Governments around the world should adopt and expand needle and syringe exchange programs and effective drug dependency treatment as part of their efforts to address HIV among people who use drugs, Human Rights Watch said , ahead of World AIDS Day on December 1.

“HIV epidemics around the world are being driven by lack of access to needle exchange programs and methadone-maintenance treatment, both proven to reduce drug use,” said Joe Amon, director of the HIV/AIDS and Human Rights Program at Human Rights Watch. “We’ve known for decades that these approaches work, but many governments and international donors either provide too little support or refuse to try them.”

Outside of sub-Saharan Africa, as many as 30 percent of all new HIV infections occur among people who inject drugs, and within sub-Saharan Africa, injection drug use is increasing.

International health and drug-control agencies – including the UN Office on Drugs and Crime, UNAIDS, and the World Health Organization – all endorse comprehensive harm reduction services, including needle and syringe exchange and medication-assisted therapy (for example, with methadone), both inside and outside prisons, as essential to address HIV among people who use drugs.

Despite broad endorsement and overwhelming evidence that they work, these approaches remain out of reach of the vast majority of people who need them.

Approximately 80 percent of injection drug users live in developing or transitional countries, many receiving no HIV-prevention services. UN Secretary-General Ban Ki-moon has decried the lack of HIV-prevention services to this population, noting that, “[e]stimates from 94 low- and middle-income countries show that the proportion of injection drug users receiving some type of prevention services was 8 per cent in 2005, indicating virtual neglect of this most-at-risk population.” By contrast, many countries that offer harm-reduction measures on a sufficiently large scale have successfully controlled HIV epidemics.

Human Rights Watch said the situation in prisons and detention centres is particularly dire, with little access to drug dependency treatment or HIV-prevention services, and with risky behaviour and drug use common. HIV prevalence is typically much higher in prison, largely due to high rates of incarceration of people who use drugs and the lack of access to needed services. Many opioid-dependent prisoners are forced to undergo abrupt withdrawal and needlessly suffer profound mental and physical pain.

Human Rights Watch also expressed concern about rights abuses stemming from detaining drug users for “rehabilitation” or treatment. In some cases, drug users can be held for months or years without due process. Basic medical services are often unavailable, and the “treatment” often consists of forced, unpaid labor and, in some cases, physical and psychological abuse.

“Many people will look on World AIDS Day at how far we’ve come in terms of providing HIV treatment and prevention, and that’s important,” Amon said. “But we must also look at how we’ve failed to hold governments accountable for refusing to adopt effective strategies and denying prisoners and drug users’ access to lifesaving HIV-prevention tools and drug-dependency treatment.”

Selected statistics on drug use and HIV
The UN Reference Group on HIV and Injecting Drug Use states that HIV prevalence among those who inject drugs is greater than 40 percent in nine countries, and between 20 and 40 percent in five others. The largest numbers are in China, the United States, and Russia, where estimated national HIV prevalence rates are as high as 19 percent, 22 percent, and 74 percent respectively.

• In Russia, more than 64 percent of people living with HIV were infected through injection drug use, and this remains the main route of HIV infection. Methadone and buprenorphine are banned by law, and the government has impeded access to clean needles.
• In Ukraine, nearly 70 percent of people with HIV are injection drug users and 50 percent of new infections in 2007 were related to injection drug use. Harm reduction programs have expanded in the past few years, but coverage remains inadequate and rights abuses, such as targeting injection drug users who visit harm reduction centers for arrest, drive many people away.
• In China, nearly half of all new infections in 2007 were related to injection drug use, and HIV prevalence among drug users is high. Studies have estimated that rates in Guangxi, Yunnan, Xinjiang, Sichuan, Guangdong, and Ningxia Provinces range from 10 to 80 percent, and that 8 to 19 percent of drug users nationwide are HIV-positive.
• In Vietnam, where the number of people living with HIV has more than doubled since 2000, the epidemic is being driven by injection drug use and as many as 65 percent of drug users are estimated to have the virus. Distributing condoms, needles, and syringes can be considered evidence of criminal behavior, driving harm reduction programs underground and impeding drug users’ access to them.
• In Mauritius, injection drug users represent 86 percent of the population living with HIV and they account for most new infections.
• Injection drug use is also well-established in a number of sub-Saharan countries with high HIV prevalence, including Tanzania, where despite a recent decline in overall HIV prevalence, prevalence among injection drug users exceeds 40 percent, and Kenya, where more than 60 percent of injection drug users are HIV-positive.

In the United Kingdom and Australia, strong national responses early in the epidemic contained potentially serious HIV epidemics among drug users, and HIV rates among them remain low. In Western European countries that were slower to embrace harm reduction approaches, such as France, Italy, and Spain, severe HIV epidemics have eventually been stabilized by harm reduction measures. Poland’s strong national response, including syringe exchange and other targeted interventions for injection drug users, has also been credited for containing the epidemic among injection drug users, and averting a more widespread epidemic in non-injecting populations.

Background information on harm reduction in prison
Only 33 countries provide medication-assisted therapy (for example, with methadone or buprenorphine) to prisoners, but they often restrict it to those who have been receiving such treatment prior to incarceration. Only eight countries provide needle and syringe exchange in prison, despite numerous recommendations from the United Nations and clear evidence that such programs can work safely and effectively in prisons.

• In the United States, at least 20 percent of people with HIV have a history of incarceration. One in five incarcerated people is there for drug-related crimes and many others are incarcerated for crimes committed to support a drug habit. Yet most prisoners have no access to comprehensive harm reduction services. Methadone is unavailable to most prisoners, and in many prisons, harsh punishment of drug users denies treatment to those who may need it most.
• In Ukraine, which has the most severe HIV epidemic in Europe, an estimated 13 percent of prisoners are HIV-positive. Since 2006, Ukraine has taken important steps to increase access to methadone and buprenorphine in the community, but neither is available in prison.
• In Sweden, at least half of all entering prisoners are regular injection drug users, and injection drug use accounts for nearly one-third of all HIV infections. While medication-assisted therapy is not officially prohibited, prison policy includes stopping methadone upon incarceration for persons successfully engaged in treatment programs.
• In Vietnam, nearly 30 percent of the prison population is living with HIV; in some facilities, this figure reaches 40 percent.

Background information on detention of drug users for ‘treatment’

• Since 2003, thousands of people in Thailand have been coerced into “drug treatment” centers run by security forces, without a clinical assessment that they are indeed drug-dependent. Many have been held for extended periods, with “rehabilitation” often provided by security personnel and with military drills a mainstay of “treatment” provided. This policy of coercion has had long-term consequences on the health and human rights of drug users, as many continue to avoid drug treatment or any government-sponsored health services out of fear of arrest or police action.
• In China, as many as 350,000 people are interned in mandatory drug-detoxification and “re-education through labor” centers, where they can be detained without trial or due process on suspicion of drug use for up to six years. Detainees are required to work without pay to produce goods for market, including trinkets for the tourist trade. “Drug treatment” in these centers consists of little more than the rote repetition of slogans (such as “drug use is bad, I am bad”) and military-style drills.
• In India, drug users are physically isolated, chained, denied meals, and forced to work as “treatment.” Drug users are also caged and beaten, and in some cases administered medication that has been discontinued outside of India because of adverse side effects.
• In Russia, drug users in some facilities have been subjected to “flogging therapy,” handcuffed to beds during detoxification, and denied medication to alleviate painful withdrawal symptoms. Drug users who enter treatment voluntarily are consigned to locked wards, in some cases with fatal consequences. In 2006, 46 young women died in a fire in a Moscow substance-abuse hospital, where staff had abandoned residents to struggle against locked windows and doors.

Link to HRW