Here is a report of the discussion forum on Chemical
Dependency and HIV/AIDS organized by SAATHII on
November 12, 2004. If you don't have time to read
through the entire report, scroll down to the end of
the document for a list of recommendations and a
listing of resources available in Chennai on Chemical
Dependency.

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INTRODUCTION:
SAATHII: Solidarity and Action Against the HIV
Infection in India, organized a discussion forum on
the subject of Chemical Dependency and HIV/AIDS on
Friday November 12, 2004. 21 people attended and
participated in the discussion which was held in Tamil
and English.

Participants included representatives of the following
agencies -
Association for Rural Development. Sriperubudur,
Kanchipuram District
AGAPE, Chittoor
SIP+ South India Positive Network, Chennai
FPAI Family Planning Association of India, Chennai
TT Ranganathan Clinical Research Foundation, Chennai
World Vision India - New Hope ADP, Chennai
Arunodhaya Migrants Initiative, Chennai
PWN+ Positive Women's Network, Chennai
SAATHII Solidarity and Action Against the HIV
Infection in India, Chennai

Three resource persons were present on the occasion:

- Dr. Rajan Gupta, a physicist from Los Alamos who has
been involved in HIV/AIDS education and awareness
raising for the past five years.
- Dr. L. Ravishankar, Chennai-based psychiatrist
affiliated with R.S. Home, who works in multiple areas
including chemical dependency and mental illness.
- Dr. Wenoah Veikley, Director of Nursing and Clinical
Research at SouthWest Care Center, New Mexico, USA.

There was a round of introductions during which each
participant spoke about their work and/or their
organization. Some highlights are given below,
organized thematically.

ALCOHOLISM:
Dr. Gupta noted that in the current Indian
perspective, alcoholism is considered a separate
problem from other chronic diseases such as HIV/AIDS.
He urged participants to have an open discussion on
how to integrate HIV infection and prevention with
issues around substance abuse: a paradigm shift in
dealing with drug-related issues and HIV.

He highlighted the various issues contributing to the
problem: lack of societal awareness of the social and
economic issues regarding the separation of HIV and
substance-abuse, lack of awareness on the government's
part regarding the relationship between HIV and
alcoholism, and the general sentiment that regards
alcoholism as an isolated problem.

For the past five years, Dr. Gupta has been visiting
affected slums, cities, and villages and their people.
He reported that all areas are deeply affected by
alcohol. This problem is a national problem, not a
regional one. He spoke about the issue of domestic
violence in combination with alcoholism and sex. He
said it has an ongoing effect in terms of separating
and ruining the structure of families. For example,
when a parent, particularly the father, has an
addiction, that family tends to face economic
hardships; children drop out of school or cannot go to
school due to economic and social tensions that have
resulted.

In the discussion that ensued, participants also
discussed the connection between economic need,
alcohol, sex work and HIV:
(i) Alcohol helps both the client and the sex worker
in performing sexual transactions.
(ii) From the perspective of a sex worker, he/she can
earn more money if they do not use a condom and if the
client is drunk.
(iii) Sex workers can also bargain for higher fees
when clients are inebriated.
(iv) Alcohol intake by the sex worker is used to numb
the physical pain of repeated vaginal or anal
penetration; but it also sets the stage for rape and
other kinds of abuse.
(v) Alcohol also lowers the inhibitions of the sex
workers, especially when asked by clients to perform
less conventional types of sex acts like anal or oral
intercourse.
(vi) Some of the discussants brought up the popular
perception that alcohol helps the client in prolonging
erections, while scientific research has demonstrated
the opposite. A more complicated but plausible pathway
linking alcohol to sexual pleasure was suggested by
one of the participants: alcohol use by the sex
worker lowers her/his inhibitions enough to perform
oral sexual acts. These acts arouse the client
sufficiently to perform other kinds of penetrative
sex.
(vii) For both parties, alcohol lets them escape from
life's stressful circumstances and its use can be seen
as a coping mechanism. Alcohol allows them to
experiment and to be sexually open. Unfortunately,
there is a direct correlation between increased
alcohol ingestion and decreased condom use.

The effect of alcoholism on families is tremendous.
The pressure to earn more money to support a drug
habit often falls onto the children. Children are
forced into prostitution or to drop out of school due
to the structural changes in their family. It was
pointed out that many families and individuals face a
lack of social and economic capital, which exacerbates
the situation to become addicted to substances or to
become involved in sex work.

Discussants speculated on different causative pathways
leading up to risky sexual behaviors -
(a) migration: individuals end up geographically
isolated from their families, with sexual
opportunities and alcohol offering the only succor.
(b) domestic violence plays a major role in causing
individuals to leave home and take to alcohol (alcohol
also leads to violence)
(c) children from families rendered dysfunctional due
to alcohol and/or abuse, tend to drop out of school
and occasionally leave the family, getting exposed to
substances and premature sexual activity.
(d) People in rural areas living/working in urban
areas return to their places of origin and bring back
vanity items, e.g., electronics, make-up or fancy
clothes, that other children desire, causing other
children to leave town and seek those same things. In
all cases, children are exposed to drug use and sex at
an early age.

INJECTING DRUG USE (IDU):
Injecting drug use was also discussed. Dr. Gupta
noted the different mechanisms employed to make the
effects of drugs (appear to?) last longer. This
included re-injections, as well as the mixing of blood
and the sharing of needles. Ms. Wenoah Veikley asked
if India had a needle-exchange program and if this was
a possible or temporary solution to addressing the
relationship between drugs and infection.

This led the discussion into talking about Hepatitis B
and C. Dr. Subha Raghavan pointed out the Hepatitis C
estimates in India. It was brought to the attention of
the meeting about the deadly combination of Hep C,
mixing of drug use and HIV infection. Dr. Ravishankar
spoke from his clinical experience of working with
detoxification programs.

Representatives from several organizations talked
about resources and services available in Chennai for
people with chemical dependency issues. Mr. David
Williams spoke about the services offered by the T. T.
Ranganathan Clinical Research Foundation. Services
provided include
- outreach center
- 21 day rehabilitation program, and getting financial
support,
- substitution therapy similar to methadone program
- counseling services and family counseling on
addiction
- pretest and posttest counseling for HIV
- safe IV use counseling
- meetings and classes every morning
- group therapy with community people about the social
and physical damages that result from HIV and drug use
- outreach workers who are recovering addicts
- collaborate with other NGOs, peer education
- has served 461 clients in 3 years, Prevalence= 23
HIV positive people, and 67 with
Hep C.

A LIST OF CHENNAI RESOURCES IS APPENDED TO THIS
REPORT.

Ms. Wenoah Veikley described the needle-exchange
programs existing in New Mexico, which included
specific centers for exchange of needles and mobile
services that take needles to people living in remote
areas.

SCIENCE AND POLICY ISSUES:
- One problem is that there is there is no national
data regarding the prevalence/incidence of different
types of drug use and or of those concurrently
infected with Hep B, C and HIV. Dr. Subha brought up
the relationship between Hep C and HIV co-infection,
and pointed out that there were as yet there are no
standard guidelines for screening blood for Hep C.

- There was a brief discussion on the shortcomings and
benefits of female condoms, sex work and negotiation.


- It was mentioned at this point, there has been no
push for policy-level changes to integrate the concept
of substance abuse and HIV infection. There is a
need for a best or better practices model to be
established so that services can implement the proper
changes to address these issues. In delivering better
models aimed at service-delivery, policy makers will
see the necessity to implement national changes.
Alcoholism is still considered an isolated issue;
however, more systemic causes of alcoholism, like
poverty, lack of social capital, family infrastructure
and stress are common factors that contribute to
becoming infected with HIV or other substance abuse
issues.

- Treatment and care issues were also briefly
discussed. Dealing with the combination of ARVs, drug
use, alcohol use, and possibly Hep C can be a deadly
combination. Due to the high level of toxins filtered
by the liver, it is possible that the liver has
severely deteriorated. In addition, access to drugs
is very limited. There is a large demand but a small
supply. Second line of ARV drugs is not available,
while a lack of nutrition required for successful
treatment is usually not an option.

- Lowered quality of life (qol) and poverty are
usually direct correlates of HIV infection. Positive
men and women are thrown out from their homes, seen as
cursing and shaming their family- qol decreases. Data
shown that in families where women and men are both
HIV positive, men are more likely to stop working.
Women, on the other hand, are pressured to produce
children, regardless of serostatus.

RECOMMENDATIONS:
1) Policy/government oriented: For policy makers and
the government to acknowledge the relationship between
HIV infection and substance abuse: to treat the two
entities as connected realms with similar social and
economic causes and impacts
2) Service-delivery oriented: To develop a best or
better practices model to guide the co-implementation
of HIV and drug-related services.
3) To drive agencies to understand the social and
economic driving forces that contribute to HIV
infection and drug-dependence so that services will be
more integrated.

ACKNOWLEDGEMENTS:
SAATHII would like to thank all the resource persons
and participants who showed up despite the pouring
rain and holiday engagements (12th being the day after
Diwali).
Special thanks are due to the participants who helped
with translating discussions between Tamil and
English. Documentation by: Christina Pili, S. Alwin
and L. Ramakrishnan. Logistics: S. Alwin, Vaithee Rao

CHENNAI RESOURCES

1) SAHAI TRUST ( Head office) South
# 27, Sripuram colony, Ist cross street,
ST-Thomas Mount, Chennai – 600 016
Ph - 2232 8506.

2) SAHAI TRUST - Drop in center
71/33, Madevakkam, tank road, opp: IMH,
Kilpauk, Chennai - 600 010
Ph – 2660 1573

3) SAHAI TRUST – Drop in center
11, Parthar Mills Road,
Lutheran Shrine church,
Perambur, Chennai – 600 011
Ph – 2670 3644

4) T T Ranganathan Clinic Research Foundation
IV Main Road, Indira Nagar,
Chennai – 600 020
Ph – 2291 2948

5) T.T. Ranganathan Clinic Research Foundation
39 A, MIG flats, K.K. Nagar,
P.T. Rajan Salai,
Chennai – 600 078
Ph – 2489 4914

6) Dr. L. Ravishankar
R. S. Home
Plot No: 5099, Door No:7, New No:4,
7th Street, Ramnagar North Ext; Puzhithivakkam,
Madipakkam, Chennai – 600 091
Ph – 2501 1630 / 98410 43308

7) World Vision Of India – New Hope ADP
# 14, Shanmugarayan Street,
Purasawakkam,
Chennai 600 007
Ph – 2662 1698, 2662 3781

8) St-Paul’s Hospital
# 23, Thirvallur Salai, Thiru nagar
Alwarthirunagar,
Chennai – 600 087
Ph – 2486 5931

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