School of Public Health and Community Medicine
How policies and repressive law-enforcement fuel the HIV epidemic among people who inject drugs
Professor Kate DolanProgram of International Research and
TrainingNational Drug and Alcohol Research Centre UNSW, Sydney, Australia
Policy and HIV epidemics Government Policy Restrict
A) HIV prevention programs
B) Scale up of effective HIV prevention
Policy restricts HIV prevention
Case study RussiaNo 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
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Ban started in 1988 Repealed in 2009 Reinstated 2011 1,800,000 PWIDs - 16% HIV positive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.
Policy restricts HIV prevention 196 countries
Countries without Community Programs
Countries without Prison Programs
No NSP 72 185
No OST 81 160
No ARV 149 153
Policy Restricts scale up of HIV prevention
Coverage for PWIDs 2010
NSP %
OST %
ARV %
Global estimate 8 8 4
Law enforcement and HIV epidemics Law enforcement increases
the likelihood of sharing syringes
incarceration of PWID increase HIV transmission
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
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
Recommend
Drug treatment (esp. OST), NSP and ARV
Educate on benefits of HR in and out of prisonand 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
References1. 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):1372-756. 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 programs10. 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.