An excessive reliance on drug law enforcement is the major barrier to stemming the tide of new HIV infections amongst injecting drug users (IDUs), Australian harm reduction expert Alex Wodak told the Sixteenth International AIDS Conference during a plenary session on HIV prevention. The former President of the International Harm Reduction Association said that this policy is "inadvertently pro-HIV" and accused policy makers who ignored "the scientifically proven benefits of harm reduction" of being "obscenely and indulgently in denial".
In 2003, a UNAIDS report highlighted that injecting drug use was fuelling exploding HIV epidemics throughout the world, particularly in eastern Europe and central Asia. UNAIDS now estimates that injecting drug use currently accounts for around 30% of new HIV infections outside of sub-Saharan Africa, and one-in-ten of new HIV infections globally. However, injecting drug use is a growing concern in some sub-Saharan African countries, according to a recent report.
"The proportion of global HIV infections attributable to injection drug use are growing," Dr Wodak, Director of the Drug and Alcohol Service at St. Vincent's Hospital in Sydney, Australia told a packed Toronto auditorium. He argued that the benefits of needle and syringe exchange and opiate substitution programmes for IDUs was "one of the most effective interventions in the HIV/AIDS repertoire".
In fact, harm reduction experts have known how to prevent HIV infection in IDUs "for at least 15 years", he said, adding that the "scientific debate is now over: harm reduction is effective, safe and cost-effective."
Harm reduction has been adopted by many countries where IDUs are at risk of HIV, he added, and it is now an accepted intervention by most UN agencies. However, it is primarily opposed by the United States on moral and political grounds. "The opposition in the United States prevents these pragmatic approaches being spread throughout the world," he said.
Indeed, US influence is wide-reaching. As well as affecting UN policy, it is also a stipulation of the US President's Emergency Plan for AIDS Relief (PEPFAR) to prevent organisations in receipt of PEPFAR funds from talking about - and addressing - harm reduction strategies for IDUs.
He pointed out the ironic situation faced by the United States where around 25% of new HIV infections are amongst IDUs. By ignoring harm reduction, the US has the highest incidence of HIV infections of any high income country – about five times greater than runner-up, Spain.
Dr Wodak noted that the UN Office on Drugs and Crime currently estimates that the drug trade has an annual turnover of more than US$322 billion a year and accounts for around eight per cent of total international trade. It was clear, he said, that the war on drugs has failed, and that it was time to be pragmatic. "Drug use around the world is a growing problem that the war on drugs has completely failed to arrest," he said.
The US was not alone, however. Dr Wodak also pointed out that France is currently trying to reclassify the heroin substitution drug, buprenorphrine, as a narcotic. Recent reports also suggest that there is a lack of access to substitution therapy in Eastern Europe and Central Asia. And he pointed out that even in countries where harm reduction measures are in place, access to clean needles in prisons is almost non-existent.
"I find it particularly galling and tragic in that this is one part of the epidemic we really could do something about," said Dr Wodak, "and yet it's the politics in so many countries that prevents us from doing what has to be done." He added that policy makers who ignore the benefits of harm reduction are "obscenely and indulgently in denial" and argued that surely "80% of something is better than 100% of nothing." Warm applause greeted both of these statements.
He concluded by arguing that it was now the major issue for policy makers to recognise that drug use is "primarily a health problem" rather than a law and order issue, and that future policy should be based on "science and human rights."
"The choice," he said, "is either controlling drug-related HIV infections, or sending what some consider to be the right message. We can't have both."
Wodak A. Controlling HIV among injecting drug users: current status of harm reduction. Sixteenth International AIDS Conference, Toronto, TuPl04, 2006.
Video and slides of Dr Wodak's presentation are available here.