Harm reduction Iranian case

1
Harm reductionIranian case

• EAST TO EAST MEETING WARSAW 13 MAY, 2007
• Bijan Nassirimanesh, MD
• Bijan.nassirimanesh_at_gmail.com

2
Iran An example of moving from one pillar
approach since 1900 to 4-pilar approach at 2006

• Iran has been one of the opium producing country
  for decades and opium use has been embedded in
  socio-cultural values.
• There have been no serious rules and regulation
  addressing bio-psycho-social dimensions of drug
  use and almost all of the reaction to widespread
  opium use (and other drugs) have been up and down
  crackdown of dealers and users.

3
Iran An example of moving from one pillar
approach since 1900 to 4-pilar approach at 2006

• Like other only-law enforcement approach there
  have no evidence that either total number of
  people using drugs or availability of drugs have
  been affected by theses so called war on drug
  during all these decades.
• In 1979 Islamic revolution started a very tough
  crack down on drug users and dealers without any
  attention to the other aspects of effective drug
  policy. This is usually the case when politicians
  use moral standards for getting social
  approval/acceptability among population by attack
  on the most vulnerable part of the society by
  labeling cleaning social evils!

4
1. Zero tolerance

• First only approach Sever penalty (death
  sentences, life imprisonment) harsh
  confrontation no mater if you are a user or a
  dealer

5
2. Military camp

• Heavy military exercise without any treatment
  option available but cold water

6
3. Vocational prison camp

• Cold turkey detox following 3-12 months stay
  combined with Sewing machine therapy

7
4. Out patient clonidine detox

• Followed by heavily medical (mostly psychiatric)
  aftercare and referral to only available self
  help groups so called Narcotic anonymous NA with
  resulting 95 relapse rate after one year. There
  are several debates and unresolved points how
  much classical psychiatry is capable and needed
  addressing wide range of needs of people using
  drugs in daily life.

8
Shift from almost criminal point of view to
broad perspective

• Characteristic of this change in policy was
  acceptance of prevention and treatment beside
  supply reduction as 2 other pillars of the
  effective drug policy even in weak and none
  functional state. From then picture was
• Supply reduction still comprised of 95 of total
  budget
• Prevention not fully evidence based and mostly
  using scare tactics and forbidden fruit theory
• Treatment in its very limited choice Total
  abstinence

9
Result

• Total number of drug users not decreased if not
  increased 2 million
• Shifting in traditional mode of use mostly
  smoking to injecting
• Crowded prison settings
• Harms -Economic
• -Social
• -Public Health

10
Response for 4th pillar

• First Workshop on agonist maintenance treatment
  possibilities in Iran
• First MMT Pilot project in governmental hospital
  supported by UNODC with outstanding result
• National HR committee (before that AIDS committee
  scientists have been working hard to prepare
  the whole atmosphere for accepting the 4th
  pillar)

11
Response (Cont)

• 4. Harm reduction strategic plan (5/10 years)
• 5. First official harm reduction project
  supported by UNODC with the supervision of
  MOH/DCHQ
• 6. First low threshold MMT project
• 7. Official acceptance of harm reduction by
  judiciary organization
• 8. Lunch of harm reduction centers by MOH/WO/NGOs

12
Advocacy program for stakeholders

• Exhibitions City AIDS Bus
  IEC materials
• 
  
  
  Mass media
  Law enforcement

13
Training syllabus
14
Learning from others
15
Why so rigorous so fast

16
(No Transcript)
17
HIV prevention among drug users

• Start early Before Prevalence reach 5
• Provide information/means to DU to protect
  themselves
• Implement multiple program at a time
• -Outreach/drop in
• -NSEP
• -Maintenance treatment
• -VCT

18
Persepolis working with hard core homeless
street users

• Principles
• 1. PDM
• 2. Outreach
• 3. DIC
• 4. Low threshold MMT
• 5. VCT
• 6. Social Care

19
Decision where to start
20
Using WHO RSA study
.Shooting galleries.Drug dealing area.night
life.Sex area.police stations.Charity
org.Others
21
Outreach education using peer educators If this
is a disaster you must leave your clinic reach
out
22
Provision of information programs to inform
IDUs of the risks
23
Information

• Short, accurate to the point
• User friendly (ST/FF)
• Attractive with illustration cartoons
• Use local language dialect

24
You must bring the knowledge close to their real
daily life to be absorbable
25
It is not always easy!
26
Why?
27
1 month1 year10 years
Knowledge
Attitude
Behavior
28
Communication principles

• R espect E mpathy G enuineness

29
Developing a Brief Intervention

• F Feedback of personal risk or impairment
• R An emphasis on personal Responsibility for
  change
• A Clear Advice to reduce any harm
• M A Menu of alternate change options
• E Therapeutic Empathy as a counselling style
• S Enhancement of client Self-Efficacy or optimism

30
Counseling (pre/post) for HIV/HEP among IDUs
31
Testing
32
Safe sex education

• Culturally sensitive
• Religiously acceptive
• Language used understandable
• Ask people to rehearse thus be sure that they got
  the practical points

33
Increasing access to primary health care
34
NSEP
35
Why people share?!

• Access
• Cost
• Fear of being arrested/questioned
• Knowledge
• Peer pressure
• Closed setting

36
NSEP 1. Vein care 2. Clean day
3. Comprehensive
package
37
Strong
Community message
38
MMT
39
Social care
40
Micro-credit
41
Social Events
42
Change in life
43
Rewards