The cost of punitive drug legislation

On March 10, at the 69th session of the Commission on Narcotic Drugs, UNAIDS, the UN Development Programme, and the International Network of People who Use Drugs launched a joint guidance note: Decriminalization of drug use in the context of HIV. The document sets out an evidence-based, public-health-led approach to drug legislation focused on human rights and positive health outcomes. The potential for gains in combating HIV among the key population of drug users is enormous, and this forms a core argument in the guidance note.The impact of HIV on people who use drugs has been obvious since the pandemic was first recognised: “the 4H disease” was one of the early labels for the US epidemic referring to Haitians, homosexuals, haemophiliacs, and heroin users. Although the world has thankfully moved on from the reductive and stigmatising understanding of HIV, drug users remain a key population. Unsafe injected drug use carries a risk of acquisition of HIV and other blood-borne diseases. According to UNAIDS data, prevalence of HIV is ten times higher in people who inject drugs than the global average, and the risk of acquiring HIV is up to 34 times higher among people who inject drugs. In some regions, injection drug use drives HIV epidemics. In 2024, 25% of new HIV acquisitions in eastern Europe and central Asia were among people who inject drugs. Other forms of illegal drug use are also deeply entwined with HIV, partly through effects on risk behaviours, but also through marginalisation and stigmatisation of populations, leading people to avoid health contact and increasing exposure to carceral systems.The guidance argues that decriminalisation, or less punitive and more health-oriented approaches to drug legislation, can help to direct people who use drugs to relevant health care when implemented with the correct connection to services. Less punitive approaches to drug use and possession can also encourage people who use drugs to come forward for other health services such as HIV testing, prevention, and treatment. When Portugal decriminalised drugs in 2001, the positive effects on drug use, drug-related deaths, and HIV incidence were clear and rapid: new cases declined from 973 in 2004 to 24 in 2023. However, the guidance also makes it clear that, without appropriate support systems, decriminalisation alone might not achieve the desired outcomes and could even have unintended harms.