Lithuanian AIDS Centre
Conference Secretariat
Nugaletoju St. 14D, LT-2016 Vilnius
Lithuania
Tel. +3705 300125
Fax. +3705 300123
e-mail: aids@aids.lt

 
 
Different ways to combat drugs and HIV - A Critical View

Tomas Hallberg, ECAD, Director,
City Hall, S-105 35 Stockholm, Sweden

 
The major dividing line between a restrictive drug policy and a more liberal one is not whether drugs are dangerous or not. Neither is it whether you want to decrease drug abuse in society or not.

It is rather details in various methods and how much faith you place in people's capability that makes the dividing line between these two outlooks.
Naturally also the level of knowledge plays a role when people choose their point of view. These differences are clearly noticeable when an issue like injecting rooms for drug addicts is discussed.
Of course we all want that these grave drug addicts stop destroying their lives, but some people just don't think it is possible to influence them.
According to those people, the only solution is to try to make drug taking as safe as possible in order to prevent the addict from getting sicker or dying, and hope that the addict pulls himself together and stops taking drugs.

To my mind this outlook is unbelievably cynical, and as a humanist it is against my basic view on people to point a person out as an incurable drug addict, or, like drug liberals prefer to say, …'treatment resistant'.

If we should scale different phenomena within this cynical outlook, topmost would be heroin distribution. To give heroin to a heroin addict would seem unbelievably stupid, if one does not realise that heroin is given only to addicts we have completely given up hope for. Only then can some sort of logic be found in heroin distribution.

To set up injection rooms for those who don't get their heroin free, but have to prostitute themselves or steal the money for drugs, where they can undisturbed inject themselves with dangerous drugs, shows the same cynical attitude.

The difference between these two methods is only how far they dare to go.
The basic view on people is the same.

A little lower on the scale I place methadone treatment for opiate addicts.
Also this treatment is given to those who largely are given up as hopeless.
Hopeless for a healthy life without drugs. We all know that methadone is a variant of synthetic heroin. We know that opium is a painkiller that does not cure the disease but at the best relieves the symptoms. In other words, we are not talking about a remedy, a solution of the problem, but something quite different.

Methadone programs in many countries work along those lines.
It is seldom a high-priority goal that the patients should become completely drug-free. Instead the programs aim at relieving the symptoms and minimising the damage. The longer the patients stay in the programs without contracting any dangerous disease, without committing any crimes, the more successful the treatment is considered.

Perhaps the least controversial issue I am going to talk about is needle exchange.
Again, this method reflects a form of resignation. I don't believe that I can influence your LIFE, so instead I give you a syringe so you don't get HIV.

What are the results of these various methods? I intend to concentrate on the two latter methods and try to describe the experiences from Sweden. In Sweden we don't have heroin distribution or injection rooms. We might have had them if we had continued the Swedish drug policy from the 60-ies when we had legal prescription of amphetamine. However, we do have both methadone programs and needle exchange programs.

I'll try to briefly go through the results and conclusions of these both methods.

In 1985 there was an alert about HIV among drug addicts in Sweden. During one year 250 intravenous drug addicts tested positive for HIV. This led to many debaters demanding quick and resolute measures. It turned out that many of those infected had exchanged needles with each other. Accordingly, the solution was to distribute clean needles in order to decrease the risk of infection.
Only two cities swallowed this hook , namely Lund and Malmö which both are in the south of Sweden. In the rest of the country there was an opposition for various reasons. Partly it was found contradictory to the pronounced Swedish policy of 'a Drug-Free Society', partly there was a general scepticism about the method.

These needle exchange programs have been conducted as experiments and have been evaluated a couple of times. The evaluations have been critical and the results have shown that there is no real evidence of decreased spread of HIV.
There is notable lack of scientific proof that needle exchange programs prevent the spread of HIV. In spite of industrious searching I have not been able to find reports that stand trial of hard facts. Instead I find plenty of reports which reflect the spread of HIV in a city or region before and after the introduction of a needle exchange program. Using a simple parameter there are more than one project leader who can establish that new registrations of HIV-infected intravenous drug addicts have gone down during the time the project has been going on. However, this does not prove that it is the needles that make the difference.

Looking at Malmö as an example: in 1992, four intravenous addicts were reported as HIV-positive in the city. In 1998 there were five and in 2001 only one. These are fine figures but do they prove that needle exchange is effective against HIV?
Let's take Gothenburg as a comparative example. Gothenburg has almost twice as many inhabitants as Malmö, but has no needle exchange program. In the years I mentioned, the figures for Gothenburg were eleven, zero and one.
The number of HIV-infected among intravenous addicts has during a 15-year period been lower in Gothenburg than in Malmö. And this in actual figures without comparing the size of population.

But surely we have to do something about the spread of such an serious disease?
Of course we have to. But we should focus on the primary goal and use the resources in right way. What, then, is my advice?

An overall restrictive drug policy. The fewer drug addicts, the fewer HIV-infections.

A strongly built net of various care and treatment alternatives for drug addicts.

In Sweden until the year 2001, 840 people have become HIV-infected because of intravenous drug abuse or sexual intercourse between drug abusers.
There is a study which has followed a group of 1700 drug addicts who received treatment before HIV became known among the general public, that is in the middle of the 80-ies. Of these 1700 in treatment, only 44 had become HIV-infected.

Information is of vital importance. In Sweden, a massive information campaign was launched when HIV first became known. During a couple of years in the middle of the 80-ies and in the beginning of the 90-ies, it was practically the only thing the drug addicts talked about with each other. HIV or how to get the next dose of drugs.

Testing. To test the risk groups continuously. It has to be easy and free of charge to take a test. It is also important that a positive test should not lead to any sort of rejection. Accordingly, we should not place HIV-infected to separate wards in prisons or institutions. That only leads to that they don't want or dare to be open about the infection.

The other method I chose to speak about is methadone treatment.

Methadone has been used in Sweden during more than 30 years. Due to among other things the fact that risks of leakage to the illegal market were recognised early, methadone prescription was subject to numerous restrictions.
At present, methadone is distributed only to 650 patients in 4 different methadone programs in different places in Sweden.
The National Board of Health and Welfare has conducted a long-time study on over 261 heroin addicts registered in methadone treatment between 1989-91.
These addicts were followed up during nine years. With help of various registers the study tried to establish the level of health, criminality, mortality and dependence on social welfare benefits among these people.
The Director General of the Board Kerstin Wigzell states in the summary of this study that methadone treatment mainly has a supporting role, but seldom is the remedy.

What about the figures in this study?

4 % , that is 11 persons, were rehabilitated. They voluntarily left the treatment and did not reappear as drug addicts.

26 % stayed in the program the whole period.

33 % died. Half of which while still in the program.

92 % of the patients in the program were sentenced for crime before they received methadone.

69 % of the patients in the program were sentenced for crime while they received methadone.

The methadone patients were treated in hospital for various ailments an average of twice a year.

The last time I interviewed the head of the methadone program in Stockholm, none of the patients in the program were employed.

I must admit that I find it difficult to be completely satisfied with these figures.
We all know that those involved are a group of grave drug abusers.
But are we supposed to set up a treatment which accepts the fact that a vast majority of the patients commit crimes, live on social allowance, are heavy consumers of other forms of health care and then die prematurely?

Again it is a question of basic view on people. What sort of a life does a methadone addict lead? Should we accept a form of treatment that as a matter of fact does not seek a solution to the basic problem but only offers relief of the symptoms?

The question is: Can we afford to give up the fight for drug addicts, and if we do, what are the consequences to the society in general?

 
 
[< Back]