Safer fixing
by John Sparrow
and Caroline Ohreen

The needle exchange programme of the Latvian Red Cross is one part of a project to reduce HIV/AID transmission among intravenous drug users.

From the Baltic to the Adriatic, Red Cross harm-reduction programmes are lessening the consequences of a dramatic increase in drug abuse.

Oleg, a 26-year-old drug abuser, has come to a centre in downtown Riga, capital of Latvia, to exchange his used syringes for clean ones. Oleg is not his real name and he doesn't want to be photo-graphed, afraid his neighbours may see the picture and discover he's an addict.

He's a reluctant talker but does venture an opinion. "This place is needed," he says. "Even if you don't have a needle or syringe to hand in, they will still give you new ones on credit."

Oleg isn't alone and the need is reflected in numbers. Around 1,000 people a month visit the premises on Birznieka-Upisa Street, a project supported by Latvia's Red Cross youth section. As well as acquiring paraphernalia, drug abusers can test for AIDS, and get information and advice that leaves them, and the community, safer. To use the clinical term, the exchange point practises harm reduction.

Latvia has seen a rapid increase in HIV infection since 1998, when the number of reported new cases jumped to 163 from 25 the year before. At the end of 2000 a total 1,765 Latvians were living with HIV and 80 per cent of cases were intravenous drug users. The Latvian Red Cross is convinced that to turn the tide needle exchange programmes must accompany their public information campaigns.

Some 1,300 kilometres to the south in Zagreb, Croatia, addicts visit the basement of a Red Cross building with a similar programme. HIV is not an emergency here and less than 1 per cent of drug users have tested positive. But over the past decade intravenous drug use has at least quadrupled in Croatia and the Ministry of Health is taking no chances with the accompanying threat of disease. Since 1998, the Croatian Red Cross has run harm-reduction programmes with government blessing, and today has three exchange centres: one in the capital, the others in Pula and Zadar on the Adriatic.

Says Red Cross health coordinator, Sinisa Zovko, "Croatia today is known to have 15,000 hard-drug users, most of them on heroin. Eighty per cent have hepatitis B and C. Harm reduction is about stopping the spread of any blood-related disease.You cannot separate HIV from drug programmes. Along with safer sex we must have safer fixing."

Heroin highway

Red Cross Red Crescent policy on harm reduction has yet to be formed. The prime focus globally is on awareness raising and prevention programmes, as reflected in the peer-to-peer education central to many Red Cross youth efforts. But with the European Red Cross and Red Crescent Network on HIV/AIDS (ERNA) adamant an upscaled response to the spread of HIV is required to avert another catastrophe, there is a groundswell of opinion that a position needs to be taken. In the meantime National Societies are finding their own solutions.

Nowhere is the pressure greater than along a heroin highway running out of Afghanistan. The flow of drugs north through central Asia to Russia, then west into the Baltic region is ever greater, and the intravenous use of them is the major cause of what today is the world's most explosive HIV/AIDS epidemic. Latvia and its northern neighbour, Estonia, are among the casualties. The figures themselves may be modest compared to Russia's but the growth rate is staggering. The upward spiral in Latvia has a parallel development in Estonia where the authorities report that an average 150 people a month are being infected by HIV.

The most important element of harm-reduction programmes, as identified in a recent report by the UN body responsible for drug control, is that of reaching out to drug users. This is often best done by peer support. A more comprehensive approach was developed in Latvia when the National Society's youth section consulted with the state AIDS Prevention Centre. A need for clean syringes at exchange points was identified and action was soon underway.

Egils Fuksis, director of the youth project, has been confronted by people asking why the Red Cross is involved in giving needles to abusers. "Many times I have explained that this project stops needles and syringes, possibly carrying a hepatitis virus, from being left lying around on the streets. It is a question of public health to start with. But young drug abusers, with their lives ahead of them, are also being given a chance to survive. If they give up drugs the likelihood of them avoiding HIV/AIDS is greater."

AIDS Prevention Centre statistics indicate the needle exchange is working well. Last October, for example, 8,110 used needles and syringes were collected by Riga's two exchange points and street workers, while 8,300 clean ones were given out. The Prevention Centre's deputy director, and Latvian Red Cross adviser, Inga Upmace, is at pains to point out that the operation has full government support. The accelerating spread of HIV in Latvia alarms everyone. "We have an epidemic among drug users," she says.

Cheap drugs

Latvia's first HIV-positive case was registered in 1987, and it came through sexual transmission. Ten years later the first five drug users carrying the virus were recorded, and by then the total number of infections had grown to 88.

"The reason HIV/AIDS started to spread among drug users in the mid-1990s was that more drugs, including heroin, were entering the country," says Upmace. "It became easier to buy drugs and they became less expensive."

Birznieka-Upisa Street was the first response in harm reduction and today is one of six service and outreach programmes. Estimates vary of how many users there are in Latvia but there could be as many as 50,000. It takes time for results to be seen, according to Upmace, but the first are now visible. "This year we believe figures will stabilize," she says, and points to southern neighbour Lithuania where needle exchange programmes began in 1996. The Lithuanian incidence of HIV/AIDS among drug users is lower.

The provision of needles and syringes is scheduled to end in August 2002 but Egils Fuksis would like it to continue alongside peer-to-peer education and other youth information programmes. "We cannot stop now," he says.

Relationship building

The sentiment is understood in Zagreb where Sinisa Zovko underlines needle exchange is a step in building relationships with drug users, part of a wider drug strategy that embraces awareness campaigns and, starting this year, will see Red Cross advice centres established in up to 30 municipalities the length and breadth of the country.

But Red Cross efforts to help drug users are above reproach. A 1996 act of parliament approved harm-reduction programmes as the country faced up to the drug problem. Zovko does not see the dilemma that still troubles some in the Movement. "I have heard the argument," she says. "Should we help people to use drugs? For a health professional it is not a question. Drug abusers are members of the community. They are ill because of addiction, and they have rights. My job is to help and advise them, reduce the risk they are exposed to. We must help them to protect themselves and in doing that protect the community."

Massimo Barra, chairman of ERNA and director of the Foundation Villa Mariani that works with drug addicts corroborates this "As a humanitarian organization, our objective must be to allow them to pass through their drug-using phase, however long that may be, and come out at the end with their health unaffected". This is the main aim of harm reduction.

John Sparrow
John Sparrow is Federation regional information delegate in Budapest.

Caroline Ohreen
Caroline Ohreen is a freelance journalist based in Sweden.