Since July, thousands of individuals and organizations around the world have endorsed the Vienna Declaration, issued in conjunction with the International AIDS Conference held in that city. The core principle of the Declaration is stated clearly and boldly at the beginning: “The criminalization of illicit drug users is fueling the HIV epidemic and has resulted in overwhelmingly negative health and social consequences.  A full policy reorientation is needed.” To quote Hillel, “The rest is commentary.”

Nowhere in public health have the consequences of drug policy been more pronounced than HIV/AIDS. About 12 percent of new HIV infections in the United States occur among injecting drug users. In countries in Eastern Europe and Central Asia the numbers are even higher—50 to 83 percent of HIV cases are among injectors. HIV vulnerability in these populations occurs chiefly as a result of using and sharing contaminated injection equipment—needles, syringes and associated paraphernalia—which provides a very efficient route of HIV transmission. It is estimated that needle sharing can lead to HIV prevalence rates among injectors as high as 40–90 percent within a period of only a few months to a few years.

But HIV infection is not a foregone conclusion for injecting drug users, and HIV prevalence among them has declined precipitously where the right kind of interventions have been implemented. A robust portfolio of research from around the world has demonstrated the effectiveness of two key public health approaches to preventing the spread of HIV among drug users: expanded access to sterile syringes, particularly through syringe exchange programs, and substitution therapy (e.g., methadone maintenance) for mitigating opiate dependence.  These approaches are usually referred to under the rubric of “harm reduction” in that they attempt to mitigate the harms of drug use, while not necessarily eliminating such use altogether. Underlying these approaches is recognition that many people cannot escape addiction but can benefit from health promotion and disease prevention interventions while still using drugs. (Harm reduction also has a long history in areas such as seat belt and motorcycle helmet use and minimum-age laws for alcohol consumption.) 

Expanded access to sterile syringes and associated health services provided through needle exchange programs have resulted in decreased needle sharing and reduced HIV incidence and prevalence in many locations in Europe, Asia, Australia and North America. Substitution therapy has been shown to reduce both frequency of needle sharing and probability of HIV disease progression among those already infected. 

But these well-proven harm reduction strategies have not been implemented or scaled up sufficiently in many places with drug use–driven HIV epidemics. It is estimated that only about 8 percent of injecting drug users at risk for HIV infection globally have access to harm reduction programs. Why? Because of punitive laws and policies that relate to drug possession and use, possession of drug paraphernalia or acquiring syringes from pharmacies without medical prescriptions. These laws and policies stem from a zero-tolerance approach to drug use that criminalizes drug users, drives them underground, and condemns them to heightened risk for a range of transmissible diseases, including HIV and hepatitis. This approach has led some countries with significant drug use–driven epidemics, like Russia, to outlaw substitution therapy altogether.

Many people cite “moral” objections to harm reduction because they believe it facilitates drug use. But there is an equally “moral” view that everyone—including people who use drugs, and their partners and children—deserve a chance to protect themselves from HIV. Drug recovery is a long and uncertain process, marked by chronic relapse. HIV infection can happen very quickly and is irreversible.   Reexamining and reorienting drug policy with a public health and evidence-based frame will go a long way toward eliminating the dual epidemics of drug addiction and HIV infection in the United States and globally.

Read more from the special forum on drug policy reform: Ethan Nadelmann, "Breaking the Taboo"   Marc Mauer, "Beyond the Fair Sentencing Act"   Bruce Western, "Decriminalizing Poverty"   Tracy Velázquez, "The Verdict on Drug Courts"   David Cole, "Restoring Lost Liberties"   Laura Carlsen, "A New Model for Mexico"