Strict laws on the criminalisation of drug use and drug users are fuelling the spread of HIV and other serious harms associated with the criminal market and should be reviewed, say experts in a series of articles published on bmj.com today to coincide with the 18th International AIDS Conference in Vienna, 18-23 July 2010.
Countries most affected include Russia and Ukraine, which operate strict drug laws and remain resistant to evidence-based harm reduction services like opiate substitution therapy and needle exchange programmes.
Professor Tim Rhodes and colleagues estimate that Russia could cut HIV rates by up to 55% if it legalised and scaled-up opiate substitution therapy and call for legal change to enable such treatment to tackle drug related harms.
Research shows that opioid substitution treatment can reduce risk of HIV infection by 60-84%, say Rhodes and colleagues. The World Health Organization promotes it as an "essential medicine" and methadone or buprenorphine substitutes are prescribed to over 650,000 people in Europe. Opioid substitution treatment is a core harm reduction intervention alongside distributing clean needles and providing easy access to HIV treatment.
Yet Russia prohibits opioid substitution treatment and has only about 75 needle and syringe programmes for its two million injecting drug users. It also has one of the fastest growing HIV epidemics in the world. A strong emphasis on the criminalisation of drug users hampers HIV prevention.
Using mathematical models, Rhodes and his team estimate that "Russia could substantially reduce the incidence of HIV infection if it permitted the use of opioid substitution treatment."
"The roots of resistance to harm reduction in Russia are complex," they add, "and show why efforts to bring about structural changes in national laws and policies should be at the forefront of global efforts to scale-up HIV prevention." The prohibition of opioid substitution treatment "limits rights of access to evidence-based health care, as championed by the UN and other international agencies."
In a second article, Stephen Rolles, Senior Policy Analyst at Transform Drug Policy Foundation argues that we need to end the criminalisation of drugs and instead set up regulatory models that will control drug markets and reduce the health and social harms caused by current policy.
He outlines Transform's blueprint for regulating drug availability and points to evidence that less punitive approaches do not necessarily lead to increased use. "Transform's blueprint does not seek to provide all the answers but to move the debate beyond whether we should end the war on drugs to what the world could look like after the war on drugs," he says. "It is a debate that the medical and public health sectors have failed to engage with for far too long."
In an accompanying feature, Richard Hurley of the BMJ reports on the situation in Ukraine, which has an estimated 290,000 drug injectors and possibly the highest prevalence of HIV in Europe. Despite entrenched corruption and police interference, he explores how community organisations are leading the fight against HIV among drug injectors and sex workers.
A linked study of injecting drug users in Edinburgh finds that while long term opiate substitution treatment reduces the risk of death, it does not reduce the overall duration of injecting. An editorial believes that doctors and scientists working in the field of drug addiction have an ethical obligation to speak out about the need for evidence based approaches to tackle drug related harms.
Finally a doctor and former heroin user gives a personal and candid account of his addiction. Writing anonymously, he says, "It has made me a better doctor, more understanding of human frailty because my own frailty is so stark."
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