|Drug Use and HIV Vulnerability (UNAIDS, 2001, 238 p.)|
|Chapter 1: Main report|
The role of United Nations guidelines in drugs and HIV/AIDS prevention
Below is a brief review of the guidelines and advice provided by key UN agencies i.e. the World Bank, UNDCP, WHO and UNAIDS on drug use and HIV vulnerability and the extent to which these were applied in the study-countries.
The World Bank in a Policy Research Report on AIDS (1997) notes that there is considerable evidence that HIV transmission can be slowed down dramatically by effecting changes in the behaviours of drug users (especially if they reduce the number of sexual and drug injecting partners and use condoms and sterile injecting equipment).
The UNDCP whose role is to provide support and advice to states on drug prevention, treatment and rehabilitation - or demand reduction promotes a 'balanced approach' to drug control. Supply reduction such as policing or alternative development to drug cultivation should be counter balanced by demand reduction. The concept is explained thus:
The distinction between demand reduction and supply reduction is that demand reduction activities are concerned with the drug abusers or potential abusers, while the latter concentrates on stopping illicit production and trafficking. The interrelationship between the two can be seen when producers begin to consume part of their own illicit production, when traffickers pay for co-operation with illicit drugs along the supply route, and when the end user, the drug abuser sell illicit drugs to pay for and obtain their own supply thus supply may help create and augment demand and demand sucks in supply of illegal drugs50
50 U.N Economic and Social Council, Commission on Narcotic Drugs, March 1995
Further guidelines to states on demand reduction was included in the Declaration on the Guiding Principles of Demand Reduction which UNDCP proposed to the General Assembly of the United Nation in June 1998. Although HIV/AIDS is not mentioned as a specific consequence of drug use the declaration proposed that demand reduction should cover all areas of prevention from discouraging initial use to reducing the negative health and social consequences of drug abuse. Furthermore, it notes that drug demand reduction should be integrated into broader social welfare programmes, included in health promotion and preventive education programmes so as to ensure an environment in which healthy choices become attractive and accessible. Importantly, the declaration suggests that demand reduction policies should be based on evidence and knowledge acquired from research and from lessons learnt from past programmes. Systematic and periodic assessments of drug problems are to be encouraged, as are careful evaluation of ongoing policies and programmes.
In the study-countries a 'balanced approach' is accepted but not necessarily practised. Law enforcement expenditure and resources invariably exceed all demand reductions resources and efforts. The proposal that countries should reduce the negative health and social consequences of drug abuse are only partially heeded if HIV/AIDS, which constitutes the most serious potential harm, is not adequately dealt with. Moreover the suggestions that demand reduction policies should be based on evidence and knowledge from research and other programmes is likewise rarely considered.
The WHO articulated the principle of 'Health For All' in a number of declarations.51 The need to ensure that drug use and HIV prevention should be dealt with in the context of public health is made clear. Drug use should be addressed through public health interventions as one of the many harms in the population.
51 The Declaration of Alma-Ata on Primary Health Care (WHO 1978), Global Strategy for Health for All by the Year 2000(WHO 1981) and the Ottawa Charter on Health Promotion (WHO 1986)
In the study-countries the public health approach is not generally extended to drug users. It is evident that the 'harms' associated with drug use are not generally addressed because such an approach is seen to conflict with drug control policies. In addition, a much quoted findings from experience worldwide by WHO recommends that activities to prevent the spread of HIV among IDUs should begin early (before the prevalence reaches 5%). This advice is all too often ignored.
UNAIDS whose co-sponsors include WHO, UNDCP and the World Bank, presented the United Nations General Assembly at the Special Session on Drugs (March 1999) with a statement advocating the following key measures for strengthening effective HIV prevention programmes:
Early interventions while the HIV prevalence is still low
Providing a comprehensive package of measures to include sterile injecting equipment, raising awareness among and educating injectors and their sexual partners, and
Making available drug treatment programmes, providing access to counselling and to care and support for HIV infected injectors and providing condoms.
UNAIDS singles out outreach and peer-education programmes as effective ways of reaching drug users who constitute a 'hard to reach' population. Beyond specific prevention approaches UNAIDS highlights the need to ensure a supportive environment within which these programmes can be implemented.
The report indicates that in order to create such environment it may be necessary to challenge and change the ways in which the community regards drug users (e.g., as a criminal, the perpetrator of social evil, a deviant, a subversive), and the ways in which drug users are managed (e.g., involuntary or compulsory treatment, imprisonment).
It is evident that there are many opportunities in the study counties for improving policy and interventions on preventing HIV/AIDS among drug use in ways that will be fully supported by the international community.
The impact of UN Conventions on national drug control legislation
It is important to dispel the notion that the UN Conventions on illicit drugs recommend heavy penalties for drug possession or for personal consumption. Nor do the conventions rule out the use of agonist pharmacotherapies such as methadone maintenance or buprenorphine treatment or prescribe that national laws should prohibit the implementation of programmes that facilitate access to sterile drug injection equipment.
In fact, the 1988 UN Convention Against Illicit Traffic in Narcotic Drugs and Psychotropic Substances is the only one that addresses the issues of punishment for drug use per se stating that:
'...each party shall adopt such measures as may be necessary to establish as a criminal offence under its domestic law, when committed intentionally, the possession, purchase or cultivation of narcotic drugs or psychotropic substances for personal consumption'.
However, it is made clear in the Commentaries to the Convention that governments can choose between wide ranges of judicial responses. The offence of 'possession of drugs for personal consumption' may for example be punished by a fine or by simple censure and not necessarily by a prison sentence.52 This confirms what has already been discussed namely that national laws can legitimately facilitate strategies designed to help prevent drug users from becoming infected with the HIV.
52 Commentary on the United Nations Convention Against Traffic in Narcotic drugs and Psychotropic Substances 1988 (December 1988)
It is clear from the findings reported above that injecting drug use is a major vector for HIV transmission in all the countries examined in this study. Of all the different ways that the AIDS virus can be transmitted, directly injecting a substance contaminated with HIV into the blood stream is by far the most efficient. It is also evident that injecting drug use contributes disproportionately to the scale of the epidemic in the region.
However, despite widespread high risk behaviours among drug users none of the study-countries (with the exception of Viet Nam) include in their stated public policies the kind of measures to prevent HIV/AIDS among drug users and their sexual partners advocated by scientific community and UN agencies. To-date, there are relatively few programmes in the region, which directly address problems presented by the interface between drug use and HIV/AIDS.
As indicated in this report, there is little dialogue between drug prevention and treatment, law enforcement and HIV/AIDS prevention authorities and while a number of the study-countries have nominally established multi-sectoral responses these are yet to be rendered effective in most cases.
Drug treatment generally focuses on detoxification treatment only, and in all seven study-countries, drug users are afforded limited access to voluntary treatment. In the main, drug treatment is of a compulsory nature and includes a strong penal element. In general, drug policies are not supportive of effective HIV prevention strategies among drug users. Measures are often localised, short-term, under-funded, and insufficient in scope. Even where policies targeting vulnerable groups are favoured by policy makers they are not necessarily translated into practice, because of insufficient resources and inadequate training.
The challenge remains to identify factors that might facilitate change, and to identify useful opportunities and levers that might lead to policy changes in the direction of a more benign and effective policy improving the efficacy of HIV/AIDS prevention. Such opportunities exist in all study-countries. Many policy makers are beginning to accept that although the goal of a drug-free society is preferable, it might be difficult to achieve in the short term and that the threat of the HIV epidemic necessitate some interim measures to keep the epidemic.