Current status of harm reduction in India: Are we doing enough?

INTRODUCTION

Supply reduction, demand reduction, and harm reduction serve as three-pronged strategies to address the problem of substance use.[1] The term “supply reduction” refers to activities intended to reduce the availability of illegal drugs by law enforcement measures and policies. They make drugs scarcer and costlier and decrease their social tolerability. Demand reduction includes measures to reduce the public desire for illicit and illegal drugs through educational and behavioral training programs. Demand reduction includes prevention, early identification, treatment, and rehabilitation services. The third prong is harm reduction. It is more of a relativistic than an absolutist approach. It attempts to reduce the harmful and adverse consequences of drug use through pragmatic measures, even though not targeting to achieve reduction or complete cessation of its use.

WHAT IS HARM REDUCTION?

Many different definitions exist for harm reduction. Harm Reduction International defines harm reduction as “Policies, programs, and practices that aim primarily to reduce the adverse health, social, and economic consequences of the use of legal and illegal psychoactive drugs without necessarily reducing drug consumption. Harm reduction benefits people who use drugs, their families, and the community.”[2] Harm reduction is used interchangeably with terms such as “harm minimization,” “risk reduction,” “risk minimization,” and “use reduction,” among many other terminologies. However, the important attributes of such initiatives include 1) focus on harm rather than drug use, 2) people who use drugs (PWUDs) as key stakeholders in planning and delivery, 3) promotion of human rights, 4) public health approach, 5) value neutrality and non-judgment, 6) pragmatism, and 7) adaptiveness and innovation.[3] Such strategies have been applied to substance use, sexual practices, gambling, and other risky behaviors. Some common examples of harm reduction initiatives include opioid agonist therapy (OAT), needle syringe exchange programs (NSEPs), supervised drug consumption rooms (DCRs), supervised injection sites, naloxone distribution, safe sex supply distribution, overdose training, and heroin-assisted treatment, among many others.[4]

GLOBAL STATUS OF HARM REDUCTION

As per the recent systematic review, 93 countries are implementing NSEP, while 90 countries are implementing OAT in 2022.[5] A total of 17 countries have supervised DCR, 43 countries have naloxone distribution services, and 26 have drug-checking services. Globally, 18 out of 100 people who inject drugs (PWID) receive OAT, while 35 needles and syringes are distributed per PWID per year. Both these are considered low coverage as per the World Health Organization (WHO). The corresponding figures for South Asian countries are 44.7 out of 100 PWID for OAT and 29.4 needles and syringes distributed per PWID per year. Largely similar findings have been reported by the Harm Reduction International Report 2022.[6]

INDIAN STATUS OF HARM REDUCTION

History of harm reduction in India

In India, harm reduction services were started in the early 1990s. This was in response to the injecting drug use and a resultant increase in blood-borne infections that were noticed in many parts of India, especially in north-eastern states like Nagaland, Mizoram, and Manipur and in cities such as Delhi, Kolkata, and Mumbai.[7] The services were initiated through peer contact and outreach. In the north-eastern states, the initiatives started out of homes and communities. The services started in places like railway stations and parks (where drug users are easily accessible and may be approached). OAT in a community setting was started by an NGO in 1993.[8] Until 2005, OAT was provided by a handful of NGOs and medical colleges. National AIDS Control Programme (NACP) III (2007–2012) formally included harm reduction strategies (OAT and NSEP) to reduce the spread of HIV among PWIDs.[8] This gave a major push to harm reduction services in India. Though the program initially started providing OAT only through NGOs, government hospitals were later included under the program to provide OAT through a collaborative model.

Harm reduction in Indian drug policy

The first National Policy on Narcotic Drugs and Psychotropic Substances (NDPS) Policy was released in 2012. The Department of Revenue of the Ministry of Finance prepared the policy document. It has many sections, primarily focusing on supply reduction aspects. There are separate sections on “treatment, rehabilitation and social integration of drug addicts” and “harm reduction.” The policy mentions harm reduction primarily in the context of “injecting drug users” (IDUs) and sees it as “helping… abuse drugs safely” among IDUs and further states that “if IDUs cannot be de-addicted, he should at least be saved from infections.” The policy mentions four strategies as harm reduction approaches: (1) shooting galleries, (2) encouraging the “addict” to smoke instead of injecting, (3) needle syringe exchange programs (NSEP), and (4) oral substitution (“IDU is supplied with buprenorphine or methadone and persuaded to abuse them orally instead of injecting heroin or other drugs”). Further, the NDPS policy mentions that only NSEP and oral substitution shall be allowed. The policy does not permit the use of OAT in the prison setting. Finally, the policy allows harm reduction only as a “step towards de-addiction.”

Harm reduction in the Indian drug law

India enacted the Narcotic Drugs and Psychotropic Substances (NDPS) Act in 1985.[1] The NDPS Act allows the use of narcotic and psychotropic drugs such as methadone and buprenorphine for medical and scientific purposes. Although harm reduction has not been specifically referred to in the NDPS Act, the recent amendment in 2014 included the management of drug dependence in section 71.[9]

Harm reduction in other policies

The National AIDS Prevention and Control Policy 2002 supported harm reduction as one of the strategies to prevent HIV among IDUs.[10] The policy supported the provision of sterile needles and bleach. OST was included in 2007 in the national program. Apart from the national policy, certain states also supported harm reduction. It was the Manipur state that included harm reduction as a strategy for HIV/AIDS reduction in 1996. The policy supported needles/syringes, bleach, and condoms for IDUs.[10]

Current status of harm reduction strategies

Opioid agonist therapy

The current coverage of OAT in India is 3 per 100 PWID. Among PWID who inject primarily opioids, the coverage is 4 per 100 PWID.[5] Thus, the coverage of OAT is extremely low in India and falls under the low coverage category of the WHO ((low <20 people; moderate 20–39 people; high ≥40 people).

OAT is currently being provided by the following schemes of central and state governments (this list is not exhaustive).

1. Centers and clinics under the Drug De-Addiction Program (DDAP) of India: DDAP provides services primarily through de-addiction centers (DACs) and drug treatment clinics (DTCs).[11] Under this scheme, 122 DACs were established, of which 43 were in northeastern states. On the other hand, a total of 27 DTCs were functional across India as of 2019.[11]

2. Addiction Treatment Facility (ATFs) under the National Action Plan for Drug Demand Reduction 2018, Ministry of Social Justice and Empowerment (MoSJE): Similar to DTCs, other centers, called ATFs, for out-patient treatment, including OAT, were initiated under the MoSJE. As of February 2023, 25 such centers were functional, with a plan to scale up such centers to 125 districts in India.[12]

3. Opioid Substitution Therapy (OST) centers under the National AIDS Control Organization (NACO): NACO provides OST to PWID through OST centers run by three models: GO-NGO model, NGO model, and Satellite clinics.[13] (NACO uses the term OST, and not OAT, and hence, it is used here). Apart from this, they also provide NSP through targeted intervention sites. As per the Sankalak: Status of National AIDS Response 2023, there are around 393 OST centers across India including 200 in public health settings, 46 in NGO facilities, and 147 satellite centers.[14] Under this program, around 44,553 PWIDs are currently receiving OST [Figures 1 and 2]. As per NACO estimation, 23% of the active PWID population is receiving OST during this period.

4. Outpatient Opioid Assisted Treatment (OOAT) clinics under the Punjab Government: OOAT clinics were started in 2017 in both government and private settings in the state of Punjab (National Health Mission, Punjab, 2017).[15] In 2022, OOAT clinics were initiated in PHCs, CHCs, and prisons. As of one estimate, there are around 225 OOAT centers in Punjab, and around 2.5 lakh patients seek treatment daily at these centers.[16]

Figure 1.

Client coverage on OAT through NACO OST centers in the last 5 years (adapted from the National AIDS Control Organization 2023: Sankalak Fifth Edition)

Figure 2.

Current status of harm reduction services for PWID in India. *n of PWID = 8.5 lakhs (as per the national survey 2019). *n of PWID receiving TI services = 2.07 lakh, n of PWID on OAT = 44553 (as per the National AIDS Control Organization 2023: Sankalak Fifth Edition). These figures do not include people receiving OAT from services other than NACO

Thus, over the past decade, the OAT provision has increased further through various central government schemes [such as DTCs under the Ministry of Health and Family Welfare (MoHFW) and ATFs under MoSJE and state government initiatives such as (OOAT clinics in Punjab].

Needle syringe exchange programs

Needle and syringe exchange was introduced into NACP III 2007-2012. These are provided through targeted interventions. As per the Sankalak 2023 report, there were 1543 targeted intervention sites nationwide.[14] On the other hand, there were 277 NSEP sites.[5] Around 39,235,718 new needles and 27,917,942 new syringes were distributed among PWID during the 2021–2022 period. One-time coverage of about 80% has been reached during NACP-III. However, there is not much information about the regular coverage of NSEP. As per the recent systematic review and meta-analysis, 34 needles and syringes are distributed per PWID per year in India.[15] This is considered low coverage as per the WHO (low <100 needles; moderate 100–199 needles; high ≥200 needles).

Opioid agonist therapy (OAT) in prison

Injecting drug use in prisons is also common in India. For example, as per the HIV Sentinel Surveillance Plus Report 2021, 2.3% of inmates from central prisons reported that the inmates use drugs through the injecting route.[17] On the other hand, 3.7% of study inmates reported injecting drug use during prison time. As per the Harm Reduction International Report 2022, OAT is available in at least 1 prison in India. Previously, OAT was available in Tihar prison through a pilot project.[18] However, the data regarding the total number of PWID in prisons and coverage of OAT in such prisons is largely unavailable.

Take-home naloxone program and other strategies

Very little information is available about take-home naloxone programs in India. As per the Harm Reduction International Report 2022, such services exist in India.[6] A recent systematic review also suggests the same. However, details about the number of such services and coverage are largely unavailable. Supervised DCRs and drug-checking services do not exist in India.[19]

Condom distribution services are provided by NGOs providing a comprehensive package of services, commonly known as targeted interventions. As per the recent NACO report, 50% of the PWID population report consistent condom use. A systematic review suggested that inconsistent condom use was common among Indian PWIDs.[20]

CONCLUSION

Harm reduction services are aimed at reducing the public health burden of drug-related complications and improving the quality of life. Most people who use drugs do not have access to harm reduction services in India, suggesting that they still face a huge risk of morbidities and mortality linked to their injecting practices. There is a need to upscale the harm reduction services in India. This is especially important considering the huge numbers of PWID in India,[21] more so in the northern and north-eastern states of the country. There is also a need for improved programmatic data in relation to coverage of these services, not just at the country level but also at the state level. Indian NDPS policy allows only OAT and NSEP as harm reduction strategies, primarily in the context of reducing blood-borne infections among PWID. There is a need to apply harm reduction principles in its spirit in national policy, not just in the letter. Such policy should be applied with the objective of reducing harms associated with drugs in general and not just in the context of PWID. Finally, there is a need for more advocacy for improved support and funding for harm reduction services.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.