Pubdate: Sat, 15 Sep 2007
Source: National Review of Medicine, The (Canada)
Copyright: 2007 Parkhurst Publishing
Authors: Kora DeBeck (BC Centre for Excellence in HIV/AIDS), Evan 
Wood Thomas Kerr, Julio Montaner (BC Centre for Excellence in 
HIV/AIDS and Dept of Medicine, UBC), Vancouver, BC
Bookmark: (Harm Reduction)
Bookmark: (Needle Exchange)
Bookmark: (Supervised Injection Sites)


Injection drug use continues to be a driving factor in the global 
HIV/AIDS epidemic.1 Harm reduction services, including needle 
exchange programs, have long been identified as essential components 
of an effective HIV prevention strategy. While scientific consensus 
has been reached regarding their efficacy in reducing HIV 
transmission,2,4 such interventions remain controversial. In 
contrast, 'zero tolerance' approaches to drug use have been shown 
ineffective,5 however, they remain popular among conservative 
policymakers over evidence-based public health approaches. These 
should be matters of grave concern as they have a potentially 
devastating impact on HIV prevention efforts.6-8

For instance, in the US, while close to one quarter of all new HIV 
infections have been attributed to injection drug use,9 there remains 
a federal ban on funding for needle exchange programs. In Russia, 
between 2002 and 2004 funding for needle exchange programs has 
reportedly fallen 29% while the prevalence of HIV among local 
injection drug users (IDU) populations is up to 60% in some areas.1 
Unfortunately, the "new" Conservative federal government of Canada is 
similarly allowing ideology to undermine the adoption of 
evidence-based HIV prevention policies. This was clearly illustrated 
by the recent statements of the Minister of Health, Tony Clement 
reported separately in this issue (see "'Doctors, get tough on 
drugs': Tony Clement" on page 22). Despite evidence of continuing HIV 
transmission among IDUs nationally,10 this government recently 
announced that no federal funds would be directed to support the 
operation of needle exchange programs in Canada or the supervised 
injection facility in Vancouver.11-13

The government has also taken steps apparently aimed at eliminating 
harm reduction strategies. As part of this effort, the existing 
Canada's Drug Strategy (CDS) is being replaced with the new Anti-Drug 
Strategy which has been described as focusing on enforcement, 
prevention and treatment interventions.13 Harm reduction is no longer 
part of the strategy, a worrisome departure from the CDS's 
traditional approach: "Because substance abuse is primarily a health 
issue rather than an enforcement issue, harm reduction is considered 
to be a realistic, pragmatic, and humane approach." 16

The exclusion of harm reduction initiatives from the new Anti-Drug 
Strategy is a dangerous step backwards in the fight against HIV/AIDS. 
Its increased emphasis on law enforcement has potential to further 
increase HIV and other blood born infections among IDU. Through 
sexual transmission, the partners of infected IDU can then be 
expected to spread the virus among a wider population. The focus on 
law enforcement will also likely prompt a rise in the incarceration 
rates of IDUs, with marginalized populations, particularly Aboriginal 
peoples, being hardest hit.17 Imprisonment may further fuel the rate 
of disease transmission as incarceration has been independently 
associated with HIV infection among Canadian IDU.18

Canada's new 'Anti-Drug Strategy' appears ill conceived. Furthermore, 
the new Anti-Drug Strategy is not anti-HIV. As such, this should not 
be accepted as a legitimate policy shift. In deviating from 
internationally established HIV prevention standards, which are based 
on the best available evidence, this strategy may in fact be better 
described as "anti-health" and "anti-science." It has been over four 
years since former US president Bill Clinton publicly acknowledged 
that he was wrong to withhold federal funds for needle exchange 
programs in the United States.20 How long will take before the 
Government of Canada expresses the same regret? More importantly, how 
much unnecessary suffering and new HIV infections will be needed 
before our political leadership finally embraces evidence -based 
public health principles in the fight against HIV/AIDS?


1. UNAIDS. 2006 report on the global AIDS epidemic. Geneva: UNAIDS; 2006.

2. World Health Organization, UNAIDS, UN Drug Control Office. Policy 
brief: Provision of sterile injecting equipment to reduce HIV 
transmission. WHO; 2004.

3. UNAIDS. Progress report on the global response to the HIV/AIDS 
epidemic 2003: Follow-up to the 2001 United Nations General Assembly 
special session on HIV/AIDS. Geneva: UNAIDS; 2003.

4. Wodak A, Cooney A. Do needle syringe programs reduce HIV infection 
among injecting drug users: A comprehensive review of the 
international evidence. Subst Use Misuse. 2006;41:777-813.

5. The Lancet. Losing tolerance with zero tolerance. The Lancet. 

6. Wood E, Kerr T, Small W, Jones J, Schechter MT, Tyndall MW. The 
impact of a police presence on access to needle exchange programs. J 
Acquir Immune Defic Syndr. 2003;34:116-8.

7. Dixon D, Coffin P. Zero tolerance policing of illegal drug 
markets. Drug and Alcohol Review. 1999;18:477-486.

8. Kerr T, Small W, Wood E. The public health and social impacts of 
drug market enforcement: A review of the evidence. International 
Journal of Drug Policy. 2005;16:210-220.

9. Centers for Disease Control and Prevention. Drug-Associated HIV 
Transmission Continues in the United States. Available: (accessed 2007 April 10).

10. Health Canada. HIV and AIDS in Canada: Surveillance report to 
June 30, 2006. Ottawa: Division of HIV/AIDS Epidemiology and 
Surveillance, Centre for Infectious Disease Prevention and Control 
(CIDPC), Health Canada; 2006.

11. O'Neil P. B.C. blasts budget for favouring Quebec: Trade minister 
denies province is being 'punished'. The Vancouver Sun. 03/20/2007:A1.

12. Wood E, Tyndall M, Montaner J, Kerr T. Summary of findings from 
the evaluation of a pilot medically supervised safer injecting 
facility. CMAJ. 2006;175:1399.

13. Department of Finance Canada. The Budget Plan 2007. Ottawa: 
Government of Canada; 03/19/2007.

14. Office of the Auditor General of Canada. Report of the Auditor 
General of Canada -2001, chapter 11--illicit drugs: The federal 
government's role. 2001.

15. DeBeck K, Wood E, Montaner J, Kerr T. Canada's 2003 renewed drug 
strategy -an evidence-based review. HIV/AIDS Policy and Law Review. 

16.Government of Canada. Canada's Drug Strategy. Ottawa: Minister of 
Public Works and Government Services Canada; 1998.

17. Brzozowski J, Taylor-Butts A, Johnson S. Victimizing and 
offending among the aboriginal population in Canada. Jurisdat 
Statistics Canada; 2006.

18. Hagan H. The relevance of attributable risk measures to HIV 
prevention planning. AIDS. 2003;17:911-3.

19. International Covenant on Economic, Social and Cultural Rights. 
United Nations General Assembly, 993 UNTS 3, Article12. 1996.

20. Altman L. Clinton urges global planning to halt H.I.V. New York 
Times. 07/12/2002. 
- ---
MAP posted-by: Richard Lake