The International Narcotics Control Board and HIV/AIDS
Policies and programs to address the use of illicit drugs at both the national and the international level are fundamental to the success of government responses to HIV/AIDS. In countries where HIV transmission among people who inject drugs is very low, that outcome is usually the result of policies and programs that ensure ready access to sterile syringes (including in prisons in some countries); accessible and affordable opiate substitution therapy for people who inject heroin; and, in some cases, measures such as supervised injection facilities and decriminalization of syringe possession.
In contrast, in countries such as Russia where methadone therapy is illegal, needle exchanges are few, and people who use drugs have been subjected to arrest and imprisonment for the residue in used syringes, HIV/AIDS thrives. In the U.S., where there is a ban on federal funding of needle exchange, serious impediments to opiate substitution, and harsh drug laws that make it difficult to draw drug users into public health services, some 15% to 20% of new HIV transmissions and reported AIDS cases are linked to drug injection.1 Worldwide, about 30% of HIV transmission outside sub-Saharan Africa is linked to injection drug use. For many countries, this is the most difficult aspect of HIV/AIDS to address.
National drug policy is often caught up in the politics of the moment and politicians get considerable mileage by being "tough on crime" and "tough on drugs."
Many countries experiencing new and explosive HIV epidemics among drug users, often occurring at the same time as major economic or political transitions, look to the United Nations for guidance on how to respond both to drug use and HIV. International leadership, therefore, is critical and should reflect the lessons of effective public health -- and not just law enforcement -- responses to HIV/AIDS among drug users from over 20 years of accumulated experience and evidence. U.N. General Assembly resolutions2 and other U.N. documents have emphasized the importance of access to sterile injecting equipment and medications as methadone and buprenorphine for treatment of opiate addiction, and U.N. technical bodies have supported those resolutions with guidelines and reviews of programmatic evidence. The U.N. Office on Drugs and Crime has affirmed the importance of these strategies as part of a broader effort aimed at drug treatment and demand reduction.
One part of the U.N. machinery on illicit drugs, however, is out of step with these General Assembly resolutions and technical guidelines. The International Narcotics Control Board (INCB) is a 13-member self-described "quasi-judicial" body of experts whose work is paid for by the U.N. Its current members come mostly from the fields of psychiatry, pharmacology, psychopharmacology, forensic medicine, and toxicology. According to their published biographies, none of the current members have formal training in international law, and only one claims any formal expertise or experience on HIV/AIDS. A search of peer-reviewed medical, law, and public policy journals shows no contributions by any current member of the board on HIV/AIDS. Indeed, the board has become an obstacle to the establishment and implementation of effective programs to prevent and treat HIV and drug dependence.
INCB's Resistance to Harm Reduction
The INCB is responsible for monitoring countries' compliance with the U.N. drug conventions. The three drug conventions, developed 1961, 1971, and 1988, mostly predate the identification of AIDS as a disease or the explosive drug use -- linked AIDS epidemics of the 1990s. The conventions encourage countries to criminalize the manufacture, sale, possession, and use of illicit drugs and do everything possible to limit the use of illicit drugs "exclusively to medical and scientific purposes." They also urge governments to ensure "treatment, education, after-care rehabilitation, and social reintegration" of people who use drugs and provide that treatment for drug dependence may be an alternative to criminal penalties in some cases.3 The INCB's duties include monitoring countries' estimates of their needs for illicit substances for "medical and scientific purposes" -- such as methadone for treatment of heroin addiction -- and ensuring that controlled substances are not diverted to illegitimate uses. The board makes about 20 country visits per year, issues an annual report where country-level developments are reviewed, and sends many letters to governments guiding or pressuring them into actions the board deems to be consistent with the drug conventions.
In theory, the INCB should therefore play a major role in ensuring that methadone and buprenorphine are available for opiate substitution therapy (OST). OST is a crucial part of national HIV/AIDS responses where opiate dependence is prevalent -- not only because it provides an opportunity for people who inject heroin to stabilize their opiate cravings with opiates that are not injected, but also because OST is a determinant of success in antiretroviral treatment for people living with HIV. Instead, INCB reports regularly note the importance of drug injection in driving the AIDS epidemic but fail to take the next logical step and urge countries to ensure OST availability.
The INCB's failure to push countries to act on the heightened urgency of OST in the era of AIDS is especially egregious in other countries where methadone is banned (such as Russia) or effectively unavailable (as it is in many countries of the former Soviet Union). The board visited Russia in 2005 and noted with concern the country's fast-growing AIDS epidemic linked to heroin use. But rather than pressuring the Russian authorities to reverse their lethal ban on methadone, the INCB highlighted "the commitment of the government of the Russian Federation to addressing the problems of drug abuse and trafficking."4
The INCB's credibility and competence on the issue of OST were further undermined in 2005 when Russian board member Tatyana Dmitrieva -- identifying herself as a member of the INCB -- co-authored an article in a widely read Russian medical journal in which methadone therapy was condemned with numerous half-truths and inaccuracies.5 Addiction care specialists and scientists from twelve countries issued a heavily referenced, point-by-point refutation of the Russian article, correcting the multiple errors.6 Despite the use of its name in the article, the INCB has not published a correction. This incident calls into question the board's frequent assertions that its members are independent of the influences of their governments and are persons whose expertise in the field inspires confidence.
The INCB's sad record on OST is nearly matched by its views in other areas of HIV prevention for people who use drugs. Although officially the board has recognized that governments are within their rights to ensure that sterile syringes are available to limit needle-sharing among people who use drugs, board president Philip Emafo suggested in a 2002 U.N. publication that "to promote drug use illicitly through the giving out of needles...would, to me, amount to inciting people to abuse drugs, which would be contrary to the provision of the conventions."7 Statements such as this, coming from an individual in a position of authority to whom countries turn for guidance on drug control carry considerable weight and have the potential to be extremely harmful. Although the board's report the following year recognized that needle exchange did not contravene the conventions, neither this nor subsequent INCB reports have raised concerns about countries where people who inject drugs have inadequate access to syringes, or about the many countries where police target syringe exchange sites to arrest or harass people who use drugs. This is supported in name only, with no leadership to back it up.
The INCB has repeatedly said that supervised injection facilities (SIFs), like the one in Vancouver, Canada and the many in Europe, which allow people to inject their own drugs under medical supervision, are in violation of the U.N. drug conventions. The board clings to this view even though the legal office of the U.N. Drug Control Program has stated that SIFs do not "aid, abet, or facilitate the possession of drugs" and are consistent with the drug conventions in that they "provide healthier conditions for IV drug abusers" and "[reach] out to them with counseling and other therapeutic options." Ignoring this advice from the U.N., the INCB makes it a habit every year to berate countries that run SIFs as violators of the drug conventions.
The INCB took its campaign against SIFs to new heights in 2006 when it confronted the then-U.N. special envoy for HIV/AIDS in Africa, Stephen Lewis of Canada. Lewis had visited the SIF in Vancouver and made a speech praising its services and encouraging the Canadian government to allow other such centers to open across the country. The INCB wrote to Lewis's boss, former U.N. secretary-general Kofi Annan, demanding that Lewis retract his positive statements about the SIF because they supported a practice that the board has judged to be prohibited by the drug conventions. While the INCB is in many ways out of step with the harm-reduction and HIV/AIDS policies and programs of other U.N. agencies, in this case the board went so far as to silence another U.N. actor. Speaking out later about this incident, Stephen Lewis noted that INCB secretary Koli Kouame, who called him before sending the letter to Annan, referred to the Vancouver SIF as an "opium den." Lewis said that Kouame's use of that term was a sign that Kouame was "incompetent to do his job."8
Not "Set Up" for Human Rights
Because drug use is so harshly criminalized in so many countries, it is challenging to ensure that HIV/AIDS prevention and treatment programs reach people who use drugs and who may have good reason to fear using established health services. United Nations documents and declarations have emphasized the importance of respecting the human rights of people who use drugs and others who are disproportionately affected by HIV/AIDS. But the INCB has been dismissive of this idea, referring more to the "human rights to be protected from drug abuse" than to the human rights of people who use drugs, whom it always refers to as "drug abusers."
This attitude can lead to missed opportunities and worse. In 2003, Thailand conducted one of the most brutal drug crackdowns in recent history, resulting in the arrest and/or internment of more than 50,000 citizens and the killing of more than 2,500 people in what human rights groups said were professionally executed assassinations. The INCB visited Thailand in 2004 to examine the impact of these "drug war" measures. While human rights organizations in the country and across the world were -- and still are -- calling for the government to allow an independent investigation of the crackdown, the INCB expressed appreciation of the government's investigation of the killings. It expressed no concern about the thousands arrested in the name of drug treatment or the impact of the crackdown on health services for people who use drugs.
Similarly, following the passage of one of the world's harshest drug laws in Bulgaria -- a law questioned by the European Commission for leading to incarceration for very minor drug offenses -- the board's visiting delegation congratulated the country for its "political commitment and the will to deal with drug abuse" and described the country's drug control framework as "well-developed." Though the board has made several visits to China in recent years, it has yet to comment on widespread reports that the country has regularly used the occasion of the U.N. International Day Against Drug Abuse and Illicit Trafficking to engage in show trials and executions, sometimes in public, of people charged with drug smuggling and trafficking. When asked at a press conference in March 2007 about the board's negligence regarding the human rights of people who use drugs, Kouame said the board was not "set up" for human rights and "therefore we will not talk about human rights."9
The press conference at which this statement was made provided an unusual opportunity for journalists to be able to question the INCB president and secretary. At a time when the United Nations is seeking more ways to engage with civil societies and with representatives of its member states, the INCB works in secrecy. Its meetings are closed, and no minutes are provided. It refuses to engage with nongovernmental organizations, saying that its business is with governments.
It is time that this small but influential body is brought into step with the resolutions and programs of the United Nations on HIV/AIDS and drug use. The curtains should be drawn on the INCB's secret deliberations, which should be made more open to civil society, U.N. member states, and independent technical experts. The board must start doing its job on OST by challenging countries to ensure adequate availability of opiate substitutes for this purpose. The U.N. Economic and Social Council and World Health Organization are jointly responsible for electing people to the INCB and must ensure that the board includes genuine experts on HIV/AIDS. Furthermore, the U.N. secretary-general should commission an independent evaluation of the INCB's work to see if the U.N. is spending its funds wisely in supporting this secretive body.
This article is based on the report "Closed to Reason: The International Narcotics Control Board and HIV/AIDS" by these authors, published in February 2007 by the Canadian HIV/AIDS Legal Network and the International Harm Reduction Development Program of the Open Society Institute. The full report, including complete reference citations, is available at www.aidslaw.ca and www.soros.org.
This article was provided by Gay Men's Health Crisis. It is a part of the publication GMHC Treatment Issues. Visit GMHC's website to find out more about their activities, publications and services.