Approaches, Trends and Situation of Drug Related Harm Reduction Programs in Iran

1
Approaches Trends and Situation of Drug Related
Harm Reduction Programs in Iran
2

• The Islamic Republic of Iran is at a critical
  stage in its HIV/AIDS epidemic. There is
  unambiguous evidence that HIV is spreading
  alarmingly among injecting drug users (IDUs) and
  some evidence of extensive spread from this group
• Harm Reduction in Iran Issues in national
  scale-up
• Summary of Report for World Health Organization
  by
• Dave Burrows and Alex Wodak
• September 2005)

3
Latest Data about HIV/AIDS21/6/2007
In both sex group age of 25-34 years old have
priority 39.9 of men and 38.6 of women are in
this age groupthe next age group is 35-44
4
Islamic Republic of Iran

• Population 70.5 million
• Number of HIV cases (June 2007)
• Notified 15587 (94)
• All cases Estimate about 70000
• AIDS deaths
• 2062 (96)

5
Prevalence of notified HIV cases in Iran (2004)
6
Notified HIV cases in Iran

• Mode of transmission (June 2007Number has been
  rounded)
• Sharing needles and syringes 67 (99 male)
• Sexual contact 7 (56 male)
• Unknown 24 (94 male)
• Transfusion 2 (92 male)
• MTCT 0.5 (52 male)

7
Frequency of the way of transmission in all
Identified cases
8
Frequency of the mode of transmission in known
mode of transmission cases
9
Number of Identified HIV by Year
10
Mode of Transmission by Age Group
11
Mode of Transmission by Year
12
History of Harm ReductionActivities in Iran

• Harm reduction activities in Iran are very young
  and are less than 10 years history because
  before the reformation of law against drug at
  1998providing any facilities for using drugs
  might be faced with penalty via judiciary
  systems. The first flames of harm reduction
  programs flared at self introduced outpatient
  clinics that were under supervision of SWOthe
  main strategy at that years were only education
  for most at risk population.

13

• Educational materials were about HIV/AIDS
  Hepatitis and in somewhere about Safe sex and
  Safe Injection.
• Also it is only 7 years that we started our
  activities in the field of harm reduction but
  due to some changes in political and social
  situations our speed in spreading the quality
  and quantity of the harm reduction programs were
  very fast.

14

• Talking about harm reduction programs without
  considering the situation of HIV/AIDS in a
  country seems not so good !!
• thus firstly we will review our situation about
  HIV/AIDS and its related issues in nexts

15

• The population of the Islamic Republic of Iran
  as the title implies is made up of a Muslim
  majority. Arguably in Iran religious precepts
  are observed and valued as meticulously as any
  other country in the word. Quite possibly Iran
  may be absolutely unique in terms of its
  comprehensive system of religious instruction
  encompassing every realm of life at every age
  from early childhood up until death. That is why
  high-risk behaviors such as risky sexual contact
  drug abuse which expose individuals to the risk
  of HIV infection are considered completely
  unacceptable to Iranian conventional wisdom
  legislated laws and most importantly the
  canonical laws of the Holy Sharia.

16

• Yet it cannot be helped that such behaviors
  exist in Iranian society just as they do in
  every country in the world. This is particularly
  true given the fact that in many cases such
  behavior is beyond the individuals will and may
  be caused by factors that are genetically
  inherited psychological or deeply rooted social
  issues.
• Such behavior is often influenced by poverty
  illiteracy unemployment marginalization and so
  on.
• Indeed we need to think of the individuals
  involved as societys victims. The term victim
  here is intended to remind us that our duty as
  human beings is to suspend judgment and support
  those who have been victimized. The same duty
  applies to the national health network which
  must without any delay make sure that the
  remaining opportunities are
• fully utilized in the interest of the victims.

17

• The Islamic republic of Iran is faced with a
  critical phase of the HIV epidemic. The rampant
  spread of the infection over the past decade has
  shifted the epidemic from a state of low
  prevalence to one of concentrated prevalence
  resulting in serious concerns about increased
  prevalence among injecting drug users (IDUs)
  their sexual partners and other population groups
  with high-risk sexual behavior.

18

• Despite key decisions on harm reduction
  interventions and effective action taken at the
  upper governmental levels in policy-maker
  advocacy and in the delivery and extension of
  HIV/AIDS services throughout the country the
  qualitative and quantitative improvement of the
  said services seem vital at this juncture.
• World Bank projections indicate that failure to
  act in a timely manner could result in a 5 drop
  in Irans GNP by 2015. Therefore having a
  strategic plan developed with diligence scrutiny
  and consideration of all aspects of the issue to
  delineate the outlines of all HIV/AIDS-related
  activities is of utmost importance.

19
Key National Strategic Guidelines

• A document titled Islamic Republic of Irans
  Policies on HIV/AIDS has been compiled that
  includes a detailed description of the countrys
  key national strategy guidelines in this regard.
  Some of the main headings include
• the necessity for multi-sectorism
• Political support
• Accountability
• Leadership and unified coordination
• Ttransparency
• Flexibility
• Observation of the rights of people involved
• Participation of PLHIV
• Compliance with Iranian ratified UN goals on HIV
  and finally
• Objective evidence-based action.

20
Women and AIDS

• One of the most important issues about HIV/AIDS
  situation is situation of the women in each
  country
• Justice is the underlying basis of all legal
  principles of Islamic law and Islamic precepts.
  Interpretations of Islamic teachings and the
  Holly Koran in particular hold that women and
  men are equal in status personhood and human
  dignity and that gender has no bearing on human
  worth or potentials. Nevertheless gender
  inequality is a reality throughout the world and
  a concern among
• international bodies. According to UN statistics
  over two thirds of the worlds illiterate persons
  are women.12 Nearly half of the people living
  with HIV/AIDs are women and girls.

21

• In Irans third development plan unlike the
  first two special emphasis was placed on
  expansion of formal education as well as
  vocational training for women particularly in
  rural areas. The ever increasing rate of female
  enrollment in Irans universities
• constitutes a major achievement whereby in 2004
  women made up over 62 of all new admissions.
  Womens share of the official workforce has
  increased from 8.7 in 1991 to 14.8 in 2003.
  Womens participation and access has also
  improved significantly in decision-making
  processes in socio-cultural economic
  legislative executive and research sectors.
  Nevertheless great educational social
  cultural economic political and legal
  challenges lie ahead.

22

• Though women comprise only a small portion of
  people living with HIV in Iran there are
  alarming signs of the spread of the epidemic
  among them. Over the 2000-2004 period the
  proportion of women among PLHIV rose from 4.99
  to 5.82. Furthermore within those provinces
  where the epidemic began to emerge among IDUs the
  rise in the proportion of infected women was
  quite steady during this period.13 It is
  noteworthy that national data on the ratio of
  infected women probably underestimate its real
  state in that the nature of Irans diagnostic
  and monitoring mechanism is such that men are
  more likely to be diagnosed since most testing
  centers are located inside prisons or clinics
  where IDUs are to seek services.

23
Social Marginalization and Its Potential Effects
on the Dual AIDS/Drug Abuse Epidemic

• Marginalization is often associated with marginal
  urban settlements which constitute an issue
  visible in almost every major city in the world.
  This is among the consequences of
  over-urbanization particularly in metropolitan
  areas. It is not necessarily even a spatial
  notion. Socially marginalized is any person
  denied equal access to facilities and
  opportunities available to ordinary citizens.
  This may mean denial of educational opportunities
  to oneself or ones family members. It may mean
  that ones social standing is considered inferior
  because of socially unacceptable behavior such as
  being a drug user or a sex worker. In short
  social marginalization consists of being deprived
  of certain social opportunities and resources
  available to other citizens such resources and
  opportunities as employment proper health and
  treatment services housing nutrition
  education participation in the social
  decision-making process and whatever else is
  considered a citizens right.

24

• Social marginalization is often concurrent with
  urban ghettoization . In Iran due to the steady
  trend of urbanization ghettoization has been on
  the rise. In 1996 about one fifth of the
  population of the greater Tehran area lived in
  peripheral informal shanty dwellings. This is a
  major factor in the reproduction of poverty due
  to social marginalization. The social
  consequences of poverty are well-known. The Holy
  Koran in Baqara 268 clearly states It is Satan
  who calls humans into poverty and then forces
  them into prostitution. This tells of a clear
  correlation between poverty and social ills.
  Various scientific studies have confirmed this
  correlation

25
Islam and Harm Reduction

• Faith has an undeniable role in HIV/AIDS
  prevention and control programs throughout the
  world. Support from religious leaders is among
  the main factors contributing to the success of
  AIDS control programs. Religious ethics and
  teachings are among the best instruments in
  encouraging fidelity and abstinence for
  prevention and control of
• HIV/AIDS as well as protection of people living
  with HIV. The laws of the Islamic Republic of
  Iran are based on Islamic principles since more
  than 99.5 of the population is Muslim.

26

• Islam strongly encourages the formation and
  consolidation of the family institution and
  clearly the reduction of extra-marital sexual
  relations also reduces the risk of transmission
  of STDs and HIV. In cases when for whatever
  reason marriage
• is not an option Islam has recommended
  abstinence and piety. By utilizing religious
  morals and teachings persons living with HIV can
  be persuaded to help prevent the spread of the
  disease. These same religious precepts instruct
  us to avoid suspicion accusation and abuse of
  the victims.

27

• They promote compassion integration and sympathy
  for people living with the infection. Another
  interesting issue is Islams emphasis on
  prevention and its importance in various spheres.
  There is a verse in the Holy Koran where human
  beings have been called upon to refrain from
  intentionally
• putting themselves in harms way. This can be
  understood to mean refraining from any act that
  could destroy human life. The dynamic nature of
  Shiite theology allows for theological reasoning
  based on four different sources.

28

• These are the Holly Koran rational judgment
  Islamic traditions and what it calls community
  consensus. Emerging new problems and issues of
  the Islamic society are to be deliberated by
  contemporary specialists of the relevant fields.
  The final decision on each such issue should be
  the result of the collective expert opinion of
  the relevant disciplines together with evidence
  stemming from the other three theological sources
  of reasoning. Hence based on theological
  declarations of various Shiite sources of
  emulation HIV prevention measures including harm
  reduction interventions have been judged to be
  compatible the canonical laws of the Holy
  Sharia.

29
Health as an essential human need

• In Islam there is a great emphasis on this need
• The God in description of the holy Koran has
  said which means
  whatever has been said in this book is the source
  of health and wealth for the human being.

30

• It has said in religious traditions that
• Blessing gifts are two types health and
  security.
• It means that in shadow of these two flavors
  societies can reach the blossom of financial
  cultural and social improvements

31
Inclusion in Principle law of IRAN

• There is also special emphasis on health in
  Irans principle law
• it has been known as the task of government
• and an essential right of people

32

• Finally I should add that in our Islamic system
  maintaining the health of people and prisoners is
  one of the most important priorities
• And the logo of IRAN prisons organization
  contains this sentence from Holy Koran
• which
  means everybody who rebirths a person ( from
  physical mental aspect) is like that he has gave
  birth to all people of the world.
• This is why harm reduction is accepted for
  maintaining the lives although it may seem
  against some religious rules.

33

• There are many religious principles that are seen
  as models
• 1 - The rule of
  (LAZARAR VA LA ZARAR FED-DIN) or not being in
  harm and also no harm to others
• 2 The rule of (
• DAFE AFSAD BE-FASED) which means avoiding the
  worth action by doing a bad action

34
Stigmatization and Discrimination against
PLHIV/AIDS

• Defamation stigmatization and social
  discrimination continue to threaten all efforts
  for prevention of the disease throughout the
  world. Among policymakers such attitudes and
  actions lead to silence denial and failure to
  plan for infection control. For the individual
  the negative consequences to such attitudes
• include

35

• Denying the dangers of risky behavior
• Failure to seek testing
• Being unaware of ones positive status
• Delay in seeking treatment
• Delayed prevention against transmitting the
  disease to others
• Suffering in silence
• and a host of serious personal and social
  repercussions

36
Sexually Transmitted Diseases

• Data on STDs is currently collected from both
  symptomatic and syndromic cases by the national
  network of medical science universities. Their
  reports are based on people referring to their
  network of health and treatment clinics. These
  are mostly women. The average annual growth rate
  for symptomatic cases since 1998 amounts to 38.
  The annual number of symptomatic cases reported
  has quadrupled from 1992 to 2004 reaching about
  1.5 cases in one-hundred. It must be noted that
  45 of these cases occur in the 20-29 year-old
  age range.

37

• The number of cases of genital lesions which may
  be a better indicator in this regard has grown
  by a factor of 6.2 over the same period. Though
  the general prevalence of syphilis has been low
  during these yearsthe portion of positive cases
  of VDR/RPR out of the total number of serologic
  syphilis tests was reported to be just one in one
  thousand still there are alarming signs of the
  spread of STDs among the general population.

38
The Changing Prevalence and Patterns of Drug Use

• About drug and it situation in Iran we
  completely talked at first session but at this
  time we have a glance at changes in drug using
  pattern in recent years
• Many assessments that mentioned before
  indicate that in the years leading to these
  studies the increase in heroine use outpaced that
  of opium and that the share of injection among
  various methods was on the rise. According to
  Rahimi Movaghar et al the average annual increase
  in the incidence of drug use over the 1978-1998
  period was 8 while the average increase in the
  incidence of injecting drug use in the decade
  prior to the study was found to be 33.33
• There have been serious indications of
  pervasiveness of certain psychoactive drugs such
  as Ecstasy among young people. Unfortunately no
  referable study has been conducted on the
  prevalence of such substances or on the
  prevalence of high-risk behavior among their
  users.

39
Prevalence of Injecting Drug Use

• The number of IDUs in RSAs conducted in 1999 and
  2001 were found to be 130000 and 200000
  respectively. Current expert estimates usually
  concur of the figure 200000

40
Injection Related High-Risk Behavior

• The 1999 RSA found that about 70 of IDUs had a
  history of shared injection. The 2001 RSA showed
  that 50 of them had shared injection
  paraphernalia.
• The 2004 RSA found that 55 of the injections
  were done using sterile syringes. 43 of IDUs had
  at some point lent or borrowed a syringe. The
  interviewers conducting this study believed that
  syringe sterilization had recently increased.

41
HIV/AIDS prevalence among Drug Users

• Several studies have estimated HIV prevalence in
  the IDU population to range from 5 t0 25.
• Furthermore very high prevalence rates have been
  reported for hepatitis particularly hepatitis C.
  In one study the prevalence of HIV among
  non-injecting drug users has been estimated at
  5.4. Nevertheless it seems that the
  characteristics of the study sample cannot be
  generalized to the whole population of
  non-injecting drug users. The study found that
  the most important risk of HIV infection among
  non-injecting dug users was unsafe sex. This
  means that due to their general tendency to risky
  behavior even non-injecting drug users are at
  great risk of HIV infection and must not be
  overlooked in planning.

42
Sexual behaviors of the Youth and Their Levels of
Awareness

• About a quarter of Irans population is comprised
  of young people aged 15 to 24. The youth in Iran
  as in any country are exposed to the threat of
  high-risk sexual behavior.
• However it is still not quite acceptable to
  openly discuss the issue of sexual behavior
  within the culture of Irans various ethnic
  groups. In the discussion and conclusion section
  of a systematic review conducted in 2004
  information and research on high-risk sexual
  behavior was judged to be scarce and sporadic.
  The ecommendation was for further research
  specifically focusing prevalence and
  characteristics of high-risk sexual behavior.

43

• Yet there are clear indications that high-risk
  sexual behavior is hardly uncommon among young
  people. In a 2002 study of Tehran youth aged
  between 15 and 18 27.7 reported having had sex.
  71.7 of these had had more than one sexual
  partner.

44

• A number of other studies throughout the country
  have reported the prevalence of high-risk sexual
  behavior among non-married youth of various
  levels of social economic and
• educational standing to be momentous ranging
  somewhere in the neighborhood of 30.

45
Prison and Inmate Situation

• As many countries prisons are one of the high
  risk places for spreading HIV/AIDS. According to
  studies in other countries in the world
  prevalence of HIV infections in prisons is
  usually several times higher than in the general
  population. 37 This has been confirmed by
  numerous studies in many industrial and
  developing countries including Australia United
  States Germany and a number of other European
  countries.
• Clearly in the developing world particularly
  given higher inmate concentrations the problem
  can only be worse.

46

• The most common means of infection in prison is
  sharing injection implements. In this setting
  such implements are not limited to syringes and
  needle rather a host of far more dangerous
  apparatus is involved. 37 In addition to the most
  dangerous forms of MSM tattooing is also a means
  of transmission. 56 The phenomenon is very
  significant because sharing injection implements
  is also the leading cause of infection in the
  general population.

47

• Despite best efforts of prison authorities drugs
  do get into prisons everywhere in the world. 58
  In many prisons access to drugs is actually quite
  simple. For example in a study conducted in
  Canadian prisons in 1995 40 of the respondents
  had used drugs while incarcerated. Also in the UK
  a study conducted over the 1997-1999 period found
  that 69 of the inmates had used drugs on the
  inside at least once.

48
History of prisons in Iran

• Before Islamic revolution (1979) prisons were
  governed by police
• After Islamic revolution it was temporarily
  supervised by a supervision council and finally
  according to parliament approval an independent
  organization shaped under direct supervision of
  head of judiciary power

49

• Before the establishment of prisons organization
  IMAM Khomeini the founder of Islamic republic of
  Iran in a meeting with the supervision council
  has said I hope the situation of prisons could
  be in such a way that prisons except than
  incarceration have no other consideration
  especially about the health and treatment of
  prisoners.
• This shows the importance of health in Iran
  prisons as a very important priority

50
In Iran incarceration is not seen due to an
individual criminal behavior

• But it is known as the result of social
  interactions and sometimes the miss managements
  and social harms.
• In this way Iran prisons organization with the
  perception of physical mental and social health
  of prisoners has established the health and
  treatment directorate of prisons organization for
  policy making and supervision on health of
  prisoners

51

• At least 75 of prisons annual budget is spent
  for their health and nutrition which is already
  managed in health and treatment directorate.

52
The comprehensive opinion about prisoners
healthcorrection and rehabilitation viewpoint

• Has lead to essential changes in organizational
  chart
• Establishment of deputy for health correction
  and rehabilitation which handles more than 90 of
  incarceration process
• The philosophy of these changes is that
  incarceration is seen as the result of poverty in
  physical mental cultural and educational health
  and in belief and faith and occupational and life
  skills.

53
If we would like to lead human being to health we
should care for prisoners

• Under supervision of mentioned deputy there are
  four directorates
• 1-health and treatment
• 2-culturaleducational
• 3-occupation and job training
• 4-After release care and security measures
• Finally after completion of individualized
  interventions and release from prison the after
  release centers will care about the continuation
  of rehabilitation process and provision of social
  supports and occupational opportunities.

54
This comprehensive viewpoint to health and
rehabilitation has had valuable effects

• Before this dominant viewpoint most of the crimes
  were repeated and prisoners had history of
  several times of incarceration.
• But now the rate of re-incarceration has reduced
  and the prisoners with the first entrance to
  prisons has increased.

55
We hope by dominancy of this viewpoint in the
society we can observe the primary prevention of
crime incidence

• The completion of these chains will dramatically
  reduce the re-incarceration rate as an important
  international prison management indicator.
• Before implementing this process (about 15 years
  ago) the re-incarceration rate was about 37 and
  now with this new approach it has reduced to 19
  and in a group that have all four chains it has
  reached to less than 5.

56

• However due to limited facilities that can not
  provide 100 coverage and high turn over of
  prisoners ( more than 59 short stay in prisons
  less than 21 day) only part of prisoners can
  complete these chains.
• We hope by establishing the same components in
  community and completion of the chain by other
  supportive and treatment organizations we can see
  the high decrease in re-incarceration rate and
  provision of all health aspects for prisoners.

57

• I thinks that now we have a good view about
  HIV/AIDS related issues in Iran In 2001 a 5-year
  National Strategic Plan was developed by the
  MOHME together with other stakeholder
  institutions for the 2002-2006 period. It was
  presented with the relevant executive guidelines
  to the contemporaneous government of the time.
  The plan emphasized the participation of other
  sectors and GO/NGO institutions.
• In the continue we firstly review strategies of
  Iran against HIV/AIDS in a nut shell and then
  will talk more about one of these strategies that
  is Harm Reduction

58
Strategies for National Response

• 1- Education and information campaigns
• 2- Provision of safe blood supplies
• 3- Strengthening of the epidemiological care
  system
• 4- Strengthening of the prevention system against
  virus transmission at Irans diagnostic health
  and treatment centers
• 5- Counseling for at-risk individuals and
  voluntary testing for most-at risk populations
• 6- Harm reduction
• 7- STI care and treatment
• 8- Counseling care and treatment for PLWHA and
  their families
• 9- Strengthening and expansion of infrastructure
  and (financial human and management)
• resources in all HIV/AIDS related spheres
• 10- Strengthening of applied research
• 11- Social and financial support for PLWHA their
  families and individuals most-at-risk

59
Harm ReductionNational Provincial Working
Groups

• The harm-reduction subcommittee was formed in
  2002 and comprises representatives from MoH the
  Welfare Organization DCHQ Judiciary Prisons
  Organization NGOs etc. All harm reduction
  interventions are designed monitored and
  evaluated by the committee. The committee
  actively designs MMT Syringe Needle programs
  and other prevention services for drug users.
  These services are then delivered either within
  the organizational structure of the MoH or the
  Welfare Organization or by NGOs and the private
  sector.

60
Drop-in Centers

• Since 2003 Drop-in Centers began to proliferate
  in Iran providing harm reduction interventions
  including syringe needle services lesion care
  basic health services and counseling and
  education services delivered by healthcare staff
  peers and other volunteers.
• Nevertheless DIC-type interventions did exist
  prior to 2003 as well they were offered by the
  triangular clinic in Kermanshah and then later
  in other
• triangular clinics elsewhere across the country
  and inside prisons.

61

• Presently DIC service delivery is provided
  outside of Tehran and in many points across the
  country.
• Sterile injection implements condoms and
  information brochures are provided often in
  combination by peers or volunteers at DICs or by
  outreach teams. Most DICs began working over the
  past year. By spring of 2005 there were only 2
  DICs while by spring of 2006 there were 34.
  These 34 centers were associated with 71 outreach
  teams.
• And in January 2007 we had more than 200 DIC in
  Iran
• The centers are usually operated by NGOs under
  the supervision of medical universities or local
  divisions of the Welfare Organization .

62
Needle and Syringe Programs

• In Iran sterile syringes and needles are
  distributed among IDUs through behavioral disease
  counseling centers DICs outreach teams
  pharmacies and PHC health and
• treatment centers.
• In some cases the syringe and needle distribution
  programs are passive and do not involve
  associated outreach interventions whereby the
  drug addicts are actively sought for the delivery
  of services.

63

• A document titled
• the Needle Syringe Distribution Guidelines for
  Prisons
• has also been drafted and forwarded to the
  Judiciary chief for approval. If approved it
  would be implemented in accordance with its
  executive protocol at some incarceration
  facilities on a limited scale.
• At least in 2 prisons we have pilot NSP in
  passive methods.

64
Methadone Maintenance Treatment

• In the post-revolutionary era the delivery of
  methadone maintenance treatment was
• reinstated by the National Center for Addiction
  Studies with the support from UNODC.
• The program has been piloted in Irans prisons
  since 2003. There are now a number of MMT
  centers active on the outside within the
  framework of addiction treatment centers.
• Methadone maintenance treatment is also offered
  by behavioral disease counseling centers (for
  PLWHA) and DICs (mostly for street drug users).

65

• According to Irans report on the UN Declaration
  of Commitment against AIDS by spring of 2005
  4300 persons were receiving methadone maintenance
  treatment at 39 centers across the country. These
  centers include private GO and NGO centers
  overseen by medical universities the Welfare
  Organization and prisons. Assuming that there
  were 200000 injecting drug users in Iran at the
  time the rate of coverage for the MMT programs
  would have been 2.15.

66

• In 2005 with 27 state-run and 44 private centers
  overseen by medical universities or provincial
  departments of welfare as well as 33 centers
  supervised by the Prisons Organization a total
  of 10600 persons received MMT services.
• The share of state private and Prisons
  Organization was 4090 3020 and 3500
  respectively. As such by spring of 2006
  assuming that there are 20000 injecting drug
  users in prisons the rate of coverage for the
  MMT programs would be 17.5 while the rate of
  coverage for the country as a whole would be
  10.6.
• As DICs we have had a rapid growth in MMT
  centers that now we have totally more than .MMT
  Centers in Iran.

67
Abstinence-Based Services

• Abstinence-based services are provided to about
  30000 persons by the public sector and about
  90000 persons by the private sector.
• Based on Welfare Organization reports over two
  thirds of patients seeking detoxification are
  opium addicts while the remaining third are
  addicted to heroine. There are various methods of
  detoxification including ultra rapid
  detoxification which is particularly common
  among private sector services. There is
  naltrexone medication provided for relapse
  prevention however the costs are not covered by
  social welfare and other common forms of
  insurance.

68

• Nonmedication treatments also exist in the form
  of community based treatment and relapse
• prevention services which are provided by the
  Welfare Organization to those graduating
• from theses programs. The level of accompaniment
  of non-medication and medication treatments
  varies among different centers. The previously
  existing prison programs have also usually
  continued the delivery of MMT services upon
  induction.
• The Narcotics Anonymous also has an extensive
  network acting to treat drug users based on
  absolute-abstinence based approaches.

69
Community Education Centers

• In some provinces the Welfare Organization has
  set-up community education centers.
• These centers provide services such as substance
  abuse prevention community education prevention
  education for addicts on detoxification
  treatment and recreational
• activities for most-at-risk populations.

70
Challenges

• Limited coverage of harm reduction services
• Inaccessibility of some service centers for
  most-at-risk populations
• Irans position on the transit route of
  narcotics
• Changes in prevailing patterns of drug use from
  inhaling to injecting and from opioids to
  synthetic mind-altering substances
• Criminalization of addiction and the stigma and
  taboo associated with substance abuse
• Failure to properly manage the elimination of
  used syringes
• Shortage of competent and trained workforce
• Ambiguity of the status of MMT centers within
  the national health and treatment structure
• Scarcity of MMT centers

71
Brief Description of Irans National Response

• Finally we will have a look at Irans National
  Response to HIV/AIDS theses can shows us
  a holistic view of what happened in response to
  HIV/AIDS in Iran before that we will see a
  schematic view of structure responding HIV/AIDS
  in Iran

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Brief Description of Irans National Response

• Irans national response to the first wave of the
  epidemic the wave of transmission through blood
  transfusions was successful and decisive because
  of high-ranking official support timely
  financing and the presence of an institutional
  authority with several decades of experience in
  providing safe blood.
• With the onset of the second wave of the epidemic
  which was associated with a covert
• stigmatized behavior of marginalized IDUs
  control efforts grew increasingly complicated.

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Brief Description of Irans National Response

• Iran is known as a success story in this regard
  among not only developing countries but also in
  Islam world.Each year many of Iranian experts
  will participate in International Conference on
  Reduction of Drug Related Harm as lecturer or
  presentator and share their experiences with
  other world . In prisons our activities in recent
  years has been selected as a very modernholistic
  and useful experiences. Iran too had to taste
  the harsh truth that AIDS is not merely a health
  issue rather it encompasses political cultural
  and social aspects. Upon identification of the
  first case of HIV the formation of the High
  Council on AIDS was foreseen. Still coordination
  in approaches to deal with the issue has remained
  problematic due to differences in attitudes on
  drug use.

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Brief Description of Irans National Response

• Some are proponents of the understandable
  humane and yet puritanical idea of a society
  devoid of any high-risk behavior. They have
  insisted on penal responses against
• drug users and other most-at-risk populations.
  Incarceration of drug users and the camp-type
  solutions represent the practical component of
  such an attitude.
• Others while accepting the unavoidability of
  penal action to control the supply of drugs
  stress the necessity of policies to control
  demand and reduce the harms resulting from
• drug use. This is an attitude resigned to the
  fact that the collective knowledge of human
  society is at present inadequate in bringing
  about a society void of narcotics. It would be
  unfair to punish drug addicts for shortcomings in
  our knowledge.

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Brief Description of Irans National Response

• As the extensive dimensions of the HIV epidemic
  among IDUs and the effects of incarceration on
  its spread become more evident the number of
  proponents of physical restriction of drug abuse
  grows smaller. Nevertheless the periodic
  resurgence of the issue of camps is indicative of
  the depth of the roots of this mentality. The
  expansion of the more realistic attitude over
  recent years has led to momentous advocacy
  measures among state and spiritual authorities.
  The support afforded to harm reduction
  interventions by the Judiciary chief and a number
  of other ranking state officials together with
  Fatwas rulings on various issues in Islamic
  jurisprudence on their permissibility by
  prominent theologians represent achievements of
  such advocacy efforts.

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Brief Description of Irans National Response

• Decriminalization of drug abuse and reducing the
  flow of drug users into prisons thereby also
  reducing the net number of prisoners are both
  clearly practical steps that would help alleviate
  the harms resulting from narcotics. Nevertheless
  advocacy efforts must continue and accelerate
  firstly because the level of support
  particularly financial support remains
  inadequate and secondly because the individuals
  in charge of state administration are continually
  being replaced. It so happens that the new
  administrators are invariably selected from
  within a culture in which belief in
• a drug-free society is deeply rooted. It takes
  time for these new managers to understand the
  underlying principles of harm reduction and until
  then such interventions will be vulnerable.

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Brief Description of Irans National Response

• Harm reduction interventions have been central in
  controlling the epidemic among drug users. The
  first activities of this type began in late 1990s
  with the inception of the Kermanshah Triangular
  Clinic (center for behavioral disease).
  Consequently similar centers were established
  elsewhere in other provinces. These centers
  deliver a package of services that include ARV
  therapy healthcare services such as
  vaccinations prevention services such as
  awareness education counseling MMT
  needle/syringe condom distribution and VCT and
  support services. The quality of services is high
  but the coverage remains meager. In many places
  they practically fail in reaching the target
  population.

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Brief Description of Irans National Response

• The idea of using Red Crescent and blood
  transfusion posts for education and VCT services
  since 2000 was in fact an attempt to increase
  the coverage of VCT services.
• As such efforts continued with the successful
  and sustainable experience of launching the first
  DIC in Tehran in 2003 several DICs and their
  affiliated outreach teams were
• launched. In practice the centers provide in
  addition to care and treatment also intermediate
  and advanced HIV services as wells as other
  services available at behavioral disease
  counseling centers. With their greater access to
  drug users they have increased the coverage of
  the services. Nevertheless the quality of
  services delivered is probably inferior to those
  at centers for behavioral disease counseling.

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Brief Description of Irans National Response

• In step with other national programs the prison
  network has also worked toward delivery
• of similar services. It is usual for such
  services to be introduced into the prison health
  system within a year of the onset of delivery on
  the outside. Often the coverage of prison
  programs exceeds that of programs on the outside.

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Brief Description of Irans National Response

• Yet despite all these efforts and the
  advancements that began since 2005 program
  coverage is still not at a pace that could
  reverse the trend of the epidemic. In 2004 only
  10 of all drug users received VCT and only 2
  received syringe/needle services. In 2005 about
  11 were covered by MMT programs. The coverage of
  needle/syringe services remains severely
  inadequate. Though it seems that the coverage of
  educational programs is higher still the level
  of awareness of essential HIV issues among the
  at-risk populations indicates an insufficient
  level of coverage. Lack of adequate funding and
  infrastructural deficiencies are the main factors
  for poor coverage. Treatment services such as ARV
  therapy have also suffered from inadequate
  coverage. In 2004 only 13 of those requiring ARV
  medications were covered by the treatment
  services

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Brief Description of Irans National Response

• Abstinence based treatments did exist for IDUs
  before the identification of the HIV epidemic.
  Still their continuation constitutes a step
  toward controlling the epidemic. Such therapies
  may be medicinal or non-medicinal. In the
  post-revolutionary era medicinal therapies were
  first launched in 1996 by the Welfare
  Organization. Later medical universities and the
  private sector also entered the field.
  Non-medicinal therapies have a longer history in
  Iran. They have included the greatest level of
  drug-user participation in both planning and
  implementation. Some very powerful organizations
  such as Narcotics Anonymous are involved in these
  therapies.

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Brief Description of Irans National Response

• Irans response to high-risk sexual behavior
• Most activities have focused on spouses of drug
  users. These activities mainly include
• Condom distribution among drug users
• Counseling at triangular clinics and
  university/Red Crescent counseling posts
• Education for inmates family members

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Brief Description of Irans National Response

• These activities lack the needed coverage and
  fail to utilize all potential sensitization
  resources such as the mass media. Research on sex
  workers has been scant and activities have been
  scattered and unsystematic. The stigma associated
  with men having sex with other men is so great
  that even a single study specifically focusing on
  the issue remains absent. Activities targeting
  youth and the general public include increasing
  access to condoms. This has been done through
  distribution of condoms
• upon demand at PHC health and treatment centers
  visible display of condoms at pharmacies and
  providing variety in the supply of condoms.
  Still the social marketing component is missing
  while certain types of condoms which may prove
  effective in preventione.g. female condoms or
  anal condomsare not available in Iran.

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What Is to Be Done

• Given the main factors driving the spread of the
  epidemic and our response heretofore
• for its reversal the following seem necessary as
  the basis of future action
• 1- The government must commit itself to full
  political and financial support for HIV control
• and prevention activities. The cost involved may
  seem high but if the epidemic spreads to the
  general public a far more forbidding price would
  have to be paid.

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What Is to Be DoneConinue

• 2- The negative economic social cultural and
  health consequences of the epidemic failing the
  implementation of prevention and control
  measures must be made clear for policymakers
  planners clerics and other key stakeholders as
  well as the general public. This is essential in
  effective advocacy for funding workforce and
  equipment resource allocation as well as capacity
  building for the full implementation of the
  programs. It is also crucial in advocacy for
  legislation of protective laws for PLWHA and
  legislation of laws facilitating greater access
  to most-at-risk populations.

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What Is to Be DoneConinue

• 3- The existing structure of the national
  committee must be reviewed reinforced and
  supported in order to bring about a unified
  management on national scale to implement the
  activities foreseen in the NSP.
• 4- At present drug-use related behavior
  constitutes the leading cause driving the spread
  of the epidemic across the country. Furthermore
  Drug-user sexual behavior is the leading cause of
  the spread of the epidemic in other populations.
  Therefore all programs and policies on drugs and
  HIV must have similar or interrelated objective.

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What Is to Be DoneConinue

• 5- While continuing support for such networks as
  behavioral disease counseling centers MMT
  clinics counseling posts and DICs over a short
  period of two-to-three years the coverage of
  access and syringe/needle and educational service
  delivery to IDUs must surpass the 80 mark
  through increases in the number of outreach teams
  that actively seek access to target populations.
• 6- Drug-use interventions must comprise a host of
  various types of treatment including
  detoxification therapeutic communities and
  maintenance treatment. However the core of the
  program is currently based on methadone
  maintenance treatment which must be extended
  throughout the country.

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What Is to Be DoneConinue

• 7- Prisons must be regarded as the main component
  of the epidemic in Iran. Therefore all services
  provided in society at large must also be
  available with even greater coverage inside
  prisons. Meanwhile all effort must be made to
  refrain from driving drug users to the judicial
  process and into the prisons.
• 8- The most significant issue of concern against
  the epidemic getting out of control has to do
  with high-risk sexual behavior among youth the
  general public and certain mostat- risk
  populations such as sex workers and men who have
  sex with men. Therefore policymakers planners
  clerics and other key stakeholders as well as
  the general public must be sensitized in this
  regard. Through advocacy they must be drawn to
  support the implementation of safe sex education
  for all at-risk and most-at-risk populations and
  life skills education for youth and the general
  public.

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What Is to Be DoneConinue

• 9- Given that a large number of HIV-positive
  individuals remain unidentified despite the
• existence of a considerable number of HIV
  counseling centers There needs to be a program
  developed to extend the coverage of VCT services
  with special attention to drug users inmates
  sex workers their sexual partners and pregnant
  women in either of
• these populations.
• 10- There must be referral system directing
  identified HIV-positive persons to HIV/AIDS care
  and treatment services.

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What Is to Be DoneConinue

• 11- Regular periodical expert surveys must be
  launched to learn about levels of awareness and
  the behaviors of drug users sex workers youth
  and other most-at-risk population. These would
  also recognize the changes in these behaviors and
  find the vulnerabilities that expose these
  populations to the risks.
• 12- Pilot projects need to be implemented in
  order to find and develop the most suitable means
  of educating and informing the general public and
  youth on the national scale in the shortest
  amount of time so that comprehensive
  intervention could be implemented.
• Given what is known the greatest emphasis needs
  to focus on state-radio television schools and
  public media.

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What Is to Be DoneConinue

• 13- Finalization of the process for developing
  and implementing an evaluation and monitoring
  system on a national scale is urgent in order to
  assess program activities and the degree of
  success in reaching the objectives.
• 14- Without the participation of the private
  sector NGOs and the target populations it would
  be impossible to increase the coverage of the
  required activities to a point that reverses the
  trend of the epidemic. Therefore their
  participation must be facilitated in policy
  development activity selection implementation
  and monitoring evaluation.