Until there's a cure for HIV, equal parts creativity and pragmatism are essential for maximizing the health of people who are HIV positive while minimizing the spread of the virus. The theory and application of harm reduction techniques support both.

A very broad definition of harm reduction is "a public health concept of lowering the health consequences resulting from certain behaviors" (www.druglibrary.org). Almost all people practice some type of harm reduction in their lives without labeling it as such. The concept of a designated driver or the use of a taxi to transport people who've been drinking alcohol are commonplace. The use of seat belts and airbags makes cars safer, and people use sunscreens in an effort to lower their risk of skin cancer without giving up a tan or time in the sun. These interventions are personal and social tools that lower risk while allowing people to do things they value.

The term harm reduction originated in the 1980s in the European IV-drug-using community where needle exchange programs were developed in response to the spread of HIV and hepatitis C among users who shared needles and syringes. While harm reduction philosophy views abstinence from IV drug use as an eventual goal, it focuses on achieving specific behavior changes that lower the individual, social and community risks as long as people are using IV drugs. Because drug use of all types and sexual practices are intertwined in terms of risky behaviors, interventions based in harm reduction have been incorporated into a number of HIV prevention, care and education programs around the world.

The harm reduction perspective is radically different from two more dominant approaches to dealing with drug use and addiction. A "supply reduction" approach focuses on drug control through law enforcement and the criminal justice systems (i.e., "the war on drugs"). A "demand reduction" approach aims to rehabilitate drug users to eradicate the desire or demand for drugs. Most drug treatment programs see addiction as a disease, require complete abstinence and discharge participants from programs if they continue to use.

Instead of waiting for individuals to choose to be abstinent from drugs or sex, a harm reduction approach provides an opportunity to take immediate steps toward behavior change that lowers any risk in an individual's life. It does not require the services of legislators, law enforcement, medical or psychological professionals. Risk reduction does require a motivation to avoid some negative consequences. In terms of drug use, these consequences might include infection, loss of income, physical danger or abandonment. Experts in the development of harm reduction tools are often the individuals and social groups (including drug users and people living with HIV) who have suffered the most from these negative consequences.

Harm Reduction All Around

Probably the most high-profile intervention in the harm reduction toolbox is needle/syringe exchange. While needle exchange has been embraced as a public health policy in some places, it remains highly controversial in the United States. Many people contend that harm reduction techniques such as needle exchange only perpetuate behavior that should be totally eradicated. Harm reduction proponents acknowledge that there have always been and will always be people who use drugs or practice other high-risk behaviors and that the moral imperative is to reduce the harm those behaviors cause individuals and communities.

Harm reduction practitioners acknowledge that drug use and sexual practices can have profound negative consequences. With an eye toward reducing those negative consequences, practitioners work with people to make gradual, manageable changes -- small steps in the direction of maximum safety. Tips on reducing risk from drug use and sex are both usually available from harm reduction-based programs.

Characteristics of a harm reduction philosophy include a pragmatic attitude about sex and drug use, acknowledging that people take risks and that stigma related to those behaviors increases those risks. It strives to create a safe place where people can explore their ambivalence about personal behaviors and learn about ways to make their behavior less risky. It counts improvement in personal quality of life and community well-being as measurements of success, rather than considering abstinence as the only success. It recognizes the personal and social destruction and tragedy that are associated with drug use and unprotected sex, while understanding the forces that fuel those behaviors. It can be a slow process involving attention to everyday needs such as health care, shelter and food that support an individual's progress toward health. Many people view harm reduction programs as pretreatment efforts.

Tools for the reduction of risk associated with IV drug use include needle/syringe exchange, cleaning needles with bleach, methadone treatment and moving to methods of drug ingestion that do not involve injecting. Techniques for lowering the risk associated with other drug use (including alcohol) include lowering the frequency of use, being knowledgeable about and avoiding drug interactions, staying hydrated, keeping medical appointments, not driving or conducting other tasks that put you or others at risk and maintaining good nutrition. Some common strategies for sexual risk reduction would be knowing your HIV status, lowering the number of sexual partners, increasing condom use, lowering incidence of higher risk behaviors, minimizing or eliminating substance use, keeping medical appointments and reducing other health risks.

Assessing one's personal risk factors requires education and a safe source for information. In addition to a number of excellent Internet sites, journals and magazine articles, there are harm reduction coalitions throughout the United States, including the Atlanta Harm Reduction Coalition and the Harm Reduction Coalition in New York. Many AIDS service organizations base their programs in harm reduction, providing information about safer sex and safer using. They exist to serve you and they need your support as they struggle to meet the needs of their communities.