From: matthew@ooc.uva.nl (Matthew Lewis)
Subject: Conference newspaper - Tuesday 21 July - part 3
Note: non-commercial reproduction.
Archive-Number: 5747
Organization: Center for Innovation and Cooperative Technology, University of Amsterdam
Date: 21 Jul 92 20:09:33 GMT

CONFERENCE NEWSPAPER - Tuesday, 21 July - part 3 of 4

(continuation of article from part 2)

The answer is not simple, but the starting point is the notion that it 
is our drug policy, not the drugs themselves, that accounts for the 
problems.
Public health is still not a serious consideration in formulating 
international drug policy. The dominant social response to drug use 
and drug users is repression and, in the name of drug enforcement, 
many basic human rights are violated. This subject will be discussed 
at today's Round Table on Drug Addiction and Human Rights 
(Session 84), but here are a few actual examples:

*In Bavaria, a young heroin addict finally gets on methadone, giving 
him a new lease of life. But the state prosecutes the doctor and 
stops the prescription of methadone for the addict, who hangs 
himself in despair.

*In Malaysia, a young American who uses marijuana to relieve 
chronic back spasms associated with a teenage climbing accident is 
sentenced to death for possession of 280 grams.

*In Rockford, Illinois, in the US, a young woman whose child dies 
shortly after birth is prosecuted for attempted murder because 
traces of cocaine were found in the baby's system.

Such harsh and punitive responses destroy the potential for 
effective intervention by stigmatising and marginalising drug users. 
Instilling fear and distrust in drug users, prohibition undermines 
basic public health efforts to limit the AIDS epidemic: early 
identifica-tion and access to compassionate treatment and AIDS 
education.
More directly, the War on Drugs robs scarce resources from drug 
treatment and AIDS prevention. Since 1970, the US has spent 
more than $500 billion dollars on prosecuting and imprisoning 
drug users: the cost for 1992 alone will exceed $50 billion. No 
wonder there is nothing left for the social programmes needed to 
solve the problems underlying widespread addiction, such as 
poverty, unemployment and social dislo-cation. Further, local drug 
economies operate to remove wealth from the poorest 
communities.
It would be appropriate - even cost effective - to heavily 
"capitalise"a public health approach to drug problems. 
Such an approach would include vastly expanded treatment, 
lowering the threshold for seeking care and increasing the 
likelihood of re-entry into drug treatment in the event of relapse, 
and education directed toward responsible use of all drugs - but 
accepting recreational use as the norm it is. These programmes 
could be easily funded by the savings associated with an end to drug 
prohibition. 
Every time we arrest and incarcerate a young drug user, we commit 
ourselves to a lifetime cycle of relapse and re-arrest, and a long list 
of health and social costs borne by the public - AIDS being only the 
most recent. In the US we spend more than $500,000 on these 
punitive approaches in a user's lifetime. Wouldn't it be better to 
"invest"even a quarter of this amount for effective treatment and 
rehabilitation, education, job training and social assistance?

Ernest Drucker, director, Division of Community Health, 
Montefiore Medical Center/Albert Einstein College of Medicine

**********************************************************
HIV and STD prevention: something works!
It is now accepted that the presence of other STDs increases the 
risk of transmission of HIV. Newer information suggests that HIV 
also prolongs the infectious period of other STDs, setting up a 
dangerous synergy. So efforts to prevent the spread of HIV need to 
incorporate treatment for STDs. They also need to take into 
account the true sexual behaviour of people in a given community. 
Use of trained local workers is essential.
In two community-oriented programmes among sex workers in 
Nairobi and Kinshasa, a combination of these strategies has proved 
effective. Through peer counselling, comprehensive STD care, as 
well as negotiating and role-playing strategies, rates of condom use 
have been substantially increased and the incidence of HIV 
transmission has been greatly reduced. 
William Check reports.

Marie Laga: 
Putting knowledge into practice

An HIV prevention programme among prostitutes in Kinshasa, 
Zaire, achieved a "quite dramatic"decrease in the HIV transmission 
rate over a two-year period. The project, organized by Dr Marie 
Laga, assistant professor of microbiology at the Institute of Tropical 
Medicine in Antwerp, incorporated several important principles: 
attention to HIV and other STDs; use of trained workers from the 
local community; and empowerment of the target population.
The project, conducted in collaboration with the US Centers for 
Disease Control, US National Institutes of Health and the Zairean 
government, first determined the prevalence rates of HIV and 
other STDs among prostitutes and surveyed local sex workers' 
knowledge of and practices for preventing STDs and HIV. The 
prevalence of HIV infection was 37%, syphilis 25%, and gonorrhoea 
20%. "Three out of every four women had at least one STD,"says 
Laga. 
"What was striking was that knowledge about STD prevention was 
good, but behaviour was not. Fewer than 5% used condoms 
regularly. Many used traditional methods to protect against STDs, 
but very few used effective methods."
Laga then examined the impact of an educational intervention 
which combined monthly check-ups and treatment of STDs with 
promotion and distribution of free condoms. In addition, the 
women attended individual counselling and education sessions and, 
every three months, a group session, all conducted by trained local 
nurses and a sociologist. Advanced sessions focused on how they 
could negotiate with men who did not want to use condoms. 
At the outset, the annual incidence rate of HIV infection was 25%; 
two years later it had dropped to 4%. "This is indirect proof that if 
you promote condom use intensively you really can reduce the rate 
of new HIV infections in a group that is at high risk,"says Laga.
Many people ask, which played the greater role - condom use or 
STD treatment? Laga believes it was the synergistic combination of 
the two. "If you provide good health care, women listen better to 
the preventive messages."
But even after two years, only about half the women said they used 
condoms all the time, because men often refuse. "That's a universal 
finding,"says Laga. One alternative would be to promote the use of 
"female-controlled methods", like the female condom. "It has pros 
and cons. Men know it's there, but do they object to it? Studies are 
needed to answer that question."
Traditional spermicides are another alternative. In vitro, they act 
against viruses. "Unfortunately limited studies up to now have 
shown that when spermicides are used at high frequency, several 
times per day, as a prostitute would do, they seem to cause side 
effects that may put women at higher risk for acquiring HIV, rather 
than protecting them."These side effects include irritation and 
erosion of the vaginal mucosa. So current spermicides may not be 
useful for high-frequency use.

Tony Klouda: 
Combat at the community level 

"Without a shadow of a doubt, the majority of STDs are either 
treated or recognised outside the formal health care system,"says 
Dr Tony Klouda, coordinator of the AIDS Prevention Unit for the 
International Family Planning Foundation in London. While this 
pattern is most prevalent in developing countries, STD services in 
developed countries are also underused, especially by women, due 
to a failure to recognise STDs and the shame associated with having 
one, Klouda says. 
Klouda hopes to encourage more people into standard treatment by 
helping family planning associations (FPAs) to see the importance 
of recognising and diagnosing STDs, not only within the 
associations' clinics, but also among street traders, traditional 
healers and other people in the community whom people ask for 
advice on STDs. 
Klouda's second goal in preventing transmission of sexual diseases, 
including HIV, is to understand better people's sexual lives. Only by 
acknowledging facts - that some people have multiple sex partners; 
that some people use sex workers; that young people experiment 
with sex from an early age; and that old people also have sex - will 
effective STD control strategies be devised. 
Both priorities require an interaction with communities that is 
quite hard to achieve, says Klouda. But while participation of local 
communities is standard in community development work,      it is 
less common in family planning projects. 
He believes it is important to establish local means of coping with 
STDs using methods of research that involve local people, rather 
than formal surveys. What is necessary is to develop contacts in the 
community and then train standard health care workers 
(physicians, nurses, epidemio-logists) to be sensitive to the beliefs 
and practices of local people.
The goal is to identify what is already done in a community and to 
improve it rather than trying to change it. "It may be that street 
traders are handling antibiotics and doing it badly. What I would 
like to concentrate on is training them so that they can recognise 
and treat STDs better, while realising the realities of the situation, 
such as their commercial interest."
The traditional motivations for FPAs to work in this field - 
preventing loss of fertility from pelvic inflammatory disease - may 
not apply to HIV. "The key issue for family planning has always been 
establishing safer sex,"says Klouda. "Until recently this has meant 
sex safe from pregnancy. Now we need to work for sex that is also 
safe from disease and safe from the abuse of power in sexual 
relationships. That means sex that is pleasurable."
Klouda says: "Many women throughout the world are in no position 
to say what their partners do to them sexually or what their 
partners do with others sexually."One solution is groups which help 
women to negotiate more effectively with their partners or with 
men in general.  
"HIV is a development issue,        not just a medical problem that 
can be isolated from economic and social factors endemic in the 
community,"he says.

Elizabeth Ngugi:
Changing sex workers' attitudes

Dr Elizabeth Ngugi, lecturer in the department of community 
health at the University of Nairobi, Kenya, attempts to prevent STD 
transmission by encouraging sex workers to use condoms with 
their clients. Her programmes focus on community beliefs and peer 
counselling.
At the beginning of her project, Ngugi surveyed men, women and 
youth from the local community to determine what they knew about 
STDs. They knew that they could get conventional STDs and that 
these infections were curable. But knowledge about HIV was less 
accurate. "When we ask, TDo you think you are vulnerable to getting 
AIDS,"says Ngugi, "the answer is usually, TWell, I don't think so'."
She thinks that is denial and that people are trying to rationalise a 
contradiction: that HIV, a fatal disease, can be transmitted through 
sex, which is procreative and gives life. 
Two main strategies have been incorporated into the project. "We 
get them to do role-playing. And we get some of them who are now 
infected, who did not believe that if they did not change their 
lifestyle, they could get infected, to come back as peer 
educators."In effect, these peer counsellors say, "We should have 
changed our sexual behaviour. Now we are infected. And we cannot 
blame anyone."Ngugi focuses her project on the target community: 
"Going where people live and work is what will give us better 
coverage."The programme also tries to reach people when they go 
to hospitals or clinics to be treated for an STD. For those patients 
who are confused about how STDs are transmitted, the hospital-
based part of the programme provides an educational and 
reinforcement opportunity.
Significantly, the programme is also designed to address issues of 
procreation and power. If people of either sex think they will lose 
status by not conforming to social norms, they are less likely to 
change their behaviour.
To counter this fear, counsellors encourage the sex workers to 
change their attitudes about themselves. They tell people: "You are 
not able to negotiate when you are sick. Being healthy gives you the 
power to negotiate."
The women well understand that they cannot continue working if 
they are sick: therefore many of them now use condoms. Within a 
year, the number of sex workers in the programme who always use 
condoms went up from 4% to 32%. Of those who have been in the 
programme longest, 50% always use condoms and another 10% use 
condoms some of the time.
"That is an important achievement,"says Ngugi.  
Although unexpected, there is now a healthy debate among men 
and women about condoms, which may increase their acceptability. 
The programme held several meetings for men to talk among 
themselves about their sexual lifestyle. Without the knowledge of 
the programme staff, the men invited some women sex workers. 
The men blamed the women for not telling them about condoms; 
the women blamed the men for not letting them use condoms. 
Although the initial exchange was about blame, at least it set the 
stage for a healty and valuable debate, says Ngugi.

Photo caption: A health worker in Singapore testing for gonorrhoea 
- a disease that facilitates the spread of HIV

Photo credit: WHO/T. Farkas

(article continues in part 4)
-- 
Matthew Lewis, University of Amsterdam		Grote Bickersstraat 72
+31-20-52 51 220				1013 KS  Amsterdam
Internet: matthew@ooc.uva.nl			The Netherlands
Newsgroups: sci.med.aids