Is There Such a Thing as Safe Drug Abuse?

Human Rights Watch testimony to the Subcommittee on Criminal Justice, Drug Policy and Human Resources briefing

Harm Reduction or Harm Maintenance: Is There Such a Thing as Safe Drug Abuse?

Human Rights Watch respectfully submits this testimony to the Subcommittee on Criminal Justice, Drug Policy and Human Resources as it addresses harm reduction-based approaches to HIV prevention among injection drug users. Human Rights Watch, an independent nongovernmental organization founded in 1978, has documented human rights abuses around the world. Our HIV/AIDS and Human Rights Program has documented HIV/AIDS-related human rights abuses against injection drug users in the United States, Canada, Kazakhstan, Bangladesh, China, Russia, and Thailand. Copies of these reports are submitted along with this testimony.

Background

The sharing of syringes by injection drug users is one of the principal causes of HIV/AIDS in the world today. Injection drug use accounts for the majority of new HIV infections in eastern Europe and central Asia,1 the region that is home to the fastest growing AIDS epidemics in the world. China, Malaysia and Vietnam also face burgeoning AIDS epidemics fueled principally by injection drug use.2 Syringe exchange and methadone maintenance therapy, both proven to reduce HIV among those who inject drugs, remain out of reach to the vast majority of drug users worldwide. As of 2002, methadone therapy was banned in nine eastern European and central Asian countries that accounted for 80 percent of HIV-positive injection drug users in the region.3 At the same time, the enforcement of harsh anti-drug laws has led to rampant violations of due process by police and prolonged incarceration of drug users in overcrowded and unsafe prisons.4 In one notorious example in 2003, a brutal “war on drugs” in Thailand resulted in the extrajudicial killing of an estimated 2,275 drug suspects in its initial three-month phase.5 These violations of due process are not only illegal, but also contribute to HIV risk by driving injection drug users away from lifesaving HIV prevention services.

Drug users’ right to health

Abuses of their rights within the criminal justice system are not the only violations drug users face. They also routinely face violations of their right to the “highest attainable standard of health,” which has been interpreted by international bodies to proscribe measures that interfere with effective HIV prevention programs.6 Syringe exchange, which allows drug users to exchange used syringes for sterile ones, has been shown in repeated studies in numerous jurisdictions to reduce HIV transmission.7 Methadone, an orally administered prescription drug that reduces opiate craving, also lowers HIV risk by eliminating drug users’ reliance on syringes.8 Opponents of syringe exchange in the U.S. government have willfully distorted data on drug users’ injection risk to make their case.9 The claim that syringe exchange programs promote drug use has been disproved in repeated studies.10 Syringe exchange and methadone programs are both endorsed by the World Health Organization and function legally and effectively in many countries with injection-driven HIV epidemics, sometimes with financial support from governments.

The United States

Legal restrictions on harm reduction programs in the United States have frustrated the country’s HIV prevention efforts and set a poor example internationally. As of 2002, an estimated 28 percent of new AIDS cases in the United States stemmed from injection drug use.11 The national drug abuse “treatment gap”—the number of persons in need of treatment for drug abuse who did not receive it—was estimated in 2000 at 3.9 million people, or 83.4 percent of the population needing treatment.12 Not only does the U.S. government fail to address this treatment gap, but it exacerbates the problem by prohibiting the use of federal funds for needle exchange services, despite numerous government-funded studies establishing the effectiveness of needle exchange.13 The U.S. is the only government in the world to have such a prohibition. In addition, all fifty U.S. states have laws regulating the possession and distribution of sterile syringes as “drug paraphernalia” and/or restrictions on the purchase and sale of syringes in pharmacies14 While needle exchange programs exist in some states with limited government support, police officers in numerous jurisdictions can and do confiscate sterile syringes from participants in legal syringe exchange programs.15

Attacks on science

Impugning the evidence behind proven HIV prevention strategies is a well documented recent practice of the U.S. government. Since 2000, the U.S. government has censored or distorted factual information about the effectiveness of condoms against sexually transmitted HIV. This has included altering fact sheets on condoms on the websites of the U.S. Centers for Disease Control and Prevention (CDC) and the Agency for International Development (USAID) and appointing opponents of condoms to high-level policy positions.16 The U.S. government has also invested millions of dollars in unproven “abstinence-only” education programs while failing to highlight extensive evidence of their ineffectiveness and potential harms.17 Recent attacks on harm reduction programs for injection drug use bear a striking resemblance to these attacks on condoms and comprehensive sex education. While no one disagrees with abstinence from sex and/or drugs as an HIV prevention strategy, promoting abstinence should not come at the cost of suppressing other methods that are proven to better safeguard health and life.

Conclusion and Recommendations

Restricting access to proven HIV prevention strategies, or censoring or distorting factual information about their effectiveness, is not only poor public health policy, but also an impediment to the realization of the human right to seek and impart information of all kinds, the right to the highest attainable standard of health, and the right of life. Human Rights Watch accordingly recommends:

• That the U.S. government publicly reaffirm the evidence-base behind harm reduction strategies for HIV prevention, as established in its own government-funded studies;

• That the U.S. government withhold funding from programs that censor or distort information about the evidence behind harm reduction, including needle exchange, and redirect funding to proven strategies;

• That the U.S. government lift the ban on using federal funds for needle exchange programs; and

• That state and local governments lift all legal restrictions on harm reduction programs, including restrictions on needle exchange, and prohibit enforcement of “drug paraphernalia” laws against persons in possession of syringes for the purpose of disease prevention.

Reports cited in this testimony

“Not Enough Graves: The War on Drugs, HIV/AIDS, and Violations of Human Rights in Thailand”

July 2004: http://www.hrw.org/campaigns/aids/2004/thai.htm

“Lessons Not Learned: Human Rights Abuses and HIV/AIDS in the Russian Federation”

April 2004: http://hrw.org/reports/2004/russia0404/

“Injecting Reason: Human Rights and HIV Prevention for Injection Drug Users; California: A Case Study”

September 2003: http://www.hrw.org/reports/2003/usa0903/

“Locked Doors: the Human Rights of People Living with HIV/AIDS in China”

September 2003: http://www.hrw.org/reports/2003/china0803/

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[1] UNAIDS and WHO, AIDS Epidemic Update (UNAIDS/02.58E), December 2002, p. 12; UNAIDS and WHO, AIDS Epidemic Update (UNAIDS/01.74E), December 2001, p. 6.

[2] Wolfe and Malinowska-Sempruch, Illicit Drug Policies and the Global HIV Epidemic, pp. 3, 15; Human Rights Watch, Locked Doors: The Human Rights of People Living with AIDS in China, vo. 15, no. 7(C), September 2003.

[3] Open Society Institute, Drugs, AIDS and Harm Reduction: How to Slow the HIV Epidemic in Eastern Europe and the Former Soviet Union (New York: Open Society Institute International Harm Reduction Development, 2001); Central and Eastern Europe Harm Reduction Network (CEEHRN), Injecting Drug Users, HIV/AIDS Treatment and Primary Care in Central and Eastern Europe and the Former Soviet Union (report of a survey), July 2002, p. 24.

[4] See, e.g., Human Rights Watch, Fanning the Flames: How Human Rights Abuses are Fueling the AIDS Epidemic in Kazakhstan, vol. 15, no. 4(D), June 2003; Human Rights Watch, Ravaging the Vulnerable: Abuses Against Persons at High Risk of HIV Infection in Bangladesh, vol. 15, no. 6(C), August 2003; Human Rights Watch, Locked Doors; Human Rights Watch, Lessons Not Learned: Human Rights Abuses and HIV/AIDS in the Russian Federation, vol. 16, no. 5(D), April 2004; Human Rights Watch, Thailand: Not Enough Graves: The War on Drugs, HIV/AIDS, and Violations of Human Rights (vol. 16, no. 8(C), July 2004); Daniel Wolfe and Kasia Malinowska Sempruch, Illicit Drug Policies and the Global HIV Epidemic: Effects of UN and National Government Approaches (New York: Open Society Institute International Harm Reduction Development Program, 2004).

[5] See, e.g., Human Rights Watch, Not Enough Graves.

[6] Committee on Economic, Social and Cultural Rights, “General Comment No. 14: The right to the highest attainable standard of health,” November 8, 2000, paras. 8, 16, 33, 50. The Committee on Economic, Social and Cultural Rights is the U.N. body responsible for monitoring States Parties compliance with the International Covenant on Economic, Social and Cultural Rights.

[7] See most recently, World Health Organization, Effectiveness of Sterile Needle and Syringe Programming in Reducing HIV/AIDS Among Injecting Drug Users (Evidence for Action Technical Series, 2004).

[8] World Health Organization, United Nations Office on Drugs and Crime and Joint United Nations Programme on HIV/AIDS (UNAIDS), WHO/UNODC/UNAIDS position paper: Substitution maintenance therapy in the management of opioid dependence and HIV/AIDS prevention (2004), pp. 13, 14, 18.

[9] In 1997, two observational studies from Vancouver and Montreal reported a higher incidence of HIV among syringe exchange clients than those injection drug users not using a syringe exchange service. These studies were subsequently erroneously cited, including by former ONDCP director Barry McCaffrey in testimony to the U.S. Congress, as having shown that syringe exchange contributed to this increased HIV risk, when in fact the studies concluded no such thing. In numerous statements, including an op-ed published in the New York Times in April 1998, the authors clarified that pre-existing risk factors, not syringe exchange programs, contributed to higher HIV rates among program clients. “Because these programs are in inner-city neighborhoods, they serve users who are at greatest risk of infection,” the authors wrote. “Those who didn’t accept free needles often didn’t need them because they could afford to buy syringes in drug stores. They were also less likely to engage in the riskiest activities.” In a 1999 letter to members of the California legislature, one of the authors of the Vancouver study, Steffanie Strathdee, wrote that “[i]n no way did needle exchange programs contribute to the spread of HIV among drug users in Vancouver. In our opinion, if needle exchange had not been in place, rates of HIV would have been much higher, much sooner.” The 1997 NIH Consensus Panel, which recommended the removal of all legal barriers to syringe access, included a review of the Montreal and Vancouver studies. Subsequent, uncontradicted research in both Montreal and Vancouver has shown no causal association between HIV transmission and syringe exchange in those cities. See Julie Bruneau and Martin T. Schecter, “Opinion: The Politics of Needles and AIDS,” The New York Times, April 9, 1998; letter from Steffanie A. Strathdee, Associate Professor, Johns Hopkins University School of Hygiene and Public Health, to members of the California legislature, August 19, 1999; National Institutes of Health Consensus Panel, Interventions to Prevent HIV Risk Behaviors; American Foundation For AIDS Research (amfAR), “The Facts About Montreal and Vancouver: New Studies Find No Evidence That Needle Exchange Programs Lead to HIV Transmission” (1999).

[10] See, e.g., Human Rights Watch, United States: Injecting Reason: Human Rights and HIV Prevention for Injection Drug Users (vol. 15, no. 2 (G), Sept. 2003), pp. 12-17; M. Ainsworth et al., Thailand’s response to AIDS, p. 44; World Health Organization, “Harm Reduction Approaches to Injecting Drug Use,” online: http://www.who.int/hiv/topics/harm/reduction/en/print.html (retrieved April 28, 2004).

[11] U.S. Centers for Disease Control and Prevention, “Drug-Associated HIV Transmission Continues in the United States,” May 2002, p. 1; U.S. Centers for Disease Control and Prevention, HIV/AIDS Surveillance Report: U.S. HIV and AIDS cases reported through December 2001 (vol. 13, no. 2), Tables 5, 6, 9, 10.

[12] Of those, approximately 9.8 percent reported that they felt they needed treatment for their drug problem, and 3.3 percent said they had made an effort but were unable to get treatment. These are the most recent estimates of the national treatment gap, released in July 2002. The survey does not distinguish between injection and non-injection drug use; however, Lurie and Drucker estimate that “only about 15 percent of the estimated 1-1.5 million [injection drug users] in the USA are in drug treatment on any given day.” Office of Applied Studies, National and State Estimates of the Drug Abuse Treatment Gap: 2000 National Household Survey on Drug Abuse, Rockville, MD: Substance Abuse and Mental Health Services Administration (SAMHSA), 2002; Peter Lurie and Ernest Drucker, “An opportunity lost: HIV infections associated with lack of a national syringe-exchange programme in the USA,” The Lancet, vol. 349 (March 1, 1997), pp. 604-608.

[13] Health Omnibus Programs Extension of 1988, Pub L No 100-607, 102 Stat 3048 (sec. 256(b)); Comprehensive Alcohol Abuse, Drug Abuse, and Mental Health Amendments Act of 1988, Pub L No 100-690 (Title II, Subtitle A), 102 Stat 3048 (sec. 2025(2)(A)); Ryan White Comprehensive AIDS Resources Emergency Act of 1990, Pub L No 101-381, 42 USC 300ff (sec. 422); “Evidence-Based Findings on the Efficacy of Syringe Exchange Programs: An Analysis from the Assistant Secretary for Health and Surgeon General of the Scientific Research Completed Since April 1998,” October 6, 2000.

[14] Scott Burris et al., “Syringe Access Law in the United States: A State of the Art Assessment of Law and Policy,” online: www.publichealthlaw.net (retrieved November 5, 2002), p. 18.

[15] See, e.g., Human Rights Watch, Injecting Reason, pp. 20-33.

[16] Human Rights Watch, Access to Condoms and HIV/AIDS Information: A Global Health and Human Rights Concern (Backgrounder, December 2004), pp. 3-9.

[17] Human Rights Watch, Ignorance-Only: HIV/AIDS, Human Rights and Federally Funded Abstinence-Only Programs in the United States: Texas: A Case Study, vol. 14, no. 5(G), September 2002.

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