1. School of Public Health and Community Medicine How policies and repressive law- enforcement fuel the HIV epidemic among people who inject drugs Professor Kate Dolan Program of International Research and Training National Drug and Alcohol Research Centre UNSW, Sydney, Australia

2. Policy and HIV epidemics Government Policy Restrict A) HIV prevention programs B) Scale up of effective HIV prevention

3. Policy restricts HIV prevention Case study Russia No Opiate Substitution Treatment Limited NSP 1,700,000 PWIDs - 37% HIV positive (666,000) Advocates pursuing legal action against the government – Russia’s ban on methadone has extended to Crimea

4. Policy restricts HIV prevention Case study of NSP in USA Ban on Federal funds for NSPs home and abroad Ban started in 1988 Repealed in 2009 Reinstated 2011 1,800,000 PWIDs - 16% HIV positive (280,000) If USA adopted NSP like Australia ~ 5,000 HIV infections avoided p.a.

5. Policy restricts HIV prevention 196 countries Countries without Community Programs Countries without Prison Programs No NSP 72185 No OST 81160 No ARV 149153

6. Policy Restricts scale up of HIV prevention Coverage for PWIDs 2010 NSP % OST % ARV % Global estimate 8 8 4

7. Law enforcement and HIV epidemics Law enforcement increases the likelihood of sharing syringes incarceration of PWID increase HIV transmission

8. Law Enforcement: increases syringe sharing PWIDs arrested for drugs / confiscate syringes Drive drug users away from services Interrupt OST, ARV treatment Strathdee’s study on the Mexico US border HIV infection among female sex workers who injected was linked to syringe confiscation by the police

9. Law Enforcement: increase incarceration of PWID can increase HIV transmission Arrest, registry of drug users, report to police Leads to mass incarceration of PWIDs 30-60% vs. 1% Detained without access to prevention or treatment Numerous studies link HIV Infection to a history of incarceration Prevalent syringe sharing in prison, multiple partners, HIV outbreaks in prison Thailand, Russia, Iran, Lithuania

10. Recommend Drug treatment (esp. OST), NSP and ARV Educate on benefits of HR in and out of prison and harms of arresting and imprisoning PWIDs Work with police: refer to treatment, manage intoxicated offenders and Needle Stick Injury Shift resources from supply reduction to demand and harm reduction

11. References 1. Dolan, K. et al Needle and syringe programs: A review of the evidence. Australian Government 2005. 2. Mathers et al. HIV prevention, treatment, care services for PWIDs Lancet, 2010; 375(9719):1014 3. IHRA Global state of harm reduction 2012. 4. Lurie, P & Drucker, E. An opportunity lost:. The Lancet,1997,349(9052):604-608. 5. Dole, Methadone treatment of randomly selected criminal addicts NEJM, 1969;280(25):1372-75 6. Hickman OST & HIV transmission in PWIDs: review and meta-analysis BMJ 2012;345:e5945. 7. Metzger, HIV seroconversion among ID in- and out-of-treatment: JAIDS, 1993;6(9):1049–1056. 8. Xing, Y, Economic evaluation of MMT in HIV/AIDS AIDS Care: 2012; 24(6): 756-762. 9. Dolan, K HIV/AIDS in prison: A global review of prevalence, incidence, mortality and HIV programs 10. Rhodes T, Situational factors influencing drug injecting, Soc Sci Med 2003;57(1):39-54. 11. Sarang Policing drug users in Russia: risk, fear, structural violence. Subst Use Misuse, 2010; 45(6): 813-864. 12. Global commission on drug policy. The War on Drugs and HIV/AIDS How Criminalization of Drug Use Fuels the Global Pandemic, 2012 13. Strathdee HIV and risk environment for injecting drug users: the past, present, and future. Lancet, 2010; 376(9737): 14 Strathdee Social and structural factors associated with HIV infection among female sex workers who inject drugs in the Mexico-US border region. PloS one. 2011;6(4):e19048. 15. Pollini Syringe possession arrests are associated with receptive syringe sharing in two Mexico-US border cities. Addiction (Abingdon, England). 2008;103(1):101-8. 16. Dolan K, HIV in prison in low income & middle-income countries. Lancet Inf Dis, 2007;7(1):32-41.

12. Acknowledgements Anya Sarang, Dr Alex Wodak and Professor Michael Farrell