Above All, Do No Harm: Searching for HIV Harm Reduction Strategies at the UN Special Session on Drugs

The end product of the United Nations General Assembly Special Session (UNGASS) on the World Drug Problem left a lot to be desired when it comes to HIV, but there is a silver lining to be found in UNAIDS' harm reduction-centered approach to drug use.

To borrow an analogy from Shakespeare on the quadricentennial of his death, searching for positive reforms in the outcome document released by the United Nations General Assembly Special Session on the World Drug Problem last week is like looking for two grains of wheat in two bushels full of chaff: It'll take you all day to find them and, once you have, you'll discover they're not worth the search.

Somehow, at a time when the global paradigm for addressing drug abuse is experiencing a seismic shift from the punitive and repressive to the therapeutic and permissive, the UNGASS outcome document struggles mightily to differentiate itself from the previous one released 18 years ago. Given the severity of the global drug problem, the widespread condemnations of the war on drugs, and U.S. politicians increased willingness to adopt a public health-based approach to drug use in the wake of the unprecedented rise in opiate abuse in America, the UNGASS outcome appears regressive and stagnant.

At UNGASS, A Showcase for Progressive Strategies. In the Outcomes Report, Not So Much.

While it is quite evident that UNGASS didn't embrace a harm reduction-based approach to drug reform -- the term "harm reduction" isn't used once in the entire document -- it's harder to parse out its consensus on the prevention and treatment of HIV because HIV was barely mentioned. In the entire 24-page UNGASS outcome document, HIV is addressed only once, and even then in a generalized statement that also addresses viral hepatitis and other blood-borne diseases. Given that 10% of all new HIV infections are due to injection drug use and nearly one in five injection drug users is living with HIV worldwide, one would have hoped for more than a passing mention, but that sort of oversight seems to be par for the course in a document that the Global Commission on Drug Policy described as "profoundly" disappointing.

It would be easy, given the failure of the UNGASS to reject the war on drugs or to highlight HIV in the session's outcome document, to adopt a fatalistic view of the future of HIV prevention strategies for people who use drugs. But it would also be wrong, as the UNGASS on drugs also provided a showcase for the progressive, person-centered and supportive harm reduction strategies being promoted by other UN programs such as UNAIDS.

On the first day of the UNGASS, UNAIDS executive director Michel Sidebé gave a speech that highlighted the organization's most recent report addressing the ways in which the world can reduce HIV infection due to drug use. Entitled "Do No Harm: Health, Human Rights and People Who Use Drugs," the report's advocacy for the universal implementation of a "people-centred, public health and human rights-based approach to drug use" is a refreshing departure from UNGASS's intransigence.

Unlike the UNGASS outcome document, which in many ways stubbornly clings to the regressive framework that has characterized global drug policy in the past, the UNAIDS report makes it perfectly clear that it not only supports harm reduction measures such as syringe exchange programs, medication-assisted therapy and antiretroviral therapy, but also roundly rejects a punitive approach to drug policy by advocating for the implementation of alternatives that support and care for drug users -- such as the decriminalization of drugs and the abolition of incarceration for people who use drugs. Beyond that, the UNAIDS report suggests that measures like supervised drug consumption facilities and heroin-assisted treatment may provide benefits to injection drug users.

A Blueprint for the United States?

Many people, especially those who grew up in an America fixated on an abstinence-only drug policy, might look at these recommendations with a measure of shock and apprehension. After 40-plus years of bombardment by the fearmongering of the war on drugs, the anti-drug bogeymen are firmly entrenched in the minds of the American people. Suggest the implementation of a needle exchange or some form of medication-assisted therapy and the typical reaction is a claim that providing injection drug users with clean needles enables their addiction or a refusal to countenance a methadone clinic in one's backyard because it'll bring crime along with it.

Of course, there's no evidence that needle exchanges increase drug use by their clientele or that methadone clinics increase the incidence of crime in surrounding areas, but there is plenty of evidence showing that harm reduction-based approaches to drug use work, particularly in preventing the spread of HIV. Perhaps the most staggering example of this can be found in Portugal, where the decriminalization of drug possession and use and an increased emphasis on harm reduction has seen new HIV diagnoses among injection drug users decline 95% over 10 years.

Meanwhile, in the United States, politicians and much of the drug treatment industry have been stuck in a grey area between the war on drugs and an embrace of harm reduction. With heroin overdoses skyrocketing and small towns like Austin, Indiana, making international headlines as HIV spreads like a brushfire through their injection drug use communities, more and more public officials and everyday Americans are becoming willing to contemplate an approach to drug use focused on public health instead of imprisonment. Unlike the UNGASS outcome document, UNAIDS report provides them a blueprint to follow.