Injection drug use accounts for only five per cent to ten per cent of cumulative HIV infections globally, but in some parts of the world it is the major mode of HIV transmission and incidence continues to rise. For more information, see the HIV epidemiology chapter.

In any country with unsafe drug-injecting practises, a fresh outbreak of HIV is liable to occur at any time. Worst affected are the Russian Federation, Ukraine, and the Baltic states (Estonia, Latvia, and Lithuania), but HIV continues to spread in Belarus, Moldova and Kazakhstan, while more recent epidemics are now evident in Kyrgyzstan and Uzbekistan. In the Russian Federation, a new outbreak of HIV among injecting drug users (IVDUs) in the Moscow region in 1999, resulted in the reporting of more than three times as many new cases in that year as in all the previous years combined. It is now estimated that around 860,000 people aged 15-49 are living with HIV in the Russian Federation, although reporting of HIV cases is at best patchy in many areas. The epidemic in Eastern Europe is driven by injecting drug use, and the criminalisation of this practise makes it difficult to gain an accurate picture of the proportion of drug users who are HIV positive. In some cities, such as Svetlogorsk in Belarus, HIV prevalence among IVDUs rose to more than 55% within one year of identifying HIV among the city's IDU population. It is estimated that in China, Malaysia, and Vietnam at least half of HIV infections are associated with drug injection.

HIV epidemics among IVDUs are distinguished from those of other populations by their potential for rapid spread of the virus within the IVDU community and outward into the general population. In Bangkok, New York and Odessa, experience has shown that once HIV prevalence reaches a threshold of about 10%, it can surpass 40 - 50% within one to four years. Most of these infections result from sharing or reusing contaminated equipment (mainly needles and syringes) or from injecting tainted drug preparations.

Adolescence is also the time many young people are at risk of experimenting with drugs, and many of the new infections worldwide result from the sharing of drug use paraphernalia by young people (http://www.aacap.org/publications/factsfam/teendrug.htm). Young people often do not have the skills or the incentives to avoid starting doing drugs. Once they have started, many quickly progress from inhaling or snorting to injecting, which dramatically increases their risk of infection. In the Russian Federation, there were 3,008 reported new HIV infections among injecting drug users aged 10 to 19 in 1999. By 2000, that number had more than tripled to 9,612. In Thailand, 80 per cent of women and girls admitted to drug treatment centres during 1999-2000 were under 25. Everywhere in the world, drug use is also associated with heightened sexual transmission of HIV.

Repressive laws and policies as well as punitive policing are the most common responses to drug use and drug users in many countries. A number of countries have recently passed legislation partly inspired by the “zero-tolerance” approach that dominates current US drug policy. In general, official policy in many countries continues to be guided by international conventions on drug use that emphasize drug interdiction and drug user incarceration approaches. Police harassment of drug users is also widespread. It is reported that, in some countries, particularly in Eastern Europe and Central & South East Asia, police round up young people suspected of drug use to search for signs of injecting or force them to be tested for HIV. Those who test positive have their drug use and HIV status registered.

These and other human rights abuses are compounded by the failure to provide needed services to drug users. In many countries, the few official drug treatment programs that do exist often share the punitive approach to drug users that characterizes official drug policy, hence many drug users do not access the treatment that is available. Counselling, peer support, and other approaches that address the psychosocial needs of people trying to deal with their addiction are rarely used. Substitution treatment is unavailable in many countries, and illegal in some, despite the overwhelming international evidence that points to the efficacy of harm reduction approaches in reducing the individual and social harms associated with drug use, especially HIV/AIDS and other diseases.

In the UK, for example, with efforts to reduce the supply of and demand for illicit drugs there are also policies and programmes in place which attempt to decrease the adverse health, social and economic consequences of drug use. However, developing harm reduction in many countries brings a number of challenges, especially in those with hostile policies together with negative social attitudes toward drug users and people with HIV/AIDS which inhibits the expansion of harm reduction services to the requisite scale.

Fair and accurate reporting plays a vital role in raising public awareness of and shaping national and international responses to drug use and HIV/AIDS. However, many news stories continue to portray drugs users and people with HIV/AIDS only in terms of the threat they pose to others. All too often, drug users and their families are merely represented as silent objects of law enforcement or drug control campaigns, or not included in media coverage at all.

The spread of injecting and drug use in developing countries

One of the most powerful factors governing the spread of HIV in developing countries is the globalisation of the heroin and cocaine trade, and the unintentional impact of policies to combat that trade.