As Executive Director of INPUD, the key international NGO for one of the key affected populations, namely people who inject drugs, I welcome references in the report of the co-sponsoring organisations to
- The impact of stigma & discrimination against PWIDs and the role that it plays in creating barriers to services
- The recognition of the importance of empowering PWIDs through their own peer organisations and the key role that we can play in the development of appropriate, effective policies, services and programmes
However, stigma and discrimination do not exist in a vacuum and nowhere is the link made between, stigma and discrimination against injecting drug users, drug control regimes and repressive legal environments and the ways in which these three are currently stoking the epidemic such that a third of new infections outside of Sub-Saharan Africa are due to the use of non-sterile or shared syringes; indeed in some populations of injecting drug users, notably in the EECA region prevalence rates are as high as 85%.
If we are to make significant progress in stemming the growth of the epidemic amongst people who inject drugs we have to recognise the need for enabling, legal environments as the thematic segment makes abundantly clear. We work very closely with our fellow key affected populations – notably, sex workers and men who have sex with men, on the many issues and challenges that we face in common, these range from stigma and discrimination, lack of appropriate services and criminalization. It is time for the universal action that is called for by the recognition that it is only supportive legal environments, which are the only ones in which key harm reduction interventions including NSP and OST can flourish, that we can make significant progress in halting and reversing the epidemic amongst people who inject drugs. Given that outside Sub-Saharan Africa the epidemic is largely being driven by the use of non-sterile or shared syringes, this would in and of itself be a significant step towards getting towards zero new infections.
As such, the ways in which the legal environment impacts on the HIV response is unambiguous.
There is substantial flexibility around the world in applying and interpreting UN drug control regulations and we welcome this innovation and flexibility. There is an urgent need to draw together the learning from these different models which clearly demonstrate that when the legal environment is enabling rather than repressive, and when pressures are removed from people who inject drugs and drug scenes then health improves, engagement in NSP and OST can double and HIV rates amongst people who inject drugs can drop by half within 5 years.
I commend those countries that are exploring new models for decriminalizing people who inject drugs and urge the UN family and member states to reduce the contradictions between, on the one hand, the HIV public health approach which is rooted in a commitment to human rights and a recognition of the need to end stigma and discrimination and on the other, the drug control regime which does neither, but in fact exacerbates them.
There is considerable scope within the drug control conventions for innovation which many countries have explored to create more supportive legal environments for people who inject drugs, these innovations include but are by no means limited to the prescription of heroin, safe consumption rooms, decriminalization of people who use drugs, the support of peer led organisations of people who inject drugs to initiate and carry out education programmes and conduct research, to the implementation of the comprehensive package of harm reduction measures as identified in the technical guidance for reducing HIV amongst injecting drug users; it is notable that those countries that have explored the latitude offered by the conventions, either early or comprehensively, and preferably both, have managed to keep HIV amongst people who inject drugs at extremely low levels. On the other hand, we note that other countries notably in the EECA, and Asian regions have maintained extremely repressive legal environments, which encourage stigma and discrimination amongst injecting drug users, and prevents the roll out of comprehensive harm reduction measures, crucially NSP and OST. There is a direct correlation between such repressive legal environments and high prevalence rates amongst injecting drug users. To conclude, the epidemiology clearly demonstrates the link between repressive legal environments and high prevalence rates amongst PWID as well as the converse. We know too what needs to be done to prevent transmission, and even reverse the epidemic amongst PWID, the evidence supporting the efficacy of NSP and OST is irrefutable, and the role that stigma and discrimination play in marginalizing PWID and keeping them away from services, where they exist, is evident. It is time to act, and time to act boldly.
Dr Eliot Ross Albers, PhD
International Network of People who Use Drugs