Implementing Harm Reduction
in Afghanistan
in Afghanistan
Th b ll t
i
Oli i M t
« The bullets price »
Olivier Maguet
Head of Mission - Médecins du Monde (MDM)
Drug is a major problem in
Afghanistan
2 figures:
9 93% of worldwide opium productionp p
9 At least 1 million drug
9 At least 1 million drug users in Afghanistan (among 28 million
(among 28 million inhabitants)
Main reasons
Main reasons
30 f d i l di i t ti
• 30 years of war and social disintegration:
Soviet invasion (1 million Afghans lost their lives and hundred thousands were wounded and disabled) civil war Taliban
thousands were wounded and disabled), civil war, Taliban rule, international intervention since Nov 2001 and on going military process (« Enduring Freedom » and ISAF) and
durable insurrection durable insurrection.
• Some consequences:
– 70% of mental health problems70% of mental health problems
– 10 millions refugees (Iran, Pakistan, …)
– State failure and warlords/criminal activities – …
DUs’ number is rising
DUs number is rising
• Support life (tragic stories) • Returnees
9New drugs and new routesg
9HIV
Social and economic unfair development • Social and economic unfair development
Figures in Kabul
Figures in Kabul
C t l i (K b l i ) 45% f
• Central region (Kabul province): 45% of the all heroïne users in the country
• Kabul city: 1 200 to 3 500 heroïne IDUs
(official data Æ underestimated figure)
( g )
• Kabuli IDUs prevalence & behavioral survey:
survey:
- HIV=3%, HCV=36,6%
Sh i i 50 4%
- Sharing syringes: 50,4%
(Todd CS, Abed AMS, Strathdee SA, Scott PT, Botros BA, Safi N, et al. “HIV, hepatitis C, and hepatitis B infections and associated risk behavior in injection drug users, Kabul, Afghanistan”. Emerg Infect Dis. 2007 Sep.)g p )
HIV/AIDS: an arising concern
HIV/AIDS: an arising concern
• An early epidemic phase with low HIV prevalence in general population …
p g p p
• … but already settled in high risk groups (IDUs SWs truckers)
2005 assessment
2005 assessment
• June 2005: MDM exploratory mission in Kabul • Findings out:g
9 Detoxification and Drug Demand Reduction (DDR) – No basic care for DUs (abscess dressing, etc.)
9 DUs stigmatization (social level and access to health services)
9 No HIV answer (ART, OI)
9 Authorities and stakeholders awareness on the drug problem as an essential arising issue for the country
2005 assessment
2005 assessment
• At this time, HR was an approach endorsed by authorities and support explicitely in national policy documents…
– December 2005 Counter narcotic law
– National Counter Narcotic strategy and national HIV/AIDS strategy on progress
• … but a concept directly translated from
international guidelines with no skill neither experience
MDM program to adress HR
Challenges for the country
T l i h t i HR th h l ( d
• To explain what is HR through an example (and not a pilot program) (“the showcase”).
• To train further Afghan HR teams and policy • To train further Afghan HR teams and policy
makers as soon as possible (scale up).
• To advocate for an health and social approachTo advocate for an health and social approach on drug use under MoPH umbrella (OST).
• To contribute to national HIV/AIDS response (community involvement).
Background: “g The entire population is considered to be at risk of drug abuse requiring development of universal prevention strategy to be targeted for DDR (drug
Strategy definition
Strategy definition
3 k i t
• 3 key points:
1°) A DIC and Training and Resource Centre (TRC) in the same place
Centre (TRC) in the same place
2°) f
2°) The choice of Kabul city
First results
First results
• May-June 2006: RAR
• July 2006: HR outreach team recruitmentJuly 2006: HR outreach team recruitment
and training process
A t 2006 DIC ttl t
• August 2006: DIC settlement
• September 2006: outreach work beginingSepte be 006 out eac o beg g
• October 2006: DIC opening
On going
On going
• OST implementation: on-going
• TRC activity implementationTRC activity implementation
• Self support and drug users’ organization, HIV CBO
HIV CBO
• Regional cooperation (INCAS Partnership eg o a coope at o ( C S a t e s p
Challenges for the country
Challenges for the country
• HR Scale up
• Mental healthMental health
• Evaluation & research
• The meaning and the efficiency of
reconstruction process if country (poppy eco st uct o p ocess cou t y (poppy
crop and trafic) and people (addicts) are under drugs?
Challenges for HR
Challenges for HR
• Afghanistan: international laboratory for
opium tincture?p
• Afghanistan: an HR implementation model for post conflict countries?
for post-conflict countries?
• Afghanistan: place of a new advocacy on international regulation regarding
pyschoactive products? pyschoactive products?
The bullets price
The bullets price
• 2007-2008: 298 millions USD for old
Chinese military bulletsy
Î 149 millions USD per year for useles bullets for the country
bullets for the country
• 2007-2011: 20 millions USD for Afghan HIV/AIDS program including treatment (ART and OST)
(ART and OST)
In memory of Hussain Jafary
In memory of Hussain Jafary
• Hussain was one of the first MDM outreach
worker involved in this worker involved in this HR program and in the nascent self support pp group.
• He couldn’t live enough time to benefit from a
maintenance substitution t t t i Af h i t
Tachakor!
Tachakor!
• Afghan staff (12 people directly on the program, 13 on overhead tasks) 13 on overhead tasks) • Program managers on
the field (Guive Rafatian the field (Guive Rafatian, Miodrag Antanasijevic, Carole Berrih, Julien Klisnick)
• MDM colleagues (Patrick Beauverie, Béatrice