Feature story

OPINION: HIV and drugs: two epidemics - one combined strategy

20 April 2009

By Michel Sidibé, Executive Director, Joint United Nations Programme on HIV/AIDS (UNAIDS) Geneva, Switzerland

(This article also appeared in the Bangkok Post on 20 April 2009)

At the Mitsamphan drug user harm reduction drop-in centre in Bangkok drug users are able to get clean needles, condoms and counselling. Access to these services allows them to stop HIV, look after their health and lead productive lives. The centre is run by community members, including ex-drug users, and has restored dignity and is giving hope to many. Thanks to many such centres worldwide, new HIV infections among drug users are being stopped. This is not a surprise for the delegates attending the 20th international conference on harm reduction in Bangkok this week. But for a majority of policy makers in national drug programmes, the term ‘harm reduction’ invokes silence and controversy. However nearly 16 million people inject drugs worldwide – 3 million of whom are estimated to be living with HIV – silence on harm reduction therefore is not an option.

National drug control and HIV programmes must work together. They must be informed by evidence and grounded in human rights. Drug issues are complex but they do not take away from the fact that people who inject drugs, just as everyone else, are entitled to the full spectrum of human rights. Evidence shows that harm reduction programmes save lives. Many countries are still not providing access to the harm reduction services. This is killing people as much as the drugs themselves.

Regrettably the 52nd session of the Commission on Narcotic Drugs in March of this year missed an occasion to make a bold political commitment to holistic harm reduction. Yet member states had committed to accelerating access to harm reduction efforts related to drug use in the Political Declaration on AIDS adopted at the UN High level meeting on AIDS in 2006.

But why are drug control authorities against harm reduction? Harm reduction programmes include access to sterile injecting equipment, opioid substitution therapies, and community-based outreach. These are the most cost effective means of reducing HIV-related risk behaviors. They not only prevent transmission of HIV but also of hepatitis C and other blood borne viruses. In Australia, the return on investment of a decade of needle and syringe programmes was estimated at one and half billion US dollars. And in Ukraine, for $0.10 cents per day one drug user can be protected against HIV through the provision of comprehensive harm reduction services.

Countries that have adopted a comprehensive approach to HIV and drug use have seen a decline in the spread of HIV among people who inject drugs. This includes Australia, United Kingdom, France, Italy, Spain, and Brazil, and in some cities in Bangladesh, the Russian Federation, and Ukraine.

We can protect drug users from becoming infected with HIV. China is doing its part. In 2004, there were only 50 needle and syringe programmes. Today there are more than a thousand such programmes in all priority provinces. By achieving universal access targets for 2010, nearly 10 million drug users will be able to access such life saving harm reduction programmes worldwide.

Harm reduction is not an obstacle in reaching the goal of a drug-free world. Drug control authorities need not fear a rise in drug use simply because people are taking steps to protect themselves from HIV and reduce their drug dependency.

There is no evidence that providing harm reduction services has led to more people becoming drug users. There is also no proof that current drug users increase their intake of drugs or choose to use them longer. In contrast to the overwhelmingly beneficial effects of harm reduction, law enforcement approaches alone do little to reduce drug use and drug-related crime and are often associated with serious human rights abuses and poor health outcomes for people who use drugs. They include arbitrary arrests, prolonged detention, compulsory drug registration and unwarranted use of force and harassment by law enforcement officers.

Many drug laws make possessing and distributing sterile needles and syringes an offence, and opioid substitutes such as methadone and buprenorphine are classified as illegal despite being on the WHO list of essential medicines.

When law enforcement and public health efforts come together, the outcomes are very successful – for example in Britain and Australia where drug action teams and police focus on crime fighting and successfully refer drug users to health and welfare services.

The Supreme Court in Indonesia rightly ruled that drug users should not be sent to prison; instead they should have access to treatment. It should not be a crime to access clean needles. It should not be a crime to access substitution therapy.

We need to get rid of drug laws that block the response to AIDS and drug use. HIV and injecting drug use are two epidemics but need a combined strategy. We cannot leave it to the next generation to reconcile the separate approaches to HIV and drug control.