HIV, hepatitis & drug policy reform

Introduction

The prohibition and criminalization of drug use and possession continue to fuel the global HIV and viral hepatitis epidemics — sharply increasing risks for people who use drugs, obstructing efforts to prevent new transmissions, and hindering treatment. Proven harm reduction interventions are scarcely resourced, while billions are spent to enforce punitive drug laws and policies. People who use drugs are routinely caught up in the criminal justice system, frequently remain the target of abusive policing practices, and are incarcerated at massively disproportionate levels — all of which further increase their risks for HIV and viral hepatitis. Meanwhile, stigma and discrimination created and perpetuated by criminalization drive people to use drugs in increasingly dangerous settings and impede their ability to use drugs safely. At the same time, people who use drugs face prohibition- and law enforcement-related barriers to accessing services within and beyond the health sector.

Even on its own terms, prohibition is a failure. As the Global Commission on Drug Policy noted more than a decade ago, current drug control efforts have failed to reduce drug use or supply, or to reduce the risks for HIV and viral hepatitis among people who use drugs. While people who inject drugs are at particular risk, there has been no appreciable decline either in the prevalence of injecting drug use, nor in HIV, hepatitis C (HCV) or hepatitis B (HBV) prevalence among people who inject drugs.

People who use drugs have been left behind. Among people who inject drugs, one in seven is living with HIV, one in five is living with chronic HCV and one in 12 is living with chronic HBV.

None of this has to be the case. Globally, the end of the HIV and viral hepatitis epidemics is within grasp. Aligned with the Sustainable Development Goals, the UN has set achievable targets for ending HIV and eliminating viral hepatitis as a public health threat by 2030. The scale-up of antiretroviral treatments for HIV over the past 20 years has been a dramatic success, reducing HIV-related deaths to their lowest in almost three decades. And yet… because of denial or willful neglect, many countries have failed to address epidemics among people who use drugs

A course correction is greatly needed. Effectively addressing HIV and viral hepatitis among people who use drugs could end both epidemics. On the other hand, the continued failure to systematically confront HIV and viral hepatitis among people who use drugs will thwart global efforts.

We have the knowledge and the means. But such a shift will require political will — and for governments and societies to embrace a new way of thinking about drugs. It has been more than a decade since the Global Commission called on the international community to act urgently to avert the significant public health harms that result from HIV and viral hepatitis. We need a new path forward. The time to act is now.

Recommendations

The Global Commission on Drug Policy calls on the United Nations to:

• Fully and effectively implement the UN Common Position on Drugs (2018), which calls for changes in laws, policies and practices that threaten the health and human rights of people. UN agencies should implement the United Nations system common position supporting the implementation of the international drug control policy through effective interagency collaboration77 through joint actions at regional and country levels to support decriminalization of drug possession for personal use and measures to reduce stigma and eliminate discrimination faced by people who use drugs.

The Global Commission on Drug Policy calls on Member States to:

• Decriminalize drug use, drug possession for personal use, and the possession of drug paraphernalia. Decriminalization entails eliminating all punitive measures associated with drug use or possession. It is also critical to address police harassment, coercion, extortion and violence against people who use drugs. Where drug use or possession remains illegal, people who use drugs must be guaranteed due process and judicial responses must be proportional. Legal impediments to opioid agonist treatment, or to the availability of harm reduction programs, such as drug paraphernalia laws, should be eliminated. The death penalty for drug-related offenses is a never justifiable violation of human rights that must be abolished.
• Implement anti-discrimination measures to protect people who use drugs from discrimination in accessing benefits or services, including healthcare, education, housing, social benefits, and employment.
• Ensure the availability of drug dependence treatment.
  Opioid agonist treatment should be a basic and essential service standard for the treatment of opioid dependence.
  Rigid requirements for daily clinic visits and observed dosing are demeaning and counterproductive, as they may limit retention and impede employment. Abstinence requirements or other conditions, such as compulsory psychosocial care or requirements for negative urine tests, constitute an unjustifiable barrier and should be eliminated.
  Compulsory drug dependence treatment should be discontinued. Compulsory drug treatment detention centers must be closed.
• Fully resource and scale-up HIV and viral hepatitis prevention (harm reduction), diagnosis and treatment programs, including in prisons and other closed settings.
  Resources should be reallocated from prohibition-driven law enforcement to health programs, including HIV and viral hepatitis prevention and treatment. HIV and viral hepatitis services should be integrated with programs to address overall health needs, including drug dependence treatment, mental health, and sexual and reproductive health services, and should be accessible and acceptable to people who use drugs. At minimum, prevention programs should provide sufficient coverage of needle-syringe programs, opioid agonist treatment for opioid dependence, and take-home naloxone for overdose management. Individuals who test positive for HIV or viral hepatitis should be offered treatment immediately and without conditions, preferably on the same day and at the same site. Ideally, rapid point-of-care diagnostic testing (for multiple pathogens) should be offered in settings that facilitate access, including primary care, harm reduction sites and prisons. Self-testing and community-led testing initiatives should be expanded. HIV and viral hepatitis prevention and treatment services must be available in prisons and other closed settings, both when people are incarcerated and via linkages upon release.
• Support the exploration, development and evaluation of innovative harm reduction strategies — including drug consumption rooms, drug checking, heroin-assisted treatment and safe supply initiatives.
  Harm reduction strategies have the potential to mitigate the multiplicity of risks faced by people who use drugs and connect them with HIV, viral hepatitis and drug dependence treatment services. While many programs target people who inject opioids, some newer initiatives help people who inject non-opioid drugs such as stimulants, use non-injection drugs such as smoked crack cocaine, or use novel psychoactive substances.
• Involve people who use drugs in the design, implementation, monitoring and evaluation of all HIV and viral hepatitis programs. Many people who use drugs experience directly the harms caused by prohibition, including discrimination, incarceration, police violence and overdose, and are well positioned to understand and mitigate service barriers, contribute to program design, monitor the extent to which programs meet targets, and in many instances, deliver services, enhancing their effectiveness.