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The role of harm reduction in Cambodia


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Each month The Loop is featuring highlights of citizen journalism from the Key Correspondents programme.

This month Choub Sok Chamreun questions whether Cambodia will be able to curb the spread of HIV among injecting drug users without embracing harm reduction. Choub Sok Chamreun is Director of Technical Support and Best Practices at KHANA, a linking organisation of the International HIV/AIDS Alliance.

Achieving Cambodia universal access goal on IDUs: A pipe dream
By Choub Sok Chamreun

Harm reduction can save the lives of injecting drug users (IDUs) but in Cambodia, the approach has not been popular or well received by the public. Many people deny and oppose the harm reduction strategy. This is possibly because current efforts are not promoting the understanding and knowledge of harm reduction issues among policy makers and the public.

Harm reduction is a strategy to reduce harm associated with drug use amongst IDUs. Internationally, the program has produced positive results. It has contributed to a reduction of new HIV infections and other communicable diseases such as hepatitis B and C (HBV & HCV).

Harm reduction consists of a needles and syringes program (NSP) and a methadone maintenance therapy (MMT). An NSP enables injecting drug users to exchange used needles and syringes for clean equipment. Through an MMT, drug users are prescribed the replacement drug methadone to help them reduce or eliminate their use of heroin.

In Phnom Penh, only two non-governmental organizations (NGOs), Korsang and Mitsamlanh, were licensed to operate a needles and syringes program in response to the rising demand for harm reduction interventions.

Harm reduction in Cambodia was first piloted in 2004 when the National Authority for Combating Drugs (NACD) licensed Mitsamlanh to distribute needles and syringes to street based children in Phnom Penh.

In late 2005 and early 2006, Korsang – an NGO specialized in harm reduction funded by USAID and the Global Fund to fight AIDS, Malaria and Tuberculosis (GFATM) through Khmer HIV/AIDS NGO Alliance (KHANA) – was authorized to carry out the needles and syringes program targeting adult IDUs in Phnom Penh.

Over the last four to five years, Korsang has reached many IDUs in Phnom Penh and has been implementing programs to raise HIV awareness, education on safe injection methods and safer sex. The program has distributed condoms and other harm reduction related services to IDUs. By December 2008, Korsang reached 1,030 IDUs in Phnom Penh.

However, Korsang’s programs have received varying reactions from the public. They have met frequent confrontations with the police, local authorities and the neighbors.

Will Cambodia sustain efforts to reduce HIV prevalence, if IDUs are living in fear, criminalized and stigmatized?

Recent estimates show that the national HIV prevalence rate is 0.9% but can be as high as 24.4% among IDUs. Lessons learnt from neighboring countries have revealed that the HIV prevalence among IDUs can double or triple within a year. It is quite urgent for all programmers to design and develop an informed program on harm reduction to reduce HIV. Currently, the needles and syringes program is the only approach that can slow down HIV prevalence within this population.

But as mentioned earlier, there is growing opposition from the public who regard the program as a way to promote the injection of drugs by drug users. Below are some of the key concerns that are being raised:

Does a needles and syringes program increase the number of people who inject drugs?

  • Have NSPs led to an increase in injecting drug use in Cambodia?
  • Has the number of drug users increased in Cambodia since the beginning of NSPs?
  • Does injecting drug use only occur in those Cambodian cities/provinces which have NSPs?
  • What does evidence from other countries tell us?

Presently, there is lack of reliable evidence to show whether the number of IDUs has increased before or after the NSPs. The available data does not show a significant increase.

More than 200 research papers that have been published about NSPs over the last two decades in Asia, Europe, America, Australia and New Zealand do not show any evidence of NSPs increasing numbers of IDUs. Also, there is no evidence that NSPs increase transition from non-injecting to injecting drug use.

A study carried out in the US through interviews with IDUs who had used NSP and those who had not indicated that IDUs who had used NSP were less likely to inject drugs or injected less frequently and they were more likely to enter into treatment for drug dependence.

People who use NSPs are less likely to share needles/syringes and less likely to have unsafer sex and at the same time, the cities with NSPs have fewer discarded needles/syringes in the community.

In Australia, $AU 130 million was spent on needles and syringes programs in 10 years. Within those years, NSPs prevented 25,000 new cases of HIV and 21,000 cases of hepatitis C and saved $AU 7.8 billion in treatment costs for HIV and hepatitis C.

In Cambodia, it is unclear whether NSPs lead to more IDUs but evidence from other countries have revealed that they do not lead to an increase in the number of IDUs. However, one thing which is certain is that HIV infection can explode within the community of IDUs.

Will Cambodia be able to achieve the national universal access target of reaching 80% of IDUs by 2010, if this community is living in fear, hidden, criminalized and stigmatized?

1. Dolan, K. MacDonald, M., Silins, E. & Topp, L. 2005. Needle and syringe programs: A review of the evidence. Canberra: Australian Government Department of Health and Ageing.

2. Hagan H et al. Reduced injection frequency and increased entry and retention in drug treatment associated with needle-exchange participation in Seattle drug injectors. Journal of Substance Abuse Treatment, 2000, 19(3):247-52.

3. Wodak, A. and Cooney, A. 2004. Evidence for action technical papers: effectiveness of sterile needle and syringe programming in reducing HIV/AIDS among injecting drug users. Geneva: World Health Organization.

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