Harm Reduction strategies implemented in our area of work

 INFECTIONS

Infections are microorganisms such as viruses or bacteria that can cause disease in people. There are many different pathogens but we will focus on hepatitis A, B and C, Human Immunodeficiency Virus (HIV) and other sexually transmitted infections (STI). Pathogens such as hepatitis B virus (HBV) and HIV can be transmitted through contact with infected human blood and other potentially infectious body fluids such as:

  • Semen
  • Vaginal secretions
  • Cerebrospinal fluid
  • Synovial fluid
  • Pleural fluid
  • Peritoneal fluid
  • Amniotic fluid
  • Saliva (in dental procedures), and
  • Any body fluid that is visibly contaminated with blood.

The goal of harm reduction in the context of drug use is to reduce the harms, such as transmission of infections, associated with the behavior.  This may be achieved by prevention through education around safer sex practices and safer substance use, and by providing relevant supplies.    There are various routes of transmission of infections therefore harm reduction approaches must be varied and at times used simultaneously.

HIV/AIDS

HIV is the virus that causes Acquired Immunodeficiency Syndrome (AIDS). HIV attacks the immune system, resulting in a chronic, progressive illness which leaves infected people vulnerable to opportunistic infections and cancer. HIV can be transmitted by unprotected sexual intercourse (vaginal, anal, oral); shared needles or equipment for injecting drugs; unsterilized needles for tattooing, skin piercing; pregnancy, delivery and breast feeding (from an HIV-infected mother to her infant); and occupational exposure in health care settings.

Hepatitis

Hepatitis, is inflammation of the liver, and may be caused by a virus such as hepatitis A; hepatitis B and hepatitis C. Chronic hepatitis may cause permanent liver damage, scarring, cirrhosis of the liver, liver cancer and liver failure. Approximately 40,000 cases of chronic hepatitis B and 60,000 cases of hepatitis C have been identified in BC since early 1990’s; rates of infection in BC are higher than the national average. Effective vaccines are available to prevent hepatitis A and B There is no vaccine for hepatitis C.

Hepatitis A virus (HAV) can be transmitted from the feces of an infected person through oral-anal sex. HAV causes an acute infection lasting from a few weeks to several months. It does not lead to chronic infection. Outbreaks of HAV have occurred amongst individuals who use intravenous drugs; transmission may be related to poor hygiene and sharing drugs, syringes, and drug preparation equipment. HAV also can be transmitted through poor food handling such as eating food or drinking water that has been contaminated with fecal matter containing the virus.

Hepatitis B virus (HBV) is transmitted through contact with blood or other body fluids (i.e. semen and vaginal fluid) of an infected person. Modes of transmission are sexual contact, unsafe injections practices; close interpersonal contact with infected household contacts, prenatal (from mother to baby at birth) and blood transfusions. HBV is not spread by casual contact. HBV chronic infection is inversely related to the age at infection; 90% infants and 5-10% adults remain chronically infected.

Hepatitis C virus (HCV) is transmitted mainly by blood-to-blood contact. Sharing needles, syringes and other drug-use equipment is the most common way of transmitting HCV. Some British Columbians were infected with HCV before 1990, through blood products received before reliable tests to identify the virus in blood donors were available.  Most people have no symptoms and therefore are unaware when they are infected with HCV. About 10% of people have a brief illness with symptoms of hepatitis: fever, tiredness, loss of appetite, nausea, jaundice (yellow skin or eyes), abdominal pain, and dark urine 6 – 9 weeks after they have been infected. The majority of people infected (70-85%) do not clear the virus and become chronically infected with HCV. They may experience long-term health concerns, such as tiredness, lack of energy, or digestive problems and liver damage (cirrhosis).

Prevention Strategies

Avoid sharing needles or other equipment used for injecting, snorting or smoking drugs; and avoid sharing household items which may be contaminated with blood such as razors and toothbrushes.

Sexually Transmitted Infections

The term Sexually Transmitted Infection (STI) is now commonly used in the place of STD (Sexually Transmitted Disease). STIs are generally transmitted through various forms of sexual contact or activity. Some of the most common STIs are Chlamydia, genital herpes, gonorrhea, human papillomavirus (HPV) and syphilis.

Chlamydia – is a sexually transmitted bacterium that infects the urethra, the cervix and the rectum. The bacteria, Chlamydia Trachomatis (CT) is passed between people by direct contact with infected sexual fluids from the genitals. Actual penetration is not necessary for the bacteria to be transmitted. Close contact of a penis and vagina, prior to condom use, or masturbation with the sexual fluids may transmit the bacteria if one partner has the infection. If the bacteria is rubbed into the eye, it is possible to get an eye infection (conjunctivitis)

Genital Herpes – Herpes is the common name for two viruses – Herpes Simplex Type 1 and Herpes Simplex Type 2. Herpes can affect mouth/face, genital and/or rectal area. It used to be thought that Herpes Simplex Type 1 caused sores and blisters on the mouth or face whereas Herpes Simplex Type 2 caused these same symptoms in the genital and/or rectal area. It’s now known that Herpes Simplex Type1 can spread to the genital and rectal area and Herpes Simplex Type 2 to the face and mouth.

Herpes is incurable and once a person is infected with the virus they will have it for life and may periodically experience symptoms associated with it. The herpes virus is spread by skin-to-skin contact either genital to genital or face/mouth to genital (oral sex). Symptoms do not need to be present for the virus to be passed from one person to another. In fact, the herpes virus can be inactive or latent for long periods of time.

For this reason many people who have Herpes never realize it, and most people who pass it on to someone else are unaware of their infection at the time. This is called asymptomatic shedding. The good news is that over 95% of the time herpes can be detected when the virus is active allowing the person to avoid exposing a partner

Gonorrhea – is a sexually transmitted infection that can infect the urethra, cervix, throat and rectum. A bacterium called Neisseria Gonorrhea causes these infections. Also known as: GC, “Clap”, VD, “Drip.” Gonorrhea is spread between people by direct contact with the infected sexual fluids from another person. These fluids are not always seen. Gonorrhea can be spread from an infected person’s throat to a penis and vice versa, but not when oral sex is performed on a woman.

Penetration or ejaculation is not necessary for gonorrhea to be transmitted. Close contact, like touching before condom use, or masturbation with the sexual fluids of an infected person can transmit the bacteria from one person to another.

It is also possible, though not common, to transmit the bacteria by your hands or fingers. For example, touching  infected  sexual  fluids  then  rubbing  an  eye  could  result  in  an  eye  infection  known  as conjunctivitis.

Human Papillomavirus (HPV) – is one of the most common causes of STIs in the world. Scientists have identified more than 100 types of HPV, most of which are harmless. About 30 types are spread through sexual contact. Some types of HPV cause genital warts and some can cause cervical cancer and other genital cancers. Any person who is sexually active can get genital warts. Genital warts can be transmitted by direct skin to skin contact during vaginal and anal sex. Oral transmission of this virus is extremely rare. Warts on other parts of the body, such as the hand and feet, are caused by a different type of wart virus. These warts cannot be spread can be spread to the genital

Syphilis – is an infection with the bacterium Treponema pallidum from the spirochete family. Symptoms for syphilis come in stages and vary from person to person. It is also known as the great imitator since it appears to be like many other diseases and is difficult to diagnose. Syphilis is most commonly transmitted through sexual activity, including penis to vagina, penis to mouth, penis to rectum and mouth to vagina.

Safer sex with clients

Talking about sex is often difficult, it is important for workers to find ways to discuss safer sex practices more openly with individuals. It is helpful to speak with individuals using terms they will understand and acknowledge that they may find the discussion difficult. When talking about sex it is essential to consider the individuals experience, understanding and beliefs about sex.

Safe sex practices

Safe sex means not allowing your partner’s body fluids (blood, semen, vaginal fluids) into your body.  It can also mean covering up or avoiding contact with parts of the body that might be infectious (e.g. herpes sores or warts).    Condoms  are  most  commonly  used  in  safe  sex  practice  to  reduce  the  risk  of transmission of infectious diseases such as HIV and various STI’s. There are male and female condoms;

Male condoms – latex condoms are the most common barrier used for safe sex.  Most of condom failures is not due to the condom, but because people using the condom didn’t put it on correctly. Please review the steps below.

  • Open the condom wrapper carefully; keeping in mind condoms can be torn by fingernails and sharp objects such as jewelry, zips and buckles. Only put on condom after there is a partial or full erection.
  • Air trapped inside a condom can cause it to break. Squeeze the tip of the condom with your fingertips to leave some extra space in the tip, and put on condom, rolling the entire condom down to the base of the penis, still pinching the top. Be sure that the roll is on the outside.
  • Make sure the condom stays in place during sex; if it rolls up; roll it back into place immediately. If the condom comes off, withdraw the penis and put on a new condom.
  • Soon after ejaculation – or when sex is finished – withdraw the penis while it is still erect, making sure to hold the condom firmly in place. Remove  the condom only once the penis is fully

Female condoms – are not as commonly used as the male condom but are just as effective. The female condom is a tube made of thin polyurethane plastic or rubber. It is closed at one end, and designed to form a loose lining to a woman’s vagina with two flexible rings, one at each end, to keep it in place. The ring in the closed end fits inside the vagina, just behind the pubic bone.  The ring at the open end stays outside the vagina, lying flat against the area around the entrance to the women’s vagina

How to put on a female condom:

  • Open the package carefully. Choose a position that is comfortable for insertion – squat, raise one leg, sit or lie down. Make sure the condom is lubricated enough.
  • Make sure the inner ring is at the closed end of the sheath, and hold the sheath with the open end hanging down. Squeeze the inner ring with thumb and middle finger (so it becomes long and narrow), and then insert the inner ring and sheath into the vaginal opening. Gently insert the inner ring into the vagina and feel it go up. Place the index finger inside the condom and push the inner ring as far as it will go. Make sure the condom is inserted straight, and is not
  • Twisted inside the vagina. The outer ring should remain on the outside of the vagina.
  • The penis should be guided into the condom in order to ensure that the penis does not slip into the vagina outside the condom. Use enough lubricant so that the condom stays in place during sex. The female condom should not be used at the same time as a male condom because the friction between the two condoms may cause the condoms to break.
  • If the condom slips during intercourse, or if it enters the vagina, then you should stop immediately and take the female condom out. Then insert a new one and add extra lubricant to the opening of the sheath or on the penis.
  • To remove the condom, twist the outer ring or frame gently and then pull the condom out keeping the sperm inside. Wrap the condom in the package or in tissue and throw it away. Do not put it into the toilet. It is generally recommended that the female condom should not be reused.

The female condom will feel unfamiliar at first and some people find it difficult to insert. It is important to clear instructions for use, diagrams are also found on the packet. Women may find that with time and practice using the female condom becomes easier. The female condom can be inserted prior to sexual intercourse and does not rely on the male partners willingness to use it, therefore it may provide women the opportunity to feel empowered and in control of their own sexual health and safety.

About

Uganda Harm Reduction Network (UHRN) is a Community Based Organisation, established in 2011, Reg No. WCBO/1253/11, found by former drug users, to provide a national platform and reduce the health, social and economic harms associated with “drug use”. We further seek to develop an enabling environment for the implementation and expansion of human right interventions for Drug Users (IDUs, Sex Workers and Youth) in Uganda in partnerships with other stakeholders as we strive for victory. Vision: “A Ugandan society that reorganizes and protects the health, social, economic and human rights of drug users”. Mission: “To reduce the health, social and economic harms associated with drug use to develop an enabling environment for the implementation and expansion of human right interventions for drug users in Uganda. Objectives: We work to: • Promote access to cancer screening, psychosocial support and comprehensive care (HIV, SRHR, TB, and Hepatitis B and C treatment). • Organize and equip drug users whose rights have been violated to take responsibility of their health, social, economic wellbeing and sustainability through economic empowerment trainings and functional adult literacy programmes. • Document and expose human rights violations against drug users and call for legal protection and engage in policy reforms on laws that negatively impact on drug users. • Build partnership, synergy and develop the leadership capacity of drug users to take charge of their program. • Promote the health, social economic and human rights of “drug users” in Uganda irrespective of their social, economic, academic, cultural or political background. • Promote safer sex education such as condom use, needle and syringe exchange program, comprehensive care and mechanism on how to deal with issues of overdose, trafficking and violence against drug users. • Call for an enabling environment and strengthen partnerships towards “drug users”. Core values for UHRN: The driving forces that guide all actions and practices in UHRN are:- • Social justice, protection and recognition in society • Love and respect for one another. • Support and care for one another • Honesty in all our undertakings • Empathy for each other as drug users • Sharing the available resources.

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