“Mauritian harm reduction programs address health not morality to combat HIV and hepatitis C
By Allyn Gaestel
A rarely discussed aspect of the HIV epidemic in Africa is transmission through needle sharing. An even less discussed, but nonetheless worrisome health issue is the prevalence of hepatitis C among needle sharing populations.
Under US President Barack Obama the Presidential Emergency Plan for AIDS Relief can fund needle exchange programs, which had been restricted under the “morality clauses” imposed by former President George W. Bush. However the financial crisis and “donor fatigue” have weakened international AIDS funding, and the programs that continue tend to focus on prevention education, condom distribution, and access to medication.
Yet in Mauritius, an island nation off the coast of southeast Africa, 80 percent of new HIV cases in 2007 were linked to injection drug use. Mauritius has the second highest per capita rate of opiate use in the world after Iran.
The primary drugs people inject in Mauritius are opioids, including a form of heroin known as “brown sugar,” and forms of buprenorphine, a drug intended to treat opioid dependence.
Heroin has been available in Mauritius since the 1970s, and in the 1980s users transitioned in greater numbers from smoking to injecting the drug, as it allowed for a quicker and more efficient high. Heroin is expensive in the country, so people try to optimize their use.
On the other hand, buprenorphine is significantly cheaper even than marijuana, which contributes to its popularity and accessibility. Buprenorphine is estimated to make up 70-80 percent of the Mauritian recreational drug market.
Injecting drugs can lead to significant public health issues, primarily with the spread of HIV and hepatitis C. While HIV has a higher profile, hepatitis C is a similarly devastating blood-borne virus. Hepatitis C is particularly contagious, as the virus can survive for lengthy periods of time even in dried blood.
If people do not have access to clean injection equipment and share needles, traces of the first user’s blood can remain in the syringe and enter following users’ blood streams. Both HIV and hepatitis C are long-term diseases, and people with the viruses can live for years before feeling the effects. This makes them especially prone to contagion as there is ample time to spread infection.
Hepatitis C’s lengthy dormant period also concerns Mauritian health providers who anticipate in the next 10-15 years an epidemic of cirrhosis, a liver disease caused by hepatitis C that can lead to liver failure and death. Mauritius currently does not have treatment available for liver disease except in the expensive private sector.
In the early 2000s prevention and detoxification programs existed in Mauritius. But these programs were not funded to work with active drug users. Nathalie Rose, program coordinator at Collectif Urgence Toxida (CUT), an NGO working with injecting drug users (IDUs), explained to MediaGlobal, “There were social workers within these organizations that saw the problem that was occurring with HIV among the IDU population so they came together to discuss what were the possibilities, what were the solutions, what could be done, outside at the international level?”
The social workers opted to implement a harm reduction program to address the situation in Mauritius. Harm reduction is widely seen as the most effective public health method for IDUs.
Harm reduction service providers address the health risks of drug use without stigmatizing people who engage in these activities. The idea is to minimize the harms associated with certain practices, instead of trying to force people to immediately end their use.
Programs that focus on abstinence can isolate users who do not want to or cannot quit using drugs immediately. If people cannot maintain detoxification programs they often find themselves without any health support. Harm reduction, on the other hand, meets people where they are, and provides them with as many options as possible for them to take care of their own health.
CUT currently operates 6 needle exchange sites, primarily in urban areas, but also in two villages. They are present in each community for two hours each day, and as clients exchange their used syringes for new, sterile supplies, they also communicate with outreach workers. Outreach workers provide referrals for other services and treatment if clients want them, and if not they act as a respectful support system.
The government is supportive of the initiative, and provides funding for some of the activities as well as runs another needle exchange caravan which travels to different sites once per week. The ministry of health has 39 locations for needle exchange.
Mauritius’ support for needle exchange is significant, as it is the first African country to implement harm reduction. Many government policies on the continent continue to reflect stigma towards drug users and maintain criminalization policies.
Serwaz Corceal, head of the syringe exchange program at the ministry of health, attributed the government’s support of harm reduction to the alarming figures linking HIV and hepatitis C to drug use: “Given the scale of the situation of drug injection it was imperative to expand access to syringe exchange.”
Nonetheless there are still enormous hurdles to fully address the HIV and heptatitis C epidemics and drug use. The laws concerning drug use and paraphernalia in Mauritius are contradictory: While the 2006 HIV and AIDS act says that someone who possesses needles or syringes shall not be considered to have committed a criminal offence, the Dangerous Drug Act of 2000 states that anyone in possession of drug paraphernalia including syringes has committed an offense and shall be fined. This leads to confusion and the police continue to harass drug users and intervene or intimidate NGO workers as they facilitate needle exchange.
Furthermore, users with criminal records struggle to regain their footing, even after ceasing to use. It takes ten years to clear a criminal record in Mauritius, and users expressed frustration that even after putting in the effort to regain their capacity to work they are often unable to find employment due to discrimination and stigma.
The criminalization of drug use undermines the public health response. Rose explained, “We are advocating…that the drug issue is tackled from a health perspective rather than a criminal one.” But the criminalization continues and in April Prime Minister Navin Ramgoolam announced in his re-election campaign that he would reintroduce capital punishment for buprenorphine dealers.NGOs responded with a public awareness campaign, and hope that the campaign promise will not come to fruition.
Measurable impacts of the harm reduction program will likely require an increase in services. Corceal told MediaGlobal by email, “The impact of the program has not yet been evaluated, but our satisfaction is primarily due to the fact that it’s an initial contact with health services for drug users.”
Currently CUT sees approximately 400 users each day, and distributes 600 new syringes. Of participating IDUs, 96 percent say they no longer share needles. The ministry of health has programs in “practically all the regions of the island where there is a community of IDUs”, according to Corceal. Yet with an estimated 17,000 to 18,000 IDUs in the country, there is still a need to expand service delivery.
Injection drug use is an important part of the HIV epidemic that is too often overlooked. As Mauritian NGOs and health officials address this population they continue to press for a shift from moralizing drug use to maintaining a health perspective on the epidemic.”