Harm reduction;Iranian case

Bijan Nassirimanesh, MD

Aug 2006, Toronto AID conference

bijan@ahrn.net

Iran: An example of moving from one pillar approach in 1979 to 4-pilar approach at 2006

1. First & only approach: Sever penalty (death sentences, life imprisonment) & harsh confrontation from start (user) to the end (big dealer)

2. Military camp (heavy exercise without any treatment option but cold water)

3. Vocational prison camp (cold turkey following 3-12 months stay)

4. Out patient clonidine therapy followed by heavily psychiatric/NA follow up with %90 relapse after one year for hard core users

Till then (4 years ago) we had 3 pillars if not fully functional & developed

1. Supply reduction (%95 of total budget)

2. Prevention (not fully evidence based and mostly using ST/FF)

3. Treatment in its narrow angle view (only separate professional groups): Total abstinence

Result

1. Total drug user's number not decreased if not increased; 2 million

2. Shifting in traditional mode of use mostly smoking to new injecting

3. Crowded prison settings

4. Harms: -Economic

-Social

-Public Health

Response for 4th pillar

1. First Workshop on agonist maintenance treatment possibilities in Iran

2. First MMT Pilot project in governmental hospital supported by UNODC with outstanding result

3. National HR committee (before that AIDS committee & scientists have been working hard to prepare the whole atmosphere for accepting the 4th pillar)

Response (Cont;)

4. Harm reduction strategic plan (5/10 years)5. First official harm reduction project

supported by UNODC with the supervision of MOH/DCHQ

6. First low threshold MMT project 7. Official acceptance of harm reduction by

judiciary organization8. Lunch of harm reduction centers by

MOH/WO/NGOs

Why so rigorous & so fast

HIV prevention among drug users

• Start early Before Prevalence reach %5

• Provide information/means to DU to protect themselves

• Implement multiple program at a time:-Outreach/drop in

-NSEP

-Maintenance treatment

-VCT

Persepolis: working with hard core homeless street users

• Principles:1. PDM

2. Outreach

3. DIC

4. Low threshold MMT

5. VCT

6. Social Care

Decision where to start

Using WHO RSA study

.Shooting galleries

.Drug dealing area

.night life

.Sex area

.police stations

.Charity org

.Others

Outreach education using peer educators: If this is a disaster you must leave your clinic & reach out

Provision of information programs to inform IDUs of the risks

Information

• Short, accurate & to the point

• User friendly (ST/FF)

• Attractive with illustration & cartoons

• Use local language & dialect

It is not always easy!

Why?

1 month

1 year

10 years

Knowledge

Attitude

Behavior

Communication principles

• R espect E mpathy G enuineness

Developing a Brief Intervention

• F Feedback of personal risk or impairment• R An emphasis on personal Responsibility for

change• A Clear Advice to reduce any harm• M A Menu of alternate change options• E Therapeutic Empathy as a counselling style• S Enhancement of client Self-Efficacy or

optimism

Counseling (pre/post) for HIV/HEP among IDUs

& Testing

Safe sex education

• Culturally sensitive

• Religiously acceptive

• Language used understandable

• Ask people to rehearse thus be sure that they got the practical points

Increasing access to primary health care

NSEP

Why people share?!

1. Access

2. Cost

3. Fear of being arrested/questioned

4. Knowledge

5. Peer pressure

6. Closed setting

Change in life