Substance abuse is a multi-facetted problem that plagues a whole society, irrespective of different age categories and social classes. The consequences and the amount of harm caused to the individual, the family and society are diverse. Mauritius, while being a small island of approximately 1.2 million [1] inhabitants only, far away from the leading powers of the global economy, and niched at the heart of the Indian Ocean has not been spared from this issue.
According to the National Drug Control Masterplan 2004-2009 [2] , the age of initiation to substance abuse in Mauritius starts from as early as 11 years because of peer or media influence. The rationale of substance abuse is however not this simple. Sometimes, some people give in to the instinctive human behaviour which is trying to find the easiest escape from harsh realities and nuisances of daily life, and resort to substance abuse.
Evolution of substance abuse in Mauritius
Substance abuse may have become an alarming phenomenon of late, but drugs have been present in Mauritius for a far longer time. The use of drugs has been recorded to have started with as early as during the French colonisation [3] with illicit rum production by slaves. With the arrival of indentured labourers, Indians brought along with their culture and traditions, cannabis, while Chinese immigrants brought opium [4] . These drugs were mostly utilised in a socio-cultural circumstance, by adults without being a cause for serious concern. Mid-sixties brought with it the Hippie Culture [5] to Mauritian shores as well as new forms of drugs such as LSD [6] , Mandrax [7] and other hallucinogens which became synonymous to ‘new highs’ to youngsters.
The seventies caused an altogether different trend of substance abuse, as the situation changed drastically from its socio-cultural to a more significantly worrying use. A rudimentary form of heroin [8] known as “Brown Sugar” was introduced in Mauritius. Brown Sugar was smuggled through the airport, harbour and through postal packets.
The ”Amsterdam Affair” [9] that broke out in 1985 was the quintessence of the scope of the drugs problem in Mauritius. As an attempt to display its willingness to leave no stone unturned in the combat against drug trafficking, legislation was amended [10] and death penalty was introduced for proved traffickers. No drug trafficker have however been executed because of the thorny legal issues surrounding capital punishment. A sudden downward trend was observed in 1987 and continued until 1990 after which indicators revealed a slight increase in illicit trafficking and consumption [11] .
In 2003, the “White Lady [12] ” was a psychotropic drug opted by most drug users. Post 2005, Subutex [13] , which is normally used as treatment on those dependent on narcotic pain killers, and opiates, soon became the most sought-after drug in Mauritius.
Substance Abuse and Repercussions
Social Consequences
Significant social consequences include the disintegration of the family unit, with the emotional and psychological well-being of family members being upset. Substance abuse and delinquency go hand in hand; as sometimes dependency and withdrawal syndromes overcome reason and push addicts towards theft, violence and similar such acts to procure the financial means to obtain their required dosage. The 2009 World Drug Report [14] shows that number of drug-related crimes has increased by 18% from 2006 to 2007.
Health Consequences
Substance abuse affects the personal health of drugs addicts themselves. Withdrawal and apathy are a few of the psychological dysfunctions they might face. The impact of addiction can be far reaching. Cardiovascular disease, stroke, cancer, and lung disease can all be caused by drug abuse [15] .
Because of needle sharing behaviour [16] , a well-established norm among IDUs as has been shown by the IDUs Respondent Driven Sampling [17] , which is explained by the increased costs and low financial means of IDUs as well as Police Services continuous stalking of IDUs in possession of drug paraphernalia, blood borne diseases such as AIDS or Hepatitis [18] are easily transmitted, repercussions of which is catastrophic both for the IDU and society at large. IDUs who get affected by such blood borne diseases will often through a domino effect, affect their sexual partners, while pregnant women who are IDUs run the risk of contaminating their unborn children with such. Injecting drug use is the cause for an increasing proportion of HIV infections in many parts of the world, Mauritius included. It is estimated that between 11 and 21 million people worldwide inject drugs, and of those, between 0.8 and 6.6 million are infected with HIV [19] .
Financial Impacts
Health services that have to be provided to drug addicts include treatment of diseases which may develop in drug addicts as a consequence of substance abuse, as well as costs of rehabilitation services, which is often overlooked by most persons. The cost of non-generic antiretroviral treatment per person per annum may amount up to $ 1500 [20] , averaging to about Rs 50, 000 based on current exchange rates.
Financial consequences on the economy are grave, with the parallel running of a black economy with profits obtained from the illicit traffic, as well as with the effects of drugs abuse of members of the workforce which reduces productivity.
Conventional Approaches to Substance abuse
Mauritius has ratified the United Nations Drug Control Conventions [21] . It has also ratified the 2000 Convention on Trans-National Organized Crime [22] and is also signatory of both the African Union [23] and the SADC Drug Control Protocol. Existing legal frameworks that were used, and still are used to control drugs supply and demand reduction are:
The Dangerous Drug Act 2000 [24]
The Pharmacy Act 1983 [25]
The Financial Intelligence and Anti Money Laundering Act 2002 [26]
Drugs Demand Reduction
Drugs demand reduction is one of the approach used to combat the substance abuse crisis at its core. Drug demand reduction refers to policies and programmes directed towards reducing the consumer demand for narcotic drug and psychotropic substances as covered by the three main International Drug Control Conventions, as mentioned above. The National Agency for Treatment and Rehabilitation of Substance Abusers (NATReSA) is a parastatal body under the aegis of the Ministry of Social Security, National Solidarity and Reform Institutions which was set up by an Act of Parliament in 1996 [27] and it is responsible for all demand reduction activities in the country. By conducting a number of prevention activities in the community, schools and the workplace, NATReSA uses education as its main vehicular weapon to try to diminish the demand for drugs. It provides funding to a number of NGOs engaged in prevention, treatment and rehabilitation work. The National Prevention Unit set up by the NATReSa in 2002 has set up a Demand Reduction Integrated Program, from which more than 25 regions have already benefitted till date.
Supply Side Reduction
As to supply side reduction, the law enforcement side is actively involved and a number of institutions operating under the aegis of different ministries are responsible for drug control activities.
The Anti Drug Smuggling Unit (ADSU) [28] , the National Coast Guard and the Special Mobile Force are special units of the Mauritius Police Force, working under the command of the Commissioner of Police involved in drug control. The Passport and Immigration Office also operates under the supervision of the Commissioner of Police and has a role in the screening of passengers at the seaport and airport while Custom Investigation and Intelligence Unit plays a noteworthy role in the checking of containers and other luggage entering the country. The Pharmacy Section of the Ministry of Health and Quality of Life is responsible for the issuing of licenses for the import of licit narcotic drugs and psychotropic substances.
Finally, Mauritius Post Services work in close cooperation with the above units to exercise close control to guarantee that drugs do not enter the country through letters and postal packages and the Forest Department aids through its field work in forests, mountains and state lands, and is instrumental in detecting cannabis cultivation.
According to the 2010 World Drug Report [29] , Mauritius is the country with the highest opiates consumption prevalence in the African continent with an estimate of 1.9 %. This demonstrates clearly that conventional approaches to the Mauritian drug problem have not met expectations in terms of efficiency in tackling it. Instead, new factors borne due to a rapidly changing society contributed to the rendering them inefficient – opening up of airspaces which while increasing benefits from the tourism and travel industry has also increased the risks of drugs being brought into the country by foreigners, expansion of the offshore sector through which large sums of money transits through Mauritius, sources of which remain confidential to the offshore companies and the open secret being that sometimes, part of these monies go into the black economy, financing drug transactions and poverty and prostitution which are key contributory factors as well to the expansion of the Mauritian drug market among others. The escalation of drug use became a cause for worry as the main vehicle for substance abuse being through injection, this implied a heightened risk of transmission of blood borne diseases [30] among the IDU population and hence a greater number of HIV positive and hepatitis cases amongst others.
An altogether new approach was hence adopted to counter this eventuality, known as the harm reduction approach. The harm reduction which consists of needle exchange programs as well as methadone substitution therapy implied a completely different perspective, the core principle being admitting the existence of a substance abuse issue in a community, which often is stubbornly resisted by authorities, hence displaying the huge difficulty in the implementation of this method.
Over the years, numerous observations have been made by journalists and Non-Governmental Organisations (NGOs) representatives on the structural changes of the drug situation in Mauritius, the worrying dimensions of the issue of substance abuse and its relations with transmission of blood borne diseases. Harm reduction however, being a relatively new concept in Mauritius dating only back to 2006, remains a rather unexplored path.
Hence, the purpose of this dissertation would be to bring focus on Needle Exchange Programs (NEPs) as they are carried out in the Mauritian context. While running through a general overview of the harm reduction approach, the rationale behind it will be examined along with implementation timeline of NEP in Mauritius. Policy aspects will be reviewed and an analysis of the legal backdrop of NEPs in Mauritius will be presented, which will consist of a study salient features of the existing laws and NEPs and eventually the NEP specific framework which is the HIV/AIDS Act 06. NEP in prisons, being a delicate and debatable issue, will be considered and the prospect of such in Mauritian prisons discussed. The dissertation will be concluded by evaluating the Mauritian NEP, and proposing recommendations of possible ways to gear more towards efficiency and best practice with regards to Mauritian laws and needle exchange.
Preliminary Chapter: Understanding Harm Reduction
The Basic Concept
Harm reduction refers to policies, programmes and practices utilised and applied with the objective of diminishing risks associated with the use of drugs by substance abusers [31] . Subdivided into needle exchange programs and methadone substitution therapies, harm reduction is viewed as a far-reaching innovative approach to the problem of substance abuse and its related risks. The salient feature of this novel method is the radical shift in focus to the prevention of harm caused by substance abuse, rather than on the prevention of drug use itself. This entails recognising the existence of a substance abuse problem in society which in turn indicates the inability or sometimes even failure of concerned authorities in tackling the drug problem.
This approach was often discussed in Mauritius after recognition of the threat of HIV as well as other blood borne diseases which were spreading through injecting drug use. (RSA(??)) [32] . Stakeholders including the National AIDS Secretariat [33] agreed that harm reduction does not undermine but instead complements approaches seeking to prevent or decrease drug consumption. It is based on the recognition that many people throughout the world continue to use drugs despite the best of efforts to prevent drug use.
Rationale Behind Harm Reduction
Harm Reduction and Human Rights
The harm reduction approach to drugs is based on a strong pledge to public health and human rights. Harm reduction interventions have found support among numerous United Nations (UN) [34] human rights mechanisms, specifically in context of HIV prevention and the right to attain the highest achievable standard of health
International Covenant on Economic, Social and Cultural Rights [35] (ICESCR) And Harm Reduction.
The Committee on the Economic, Social, and Cultural Rights [36] (CESCR) has recommended [37] many times that States Parties scale up their harm reduction programmes in order to meet their obligations under Article 12 [38] of the ICESCR. In its Concluding Observations on Ukraine (2007), the Committee stated that it was “gravely concerned at…the limited access by drug users to substitution therapy,” and recommended that the state party “make drug substitution therapy and other HIV prevention services more accessible for drug users” [39] .
In 2009, the UN Human Rights Council [40] adopted a resolution on human rights and HIV/AIDS that unequivocally provided support to harm reduction programs, including needle exchange. The resolution reflected past Commitments [41] made at the General Assembly [42] in 2001 and again in 2006. In 2010, the UN Commission on Narcotic Drugs [43] adopted a resolution more than ever, backing the far-reaching package of interventions for HIV prevention treatment and among injecting drug users. Both ECOSOC and the UNAIDS Programme Co-ordinating Board(will be explained in footnote) have also endorsed these interventions.
Article 15.1.b ((will be laid out in footnote) guarantees the right of everyone to benefit from scientific progress and its applications. In the context of injecting driven HIV, this implies a right to benefit from evidence based programs that can prevent, treat and control HIV/AIDS and other drug related potential diseases. Harm reduction methods have been backed by extensive scientific evidence base indicative of their effectiveness at reducing injecting-related risks.
Research Based Rationale
Supply reduction has been used in Mauritius now, since many years and although being an expensive method to combat substance abuse, drug trafficking crimes and substance abuse is still well present in the Mauritian society.
2002, 2003 to 2004 mode of transmission of HIV and blood borne infections steadily shifted from heterosexual activities to injecting drug use.(annexed charts)
The 2009 Injecting Drug User HIV surveillance survey was implemented by the AIDS Unit of the Mauritius Ministry of Health and Quality of Life (MOH&QL). HIV prevalence is 47.4%. Hepatitis C prevalence is 97.3%. (Results of the survey will be annexed as table)
Currently, injecting drug use comprises the bulk of HIV infections in Mauritius. Whereas in 2002 injecting drug use accounted for 14% of all new HIV infections in Mauritius, this percentage increased dramatically to 92% in 2005. [44] Although HIV prevalence among Injecting Drug Users appears to have decreased gradually to 73% in 2008, this percentage is still cause for worry. The use of non-sterile needles and syringes and other injecting drug equipment is an extremely efficient mode of HIV transmission and remains a key factor aggravating the HIV epidemic among drug users worldwide.
Estimation of population size of IDUs in 2009 has been rounded off at 10000.
High-risk injection drug use practices 61.2% of Injecting Drug Users reported injecting two to three times a day and 29.3% reported injecting with a previously used needle in the past month
The Implementation of Harm Reduction In Mauritius
Harm reduction implemented in Mauritius under two programs: Methadone Substitution Therapy and The Needle Exchange Program
Methadone Substitution Therapy (MST)
Methadone hydrochloride is an opioid (will be explained in footnote). Methadone is now primarily used today for the treatment of narcotic addiction. Methadone’s effects can last up to 24 hours, thereby given only once a day in heroin detoxification and maintenance programs for the treatment of people dependent on heroin and other opioids. (sources will be provided in footnote) Methadone is usually available as a liquid and drunk with fruit juice.
MST works by reducing cravings and blocking “highs” from heroin. It does not provide the euphoric rush. The drug user under MST will no longer experience extreme highs and lows that results from the level of heroin in the blood. (source will provided in footnote). Ultimately, the patient remains physically dependent on the opioid, but is freed from the uncontrolled, compulsive, and disruptive behavior seen in heroin addicts. National Detoxification Centre For MST found at Cité Barkly. Program may be residential (15 days) or day-care. Drug users are induced on methadone under medical supervision and doses consequently adjusted.
16 methadone dispensing points from which drug users, after having gone through initial induction receive their daily doses of methadone.
Needle Exchange Program
Forms part of harm reduction strategy and is funded by the Government through the Ministry of Health and Quality of Life and partially by international organisations such as the Global Fund.
NGOs and Government through Ministry Of Health and Quality of life both carry out NEPs.
The program offers a comprehensive package of services which include exchange of used needles, HIV counselling and testing, provision of condoms and alcohol swabs and referrals for rehabilitation services (where requested) as well as other HIV-related services.
The Mauritian Needle Exchange Program
Implementation of Needle Exchange Program In Mauritius
Having recognised injecting drug use as the main vehicle of blood borne transmission, the aim behind carrying out needle exchange programs is to transmission of HIV and other viral infections (Hepatitis B & C) which travels through contaminated syringes and equipments.
NEP protects the IDU, by ensuring provision of safe, clean and sterile injecting equipment, eliminating risk of transmission of HIV and blood borne infections through sharing.
NEP protects not only the IDU but also IDU’s sexual partner.
Needle exchange started in 2006 by two NGOs- Ki Nu été and Prevention Information et Lutte contre le Sida (PILS) on two sites – Batterie Cassé and Baie Du Tombeau (source will be cited in footnote)
Adoption of HIV/AIDS Act in 2006 which provided legal framework for NEP following which November 2007 saw government through the Ministry of Health And Quality of Life endorse NEP in Mauritius through the official launching of the NEP in Mauritius.
A third NGO started NEP on a new site at Tranquebar in November 2007
In 2008, MOHQL called for tenders for new NGOS willing to participate in NEP, with only one response and in February 2008 Idriss Goomany Centre (IGC) started Needle Exchange on a new site in Plaine Verte
March 2008 saw some of the non-governmental organisations undertaking needle exchange till date regroup themselves under the aegis of one central organisation – Collectif Urgence Toxida (CUT). CUT consists of Ki Nu Eté, PILS and Rapid IGC joined CUT for a limited time period only. In April 2008 two new sites for needle exchange were put into operation by CUT.
May 2008 : official kick – off of government run NEP It is worth noting that Mauritius has pioneered government run needle exchange in Sub-Saharan Africa
As of date- 35 sites officially operating for Government run NEP and 17 sites for NGOs run NEP
Operation of the Mauritian Needle Exchange Program
Two principal methods of operation, NGO run NEP and Government Run NEP
NGOs: street based needle exchange. Usually, two members of the NGO visit a fixed spot in the locality – the site, a certain number times per week (depending on the NGO in question) and have a number of syringes with them and an empty gallon. IDUs come to see them , bringing with them the used syringes which are disposed in the gallon and are given new sterile syringes by the members. IDUs are assigned a ‘code’ when they visit the sites. It should be noted that this is not for identification purposes of the IDUs but rather for monitoring and reporting purposes (Number of syringes per IDUs, number of IDUs visiting each sites…). Disposal of the needles is made after closure of sites for the day, by dropping them off at regional hospitals, where they are burnt in the incinerators.
MOHQL: Mobile NEP through two operational caravans. Two authorised health care assistants and one qualified nurse per caravan (identified by Ministry issed identification cards). Each caravan visit three sites daily, spending an average of one hour and a half to two hours on each site. Work in collaboration with peer leaders amongst IDUs who help facilitate smooth interacting between IDU crowds and the government staff.
The Needle Exchange Program in Mauritius and Other Policy Measures
Needle Exchange And Demand Reduction:
Demand reduction, focuses on detoxification and management of withdrawal syndromes with the aim of long term abstinence. However, the results yielded are not the expected ones as detoxification succeeds in removing people from the drug scene in the short term but the relapse rates usually approach 100 per cent (Fact Sheet Supply Demand And Harm Reduction, Burnet Institute Centre For Harm Reduction).
Needle Exchange And Methadone Substitution Therapy
Contrasting costs of providing needle and costs of providing methadone
Return rate of syringes; and treatment follow-up statistics and relapse rates for MST
Efficiency of both harm reducting programs in the sense that they would still cost less even than provision of antiretroviral treatment to an HIV positive person (provision of non-generic anti-retroviral may approximate $15000)
The Needle Exchange Program and Its Framework In Mauritius
Adoption of the HIV/AIDS Act 2006
Needle exchange was carried out by NGOs even before the HIV/AIDS Act came into effect. As such, they faced a legal impediment in the sense that the practice of needle exchange was inconsistent with the provisions of existing laws which is the Dangerous Drugs Act at its section 34(c) which made possession of injecting equipment and drug paraphernalia a criminal offence.
Following several committees of various stakeholders including the MOHQL itself, police officers, specially members of the ADSU and NGOs , it was agreed that there was a need for a framework to regulate the situation of NEPs. HIV/AIDS Act 2006 was then adopted in 2006 with general consensus by members of parliaments (comments of few members from Hansard will be included here and lengthier works will be attached) and came into effect in August 2007.
Aims of HIV/AIDS Act 06 according to the act itself is “to provide for measures for the prevention and containment of HIV and AIDS”
Analysis of this aim – was a framework really required to provide for prevention measures which are done principally through education, information and sensitization, and containment which is already handled through supply-side reduction. This tends to lead to the conclusion that the true motive behind the HIV/AIDS Act was to provide a legal framework for the NEP
Possession of Syringes and Needles and the HIV/AIDS Act 06
Article 2 of the International Convenant on Economic, Social and Cultural Rights also requires legislative reform in order to create a legal and policy environment conducive to the scale up of these services and the removal of barriers to access and coverage to improve accessibility. Hence in line with this, Section 16 of the HIV/AIDS Act deals with the Possession of syringes and needles in the context of NEP. It in fact through very explicit terms decriminalizes its possession in the circumstance of the NEP.
This was crucial because :
possession of a used needle and syringe may be used as circumstantial evidence to lay other drug-related charges. For this reason some clients may be reluctant to return used equipment to NEP site.
fear of being arrested while in possession of drugs and/or injection equipment can lead IDUs to rush injections, skip safer injection techniques (e.g., hand and skin cleaning) and to feel so anxious that they cannot inject with accuracy. All of these consequences can increase the risk of injection-related problems such as infections and skin and soft-tissue damage
However – Section 34 (c) has still not yet been repealed. Questionned by NGOs as to whether this is a best practice.
Needle Exchange: Health and Safety Under the HIV/AIDS Act 06
Handling of used syringes by personnel involved under the NEP – compliance with Occupational Health and Safety Act – Applicable only for Govt. Run NEPs
Section 10 Risk Assessment By Employment (Will be showed in footnote) –
Is this carried out?
Section 35 Cleanliness – (Will be showed in footnote)
Analysis of whether the caravans meet up with these requirements
Section 37 Ventilation and Temperature (Will be showed in footnote)
Analysis of whether the caravans meet up with these requirements
Section 39 Sanitary Conveniences (Will be showed in footnote)
Analysis of whether the caravans meet up with these requirements
Section 40 Supply of drinking water (Will be showed in footnote)
Analysis of whether the caravans meet up with these requirements
Section 41 Washing Facilities (Will be showed in footnote)
Substance abuse is a multi-facetted problem that plagues a whole society, irrespective of different age categories and social classes. The consequences and the amount of harm caused to the individual, the family and society are diverse. Mauritius, while being a small island of approximately 1.2 million [1] inhabitants only, far away from the leading powers of the global economy, and niched at the heart of the Indian Ocean has not been spared from this issue.
According to the National Drug Control Masterplan 2004-2009 [2] , the age of initiation to substance abuse in Mauritius starts from as early as 11 years because of peer or media influence. The rationale of substance abuse is however not this simple. Sometimes, some people give in to the instinctive human behaviour which is trying to find the easiest escape from harsh realities and nuisances of daily life, and resort to substance abuse.
Evolution of substance abuse in Mauritius
Substance abuse may have become an alarming phenomenon of late, but drugs have been present in Mauritius for a far longer time. The use of drugs has been recorded to have started with as early as during the French colonisation [3] with illicit rum production by slaves. With the arrival of indentured labourers, Indians brought along with their culture and traditions, cannabis, while Chinese immigrants brought opium [4] . These drugs were mostly utilised in a socio-cultural circumstance, by adults without being a cause for serious concern. Mid-sixties brought with it the Hippie Culture [5] to Mauritian shores as well as new forms of drugs such as LSD [6] , Mandrax [7] and other hallucinogens which became synonymous to ‘new highs’ to youngsters.
The seventies caused an altogether different trend of substance abuse, as the situation changed drastically from its socio-cultural to a more significantly worrying use. A rudimentary form of heroin [8] known as “Brown Sugar” was introduced in Mauritius. Brown Sugar was smuggled through the airport, harbour and through postal packets.
The ”Amsterdam Affair” [9] that broke out in 1985 was the quintessence of the scope of the drugs problem in Mauritius. As an attempt to display its willingness to leave no stone unturned in the combat against drug trafficking, legislation was amended [10] and death penalty was introduced for proved traffickers. No drug trafficker have however been executed because of the thorny legal issues surrounding capital punishment. A sudden downward trend was observed in 1987 and continued until 1990 after which indicators revealed a slight increase in illicit trafficking and consumption [11] .
In 2003, the “White Lady [12] ” was a psychotropic drug opted by most drug users. Post 2005, Subutex [13] , which is normally used as treatment on those dependent on narcotic pain killers, and opiates, soon became the most sought-after drug in Mauritius.
Substance Abuse and Repercussions
Social Consequences
Significant social consequences include the disintegration of the family unit, with the emotional and psychological well-being of family members being upset. Substance abuse and delinquency go hand in hand; as sometimes dependency and withdrawal syndromes overcome reason and push addicts towards theft, violence and similar such acts to procure the financial means to obtain their required dosage. The 2009 World Drug Report [14] shows that number of drug-related crimes has increased by 18% from 2006 to 2007.
Health Consequences
Substance abuse affects the personal health of drugs addicts themselves. Withdrawal and apathy are a few of the psychological dysfunctions they might face. The impact of addiction can be far reaching. Cardiovascular disease, stroke, cancer, and lung disease can all be caused by drug abuse [15] .
Because of needle sharing behaviour [16] , a well-established norm among IDUs as has been shown by the IDUs Respondent Driven Sampling [17] , which is explained by the increased costs and low financial means of IDUs as well as Police Services continuous stalking of IDUs in possession of drug paraphernalia, blood borne diseases such as AIDS or Hepatitis [18] are easily transmitted, repercussions of which is catastrophic both for the IDU and society at large. IDUs who get affected by such blood borne diseases will often through a domino effect, affect their sexual partners, while pregnant women who are IDUs run the risk of contaminating their unborn children with such. Injecting drug use is the cause for an increasing proportion of HIV infections in many parts of the world, Mauritius included. It is estimated that between 11 and 21 million people worldwide inject drugs, and of those, between 0.8 and 6.6 million are infected with HIV [19] .
Financial Impacts
Health services that have to be provided to drug addicts include treatment of diseases which may develop in drug addicts as a consequence of substance abuse, as well as costs of rehabilitation services, which is often overlooked by most persons. The cost of non-generic antiretroviral treatment per person per annum may amount up to $ 1500 [20] , averaging to about Rs 50, 000 based on current exchange rates.
Financial consequences on the economy are grave, with the parallel running of a black economy with profits obtained from the illicit traffic, as well as with the effects of drugs abuse of members of the workforce which reduces productivity.
Conventional Approaches to Substance abuse
Mauritius has ratified the United Nations Drug Control Conventions [21] . It has also ratified the 2000 Convention on Trans-National Organized Crime [22] and is also signatory of both the African Union [23] and the SADC Drug Control Protocol. Existing legal frameworks that were used, and still are used to control drugs supply and demand reduction are:
The Dangerous Drug Act 2000 [24]
The Pharmacy Act 1983 [25]
The Financial Intelligence and Anti Money Laundering Act 2002 [26]
Drugs Demand Reduction
Drugs demand reduction is one of the approach used to combat the substance abuse crisis at its core. Drug demand reduction refers to policies and programmes directed towards reducing the consumer demand for narcotic drug and psychotropic substances as covered by the three main International Drug Control Conventions, as mentioned above. The National Agency for Treatment and Rehabilitation of Substance Abusers (NATReSA) is a parastatal body under the aegis of the Ministry of Social Security, National Solidarity and Reform Institutions which was set up by an Act of Parliament in 1996 [27] and it is responsible for all demand reduction activities in the country. By conducting a number of prevention activities in the community, schools and the workplace, NATReSA uses education as its main vehicular weapon to try to diminish the demand for drugs. It provides funding to a number of NGOs engaged in prevention, treatment and rehabilitation work. The National Prevention Unit set up by the NATReSa in 2002 has set up a Demand Reduction Integrated Program, from which more than 25 regions have already benefitted till date.
Supply Side Reduction
As to supply side reduction, the law enforcement side is actively involved and a number of institutions operating under the aegis of different ministries are responsible for drug control activities.
The Anti Drug Smuggling Unit (ADSU) [28] , the National Coast Guard and the Special Mobile Force are special units of the Mauritius Police Force, working under the command of the Commissioner of Police involved in drug control. The Passport and Immigration Office also operates under the supervision of the Commissioner of Police and has a role in the screening of passengers at the seaport and airport while Custom Investigation and Intelligence Unit plays a noteworthy role in the checking of containers and other luggage entering the country. The Pharmacy Section of the Ministry of Health and Quality of Life is responsible for the issuing of licenses for the import of licit narcotic drugs and psychotropic substances.
Finally, Mauritius Post Services work in close cooperation with the above units to exercise close control to guarantee that drugs do not enter the country through letters and postal packages and the Forest Department aids through its field work in forests, mountains and state lands, and is instrumental in detecting cannabis cultivation.
According to the 2010 World Drug Report [29] , Mauritius is the country with the highest opiates consumption prevalence in the African continent with an estimate of 1.9 %. This demonstrates clearly that conventional approaches to the Mauritian drug problem have not met expectations in terms of efficiency in tackling it. Instead, new factors borne due to a rapidly changing society contributed to the rendering them inefficient – opening up of airspaces which while increasing benefits from the tourism and travel industry has also increased the risks of drugs being brought into the country by foreigners, expansion of the offshore sector through which large sums of money transits through Mauritius, sources of which remain confidential to the offshore companies and the open secret being that sometimes, part of these monies go into the black economy, financing drug transactions and poverty and prostitution which are key contributory factors as well to the expansion of the Mauritian drug market among others. The escalation of drug use became a cause for worry as the main vehicle for substance abuse being through injection, this implied a heightened risk of transmission of blood borne diseases [30] among the IDU population and hence a greater number of HIV positive and hepatitis cases amongst others.
An altogether new approach was hence adopted to counter this eventuality, known as the harm reduction approach. The harm reduction which consists of needle exchange programs as well as methadone substitution therapy implied a completely different perspective, the core principle being admitting the existence of a substance abuse issue in a community, which often is stubbornly resisted by authorities, hence displaying the huge difficulty in the implementation of this method.
Over the years, numerous observations have been made by journalists and Non-Governmental Organisations (NGOs) representatives on the structural changes of the drug situation in Mauritius, the worrying dimensions of the issue of substance abuse and its relations with transmission of blood borne diseases. Harm reduction however, being a relatively new concept in Mauritius dating only back to 2006, remains a rather unexplored path.
Hence, the purpose of this dissertation would be to bring focus on Needle Exchange Programs (NEPs) as they are carried out in the Mauritian context. While running through a general overview of the harm reduction approach, the rationale behind it will be examined along with implementation timeline of NEP in Mauritius. Policy aspects will be reviewed and an analysis of the legal backdrop of NEPs in Mauritius will be presented, which will consist of a study salient features of the existing laws and NEPs and eventually the NEP specific framework which is the HIV/AIDS Act 06. NEP in prisons, being a delicate and debatable issue, will be considered and the prospect of such in Mauritian prisons discussed. The dissertation will be concluded by evaluating the Mauritian NEP, and proposing recommendations of possible ways to gear more towards efficiency and best practice with regards to Mauritian laws and needle exchange.
Preliminary Chapter: Understanding Harm Reduction
The Basic Concept
Harm reduction refers to policies, programmes and practices utilised and applied with the objective of diminishing risks associated with the use of drugs by substance abusers [31] . Subdivided into needle exchange programs and methadone substitution therapies, harm reduction is viewed as a far-reaching innovative approach to the problem of substance abuse and its related risks. The salient feature of this novel method is the radical shift in focus to the prevention of harm caused by substance abuse, rather than on the prevention of drug use itself. This entails recognising the existence of a substance abuse problem in society which in turn indicates the inability or sometimes even failure of concerned authorities in tackling the drug problem.
This approach was often discussed in Mauritius after recognition of the threat of HIV as well as other blood borne diseases which were spreading through injecting drug use. (RSA(??)) [32] . Stakeholders including the National AIDS Secretariat [33] agreed that harm reduction does not undermine but instead complements approaches seeking to prevent or decrease drug consumption. It is based on the recognition that many people throughout the world continue to use drugs despite the best of efforts to prevent drug use.
Rationale Behind Harm Reduction
Harm Reduction and Human Rights
The harm reduction approach to drugs is based on a strong pledge to public health and human rights. Harm reduction interventions have found support among numerous United Nations (UN) [34] human rights mechanisms, specifically in context of HIV prevention and the right to attain the highest achievable standard of health
International Covenant on Economic, Social and Cultural Rights [35] (ICESCR) And Harm Reduction.
The Committee on the Economic, Social, and Cultural Rights [36] (CESCR) has recommended [37] many times that States Parties scale up their harm reduction programmes in order to meet their obligations under Article 12 [38] of the ICESCR. In its Concluding Observations on Ukraine (2007), the Committee stated that it was “gravely concerned at…the limited access by drug users to substitution therapy,” and recommended that the state party “make drug substitution therapy and other HIV prevention services more accessible for drug users” [39] .
In 2009, the UN Human Rights Council [40] adopted a resolution on human rights and HIV/AIDS that unequivocally provided support to harm reduction programs, including needle exchange. The resolution reflected past Commitments [41] made at the General Assembly [42] in 2001 and again in 2006. In 2010, the UN Commission on Narcotic Drugs [43] adopted a resolution more than ever, backing the far-reaching package of interventions for HIV prevention treatment and among injecting drug users. Both ECOSOC and the UNAIDS Programme Co-ordinating Board(will be explained in footnote) have also endorsed these interventions.
Article 15.1.b ((will be laid out in footnote) guarantees the right of everyone to benefit from scientific progress and its applications. In the context of injecting driven HIV, this implies a right to benefit from evidence based programs that can prevent, treat and control HIV/AIDS and other drug related potential diseases. Harm reduction methods have been backed by extensive scientific evidence base indicative of their effectiveness at reducing injecting-related risks.
Research Based Rationale
Supply reduction has been used in Mauritius now, since many years and although being an expensive method to combat substance abuse, drug trafficking crimes and substance abuse is still well present in the Mauritian society.
2002, 2003 to 2004 mode of transmission of HIV and blood borne infections steadily shifted from heterosexual activities to injecting drug use.(annexed charts)
The 2009 Injecting Drug User HIV surveillance survey was implemented by the AIDS Unit of the Mauritius Ministry of Health and Quality of Life (MOH&QL). HIV prevalence is 47.4%. Hepatitis C prevalence is 97.3%. (Results of the survey will be annexed as table)
Currently, injecting drug use comprises the bulk of HIV infections in Mauritius. Whereas in 2002 injecting drug use accounted for 14% of all new HIV infections in Mauritius, this percentage increased dramatically to 92% in 2005. [44] Although HIV prevalence among Injecting Drug Users appears to have decreased gradually to 73% in 2008, this percentage is still cause for worry. The use of non-sterile needles and syringes and other injecting drug equipment is an extremely efficient mode of HIV transmission and remains a key factor aggravating the HIV epidemic among drug users worldwide.
Estimation of population size of IDUs in 2009 has been rounded off at 10000.
High-risk injection drug use practices 61.2% of Injecting Drug Users reported injecting two to three times a day and 29.3% reported injecting with a previously used needle in the past month
The Implementation of Harm Reduction In Mauritius
Harm reduction implemented in Mauritius under two programs: Methadone Substitution Therapy and The Needle Exchange Program
Methadone Substitution Therapy (MST)
Methadone hydrochloride is an opioid (will be explained in footnote). Methadone is now primarily used today for the treatment of narcotic addiction. Methadone’s effects can last up to 24 hours, thereby given only once a day in heroin detoxification and maintenance programs for the treatment of people dependent on heroin and other opioids. (sources will be provided in footnote) Methadone is usually available as a liquid and drunk with fruit juice.
MST works by reducing cravings and blocking “highs” from heroin. It does not provide the euphoric rush. The drug user under MST will no longer experience extreme highs and lows that results from the level of heroin in the blood. (source will provided in footnote). Ultimately, the patient remains physically dependent on the opioid, but is freed from the uncontrolled, compulsive, and disruptive behavior seen in heroin addicts. National Detoxification Centre For MST found at Cité Barkly. Program may be residential (15 days) or day-care. Drug users are induced on methadone under medical supervision and doses consequently adjusted.
16 methadone dispensing points from which drug users, after having gone through initial induction receive their daily doses of methadone.
Needle Exchange Program
Forms part of harm reduction strategy and is funded by the Government through the Ministry of Health and Quality of Life and partially by international organisations such as the Global Fund.
NGOs and Government through Ministry Of Health and Quality of life both carry out NEPs.
The program offers a comprehensive package of services which include exchange of used needles, HIV counselling and testing, provision of condoms and alcohol swabs and referrals for rehabilitation services (where requested) as well as other HIV-related services.
The Mauritian Needle Exchange Program
Implementation of Needle Exchange Program In Mauritius
Having recognised injecting drug use as the main vehicle of blood borne transmission, the aim behind carrying out needle exchange programs is to transmission of HIV and other viral infections (Hepatitis B & C) which travels through contaminated syringes and equipments.
NEP protects the IDU, by ensuring provision of safe, clean and sterile injecting equipment, eliminating risk of transmission of HIV and blood borne infections through sharing.
NEP protects not only the IDU but also IDU’s sexual partner.
Needle exchange started in 2006 by two NGOs- Ki Nu été and Prevention Information et Lutte contre le Sida (PILS) on two sites – Batterie Cassé and Baie Du Tombeau (source will be cited in footnote)
Adoption of HIV/AIDS Act in 2006 which provided legal framework for NEP following which November 2007 saw government through the Ministry of Health And Quality of Life endorse NEP in Mauritius through the official launching of the NEP in Mauritius.
A third NGO started NEP on a new site at Tranquebar in November 2007
In 2008, MOHQL called for tenders for new NGOS willing to participate in NEP, with only one response and in February 2008 Idriss Goomany Centre (IGC) started Needle Exchange on a new site in Plaine Verte
March 2008 saw some of the non-governmental organisations undertaking needle exchange till date regroup themselves under the aegis of one central organisation – Collectif Urgence Toxida (CUT). CUT consists of Ki Nu Eté, PILS and Rapid IGC joined CUT for a limited time period only. In April 2008 two new sites for needle exchange were put into operation by CUT.
May 2008 : official kick – off of government run NEP It is worth noting that Mauritius has pioneered government run needle exchange in Sub-Saharan Africa
As of date- 35 sites officially operating for Government run NEP and 17 sites for NGOs run NEP
Operation of the Mauritian Needle Exchange Program
Two principal methods of operation, NGO run NEP and Government Run NEP
NGOs: street based needle exchange. Usually, two members of the NGO visit a fixed spot in the locality – the site, a certain number times per week (depending on the NGO in question) and have a number of syringes with them and an empty gallon. IDUs come to see them , bringing with them the used syringes which are disposed in the gallon and are given new sterile syringes by the members. IDUs are assigned a ‘code’ when they visit the sites. It should be noted that this is not for identification purposes of the IDUs but rather for monitoring and reporting purposes (Number of syringes per IDUs, number of IDUs visiting each sites…). Disposal of the needles is made after closure of sites for the day, by dropping them off at regional hospitals, where they are burnt in the incinerators.
MOHQL: Mobile NEP through two operational caravans. Two authorised health care assistants and one qualified nurse per caravan (identified by Ministry issed identification cards). Each caravan visit three sites daily, spending an average of one hour and a half to two hours on each site. Work in collaboration with peer leaders amongst IDUs who help facilitate smooth interacting between IDU crowds and the government staff.
The Needle Exchange Program in Mauritius and Other Policy Measures
Needle Exchange And Demand Reduction:
Demand reduction, focuses on detoxification and management of withdrawal syndromes with the aim of long term abstinence. However, the results yielded are not the expected ones as detoxification succeeds in removing people from the drug scene in the short term but the relapse rates usually approach 100 per cent (Fact Sheet Supply Demand And Harm Reduction, Burnet Institute Centre For Harm Reduction).
Needle Exchange And Methadone Substitution Therapy
Contrasting costs of providing needle and costs of providing methadone
Return rate of syringes; and treatment follow-up statistics and relapse rates for MST
Efficiency of both harm reducting programs in the sense that they would still cost less even than provision of antiretroviral treatment to an HIV positive person (provision of non-generic anti-retroviral may approximate $15000)
The Needle Exchange Program and Its Framework In Mauritius
Adoption of the HIV/AIDS Act 2006
Needle exchange was carried out by NGOs even before the HIV/AIDS Act came into effect. As such, they faced a legal impediment in the sense that the practice of needle exchange was inconsistent with the provisions of existing laws which is the Dangerous Drugs Act at its section 34(c) which made possession of injecting equipment and drug paraphernalia a criminal offence.
Following several committees of various stakeholders including the MOHQL itself, police officers, specially members of the ADSU and NGOs , it was agreed that there was a need for a framework to regulate the situation of NEPs. HIV/AIDS Act 2006 was then adopted in 2006 with general consensus by members of parliaments (comments of few members from Hansard will be included here and lengthier works will be attached) and came into effect in August 2007.
Aims of HIV/AIDS Act 06 according to the act itself is “to provide for measures for the prevention and containment of HIV and AIDS”
Analysis of this aim – was a framework really required to provide for prevention measures which are done principally through education, information and sensitization, and containment which is already handled through supply-side reduction. This tends to lead to the conclusion that the true motive behind the HIV/AIDS Act was to provide a legal framework for the NEP
Possession of Syringes and Needles and the HIV/AIDS Act 06
Article 2 of the International Convenant on Economic, Social and Cultural Rights also requires legislative reform in order to create a legal and policy environment conducive to the scale up of these services and the removal of barriers to access and coverage to improve accessibility. Hence in line with this, Section 16 of the HIV/AIDS Act deals with the Possession of syringes and needles in the context of NEP. It in fact through very explicit terms decriminalizes its possession in the circumstance of the NEP.
This was crucial because :
possession of a used needle and syringe may be used as circumstantial evidence to lay other drug-related charges. For this reason some clients may be reluctant to return used equipment to NEP site.
fear of being arrested while in possession of drugs and/or injection equipment can lead IDUs to rush injections, skip safer injection techniques (e.g., hand and skin cleaning) and to feel so anxious that they cannot inject with accuracy. All of these consequences can increase the risk of injection-related problems such as infections and skin and soft-tissue damage
However – Section 34 (c) has still not yet been repealed. Questionned by NGOs as to whether this is a best practice.
Needle Exchange: Health and Safety Under the HIV/AIDS Act 06
Handling of used syringes by personnel involved under the NEP – compliance with Occupational Health and Safety Act – Applicable only for Govt. Run NEPs
Section 10 Risk Assessment By Employment (Will be showed in footnote) –
Is this carried out?
Section 35 Cleanliness – (Will be showed in footnote)
Analysis of whether the caravans meet up with these requirements
Section 37 Ventilation and Temperature (Will be showed in footnote)
Analysis of whether the caravans meet up with these requirements
Section 39 Sanitary Conveniences (Will be showed in footnote)
Analysis of whether the caravans meet up with these requirements
Section 40 Supply of drinking water (Will be showed in footnote)
Analysis of whether the caravans meet up with these requirements
Section 41 Washing Facilities (Will be showed in footnote)