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Fear can lead drug users to inject quickly and furtively.
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92 | OUTLOOK | www.unaids.org
Africa occur among injecting drug users. Between China, the Russian Federation and the USA, there are about six million people who inject drugs. The use of drugs is criminalized in all these countries and the majority of drug control efforts are spent on policing and imprisonment. This provides a fertile ground for sharing. Costs of drugs are often high, so individuals are often involved in supporting their own drug use by selling small amounts to other drug users. The risks of being caught with needles and syringes weigh heavily on the minds of users, as many law enforcement officials use their possession as a proxy for drug use. Fear can lead drug users to inject quickly and furtively. Choton navigates the busy streets of Dhaka, Bangladesh. An injecting drug user for many years, he does not carry his own needles and syringes, because of fear of getting caught. “I would rather use a dirty needle at an injecting site than carry my own and go to jail,” he says. Bureaucracy doesn’t help either. Pharmacies often do not sell needles without a prescription, or they ask too many questions. Where legal access is available, drug users seldom trust health officials to maintain confidentiality. Fear of discrimination and intimidation from employers and the police if they register as drug users is very real in many countries. Mr Timur Islamov, Director of the Russian nongovernmental organization Development of Education, Health and HIV/AIDS Prevention, is a former drug user and has experienced this first-hand, “If you are registered as a drug user you cannot have a driver’s licence and there are restrictions on certain types of work,” he says. “In addition, many organizations have security services that have access to databases of drug clinics. That means that this personal data can be used to not hire someone because of his/her past experience. One can be stopped at any time on the street and be forced to undertake a medical drug test. If the test is positive, the person can be imprisoned for three to 15 days.” In Bangladesh, the authorities converted their extensive database of drug users into an anonymous one in order to avoid misuse by the police and other entities. Dr Munir Ahmed, a former Team Leader for Operations of the HIV programme of CARE Bangladesh, led this process. “This helped restore confidence among drug users to access services from drop-in centres and meet with outreach workers without fear,” he says. “This system is now followed by all nongovernmental organizations working on harm reduction programmes with drug users in Bangladesh.”
Two authorities, one problem: getting public health and law enforcement on the same side The relationship between health services and law enforcement agencies has sometimes been difficult. At times they have worked at cross-purposes. Breaking the vicious cycle of HIV and drug dependence demands that society build supportive relationships between people who use drugs, health authorities and law enforcement agencies. As Portugal has shown, civil tribunals that provide counselling and support can be a more effective response to drug offences than courts handing out custodial sentences. Alternatives to imprisonment and courts sensitive to the needs of drug-dependent people are appearing across the world. The agreement at the annual meeting of the Commission on Narcotic Drugs that health solutions are better than criminal solutions is difficult for some drug enforcement officers—more comfortable with populist ‘zero tolerance’ campaigns—to accept. “This sends the wrong message” is the refrain that can be heard. But where they have worked together they have been able to effectively balance the twin goals of drug control and HIV prevention. Kyrgyzstan is a recent success story. There are approximately 26 000 drug users in the country. Mr Nurlan Shonkorov is one who has benefited from the introduction of harm reduction programmes there. “I have been on methadone for about three years and receiving antiretrovirals for more than three years,” he says. “I receive free condoms and some treatment for free. The treatment has been mainly arranged by the AIDS Centre’s dispensary department.” The country’s harm reduction programme has backing from both law enforcement and public health officials. Opioid substitution therapy has been endorsed by both the national AIDS programme and the national counternarcotics programme. Methadone and buprenorphine have been included in the national essential medicines list. Civil society activists, drug treatment specialists and parliamentarians engage with people who oppose the strategy. The results are promising. Increasing numbers of drug users have found employment. Self-reported quality of life increased by ten-fold after drug users went on methadone substitution therapy. A survey showed that casual sexual encounters went down by over half. Only 14.5% of drug users had injected drugs in the past three months and only 3.6% shared injecting equipment. Most importantly, crime dropped to zero. “These programmes are effective both in terms of prevention and treatment. They help