Title: 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
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
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.
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.
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
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.
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.
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.
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
Leadership and unified coordination
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.
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.
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.
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.
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.
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.
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.
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
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.
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
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.
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.
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.
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.
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.
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
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
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
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.
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.
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.
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
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.
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).
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.
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.
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.
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
72 (No Transcript) 73 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.
74 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.
75 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.
76 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.
77 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.
78 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.
79 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.
80 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.
81 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
82 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.
83 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
84 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.
85 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.
86 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.
87 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.
88 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.
89 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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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
10- There must be referral system directing identified HIV-positive persons to HIV/AIDS care and treatment services.
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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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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.
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