By Uma Sudhir
From condemn to condom. The Pope it would seem, has come a long way. For the first time, he has said using a condom is okay. Not just that, he has said it is in fact a first step in being moral and responsible, to reduce the risk of infection. Just last year, on a visit to Africa, the same Vatican pontiff, Pope Benedict XVI, had during a visit to Africa famously said condoms “aggravated” the HIV/AIDS problem.
As most people familiar with Catholic beliefs would know, the denomination believes that sex should happen only between a married couple and too only for procreation. So the use of a condom, even for contraception, was not acceptable.
The Pope has now said that while the use of condoms may not be a real or moral solution, it is a first step in a more human way of living sexuality, to stop the spread of disease.
To me, it seemed an acknowledgment of the gap between the ideal world the church believes in, and the real world. And the willingness of the religious leader of great standing across the world to modify his stance, reflects a deeper commitment to do whatever best one can to make the world a better place, without sitting in moral judgment.
These decisions are not so easy. Anyone familiar with HIV prevention strategies knows about A,B,C. What it means is that since the sexual route is known to be number one culprit, the prescription, as a first option, is A for abstinence, second is B, Be faithful to your partner, and if the above two options don’t work for you, C, use a Condom.
It took a while to even start talking about these sexual choices that people make. But when it was proposed that school students and jail inmates would be familiarised with the ABC, there was an outcry of outrage and protest.
The arguments were not without merit. It could make youngsters curious to experiment. Are we suggesting that school-going children are sexually active? And within jails, is homosexuality to be condoned and even encouraged, when the law still prohibits it as an illegal activity?
Fact was surveys indicated that sexual activity begins among youngsters much earlier than parents would like to acknowledge. So is it better to expose Gen-Next to high-risk or equip them with knowledge and strategies that gives them a chance to make informed choices and minimise risks?
And jails are known to be high-prevalence zones where risky behaviour is not easy to stop. Sometimes, when you can’t stop something bad, you have to learn to at least deal with minimising its dangers. Harm-reduction is an important strategy.
Last month, I was touring Manipur that has the highest HIV epidemic driven by injecting drug use. To put in context, India is estimated to have an injecting drug use population of at least 2 lakh people. 25 per cent of them are from the northeast. Manipur is estimated to have about 38000 injecting drug users, about four in every 100 males, the highest in the country.
The experiences from there have important implications for, say Chennai, that has a high number of injecting drug users. Prevalence of blood-borne diseases (not just HIV) like Hepatitis C in this group is the highest in the country. In 2006, for example, the prevalence of HIV among the IDUs in Tamilnadu was 24 per cent while it was only 3.6 per cent in the case of sex workers.
While the drug use itself has frightening consequences for the individual, the family and surroundings, one characteristic of injecting drug use driven HIV is that it can quickly escalate from a core group to the general population. To give an idea of how vulnerable and at high-risk this group is, here are some figures :
The first case of HIV/AIDS in Manipur was reported in December 1989. The same decade in which injecting drug use of opiates like heroin and brown sugar grew to be a fad among youngsters.
In just one year, HIV prevalence among people injecting drugs went up from zero to 50 per cent. By 1994, it was 60 per cent and by 1997, it had reached 80 per cent. The reason: injecting drug users shared needles and syringes.
“We were reluctant to buy syringe from pharmacy as we did not want to people to know about our habit. When even that was not available, we used ink-droppers. We cut the tip of the dropper, cap it with metallic cycle valves to pierce the skin and nerve while pumping heroin into our body,” explains a veteran drug user.
What could the government do? Reduce demand and supply. Experts say experience has shown that legal prohibition only pushes the drug and its users underground and risk-behaviour increases. For Manipur it was not easy, with a 360-kilometre international porous border with Myanmar, proximity to the Golden Triangle and to transit routes, situation of internal conflict and unrest, and a huge problem of unemployment and underemployment of youth.
Detoxification and rehabilitation clinics were started but rate of relapse is very high, as much as 85 per cent. So what is the option? The government decided the youth must be given a choice of harm reduction. So the Needle Syringe Exchange programme was started to promote safe injecting practices. Clean needles and syringes are distributed free-of-cost and used needles and syringes were collected. That was complimented with condom supply as well
“Manipur was a pioneering state in this intervenion. Questions were raised whether we were encouraging intravenous drug use, supporting a negative activity. But the impact was very useful,” says the state’s family welfare and health commissioner.
In 10 years HIV prevalence among IDUs came down from 76 per cent in 1996 to 17 per cent in 2007. And it has been on the decline.
After a pilot in 2001, in 2006, the Oral Substitution Therapy was started. About 2000 people have registered for this treatment option that has now emerged as the most acceptable among IDUs, their family and community.
How it works? The use of the illegal drug like heroin is replaced with an appropriate dose of the legal drug buprenorphine, so that the drug user doesn’t suffer painful withdrawal symptoms. The daily dose is given sublingually at the OST centre. Many may need the maintenance dose for a lifetime.
But almost everyone I met who had registered for the OST said it had changed their life and were truly grateful for it. Their 24-hour quest was no longer about where the next dose of drug would come from, they were able to use what they earned for themselves and their family, and, more than anything else, they had regained the trust of their family, and had some hope of living a normal life.
The treatment option is of course, expensive. But given the expectations it has raised, Manipur is hoping for a scale-up where 10-20 per cent of IDUs will be able to access OST.
For other states with a sizeable and increasing number of injecting drug users like Haryana, Punjab, Delhi, Uttar Pradesh, Kerala and the cities of Chennai and Mumbai, the experiences of Manipur have provided important insights.
What it taught me is that for a daunting situation, you need innovative strategies, that can offer a range of options for the most vulnerable to regain hope and health, without being judgmental.
Life is not just black and white. The challenges are an unlimited range of shades in between. It is time we recognised that.