The Outcasts

Malik Aftab Ahmed Awan, Pakistan

“He was already an addict and a shame for family. Now he has contracted AIDS as well. He has brought us nothing but sorrow, shame and disgrace. We shall never allow him to get back into this house.”

According to the reports of Pakistan Narcotics Control Division and UNODC, Pakistan is home to around five hundred thousand drug addicts who abuse different substances in one form or other. A significant percentage of them are injecting drug users. The injecting drug users commonly referred to as IDUs are a group marginalized and stigmatized by the society which shows little concern for the factors leading or driving them to drug abuse. The increasing prevalence of HIV among them has worsened their condition and added to their woes. Harassed by law enforcement agencies, stigmatized and ill-treated by health practitioners and shunned by their own families, they are the true outcasts of the society. You find them huddled together under the bridges, curled up in the dark corners of ill lit streets and sometimes sharing syringes and needles in deserted and desolate parks but prefer to ignore them pretending that they don’t exist. But by ignoring it we can make the problem go away. If we think the problem will automatically solve itself one day, we are badly mistaken. Drug use is an issue which we have been facing for many decades and by the looks of it, it is here to stay for a long time. Its repercussion and implications for development process in particular and for society in general are far reaching and manifold. It needs special attention from all of us and especially from those who matter like policy makers.

Though all the drug users face stigma and discrimination but the injecting drug users among them face it in much severe form due to many reasons and factors. Sharing of syringes and needles is a common practice among the group of injecting drug users. Injecting drug use is associated with many local and systemic complications for the individual and also is associated with the transmission and spread of infectious diseases including HIV via needle sharing and sexual activity. In recent years the prevalence of HIV epidemic has risen dramatically among injecting drug users and this rise has driven Pakistan in the second stage of HIV epidemic. According to internationally agreed definitions every epidemic passes through three stages. If the prevalence of epidemic is less than 0.1 % among general population, the country is termed as low prevalence. If the prevalence is more than 5 % in any sub group of the population, it is called concentrated epidemic and it is the second stage of epidemic. The epidemic is called generalized epidemic if 1 % of all pregnant women are positive. Pakistan today has reached the concentrated epidemic stage of HIV as more than 15%  of all the injecting drug users are HIV positive. In some cities of Pakistan the prevalence of HIV among injecting drug users is as high as 50%. To say that it is an alarming state is an understatement. There is every probability that in coming years we will be faced with a generalized HIV epidemic.

The spread of HIV among IDUs highlights many development issues as well as the issues of human rights. Risk behaviours leading to HIV transmission through shared needles and syringes are closely linked to development problems such as poverty and lack of sustainable livelihoods, exploitation, inadequate education and political repression. It is notable that some of the countries and communities most at risk from HIV and injecting drug use are often some of the least developed and Pakistan is no different. Even among these least developed countries drug use and HIV affect the most vulnerable and marginalized groups within communities. So they are the disadvantaged of the disadvantaged. The social and moral rejection and criminalization of drug use add to the plight of the drug users and drive further into isolation.

We must remember that problems associated to drug use and injecting drug use never remain confined to the group of injecting drug uses. Rather these affect the whole fabric of society in one form or another. Injecting drug use destroys social cohesion and erodes social capital. Through the cumulative loss of potentially important contributors to society, ultimately, injecting drug use undermines sustainable human development. Experience in many countries has shown that human development index suffers a severe setback. Add to this the spread of HIV and the gravity of the situation increases manifold. It is not uncommon for the HIV epidemic to travel to general population from IDUs through bridge populations. The wives (52% of all IDUs are married), children, families, clients and other people in direct contact with IDUs are called bridge population. Some of the IDUs are involved in selling and buying sex as well. Almost all the sexual encounters, which the IDUs have whether within the marriage or out side the marriage, are unsafe and unprotected. So it is not very far fetched to predict that in Pakistan too the epidemic is soon going to travel to general population through the bridge populations.

HIV epidemic though concentrated only in the certain sub groups of population is already costing us millions of dollars in loans and grants. If it travels into general population, the resources required to control it are definitely going to be out of our reach. Today we deny HIV positive IDUs the provision of ARVs (Anti Retroviral Drugs for treatment not cure of HIV) completely violating of their basic human rights of access to treatment and services. Will we be able to do the same to out general population if the HIV epidemic reaches the generalized epidemic levels? Do we know that 40% of the IDUs are less than 30 years of age, which is considered the prime working age? By letting the problem grow unattended we are essentially exposing our entire young generation and thus our future to risk of a full fledged HIV epidemic.

Unfortunately, like most of the developing countries Pakistan has not yet been able to devise a comprehensive strategy to address the issue of injecting drug use in general and of spread of HIV epidemic among IDUs in particular. Though a few NGOs like Nai Zindgi are doing remarkable work, yet the coverage of the entire group remains a big issue. The problems include:

• The current policy environment, making it difficult for community-based programs to prevent HIV among injecting drug users

• Lack of policy dialogue between sectors of government responsible for responses to HIV and drug use

• Economic, social and political dislocation, leading to increases in drug injecting, needle sharing and, consequently, HIV

• Low community capacity, in terms of skills, resources and experience to respond to HIV among IDUs

• Injecting drug users, being demonized for their drug use, rather than supported, placing them at particular risk of both human rights abuses and HIV infection

Lack of reliable data regarding the actual number of IDUs in Pakistan is another great impediment. According to the Mid Term Review report commissioned by Government of Pakistan and National AIDS Control Program in 2006-7, there are around five hundred thousand persons who use drugs in one form or the other in Pakistan. Out of these 150,000 are injecting drug users. Whereas according to the report of HIV and AIDS Surveillance Project which was also commissioned by National AIDS Control Program, the number of injecting drug users in 12 major cities of Pakistan is around 30,000 which when extrapolated to all urban areas comes to approximately 49,000. Yet another report by Narcotics Control Board says that out of 500,000 drug users in Pakistan 15% are injecting drug users i.e. 75,000. With different government departments providing different figures about the numbers of the same group, it is extremely difficult for any one to devise an effective strategy to address the numerous issues related to injecting drug users.

The above mentioned challenges do not mean that it is impossible to address the issue. The goal is not only control the spread of HIV among IDUs but also to provide them another chance of living healthy positive lives. In many countries community-based harm reduction programs including needle and syringe exchange programs, primary health care, peer education and counseling along with rehabilitation and re-integration have been very successful and they have been able to control the spread of HIV among the group. There is no reason why it can’t be done in Pakistan as well if we have the will to do so. (2008)

Malik Aftab Ahmed Awan is a dedicated and passionate development professional, working as the National Manager of Society for Sustainable Development and resident of Islamabad, Pakistan