HIV, HARM REDUCTION AND HUMAN RIGHTS

One of the most important facts about the global AIDS epidemic facing us in
2005 is that 10% of new HIV infections are now related to illicit injection
drug use. Outside Africa, at least one in three new infections results from
the sharing of a contaminated needle.

Russia, China, Malaysia, Ukraine and Vietnam have entrenched epidemics in
which most cases are related to injection drug use. Injection drug use
accounts for most cases in Tajikistan, Kazakhstan, Uzbekistan, Iran,
Indonesia and Nepal and is the leading mode of transmission in most of
Western and Eastern Europe, North Africa, and the Middle East.1

The fact that there are an estimated 13 million injection drug users (IDUs)
in the world makes this state of affairs all the more urgent.

As the authors of a report to the UN Millennium Project note,
"injection-driven epidemics are ... distinguished by the extreme rapidity
of their spread."1 The soaring infection rates among IDUs are in large
measure the byproduct of a law-enforcement approach to drug policy, which
deepens the social isolation of IDUs and presents barriers to
harm-reduction strategies such as needle exchange and opioid substitution
therapy.

In some contexts, the paradoxical effects of the "war on drugs" are even
more complex: "Law enforcement efforts restricting opium supplies lead
users to shift to heroin use, or from smoking to injection.

Criminalization of needle possession encourages use of shooting galleries
or contaminated injection equipment."1 In many jurisdictions, the prisons
and "treatment centres" where IDUs are incarcerated are themselves sites of
drug trafficking, needle sharing and unprotected sex where harm-reduction
measures are denied on the grounds that they condone criminal behaviour.

Another layer to this miserable picture is the generally poor access to
antiretroviral (ARV) therapies among IDUs, even in developed countries.

The WHO's "3 by 5" initiative to deliver ARV therapy to 3 million people by
the end of 2005 has brought the number of recipients from 440 000 to 700
000, but this number accounts for only 12% of those who need it. Although
the WHO has stipulated that ARV therapy should be made available to all,
some jurisdictions report that none of the recipients of ARV therapy are
IDUs.2 (A notable exception is Brazil, where a comprehensive harm-reduction
and drug-access program reduced AIDS mortality among IDUs by 50%.)

As Richard Elliott and colleagues discuss in this issue (see page 655),3 a
harm-reduction approach to HIV control among IDUs is at odds with the
prevailing framework of international drug control, which rests on law
enforcement and the criminalization of behaviours related to illicit drug
use. Treatment and rehabilitation are given lip service within the UN Drug
Conventions, but the liberalization of drug policy and attempts to replace
(or at least supplement) failed law enforcement policies with
harm-reduction strategies have proceeded at a snail's pace.

Elliott and colleagues argue for a small but significant policy change as a
matter of both pragmatism and human rights: namely, to promote access of
IDUs to medical care by adding opioid substitutes to the WHO's Model List
of Essential Medicines. In 1977 the WHO published its first such list: 208
therapeutic agents deemed to be the most efficacious, cost-effective and
safe treatments available against the majority of infectious and chronic
diseases, a pharmacologic tool kit needed by any health system that hopes
to serve its population's basic health care needs and rights.

From March 7--11 the UN Committee on the Selection and Use of Essential
Medicines will consider applications for changes to the list; among those
proposed are the addition of the opioid substitutes methadone and
buprenorphine. We hope that including opioid substitutes to the
WHO-endorsed pharmacopeia will give timely support to the establishment and
wider use of addiction treatment programs, and in so doing will help more
IDUs to come inside the tent of HIV treatment and prevention.

References

1. Wolfe D, Malinowska-Sempruch K. Illicit drug policies and the global HIV
epidemic: effects of UN and national government approaches. Working paper
commissioned by the HIV/AIDS Task Force of the Millennium Project. New
York: Open Society Institute; 2004. Available:
http://www.soros.org/initiatives/ihrd/articles_publications/publications/cnd 20040316 (accessed 6 Feb 2005).

2. Oppenheimer E, Hernandez Aceijas C,
Stimson G. Treatment and care for drug users living with HIV/AIDS. London:
Imperial College Centre for Research on Drugs and Health Behaviour; 2003.
Available:
www.ahrn.net/library_upload/uploadfile/Treatment_care_for_DUs.pdf (accessed
6 Feb 2005).

3. Elliott R, Csete J, Palepu A, Kerr T. Reason and rights in
global drug control policy [editorial]. CMAJ 2005;172(5):655-6.[