Aids Alert International: Global HIV epidemic fueled by UN policies
Study says major funding, changes needed soon
New HIV epidemics in Eastern Europe, Central Asia, and China are spreading fast due to injection drug use (IDU) transmission, and these epidemics will continue to escalate unless the United Nations and individual countries make major policy changes, a new report charges.
"Our 20 years of experience in how to address [HIV prevention among] vulnerable populations are not at all being put to use among drug users," says Kasia Malinowska-Sempruch, director of the International Harm Reduction Development Program at the Open Society Institute in New York City.
"The U.N. convention criminalizes possession of drugs even for personal use," she says.
This approach marginalizes IDU communities, pushing their drug use underground, which facilitates the sharing of needles and spread of HIV, Malinowska-Sempruch explains.
The result is the situation now at hand, according to the report Illicit Drug Policies and the Global HIV Epidemic:
- HIV has spread rapidly among former Soviet Union states, where 1% of the populations in Russia and the Ukraine (1.4 million people total) are infected with HIV; HIV rates tripled in Russia between 2000 and 2003; among IDUs in Russia, 80% are HIV-positive.1
- In the Central Asian nation of Uzbekistan, 60% of all HIV cases are among IDUs, and in Kazakhstan, 80% of the estimated 25,000 people. An estimated 1 million to 1.5 million people in China are HIV infected, and an estimated 64% of these cases are due to IDU transmission.1
- Of the estimated 59,200 HIV cases in Vietnam, nearly 60% are believed to be due to IDUs; likewise, 76% of the 51,000 HIV cases registered in Malaysia were among IDUs.1
- In Burma, a large producer of heroin, there are reports that more than 680,000 people are infected with HIV, and nearly a third of these cases are thought to be due to contaminated injection equipment.1
Instead of tackling the epidemic head-on with harm-reduction strategies, such as providing drug treatment and clean needles, which would prevent it from spreading to the general population, these nations have followed the U.N.’s lead in treating drug users like criminals, Malinowska-Sempruch says.
"Many people are hostile to drug use as a principle . . . and do not put into place harm reduction programs," she notes. "The U.N. has not spoken in favor of harm reduction, so it provides cover to people who are not sympathetic."
Without harm-reduction programs, which were used very successfully in Australia, the United Kingdom, Poland, Canada, and some Western European nations, it’s likely HIV epidemics will grow in many of these countries where the epidemics are relatively new, Malinowska-Sempruch says.
Although organizations like the Open Society Institute are doing what they can to introduce harm reduction programs to Russia and other countries, these efforts provide only a small amount of coverage and cannot stop HIV from spreading, she explains.
For instance, the Open Society along with the British Development Agency have funded nearly four dozen harm-reduction programs in Russia, but even at that number, the programs reach only 5% to 7% of the people who need assistance, she says. "Unless the government steps in and uses its own clinics and AIDS centers to spread information out to people, we’re not stopping the epidemic, and we only have a large-scale pilot program," Malinowska-Sempruch says.
So it will be crucial for nations to change their policies regarding IDUs and to fund programs that help stop the HIV epidemic rather than worsening the problem. With these goals in mind, the Open Society report makes very specific recommendations for the United Nations, including the following:
- The United Nations needs to embrace harm reduction with a drug control convention that explicitly supports HIV prevention for drug users, rather than continue to offer ambiguous messages on the topic. For instance, the World Health Organization and UNAIDS say the United Nations supports harm reduction efforts at the same time that the Office on Drugs and Crime takes no position on harm reduction and the International Narcotics Control Board (INCB) condemn harm reduction as contributing to drug abuse.
- Governments in Asia and the former Soviet Union, which have established HIV epidemics due to IDU transmission, imprison drug users and offer only abstinence-based treatment — all of which only increases the spread of HIV. Instead, what is needed is funding for sterile injection equipment and other harm reduction measures.1
- There should be the creation of an international "memorandum of understanding" that expresses government commitment to harm reduction programs and summarizes legal arguments in support of such programs. This is in contrast to current policy in which countries that pursue harm-reduction programs are censured by the INCB and the Commission on Narcotic Drugs (CND).1
- There needs to be better data collection to ascertain the extent of discrimination against drug users seeking HIV care.1
- Methadone should be reclassified from a schedule 1 drug to a less-restrictive category.
- There should be a repeal of mandatory imprisonment/institutionalization for possession of small amounts of illegal drugs, because imprisonment exposes IDUs to HIV, hepatitis C, tuberculosis, and other health risks.1
- Drug paraphernalia, including syringes, should be made available without prescription, so drug users will not fear arrest.1
- Legislation that criminalizes drug users based on addiction or past behavior should be repealed, and mass arrests based on suspicion of drug use or as the basis of political campaigns should be prohibited.1
- IDUs’ confidentiality should be protected when they are in HIV and drug-treatment settings. Likewise, there should be an end to punitive registration or surveillance of IDUs and people with HIV.1
- There should be an end to practices that deprive drug users of due process while in police custody, including an end to practices that violate human rights.1
- Drug treatment standards should be set by health care professionals rather than by police officers, judges, political officials, and others.1
- Prison settings should have harm-reduction programs, including needle exchange, condoms, and HIV education.1
- Minimum standards of care are needed for treatment and rehabilitation centers, and full-scale drug demand reduction and HIV prevention measures need to be financed by governments.1
- There need to be aftercare programs for active drug users and an abolition of punishments for relapse.1
Government funding for harm reduction programs is crucial if there is any hope of stopping the spread of HIV among IDUs and others, Malinowska-Sempruch says.
The magic number that has shown to stop HIV among IDUs in other countries is 60%, she notes.
"Sixty percent of the drug users need to be offered services if you are going to stop the HIV epidemic," Malinowska-Sempruch says. "If you have one or two harm-reduction programs, and the coverage is 1% — that simply is not going to stop an epidemic; it’s a gesture that shows good will, but it won’t make a difference."
1. Wolfe D, Malinowska-Sempruch K. Illicit drug policies and the global HIV epidemic: Effects of U.N. and national government approaches. Published on-line by the International Harm Reduction Development, the Open Society Institute. New York City; March 2004. Web site: www.soros.org.