“Most IDUs don’t give their contact numbers because they don’t have a cell phone,” Tac-an said. “If they had a cell phone, they had already pawned it (to buy drugs). They changed their number, so we just try to look for the peer educator (fellow IDU) who referred them to us.”

Results are available the day after testing, but she said due to the distance or lack of fare money, some people don’t return until months later. This means in the interim, those with HIV and didn’t know it could have infected others.

In the past, since the distribution of the needles and syringes was weekly, the drug addicts came often.

“We gave them an incentive to come, plete (fare money), snacks, tag (just) P10 ra gud,” she said. “Then we could monitor whether they had already started on their medication.”

In the end, the fate of the needle and syringe exchange program will hinge on whether drug users should be considered criminals or medical patients.

Tac-an told the WHO, “The health of all citizens must be a priority,” and that public officials would not be working at cross-purposes if health officials focused on harm reduction for drug users while law enforcers addressed drug trafficking.

(Second of three parts)