Annie Madden, Executive Officer of the Australian Injecting and Illicit Drug Users League (AIVL) has announced her resignation from her role at AIVL after 16 years leading the organisation. Annie has made the decision for personal reasons and is looking forward to what the future will bring and to staying connected to a movement and a sector that will continue to be central to her life.
PrEP?! Not another acronym! Help! PrEP stands for Pre Exposure Prophylaxis (- Not the similar sounding PEP, which is Post Exposure Prophylaxis). Keep reading, all will be made clear. This is one of the latest HIV subjects on the table these days, with debate now rather well formed. The utilisation of the realms of research that has finally began to emerge now after the numerous PrEP trials that have lasted through the last decade.
In a nutshell, what is PrEP?
(Excerpt from earlier INPUD Diaries article) “It is an experimental HIV prevention strategy that, if proven, would use HIV drugs / anti retrovirals (ARVs) to drastically reduce the risk of HIV infection in HIV negative people who may be at a greater risk of contracting it due to circumstance etc.” However, while the empirical research is coming in, there remains questions. Some big ones. INPUD has taken a clear position, that among other things, PrEP must not come to eclipse other essential harm reduction interventions. It also loudly questions the ethical position of advocating for #PrEP for PWID not living with HIV is unethical when 4% of people who inject drugs and living with HIV are not receiving ART.
“People who use and inject drugs must have the right to choose for themselves which HIV prevention options best suit them, and all well-evidenced options must be available.”
The previous INPUD blog excerpt from PrEP’s early days in 2009 continues with this statement, “So, could PrEP, through the ingestion of a single drug (or combination) taken daily, reduce the chance of exposure to HIV infection – in HIV negative people? If found to be effective, how would such a prevention approach be rolled out? And to whom? In combination with what other prevention measures? And would HIV negative people even adhere to such a potentially uncomfortable and serious drug regime with no immediate tangible benefit – and perhaps even possible long term consequences from such a drug regime? And what about drug resistance – could we be making a rod for our own backs?“
INPUD rolls out a useful introduction on PrEP for the drug using community
Well, INPUD has released a basic introduction statement to Pre-Exposure Prophylaxis (PrEP) for people who inject drugs, outlining some of the pros, cons, and concerns surrounding this relatively new method for preventing HIV infection. INPUD states “People who took pre-exposure prophylaxis every day were significantly less likely to get infected with HIV. In an open label study, involving men and transwomen where participants were offered PrEP at the end of the trial, there was zero new HIV incidence amongst those who took between 4 and 7 doses per week, suggesting that PrEP could be somewhat forgiving with regard to missed doses.” INPUD went on to warn however that “Though clinical trials have shown efficacy for PrEP, INPUD stress that PrEP must not come to eclipse other essential harm reduction interventions. People who use and inject drugs must have the right to choose for themselves which HIV prevention options best suit them, and all well-evidenced options must be available.”
The advantages among the complexities
The data is flooding in
All the previously developed trials are finally coming in for the real number crunching and many have just been published.. “The research has looked at a range of transmission routes in diverse populations such as; Serodiscordant couples (one positive, the other negative); heterosexual men and women in high prevalence areas; people who inject drugs; gay men and other men who have sex with men. ” However, most of the now conceptualized data out there seems to focus on gay men and not on women and drug users, both who could potentially have a real part to play in properly targeted and thoughtfully implemented PrEP pilots etc. More on this in Silvia’s blog.
Where is the World Health Org Standing on PrEP?
And a Few Other Views?
In her blog Silvia asks the uncomfortable yet important questions but clearly states “I believe that it has been proven that PreP, if provided properly, could save many lives. I know that PrEP research has been community driven, and this is also important. But Silvia asks, “What about other vulnerable populations, such as black women and migrants? What about trans women? All the data we have here [in the UK] is about men who have sex with men, and this worries me. I have so many questions in my head….For now I would just like to share some questions I have regarding women’s access to PrEP that keep popping into my head. What are yours?…”
You can see the key questions Silvia raises in her blog such as:
- How will healthcare providers be trained in providing PreP to women? How will they be trained to deal with HIV stigma and gender based violence?
- How are we going to ensure that provision of PrEP for women provides pathways to other key services for women: including mental health services, drug and alcohol services, access to refuges and safe housing (for those exiting abusive relationships) etc. ?
For her article “Are Women Prepared for PrEP and a link to her very interesting blog, click here.
To add to the debate, a very useful article published by Daniel Wolfe, who as Director of the International Harm Reduction Development Program, Open Society Foundations and writing for the Huffington post (see full article here) warns us to not get swept away with the hype that is coming with PrEP. Wolfe goes on to give us a quick look behind the research figures revealing just how impossible it is to supplant the trial results in one country, as an affirmation of what will work in another. In this case it is about the large PrEP trial held over some years involving over 2,400 men and women who use drugs in Thailand.
Wolfe explains “The Bangkok Tenofovir Study was the first study of its kind examining a once-a-day HIV prevention method known as PrEP, or pre-exposure prophylaxis, among a population of injection drug users in Thailand. The study gave a single Tenofovir pill, along with counseling and risk reduction education to half of study participants, and offered placebo and counseling and risk reduction to the other half. Results showed overall reduction of almost 50 percent among those who received the medicine, and reduction of 74 percent for those who adhered best to the daily regimen.”
He continues, “The clinical trial finding that a once-daily pill halved HIV infection among people who inject drugs in Thailand is an important development in HIV prevention science, and brings welcome attention to a group often excluded from clinical trials.”
However, what makes this article so interesting is that he explains just how difficult it is
to assess the relevance of these trials in the real world when supplanted amongst communities of people who use drugs in countries where the simple act of just accessing your medication could be dangerous. For example, Wolfe tells us that the trial relied primarily on “directly observed therapy, meaning that most study participants had to come daily to receive the medicines.” Now to try and expect to roll out a PrEP process and gain similar positive results in another country where “going for an HIV test or even admitting that you have used drugs can result in the addition of your name to government registries shared with police” is outlandish. It also begs the question about the role of big pharma and the over medicalisation of the HIV prevention field.
“Pharmaceuticalization of HIV prevention for injecting drug users without corresponding reform in law enforcement and healthcare delivery is in no one’s interest, and will result in money wasted, new infections, and lives lost.”
In a fascinating piece of additional information which Wolfe says would of given us the chance to compare PrEP to effective needle and syringe programmes, Wolfe tells us where there lies a rather worrying case of missed opportunity; “Firstly, this study had an ethical obligation to compare the pharmaceutical intervention with needle and syringe programs — the recognized standard for HIV prevention among people who inject drugs. This standard was not observed, since the government in Thailand fails to offer needles and syringes through government programs. The omission means we lost a real opportunity to see how this daily pill compared to standard harm reduction services.”
I personally (not INPUD’s views here) have to wonder about the thought processes behind this examination which, if the data came out to be significantly similar and PrEP was compared to good quality NSP services, the drug companies could have lost out in a big way.
Indeed in his summary Daniel Wolfe states things a little more clearly for us saying “Pharmaceuticalization of HIV prevention for injecting drug users without corresponding reform in law enforcement and healthcare delivery is in no one’s interest, and will result in money wasted, new infections, and lives lost.”
Back to INPUD and the WHO
In the INPUD fact sheet on PrEP no 2, it summarises with the statement “The World Health Organisation, in the recently released Consolidated Guidelines on HIV Prevention, Diagnosis, Treatment and Care For Key Populations concluded on the basis of systematic reviews of the scientific evidence, and also the review of benefits, harms, costs as well as values and preferences of the community of people who inject drugs that it should not recommend PrEP for people who inject drugs. INPUD is in the process of developing a position statement on PrEP, so that we can systematically review the evidence and the opinions and values of the community so that they can be taken into consideration in forming policy.”
And finally, if that hasn’t given you some food for thought on PrEP, here are just a few fascinating insights into what concerns drug users have had around PrEP and its future implementation. (Note: INPUD is compiling a multi country consultation around what people think about PrEP and result will be published this year).
Guest blog: Thank you to our guest blogger this month, who has given us, incredibly in just under 600 words, an engaging, intimate yet candid reveal of over 38 years of a life entwined with heroin. A small yet perfectly formed piece of literature, complete and ready for the drug user’s historical book of insight and prose. Now there’s a book in the making friends: Page 1…
Written by Anon: or rather A Mature User – AKA Muser.
Sister Morphine, Mother Methadone
After that first snort – that was it – I thought ‘my life was sorted’. I just felt like, I was at peace. I had confidence. It got rid of the fear of intimacy, I enjoyed sex. It really was a eureka moment. I didn’t wake up with a hangover (little did I know) and it just seemed like you didn’t have to pay the piper. I thought, ‘You and I can get on well together, Sister Morphine’.
I shoulda known it couldn’t last.
Even as a very young kid, when someone used to put their arm around me and say ‘everything is going to be ok’, I never believed them. Never. But heroin, then, made me believe that all was good with the world, for a while anyway. The ritual, the scoring, bringing it home – it was like a present, unwrapping it, it was exciting. It takes away that angst. Until it becomes all about where that next hit is coming from.
I sometimes think I’ll probably never give it up. Because over the years it became more than just about the drug, it became a habit – it became everyone, and touched everything, I knew. It’s not exciting anymore. I think now, ‘why the fuck am I still doing this?’. Sister morphine has become mother methadone, and the thought of withdrawals terrify me. I have to say methadone is the most boring fucking drug…Its just so BORING!
What have I got from 38 years with heroin, apart from ageing and hepatitis C?! ….. Well, I’ve met so many ‘interesting” people, the good, the bad and the ugly and all sorts in between; worked with some wonderful people and I’ve ducked, dived and taken some mind-blowing gambles that I’d never have considered taking without the need for smack pushing me on. I was never gonna make it as a suburban housewife anyway. I think the older users’ voice needs to be heard. There is this old people’s home up the road from me and when I pass it I look in the window and I just think I couldn’t do it. The patients, people, and none of them would be users, I mean what would they do with people like me; how would we get treated? Older junkies with attitude …..Crash, bang, pow!!
But Then Again…
But…I dunno. I often wonder what I would of done if I didn’t take heroin. I think I would
have been an alcoholic. Coz I’ve always needed a little something between me the world. Wordsworth said in some poem, ‘“The world is too much with us”’* I often think that’s one of the truest sayings ever, it could be my motto. For me and I’m sure for many others, we just need a filter between us and reality. Wait, that’s a bit strong…It’s like, when you’re walking across the road and there’s bright lights and cars and horns blaring, it’s like an assault; Heroin is the filter that helps make things a bit more bearable.
I do think tho that, people have such low expectations of drug users, yet the people I’ve met, seriously, are so amazing, different, sensitive and…yeah, it really saddens me when I talk to people and how they think drug users are. Because it’s not just about the publics’ attitude to us; it’s about how powerfully that can impact our view of ourselves. So, what to do? An older woman .with Hep, C , on a methadone script, using on top with hepatitis C with other aches and pains?…beam be up Scotty!! A Mature User AKA Muser.
* The World Is Too Much with Us
By William Wordsworth, 1806
The world is too much with us; late and soon,
Getting and spending, we lay waste our powers;
Little we see in Nature that is ours;
We have given our hearts away, a sordid boon!
This Sea that bares her bosom to the moon,
The winds that will be howling at all hours,
And are up-gathered now like sleeping flowers,
For this, for everything, we are out of tune;
It moves us not. –Great God! I’d rather be
A Pagan suckled in a creed outworn;
So might I, standing on this pleasant lea,
Have glimpses that would make me less forlorn;
Have sight of Proteus rising from the sea;
Or hear old Triton blow his wreathèd horn.
For More Information about the poem and its meaning go to…
Catching Up on Dutch Coffee Shop News
Just thought readers might like a small update on the coffee shop / marijuana situation in the Netherlands and the city we all adore, Amsterdam. For a while now we have been hearing about a ban on cannabis for any foreigners visiting Amsterdam, in fact there were a lot of rumours and myths going around as to what exactly was going on. The reality today is quite a complex set of rules pressing down on the coffee shops of old and making their existence that much more difficult.
In fact, as is usual when the government gets involved and doesn’t really seek the views of the affected communities (and only focuses on the needs of big business), it seems the Netherlands’ has become more of a place where its coffee shops are being run and supplied by those without any community mindedness while others are busy tying up legislation to make sure only the right kind of fat cats will reap the rewards. There is angst and consternation behind the scenes of our dearly loved Dutch coffee shop system these days!
Let’s just put things in a little perspective; there were around 400 coffee shops dotted around Amsterdam in the 1990’s, of every shape and size, ambience and groove to suit even the fussiest dope smoker – we all remember the sounds, smells and conversations emerging from those smokey hubs of conversation, chillin’ and ‘the big lazy idea’! But today, in 2015, there are less than half of those coffee shops left.
The Poke in the Blind Eye
For decades now, it has been Dutch leaders who have been agreeing to turn a blind eye to the running of the coffee shops as long as they met certain requirements and the locals declared they were happy enough too. However, those requirements are now constantly changing and are being too often being implemented alongside the popularity contests and whims of local politicians.
So today, many more rules and regulations have come to the door of the Dutch coffee shop, some owners felt they were being squeezed out of business; rules such as –
- not more than 5 grams per person per day may be sold;
- hard drugs must not be sold;
- there must be no sales to minors and minors must not be allowed into a coffee shop;
- no alcohol may be served on the premises;
- there must be no advertising of drugs;
- there must be no disturbances in the vicinity of the shop;
- the shops’ stock must not exceed 500 grams.
OK – all of those sound relatively reasonable. But it isn’t those rules, it is others that are cause the difficulties, such as the particularly challenging ‘a premises cannot be within 250 meters from a school’, which caused 40 coffee shops to instantly close. (A coffee shop is unable to re-open once it is shut, causing people to rightly fear that, after a time, no coffee shops will be left at all). And there are more discretionary rules like “do not cause a nuisance.” In the end, each municipality has to decide if these rules are being followed.
Another rule has become known as the ‘Wietpas’, better known as ….
The Weed Pass for Foreigners
This ‘Wietpas’ or Weed Pass rule is probably the most infamous one to have happened. It is also the one all of us foreigner’s want to know about. What has happened to this law?
In 2012, which we reported on here, the ‘wietpas’, or weed pass, was brought in. It was designed as we know, to curb cannabis tourism by banning those annoying, drunk foreigners from the many usually peaceful, coffee shops. Fortunately for many, cities were allowed to opt out of the scheme, and for Amsterdam – which stood to lose millions of tourist dollars – the decision was simple, the mayor said, ‘No Thanks’. The national law that was banning foreigners from buying weed at the legal coffee shops has actually become widely ignored in most of the country since its inception, including Amsterdam and Rotterdam, the two largest cities whose mayors basically refuse to comply with the central government’s decision.
Currently, it is only the country’s southern provinces that have implemented the ban outlawing the sale of drugs to tourists by the infamous coffee shops and have limited sales to government-issued “weed pass”-carrying locals.
The coffee shop owners argue that the ban has devastated their business, damaged the local economy and led to an increase in illegal street dealing.
We Told You So!
A Dutch News article comparing ‘police and city council figures’ reports that “the decision to ban foreigners not resident in the Netherlands’ from the country’s cannabis cafes have led to an ‘explosion’ in drug-related crime in the south of the country. The governments’ decision to turn the cafes into ‘members only clubs’ in the southern provinces last May led to a sharp rise in street dealing. In Maastricht, at the forefront of efforts to reduce drug tourism, the number of drug crimes has doubled over the past year while in Roermond they are up three-fold with at least 60 active street dealers.”
Although according to other surveys recently published in the local Dutch press, two-thirds of the entire country’s 478 cannabis cafes continue to sell marijuana to tourists, it appears to be creating a new, north-south cannabis selling divide. And although there were many tourists in the border areas in the past, they were busy buying food, smoking dope, staying in hotels, spending money in legal places, etc. Now the local inhabitants seem to be really annoyed at the ‘change’ of the atmosphere into ‘pushy drug dealing’. Cannabis buyers must now buy off the local heroin or crack dealer in some darkened street, which is a real shame when all of us could have just bought it in a COFFEE SHOP like a normal person! Prohibition strikes again.
In any case, the ban at least appears to leave a loophole for a local, ‘tailor-made’ approach, permitting licensed coffee shops to continue selling small amounts of cannabis to any adult for personal use and there has been a court case brewing declaring the ban ‘unconstitutional’, which it may indeed be.
Amsterdam’s mayor, Eberhard van der Laan, for example, has made clear that his city will not ban tourists from its 220 coffee shops because “the legislation makes it possible to take local circumstances into account.” The mayors of many other towns support and follow his position, and a recent visit to Amsterdam by yours truly also confirms this kind of weedy old fashioned kindness still extended to foreigners. Phew!
Once again, the grey areas in Dutch laws, mean the rest of us can breathe a massive sigh of relief and can still squeeze quietly through the doors marked ‘this way, just more quietly please’. And do keep in mind, while possession is not legal the police do turn a blind eye to people with less than five grams. So civilised!
At least 10 of Netherlands’ local councils, among them some of the biggest cities like Amsterdam, Rotterdam, Utrecht and The Hague have called for regulated growing, arguing that legalized production would remove organized crime from the equation. But others think that such solution would just require only government-licensed growers, and that would mean an even greater crackdown on foreign imports and possibly even dumping any local producers in favour of the slicker big business types.
What About Americas’ Smokin’ Hopefuls?
If vast legal grey areas are still the Dutch model’s biggest liabilities, then, where America is concerned, stability is Washington’s biggest strength. Very little is going to be left to chance under ruling I-502. “Each marijuana grower, processor, and seller will be vetted, licensed, and watched over. Marijuana will be traceable, tested for quality, and come equipped with a lot number, a warning label, and the concentration of THC. Retailers will look more like pharmacies than drug dens and, most importantly, smoking pot inside the stores will be strictly verboten. Prohibiting Amsterdam-style coffee shops wasn’t an oversight, but a pragmatic decision meant to allay the fears of some of Washington’s more conservative voters. After spending much time and money on public opinion research, I-502 organizers realized the idea – however unfounded – of a bunch of perpetually stoned kids lurking around neighborhood coffee shops was just too much for many Washingtonians to stomach.” Thanks to C. Rodreigez from Forbes Life.
BUT!!! Don’t Miss This!!!
This terrific new short movie, supplementing the fascinating report of the Open Society Foundation
, tells the story of the Dutch model and highlights its successes, as well as the challenges ahead of it. Drugreporter says ” It is an English website created by the Hungarian Civil Liberties Union. The website was created in 2004 to promote drug policy reform advocacy in the region. In 2007 we started our video advocacy program and our website has become an international hub for English and Russian language news articles, blogs and films about harm reduction and drug policy reform. Our film database has hundreds of short films aiming at educating and mobilising people.”
But Wait Again!!
Drug-related death and disease are less prevalent than in many countries with restrictive drug laws. This is the conclusion of the report produced by the Open Society Foundations, authored by two excellent researchers, Jean-Paul Grund and Joost Breeksema. Click the link ahead to download the report! coffee-shops-and-compromise-20130713
Check Out The DR Film, thanks HCLU!
Final note: Just a thought – this was a story about Britain getting its first cannabis coffee shop in Kent, discussed just last year! Click here if your interested. We in Britain await with baited, but ageing, breath…