According to a new report released by The Global Commission on Drug Policy, punitive anti-drug policies of the war on drugs have been fueling the HIV epidemic in injection drug users. While the report covers several causes, there are two major aspects of the war on drugs that are significantly worsening the HIV epidemic: global diversion of funds from evidence-based harm reduction programs, and mass incarceration of injection drug users and the resulting barriers to public health services.

The Epidemic

According to the Commission’s report, the number of new HIV infections worldwide has declined since the 1990s, but it has increased by 25 percent in seven countries—largely in injection drug using populations. “Five of these countries are in Eastern Europe and Central Asia, where the war on drugs is being aggressively fought and, as a result, the number of people living with HIV in this part of the world has almost tripled since 2000.”

Globally, there are 16 million people who inject illegal drugs and nearly one in five are living with HIV. Outside of sub Saharan Africa, 30 percent of all new HIV infections occur in injection drug users.

Lost Opportunity Costs

The costs incurred by the war on drugs has led to a diversion of public funding from sound evidence-based public health measures, like needle exchanges, addiction treatment centers and opioid substitution therapies, that could prevent up to 130,000 new HIV infections annually.

While harm reduction programs have been historically underfunded, drug interdiction and crop reduction efforts—two pillars of the failed and deluded effort to eradicate the growing global drug supply—have received comfortable increases each year.

Between FY2002-2009, U.S. funding for international crop eradication efforts increased by 100 percent, and funding for drug interdiction at U.S. borders increased by 98 percent. During the same time, appropriations for drug dependence programs increased by only 22.7 percent.

Globally, about $100 billion is spent enforcing the war on drugs ever year. In a global recession, justifying heavy investment in a policy with so little return is difficult. Last year, the Global Fund, the largest multilateral funding source for harm reduction programs, announced funding suspensions until 2014 due to economic distress in donor countries. Needless to say, this funding shortfall has dire consequences for HIV infected populations worldwide.

Alternatively, harm reduction programs would cost less than one third of the war on drugs per year. The Joint United Nations Programme on HIV/AIDS (UNAIDS) estimated that $3.2 billion was necessary in 2010 to meet global harm reduction needs, and present funding levels are nowhere near this level. Between 2004 and 2008 the Global Fund could only provide US$180 million to harm reduction programs in 42 countries.

Under the punitive paradigm, there is little investment in treating drug-dependent populations, in which HIV infection is skyrocketing. According to the Global Commission’s report, the Russian Federation, which boasts an annual investment of US$800 million in HIV-related initiatives, commits less than one percent to HIV-prevention in injection drug users. About one in every hundred Russian adults is infected with HIV. 

And of course, the resulting mass incarceration of drug users has undoubtedly contributed to the unsustainable overspending in the U.S. penal system, further diluting the availability of public funding for effective treatment programs.

Mass Incarceration

The Commission’s report also details public health consequences of mass incarceration of non-violent drug law offenders in prisons, where there is little to no drug addiction treatment, and risks of needle sharing, unprotected sex, and HIV outbreaks are markedly higher. Incarcerations of HIV positive drug users have been linked with the disruption of anti-retroviral therapy and increased risks for viral treatment failure, which further fuels the HIV epidemic.

In 2009, 1.7 million Americans were arrested on drug charges (more than for assault or larceny) and four of five of those arrests were simply for drug possession.

It is estimated that drug related incarcerations in the United States increased ten fold between 1982 and 2002 and more than half of Americas inmates are in prison for drug convictions. Despite making up only five percent of the world’s population, the United States currently houses 25 percent of the world’s prison population.

According to the Commission’s report, “ethnic minorities are many times more likely than whites to be incarcerated for drug-related offenses [and]…disproportionate incarceration rates are one of the key reasons for the markedly elevated rates of HIV infection among African Americans.” This is especially concerning because although African Americans make up just 12 percent of the American population, they make up more than 50 percent of all new HIV infections in the United States. 

Rampant incarceration and aggressive enforcement worsens the epidemic because injection drug users chose to forego treatment due to fear of prosecution. These fears are driven by numerous documented human rights abuses against injection drug users, including police violence and torture, coercion, denial of harm reduction services, and discrimination in the use of drug registries.

Ultimately, the criminalization of drug use has fantastically failed to reduce drug use and demand, which is expected to rise 25 percent worldwide by 2050.

Stopping the epidemic

At the heart of the policy’s failure is a discounting of human life. It is evident in the senseless explosion of drug-related violence in Mexico and Latin America, the flippant extrajudicial killings in Thailand and manifest most malignantly in the marginalization of vulnerable populations who need treatment, not punishment. Criminalizing drug abuse with no offer of rehabilitation is systematically condemning an entire population that society has devalued. This marginalization is made more unconscionable when you consider its role in driving HIV infection—and ultimately death—in hundreds and thousands of people. Incarceration alone does far too little for far too many.

If held to the same moral standards of public health ethics, the zero tolerance approach would have been stopped long ago. In clinical trials, there are built in rules to end a trial if the interim data suggests the trial causes more harm than good or has unforeseen and harmful side-effects. Might policies as far reaching and unsubstantiated as the war on drugs have predetermined stopping rules, the data would clearly indicate at this critical point, to end this policy, assess the evidence, consider alternative approaches, and observe the moral rule to minimize risk and faithfully–do no harm.

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