NDARC Technical Report No. 263 (2007)
In many countries in Central, South and South-East Asia, the HIV epidemic is being driven by injecting drug use (IDU). Harm reduction programs aim to reduce the transmission of HIV among IDUs. Harm reduction does not oppose the traditional abstinence goal of drug treatment services. Rather, harm reduction complements abstinence-based approaches by providing IDUs with the knowledge and tools to stay HIV negative until they are able to achieve and maintain abstinence.
Therapeutic communities (TCs) have traditionally provided abstinence-based services for drug users. However, with the advent of HIV many TCs have moved towards offering HIV education and making condoms and sterile needles and syringes available to their clients. One organisation that has taken these steps is We Help Ourselves (WHOS), a drug treatment service operating several TCs in Australia. WHOS began to offer harm reduction services to clients in the 1980s and continue to do so today.
The process by which WHOS incorporated harm reduction into their abstinence based program can be conceptualised using the “stages of change” of the trans-theoretical model: pre-contemplation; contemplation; preparation; action; and maintenance. Treatment services in the pre-contemplation stage are yet to consider the possibility of incorporating harm reduction into their program. Those in the contemplation stage are aware of HIV among their client group and are willing to explore options for preventing further HIV transmission. Organisations in the preparation stage are taking steps to introduce harm reduction strategies and those in the action stage have implemented harm reduction. Finally, treatment services in the maintenance stage are evaluating their harm reduction strategies and disseminating the findings.
The experiences of WHOS have provided several lessons for the drug treatment community:
1. Organisations for IDUs need to consider their role in HIV prevention
The advent of HIV has dramatically increased the risks associated with injecting drug use. Organisations that try to help IDUs have to think about what kinds of activities they can undertake with their clients to help prevent the spread of HIV between IDUs and into the wider community.
2. The reality of relapse: Balancing abstinence and HIV prevention
While the best way to avoid drug-related harms like HIV is to be abstinent from drug injecting, the reality is that many clients of drug treatment services relapse. While it is important to help IDUs achieve abstinence, it is also important to ensure that they are aware of the risks of HIV and how to protect themselves if they do relapse.
3. HIV prevention for IDUs can be addressed in many ways
Efforts to reduce HIV infection can range from providing clients with education about HIV and how to protect themselves, through to outreach, to making condoms and sterile needles and syringes available to clients as they are needed. All efforts to prevent HIV are valuable and should be encouraged.
4. Drug treatment services can change their goals without compromising their values
Abstinence and harm reduction are often presented as opposites or as conflicting approaches to drug use. In reality, abstinence-based organisations that implement harm reduction services find there is little conflict between the two approaches. It is possible to incorporate harm reduction into therapeutic communities while still promoting abstinence.
5. The process of change
Careful guidance is needed to ensure introducing harm reduction helps rather than hinders the service. Dividing the process of change into manageable steps (as in the previous section) and conquering each step before moving on to the next step will help ensure the success of harm reduction within a service.
6. Adding harm reduction to treatment services improves client outcomes
Many therapeutic communities have found that making changes to their service in response to the threat of HIV has improved their ability to attract and retain drug users in treatment. More drug users in treatment leads to decreased HIV transmission and increased numbers of clients completing treatment and remaining drug free, the best outcome that could possibly be hoped for.
WHOS’ journey from an abstinence-based therapeutic community to a harm reduction-based therapeutic community promoting abstinence is a case study of an organisation transforming itself in response to the challenges of the HIV/AIDS epidemic. This case study shows clearly that the process of change, while rarely easy, can be managed. Change can produce many benefits for the organisation, staff and above all, clients. Many drug treatment organisations have made the transition to harm reduction and few have regretted the change.
Citation: Larney, S., Corcoran, K., Wodak, A. and Dolan, K. on behalf of the World Health Organisaton Regional Office for the Western Pacific (2007), The integration of harm reduction into abstinence-based therapeutic communities: A case study of We Help Ourselves. Sydney: National Drug and Alcohol Research Centre.