Sankalp Rehabilitation Trust

Popularizing Harm-Reduction Strategies

In a tiny single-story tenement on a busy street in the heart of India's financial capital Mumbai, men of different ages are waiting to see the nurse. Some are staring blankly at the ceiling, while others, who appear to be regulars there, are chatting among themselves.

The men are waiting outside one of the five drop-in centers (DICs) of the Sankalp Rehabilitation Trust, where Mumbai's marginalized group of drug-using street-dwellers, come regularly seeking help to reduce the risk of HIV transmission. Sankalp works among Mumbai's drug-users who live on the streets, of which there are about 40,000 in the city, many of whom are at high risk of contracting HIV because of needles they share.

Sankalp was started by Eldred Tellis, himself a drug user and who quit at a time (in 1983) when there was very little help for people who use drugs. Having experienced the pain and the trauma of getting over the deadly habit, Tellis volunteered at an institute that provided rehabilitation. Inspired, Tellis went on to get trained in a well-known therapeutic community in New York. After a stint at a community center, he set off to work in India's north-eastern States which are home to a significant number of drug users. After three years of building from scratch small help communities and enhancing their capability to help drug users, Tellis returned to Mumbai to reach out to the marginalized street drug users who had no support or access to rehabilitation.

In 1995, he started Sankalp (meaning 'resolve' or 'determination') and built it brick-by-brick, developing a comprehensive and meaningful programme for intra-venous drug users (IDUs), largely responding to the needs of this group as they surfaced. Today, Sankalp is a member of federal government's National AIDS Control Organization's (NACO) Technical Resource Group for harm reduction programmes and a leading advocate of such efforts in the country. 

Sankalp provides services through drop-in centers, where any one can come for medical care. It works with volunteers who reach out in areas that are frequented by drug users – such as railway stations and slums. Every Sankalp volunteer adheres to its motto: "Do not coerce the drug user to change his pattern if he does not wish to. Just provide unconditional help to make at least a slight improvement in his life".

According to Freny Manecksha (InfoChange News & Features, April 2009), Sankalp believes drug users can make decisions to change their lives if they are treated with respect. "While it is obvious that abstinence is most desirable, it cannot always be achieved. So, the next best thing is to adopt the harm reduction approach – that is, provide the means to reduce the risks of HIV transmission for those who continue to inject drugs or those who stopped but have relapsed," he says. 

Since drug users often shared needles and syringes which can spread HIV, Sankalp gives them clean needles and syringes in exchange for the used ones, and gives them treatment as part of a risk containment strategy that effectively prevents HIV among IDUs, and at a low cost too. Sankalp has five drop-in centers in Mumbai - Central, Govandi, Kalyan, Bhiwandi and Kurla. There is also one for women at Mumbai Central as some 5-10 per cent of the city's IDUs are women.

The staff at these centers develops a rapport with drug users who have little or no access to any other rehabilitation measure. "The low threshold nature of the drop-in centre allows the drug user to understand the various options available to him/her and make choices when 'ready'," says Tellis. For Tellis, the twin pillars of the harm-reduction approach are public health and upholding human rights. In its interventions, Sankalp lays equal stress on both. 

Initially, drug users did not care too much about contracting HIV and it was quite difficult to convince them to seek help. But over the years IDUs have become aware of the risk of infected needles. Through Sankalp's peer educators, who cover the length and breadth of the city, drug users are encouraged to exchange their old needles and syringes for new ones and are also educated on how to prevent HIV/AIDS. Condoms are also handed out to promote safe sex. Says Thomas George, a volunteer at Sankalp: "This is how rapport is built and they are encouraged to visit the drop-in centers where they are always welcome and given food and clothes."

Sankalp's support goes beyond the needle/syringe exchange programme. At the drop-in centers, IDUs can get the services of a counsellor or learn about managing the abscess caused because of injecting, or about the importance of nutrition in AIDS prevention. Each center has peer educators, peer counsellors, a nurse, and a part-time doctor. Group counselling is provided daily and also referral services for HIV or TB testing and doctor consultation.  The harm-reduction approach seems to be yielding results with HIV infection rates among IDUs dropping.

With just 400 beds available for the over 40,000 drug users who live on the streets on Mumbai, hospitals are reluctant to admit the IDUs who often have no family or relatives to take care of them and it is extremely difficult for drug users to get institutional help. Thus, Sankalp has established a community-care center where drug addicts and IDUs can be admitted for treatment of opportunistic infections related to HIV. The center provides 24-hour medical treatment with a nurse on duty at all times, doctors are on call and it has its own ambulance. 

Sankalp also works with drug users in prisons that house many on substitution treatment who are often rounded up with other street urchins. In jail, their situation becomes extremely vulnerable with no access to risk-reduction services. Besides the needle/syringe exchange and substitution treatment, doctors from Sankalp run an outpatient medical service in jails, arrange for check-ups or referrals, and even provide antiretroviral treatment (ART) to those who need it.

Thus IDUs can  avail one or a combination of programmes offered by Sankalp - the needle/syringe exchange; the Integrated Counselling and Testing for HIV; screening for TB and Hepatitis B and C; taking care of opportunistic infection; and support/help if they are jailed under the Narcotics Drugs and Psychotropic Substances Act.

Sankalp also has detoxification programmes for those wanting to kick the drug habit. It also offers these patients an opportunity to learn how to use computers for specific 'job work'. This boosts the self-esteem of the patients, says Tellis. Some are also placed with catering companies, security outfits, ship-breaking units or in offices of friends of Sankalp.