harmreduction

How is harm reduction a human rights issue?

What is harm reduction?

There are an estimated 16 million people who inject drugs in over 148 countries around the world.1This practice can carry significant health risks, including increased exposure to HIV, hepatitis C and hepatitis B.2 Yet repressive drug policies and practices create and exacerbate the harms associated with illicit drug use. People who use drugs are regularly harassed and detained, subjected to involuntary and abusive treatment procedures, and denied life-saving medical care. This is true despite evidence that people who use drugs can benefit from many health services even before abstaining from drug use, and that the denial of services makes them and their communities more vulnerable to a range of health and social problems.3

“Harm reduction” refers to policies, programs, and practices aimed at reducing drug-related risks and harms by advancing the health and human rights of people who use drugs.4 As Harm Reduction International notes, “The defining features are the focus on the prevention of harm, rather than on the prevention of drug use itself, and the focus on people who continue to use drugs.”5 This approach recognizes that “people unable or unwilling to abstain from drug use can still make positive choices to protect their own health in addition to the health of their families and communities.”6 Harm reduction thus seeks to create an enabling environment for people who use drugs to protect their health and other human rights by providing them with evidence-based information, services, and resources.7

While harm reduction refers to an approach, rather than a set of health interventions, the term is commonly applied to a number of measures designed to minimize drug-related risks, particularly in the context of injection drug use. Examples include needle and syringe programs to reduce syringe sharing and reuse; opioid substitution therapy to reduce drug cravings (e.g., methadone and buprenorphine); opioid medications to relieve pain (e.g., morphine); drug-consumption rooms to facilitate access to health care; route-transition interventions to promote non-injecting drug administration; and overdose prevention practices (e.g., naloxone to reverse opioid overdose).8 Harm reduction measures also encompass broader projects to help people who use drugs access their economic, social, and political rights—including outreach and education programs, provision of legal services, and creation of public policies that are supportive of health.9

Harm reduction services are most effective when they meet people who use drugs “where they are,” rather than requiring them to undergo many complicated steps and behavioural changes before they receive help. This is especially true given the range of factors that contribute to drug-related risks and harms, including “the behaviour and choices of individuals, the environment in which they use drugs, and the laws and policies designed to control drug use.”10 For example, while access to treatment for drug dependence is important, not all people who use drugs want or even need such treatment. Access to informal and non-clinical methods of harm reduction is thus equally important. According to Harm Reduction International:

Harm reduction interventions are facilitative rather than coercive, and are grounded in the needs of individuals…. The objective of harm reduction in a specific context can often be arranged in a hierarchy with the more feasible options at one end (e.g. measures to keep people healthy) and less feasible but desirable options at the other end. Abstinence can be considered a difficult to achieve but desirable option for harm reduction in such a hierarchy. Keeping people who use drugs alive and preventing irreparable damage is regarded as the most urgent priority while it is acknowledged that there may be many other important priorities.11

Harm reduction strategies are therefore complementary to other approaches, including those focused on the reduction of the overall level of drug use in society. According to Anand Grover, the UN Special Rapporteur on the right to the enjoyment of the highest attainable standard of physical and mental health (UN Special Rapporteur on the Right to Health), harm reduction interventions “may operate within restrictive legal regimes.”12 Nonetheless, it is now recognized that overly restrictive regimes are among the key drivers of drug-related harm. They create risky environments for drug use, drive the problem further underground, and run counter to public health objectives. Harm reduction efforts must therefore include measures to challenge international and national laws and policies that maximize harm.13 Human rights-based and evidence-based approaches to drug use can assist in this endeavor.

Harm reduction strategies are UN-endorsed and are applied in a range of drug-related health contexts, including injection drugs (such as heroin and other opiates) and non-injection drugs (such as marijuana).14 They have also been applied to non-drug settings, such as the distribution of condoms to prevent sexually transmitted HIV/AIDS.15 This chapter will focus primarily on harm reduction aimed at injection drug use. This context offers the largest and most established body of evidence for supporting the development of human rights based programming. However, practitioners working in analogous contexts are encouraged to draw on this chapter for ideas to guide their own work.

What are the issues and how are they human rights issues?

The current approach to global drug control fuels widespread human rights violations against people who use drugs. In many countries, they are subjected to torture and ill-treatment by police, extrajudicial killings, arbitrary detention, coercive and abusive drug treatment, and denial of essential medicines and basic health services.16 These abuses are often committed in the name of “medicine, public health or public order.”17 Yet repressive drug laws and policies have not reduced drug use or prevented health-related risks and harms. As the UN Special Rapporteur on the Right to Health states:

First, people invariably continue using drugs irrespective of criminal laws, even though deterrence of drug use is considered the primary justification for imposition of penal sanctions. Second, drug dependence, as distinct from drug use, is a medical condition requiring appropriate, evidence-based treatment—not criminal sanctions. Finally, punitive drug control regimes increase the harms associated with drug use by directing resources towards inappropriate methods and misguided solutions, while neglecting evidence-based approaches.18

For example, the majority of people who use drugs do not become dependent on drugs and do not require treatment for drug dependence.19 Even where drug dependence is an issue, it should be treated like any other medical condition—meaning with treatment methods that are voluntary, scientifically and medically appropriate, and of good quality.20 Finally, people who use drugs are entitled to harm reduction measures as a matter of right under international human rights law.21 According to Harm Reduction International:

Human rights apply to everyone. People who use drugs do not forfeit their human rights, including the right to the highest attainable standard of health, to social services, to work, to benefit from scientific progress, to freedom from arbitrary detention and freedom from cruel inhuman and degrading treatment. Harm reduction opposes the deliberate hurts and harms inflicted on people who use drugs in the name of drug control and drug prevention, and promotes responses to drug use that respect and protect fundamental human rights.22

Human rights are relevant to reducing drug-related risks and harms in at least three ways. First, lack of human rights protection creates risky environments for people who use drugs.23 They are often members of socially and economically marginalized groups to begin with,24 and their vulnerability is increased by the stigma associated with drug use. Criminalization of drug use and possession often forces people who use drugs to adopt risky injection practices that increase the risk of poor health and illness, such as reused or shared needles, hurried injection to avoid detection, or improper disposal of syringes.25

Second, lack of human rights protection prevents people who use drugs from accessing services and treatment. In many countries, repressive drug laws and policies have “reinforced the status of people who use drugs as social outcasts, driving drug use underground, compromising the HIV/AIDS response, as well as discouraging people who use drugs from accessing treatment.”26 People who use drugs may refrain from seeking assistance for drug use or drug-related health issues in order to avoid discrimination, violations of their privacy, arrest, imprisonment, and involuntary treatment.27

Third, lack of human rights protection in the context of drug use disproportionately impacts members of vulnerable and marginalized communities. In the United States, African-Americans are arrested at higher rates than white Americans for comparable offenses and more than 80% of drug-related arrests are for drug possession rather than sales. The UN Special Rapporteur on the Right to Health notes: “Accumulation of such minor offences can lead to incarceration and further marginalization of these already vulnerable individuals, increasing their health-related risks.”28 The social vulnerability of drug users is demonstrated by the fact that in some countries, they are confined with other “social outcasts”—including people with mental disabilities, sex workers, and the homeless.29

The following are some examples of key human rights issues related to people who use drugs, denial of harm reduction services, and human rights.

Criminalization of drug use and possession

Around the world, criminalization of drug use and possession “creates more harm than the harms it seeks to prevent.” Repressive drug laws and policies disproportionately punish people who use drugs compared to those who sell or produce drugs. They also perpetuate stigma, risky forms of drug use, and negative health and social consequence—not only for those who use drugs, but the wider community as well.30 The Vienna Declaration, adopted at the 2010 International AIDS Conference, recognizes that the criminalization of drug use directly fuels the global HIV epidemic.31 The UN Special Rapporteur on the Right to Health confirms that criminalization runs counter to public health aims:

Higher rates of legal repression have been associated with higher HIV prevalence among people who use injecting drugs, without a decrease in prevalence of injecting drug use. This is a likely result of individuals’ adopting riskier injection practices such as sharing of syringes and injection supplies, hurried injecting, or use of drugs in unsafe places (such as needle-shooting galleries) out of fear of arrest or punishment.32

As a result, around one in ten new HIV infections result from injection drug use and up to 90% of all infections occur in people who inject drugs in regions such as Eastern Europe and Central Asia. In many of the same countries, harm reduction services are not only unavailable but prohibited by law, further increasing the risk of HIV transmission.33

The harshness of drug laws and law enforcement practices varies considerably by jurisdiction.34 In many countries, people are arrested and detained for using drugs “on the basis of mere police suspicion or a single positive urine test” and may be remanded to treatment centers “for months or years without medical assessment or right of appeal.”35 In other countries, including several members of the Commonwealth of Independent States, drug use may not be prohibited per se, but possession of drug paraphernalia, including unused syringes to prevent HIV, can be cause for arrest. Additionally, individuals can be subjected to prolonged imprisonment if they are found with “large” or “extra-large” quantities of illicit drugs—in some countries, defined as the residue in a used syringe or half a cigarette of cannabis.36

At the extreme end, more than 30 UN member states retain the death penalty for drug offenses,37 despite clear guidance from human rights authorities that the death penalty must be reserved for the most serious crimes, and that drug-related offenses do not meet those criteria.38 For example, in 2003, “the Thai government’s efforts to make the country ‘drug free’ led to the extrajudicial killing of some 2800 people.”39 People have also been executed for drug offenses in China, Iran, Saudi Arabia, Vietnam, Singapore, and Malaysia, although Singapore and Malaysia have limited enforcement in recent years and China and Vietnam are reviewing their legislation. The International Harm Reduction Association notes:

Retentionist governments sometimes justify harsh sentences for drugs as a necessary deterrent to social risks linked to drug use—such as addiction, overdose and blood-borne infections usually associated with drugs like heroin, cocaine and amphetamine-type stimulants. Yet the reality is more nuanced. Many of the people sentenced to die are not traders in so-called ‘hard’ drugs and instead are subject to the death penalty for trafficking in marijuana or hashish.40

Moreover, drug users can also be charged with trafficking, particularly in countries with weak rule of law. Jurgens et al. note, “The amount of illicit drugs possessed, produced, or sold to constitute a capital crime varies from 2 grams to 25 kilograms, indicating an arbitrariness that defies human rights norms on the death penalty.”41

Criminalization of drug use is implicated in the violation of many human rights, including the right to life, to health, to bodily integrity, to due process, to freedom from arbitrary arrest, and to freedom from torture and cruel, inhuman, and degrading treatment.42 While the 1984 Siracusa Principles on the Limitation and Derogation of Principles in the International Covenant on Civil and Political Rights permit restrictions on individual liberties in limited circumstances, they must be “sanctioned by law, serve a legitimate public health goal… necessary to achieve that goal… no more intrusive or restrictive than necessary, and … non-discriminatory in application.”43 The criminal penalties imposed against people who use drugs lack an evidence basis in public health and fall short of these stringent requirements.

Incarceration and denial of services in prisons

Due to harsh and repressive drug control regimes, people who use drugs but who do no harm enter the criminal justice system in large numbers. Jurgens et al. note:

The incarceration of many drug-dependent people—often for lengthy periods of time and for minor offences such as possession of very small amounts of drugs—also raises human rights and health concerns. In many countries, a substantial proportion of prisoners are drug dependent. For people who inject drugs, imprisonment is a common event, with reported incarceration rates of 56–90% in this population.44

Once in prison, they are often exposed to conditions that further jeopardize their rights, including unsanitary facilities, overcrowding, inadequate food, violence, sexual assault, and inadequate medical attention.45 HIV, hepatitis B and C, and tuberculosis are especially prevalent in prison settings given high rates of injection drug use, risky injecting practices, and lack of prevention and treatment services.46 Access to sterile injection equipment, the single most important determinant of HIV infection, remains poor, as does access to antiretroviral therapy.47 The UN Special Rapporteur on the Right to Health notes that these factors “create enormous risk for inmates [which] is then passed on to members of the public upon prisoners’ release.”48

Many prisons also fail to provide medically appropriate care and medications, including treatment for drug dependence. For example, substitution therapy, considered the standard of care for opiate addictions, is rarely available, leaving many people alone to face withdrawal without medical support. In New York, many prisoners are denied such services “as part of the disciplinary sanction.”49 At the same time, prisons often deny people who use drugs the right to give informed consent before undergoing medical procedures, including mandatory HIV testing, or deny them the opportunity to refuse treatment, including for drug dependence. These practices constitute a breach of medical ethics and a violation of international human rights law.50

Extrajudicial detention, abuse, and compulsory treatment

Even when governments profess to treat people who use drugs as patients rather than criminals, the result is frequently harsh, punitive regimes with no medical or public health benefit. Many countries use compulsory detention as a form of “treatment,” and people suspected of using drugs are regularly confined for months or years without a trial or even an evaluation of their drug dependency.51 As Clark et al. note, these so-called compulsory treatment centers “are probably more aptly named ‘extrajudicial drug detention centres.”52 They typically fall outside the criminal justice system, are run by police, military, or security personnel, and lack judicial oversight, government regulation, and medical supervision.53

People remanded to these facilities for drug treatment rarely receive effective, medically necessary therapies based on scientific evidence and offered under conditions of informed consent. Instead, they are frequently subjected to egregious violations of their human rights, in some cases rising to the level of torture. The Open Society Institute’s International Harm Reduction Development Program (IHRD) notes:

What is referred to as ‘treatment’ in many centers in fact includes painful, unmedicated withdrawal, beatings, military drills, verbal abuse, and sometimes scientific experimentation without informed consent. Forced labor, without pay or at extremely low wages, at times in total silence, is used as ‘rehabilitation,’ with detainees punished if work quotas are not met.54

IHRD has documented numerous examples of patients forced to undergo perverse, punitive, and abusive treatment:

      • “Former detainees in Cambodia report being locked in cement facilities where they are forced to withdraw ‘cold turkey,’ and not allowed to use the toilet despite the diarrhea that is commonly associated with such withdrawal, subjected to sexual violence and beatings with batons and boards, and compelled to confess to unsolved criminal cases.”
      • In South Africa, “[Former residents of one center report being kicked and beaten if they did not maintain sufficient speed during physical training, which consisted of carrying boulders on their bare backs, rolling long distances on hot pavement, or running while carrying as much as 25 liters of water and then being forced to drink it all, pausing only to vomit.”
      • “In Nagaland, India, drug users have been crammed into thorn-tree cages in a sitting position. In Punjab, drug treatment patients are routinely tortured, and in some cases have been beaten to death.”55
      • Moreover, people may be forced to undergo dangerous and experimental therapy, a clear violation of their right to be free from “torture, nonconsensual medical treatment and experimentation.” IHRD has documented:56
      • In China, “Private and voluntary treatment methods include partial lobotomy through the insertion of heated needles clamped in place for up to a week to destroy brain tissue thought to be connected to cravings.”
      • “Throughout Eastern Europe and Central Asia… patients have ampoules or substances injected under the skin and are told that they will explode and poison them if they drink or use drugs.”57

Beyond this so-called treatment, people detained in these centers are frequently denied access to basic medical treatment and care, including evidence-based treatment for drug dependence, medical care for HIV and other health conditions, and access to HIV prevention measures. As the UN Special Rapporteur on the Right to Health notes, “Imposition of compulsory treatment, at the expense of OST and other harm reduction interventions, also increases the risk of disease transmission, particularly HIV/AIDS.” This constitutes a further violation of the right to health.

While the heads of 12 UN agencies have signed a statement calling for an end to detention as treatment, the practice continues.58 For example, there are an estimated 300,000 to 500,000 people undergoing compulsory drug detention in China, and as many 60,000 people each year in Vietnam. Thousands more are interned in Cambodia, Thailand, Malaysia, Laos, Burma, and other countries in Asia.59 Conditions in drug detention centers are so severe that people who use drugs are sometimes forced to resort to desperate measures. In one Chinese study, up to 10% had swallowed nails or glass to avoid such detention.60

For legal assessments detailing the violations of international human rights law represented by these practices, please consult the following Open Society Foundation resources: Treatment or Torture? Applying International Human Rights Standards to Drug Detention Centers (2011); Treated with Cruelty: Abuses in the Name of Rehabilitation (2011); and Human Rights Abuses in the Name of Drug Treatment: Reports From the Field (2009).

Police harassment, ill treatment, and torture

Criminalization of drug use is common, creating tension between law enforcement and harm reduction efforts.61 Persons who use drugs, already a marginalized group in society, are vulnerable to a range of human rights abuses by police and law enforcement officers. Police often target them in order to meet arrest quotas.62 According to Human Rights Watch:

People who use drugs are routinely subjected to violence during arrest and detention, in some cases to extract confessions. Law enforcement in many countries has relied on tactics amounting to inhuman treatment or in some cases to torture, including forcing suspects to suffer withdrawal to extract confessions and extorting money from them.

In some countries, such as Russia, Georgia, Ukraine, and Thailand, people who use drugs are identified and listed in registries that “brand [them] as sick and dangerous, sometimes for life” and fuel violations of their civil rights, including increased police surveillance and discrimination in employment, travel, immigration, and child custody.63

Police harassment and abuse directly contribute to drug-related harms and undermine important public health objectives, violating the right to health of people who use drugs and the communities in which they live. The UN Special Rapporteur on the Right to Health notes:

Police crackdowns and other interventions associated with criminalization of drug use and possession also result in displacement of drug users from areas serviced by harm-reduction programmes, decreasing their ability to participate in needle and syringe programmes, opioid substitution therapy (OST) and access to outreach workers. Access to emergency assistance in the instance of an overdose also is impeded, and the incidence of overdose may be increased by disrupting access to regular injecting networks and drug suppliers…. Any efforts to decriminalize or de-penalize drug use or possession must be coupled with appropriate strategies to ensure that the fear and stigma that were reinforced through excessive policing are ameliorated.64

Denial of evidence-based treatment and care, including harm reduction

People who inject drugs experience heightened risk of HIV, hepatitis B65 and C,66 and TB.67 Yet in many countries, harm reduction services are underutilized or even proscribed. The UN Special Rapporteur notes:

Currently, 93 countries and territories support a harm reduction approach. As of 2009, needle and syringe programmes had been implemented in 82 countries, and OST in 70 countries, with both interventions available in 66 countries. However, needle and syringe programmes have been confirmed to be absent in 55 countries where injecting drugs are used, and OST in 66 such countries. It is particularly disturbing that OST is unavailable in 29 countries throughout Africa and the Middle East, especially in the light of the HIV burden throughout Africa.68

Even where harm reduction measures are legal, people may refrain from seeking assistance for drug use or drug-related health issues in order to avoid discrimination, violations of their privacy or even incarceration.69 Human Rights Watch notes:

In some countries, many people who inject drugs do not carry sterile syringes or other injecting equipment, even though it is legal to do so, because possession of such equipment can mark an individual as a drug user and expose him or her to punishment on other grounds. Police presence at or near government sanctioned harm reduction programs (such as legal needle exchange sites) drives drug users away from these services out of fear of arrest or other punishment.70

The illegal status of drug use and possession also shape the quality and type of treatment people who use drugs receive. People who use drugs are often discriminated against in medical settings and may be denied access to antiretroviral therapy and other medical treatments.71 For example, it is estimated that only 4% of people who inject drugs with HIV are receiving antiretroviral treatment. 72 People who use drugs also face disproportionate barriers in accessing housing other social services.

Denial of access to controlled medicines

An essential aspect of reducing drug-related harms is increasing access to controlled essential medicines for therapeutic purposes, including pain, drug dependence, and other health conditions. According to the UN Special Rapporteur on the Right to Health:

These medications are often restricted excessively for fear they will be diverted from legitimate medical uses to illicit purposes. Although preventing drug diversion is important, this risk must be balanced against the needs of the patient to be treated…. Where patients with HIV are also dependent on drugs, they may be denied access to both OST and palliative care…. Restrictive laws are a particular problem in the cases of methadone and buprenorphine, drugs used for OST. In some States use of these drugs is outlawed.73

Access to essential medicines is a minimum core obligation of the right to health and the failure of states to provide people who use drugs access controlled medicines constitutes a violation of this right.

Vulnerability of women, children and young people who use drugs74

Young people frequently represent a significant proportion of people who inject drugs; in some countries, injection drug use starts as early as age 12. In one study of harm reduction programs in Georgia, 16.8% of the respondents were under 25. In another study in Romania, 16% of the participants were aged 15–19 and 45% were aged 20–24. Based on these and similar findings across Central and Eastern Europe, UNAIDS estimates that around 45% of all new HIV infections are among young people under age 25.

There is also a high prevalence of injection drug use among women in many parts of the world. According to Harm Reduction International, “Though precise data on women who use drugs are rarely available, women have been estimated to represent about 40% of drug users in the United States and some parts of Europe, 20% in Eastern Europe, Central Asia, and Latin America, between 17-40% in various provinces of China, and 10% in some other Asian countries.” Advocates also note an overlap between commercial sex work and injecting drug use in some areas, which contributes to increased risk of drug-related harms.75

What are current interventions and practices in the area of harm reduction?

Harm reduction measures include a range of interventions to address the medical and ethical problems outlined above. Some target biomedical issues while others target the social determinants of health – either root causes or the larger environment in which people access their right to health. Harm reduction measures can be tailored to take specific vulnerability factors into account, such as age, gender or incarceration, and they can be used in combination.

Additionally, some of these measures include a human rights component and are explicitly designed to respect and protect the dignity and rights of people who use drugs. The following list includes both rights-based and public health-based interventions, as well as other approaches to ensuring the respect of the rights of people who inject drugs that may not be traditionally characterized as harm reduction.

Needle and syringe programs
These programs are designed to provide sterile injection equipment to people who inject drugs and have been extensively proven to prevent and control HIV and other blood-borne infections.76 Programs differ greatly from fixed and mobile sites, community outreach, pharmacy provision, and vending machines.

Supervised injection facilities and drug-consumption rooms
Medically supervised injection facilities provide a hygienic site for injection drug use. The sites often provide sterile injection equipment, as well as information about drugs and medical and treatment referrals. Some sites may offer additional medical or counselling services.

The Special Rapporteur on the Right to Health stated that the “potential benefits of drug-consumption rooms include prevention of disease transmission and reduced venous damage, as well as encouraging entry to treatment and other services. Evidence exists that drug consumption rooms have contributed to reductions in overdose rates, and increased access to medical and social services.”77

Route-transition interventions
Route transition interventions strive to prevent transitions to more harmful methods of drug administration or attempt to change a drug users current method of drug administration to a safer method. An example would be promoting smoking heroin rather than injecting heroin.

Opioid substitution therapy
Opioid substitution therapy (OST) is the prescription of opioid medicines to persons with opioid dependence under medical supervision. This is also known as substitution or replacement therapy, drug dependence treatment, or prescription of substitute medications. OST facilitates the reduction or discontinuation of drug injection and increases the normalization of the patient’s lifestyle. OST also reduces risk of contracting blood-borne disease and increases the possibility of treatment if the patient is already a carrier, and reduces overdose mortality. Traditional opioid substitutions are methadone and buprenorphine, but some countries also use slow-release morphine or codeine. Heroin-assisted treatment (HAT) is an effective option for people who continue using intravenous heroin while on methadone maintenance or who are not enrolled in treatment. 78

Overdose prevention
Overdose prevention practices can be promoted through education and outreach and overdose interventions can be as simple as first-aid training. Administration of the drug Naloxone, “an opioid receptor antagonist used to reverse depression of the central nervous system in cases of opioid overdose,” is also crucial for minimizing overdose risk, but it must be available for distribution and administration.79

Outreach and education programs
Education and outreach programs can involve assistance with access to services, peer mentoring or counselling, support groups, provision of sterile injection equipment, or provision of educational materials on harm reduction, safe drug use, or safe sex.

Access to justice through legal aid, paralegal training, and legal empowerment 80
Evidence suggests that access to legal aid, paralegal services, and legal empowerment can greatly enhance the health of drug users. Legal services can include assistance with access to housing, health, and social services; training and supporting non-lawyers as paralegals and accompaniers; training drug users to know and assert their rights; documenting human rights abuses against drug users and related advocacy; and ensuring the legality of health services for drug users.

Access to medical services
Access to medical services
People who inject drugs are deterred from accessing available services for a variety of reasons. Harm reduction programs should ensure that people who inject drugs are afforded access to medical services without discrimination or judgment.

Access to HIV treatment
Evidence has shown that persons who inject drugs can, with proper supports, enjoy the same benefits from ART as other people with HIV. However, as mentioned above, people who inject drugs account for a large number of HIV infections, but a small fraction of those with access to antiretroviral treatment (ART).

Vaccination, diagnosis, and treatment of hepatitis B and C
WHO recommends countries provide catch-up vaccination against hepatitis B for people at increased risk (there is no vaccine against hepatitis C).81 WHO also recommends that people who inject drugs receive the rapid hepatitis B vaccination regimen as well as incentives to complete the regimen. People who inject drugs should also have access to medical services to ensure treatment of hepatitis.

Integrated services
Treatment for HIV and/or TB can be integrated with OST to more adequately address the needs of people who inject drugs. For example, if TB treatment requires hospital stays, people who inject drugs may avoid treatment to also avoid withdrawal symptoms. Models on integrated services have been developed over the past few years, resulting in more information on best practices.82

Decriminalization
Harm reduction advocates have always sought to decriminalize harm reduction services and to decriminalize drug users. On July 11, 2012, the UN assembled Commission on HIV and the Law publicly called for the decriminalization of drug use, needles, and the personal possession of drugs.83 In June 2012, the Global Commission on Drug Policy also released a report recommending the decriminalization of drug use.84 It should also be noted that harm reduction challenges laws and policies that may generate or exacerbate harm. “In many countries, harm reduction is further hampered by criminal laws, disproportionate penalties and law enforcement.”85

Elimination of the death penalty
The death penalty is one of the most egregious examples of the punitive laws, policies, and measures that operate on the situation of people who inject drugs. The death penalty can be imposed for certain drug offenses, including drug trafficking. Oftentimes people who use drugs can be charged with trafficking, particularly in countries with weak rule of law. The UN Human Rights Committee has found that drug offenses are not serious crimes, and therefore the death penalty is not permitted under international human rights law for drug offenses.

Protection against abuses by police and health care providers
Mistreatment of people who use drugs by police and healthcare providers is widespread. Police use the threat of incarceration or painful withdrawal symptoms to coerce testimony and extort money from people who use drugs. In many countries, police or health care providers release confidential information regarding HIV or drug-using status, register drug users’ names on government lists, and deny them employment or services. It is common for governments to impose lengthy prison sentences for minor drug offenses. This not only constitutes cruel and unusual punishment, but also catalyzes HIV transmission, since hundreds of thousands of people are incarcerated in environments where drug injection and unprotected sex continue, and where HIV treatment and prevention measures are often unavailable.

Support for political participation
More than two decades of experience with HIV have shown that “hard-to-reach” populations are their own best advocates. Despite the importance of involving those who are directly affected in the formation of drug and harm reduction policy, drug users have often been excluded, even from those mechanisms that are intended to increase participation of drug users.

Women often wait longer to seek diagnosis and treatment for TB. This in turn can “increase the severity of their illness, decrease the success of treatment, and raise the risks that they will infect others.”86 Where TB treatment is provided mostly via in-patients modes—the norm in many former Soviet countries—women may face particular difficulty adhering to treatment due to their child care responsibilities or inability to leave home for extended periods. While men and women may both face economic consequences related TB stigma, women can also face lost marriage prospects, divorce, desertion and separation from their children.87

Notes

1 Mathers B et al, “The global epidemiology of injecting drug use and HIV among people who inject drugs: A systematic review,” Lancet, 372, no. 9651 (2008): 1733–1745.

2 Jurgens et al., “People who use drugs, HIV, and human rights”, Lancet 376 (2010): 475–485.

3 Harm Reduction International, “What is harm reduction?,” www.ihra.net/what-is-harm-reduction.

4 Open Society Foundations, “Harm Reduction.” www.soros.org/topics/harm-reduction.

5 Harm Reduction International, What is Harm Reduction?: A position statement from the International Harm Reduction Association (2010). www.ihra.net/what-is-harm-reduction.

6 Open Society Foundations, “Harm Reduction.” www.soros.org/topics/harm-reduction.

7 Harm Reduction International, What is Harm Reduction?: A position statement from the International Harm Reduction Association (2010). www.ihra.net/what-is-harm-reduction.

8 UN General Assembly, Report of the Special Rapporteur on the right to health, A/65/255, para. 50 (Aug. 6, 2010).

9 Rhodes T and Hedrich D, “Chapter 1: Harm reduction and the mainstream in Harm Reduction: Evidence, Impacts and Challenges,” Harm Reduction: evidence, impacts and challenges (European Monitoring Centre for Drugs and Drug Addiction, April 2010). www.emcdda.europa.eu/publications/monographs/harm-reduction.

10 Harm Reduction International, What is Harm Reduction?: A position statement from the International Harm Reduction Association (2010).
www.ihra.net/what-is-harm-reduction.

11 Ibid.

12 UN General Assembly, Report of the Special Rapporteur on the right of everyone to the highest attainable standard of physical and mental health, A/65/255 (Aug. 6, 2010).

13 Harm Reduction International, What is Harm Reduction?: A position statement from the International Harm Reduction Association (2010). www.ihra.net/what-is-harm-reduction.

14 Marlatt GA, Larimer, ME, and Witkiewitz, K, eds., Harm Reduction, Second Edition: Pragmatic Strategies for Managing High-Risk Behaviors (New York: Guilford Press, 2011).

15 This approach has been implemented in Thailand, although recent policy developments threaten to jeopardize progress. OSF, Criminalizing Condoms: How Policing Practices Put Sex Workers and HIV Services at Risk in Kenya, Namibia, Russia, South Africa, the United States, and Zimbabwe (July 2012). www.opensocietyfoundations.org/reports/criminalizing-condoms. See also Human Rights Watch, Sex Workers at Risk: Condoms as Evidence of Prostitution in Four US Cities (2012). www.hrw.org/reports/2012/07/19/sex-workers-risk.

16 Human Rights Watch, “Drug Policy and Human Rights.” www.hrw.org/topic/retired-terms/drug-policy-and-human-rights. See also Jurgens et al., “People who use drugs, HIV, and human rights”, Lancet 376 (2010): 475–485.

17 Open Society Foundations, Human Rights Abuses in the Name of Drug Treatment: Reports from the Field (March 2009). www.opensocietyfoundations.org/publications/human-rights-abuses-name-drug-treatment-reports-field.

18 UN General Assembly, Report of the Special Rapporteur on the right of everyone to the highest attainable standard of physical and mental health, A/65/255, para. 15 (Aug. 6, 2010).

19 Ibid.

20 Open Society Foundations, Human Rights Abuses in the Name of Drug Treatment: Reports from the Field (2009).

21 Jurgens et al., “People who use drugs, HIV, and human rights”, Lancet 376 (2010): 475–485; UN General Assembly, Report of the Special Rapporteur on the right of everyone to the highest attainable standard of physical and mental health, A/65/255 (Aug. 6, 2010).

22 Harm Reduction International, What is Harm Reduction?: A position statement from the International Harm Reduction Association (2010). www.ihra.net/what-is-harm-reduction.

23 Jurgens et al., “People who use drugs, HIV, and human rights”, Lancet 376 (2010): 475–485.

24 United Nations Office on Drugs and Crime (UNODC). www.unodc.org/.

25 Global Commission on HIV and the Law, HIV and the Law: Risks, Rights and Health (2012). www.hivlawcommission.org/index.php/report.

26 UN General Assembly, Report of the Special Rapporteur on the right of everyone to the highest attainable standard of physical and mental health, A/65/255, (Aug. 6, 2010).

27 Open Society Institute and International Harm Reduction Development, Protecting the Human Rights of Injection Drug Users: The Impact of HIV and AIDS (2005). www.opensocietyfoundations.org/publications/protecting-human-rights-injection-drug-users-impact-hiv-and-aids.

28 Ibid.

29 Open Society Foundations, Human Rights Abuses in the Name of Drug Treatment: Reports from the Field (2009).

30 UN General Assembly, Report of the Special Rapporteur on the right of everyone to the highest attainable standard of physical and mental health, A/65/255 (Aug. 6, 2010).

31 International Center for Science in Drug Policy, The Vienna Declaration (2010). www.viennadeclaration.com.

32 UN General Assembly, Report of the Special Rapporteur on the right of everyone to the highest attainable standard of physical and mental health, A/65/255 (Aug. 6, 2010).

33 Ibid. See also: Global Commission on HIV and the Law, HIV and the Law: Risks, Rights and Health (2012). www.hivlawcommission.org/index.php/report.

34 Jurgens et al., “People who use drugs, HIV, and human rights”, Lancet 376 (2010): 475–485.

35 Open Society Foundations, Human Rights Abuses in the Name of Drug Treatment: Reports from the Field (2009). http://www.opensocietyfoundations.org/publications/human-rights-abuses-name-drug-treatment-reports-field.

36 Alternative Georgia, Reforming Drug Policy for HIV/AIDS Prevention (2005).

37 Harm Reduction International, The Death Penalty for Drug Offenses: Global Overview (2011). www.ihra.net/contents/1080.

38 UN General Assembly, Report of the Special Rapporteur on the right of everyone to the highest attainable standard of physical and mental health, A/65/255 (Aug. 6, 2010).

39 Human Rights Watch, “Drug Policy and Human Rights.” http://www.hrw.org/node/82339.

40 Harm Reduction International, The Death Penalty for Drug Offenses: Global Overview (2011). www.ihra.net/contents/1080.

41 Jurgens et al., “People who use drugs, HIV, and human rights”, Lancet 376 (2010): 475–485.

42 UN General Assembly, Report of the Special Rapporteur on the right of everyone to the highest attainable standard of physical and mental health, A/65/255 (Aug. 6, 2010).

43 Amon J, Preventing the Further Spread of HIV/AIDS: The Essential Role of Human Rights (Human Rights Watch). www.old.msmgf.org/documents/NorthAmerica/TakeAction/PreventingtheFurtherSpreadfHIVAIDSTheEssentialRlefHumanRights.pdf.

44 Jurgens et al., “People who use drugs, HIV, and human rights”, Lancet 376 (2010): 475–485.

46 UN General Assembly, Report of the Special Rapporteur on the right of everyone to the highest attainable standard of physical and mental health, A/65/255 (Aug. 6, 2010).

47 Jurgens et al., “People who use drugs, HIV, and human rights”, Lancet 376 (2010): 475–485.

48 Open Society Institute and International Harm Reduction Development, Protecting the Human Rights of Injection Drug Users: The Impact of HIV and AIDS (2005). http://www.opensocietyfoundations.org/publications/protecting-human-rights-injection-drug-users-impact-hiv-and-aids.

49 Human Rights Watch, “Drug Policy and Human Rights.” http://www.hrw.org/node/82339.

50 UN General Assembly, Report of the Special Rapporteur on the right of everyone to the highest attainable standard of physical and mental health, A/65/255 (Aug. 6, 2010).

51 Open Society Foundations, Treated with Cruelty: Abuses in the Name of Rehabilitation (2011). www.opensocietyfoundations.org/publications/treated-cruelty-abuses-name-rehabilitation.

52 Clark et al, Voluntary treatment, not detention, in the management of opioid dependence (WHO, 2013). www.who.int/bulletin/volumes/91/2/13-117184/en/index.html.

53 Open Society Foundations, Human Rights Abuses in the Name of Drug Treatment: Reports from the Field (2009). www.opensocietyfoundations.org/publications/human-rights-abuses-name-drug-treatment-reports-field.

54 Open Society Foundations, Treatment or Torture?: Applying International Human Rights Standards to Drug Detention Centers (2011). www.opensocietyfoundations.org/sites/default/files/treatment-or-torture-20110624.pdf.

55 Open Society Foundations, Human Rights Abuses in the Name of Drug Treatment: Reports from the Field (2009). www.opensocietyfoundations.org/publications/human-rights-abuses-name-drug-treatment-reports-field.

56 UN General Assembly, Report of the Special Rapporteur on the right of everyone to the highest attainable standard of physical and mental health, A/65/255 (Aug. 6, 2010).

57 Open Society Foundations, Human Rights Abuses in the Name of Drug Treatment: Reports from the Field (2009). www.opensocietyfoundations.org/publications/human-rights-abuses-name-drug-treatment-reports-field.

58 United Nations, Joint Statement: Compulsory Drug Detention and Rehabilitation Centres (2012). www.unaids.org/en/media/unaids/contentassets/documents/document/2012/JC2310_Joint%20Statement6March12FINAL_en.pdf; Human Rights Watch, Torture in the Name of Treatment (2012). www.hrw.org/sites/default/files/reports/HHR%20Drug%20Detention%20Brochure_LOWRES.pdf.

59 Open Society Foundations, Treatment or Torture?: Applying International Human Rights Standards to Drug Detention Centers (2011). www.opensocietyfoundations.org/sites/default/files/treatment-or-torture-20110624.pdf.

60 Wolfe D, “Paradoxes in antiretroviral treatment for injecting drug users: Access, adherence and structural barriers in Asia and the former Soviet Union,” International Journal of Drug Policy (2007).

61 Stevens A, Stöver H and Brentari C, “Chapter 14: Criminal justice approaches to harm reduction in Europe in Harm Reduction: evidence, impacts and challenges,” Harm Reduction: evidence, impacts and challenges (European Monitoring Centre for Drugs and Drug Addiction, April 2010). www.emcdda.europa.eu/publications/monographs/harm-reduction.

62 Global Commission on HIV and the Law, HIV and the Law: Risks, Rights and Health (2012). www.hivlawcommission.org/index.php/report.

63 Ibid. Open Society Institute, Human Rights Abuses in the Name of Drug Treatment: Reports from the Field (2009). www.opensocietyfoundations.org/publications/human-rights-abuses-name-drug-treatment-reports-field.

64 UN General Assembly, Report of the Special Rapporteur on the right of everyone to the highest attainable standard of physical and mental health, A/65/255 (Aug. 6, 2010).

65 World Health Organization (WHO), Guidance on Prevention of viral Hepatitis B and C among people who inject drug, Policy Brief (July 2012). http://apps.who.int/iris/bitstream/10665/75192/1/WHO_HIV_2012.18_eng.pdf.

66 Ibid.

67 Harm Reduction International, Global State of Harm Reduction 2012 (2012). www.ihra.net/global-state-of-harm-reduction-2012.

68 UN General Assembly, Report of the Special Rapporteur on the right of everyone to the highest attainable standard of physical and mental health, A/65/255, para. 15 (Aug. 6, 2010).

69 Open Society Institute and International Harm Reduction Development, Protecting the Human Rights of Injection Drug Users: The Impact of HIV and AIDS (2005). www.opensocietyfoundations.org/publications/protecting-human-rights-injection-drug-users-impact-hiv-and-aids.

70 Human Rights Watch, “Drug Policy and Human Rights.” http://www.hrw.org/node/82339.

71 Jurgens et al., “People who use drugs, HIV, and human rights”, Lancet 376 (2010): 475–485.

72 Harm Reduction International, Global State of Harm Reduction 2012 (2012). www.ihra.net/global-state-of-harm-reduction-2012; Mathers BM et al, “The global epidemiology of injecting drug use and HIV among people who inject drugs: A systematic review,” Lancet 372, no. 9651 (2010): 1733–1745.

73 UN General Assembly, Report of the Special Rapporteur on the right of everyone to the highest attainable standard of physical and mental health, A/65/255, para. 15 (Aug. 6, 2010).

74 Harm Reduction International, Global State of Harm Reduction 2012 (2012). www.ihra.net/global-state-of-harm-reduction-2012.

75 Harm Reduction International, Harm Reduction and Human Rights: The Global Response to Drug-Related HIV Epidemics (2009). www.ihra.net/files/2010/06/01/GlobalResponseDrugRelatedHIV(2).pdf.

76 WHO, UNAIDS and UNODC, Guide to Starting and Managing Need and Syringe Programmes (2007). www.who.int/hiv/pub/idu/needleprogram/en/index.html; World Health Organization, Effectiveness of sterile needle and syringe programming in reducing HIV/AIDS among injecting drug users (2004). http://whqlibdoc.who.int/publications/2004/9241591641.pdf; S. Burris et al, “Physician Prescribing of Sterile Injection Equipment to Prevent HIV Infection: Time for Action,” Annals of Internal Medicine 133, no. 3 (2000): 219.

77 UN General Assembly, Report of the Special Rapporteur on the right of everyone to the highest attainable standard of physical and mental health, A/65/255, (Aug. 6, 2010).

78 See, e.g., Haasen C et al. “Heroin-assisted treatment for Opioid Dependence: Randomised Controlled Trial”, The British Journal of Psychiatry 191:55-62 (2007). http://bjp.rcpsych.org/content/191/1/55.

79 UN General Assembly, Report of the Special Rapporteur on the right of everyone to the highest attainable standard of physical and mental health, A/65/255, (Aug. 6, 2010).

80 Csete J and Cohen J, “Health Benefits of Legal Services for Criminalized Populations: The Case of People Who Use Drugs, Sex Workers, and Sexual and Gender Minorities,” Journal of Law, Medicine, and Ethics (Winter 2010).

81 World Health Organization, Four ways to reduce hepatitis infections in people who inject drugs (July 2012). http://www.who.int/mediacentre/news/notes/2012/hiv_hepatitis_20120721/en/.

82 WHO, UNAIDS and UNODC, Policy Guidelines for Collaborative TB and HIV Services for Injecting and Other Drug Users: An Integrated Approach (2008). http://whqlibdoc.who.int/publications/2008/9789241596930_eng.pdf.

83 Wolfe D and Csete J, Decriminalization of Drugs as HIV Prevention (July 2012). www.opensocietyfoundations.org/voices/decriminalization-drugs-hiv-prevention; Global Commission on HIV and the Law, HIV and the Law: Rights and Health (July 2012). www.hivlawcommission.org/.

84 Global Commission on Drug Policy, The War on Drugs and HIV/AIDS: How the Criminalization of Drug Use Fuels the Global Pandemic (June 2012). http://globalcommissionondrugs.org/wp-content/themes/gcdp_v1/pdf/GCDP_HIV-AIDS_2012_REFERENCE.pdf.

85 Human Rights Watch, OSI: Public Health Program, Canadian HIV/AIDS Legal Network, and Harm Reduction International, Human Rights and Drug Policy: Harm Reduction (2010).

86 TB Alert, “TB and Women: TB is the single biggest killer of young women.” www.tbalert.org/worldwide/TBandwomen.php.

87 Courtwright A and Turner AN, “Tuberculosis and Stigmatization: Pathways and Interventions,” Public Health Reports 125, Suppl 4 (2010):34-42; Somma D et al., “Gender and socio-cultural determinants of TB-related stigma in Bangladesh, India, Malawi and Colombia,” International Journal of Tuberculosis and Lung Disease 17, no. 7 (2008): 856-866. www.who.int/tdr/publications/documents/tb-related-stigma.pdf.