Injecting drug use accounts for one third of all new HIV infections occurring outside sub-Saharan Africa. This of course, does not mean that there are no drug-related infections in Africa. It is actually a growing problem in many coastal areas of West, Eastern and Southern Africa.
Globally, an estimated 16 million people inject illegal drugs, of whom on average one in five is infected with HIV. HIV prevalence among people who inject drugs ranges from 12 and 15 percent in China and the US, respectively, to over 35 percent in the Russian Federation.
Whereas the global AIDS epidemic appears to have stabilized, with the number of new infections having decreased by 25 percent in the last ten years and fewer AIDS-related deaths occurring due to increased access to antiretroviral treatment, one region and several countries do not fit the overall trend.
Of the seven countries where UNAIDS reported on a 25 percent increase in HIV incidence between 2001 and 2009, five are in the Eastern European and Central Asian region, where transmission through drug use accounts for over 60 percent of the epidemic and where the war on drugs is actively fought with little or no attention to harm reduction and public health.
It is in this context, that - in its report released in June this year - the Global Commission called on the world, national leaders and all UN agencies to acknowledge and urgently address the causal links between the war on drugs and on users, and the spread of HIV/AIDS.
Clearly, the AIDS epidemic in people who inject drugs and their sexual partners, continues to be a serious public health emergency that the world is failing to address, despite the evidence that harm reduction strategies are highly effective in preventing HIV infection among people who inject drugs, and despite the evidence that many countries have succeeded in drastically reducing HIV incidence and prevalence among injectors.
In no other disease, and for no more marginalized population, does such willful – let me be blunt and say homicidal – blindness to the evidence persist.
Harm reduction is not just one or two interventions. WHO, UNAIDS and UNODC recommend a package of interventions, including needle exchange programs, opioid substitution therapy, information and education, overdose prevention, and engagement of people who use drugs in decision-making, to which I would add - safe injection sites. The evidence that harm reduction is effective in reducing health harms in people who inject drugs is comprehensive, compelling, conclusive and – despite the attempts to do so – absolutely undeniable.
The epidemiological evidence is also clear: in countries that have adopted harm reduction and health-based approaches to drug use and addiction, the HIV epidemic among people who use drugs has declined, as we have seen in Western Europe, Australia and Canada .
In countries and regions that have neglected harm reduction and relied on ineffective and aggressive drug law enforcement, the HIV epidemic does not decline among injectors as we see in Thailand (as opposed to a decrease in the general population), or growing fast, worsening and spreading to the general population, as we see in Russia. A mathematical model of HIV transmission among people who inject drugs in Russia suggests that, assuming a baseline HIV prevalence of 15 per cent, probably underestimated, coverage of OST from zero to 25 per cent of all people who inject drugs could decrease HIV incidence by between 44 and 53 per cent.
A lesson learned from the Western European and Australian experience is that, to be implemented successfully, harm reduction strategies require a collective dialogue and a politically and socially acceptable shift in policies, a dialogue and a shift that the Global Commission is also calling for.
More focus on evidence-based policies and cost-effective interventions is also crucial in times of economic downturn. We know too well that an economic slowdown will have a disproportionately negative impact on stigmatized and marginalized groups and the poorest segments of the society, including, I believe, an inevitable increase in the use of problematic drugs and injection rates.
Dear friends and colleagues:
Forty years of the so-called “war on drugs” and prohibition law enforcement have failed abysmally in their primary goals of, firstly, eradicating drug use and, secondly, protecting people’s health. They have failed by every conceivable metric:
• Trends in drug use have risen consistently.
• The global supply of opiates has increased by 380 per cent in the last 25 years.
• Illegal drugs have become cheaper and more available. The price of heroin in
Europe decreased by 75 per cent between 1990 and 2009, while also improving in purity in a number of markets. Similar curves of decreasing prices have been seen for both heroin and cocaine in the U.S.
At the same time as illicit drugs have become more widely available, HIV/AIDS and other health risks associated with drug use, such as hepatitis C and TB, have increased dramatically. People living with HIV who inject drugs have a two- to six-fold increased risk of developing TB, as compared to non-injectors. The prevalence of HCV in people who use drugs ranges between 30 and over 90 percent worldwide. Co-incident Hep C has been neglected for far too long. It is only beginning to receive the attention it deserves.
So let us not just speak of the twin epidemics of HIV and drug use, but rather the quartet of HIV, drug use, TB and hepatitis. We cannot address one without also addressing the other three.
We also know that drug users face tremendous barriers to accessing health services. Fear of police and stigma drive drug users underground, away from prevention and away from treatment.
And as a physician, I am sorry to say that stigma and discrimination are also often present within healthcare settings, leading to refusal of services, absurd requirements to be drug-free as a pre-condition of treatment and breaches of confidentiality.
As a result, it is estimated that at most only 10 of every 100 injectors in need of therapy accesses antiretroviral treatment. This remains a scandal at a time when ART coverage in low- and middle-income countries, globally, is now well over 50 per cent based on CD4 cell counts below 350. So while global access to ART becomes more equitable, the inequities for drug users just seem to become ever more entrenched.
A study published a few years ago has also shown that – even when HIV-positive injectors do access ART – their life expectancy on treatment is up to 12-times lower than for a non-injector. It is clear that the range of health needs of drug users on treatment is often not being met.
The emphasis on drug law enforcement has created legal barriers to evidence-based HIV prevention measures such as provision of clean syringes, needles and methadone maintenance therapy. The result is that only eight of every 100 injectors globally receive opioid substitutive therapy at this time. Methadone is still illegal in Russia and access to it is far too limited in many countries, particularly in Asia and countries of the former Soviet block. Tragically, in my view, the US Congress recently re-instated the ban on federal funding of syringe exchange programs domestically and abroad, only two years after it lifted a 21 year-old ban.
Every one of us is deeply aware of the social harms associated with drugs, but these harms are only exacerbated by prohibition law enforcement. The 50,000 homicides reported in Mexico since the war on drug cartels began is an extreme example of such devastating social harm.
There is also evidence that prohibition policies have been tilting the markets towards more potent and risky products, often cut with contaminants, and that such policies actually contribute to high risk behaviors, including injection in highly unhygienic environments, something I heard repeatedly in Kiev.
And prohibition law enforcement has led to a true “war on users” and what I would call an epidemic of human rights abuses. People who use drugs who are arrested or suspected of drug offences are subject to police harassment, police violence, abuse of power and extortion.
Incarceration for minor drug-related offences is one of the main reasons behind the increase in prison populations globally. To make matters worse, incarceration is itself a risk factor for acquiring HIV through needle sharing or unprotected sex. HIV prevalence among the 2.4 million people currently incarcerated in US prisons and jails is estimated to be close to 10 per cent. Around 25 percent of people living with HIV in the US and 30 percent of those infected with HCV, have spent time in correctional facilities. The disproportionate incarceration rates of African-Americans, including for drug offences, is considered as a factor in the markedly elevated rates of infections in that population.
At a global level, the risk of contracting TB in prisons is on average an extraordinary 23 times higher than the level in the general population.
The cost of ineffective prohibition law enforcement is huge. On the other hand, the social benefits of harm reduction are clearly cost effective. Here I deliberately cite examples from the Eastern European region, which is so late in bringing harm reduction to scale.
The $5 million that the Republic of Georgia spends annually on incarceration of drug offenders could cover OST for 1200 patients a year, a one year enrollment of over 6,000 patients in a needle and syringe exchange program, in- and outpatient detoxification for 3500 patients and psychosocial support for over 20,000 people.
In Kyrgyzstan, OST programs cost less than $1.40 per patient per day, yet the current coverage of OST is less than 4 per cent of the estimated 26,000 people who inject drugs.
By comparison, in Ukraine - a country that has done more than most in the region - close to 7,000 patients are currently enrolled in OST programs. A recent assessment of the social benefits of the programs has shown that some 30 per cent of clients have become legally employed and more than 16 per cent have restored family relations. Participation in drug trafficking decreased seven-fold, and rates of other crime about four-fold.
Ladies and gentlemen:
Current approaches to controlling the drug problem in many parts of the world have failed. Drug supplies and violence are increasing. Community health and safety are worsening.
The war on drugs is still driving the HIV/AIDS epidemic in many countries of the world. As the Global Commission emphasizes in its recent report, fear of arrest drives people who use drugs underground, away from HIV services and into high risk environments; restriction on provision of sterile syringes results in increased syringe sharing; prohibition or restrictions on opioid substitutive therapy result in untreated addiction and avoidable high risk behavior; lack of HIV prevention measures in prison leads to HIV outbreaks among incarcerated drug users; vast amounts of precious public funds are wasted on harmful and ineffective drug law enforcement efforts instead of proven HIV prevention and treatment strategies.
It is no longer sustainable or credible to pretend that the current reliance on drug law enforcement is effective. People struggling with drug abuse or addiction may harm themselves and their families or communities, but criminalization and social marginalization will not help them. One cannot impose health or solve drug-related social problems through a war on vulnerable people.
Policy-makers today face a clear and compelling choice: either they condemn countless more young people who use drugs to lives of destitution, incarceration and disease, or they scale up harm reduction and related public health programs urgently at the same time as they tackle the economic and social problems that are the root causes of drug abuse.
We can draw hope from the fact that in some countries, the debate has been opened. Latin America is talking about drugs like never before. Argentina, Brazil, Colombia, Ecuador, Mexico, and Uruguay have already joined a number of Western European countries in passing laws decriminalizing drug possession for personal consumption.
We need to strongly encourage and support these countries, as well as others that have traditionally employed an aggressive law enforcement approach to drug control but who are now moving, often cautiously, to a public health approach. Here I mention the examples of China, Ukraine, Belarus, Kyrgyzstan and Malaysia, who are beginning to appreciate the power of the evidence and the danger of rigid ideology.
Let us also continue to strongly support the many remarkable civil society groups in countries around the world who are doing so much – often without adequate resources and in hostile environments - to advance this cause.