A public health and rights approach to drugs: UNAIDS recommendations for the United Nations General Assembly Special Session on the world drug problem

There is irrefutable evidence that new HIV infections drop sharply when people who inject drugs have access to harm reduction and other public health programmes. Property crimes are reduced, public security is increased and there are improved health outcomes for people who inject drugs. Alternatives to criminalization and incarceration facilitate access to health services and enable drug use to be treated as a health condition rather than as a crime. Public health programmes can be fully funded for a fraction of the current investments in the criminal justice system related to drug offenses and they will produce significantly higher health and social benefits.

People who use drugs continue to face punitive legal environments, a variety of human rights abuses and poor access to harm reduction services, including needle and syringe programmes (NSP) and opioid substitution therapy (OST).

An estimated 56-90% of people who inject drugs will be incarcerated at some point during their lives, placing them in conditions of heightened infection risk due to shared injecting equipment, unprotected sex and overcrowding. Harm reduction services are scarce (and often entirely unavailable) in prison settings; instead of protecting people, prison conditions actually foster risk for sexually transmitted infections, HIV, viral hepatitis and tuberculosis among people who use drugs.

[tag theme="Harm reduction, Access to controlled medicines"]Even where opioids are needed for medical purposes, four out of five people are denied access. Naloxone – an inexpensive life-saving medicine that can prevent deaths from opioid overdose – is not widely made available.

The majority of countries are leaving behind people who inject drugs. Many national policy frameworks for drug control focus unduly on repression and punishment of drug users rather than on public health approaches and efforts to protect and promote human rights.

However, positive experiences from countries that have implemented rapid and comprehensive public health responses to emerging HIV epidemics related to drug use how success in maintaining low rates of HIV infection among people who inject drugs. This is the case for countries like Portugal, Switzerland and the Netherlands.

More recently, among those countries with the largest numbers of people who inject drugs, four (China, Malaysia, Ukraine and Viet Nam) have taken steps to increase harm reduction service coverage in recent years. China’s expansion of OST has been associated with a sharp reduction (from 43.9% in 2003 to 7.7% in 2013) in the proportion of newly diagnosed HIV cases resulting from injecting drug use. Similarly, the Islamic Republic of Iran has been a global leader in providing OST in prison settings, with the number of individuals reached by such services rising from a few hundred in 2004 to more than 41 000 in 2014. The Republic of Moldova also makes a comprehensive package of prevention services available in prisons, and Kyrgyzstan has implemented a programme to train and sensitize law enforcement officials to ensure the smooth and effective operation of harm reduction programmes. In Australia, the calculated return on investment for harm reduction programmes implemented there was 1:21, averting 32 000 new HIV infections, 90 000 hepatitis C infections and AU$ 1.28 billion in direct health costs.

1. Recognize that the overarching purpose of drug control is first and foremost to ensure the health, well-being and security of individuals, while respecting their agency and human rights at all times

2. Ensure accountability for the delivery of health services for people who use drugs by including public health and human rights pillars in the framework of the UNGASS outcome document that incorporate clear objectives for reducing new HIV infections and protect and promote the rights of people who inject drugs.

3. Commit to fully implement harm reduction and HIV services, as outlined in the Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations.

4. Commit to treating people who use drugs with support and care, rather than punishment. UNAIDS believes that this objective can only be achieved by implementing alternatives to criminalization, such as decriminalization and stopping incarceration of people for consumption and possession of drugs for personal use.

1. Ensure that all people who inject drugs, including people in prisons and other closed settings, have access to harm reduction services to prevent HIV infection, including needle and syringe programmes, opioid substitution therapy and antiretroviral medicines.

2. Ensure that all people who inject drugs and are living with HIV have access to lifesaving antiretroviral therapy and other health services to manage tuberculosis, viral hepatitis and sexually transmitted infections. In addition, ensure adequate availability and access to opioids for medical use towards reducing pain and suffering.

3. Ensure that all people who use drugs have access to non-coercive and evidence informed drug dependence treatment that is consistent with international human rights standards and the UNODC and WHO Principles of drug dependence treatment (16). All forms of compulsory drug and HIV testing and drug treatment should be replaced with voluntary schemes. The use of compulsory detention centres for people who use drugs also should cease, and existing centres should be closed.

4. Adapt and reform laws to ensure that people who use drugs do not face punitive sanctions for the use of drugs or possession of drugs for personal use. Countries should consider taking a range of measures including alternatives to criminalization, incarceration, penalization and other penalties solely based on drug use or possession of drugs for personal use. These measures include decriminalization, steps to reduce incarceration or removal of administrative penalties and de-penalization.

5. Ensure that the human rights of people who use drugs are not violated, by providing access to justice (including through legal services), prevention, treatment and other social services. Adopt smart policing measures to encourage people to access public health services.

7. Recognize that incarcerating people in prisons increases their risk of drug use, HIV infection and other health conditions, and take steps to ensure that harm reduction UNAIDS 8 and other health services are available in prisons in parallel with efforts to reduce the number of people being incarcerated for non-violent drug offences.

8. Ensure widespread availability of naloxone among health workers, first responders, prison staff, enforcement officials and family members as a life-saving public health measure to enable timely and effective prevention of deaths from opioid overdose among people who use drugs.

9. Support and empower community and civil society organizations, including organizations and networks of people who use drugs, in the design and delivery of HIV, health and social protection services

10. Undertake a rebalancing of investments in drug control to ensure that the resources needed for public health services are fully funded, including harm reduction for HIV infection, antiretroviral therapy, drug dependence treatment and treatment for hepatitis, tuberculosis and other health conditions.