Pubdate: Tue, 27 Oct 2015
Source: New York Times (NY)
Column: Global Health
Copyright: 2015 The New York Times Company
Contact: http://www.nytimes.com/ref/membercenter/help/lettertoeditor.html
Website: http://www.nytimes.com/
Details: http://www.mapinc.org/media/298
Author: Donald G. McNeil Jr.

DRUG ENFORCEMENT VS. AIDS TREATMENT

Is the war on drugs crippling the war on AIDS? And might the AIDS 
epidemic make governments more willing to treat drug abusers as 
suffering patients rather than as hardened criminals?

Those questions came to the fore last week because of a fumbled news 
story. It was announced - incorrectly, it turned out - that the 
United Nations Office on Drugs and Crime, which oversees the fight 
against cross-border drug trafficking, was about to do a startling 
about-face and advocate ending penalties for personal use of all drugs.

The schisms revealed by the news - U.N. agencies, not to mention 
nations and political parties, are sharply divided over the issue - 
showed how the debate is shifting, in part because of H.I.V.

The spread of the virus through needles may be the least-talked-about 
but most intractable aspect of the AIDS epidemic. In North America 
and Western Europe, H.I.V. is mostly transmitted through gay sex. In 
Africa, the focus of most Western aid, it is spread through heterosexual sex.

But in many countries - notably Russia and Eastern Europe, and across 
swaths of Asia where the opium poppy flourishes, the greatest H.I.V. 
risk is injected heroin.

"Our position is very clear," said Michel Sidibe, the executive 
director of Unaids, the U.N. agency fighting AIDS. "Of the 12 million 
people who inject drugs, 1.7 million are infected. We need to take 
these people out of the shadows and into services, or we will never 
control the epidemic."

Studies done decades ago on groups with different H.I.V. risk factors 
- - prostitutes in Nairobi, gay men in San Francisco and addicts in 
Bangkok, for example - showed that needle-sharing was the fastest way 
the virus spread when it entered a new population.

Around the world, users who inject drugs are 28 times more likely to 
be infected than people who do not.

Taking away the fear of arrest after being caught with a syringe or a 
gram of heroin makes it possible for addicts to sign up for 
risk-lowering interventions: clean syringes, condoms for those who 
sell sex for drugs, antibiotic treatment for venereal diseases, 
methadone to help addicts lead less chaotic lives, antiretroviral 
treatment and pre-exposure prophylaxis.

Jailing users, by contrast, increases risk. Many prisons are H.I.V. 
hotbeds because of drug needles, tattoo needles, unprotected 
male-male sex and rape.

No two countries have matching policies on the nonmedicinal use of drugs.

In the United States, marijuana is legal in four states while heroin 
is universally outlawed; 30 states allow syringe exchanges while 20 
do not. In Switzerland, by contrast, voters in 2008 effectively made 
heroin a medical problem, but kept marijuana illegal.

Iran permits clean syringes and methadone, even to prisoners. Heroin 
addicts, who once faced the death penalty, are immune from arrest 
while in treatment.

Study after study has shown that countries that reduce penalties and 
offer treatment have reduced H.I.V. infections. China, for example, 
dropped a zero-tolerance policy on heroin in favor of clean syringes 
and methadone. It now has 700 clinics treating 200,000 patients, and 
new H.I.V. cases among those patients have dropped by 90 percent, Mr. 
Sidibe said.

In 2001, Portugal made the possession of up to 10 days' worth of any 
drug legal. Only 78 H.I.V. cases there were attributed to drug use in 
2013. (Also, overdose deaths are now among the lowest in Europe - 3 
per million Portuguese versus 45 per million among residents of 
Britain, for example.)

In Germany, arrests on charges of possession of small amounts may be 
dismissed. Most addicts are in treatment, and pharmacies sell syringes cheaply.

Germany has about 3,300 new H.I.V. infections a year with only about 
100 of them from drug use - down from 1,200 in 1986. Many are in 
recent emigres from former Soviet countries, according to a 2012 Unaids report.

In Russia, by contrast, under President Vladimir V. Putin's 
"traditional values" campaign, the police crack down hard on addicts. 
Syringe exchanges and methadone are illegal. State hospitals rely on 
detoxification and group therapy.

Lord Fowler, a former British health secretary, said in a recent BBC 
magazine article that the chief of Moscow's major "narcology 
research" hospital told him that half the addicts she treated 
relapsed within a year, and 90 percent within eight years.

Russia has 85,000 new H.I.V. infections a year, and the head of 
Moscow's Federal AIDS Center said in May that 57 percent were from 
drug injection.

Questions over drug policy have split U.N. agencies. The World Health 
Organization and Unaids openly favor ending criminal penalties to fight H.I.V.

But U.N.O.D.C., the drug and crime agency, rooted in law enforcement 
and the 1946 U.N. Commission on Narcotic Drugs, is more conservative. 
Its executive director, Yury Fedotov, is Russian; high U.N. officials 
rarely flout the views of the governments that nominate them.

The agency's H.I.V. division did produce a briefing paper last week 
saying that possession of small amounts could be made permissible 
under anti-trafficking treaties and human-rights law. An agency 
representative denied that it amounted to a reversal of 70 years of 
policy and said such a momentous change would not be announced "by a 
midlevel official at someone else's conference in Kuala Lumpur."

However, a shift by the United Nations as a whole may be in the wind.

Even Secretary General Ban Ki-moon recently treaded close to the 
line, saying, "We must consider alternatives to criminalization and 
incarceration of people who use drugs."
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MAP posted-by: Jay Bergstrom