Illicit Drug Policy and the Global HIV Epidemic

1
Wrestling with Giants Effects of US Influence
on Global Policy on Illicit Drugs
NPHP Conference May 26, 2005 Istanbul
Daniel Wolfe, IHRD
Photo Hans Jürgen Burkard
2
Illicit Drug Policies and the Global HIV
Epidemic Illicit Drug Policies and the Global
HIV Epidemic Effects of US Approaches

• Democracy under President Bush is not
  self-correcting (Aryeh Neier)
• Also true that US increasingly wants to make its
  approach the global standard
• Ban on federal funding of NEP
• Gag rule on abortion
• Prostitution pledge for foreign
• HOWEVER, these things not fixed or resolved
• States in US have needle exchange
• methadone supported by US government
• UN and foreign development grants particular
  focus of tensioncan programs outside country do
  what we do inside?

3
IDUs as percentage of all registered HIV cases,
2002
Population in these countries alone is 20 of
world total.
4
Case Study UN Commission on Narcotic Drugs

• Internal tension between public health and
  criminal enforcement
• UNAIDS/WHO v. Commission on Narcotic Drugs
  historically and aggressively critical of HR
• UNODC uncomfortably in between
• This year, special focus at Commission on
  Narcotic Drugs on HIV prevention, and UNODC head
  of UNAIDS
• Also year that some Americans increases
  opposition to harm reduction
• Asst. Secretary Bobby Charles and UNODC director
  Mr. Costa
• UNODC staffer warns regional office
• Congressional hearings against harm reduction
• In some cases, emails demanded and leaked to the
  press
• Mr. Walters, US drug czar, to address CND

5
What did we do?

• Community sign on letter56 countries
• Editorials New York Times and Wash. Post
• Opinion pieces for International Herald Tribune
  (Neier), Guardian, etc.
• Outreach to friendly governments
• Coalition of human rights, HIV, and harm
  reduction groups to CND in Vienna
• Daily reports on what US said and did

6
What did we get?

• No explicit attack on NEPs
• 17 countries, including EU, Sweden (associating
  itself with EU), China, Morocco, Iran speak in
  support of HR or NEP
• US supports substitution treatment publicly and
  strongly
• HOWEVER, US systematically removes all references
  to NEP and human rights of drug users from CND
  resolutions

7
Battle Still Ongoing

• US didnt criticize NEP directly, but forces its
  removal from all CND resolutions
• UNAIDS Prevention Coordinating Board (PCB) to
  meet in end of June
• Countries increasingly aware that US virtually
  alone

8
How we move forward

• Work together to know details of policy, rather
  than acting on fear
• USAID unapologetic
• Lithuanian critics of
• Know your instruments
• UNGASS declaration
• UNODC/UNAIDS/WHO position paper on ST
• UN MDGRecs of HIV/AIDS Task Force
• See what other donors/countries can supportDfID,
  Global Fund, etc.
• Keep talkingunited we stand, divided we fall

9
Policy Responses Frameworks for Addressing HIV
and Drug Use
Human Rights
Law Enforcement
Security
Public Health
Development
Drug user, like drug, to be controlled or
contained (drug control)
Focus on risk reduction than on legal status of
drug use (HIV and HCV control)
10
Photo Dan Bigg
11
Stopping harmful culture and social evils are
the responsibility of the whole society
12
Photo Hans Jürgen Burkard
13

• Thank you for your consideration

14
Harmony on Basic Framework?
Drug Control vs. Public Health

• A drug-free world
• We can do it!
• (Pino Arlacchi, Director,
• UNODCCP, 1998 UNGASS)

• The total and immediate elimination of drug
  injecting is unlikely to be an achievable goal.
  
• (WHO, Principles for Preventing HIV Infection
  among Drug Users, 1997)

15
Harmony on Representation of Drug Users?
Drug Control vs. Public Health

• The term use or consumption should only be
  applied when it refers to the use or consumption
  of drugs for medical or scientific purposesDrug
  abusers are neither consumers nor users.
• (INCB Annual Report, 2001)

• It is crucial to implement HIV preventive
  activities on the basis of the peer support
  principle, involving people from the drug using
  community.
• (UNODC, Lessons Learned, 2001)

16
Harm Reduction Harmony?
Drug Control vs. Public Health

• UNDCP has yet to adopt an official position on
  harm reduction.
•  
• (UNDCP Legal Affairs, 2002)
•  

• The United Nations fully endorses the
  fundamental principles of harm reduction.
• (Catherine Hankins, Associate Director, UNAIDS,
  2002)

17
Strategic Fiction 1 Old UN tensions resolved in
favor of cooperation

• System-wide harmonization--position paper on
  prevention of HIV among drug abusers (endorsed by
  UN High-Level Committee on Programmes) and CND
  resolution 45/1
• UNGASS Declaration of Commitment on HIV, UN theme
  groups
• UNODC now funds needle exchange, chair of UNAIDS,
  supports substitution treatment (position paper
  released last month)

But

• UN has yet to work with bilateral donors or
  national govts. to bring single HR program to
  national scale
• Methadone remains Schedule I drug
• UN still routinely cited as reason why drug users
  offered only forced abstinence, prison, or worse
• Headlines at height of Thai drug war UN
  supports
• Russia Total prohibition of illicit drug use
  is not our own initiativebut rather a
  responsibility to implement the UN Drug
  Conventions (Interior Minister Boris Gryzlov
  2002)
• Ukraine blocks plans this week for pilot
  methadone saying UNODC chief Costa advised
  against it

18
Strategic Fiction 2 HR turning the corner even
in countries famous for harsh policies

• Growing numbers of NSPs in Russia, pilot
  methadone programs in China, HR in Vietnam,
  anti-stigma efforts and conferences like this one

But
In five countries with injection-driven mega
epidemic, virtually none support NSPs with
national funds None have national substitution
treatment, and pilot programs are often asked to
show what has been proven many places in the
globe already All require registration of drug
users with authorities All have war on drugs or
social evils campaigns All have forced
incarceration or institutionalization for very
small amounts of drugs Often include forced
testing (without treatment) for HIV Treatment
often impose punitive penalties for relapse
19
Imprisonment and Institutionalization

• Russia any heroin possession large/extra large
  (1996-2003)
• Prisons and pre-trial detention centers so
  crowded that inmates faint from lack of air by
  2000
• Even after amnesties and legal changes, 20 of
  prisoners drug offenders, and 40 of women
  prisoners
• TV program, Coma, offers weekly education
• China Peoples war on drugs
• More than 230,000 drug users arrested in 1998
  alone
• Suspicion of drug use alone sufficient for
  placement in compulsory detoxification
• Treatment includes work without pay making
  goods for tourists
• Vietnam Social Evils Campaigns, with arrests
  and roundups to 05/06 camps
• more than 2/3 of all tried on drug charges
  receive terms of 7 to 20 years in 2002
• More than 25,000 users rounded up since late 2001
• Rehabilitation (some call forced labor)
  extended to five years

20
Institutionalization or Incarceration Engine of
HIV Infection

• Mixing Bowl Effect (Beyrer, Johns Hopkins)
• bring uninfected and infected together
• Force them to remain in places where risk
  continues but means of protection unavailable
• Release them into situation where relapse
  penalized heavily and drug users stigmatized
  (e.g, registration)
• In effect, penalty for minor drug use becomes HIV
  infection, and often, death

21
Less fiction, more Action UN Level

• Reschedule methadone and add it to WHOs
  essential drugs liststatus as most controlled
  substance dates from 1961, and inappropriate for
  realities of HIV/AIDS epidemic
• Criticize overcriminalization of drug users,
  recognizing that punitive efforts work against
  HIV prevention efforts
• Create memorandum of understanding for signature
  by countries implementing successful harm
  reduction measures
• Summarize key legal opinions and precedents
• End dynamic where countries singled out by INCB
  have to respond to criticism alone

22
Less fiction, more action national level

• Stop incarceration and institutionalization for
  small amounts of drugs
• Attend to treatment effectiveness as carefully as
  INCB does to drug control efforts
• What is treatmentwhat standards do we apply?
• Set targets for scale-up to avoid perpetual pilot
  program status
• Ensure that HIV treatment and drug treatment
  integrated

23
Incremental change important, but so is increased
urgency

• Number of countries reporting HIV among IDUs more
  than doubled in last decade, from 52 in 1992, 114
  in 2002 (Strathdee and Poundstone, 2002)
• Outside of Africa, estimated 1 of every 3 new
  infections now comes from contaminated needle
  (UNAIDS)
• If standards for policy reform seem high, the
  stakes are just as high
• Every year of delay means thousands of
  infections, and deaths, that could be avoided.

24
Illicit Drug Policies and the Global HIV
EpidemicEffects of UN and National Government
Approaches
English version of full report available

• www.soros.org/initiatives/ihrd

25
2003 INCB Report Offers Qualified Support of
Harm Reduction

• INCB recognizes needle distribution and
  substitution therapy in accord with national
  sound medical practice, as part of comprehensive
  strategy of DDR,

But
Rejects safer injection rooms without providing
clear legal criteria except para 4 (1961) Issued
press release titled Cautions to governments on
harm reduction and Warnsin widely quoted
passagethat harm reduction may carry national
and international negative consequences