The Vienna Declaration: Experts highlight negative impact of drug war on HIV, call for decriminalisation

The criminalisation of illicit drug users is fuelling the HIV epidemic and has resulted in
overwhelmingly negative health and social consequences. A full policy reorientation is needed.

The Vienna Declaration is a statement seeking to improve community health and safety by calling for the incorporation of scientific evidence into illicit drug policies. We are inviting scientists, health practitioners and the public to endorse this document in order to bring these issues to the attention of governments and international agencies, and to illustrate that drug policy reform is a matter of urgent international significance. We also welcome organizational endorsements.

This is the official declaration of the XVIII International AIDS Conference (AIDS 2010) to be held in Vienna, Austria from July 18th to 23rd. The declaration was drafted by a team of international experts and initiated by several of the world’s leading HIV and drug policy scientific bodies: the International AIDS Society, the International Centre for Science in Drug Policy (ICSDP), and the BC Centre for Excellence in HIV/AIDS

The Declaration is now gathering signatures before its official launch at the XVIII International AIDS Conference, Vienna 2010. There will be a media launch event at the conference on July 20th (see here for details and press release) and a discussion event around the Declaration featuring Evan Wood from the ICSDP and other invited guests, in the Global Village Human Rights, Harm Reducation and Drug Policy Networking Zone on Wednesday July 21st at 2.15-3.15pm. The Drug Policy Networking Zone is co-organised by Transform and the International Drug Policy Consortium.

The full text of the declaration is copied below

To visit the Vienna Declaration website and register your support click here. The site contains background information, press information and comments from some of the Declaration's supporters, inclusing Michel Kazachkine is the Executive Director of The Global Fund to Fight AIDS, TB, and Malaria.

Transform is pleased to have had a role in the production of the Declaration as a member of the writing committee, providing editorial input and feedback on early drafts.

THE VIENNA DECLARATION

The criminalisation of illicit drug users is fuelling the HIV epidemic and has resulted in
overwhelmingly negative health and social consequences. A full policy reorientation is needed.

In response to the health and social harms of illegal drugs, a large international drug prohibition regime has been developed under the umbrella of the United Nations.¹ Decades of research provide a comprehensive assessment of the impacts of the global “War on Drugs” and, as thousands of individuals gather in Vienna at the XVIII International AIDS Conference, the international scientific community calls for an acknowledgement of the limits and harms of drug prohibition, and for drug policy reform to remove barriers to effective HIV prevention, treatment and care.

The evidence that law enforcement has failed to prevent the availability of illegal drugs, in communities where there is demand, is now unambiguous.^{2, 3}Over the last several decades, national and international drug surveillance systems have demonstrated a general pattern of falling drug prices and increasing drug purity—despite massive investments in drug law enforcement.^3,4

Furthermore, there is no evidence that increasing the ferocity of law enforcement meaningfully reduces the prevalence of drug use.⁵ The data also clearly demonstrate that the number of countries in which people inject illegal drugs is growing, with women and children becoming increasingly affected.⁶ Outside of sub-Saharan Africa, injection drug use accounts for approximately one in three new cases of HIV.^{7, 8} In some areas where HIV is spreading most rapidly, such as Eastern Europe and Central Asia, HIV prevalence can be as high as 70% among people who inject drugs, and in some areas more than 80% of all HIV cases are among this group.⁸

In the context of overwhelming evidence that drug law enforcement has failed to achieve its stated objectives, it is important that its harmful consequences be acknowledged and addressed. These consequences include but are not limited to:

• HIV epidemics fuelled by the criminalisation of people who use illicit drugs and by prohibitions on the provision of sterile needles and opioid substitution treatment.^{9, 10}
• HIV outbreaks among incarcerated and institutionalised drug users as a result of punitive laws and policies and a lack of HIV prevention services in these settings.^11-13
• The undermining of public health systems when law enforcement drives drug users away from prevention and care services and into environments where the risk of infectious disease transmission (e.g., HIV, hepatitis C & B, and tuberculosis) and other harms is increased.^14-16
• A crisis in criminal justice systems as a result of record incarceration rates in a number of nations.^{17, 18} This has negatively affected the social functioning of entire communities. While racial disparities in incarceration rates for drug offences are evident in countries all over the world, the impact has been particularly severe in the US, where approximately one in nine African-American males in the age group 20 to 34 is incarcerated on any given day, primarily as a result of drug law enforcement.¹⁹
• Stigma towards people who use illicit drugs, which reinforces the political popularity of criminalising drug users and undermines HIV prevention and other health promotion efforts.^{20, 21}
• Severe human rights violations, including torture, forced labour, inhuman and degrading treatment, and execution of drug offenders in a number of countries.^{22, 23}
• A massive illicit market worth an estimated annual value of US$320 billion.⁴ These profits remain entirely outside the control of government. They fuel crime, violence and corruption in countless urban communities and have destabilised entire countries, such as Colombia, Mexico and Afghanistan.⁴
• Billions of tax dollars wasted on a “War on Drugs” approach to drug control that does not achieve its stated objectives and, instead, directly or indirectly contributes to the above harms.²⁴

Unfortunately, evidence of the failure of drug prohibition to achieve its stated goals, as well as the severe negative consequences of these policies, is often denied by those with vested interests in maintaining the status quo.²⁵This has created confusion among the public and has cost countless lives. Governments and international organisations have ethical and legal obligations to respond to this crisis and must seek to enact alternative evidence-based strategies that can effectively reduce the harms of drugs without creating harms of their own. We, the undersigned, call on governments and international organisations, including the United Nations, to:

• Undertake a transparent review of the effectiveness of current drug policies.
• Implement and evaluate a science-based public health approach to address the individual and community harms stemming from illicit drug use.
• Decriminalise drug users, scale up evidence-based drug dependence treatment options and abolish ineffective compulsory drug treatment centres that violate the Universal Declaration of Human Rights.²⁶
• Unequivocally endorse and scale up funding for the implementation of the comprehensive package of HIV interventions spelled out in the WHO, UNODC and UNAIDS Target Setting Guide.²⁷
• Meaningfully involve members of the affected community in developing, monitoring and implementing services and policies that affect their lives.

We further call upon the UN Secretary-General, Ban Ki-moon, to urgently implement measures to ensure that the United Nations system—including the International Narcotics Control Board—speaks with one voice to support the decriminalisation of drug users and the implementation of evidence-based approaches to drug control.²⁸

Basing drug policies on scientific evidence will not eliminate drug use or the problems stemming from drug injecting. However, reorienting drug policies towards evidence-based approaches that respect, protect and fulfil human rights has the potential to reduce harms deriving from current policies and would allow for the redirection of the vast financial resources towards where they are needed most: implementing and evaluating evidence-based prevention, regulatory, treatment and harm reduction interventions.

REFERENCES
1. William B McAllister. Drug diplomacy in the twentieth century: an international history. Routledge, New York, 2000.
2. Reuter P. Ten years after the United Nations General Assembly Special Session (UNGASS): assessing drug problems, policies and reform proposals. Addiction 2009;104:510-7.
3. United States Office of National Drug Control Policy. The Price and Purity of Illicit Drugs: 1981 through the Second Quarter of 2003. Executive Office of the President; Washington, DC, 2004.
4. World Drug Report 2005. Vienna: United Nations Office on Drugs and Crime; 2005.
5. Degenhardt L, Chiu W-T, Sampson N, et al. Toward a global view of alcohol, tobacco, cannabis, and cocaine use: Findings from the WHO World Mental Health Surveys. PLOS Medicine 2008;5:1053-67.
6. Mathers BM, Degenhardt L, Phillips B, et al. Global epidemiology of injecting drug use and HIV among people who inject drugs: A systematic review. Lancet 2008;372:1733-45.
7. Wolfe D, Malinowska-Sempruch K. Illicit drug policies and the global HIV epidemic: Effects of UN and national government approaches. New York: Open Society Institute; 2004.
8. 2008 Report on the global AIDS epidemic. The Joint United Nations Programme on HIV/AIDS; Geneva, 2008.
9. Lurie P, Drucker E. An opportunity lost: HIV infections associated with lack of a national needle-exchange programme in the USA. Lancet 1997;349:604.
10. Rhodes T, Lowndes C, Judd A, et al. Explosive spread and high prevalence of HIV infection among injecting drug users in Togliatti City, Russia. AIDS 2002;16:F25.
11. Taylor A, Goldberg D, Emslie J, et al. Outbreak of HIV infection in a Scottish prison. British Medical Journal 1995;310:289.
12. Sarang A, Rhodes T, Platt L, et al. Drug injecting and syringe use in the HIV risk environment of Russian penitentiary institutions: qualitative study. Addiction 2006;101:1787.
13. Jurgens R, Ball A, Verster A. Interventions to reduce HIV transmission related to injecting drug use in prison. Lancet Infectious Disease 2009;9:57-66.
14. Davis C, Burris S, Metzger D, Becher J, Lynch K. Effects of an intensive street-level police intervention on syringe exchange program utilization: Philadelphia, Pennsylvania. American Journal of Public Health 2005;95:233.
15. Bluthenthal RN, Kral AH, Lorvick J, Watters JK. Impact of law enforcement on syringe exchange programs: A look at Oakland and San Francisco. Medical Anthropology 1997;18:61.
16. Rhodes T, Mikhailova L, Sarang A, et al. Situational factors influencing drug injecting, risk reduction and syringe exchange in Togliatti City, Russian Federation: a qualitative study of micro risk environment. Social Science & Medicine 2003;57:39.
17. Fellner J, Vinck P. Targeting blacks: Drug law enforcement and race in the United States. New York: Human Rights Watch; 2008.
18. Drucker E. Population impact under New York's Rockefeller drug laws: An analysis of life years lost. Journal of Urban Health 2002;79:434-44.
19. Warren J, Gelb A, Horowitz J, Riordan J. One in 100: Behind bars in America 2008. The Pew Center on the States Washington, DC: The Pew Charitable Trusts 2008.
20. Rhodes T, Singer M, Bourgois P, Friedman SR, Strathdee SA. The social structural production of HIV risk among injecting drug users. Social Science & Medicine 2005;61:1026.
21. Ahern J, Stuber J, Galea S. Stigma, discrimination and the health of illicit drug users. Drug and Alcohol Dependence 2007;88:188.
22. Elliott R, Csete J, Palepu A, Kerr T. Reason and rights in global drug control policy. Canadian Medical Association Journal 2005;172:655-6.
23. Edwards G, Babor T, Darke S, et al. Drug trafficking: time to abolish the death penalty. Addiction 2009;104:3.
24. The National Centre on Addiction and Substance Abuse at Columbia University (2001). Shoveling up: The impact of substance abuse on State budgets.

25. Wood E, Montaner JS, Kerr T. Illicit drug addiction, infectious disease spread, and the need for an evidence-based response. Lancet Infectious Diseases 2008;8:142-3.

26. Klag S, O'Callaghan F, Creed P. The use of legal coercion in the treatment of substance abusers: An overview and critical analysis of thirty years of research. Substance Use & Misuse 2005;40:1777.
27. WHO, UNODC, UNAIDS 2009. Technical Guide for countries to set targets for universal access to HIV prevention, treatment and care for injection drug users.
28. Wood E, Kerr T. Could a United Nations organisation lead to a worsening of drug-related harms? Drug and Alcohol Review 2010;29:99-100.

Keeping the Promise: Human Rights and AIDS

Below are two comments from high ranking UN figures, made on UN world AIDS day. The general tenet of the comments is positive and welcome, particularly the evident change in tone from the UNODC compared to some previous comments. That said, it is hoped that this discourse will develop in the coming years to acknowledge and discuss the role of the punitive prohibitions (enshrined in the UN drug conventions) in undermining human rights, and in creating or exacerbating many drug related harms, not least the context for the spread of HIV/AIDS though illicit drug injecting.

Statement by the UN High Commissioner for Human Rights, Navi Pillay
on the occasion of World AIDS Day

1 December 2008.

This year, we mark both the 20th World AIDS Day and the 60th Anniversary of the Universal Declaration of Human Rights. It is fitting that during these landmark anniversaries we consider how far we have come in the global effort to combat AIDS.

In 2006, UN Member States made a commitment to achieve universal access to HIV prevention, treatment, care and support by 2010. Today, fewer people are becoming infected with HIV, and fewer are dying of AIDS-related illnesses. At the end of 2007, three million people in low- and middle- income countries were taking anti-retroviral treatment. But much remains to be done.

Twenty-seven years after AIDS was first identified, stigma against people living with HIV is as strong as it ever was. One third of countries still do not have laws to protect people living with HIV. In most countries, discrimination remains against women, men who have sex with men, sex workers, drug users, and ethnic minorities.

The continued existence of punitive laws on disclosure of HIV status, the criminalization of the transmission of HIV and travel bans for people living with HIV, inadequate protection of women and girls from sexual violence, the marginalization of and hostility against sexual minorities, sex workers, injecting drug users, prisoners and other vulnerable groups all combine to drive them underground and away from HIV services. Like all people, these groups are entitled to the right to health and the full enjoyment of their human rights even though they may engage in activities that are criminalized in some countries.

AIDS thrives on injustice and inequality. A human rights-based response is critical to preventing new HIV infections and mitigating the epidemic's impact – whoever people are, and wherever they live.

In this 60th anniversary year of the Universal Declaration on Human Rights, it is unacceptable that accident of birthplace or residence should determine our HIV survival prospects.

On World AIDS Day 2008, let the promise of human dignity enshrined in the Universal Declaration of Human Rights provide the vision and impetus for reinvigorated efforts to achieve universal access to HIV prevention, treatment, care and support.

Statement from UNODC Executive Director Antonio Maria Costa
on World AIDS Day

"Let us invest in our young people"

Today, we mark the 20th anniversary of the World AIDS Day. Long ago, we pledged to "keep the promise" but we have not. AIDS is still with us. Among the estimated 16 million people injecting drugs worldwide, one in five will likely contract HIV.

Is "AIDS fatigue" setting in as other global problems compete for attention? United Nations Secretary-General Ban Ki-Moon has declared that the challenge is to sustain leadership in this fight. Without strong and committed leadership, we will fail.

It is scandalous that less than 10% of injecting drug users have access to evidence-based HIV prevention and care services. It is time to bring health back to the mainstream of drug policy. The goals are within reach. New analyses could better guide national HIV prevention programmes and treatment programmes are expanding.

As we prepare to mark the 60th anniversary year of Universal Declaration of Human Rights, we should remember that the human rights of vulnerable groups, including drug users and prisoners, are violated everyday. Instead of showing compassion we stigmatize drug users and cast them out as pariahs. No wonder many shun life-saving HIV prevention, treatment and care.

Drug-related HIV particularly afflicts young people, cutting down tomorrow's leaders in their prime. Young people aged between 15 and 24 account for an estimated 45 per cent of new HIV infections. .

Sharing contaminated needles is almost a sure-fire route way to HIV infection. Yet many young people still lack accurate information about how to avoid exposure to the virus.

Let us empower the youth with information. We must start showing leadership now.

Stopping the spread of AIDS is not only a Millennium Development Goal; it is an investment in the next generation.

That is why UNODC's campaign tells young people "Think before you start. Before you shoot. Before you share".

See also:

• UN special rapporteur documents systematic torture of drug suspects in Indonesia
  
  
• UN Secretary General calls for decriminalisation of injecting drug users
  
  
• UNAIDS and NGO statements shake CND out of its stupor
  
  
• The IHRA HR2 blog

UN Secretary General calls for decriminalisation of injecting drug users

UN Secretary-General supports calls for Asian governments to amend outdated laws criminalising injecting drug users and other stigmatized groups.

At the launch of a major new report on HIV in Asia (March 26), UN Secretary-General Ban Ki-Moon called for increased health and human rights protections for people living with HIV, sex workers, men who have sex with men, and young people who inject drugs.

"Legislation can also stand in the way [of] scaling up towards universal access -- in cases where vulnerable groups are criminalized for their lifestyles" said Ban Ki-Moon, adding in his statement on the launch of the report; "As you have heard, I fully support the recommendations of the Commission."

UNAIDS Executive Director Dr Peter Piot (left), with United Nations Secretary-General Mr. Ban Ki-Moon, during the presentation of the new report “Redefining AIDS in Asia – Crafting an effective response” on 26 March in New York.

The 258 page report by the Independent Commission on AIDS in Asia (established by UNAIDS) is entitled Redefining AIDS in Asia: Crafting an Effective Response. Commenting on the report at the UN launch press conference on March 26th UNAIDS director Peter Piot said : "I look to Asian Governments to amend outdated laws criminalizing the most vulnerable sections of society, and take all the measures needed to ensure they live in dignity,"

Professor C. Rangarajan (right), Chair of the Commission on AIDS in Asia, presented the report of the Commission to the United Nations Secretary-General Ban Ki-Moon, 26 March 2008.

The report urges governments to provide a comprehensive package of harm reduction, including needle exchange programs and opiate substitution treatment, and says governments should abandon counterproductive "war on drugs" programmes. One of its key recommendations is to:

Avoid programmes that accentuate AIDS-related stigma

It is important to recognize that not all interventions aimed at most-at-risk groups are effective, and to note which have been proven to be ineffective, or even counter-productive. In their enthusiasm to initiate large-scale prevention programmes, Governments are seen to adopt certain programmes which accentuate stigma and violate the human rights of most-at-risk groups. These include ‘crack-downs’ on red-light areas and arrest of sex workers, large-scale arrests of young drug users under the ‘war on drugs’ programmes, mandatory testing in healthcare settings without the consent of the person concerned and releasing confidential information on people who are HIV positive through the media.

These initiatives can be counterproductive and can keep large numbers of at-risk groups and people living with HIV from accessing even the limited services being provided by the countries.

Full report (1.6 megs)

UN webcast (real media) of press conference launch ( Piot at 15 mins, Ki-Moon 18 mins)

see also:

Statement from UNAIDS to the March 2008 UN Commission on Narcotic Drugs

UNAIDS and NGO statements shake CND out of its stupor

Amidst the mind numbing tedium of hours of pre-prepared self-congratulatory country presentations at this year's United Nations Commission on Narcotic Drugs (which I am currently attending in Vienna) there were a few rays of light that challenged the consensus that 'everything is fine - let's continue as before'. A few of the non state participants briefly threatened to turn the thematic session in to the 'debate' it was billed as. (a more detailed commentary on the CND to follow)

There were a series of useful contributions from various NGO's (given unprecedented access to the plenary session this year) including this powerful statement from Rick Lines at IHRA, that challenged the CND to fully incorporate human rights into drug control mechanisms, with specific reference to this being the 60th anniversary of the UN universal declaration of human rights.

Below is the complete text of the contribution from the Joint United Nations Program on HIV/AIDS (with references) delivered to yesterday's plenary session by Susan Timberlake. Its pragmatic tone was particularly striking in that it followed series of desperately dry political statements, including notably from the US, that entirely failed to touch on the public health vs criminalisation debate, HIV, or the rights of users, and in the case of the US, actively spoke out against harm reduction. That UNAIDS the statement additionally came with the UN imprimatur - so was impossible for the state representatives to ignore.

Chair, distinguished representatives, ladies and gentlemen, The Joint United Nations Programme on HIV/AIDS (UNAIDS) is pleased to have this opportunity to address the Commission on Narcotic Drugs to seek your support in breaking the dangerous link between injecting drug use and the HIV epidemic. As measures to control drugs and measures to control HIV are critically intertwined, the steps governments take in drug control are likely to have significant impact on progress against HIV.

In most regions of the world, unsafe injecting drug use is a major vector of HIV transmission. It has been estimated that up to 10% of all HIV infections worldwide result from injecting drug use, up to 30% if infections in Sub-Saharan Africa are excluded. Once HIV enters a community of people who inject drugs, it can move to the rest of the population if appropriate steps are not taken.

UNODC, WHO and UNAIDS recommend a comprehensive set of measures for people who use drugs that includes the following: (1) needle and syringe programmes; (2) opioid substitution therapy; (3) voluntary HIV counselling and testing; (4) anti-retroviral therapy; (5) prevention and treatment of sexually transmitted infections; (6) condom programming; (7) targeted information, education and communication; (8) hepatitis diagnosis, treatment and vaccination; and (9) tuberculosis prevention, diagnosis and treatment. The efficacy of these interventions is supported by overwhelming evidence.

Yet in spite of the fact that we know how to address the close links between HIV infection and unsafe injecting drug use, many countries fail to provide this comprehensive set of measures to drug users, who instead continue to face discrimination and other human rights violations. In 2006, fewer than 20% of people who inject drugs received some type of HIV prevention service, with coverage of less than 10% reported in Eastern Europe and Central Asia. Even fewer have access to opioid substitution therapy, needle and syringe programmes, or anti-retroviral therapy, despite the fact that people who use drugs can achieve the same levels of adherence to treatment as other patients with HIV.

In the 3:1 ratio mentioned by Mr. Costa – where enforcement receives three times the resources that prevention and treatment receive – it is clear that many countries take an approach to drug use that focuses on criminalization while neglecting a public health response. A public health response would provide treatment to people who evidence drug dependency and illness and would employ health and social interventions, which have been shown to reduce the harms associated with drug use. Instead, legal and social barriers severely impede access to such health and social interventions. For instance, many countries criminalize possession of syringes without prescriptions and continue to classify methadone and other opioid substitutes as illegal. In many countries, imprisonment and forced treatment with ineffective methods are the primary responses to drug use, with little to nothing being done about HIV. And in some countries, imprisonment is compounded by killings, rape, unwarranted use of force, arbitrary arrests, harassment, extortion, and violation of medical privacy and confidentiality.

Chair, distinguished delegates, UNAIDS supports countries to implement a rights-based response to the HIV epidemic for two reasons: first, because it fulfills obligations under human rights law, and secondly, because it is the most effective way to address HIV. In our efforts against the epidemic, we recognize that all people, even those engaged in activities that are deemed criminal, have human rights, including people who use drugs. Even where drug use is criminalized, people who use drugs have the rights to be free from violence and murder, to benefit from full due process before the law, to be free from discrimination and any forced treatment that violates medical ethics, and to receive comprehensive and voluntary health and social services of good quality, including for drug-related illness and for infections, such as HIV, hepatitis and tuberculosis.

In the Declaration of Commitment on HIV/AIDS (2001) and in the Political Declaration on HIV/AIDS (2006), governments have also committed themselves to an approach to HIV that is based on human rights and the full participation of those affected. In particular, they committed themselves “to intensify efforts to ensure a wide range of prevention programmes, including harm-reduction”, “to overcoming legal...or other barriers that block access to effective HIV prevention, treatment, care and support, medicines, commodities and services”, and “to intensify efforts to enact, strengthen or enforce legislation….to eliminate all forms of discrimination against and to ensure the full enjoyment of all human rights of… members of vulnerable groups”. All this in the context of committing “to scale up efforts…with full and active participation of people living with HIV, vulnerable groups.. towards the goal of universal access to…prevention, treatment, care and support by 2010”.

UNAIDS is working hard to support governments to fulfill these commitments, and much progress is being made. In this context, we ask that those engaged in drug control efforts: (1) respect and protect human rights, including the rights of people who use drugs, (2) ensure access to HIV and health and social services to people who use drugs and remove impediments to such access, and (3) allow people who use drugs or their representatives to participate in the design and delivery of HIV and harm-reduction services so that programmes will be as effective as possible.

Progress towards universal access will be reviewed at the High Level Meeting on HIV/AIDS in June where UNAIDS is also supporting the involvement of civil society as critical partners for accountability. In this regard, a representative of people who use drugs is included in the President of the General Assembly's Civil Society Task Force for the High Level Meeting. In order to provide leadership and guidance to governments in the area of HIV and drug use, UNAIDS urges the consideration by the Commission of measures to:

• Help establish a process by which States’ obligations relating to drug control are clarified to ensure that they conform to human rights obligations, and indeed support the achievement of public health and human rights, including universal access to HIV prevention, treatment, care and support.
  
  
• Support States to enact and implement domestic legislation and policy in the area of drug control that will protect human rights and the public health, including of that of people who use drugs, either vulnerable to HIV or already infected.
  
  
• Finally, encourage States to use the High Level Meeting on HIV/AIDS in June and the current review based on the UNGASS on Drugs (1998) to consider and intensify their efforts to address HIV in the context of drug use, including greatly increasing voluntary and effective HIV prevention, treatment, care and support programmes for people who use drugs.

UNAIDS thanks the Commission and its valuable Cosponsor, the UN Office on Drugs and Crime, and offers its full support in any manner possible.

References

Aceijas, Friedman, Cooper, Wiessing, Stimson, Hickman, Estimates of injecting drug users at the national and local level in developing and transitional countries, and gender and age distribution, Sexually Transmitted Infections, Volume 82, Suppl III, June, 2006.

IPU/UNDP/UNAIDS (2007). Taking action against HIV. A handbook for parliamentarians. Geneva.

Lert F, Kazatchkine M (2007). Antiretroviral HIV treatment and care for injecting drug users: An evidence-based overview. International Journal of Drug Policy 18: 255-261.

Materials produced for UNAIDS Reference Group on HIV and Human Rights, Eighth Meeting, December, 2007.

Office of the United Nations High Commissioner for Human Rights and UNAIDS (2006). International guidelines on HIV/AIDS and human rights (2006 consolidated version). Geneva.

UNAIDS (2005). Intensifying HIV prevention: a UNAIDS policy position paper. Geneva.

UNAIDS (2006). Report on the global HIV/AIDS epidemic. Geneva.

UNAIDS (2007). Practical guidelines for intensifying HIV prevention: Towards universal

access. Geneva.

UNAIDS/WHO AIDS epidemic update, December, 2007

WHO/UNODC Evidence for action series and policy briefs available at http://www.who.int/hiv/pub/idu/en/: Ball et al. (2005)

WHO/UNAIDS/UNICEF (2007). Towards universal access: scaling up priority HIV/AIDS interventions in the health sector: progress report, April 2007. Geneva.

WHO/UNODC/UNAIDS. Technical Guide for Countries to Set Targets for Universal Access to HIV Prevention, Treatment and Care for Injecting Drug Users (IDUs) (in draft)

Injecting drug use and the right to health in Sweden

.
The International Harm Reduction Association's new HR2 Harm Reduction & Human Rights programme, in conjunction with the Swedish drug users union, has today published a report examining the issues around the state's response to the growing health problems (specifically blood borne diseases) relating to injecting drug use in Sweden, and the inadequate provision of harm reduction services for Sweden's growing population of drug injectors.

The report has been produced as a shadow submission to the Swedish Government's own report to the UN Committee on Economic Cultural and Social Rights. States that have ratified the Convention on Economic, Cultural and Social rights are required to periodically submit reports to the Committee, which acts as an independent body overseeing adherence to the convention (similar bodies exist for all UN treaties).

The IHRA report background intro notes that:

This report examines Sweden’s obligations under Article 12 of the International Covenant on Economic, Social and Cultural Rights. It reviews the failure of Sweden to provide comprehensive harm reduction programmes, such as needle exchange, for people who use injecting drugs. The failure to provide such essential preventative health interventions places people who inject drugs at unnecessary and avoidable risk of HIV and hepatitis C infection, and therefore reflects a failure of the State party to respect, protect and fulfil the right to the highest attainable standard of health for this most vulnerable and marginalised population.

Sweden has one of the best domestic human rights records in the world, and in the area of economic, social and cultural rights stands above most countries in terms of life expectancy, standard of living, education and healthcare. However, there are sections of Swedish society that do not enjoy this high level of human rights protection. Some communities, like the Saami and Roma, are increasingly recognised in Swedish human rights policy as suffering from marginalisation and discrimination. Others, such as people who use illegal drugs, also experience the effects stigma and discrimination, yet this goes largely unrecognised. One illustration of this is the fact that injecting drug use and related harms such as HIV and hepatitis C infection are entirely omitted from the State’s report to the Committee, as are any references to measures taken to address drug use and reduce drug-related harms.

In 2006, Professor Paul Hunt, UN Special Rapporteur on the Right to Health, undertook a mission to Sweden. While praising the overall state of human rights, the Special Rapporteur stated that there was no room for complacency and highlighted the specific situation of people who use drugs. Professor Hunt was critical of the poor provision of harm reduction services, especially needle exchange, despite international evidence of the effectiveness of these measures in preventing HIV and hepatitis C transmission among injecting drug users (IDUs). The Special Rapporteur visited a needle exchange programme in Malmö, one of only two in the country, and confirmed that harm reduction “enhances the realization of the right to health, including sexual and reproductive health, for intravenous drug users”. He recommended that Sweden adopt, as a matter of priority, comprehensive harm reduction services throughout the country.

Swedish drug policy is fascinating. Behind the veneer of a highly developed social welfare system and operating within wider policy paradigm of public health pragmatism is a somewhat incongruous dogmatic and moralistic view of drug use. It has resulted in a zero tolerance approach to drugs and drug users involving harshly enforced prohibition and a general disdain for harm reduction principles and practice (see this recent article in Druglink magazine for more discussion) .

The IHRA report notes that (page 6):

Sweden follows a strict law enforcement approach to drug use, rather than the health-based approach utilised in many other countries. Harsh sentences are imposed, including penalties for drug use itself. Indeed, Sweden is one of the few countries in the world to impose prison sentences for the use (rather than the possession) of drugs. Coercive testing and treatment are also utilised.

It has been found by Sweden’s own National Council for Crime Prevention that “based on available information on trends in drug misuse there are no clear indications that criminalisation and an increased severity of punishment has had a deterrent effect on the drug habits of young people or that new recruitment to drug misuse has been halted”. As noted above, the number of people injecting drugs in Sweden has continued to grow despite the country’s harsh law enforcement responses.

Evidence from other parts of the world has shown that harsh criminal sanctions are counter-productive to HIV prevention efforts among injecting drug users, as they are less likely to engage with the relevant health programmes for fear of identifying themselves.

read the full report here (pdf)
includes references left out of the above quotes

UN INCB is 'obstacle' to HIV prevention and drug treatment programs

A report published today by the Canadian HIV/AIDS Legal Network (part of the Open Society Institute Public Health Program), titled 'Closed to Reason: the International Narcotic Control Board and HIV / AIDS' strongly criticises the INCB, the nominal enforcement body for the UN drug conventions. It accuses the INCB of becoming 'an obstacle to effective programs to prevent and treat HIV and chemical dependence' . The bizarre politics and machinations of this strange UN entity make for often shocking reading. The summary findings and recommendations are copied below. They should be of immediate and urgent concern to all members states:

Key findings and recommendations

The role of drug policy has been transformed since the era in which the International Narcotics Control Board (INCB), the 13-member body responsible for monitoring compliance with the United Nations drug conventions, was conceived. In a time when an estimated 30 percent of infections outside of Africa are due to injection drug use, drug policy is fundamental to the success or failure of the international response to HIV/AIDS. A significant body of scientific evidence has shown the importance of measures such as effective treatment for chemical dependence and provision of sterile syringes in preventing HIV. The INCB, which emphasizes its impartiality, independence and reliance on evidence, has an historic opportunity to help stop the injection-driven HIV epidemics now emerging and exploding in much of the world.

Instead, the Board has become an obstacle to effective programs to prevent and treat HIV and chemical dependence. INCB annual reports are rife with omissions and misrepresentations and lack both scientific documentation and justification for legal opinions. Country visits by INCB representatives fail to highlight law enforcement patterns that accelerate HIV transmission and represent clear human rights violations. Although the Board is responsible for ensuring the global availability of legal opiates, it has not acted to help countries accurately estimate their need for the opiate substitution treatment shown to be effective in reducing HIV risk and increasing adherence to antiretroviral medications.

The Board stresses the drug control aspects of its mandate. Its annual report for 2005, however, refers 18 times to the role of drug use in accelerating HIV transmission in various countries. Tellingly, that report, like other INCB documents, fails to urge countries to pursue proven strategies to reduce HIV transmission among people who inject drugs. While the UN drug conventions clearly mandate treatment for drug users, the INCB has remained silent on the shortage of effective chemical dependence programs, and the abuses committed in the name of drug treatment and rehabilitation.

The United Nations system as a whole is committed to reducing HIV among people who inject drugs, to safeguarding the human rights of people who use drugs, and to increasing accountability and civil society involvement. In this context, the INCB is an anomaly: a closed body, accountable to no one, that focuses on drug control at the expense of public health and that urges national governments to do the same.

INCB members contradict or seek to thwart evidence-based recommendations of other UN bodies and representatives.

• INCB members have spoken out against sterile syringe programs and opiate substitution treatment, despite findings by the Joint United Nations Programme on HIV/AIDS (UNAIDS), the World Health Organization, the United Nations Office on Drugs and Crime (UNODC) and the INCB itself that these measures are effective and important components of HIV prevention.

• In 2002, the president of the INCB claimed, erroneously, that distribution of sterile syringes contravened the UN drug conventions. In 2005, a memorandum signed by an INCB member from Russia included numerous misstatements of fact meant to discredit the use of methadone as a treatment for opiate addiction.

• The Board has sought to silence UN representatives who support a fuller range of HIV prevention approaches. In 2006, for example, Stephen Lewis, the UN Secretary-General’s Special Envoy for HIV/AIDS in Africa, commented favorably on Canadian data showing that a Vancouver safer injection facility had reduced HIV risk. The next day, he received an angry telephone call from the INCB Secretariat and a promise that the Board would write to the Secretary-General to urge that Lewis be censured for support of “opium dens.” In that letter, the INCB president expressed disbelief that “any officer of the United Nation [sic] could have made such statements,” and demanded that Lewis recant.

INCB reports praise governments that violate human rights.

• A Board delegation visited Thailand in 2004, several months after police forces began a “war on drugs” in which human rights experts documented extrajudicial executions, arrest quotas, use of blacklists, and the internment of tens of thousands of people, including many with no history of drug use. In its report issued after the visit, the Board did not condemn the mass arrests; instead, it expressed appreciation for the Thai government’s efforts to investigate the killings, despite findings by human rights groups that the government had failed to allow any independent investigations.

• In 2004, after Bulgaria mandated imprisonment for possession of any amount of any illicit drug, fear of arrest caused rates of drug injection and syringe sharing to increase sharply. INCB representatives visited Bulgaria in 2005, but the Board’s report made no mention of the harsh drug law or its impact, noting instead that national drug control legislation was “well-developed.”

• In Russia, authorities in 2005 moved to reverse a reform that had reduced the numbers imprisoned for very small amounts of drugs. Wholesale and prolonged incarceration had been recognized as contributing to both penitentiary overcrowding and the fact that Russia’s HIV epidemic was among the fastest growing in the world. INCB representatives visited Russia during this debate, but the Board’s subsequent report made no mention of any discussion of the issue or of concern about the human rights implications of the policy. Instead, the INCB expressed concern about the extent of drug abuse in Russia, and encouraged coordination and cooperation between HIV and drug treatment services.

• Since 1990, China has marked the UN’s International Day Against Drug Abuse and Illicit Drug Trafficking with show trials in which drug dealers are sentenced to death, sometimes as crowds chant “kill, kill.” Scores have been executed. Despite professed support for sensitive policing, the INCB has failed to criticize either this practice or the police harassment of those seeking to obtain sterile injection equipment, whether in China or in other countries visited by the Board.

The Board stresses drug control at the expense of public health, expressing concern about diversion rather than praise for scientifically proven measures that reduce HIV and other harms.

• While acknowledging that WHO added methadone and buprenorphine to its Model List of Essential Medicines in 2005, the Board has made no public effort to promote opiate substitution treatment (OST) in countries where large numbers of people inject drugs. It also has failed to highlight OST as an essential tool in HIV care or treatment. Although Ukraine, China, Malaysia and Iran have moved in recent years to expand OST programs and/or needle exchange programs to contain HIV, INCB reports have not expressed appreciation for or satisfaction with these developments. Instead, the Board has expressed concern about diversion of methadone and buprenorphine, and urged WHO to advocate for tightened controls on these medications.

The Board issues interpretations of law and pronouncements on harm reduction, despite a lack of expertise in international law and HIV policy.

• According to their published biographies, none of the Board’s 13 members has formal training in international law, despite the importance of such credentials in interpreting treaty provisions. In the case of substitution treatment, needle exchange, and safer injection facilities, the pronouncements of INCB members have contravened the fi ndings of the Board’s own legal advisors and national experts.
  
  
• Despite the centrality of drug use to HIV transmission, none of the Board members has published in peer-reviewed journals on HIV/AIDS, and few list any experience of HIV treatment or prevention in their biographies.
  

The Board conducts operations in secret, and without mechanisms for accountability.

• INCB meetings are closed to observers, and no minutes are available.
  
  
• INCB members have used their Board affiliation when making misstatements of fact, yet no public mechanism exists for member states or community organizations to contest claims, seek clarification, or offer amendments.
  
  
• Sources are selectively and inconsistently documented in INCB reports.
  
  
• The INCB does not publicize country visits in advance or convene public hearings or other opportunities for input.
  
  
• Despite the UN Secretary-General’s call for greater transparency and interaction with civil society at the UN, the INCB’s website includes no information on the Board’s budget or staff.
  
  
• The INCB Secretariat — paid for by the UN — is unresponsive to requests for information from affected communities or non-governmental organizations.

Recommendations

• To improve accountability, address the HIV epidemic, and meet its mandate to assess compliance with the UN drug conventions, the INCB must change.
  
  
• The INCB should regularly assess the supply and adequacy of treatment for chemical
  dependence. It should provide technical assistance to help countries accurately estimate the need for opiate substitution treatment, support governments that are striving to scale up such treatment, and encourage governments that have yet to provide these life-saving therapies to find safe and effective ways to do so.
  
  
• The INCB should cite scientific evidence for its observations about drug use and health, and legal grounds for its interpretation of law. It should provide sources of information for its annual reports, and opportunities for UN member states and civil society groups to offer corrections or additional information.
  
  
• The INCB should provide greater opportunity for exchange with UN member states, UN
  agencies with relevant mandates, civil society, and HIV/AIDS experts. INCB country missions should include greater opportunities for engagement with these groups.
  
  
• The World Health Organization, the UN Economic and Social Council (ECOSOC) and UN member states should ensure that INCB members include persons with expertise in HIV/AIDS policy and international law.
  
  
• The INCB should articulate, and ECOSOC should evaluate, public guidelines to clarify when INCB members are speaking for the Board, and how misstatements of fact can be corrected.
  
  
• The UN Secretary-General should commission an independent evaluation of the INCB, including a scientific evaluation of the Board’s statements on health, and an examination of Board members’ independence and expertise, with particular attention to HIV, international law and human rights.