This guide provides practical guidance on how to design, implement and monitor programmes aimed at removing human rights-barriers to HIV services.

It will help implementers of such programmes to:

Funded by GIZ BACKUP Health, the guide was developed with the help of governments, donors and civil-society organisations, and in close collaboration with The Global Fund.

 Implementing and scaling up programmes to remove human rights-related barriers to HIV services

The criminalisation of people who use drugs compounds drug-related challenges and worsens health and welfare outcomes. Across the world, there is a growing number of jurisdictions where the possession of scheduled drugs for personal use has been decriminalised. In some countries and federal states, this has been extended to the cultivation of cannabis for personal use or the sharing of substances where there is no financial gain (also known as ‘social sharing’).

In the context of drug policy, ‘decriminalisation’ refers to the removal of criminal penalties for activities related to drug use. In some legal systems criminal penalties are replaced by civil sanctions, while in other systems no penalties are applied – please see our glossary for more detailed definitions.

Some form of decriminalisation has been adopted in 30 countries – with significant differences and levels of effectiveness. This interactive map provides an overview of these models, offering insights into decriminalisation laws, their implementation and impact.

The inclusion of a jurisdiction in the map is not an endorsement. For example, countries like Mexico and Russia are highlighted below, despite the fact both countries have ineffectual frameworks as detailed in their country profiles. The gold standard of decriminalisation is the removal of all punishment for drug use, and the availability and accessibility of evidence- and human rights-based harm reduction, health and social services on a voluntary basis.

This map has been developed in partnership with Release, the International Drug Policy Consortium and Accountability International, thanks to the financial support of the Robert Carr Fund and Open Society Foundations. This map will be updated regularly – if you do have any comments or feedback please contact us.

Drug decriminalisation across the world

By Prison Reform International (PRI) and the Thailand Institute of Justice (TIJ)

This year, PRI’s flagship publication Global Prison Trends, published alongside the Thailand Institute of Justice, has been released at a crucial time as prisons worldwide are being pushed to breaking point by the COVID-19 pandemic. Global Prison Trends 2020 documents the chronic issues that have led to this human rights and public health crisis and the challenges facing criminal justice systems in responding to the global pandemic.

To mark the launch of Global Prison Trends 2020 international criminal justice practitioners and human rights leaders, including United Nations Assistant Secretary-General for Human Rights, Ilze Brands Kehris and the President of the Inter-American Commission on Human Rights, Joel Hernández García attended an online webinar launch to discuss the report and PRI’s recommendation that governments urgently reduce their prison populations and begin a long-term shift towards alternatives to detention.

The report documents a record 11 million people in prison worldwide, with over 124 prisons exceeding their maximum occupancy rate. Global Prison Trends shows how this increase in numbers is driven by a punitive approach to criminal justice where more costly prison sentences are favoured over non-custodial alternatives.

The overcrowding and underfunding of prisons, alongside the overuse of imprisonment, has resulted in poor health services and sanitary conditions for prisoners that make people in prison and prison staff acutely vulnerable to COVID-19.

The special focus of Global Prison Trends 2020 identifies the solution presented by increasing the use of alternatives to imprisonment and the challenges governments may face in implementing this. PRI advocates for an increase in the use of alternatives to detention as a solution to the global prison crisis and in the long-term to reduce reoffending rates, better protect human rights and tackle overcrowding.

Global Prison Trends 2020 explores the following subjects:

Trends in the use of imprisonment, including the funding of penitentiary systems

Prison populations such as women, children, older persons and minority groups

Prison management including the provision of health services

A special focus on alternatives to imprisonment

Global Prison Trends 2020

By Nazlee Maghsoudi & Jeanette Bowles & Dan Werb

The increasing incidence of fatal opioid overdose is a public health crisis in Canada. While buprenorphine/naloxone and methadone are the standard first-line of opioid substitution options, limitations, including difficulty achieving long-term retention for some people who use opioids, are well known. For this group, injectable diacetylmorphine or hydromorphone can achieve positive outcomes, including high retention rates, reduced use of unregulated opioids, and reduced criminal activity. In May 2019, Health Canada announced changes to increase the accessibility of diacetylmorphine and hydromorphone, and in September 2019, the CIHR-funded Canadian Research Initiative in Substance Misuse released a national clinical guideline for diacetylmorphine and hydromorphone as additional frontline substitution options. While these developments present opportunities for scale-up, significant financial, structural, and practice barriers continue to impede access. This commentary explores the current state of policy and practice for diacetylmorphine and hydromorphone as opioid substitution options in Canada, outlines the rationale for rapid expansion of access, and highlights clinical and policy changes that must be undertaken or the death toll will continue to rise.

Expanding access to diacetylmorphine and hydromorphone for people who use opioids in Canada

: Josefina Alfonsín, Gerardo Contreras Ruvalcaba, Kenya Cuevas, Teresa García Castro, María Santos, Ari Vera Morales

Across the world, trans women have been subjected to discrimination, criminalization, and institutional violence. They often face social exclusion, violations of their human rights, and transphobia. In many cases, these factors lead to them working in highly criminalized informal economies, such as the drug trade, sex work, or sex for survival. As a result, police profile them as being dangerous, making them more vulnerable to police abuse and to being incarcerated. While data is sorely lacking, our research indicates that trans women are overrepresented in prison as compared to other groups, and they are much more likely to suffer abuse and violence behind bars than other populations. In addition to the challenges that incarceration imposes on any person deprived of liberty, trans women face particular challenges with regard to housing, their identification, body searches, access to medical services, privacy, and conjugal visits, among other issues. Despite this situation, trans women who have been deprived of liberty have demonstrated their capacity for agency and created organizations to defend their rights. In countries such as Argentina, Mexico, and Uruguay, groups of trans women are building a social movement based on different types of resistance and the development of political agendas.

Meanwhile, the absence of standards and public policies to protect the rights of trans women deprived of liberty is widespread in Latin American countries. The lack of disaggregated data, efforts to monitor this population’s situation of vulnerability, and related studies have deepened ignorance about these realities and hindered public policy design. Given the dearth of information on this issue, this report explores the framework of rights protection for trans women deprived of liberty, the statistical data available, structural inequalities existing prior to detention, living conditions in contexts of confinement, post-release social reintegration, trans women’s experiences of agency, along with good practices in the region. Furthermore, the report provides public policy recommendations to guarantee the full exercise of this population’s dignity and protection of its human rights.

: Almas Cautivas A.C, Casa Hogar Paola Buenrostro, Casa de las Muñecas Tiresias A.C., Dejusticia, Equis Justicia para las Mujeres, International Drug Policy Consortium (IDPC), Procuración Penitenciaria de la Nación de Argentina, Red Corpora en Libertad, Washington Office on Latin America (WOLA)

Trans women deprived of liberty: Invisible stories behind bars

This guide is aimed at those who work with and advocate for women who use drugs in all their diversity. It equips them with practical, evidence-based interventions which will help advance the sexual and reproductive health and rights (SRHR) of women who use drugs. It is based on the experiences of Frontline AIDS partners and others in implementing community-led harm reduction programmes in Kenya, India, Indonesia, Nigeria, Tanzania, Uganda and Ukraine from 2011 to 2020 through the Community Action on Harm Reduction (CAHR), PITCH, and Integrated Harm Reduction programmes, and others. It is informed by the recommendations of the Guttmacher-Lancet Commission on Sexual and Reproductive Health and Rights 2018 report. The guide was developed in consultation with communities of women who inject drugs in select countries, and technical input was provided by the Women and Harm Reduction (WHRIN) Advisory Group.

Part 1 describes the current context for women who use drugs in relation to their SRHR. This part includes considerations of available data; the intersection of drug use with gender inequality, gender norms and stereotypes that create additional barriers to services for women who use drugs; and gender-based violence. It introduces the Guttmacher-Lancet Commission on Sexual and Reproductive Health and Rights’ 2018 definition of SRHR, and the essential service package, alongside the World Health Organization’s package for comprehensive harm reduction services.

Part 2 elaborates seven essential SRHR interventions for women who use drugs, and an additional sub-section on the sexual health and well-being of women who use drugs. Short case studies from Frontline AIDS and partners’ harm reduction programmes, as well as other NGOs, provide examples of successful interventions. In conclusion, we draw on priority recommendations from the Guttmacher-Lancet Commission for achieving SRHR that are most relevant to the context of women who use drugs.

Advancing the sexual and reproductive health and rights of women who use drugs

The criminalization of people who use psychoactive substances in the Central and Eastern Europe, and Central Asia (CEECA) region, instead of maintenance of public health and safety, increases the financial and social burden on the states. For people who inject drugs, approximately 58% will experience incarceration in their life.

Incarceration costs 2 to 6 times more than treatment from health and social service groups. However, in almost all the countries in the CEECA region, due to de facto criminalization of people who use psychoactive substances, harm reduction and other health services are severely underfunded and depend on international donors. Guidelines from the World Health Organization recommend that at least 40% of people who use opioids receive opioid substitution therapy (OST); however, most countries in the CEECA region barely reach 20%.

Governments should take evidence-based health and human rights approaches and reallocate money from policing, prosecuting, and incarceration of people who use psychoactive substances to community harm reduction and health services.

The guide contains 11 statements, followed by supporting arguments, which should be used in advocacy work. Arguments are prepared based on existing practices and evidence-based information. Arguments are created to advise on advocacy of reallocating funds from law enforcement budgets to health and harm reduction budgets for people who use psychoactive substances.

Criminalization costs in the CEECA region - A pocket guide

In 2019 EHRA together with Support, Research and Development Centre (SRDP), the Ukrainian Network of People who use Drugs (VOLNA), Drug-users Ukraine, the Drop-in Centre and the ENEY developed the methodology to access the client satisfaction with opioid maintenance therapy and conducted the pilot study in Kyiv and Kyiv Oblast region. Our approach to this study was based on the principles of equal partnership with the community of people who inject drugs and/or receive opioid maintenance therapy (OMT).

Almost from their very first days, OMT programmes in Ukraine have come under close scrutiny from the international research community. We believe that attention has been drawn to OMT programmes in Ukraine because of the low annual numbers of new patients throughout the period of the OMT implementation projects. According to UNAIDS, the estimated number of people who inject drugs in Ukraine is 346,000 individuals, of whom only 11,853 (or less than 3.5%) currently receive OMT services. The lack of attention paid to treatment satisfaction in Ukraine can probably be attributed to a shift in emphasis towards the needs of increasing service coverage, even while the quality of service is seldom included in ongoing discussions. Since OMT programmes have been operating in Ukraine for more than 10 years, the study of patient satisfaction with treatment offers opportunities for a better understanding of OMT service development prospects in the long run and of treatment trajectories and changing needs at the patient level.

As the design of this study was based on qualitative and quantitative methodological components, it was implemented in the framework of the mixed–method approach. The protocol and tools of this study were reviewed by the Ethics Review Board of the Ukrainian Institute on Public Health Policy.

The quality component of this study was implemented through semi-structured interviews with patients of OMT programmes.Within the scope of the study, the main purpose of semi-structured interviews was to highlight various aspects and criteria of satisfaction with OMT services among patients in order to develop a data-based questionnaire tool.

376 OMT patients took part in the pilot assessment, 178 structured interviews were conducted with patients who get OMT for free at state-funded OMT sites, 198 interviews were conducted with patients who buy OMT drugs in pharmacies after getting prescription at OMT sites based in private clinics. An overall satisfaction with OMT treatment is assessed as high and very high in 72% OMT patients, but the particular aspects of OMT treatment are not that highly assessed. The quality of medical care at OMT site is assessed as satisfied by 49%, 42% are satisfied with the physical environment at OMT sites and only 34 % of survey participants assess the psycho-social support as satisfied. At the same time, 89% of respondents mentioned that OMT is a vital need for them.

Based on the results of this study, we can draw the following conclusions and make some recommendations for further advocacy:

Studies like this conducted using a routine monitoring format as an integrated component of the monitoring and evaluation framework at OMT sites could help us understand the dynamics of satisfaction with treatment and treatment environment, interactions with OMT service providers and subjective treatment experiences. Which in turn could influence the long-term patient retention in OMT programmes.

For an improved understanding of the goals and outcomes of the treatment of chronic diseases like drug addiction, we recommend considering the assessment of patient quality of life as an indicator of treatment efficiency.

Survey of client satisfaction with OMT services among participants in Kyiv and the Kyiv Oblast region: A pilot study report

Venezuela’s state institutions have deteriorated and the country lacks an impartial, transparent, or even functional justice system. In this environment, armed groups and organized criminal structures, including drug trafficking groups, have thrived. But U.S government data suggests that, despite these challenges, Venezuela is not a primary transit country for U.S.-bound cocaine. U.S. policy toward Venezuela should be predicated on a realistic understanding of the transnational drug trade.

Recent data from the U.S. interagency Consolidated Counterdrug Database (CCDB) indicates that 210 metric tons of cocaine passed through Venezuela in 2018. By comparison, the State Department reports that over six times as much cocaine (1,400 metric tons) passed through Guatemala the same year.

According to U.S. monitoring data, the amount of cocaine trafficked from Colombia through Venezuela is significant, but it is a fraction of the cocaine that is sent through other transit countries. Around 90 percent of all U.S.-bound cocaine is trafficked through Western Caribbean and Eastern Pacific routes, not through Venezuela’s Eastern Caribbean seas.

There was an increase in cocaine flows through Venezuela in the period from 2012 to 2017, but that increase corresponds with a surge in cocaine production in Colombia during that same time. CCDB data suggests the amount of cocaine trafficked through Colombia rose from 918 metric tons in 2012 to 2,478 metric tons in 2017 (a 269 percent increase), and from 159 to 249 metric tons in Venezuela in that same period (a 156 percent increase). When cocaine trafficking in Colombia dropped slightly post-2017, cocaine flows in Venezuela fell as well.

U.S. CCDB data shows that cocaine flows through Venezuela have fallen since peaking in 2017. According to CCDB data, the amount of cocaine flowing through Venezuela fell 13 percent from 2017 to 2018, and appeared to continue to fall slightly through mid-2019.

A peaceful, negotiated, and orderly transition offers the best chance of allowing the reforms needed to address organized crime, drug trafficking, and corruption in Venezuela. The 2009 military coup d'etat and resulting turmoil in Honduras provides a cautionary tale for U.S. policymakers who see intervention or collapse as the best way route for a return to democracy in Venezuela.

Beyond the narcostate narrative: What U.S. drug trade monitoring data says about Venezuela

As the COVID-19 pandemic affects more people in an ever increasing list of countries, PRI has published a briefing note, 

Coronavirus: Healthcare and human rights of people in prison

. With the fast-evolving situation, there is legitimate concern at a further spread of the virus to places of detention. The difficulties in containing a large outbreak in detention facilities are clear. People in prison and the personnel who work with them are in close proximity and in many cases in overcrowded, cramped conditions with little fresh air. People in detention also have common demographic characteristics with generally poorer health than the rest of the population, often with underlying health conditions. Hygiene standards are often below that found in the community and sometimes security or infrastructural factors reduce opportunities to wash hands or access to hand sanitizer – the key prevention measures recommended by the World Health Organization.

While legitimate measures in times of such an emergency are needed to prevent further outbreaks of COVID-19 in prisons, authorities need to ensure human rights are respected. In such anxious times it is even more pertinent that people are not cut off from the outside world, they do not end up in solitary confinement, and most of all they have access to information and adequate healthcare provision – equal of that available in the community.

Our briefing outlines the key measures that criminal justice systems, including prisons and courts, have taken to prevent the spread of COVID-19 – and the impact of these in light of the UN Nelson Mandela Rules and other key standards.

Action needs to be taken now and immediately, given the risk people in prison are exposed to, including prison staff. Such action should be guided by international standards and the values of: Do no harm, equality, transparency, humanity.

Worldwide, women who use drugs are vastly underserved within health and social services and programmes. National and international research, services, guidelines, and training programmes are either gender-neutral or male-focused. As harm reduction services are primarily tailored to men, women who use drugs often find their specific needs being unacknowledged and unaddressed, leading to non gender-responsive harm reduction services.

The On the A-Gender: Community Monitoring Tool for Gender-Responsive Harm Reduction Services for Women who use Drugs aims to be a resource for community advocates to begin documenting, evidencing, and addressing this state of play. By doing so, community advocates can begin to identify areas and locales where gender-responsive services are severely lacking or identify services and programmes that can provide examples of good practice and be scaled up. The tool acknowledges the diversity and intersectionality of women who use drugs — including sex workers, lesbian and transwomen.

This tool has been developed by the International Network of People who use Drugs (INPUD) and the International Network of Women who use Drugs (INWUD), in collaboration with the United Nations Office of Drugs and Crime (UNODC) HIV/AIDS Section and Koalisi Satu Hati , a community advocacy group in Indonesia. It is based on the Policy Brief: Women who inject Drugs: Addressing Specific Needs (UNODC, UNWomen, WHO, INPUD, 2014) and its companion guidelines Addressing the specific needs of women who inject drugs: Practical guide for service providers on gender-responsive HIV services (UNODC, INPUD, 2016).

We hope this resource can be a useful and a practical first step towards developing advocacy strategies to introduce and scale up gender-responsive harm reduction services in various settings around the world. In this way, the right to health of women who use drugs can be respected and better promoted.

On the A-gender: Community monitoring tool for gender-responsive harm reduction services for women who use drugs

Smokable cocaines are commonly referred to as “the most harmful drug”, and considered not just a threat to public health, but also to public security in the urban centres of many large cities. As a result, its users are frequently subject to hostility and stigmatization.

The smokable cocaine market was established decades ago, and is definitely not a new phenomenon. Rather than disappear, it is undergoing a slow expansion: from constituting a rather localized and isolated habit in the Andean region in the 1970s, its reach has extended in all directions, throughout North and South-America, including the Caribbean and Central American regions. Societies in the Americas have coexisted with smokable cocaines for over four decades, but - surprisingly - there is a dearth of research on the development of the market, or much first-hand evidence of how this substance is actually commercialized and used by millions of people in the region.

This report reflects a study of the information collected by a network of researchers and street-corner workers assembled by TNI, and conducted from 2014 to 2018. Our objective was to understand how local markets for smokable cocaines in Latin America and the Caribbean are actually functioning. In the first phase, researchers in seven different urban locations from Mexico to Argentina were asked to collect data on the current volume and characteristics of the market, with the aim of creating an overall picture of the current situation. In a second phase, further information was solicited in order to define policy responses to stimulant use, focusing particularly on harm reduction measures.

The different forms of violence confronted by users of smokable cocaine need to be recognized and attended by public services. All policy interventions at the street level should aim to destigmatize and find concrete practical solutions to the immediate problems faced by users’ communities - initiatives inspired by the broad concept of “bed, bread and bath”.

In the design of a broader policy framework, users themselves need to be consulted and involved, enabling a form of implementation that can be checked and evaluated by its effects on the community itself. The experiences obtained in the past decade in a number of cities mentioned in this report make a strong case for developing public policy models that combine all the above features, and need to be given the appreciation and resources they deserve. A region-wide systematic evaluation of these experiences could contribute to more humane and effective polices regarding the different forms of smokable cocaine.

Publications from IDPC Members