REASON AND RIGHTS IN GLOBAL DRUG CONTROL POLICY

Among a number of compelling reasons for the international community to
reconsider the "war on drugs," the HIV/AIDS epidemic is the most urgent.
The prevailing emphasis on law enforcement in drug policy has failed to
produce its purported benefits, yet many countries insist on enforcing
prohibition and resist the implementation of evidence-based measures to
reduce the health-related harms of drug use. These policies disregard the
available scientific evidence, and in so doing directly contribute to the
harms associated with illicit drug use, including the spread of HIV/AIDS.1
Moreover, they contravene human rights obligations under international law.
Developments in the coming weeks will indicate whether the World Health
Organization and the member states of the United Nations can rise to the
challenge of mitigating the negative health impacts of global drug control
treaties or whether timidity in the face of ideological bullying will prevail.

Roughly 40 million people are infected with HIV worldwide, of whom an
estimated 5 million were infected during 2003 alone.2 Some 3 million people
died of HIV/AIDS last year.2 In many settings, opioid dependence and
associated sharing of drug injection equipment is a principal factor
fuelling the epidemic.3 It is estimated that there are over 13 million
illicit injection drug users (IDUs) worldwide.4 Of the 136 countries that
reported injection drug use in 2003, 93 also reported HIV infection among
IDUs.5 The HIV epidemic is growing exponentially in Eastern Europe and
countries of the former Soviet Union; in these regions, IDUs and their
sexual contacts account for most new infections.6,7 A similar pattern is
seen in Asia.8 An estimated 10% of all new HIV infections worldwide are now
attributable to injection drug use; this figure rises to 30% outside
Africa.9 Although antiretroviral drugs have improved HIV care, access to
these drugs is notoriously limited, including in many regions where the
epidemic is driven largely by injection drug use.10 Even where
antiretroviral treatment is available, access for drug users has been
particularly poor.1,11 In Russia, for example, over 90% of cumulative HIV
cases as reported by government HIV/AIDS programs by 2002 were among IDUs,
yet AIDS service programs in Moscow and St. Petersburg reported that none
of the patients receiving antiretroviral drugs were IDUs.12

Given the major role played by injection drug use in the HIV/AIDS epidemic,
opioid substitution therapy, which facilitates both prevention and
treatment, is a critical element of a comprehensive response.

Access to oral methadone or buprenorphine can reduce or eliminate injection
of heroin and the frequently associated sharing of injection equipment.13
Clinical studies have demonstrated that access to addiction treatment
programs significantly increases uptake of HIV treatment among
IDUs.14,15,16,17,18,19,20 Substitution therapy has been recognized as the
most effective treatment for opioid dependence21 and has been widely
implemented.22 Yet opiate substitutes are unavailable or banned in many of
the countries where HIV prevalence and incidence are high among IDUs.22

Because a significant number of people living with HIV/AIDS are IDUs,
current global efforts to scale up access to antiretroviral treatment will
necessitate universal access to substitution therapy as a matter of equity
and of pragmatism. Proposals to add methadone and buprenorphine to the
WHO's Model List of Essential Medicines23 will be considered by the WHO's
Expert Committee on the Use of Essential Drugs this month.

The addition of these drugs to the list would encourage their integration
into national health systems, facilitate funding from such mechanisms as
the Global Fund to Fight AIDS, Tuberculosis and Malaria, and signal to
governments that access to such therapy for drug users must be integrated
into HIV prevention and treatment plans.24

The international community also faces the larger question of whether it
will continue to endorse failed strategies of drug prohibition and law
enforcement or finally embrace evidence-based harm-reduction measures such
as opioid substitution, syringe exchange and supervised injection
facilities. All UN member states have a treaty obligation to cooperate with
the UN in solving international health problems and in realizing human
rights for all.25 The Universal Declaration of Human Rights, reaffirmed by
all UN member states for more than 50 years, declares that all people have
the right to a standard of living adequate for health and well-being,
including access to medical care.26 The International Covenant on Economic,
Social and Cultural Rights27 recognizes the right of all people to enjoy
the highest attainable standard of health (Article 12). Furthermore, it
requires all parties to the covenant to take steps to "progressively
realize" this right "by all appropriate means, including particularly the
adoption of legislative measures" (Article 2) and to take the steps
necessary to prevent, treat and control epidemic diseases and to create
conditions that assure medical services and attention in the event of
sickness (Article 12). At the very least this means that countries must not
block harm-reduction measures that reduce the spread of HIV among drug
users, and that they must facilitate access to health services.

At its upcoming session this month, the UN Commission on Narcotic Drugs,
the central policy-making body within the UN system with regard to drug
control, will be holding a thematic discussion on "HIV/AIDS in the context
of drug use." Already, hard-line prohibitionist countries such as the US
are preparing to resist interpretations of UN treaties on illicit-drug
control that encourage a harm-reduction approach.

Among other tactics, the US administration continues to disingenuously cast
doubt on the proven benefits of syringe exchange programs, regularly
invoking misinterpretations of the Canadian experience in cities such as
Vancouver and Montreal.28

Canada is bound by the human rights obligations it has undertaken as a
member state of the UN, and human rights are stated as a central part of
Canadian foreign policy.29,30 Canada has implemented a wide range of
harm-reduction measures domestically (partly in response to HIV/AIDS), and
the declared central objective of our national drug strategy is harm
reduction.31,32 Canada should therefore play the role of strong global
advocate for harm reduction, including at the UN Commission on Narcotic
Drugs. This debate needs rational voices informed by public health evidence
and a firm commitment to the human rights of all people, including those
who are drug dependent.

FOOTNOTES

Competing interests: None declared.

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