Community based Harm Reduction to fight high HIV

Community based Harm Reduction to fight high HIV prevalence among rug users in the north of Myanmar MEDICAL CARE FOR CRIMINALIZED POPULATIONS: SCALABLE OR DOOMED? Md. M/MSF Symposium Monday 23 rd of July 2018 Mr. Jiten Asem –Médecins Du Monde

Context § Myanmar is the world’s second largest producer of illicit opium after Afghanistan. § A large share of the production is refined into heroin for the domestic and international markets. § Myanmar is one of the largest producers of methamphetamine § Kachin is a conflict affected area, mountainous and remote Source: UNODC, Southeast Asia Opium Survey 2015 Photo credit: TNI Mr. Jiten Asem –Médecins Du Monde Medical care for criminalized populations: scalable or doomed? Mdm/MSF symposium

Drug Use & HIV in Kachin § High concentration of 100% PWID – 21, 328 out of 83, 338 estimated PWID 80% 60% § High prevalence of HIV & 81% 71% 67% 61% 50% 40% HCV among PWID- much higher than national prevalence 25. 5% 56% 45% 49% 39% 27% 20% 0% HCV positivity rate among PWID -2017, Md. M 100% 78% HIV and HCV prevalence among 85% PWID in Kachin Bhamo Hpakant Mohnyin Myitkyina Waimaw IBBS site HIV prevalence HCV prevalence Kachin total 85% 38% 50% 0% PWID (M) PWID (F) § The HIV epidemic is driven mainly by Injecting Drug Use and acquisition of HIV among partners of PWID (F) Source: 2016 HIV estimates and projections- & top line findings of IBBS 2017 Mr. Jiten Asem –Médecins Du Monde Medical care for criminalized populations: scalable or doomed? Mdm/MSF symposium

Criminalization of PWID-Field Experience § Frequent police raids in hotspots § Extortions of money § Physical violence § Punishment- cleaning of police stations & locality § Signing of bail bond ”not to use drug again” “I went to a shooting galley early morning (around 7 am) to provide services to my peers as usual. The police arrived suddenly arrested all the drug users including me. But the drug dealers run away. So the police were angry and started beating us. I explained them I am Peer Worker from Md. M and show my card. They looked at the card and told me “we are too busy because of Md. M, you distributed the needle and syringe” and then beaten again. They took me to the police station and also called village leader. They force me to sign bail bond and released” Peer Worker, July 2018 Mr. Jiten Asem –Médecins Du Monde Medical care for criminalized populations: scalable or doomed? Mdm/MSF symposium

Community Resistance- Stigma & Discrimination § Frequent drives in hotspots by anti-drug organisations § Physical violence in the name of drug treatment § Involuntary detention and forced detoxification by anti drug organisations If they are to difficult to handle and do not listen to what we said, we beat them. If the two are fighting together, we beat both of them and put them in the pillory (Man, Myitkyina) Perceptions about drug use and harm reduction in Kachin, Myanmar - A socio-anthropological, participatory approach - 2017 § High stigma and discrimination § Community resistance against HR especially NSP Mr. Jiten Asem –Médecins Du Monde Medical care for criminalized populations: scalable or doomed? Mdm/MSF symposium

Criminalization & Stigmatization of PWIDImpact on health & rights § Drive them more hidden § Low access to services § Human rights violations § Low self esteem In Kachin majority of the PWID inject drugs 2 -3 times per day. Hence they need around 21 clean needle and syringes per week to avoid sharing. When I offer to take enough supplies for the week my peers usually refused to take it because they are scare to carry it. It could be an evidence to identify as drug user. They are more afraid of police and anti-drug organization than HIV & HCV. Peer Worker, Md. M Mr. Jiten Asem –Médecins Du Monde Medical care for criminalized populations: scalable or doomed? Mdm/MSF symposium

Md. M in Myanmar § Md. M has been in Kachin since 1996 § Md. M implement a comprehensive community based harm reduction in three townships in Kachin State. § The program target people who use drugs and their sexual partners § The HIV intervention was extended for Sex workers and MSM in Yangon since 2000 Mr. Jiten Asem –Médecins Du Monde Medical care for criminalized populations: scalable or doomed? Mdm/MSF symposium

Harm Reduction Package § § § Needle Syringe Programme (NSP) Condom distribution HIV testing and counseling (HTC) Anti Retroviral treatment (ART) Clinic attached to public health facility Hepatitis B & C testing and vaccination of hep B § Screening, Diagnosis and treatment § § of TB OST (MMT) - integrated into public health facilities Diagnosis and treatment of STI IEC OD prevention and management Mr. Jiten Asem –Médecins Du Monde Medical care for criminalized populations: scalable or doomed? Mdm/MSF symposium

Community mobilization Fundamental component of Harm Reduction § Participation, involvement and ownership of the PWUD in all aspects of the program § Capacity building § Enable them to raise their own voice and drive their own local response Mr. Jiten Asem –Médecins Du Monde Medical care for criminalized populations: scalable or doomed? Mdm/MSF symposium

Medical care for criminalized PWID: Scalable or doomed? § 2018 - The Republic of the Union of Myanmar revised national drug laws & national drug control policy acknowledging harm reduction § Myanmar National Strategic Plan on Viral Hepatitis (20162020) § Harm reduction recognized as key strategy in national strategies and guidelines- NSP III (2018 -2020), national guideline on prison health, § 2018 -To address the alarming situation in Kachin, national authorities launched Sub-national operational plan in kachin (ongoing) Mr. Jiten Asem –Médecins Du Monde Medical care for criminalized populations: scalable or doomed? Mdm/MSF symposium

Way forward… § Urgent need for scale up § Essential to address the complex contextual factors § Need for innovative and a flexible response § Need for active engagement of a broad range of stakeholders Abolish CRIMINALISATION Mr. Jiten Asem –Médecins Du Monde Medical care for criminalized populations: scalable or doomed? Mdm/MSF symposium

Kyay Zuu Tin Par Tal! Mr. Jiten Asem –Médecins Du Monde Medical care for criminalized populations: scalable or doomed? Mdm/MSF symposium