People who inject drugs remain one of the highest-risk groups for contracting HIV, but infringements of their human rights around the world threatens to derail progress on ending AIDS.
As the 20th International AIDS conference gets underway in Melbourne, Australia next week it will draw around 14,000 people working in the field of HIV, including policymakers, activists and people living with HIV. And it is critical that the needs of injecting drug users are represented at the conference if the goal to end AIDS is ever to become a reality.
Globally, around 16 million people inject drugs (WHO) and 3 million of them are living with HIV. Asia Pacific is the second region in the world most affected by HIV and now home to an estimated 4.9 million people living with HIV (UNAIDS). The majority of infections have occurred through sharing injecting equipment and unprotected sex.
India and drug users
In India, there are 200,000 injecting drug users (NACO) and they are the population group with the highest rate of new HIV infections.
Kabir* ran away from his home and arrived in Mumbai in his teens. He was lonely and began living with a group of other runaways around the railway tracks. It wasn't long before he was introduced to heroin and began injecting the drug. In a few years his body was ravaged by disease and malnutrition.
In 2012 Kabir met some peer educators from Sankalp Rehabilitation Trust, an organisation that works with street-based drug users and fights for their human rights. They began exchanging his used needles for clean ones and educated Kabir about medical treatments and counselling services at their drop-in centre. During the course of his treatment at Sankalp and Nair hospital for a knee injury, Kabir got tested and discovered he was living with HIV.
Harm reduction versus criminalisation
Efforts to provide HIV prevention, treatment and care to injecting drug users are shaped by tensions between approaches that regard them as criminals and those regarding them as people with human rights, including access to health services.
According to the Lawyers Collective HIV/AIDS report Legal and Policy concerns related to IDU Harm Reduction in SAARC Countries**, provision of sterile syringes to injecting drugs users is open to prosecution under penal and/or narcotics law as abetment of drug consumption. Also, oral substitution is not considered treatment as in most jurisdictions treatment requires 'giving up drugs'.
Anand Grover, UN special rapporteur and director of the Lawyers Collective HIV/AIDs in India, stresses: "The current drug control regime is damaging the health and human rights of people who use drugs. Criminalization and excessive law enforcement practices undermine public health initiatives, perpetuate stigma, and increase health risks to which entire populations, and not only those who use drugs, may be exposed." Grover recommends that: "Governments decriminalize drug use and take a human-rights-based approach to drug control."
Harm reduction programmes
Eldred Tellis, president of the Western Indian Harm Reduction Network (IHRN) and director of Sankalp Rehabilitation Trust, says: "Our goal is to sensitize police and law enforcement to the realities of drug use, equally important is to sensitize magistrates so they are aware that people who use drugs can be referred to a harm reduction project rather than jail."
In the past two decades, needle and exchange syringe programmes have been drastically scaled up across the Asia Pacific region. Such 'harm reduction' programmes provide clean needles to injecting drug users so that the risk of transmitting HIV through used needles can be eliminated. These efforts have contributed to a declining trend of HIV prevalence in people who inject drugs.
But the continuation of such programmes is now under threat as international funding is set to decrease for middle income countries and national governments are reluctant to take over the reins.
Luke Samson, executive director of IHRN, says: "In the health budget there is no allocation for harm reduction, second line antiretrovirals, multi-drug resistant TB or Hepatitis C. National budgets do not allocate enough resources to ensure a transition from donor dependent financing to a national financing structure. International donors must step up their commitment to the goal of universal access to HIV treatment, care and support for people who use drugs. UN bodies, the World Bank, Global Fund and governments must work together for a concerted national investment plan for health."
In India, the changed political environment with a new government is an opportunity for HIV non-governmental organisations and other stakeholders to sensitize the new leaders to the issues. There is hope that the parliamentarians and policy makers attending the Melbourne conference will identify legal obstacles and that discussion around harm reduction will start to inform policy.
Support for injecting drug users
The vision of the community programme committee for the AIDS 2014 conference is the greater involvement and meaningful engagement of people living with HIV.
It is a key opportunity for advocates to push governments and donors to look at the evidence and the need to scale up harm reduction programmes. But how many injecting drug users - predominantly poor, disempowered, often incarcerated, and outside mainstream systems - will be in attendance remains to be seen.
Kabir has been clean for a year now. Sankalp's support in getting him on opioid substitution therapy, as well as providing vocational training has been invaluable in helping him turn his life around.
"Young drug users who come to cities are away from mainstream services, they are not very visible and often stigmatised, marginalised and undergo police brutality," Kabir says. "They live on streets and outside the experience of policy makers."
Protection of the human rights of drug-dependent individuals has particular urgency if a sustainable response to HIV and AIDS is to become an achievable reality.
As Kabir says: "With the right support anyone can live a drug-free life. Sankalp gave me the chance to be human again."
*Names changed for confidentiality
**commissioned by the United Nations Office on Drugs and Crime regional office for South Asia