People who use drugs are often at increased vulnerability to a variety of harms, including blood-borne viruses (such as HIV, hepatitis B and hepatitis C), overdose, infections and injuries. The sharing of injecting equipment provides a highly effective transmission route for HIV and has resulted in the rapid expansion of the epidemic among people who inject drugs in many countries. The international drug conventions themselves were created to ensure the “health and welfare of mankind”, yet drug policies around the world tend to focus more on criminal justice and repression than on health responses.

According to the United Nations, there are an estimated 12.7 million people who inject drugs in the world – of whom 13 per cent are living with HIV, and more than half are living with hepatitis C. Some countries have averted HIV widespread HIV epidemics among people who inject drugs by implementing effective harm reduction approaches. On the other hand, some countries – especially in Asia and Eastern Europe – have been unwilling to implement harm reduction responses, and currently more than one-third of their people who inject drugs are living with HIV. There are also clear links between non-injecting drug use (such as crack cocaine smoking) and blood-borne viruses, especially through sexual transmission.

Harm reduction

The term harm reduction refers to policies and programmes that aim to reduce the health, social and economic harms associated with drug use. Harm reduction is a public health and human rights approach, and takes a pragmatic and non-judgemental approach to addressing the problems associated with drug use. Rather than seeking to reduce or eliminate drug use, these approaches instead focus on providing individuals and communities with the information and tools they need to reduce health risks. The harm reduction approach can comprise a number of interventions:

The Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations reccomends the following package of interventions:

A) Essential health sector interventions (see Chapter 4 for detail) 

  1. HIV Prevention (incl. comprehensive condom and lubricant programming)
  2. Harm reduction for people who use drugs (incl. needle and syringe programmes, opioid substitution therapy and access to naloxone)
  3. HIV testing and counselling
  4. HIV treatment and care 
  5. Prevention and managemnet of coinfections and co-morbidities (incl. viral hepatitis, TB and metal health conditions)
  6. Sexual and reproductive health interventions (incl. screening, diagnosis and treatment of STIs). 

B) Essential strategies for an enabling environment (see Chapter 5 for detail) 

  1. Supportive legislation, policy and financial commitment (incl. decriminalisaation of behaviours of key populations)
  2. Addressing stigma and discrimination (incl. through antidiscrimination and protective laws)
  3. Community empowerment 
  4. Addressing violence against people from key populations.

The International HIV/AIDS Alliance recommended package also includes:

  1. Sexual and reproductive health services, including the prevention of mother-to-child transmission of HIV
  2. Behaviour change communication
  3. Basic health services, including overdose prevention and management, including the distribution of naloxone
  4. Services for people who are drug dependent or using drugs in prison or detention
  5. Advocacy
  6. Psychosocial support
  7. Access to justice / legal services
  8. Children and youth programmes
  9. Livelihood development / economic strengthening.

Finally, the IDPC Drug Policy Guide adds other relevant harm reduction interventions to this list, including:

  1. Drug consumption rooms / safer injecting facilities
  2. Drug checking services
  3. Distribution of smoking paraphernalia
Today, harm reduction is supported in policy and/or practice by 97 countries and territories, and across every continent of the world. Despite this widespread recognition, the term remains controversial in certain international forums. Harm reduction is endorsed and promoted by a number of international agencies – such as the UN General Assembly, UNAIDS, the World Health Organisation, UNODC, the Human Rights Council, the International Federation of Red Cross and Red Crescent Societies, PEPFAR, and the Global Fund to Fight AIDS, Tuberculosis and Malaria. However, within the UN Commission on Narcotic Drugs (CND) there remains a lack of consensus on harm reduction and the term is consistently omitted from any official documents and agreements.

Access to essential medicines

Another key health theme for drug policy is the availability of controlled drugs for medical and scientific purposes. Many controlled drugs are also classed by WHO as Essential Medicines, reflecting their medical value. The international drug control conventions prohibit the recreational use of these substances, but were also intended to improve and protect their use for palliative care, pain relief and other medical needs.

However, according to the WHO, more than 80 per cent of the world’s population have low or non-existent access to opioid medications for pain control – a clear failing of the international drug control system. In 2010, the INCB reported that more than 100 countries had inadequate consumption of opioid medicines – due to barriers such as overly strict regulations, pressure to underestimate need, insufficient supply and distribution systems, and fear of diversion to the illicit market and of law enforcement interventions.