This is a story about a courageous policy in an unexpected place. In this place homeless shelters have vending machines selling clean syringes for injecting drugs. Drug users are not prosecuted as long as they are in treatment programs. Drug addicts are given clean needles and methadone maintenance therapy ─ available on a widespread basis even in prison. These tactics have worked to reduce crime, lower H.I.V. rates among drug users and keep AIDS from spreading out into the general population. The place is not Amsterdam. It is Tehran.
In a week when the news about Iran is centered on nuclear facilities and desperate diplomacy, I’d like to focus instead on another serious problem, toward which this repressive, seemingly irrational theocracy has taken a pragmatic and enlightened approach.
Sometimes there is no mystery about the best strategy to solve a problem, but for political reasons, that strategy is not used. Iran’s story offers useful lessons on how to build political support for effective solutions in tough circumstances.
In Africa, AIDS is spread mostly by sexual contact. We know that people need to abstain from sex, be faithful to one partner, or use condoms. But there has been limited success on this front. We just aren’t very good at getting people to do these things.
In many countries, however, the primary propeller of AIDS is not sex, but hypodermic needles shared by injecting drug users. This is the biggest driver of the H.I.V. epidemic in Eastern Europe, much of the Middle East and Asia and parts of the rest of the world. By recent measures, 62 percent of H.I.V. infections in Russia came directly from a shared needle. In Malaysia it is 76 percent, in Iran 68 percent. This is not just a problem for drug users. Unchecked H.I.V. epidemics among drug users move out into the general population by way of drug users’ sex partners. In a recent (and highly entertaining) book, “The Wisdom of Whores,” Elizabeth Pisani, an epidemiologist and advisor to Unaids, argued that Jakarta, Indonesia, has an H.I.V. epidemic 50 times larger than it would be if it had not allowed H.I.V. infection rates for drug users to climb from 0 to 47 percent in the late 1990s.
America’s AIDS emergency among black women ─ who have an AIDS rate 23 times higher than that of white women ─ could have been prevented with timely programs to prevent needle sharing. Few of these women got H.I.V. from a needle ─ but the needle is how H.I.V. got into the black community to begin with.
Preventing H.I.V. transmission among drug users, then, is a way to protect everyone.
Unlike preventing sexual transmission of AIDS, this is something we can do. The strategy is needle exchange ─ giving drug abusers new needles, usually in return for their used ones. One reason it works is that drug users want it: every drug injector prefers using clean needles.
Needle exchange is part of an overall approach to drugs called harm reduction, which seeks to make drug use less deadly to the addict and to diminish the crime and disease that drug addiction causes. In most countries that use harm reduction, possessing drugs is still illegal. But drug abuse is treated mainly as a disease, not a crime. An example of what harm reduction looks like can be seen in the Persepolis clinics, in Tehran’s south. Persepolis began as one drop-in center in a drug-ridden neighborhood, and later expanded to five centers. The clinics have outreach teams of former drug users who contact their peers on the street. The clinics offer needles, methadone, treatment for sexually transmitted diseases, AIDS tests and other medical care. They get people into drug treatment programs. Drug users can take showers, and sit all day and drink tea. When there is money, the clinics serve lunch and give out clothing. One clinic, with an all-female staff, is only for women. The clinics are an avenue for drug users to come into the health system, where they can get help.
The evidence that harm reduction works is overwhelming. Critics of needle exchange have argued that it causes more drug use, but it has proven not to do so. Instead, it drastically reduces H.I.V. rates by preventing a small H.I.V. problem among drug users from becoming a large one in the general population. It saves money, especially compared with the usual alternative ─ prison. It fights crime. Drug users on methadone maintenance therapy commit far fewer crimes than other users, and are usually able to hold down jobs and have otherwise normal lives.
But the overwhelming majority of drug injectors have no access to harm reduction. Widespread, effective needle exchange is mainly found in the expected places ─ Western Europe, Australia and New Zealand. In Russia, the country that most needs harm reduction, methadone is illegal and needle exchange is done only by tiny groups in a handful of cities. While some American cities use needle exchange (New York City is a much safer place because of its excellent needle exchange programs), it was illegal to use federal funds for needle exchange until last year. And under the Bush administration, Washington bullied international agencies to abandon their support for needle exchange.
The problem is the politics. It seems wrong for the government to be muddying a “don’t-do-drugs” message by supplying the equipment for an illegal and dangerous activity. But to oppose harm reduction only provides the illusion of morality. Surely it is more moral to choose a strategy that does not increase drug use, but does save lives.
Harm reduction is relatively new in Iran. After the Islamic Revolution in 1979, Iran cracked down hard on drug users, declaring addiction to be counter-revolutionary. All drug treatment was stopped. Hundreds of thousands of drug users were sent to labor camps. Possession of heroin was a capital offense.
These punitive policies only added to a spiraling epidemic of drug use. Ten years ago, the United Nations Office on Drugs and Crime (UNODC) estimated that Iran’s drug problem was one of the most serious in the world (sharing a 570-mile border with opium-growing Afghanistan does not help.) The harsh policies only drove drug users further underground; fear of being caught with a needle meant users would use the community needle the dealer provided. Going to prison was particularly dangerous. Prisons are havens of needle sharing, and having been incarcerated is the single strongest predictor of H.I.V. infection in Iran. Good data is scarce, but at one prison surveyed in 2001, 63 percent of all injecting drug users were H.I.V. positive. Testing of drug users who visited the Persepolis clinic found that fully a quarter of them had the AIDS virus.
Yet by 2005, harm reduction had become official policy in Iran. Ayatollah Mahmoud Shahroudi, the head of the judiciary, sent a letter to all courts and judicial authorities instructing them to support methadone and needle exchange. Even prisons in Iran now have widespread methadone, and there have been pilot projects in prisons for needle exchange ─ something not yet found in prisons in the United States, Canada or Australia. In 2007, 95 percent of drug injectors surveyed in Iran said they had used safe equipment when they last injected. (UNAIDS report, p. 94)
The rate of new H.I.V. infections in Iran rose until 2005, and has dropped ever since. A top drug control official, Saeed Sefatian, said in 2008 that 18 percent of injecting drug users were H.I.V.-positive, but estimated that if it weren’t for harm reduction, that number would have been 40 percent. New infections among drug users have continued to drop. Surveys at sentinel sites in pre-natal clinics have not yet turned up not a single pregnant woman with H.I.V. (UNAIDS report, p. 97) ─ an excellent indication that the epidemic has been contained.
By pointing out the success of this program, I do not mean to endorse Iran’s prisons, where political dissidents are being tortured. Nor does Iran’s modern approach to harm reduction redeem the government’s stone-age approach to just about everything else. The same ayatollah who told judges not to get in the way of harm reduction was the man who closed dozens of newspapers. The important point here is that even a theocracy as repressive and rigid as Iran ─ the anti-Amsterdam ─ managed to create policies that have likely saved the country from an AIDS and drug disaster. In Saturday’s column, I’ll tell the story of how the pragmatists in Iran managed to convince the clerics to adopt these policies ─ and what other countries can learn from their accomplishment.
By TINA ROSENBERG
November 29, 2010, 8:35 pm
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An Enlightened Exchange in Iran