1 Background & history of the debate Geneva, 14 October 2009 Ralf Jürgens

2 Outline Lancet article Debate at Reference Group meeting Series of letters responding to article exchange on ITP listserv Johannesburg civil society consultation Support for strategy by prominent researchers Research interest Debate at IAS conference on pathogenesis, treatment & prevention Costing the model Future: from WHO consultation to Vienna

3 Reference Group discussion De Cock –Purpose of article “to open discussion” & “call for further research” –“should not in any way be seen as policy or technical guidance from WHO” Reference Group –welcomed confirmation of critical link between HIV prevention and HIV treatment –emphasis on attainment of UA to treatment and HIV T&C, as essential components of right to health

4 Reference Group discussion Concerns: –perception – seen as representing thinking of WHO –appears to reduce response to testing & treatment (“combined with present prevention approaches”) –costing does not include human rights programmes –uptake of HIV testing –only HR intervention = training to ensure testing remains voluntary –another step towards increasing medicalization – contrast to UNAIDS

5 Reference Group statement Importance of consultation with people living with HIV Programmes to address stigma, violence, and discrimination

6 Lancet letters (March 2009) Challenged assumptions used in the model underestimates role of acute transmission Does not accurately account for concurrency Could shift benefits of treatment from individual to community Called for development of a robust ethical framework to guide use of treatment as disease elimination strategy Reported experience in Ethiopia

Exchange on ITP listserv 1.In early days of HIV and IDU, human rights were rarely mentioned or accounted for in policy and research, and drug use was rarely mentioned in the human rights world. 2.This is slowly changing. A growing number of reports document (1) human rights violations; (2) their negative outcomes for health & other human rights of people who use drugs; (3) programmes & interventions & policy changes. Question: Quality of the evidence? What are considered valid sources of information?

Background 3. Growing recognition that extreme marginalisation, stigmatisation and criminalisation increases vulnerability to HIV and decreases accessibility of health services. 4. The great majority of papers in the medical literature on risks of HIV infection do not include human rights consideration and measures. But some do, and there is growing interest among medical researchers to increase the body of documentation of non-medical risk factors.

Highlights Human rights abuses include, among others: –Denial of harm reduction services and effective drug dependence treatment –Discrimination in access to ART –Abusive law enforcement practices Thai “war on drugs” police presence at NSPs; enforcement of drug paraphernalia laws

Highlights –Disproportionate criminal penalties death penalty in many countries, although only allowed for “most serious crimes” incarceration for minor offences –Coercive and abusive treatment in “drug treatment” camps –Denial of information & services to youth –Denial of pain medication

Highlights These abuses cannot be justified – they are entirely disproportionate to the aim of controlling drug production and use; and they are not “necessary” because they fail to reach their aim. They are abhorrent in themselves and must be combated for this reason alone. In addition, some (but not all) of these abuses have negative health impacts for people who use and the communities in which they live, increasing their vulnerability to HIV and HIV-related risk behaviours.

Highlights A few studies and reports examine practical programmes or initiatives undertaken to support the effectiveness of HIV and other health services for people who use drugs and to reduce abuses of their human rights: –Harm reduction training for police officers, judges & prosecutors –Fostering partnerships between law enforcement & public health sector –Providing legal services –Ensuring meaningful participation of people who use drugs

13 Conclusions & future directions Pursuit of human rights along with public health is crucial –because of the intrinsic value of rights –because an environment of respect for rights of people who use drugs is necessary if the response to HIV and drug use is to succeed.

14 Conclusions & future directions Countries have a legal duty to implement the comprehensive set of HIV measures for people who use drugs that have been proven to be effective. Scale up of “structural rights interventions” and their evaluation in terms of health & human rights outcomes should be a priority. In addition, countries must reform the aspects of drug policy and practice that impede HIV measures or cause or contribute to the harms suffered by people who use drugs.

15 Conclusions & future directions Decriminalisation of drugs for personal use is widely recommended and shows promising results & absence of negative consequences where implemented. Development of alternatives to imprisonment should be priority.