The report shows that the failure of many countries to adopt health- and rights-based approaches resulted in no reduction in the global number of new HIV infections among people who inject drugs between 2010 and 2014. The world has missed the United Nations General Assembly’s target set in 2011 to reduce HIV transmission among people who inject drugs by 50% by 2015.
“Business as usual is clearly getting us nowhere,” said Michel Sidibé, Executive Director of UNAIDS. “The world must learn the lessons of the past 15 years, following the example of countries that have reversed their HIV epidemics among people who inject drugs by adopting harm reduction approaches that prioritize people’s health and human rights.”
The UNAIDS report presents the evidence base for five policy recommendations and 10 operational recommendations that countries should apply to turn around their HIV epidemics among people who inject drugs. These recommendations include the implementation of harm reduction programmes to scale and the decriminalization of the consumption and possession of drugs for personal use.
Data demonstrate that countries implementing health- and rights-based approaches have reduced new HIV infections among people who inject drugs. In other countries, strategies based on criminalization and aggressive law enforcement have created barriers to harm reduction while having little or no impact on the number of people who use drugs. Imprisoning people for the consumption and possession of drugs for personal use also increases their vulnerability to HIV and other infectious diseases, such as hepatitis B, hepatitis C and tuberculosis, while incarcerated.
UNAIDS has developed the UNAIDS 2016–2021 Strategy to put the world on track to ending the AIDS epidemic as a public health threat by 2030—a target within the Sustainable Development Goals. A critical target within this Fast-Track approach is the expansion of a combination of HIV prevention and harm reduction services to reach 90% of people who inject drugs by 2020.
Achieving this target would require annual investment in outreach, needle–syringe distribution and opioid substitution therapy in low- and middle-income countries to increase to US$ 1.5 billion by 2020—a fraction of the estimated US$ 100 billion already spent each year to reduce the supply of and demand for narcotic drugs. In many middle-income countries with large populations of people who inject drugs, harm reduction is funded predominantly by international donors and private foundations.
The UNAIDS report provides many examples of countries that are delivering better outcomes for people who inject drugs by adopting a health-centred approach.
The free voluntary methadone programme piloted in China in the early 2000s now serves more than 180 000 people. People who inject drugs accounted for less than 8% of people newly diagnosed with HIV in the country in 2013, compared with 43.9% in 2003.
In prisons in the Islamic Republic of Iran, health clinics provide integrated services for the treatment and prevention of sexually transmitted infections and for injecting drug use and HIV, including the distribution of condoms, sterile injecting equipment and opioid substitution therapy. At the end of 2014, 81.5% of people who inject drugs surveyed reported the use of sterile injecting equipment the last time they injected. Newly reported HIV cases among people who inject drugs in the Islamic Republic of Iran fell from a peak of 1897 in 2005 to 684 in 2013.
A peer-to-peer outreach programme in five cities began in 2011 in Kenya encouraging people to use sterile equipment when injecting drugs. At the beginning of the pilot, 51.6% of people who inject drugs reported the use of a sterile syringe the last time they injected; this had risen to 90% by 2015.
In the Republic of Moldova, the prison system has gradually expanded a comprehensive harm reduction programme started in 1999 that includes needle, syringe and condom distribution as well as opioid substitution therapy. Coverage of antiretroviral therapy among prisoners living with HIV increased from 2% in 2005 to 62% in 2013.
In 2000, Portugal passed a law that downgraded the purchase, possession and consumption of small amounts of narcotic drugs from criminal to administrative offences while increasing investment in health-based programmes. In 2013, among a total of 1093 new HIV infections reported, just 78 were related to drug use; in 2000 there were 1497 new HIV infections among people who use drugs among a total of 2825 new HIV infections. A similar downward trend among drug users has been observed for new infections of hepatitis C and B.
As well as being humane and health-oriented, people-centred programmes are also cost-effective and deliver wider social benefits, such as lower levels of drug-related crime and reduced pressure on health-care systems. For example, each dollar spent on Australia’s needle–syringe programme has an estimated lifetime return on investment of up to US$ 5.50 in averted health-care costs. Opioid substitution therapy has been shown to be cost-effective in its capacity to reduce HIV infections—its cost-effectiveness substantially increases when its wider health, economic, psychological and social benefits are taken into account.
“Health is a human right. Investment in people-centred policies and programmes for people who use drugs is the crucial foundation for a global drugs policy that not only saves lives but is also cost-effective,” said Mr Sidibé.
The UNAIDS Fast-Track approach has a set of targets for 2020 that include reducing new HIV infections to fewer than 500 000. It also calls on countries to ensure that 90% of the more than 12 million people who inject drugs worldwide have access to combination HIV prevention services, including needle–syringe programmes, opioid substitution therapy, condoms and access to counselling, care, testing and treatment services for bloodborne viruses, such as HIV, tuberculosis and hepatitis. Achieving these targets will be a significant step towards ending the AIDS epidemic as a public health threat by 2030.