The criminalisation of illicit drug users is fuelling the HIV epidemic and has resulted in overwhelmingly negative health and social consequences. A full policy reorientation is needed.
It is always difficult to find accurate information about people who use drugs. The criminalisation of drug use, and the war declared on drugs by Nixon in the 1970s, which has been enthusiastically repeated around the world ever since, has resulted in people going underground to hide their drug use as much as they can. People who use drugs (PUD) are also often perceived to be either an embarrassment or of little interest to the authorities in their countries. Drug users are rarely a priority unless they are being targeted for arrest, such as crackdowns by police during political elections. Therefore, it is both extremely difficult and a low priority for many of these countries to try to understand accurately the number of people using drugs.
The HIV epidemic among people who inject drugs, and the money available from international donors has changed this to some extent. In 2012, the most recent data available, the United Nations Office on Drugs and Crime (UNODC) estimated the number of people who have used an illicit drug in the past year to be between 162 million and 324 million. That equates to between 3.4 and 7.0 percent of the world’s population aged between 15 and 64. This is quite a lot of people, and quite a big range in estimates. It is also possible, even likely, the numbers are underestimated. They certainly don’t include alcohol and probably don’t include people using pharmaceutical drugs for non-medical purposes.
People who inject drugs (PID) are estimated to be around 12.7 million and of these, UN agencies believe approximately 1.7 million to be living with HIV. However, these estimates differ significantly in different regions. Globally, approximately ten percent of people living with HIV (PLHIV) are PID. In Europe, PID represent about five percent of PLHIV, whereas in Asia they represent about twenty-eight percent. Only four percent of PID who are living with HIV have access to antiretroviral treatment. Around sixty percent of people who have a history of injecting drug use are thought to be living with hepatitis C, but as testing for hepatitis C is even less accessible for PUD in most of the world, there are huge gaps in knowledge about the global situation.
Harm reduction services vary in amount, quality and accessibility throughout the world. Some countries outlaw aspects of harm reduction such as needle and syringe programs (NSP) and opioid substitution treatment (OST), while others have relatively high coverage of these kinds of services and more. The majority of countries in the world with acknowledged populations of drug users now have some sort of harm reduction. This is mainly due to the high numbers of HIV transmissions and HIV prevalence in communities of people who inject drugs in these countries. NSPs were only introduced when HIV prevalence among people who inject drugs had already become extremely high.
Despite many countries with large populations of injecting drug users and high prevalence of HIV now accepting NSP, it is estimated that, globally, only two needles and syringes are distributed per drug user every month. The situation for people who are dependent on opioids is equally worrying. Only about eight percent of people who need OST are able to access it. These estimates would be far lower if only lower and middle income countries were being assessed, and lower still in countries where punitive responses remain the predominant method of addressing drug use.
In many countries, for example in South East Asian countries like Thailand, Cambodia and Viet Nam, the majority of PUD use illicit drugs other than opiates. Methamphetamine use, which is often smoked and sometimes injected, has become extremely popular in recent years, and is manufactured cheaply and in huge amounts in the area. However, because harm reduction services have been set up to respond to HIV and injecting, people who use other drugs and people who don’t inject them, are rarely provided with the same, albeit basic, level of services, if they are provided with any at all. There is very little access to mental health services or substitution treatment for people who use amphetamine type substances (ATS) in most parts of the world including Australia.
In addition, changes to economic situations are causing significant barriers to services for PUD. The few programs that exist have been funded by international donors to prevent HIV transmissions. The majority of funding for HIV prevention, treatment and care has been spent on ineffective programs, including funding that has been specifically for PUD. For example, the United States has not funded NSP in international settings. A lot of funding has gone to programs like general drug ot HIV education for the wider community rather than evidence based programs targeted at the communities most affected by HIV. Unfortunately, many countries that have funded harm reduction in low income countries are providing less funding for development programs, and less funding for health and HIV programs. This means international agencies like the United Nations agencies and Global Fund also receive less resources to use in developing countries.
A compounding difficulty for PUD who need harm reduction services in several countries with epidemics of HIV is the change in their own status. Countries including Thailand, Malaysia, Indonesia and India are no longer classed as low income and are now middle income countries. This means they aren’t eligible for funding from organisations like the Global Fund. It doesn’t, however, mean that all their citizens are suddenly able to live middle class lives with access to quality health services. In fact, some evidence has shown increased negative impacts on the poorer sections of populations in comparison to the middle and higher income parts of their communities that have resulted from similar changes in other countries. That is, the people who were in the poorest sections of the community while the country was lower income are equally badly or worse off when the country’s economic situation has improved.
The policy particularly affects people who are reliant on donor funding to meet at least some of their health needs. Many countries that have received international funding for HIV programs have expressed unwillingness to use their own money to continue these programs. For many PUD, the few services that have been available for them will no longer be available. HIV transmissions are already increasing in places where harm reduction programs have been taken away. It is not necessarily the case that more money is needed, but some funding and support is still needed where countries are not willing or able to provide it themselves. It has been stated many times that better use of available funding, in particular funding for effective, evidence-based programs like NSP in countries where people inject drugs would make a huge difference to the HIV and hepatitis C epidemics currently decimating communities of PUD.