减低危害:新一代所面临的挑战

<正>2010年4月25日-29日,在英国利物浦举行了第21届国际减低危害大会,来自90多个不同国家地区的1100多名代表参加了这次会议。在减低危害和预防治疗艾滋病前沿的科学家、医务工作者、活动人士和政府官员等出席了此次大会,大会的形式多样,包括主题演讲、全体会议、重要会议、     

Harm reduction: what it is and is not

The meaning of the term “harm reduction” has changed over the decades of its existence but it is now increasingly being aligned with public health approaches. An agreed meaning for the term would be helpful and should be sought. Antecedents are easy to find. Emphasis on small achievable steps is an important element; neither inherently supportive of prohibition nor of legalization, harm reduction is essentially pragmatic and tends to favour regulatory approaches. HIV has focused attention on harm reduction but even in the illicit drug field, a strong tradition of research and policy with an identical philosophical framework can be traced back well before the AIDS era. Harm reduction primary prevention educational approaches are more open, honest and respectful of responsible decision making processes. With current illicit drug users, harm reduction emphasizes the need to understand existing individual control mechanisms. The concept can be well understood if contrasted with prevailing approaches to drugs which generally emphasize punishment, lack of regulation and often augment harm.     

Harm reduction in action: putting theory into practice

Harm reduction interventions have been introduced in a large and growing number of countries. Fundamental components of harm reduction programmes are the need to raise `awareness', to `contact' people, to provide them with the `means' to change their behaviour, and to gain `endorsement' for this work. The UK provides a case study of public health harm reduction measures which to date appear to have successfully averted an epidemic of HIV infection. In broad terms, the basic techniques for harm reduction projects and programmes are now known, and there is substantial research and practical evidence to indicate their successful implementation and impact. The global public health challenge in the next decade of harm reduction is therefore to find ways to implement harm reduction. Many elements of good public health practice are found in harm reduction. Harm reduction can learn from public health, and public health can learn from harm reduction.     

Harm reduction policies for tobacco users

Tobacco harm reduction is a controversial policy due to the experience with filtered and ‘light’ cigarettes and concerns that the tobacco industry will use reduced harm products to undermine tobacco control strategies. The most promising harm reduction products are high dose pharmaceutical nicotine preparations and low nitrosamine smokeless tobacco, such as Swedish snus. However, despite widespread availability, existing pharmaceutical nicotine preparations have not been taken up by smokers as an alternative to smoking. In Sweden, increased snus use was associated with decreased cigarette smoking and mortality from tobacco-related disease. We suggest a graduated series of policies to explore of the public health costs and benefits of encouraging smokers to switch to these less harmful nicotine products.     

Harm reduction in the developing world

This paper examines harm reduction from the perspective of poor countries. In considering which elements of the broad approach are suitable for adaptation and adoption by poor countries, there is a need to examine critically the arguments put forth in support of it and which, if any, of these are supported by evidence. There are also significant indirect influences that the approach is likely to have on how drug use is understood and interpreted by wider society. The likely impact of these on areas other than simply services directed to drug users needs to be assessed. There are some features regarding harm caused by alcohol and other drug use that are specific to poor countries. Most important among these is that levels of use which are not deemed to be harmful in rich societies cause grave harm through diverting meagre resources away from survival needs in the poor world. Alcohol, as well as other drugs, tends in deprived settings to cause dependence and other problems much earlier in people's drinking careers and at much lower levels of consumption than in rich countries.     

Harm reduction in Argentina: a challenge to non-governmental organisations

In Argentina, the prevailing drug policy is based on a ‘drug free society’ approach. It is worth pointing out that since the 1970s there has been an important influence by USA drug policy on drug policy in Argentina. We find a high incidence of HIV transmission among injecting drug users and high levels of social exclusion. In the Argentinean context NGOs can play a fundamental role in reversing the trend of segregation and discrimination towards drug users. Nowadays, to promote harm reduction as an HIV/AIDS preventive policy more than as a drug use policy is a better strategy, considering the climate of abstinence. We are a better condition than a few years ago to reinforce its application in Argentina because of the following factors: (1) UNAIDS support; (2) the regional impact of the International Summit ‘Large Urban Cities and their Drug Plans’ (Medellin, October 1997), and the IX International Conference on the Reduction of Drug Related Harm (São Paulo, March 1998); (3) the increasing diffusion about international harm reduction experiences in the mass media; (4) discussions with university research teams; and (5) the creation of the Latin-American Harm Reduction Network.     

Harm reduction programmes in the Asia--Pacific Region

INTRODUCTION AND AIMS: This paper reports on the public health intervention of harm reduction to address drug use issues in the Asia-Pacific region. DESIGN AND METHODS: It is based on the report 'Situational analysis of illicit drug issues and responses in Asia and the Pacific', commissioned by the Australian National Council on Drugs Asia Pacific Drug Issues Committee. A comprehensive desk-based review based on published and unpublished literature and key informant data. RESULTS: Drug use in the Asia--Pacific region is widespread, resulting in serious adverse health consequences. Needle and syringe programmes are found in some parts of Asia, but not in the six Pacific Island countries reviewed. Outreach and peer education programmes are implemented, but overall appear minor in size and scope. Substitution therapy programmes appear to be entering a new era of acceptance in some parts of Asia. Primary health care specifically for drug users overall is limited. DISCUSSION AND CONCLUSIONS: Harm reduction programmes in the Asia--Pacific region are either small in scale or do not exist. Most programmes lack the technical capacity, human resources and a limited scope of operations to respond effectively to the needs of drug users. Governments in this region should be encouraged to endorse evidence-based harm reduction programmes.