Universal access for people who use drugs

A series of articles by guest writers for World AIDS Day Part of AVERT's World AIDS Day 2012 campaign, ‘Reflections on the Epidemic’ are a series of articles by guest writers. Our guest writers range from global leaders, writers, experts, activists, physicians and people personally affected by HIV and AIDS; and they represent various countries, experiences and backgrounds from all over the world. We are grateful to all our guest writers for their effort and the diverse and insightful viewpoints that they contributed to the world’s response to HIV and AIDS. We will be re-featuring these articles over the next few weeks on a weekly basis. Browse through this week’s featured articles, and see the full list below.

More people than ever before are receiving antiretroviral therapy globally.  There are now around 8 million people receiving treatment – 54 percent of those in need,¹ which reflects the great strides that have been made to expand treatment coverage.  However, the gap that remains is daunting and many more resources will need to be mobilised to meet the UNAIDS target of 15 million people on treatment by 2015. Yet buried within the global coverage estimates, there lies a far more disturbing statistic: only 4 percent² of eligible people who inject drugs have access to the antiretroviral therapy that they need. In an era of scale-up, people who use drugs are being left behind.

Injecting drug use accounts for an estimated 10 percent of global HIV infections,³ and is a major driver of epidemics in many parts of the world – not least in Eastern Europe and parts of Asia. Yet people who inject drugs consistently have disproportionately low access to antiretroviral therapy. This is often a result of the stigmatisation and criminalisation of this vulnerable population – a pervasive attitude that they are somehow less deserving of treatment and support, or that they are less likely to adhere to treatment (despite the available evidence to the contrary). When it comes to illicit drug use, public health has been deprioritised as governments have pursued tough law enforcement strategies that have sought to eradicate drug markets. The inconvenient truth is that despite the estimated US$ 100 billion per year that is spent on drug law enforcement globally, there has been little impact on drug production, trade and use. The “war on drugs” has instead resulted in a host of negative consequences, not least of which is a growing HIV epidemic among people who inject drugs. Repressive law enforcement practices drive these individuals away from health services and treatment, while the mass incarceration of non-violent drug offenders exacerbates HIV risks and increases vulnerability.

And we are not only failing to reach people who use drugs with antiretroviral therapy.  We are failing them just as dismally in terms of HIV prevention. The sharing of contaminated injecting paraphernalia is one of the most efficient ways to transmit HIV, yet only around 8 percent of people who inject drugs have regular access to sterile needles and syringes.  There is also clear evidence to show that opioid substitution therapy can reduce the frequency of injecting and therefore prevent HIV transmission, yet the coverage of this intervention is equally low (at roughly 8 percent). These global coverage estimates are unacceptable given that the evidence is unambiguous and has been formally endorsed by all the relevant international agencies – scaling up needle and syringe programmes, opioid substitution programmes and antiretroviral therapy will reduce new HIV infections among people who inject drugs and the wider community.

So we know what to do and we know how to do it – yet we still cannot make it happen.  There are several factors that continue to undermine the response to HIV and drug use, not least the serious under-investment in harm reduction. For example, current resourcing levels are only sufficient to supply people who inject with two sterile needles and syringes per month globally. The new UNAIDS Investment Framework estimates that US$ 2.3 billion will be needed in 2015 to fully fund this work (falling to US$ 1.5 billion by 2020 as a result of the averted HIV infections). If just a fraction of the US$ 100 billion spent on drug law enforcement could be diverted to protecting the health and human rights of people who use drugs, we would have a fighting chance of bucking the trend.

Even more worrying is the fact that the dominant strategies pursued by most governments are zero-tolerance approaches to drug use - policies that often manifest themselves as a resistance to harm reduction and the criminalisation of people who use drugs. Countries that have invested strongly in harm reduction interventions have very low HIV rates among people who inject drugs. Conversely, countries that continue to wilfully ignore the health needs and human rights of people who use drugs have dismally high levels of HIV prevalence among this population. For example, Russia’s HIV epidemic is driven by injecting drug use and almost one in every 100 adults are living with the virus, yet the Russian government refuses to provide sterile needle and syringes and actively opposes and outlaws opioid substitution therapy.

If we are serious about “getting to zero”, we urgently need strong global leadership to challenge the status quo and move away from failed and wasteful drug policies. It isn’t a pipe dream – we can make it happen but criminalisation of people who use drugs is fuelling the global HIV epidemic and is holding back progress toward universal access to antiretroviral therapy. It can no longer be justified.

Ann Fordham is the Executive Director of the International Drug Policy Consortium (IDPC), a global advocacy network that seeks to promote open and objective debate on drug policies.  Ann has largely contributed to international advocacy efforts on drug policy and human rights, specifically calling for reform of laws and policies that have proven ineffective in reducing the scale of the drug market and have negatively impacted vulnerable population groups such as people who use drugs and growers of illicit crops.  She has worked with policy makers around the world to review and shape drug control policies towards more humane, effective approaches that are based on principles of human rights and public health. Ann has a Masters Degree in Human Rights from Sussex University where she specialized in human rights and harm reduction.

For further information about how HIV affects injecting drug users, see AVERT's page.

Images: 'A drug user in Kyrgyzstan prepares heroin for injection', copyright: Max Adeev. 'Ann Fordham', courtesy of author.