This essay is part of a series on harm reduction responses to drug use in the MENA and Asian regions—the actors and networks engaged in such activities, the contributions they have made, and the roadblocks they have met. Read more ...
Repressive policies that stigmatize and punish drug users have tended to exacerbate social problems rather than mitigate them. In contrast, harm reduction (HR) approaches to drug use have been shown to prevent the spread of blood-borne viruses (such as HIV, HBV, and HCV), thereby lowering morbidity and mortality rates. Over the past 15 years, many HR initiatives have been launched in the MENA region, including Lebanon. However, continued progress in HIV prevention will require more structured and comprehensive HR interventions, adjusted to the needs of local populations.
Drug Use Context and Needs in the MENA Region
According to the UN Office on Drugs and Crime (UNODC) World Drug Report published in 2013, substance abuse has continued to rise in both developing and developed countries since the 1990s despite international efforts and an ongoing “war on drugs.” The report described a steady worldwide increase in the production and misuse of new psychoactive substances between 2009 and 2013. Between 167 and 315 million people ages 15 through 64 were estimated to have used an illicit substance in the preceding year.
In 2012, the Middle East and North Africa Harm Reduction Association (MENAHRA) estimated that there are 570,000 People who Use Drugs (PUDs) spanning 20 countries within the region. Heroin is the principal drug injected, and the majority of intravenous drug users (IDUs) are males in their early thirties—a third of them married, and two thirds literate. These groups are marginalized and considered criminals. Furthermore, data from the MENA region shows that 20 percent of PUDs share needles and do not have enough information about HIV, harm reduction, and preventive practices.
Harm Reduction in Lebanon
In its 2012 narrative report on Lebanon, the Joint United Nations Program on HIV/AIDS (UNAIDS) identified drug users—particularly IDUs—as a key target population for future interventions. Due to the absence of government data on drug use and HIV rates in Lebanon, NGOs that work in the field rely upon UNAIDS estimates, which suggest that 2,000-4,000 individuals use drugs, and that 5.7 percent of people living with HIV are intravenous drug users. The UNAIDS outreach program, implemented in partnership with the Drosos Foundation, gathered data between 2008 and 2009. Of the 2,012 IDUs reached, approximately 87 percent were male and 90 percent were under the age of 40. The majority started using drugs before the age of 15. Seventy-eight percent of drug users contacted were injecting heroin, while the remainder used cocaine, alcohol, hashish, or pills. An alarming 40 percent of IDUs were sharing needles with friends (three people or more). This data highlights the high rate of drug use among young people, an issue that necessitates special attention from the government. Failing policies should be abandoned in favor of new approaches, such as harm reduction.
Although drug users may be aware of HIV—its modes of transmission and methods of prevention—they often engage in risky behavior, such as needle sharing and sexual intercourse without a condom, leaving them vulnerable to infection with HIV and HCV. Records from NGOs and detoxification/rehabilitation centers in Lebanon show that more than 60 percent of the IDU community has tested positive for hepatitis C. However, according to the National AIDS Control Program (NAP), no new HIV infections have been identified among these groups.
Although needles are affordable and available for purchase without prescriptions in pharmacies in Lebanon, IDUs often avoid buying needles due to the discrimination that they face from pharmacists and the possibility of the latter turning them in to the police. As a result, drug users are at risk of HCV and HIV infection, and by extension so are their communities. According to one young intravenous drug user, “Holding a number of needles can be reason enough for the police to arrest an IDU and begin investigations.”
A number of different factors contribute to the vulnerability of drug users:
- personal and family problems
- social marginalization and discrimination (drug habits are unacceptable according to the norms and taboos of Lebanese society, and people often associate drug users with crime)
- lack of public and governmental support for harm reduction concepts and services
- repressive, punitive, and discriminatory government policies
- criminalization of drug use and drug users
- lack of access to comprehensive services
- lack of gender sensitivity in available services
- limited employment opportunities
As a result of these pressures and deficiencies, drug users are forced to keep a low profile. More specifically, they are denied easy access to information, clean utensils, and health services, and they are discouraged from health-seeking behavior.
Although the number of NGOs working on drug prevention and rehabilitation, harm reduction, advocacy, and lobbying is on the rise in Lebanon, their interventions remain limited. At this stage, relatively few are involved in harm reduction service delivery. Indeed, harm reduction is still a new concept for professionals as well as for drug users.
In 2012, Lebanon’s Ministry of Public Health (MoPH) approved the use of Opioid Substitution Therapy (OST) and developed a structure for its administration. This policy shift followed two years of strong advocacy by civil society, with the support of NAP, for the inclusion of OST in the treatment regime provided for IDUs.
This decision suggested a new level of support for drug users and a willingness to consider them patients in need of medical assistance. Yet despite the MoPH’s offer of this new treatment, drug users are still considered criminals according to the law. In addition, OST remains financially inaccessible since most IDUs are extremely poor. These factors place an additional burden on local NGOs that are working to raise public awareness about the effectiveness of OST.
Women Who Use Drugs in Lebanon: The Need for Targeted Interventions
Though the number of Lebanese women who use drugs is small compared with the number of male users, it is particularly challenging to reach them, especially in cases of intravenous drug use. The same is true for other countries in the MENA region.
Based on information obtained from the Ministry Of Interior (Drugs and Morality Police) in Lebanon, 3.5 percent of people arrested in 2013 were women. In the same year, women made up 2.9 percent of those arrested for selling and using drugs. Four and a half percent of the women arrested for sex work told the Drugs and Morality Police that they used drugs (12 of 262 female sex workers arrested in 2013). These figures show the need to better understand female drug users’ living situations and to develop targeted interventions for them.
Women who use drugs face particular risks and challenges, such as harassment, violence, sexual and reproductive problems, unwanted pregnancies, unsafe abortions, financial pressures, family rejection, challenging relationships with partners and children, legal issues, and the denial of rights in general. Therefore, interventions targeting women should promote gender equality and the empowerment of women, integrate services that cover needs specifically related to women, and motivate the women to adopt HR measures. Outreach to women should be expanded, and HR interventions and services should target subgroups among women who use drugs, such as female sex workers, women involved in the sex trade specifically for drug use, and women who inject drugs. These interventions should be based on socio-ecological and behavioral change models in order to be inclusive; they should take into consideration the needs of the female drug user, family influences and peer pressure, and the specific challenges created by her environment.
In order to address the needs of drug users in Lebanon, more effective harm reduction interventions must be implemented. Comprehensive care and support services that respect gender differences should be made accessible—financially and otherwise—for all people who use drugs and for their partners.
 United Nations Office on Drugs and Crime (UNODC), “World Drug Report,” 2013, http://www.unodc.org/unodc/secured/wdr/wdr2013/World_Drug_Report_2013.pdf.
 Afari Rahimi-Movaghar et al., “Assessment of Situation and Response of Drug Use and Its Harms in the Middle East and North Africa,” Middle East and North Africa Harm Reduction Association (MENAHRA), 2012, http://menahra.org/images/pdf/Menahra.pdf.
 UNAIDS, “Country Progress Report-Lebanon,” 2012, http://www.unaids.org/sites/default/files/en/dataanalysis/knowyourresponse/countryprogressreports/2012countries/ce_LB_Narrative_Report%5B1%5D.pdf.
 UNAIDS, “Country Progress Report-Lebanon,” 12.
 71.8 percent were under the age of 30, of which 8.9 percent were 20 years old or younger.
 This testimony was given to an outreach peer as part of a needle exchange/needle-syringe program.