The harms which result from the implementation of prohibition are global and systemic; they are the norm. States continue to fight a ‘war on drugs’ that is, in reality, a war on people who use illicit drugs, their families, and their communities. This is a war that particularly impacts people of colour, women, young people, and the economically marginalised and disenfranchised
As harm reduction programs were non-existent in many developing countries for many years, and continue to be rare, blood borne viruses including HIV and hepatitis C are prevalent in communities of people who inject drugs. Rates vary in different places. In communities in Manipur, India, and Yunnan Province, China, prevalence of HIV among injecting drug users increased rapidly in the 1990s. In a period of only six months in both these areas, the prevalence of HIV jumped from less than one percent to over forty percent among injecting drug users.
Although HIV testing is currently provided for free in most countries, most of the other tests required including viral load and CD4 tests are expensive. For people who are HIV positive, these tests are supposed to be carried out every six to twelve months. For many PUD, the tests are unaffordable. As a consequence, PUD have lower rates than other people living with HIV (PLHIV) of access to HIV tests and HIV treatment.
Opportunistic infections such as tuberculosis are prevalent among HIV positive PUD. Tests for these infections are also rarely provided free or at an affordable price, and treatment costs are often high.
Treatment costs also vary from country to country. First and sometimes second line anti-retrovirals (ARV) are often provided through international funding such as the Global Fund. Any other specialised anti-retroviral medications including third line medications are extremely expensive and harder to access, particularly for PUD. This is particularly important in the context of HIV and hepatitis C co-infection. For PUD who are co-infected, HIV treatments can kill them faster than either HIV or hepatitis C would have, as the toxicity of some of the first and second line ARV to the liver results in liver failure very quickly.
Hepatitis C has been largely neglected in developing countries. The concentration on responding to HIV among PUD did not come with a much needed understanding of hepatitis C and co-infection. Many health clinicians, as well as the general community and communities of PUD, have had very little understanding of the hepatitis C virus and its treatment.
As PUD communities succeeded in increasing access to HIV treatment among their communities, the importance of understanding and responding to hepatitis C co-infection became all too clear. People who had thought they were getting access to life saving treatment for HIV suddenly found themselves experiencing severe side effects, some were hospitalised, and in many cases people died from the toxic effects of the ARV on their livers.
In recent years, PUD advocates have learnt about hepatitis and have begun to call for increased access to education, testing and treatment for PUD. Currently, few developing or middle income countries provide affordable or free hepatitis C testing or treatment. The tests for hepatitis C are not commonly provided to PUD, and can only be accessed in particular hospitals and clinics at high cost, if at all. Understanding of the virus and tests is low, not just among PUD communities but also among clinicians. Many PUD have been tested for hepatitis C antibodies but never had follow up PCR tests to discover if they have chronic hepatitis C. Some clinicians are teaching themselves through the internet and other means, but if they don’t have access to the diagnostics necessary to appropriately diagnose the virus, they cannot adequately respond to the health and support needs of their patients.
Additionally, treatment for hepatitis C in most developing and middle income countries is non-existent or so unaffordable it may as well be. Treatment costs in these countries range from $8000 US to $30,000 US for a course of interferon and ribavirin. Pegylated interferon may be offered, but many people will opt for the slightly cheaper standard interferon if they manage to secure enough money to try a course of treatment. In some countries, one of the hepatitis C “treatments” offered, the one that is most affordable, is also not based on any evidence that it works. It’s a course of whatever a Traditional Chinese Medicine practitioner offers, which if you’re lucky, may assist you to manage some of your hepatitis C symptoms.
The devastating effects of HIV and hepatitis C in PUD communities in much of the world has resulted in an increase in PUD networks advocating for better health access for their communities. These groups are educating themselves, and educating their peers. They have gained support from a number of organisations including UN agencies, who support their attempts at increasing access to HIV and hepatitis C testing, diagnostics, treatment and education. There has been an increase in research about rates of hepatitis C among PUD communities, including some research into specific treatment needs in some countries. Continued advocacy and increased understanding of the extent of the problem will, eventually, result in more people being able to access the treatment they need.
 International Network of People who Use Drugs (2014). Taking Control: Pathways to drug policies that work. Response to Global Commission on Drug Policy report, September 10, 2014. http://www.inpud.net/en/inpud-response-global-commission-drug-policy%E2%80%99s-taking-control-pathways-drug-policies-work