Joanne Csete

People who use drugs, HIV, and human rights.

We reviewed evidence from more than 900 studies and reports on the link between human rights abuses experienced by people who use drugs and vulnerability to HIV infection and access to services. Published work documents widespread abuses of human rights, which increase vulnerability to HIV infection and negatively affect delivery of HIV programmes. These abuses include denial of harm-reduction services, discriminatory access to antiretroviral therapy, abusive law enforcement practices, and coercion in the guise of treatment for drug dependence. Protection of the human rights of people who use drugs therefore is important not only because their rights must be respected, protected, and fulfilled, but also because it is an essential precondition to improving the health of people who use drugs. Rights-based responses to HIV and drug use have had good outcomes where they have been implemented, and they should be replicated in other countries.

Public health and international drug policy.

The Johns Hopkins–Lancet Commission on Drug Policy and Health has sought to examine the emerging scientific evidence on public health issues arising from drug-control policy and to inform and encourage a central focus on public health evidence and outcomes in drug-policy debates, such as the important deliberations of the 2016 UNGASS on drugs. The Commission is concerned that drug policies are often coloured by ideas about drug use and dependence that are not scientifically grounded. The 1998 UNGASS declaration, for example, like the UN drug conventions and many national drug laws, does not distinguish between drug use and drug misuse. A 2015 report by the UN High Commissioner for Human Rights, by contrast, emphasised that drug use “is neither a medical condition, nor does it necessarily lead to drug dependence”. The idea that all drug use is dangerous and evil has led to enforcement-heavy policies and has made it difficult to see potentially dangerous drugs in the same light as potentially dangerous foods, tobacco, and alcohol, for which the goal of social policy is to reduce potential harms.

Health Benefits of Legal Services for Criminalized Populations: The Case of People Who Use Drugs, Sex Workers and Sexual and Gender Minorities

Social exclusion and legal marginalization are important determinants of health outcomes for people who use illicit drugs, sex workers, and persons who face criminal penalties because of homosexuality or transgenderism. Incarceration may add to the health risks associated with police repression and discrimination for these persons. Access to legal services may be essential to positive health outcomes in these populations. Through concrete examples, this paper explores types of legal problems and legal services linked to health outcomes for drug users, sex workers, and sexual minorities and makes recommendations for donors, legal service providers, and civil society organizations.

An inappropriate tool: criminal law and HIV in Asia.

Background:Asian countries have applied criminal sanctions widely in areas directly relevant to national HIV programmes and policies, including criminalization of HIV transmission, sex work, homosexuality and drug injection. This criminalization may impede universal access to HIV prevention and treatment services in Asia and undermine vulnerable peoples ability to be part of the HIV response. Objective:To review the status of application of criminal law in key HIV-related areas in Asia and analyze its impact. Methods:Review of literature and application of human rights norms to analysis of criminal law measures. Results and conclusion:Criminal laws in the areas considered here and their enforcement, while intended to reduce HIV transmission, are inappropriate and counterproductive with respect to health and human rights. Governments should remove punitive laws that impede the HIV response and should ensure meaningful participation of people living with HIV, people who use illicit drugs, sex workers and men who have sex with men in combating stigma and discrimination and developing rights-centered approaches to HIV.

Switzerland, HIV and the power of pragmatism: Lessons for drug policy development

Switzerland in the 1980s was an epicentre of HIV as open drug injection became part of the urban scene, especially in Zurich. Cracks appeared in Switzerlands long commitment to policing as the main drug-control strategy as law enforcement was unable to contain the health and social consequences of the rapid spread of drug injection. In the early stages of the epidemic, the pioneering health care providers who brought technically illegal harm reduction services into the open drug scene in Zurich helped open the exploration at the federal level of more balanced drug policy. Carefully evaluated pilot experiences in low-threshold methadone, needle exchange, and eventually heroin-assisted therapy yielded evidence of significant HIV prevention and crime reduction that was convincing not only to policy-makers but also to a skeptical Swiss public. Whilst not all countries have Switzerlands resource base, the Swiss experience still holds many useful lessons for establishing evidence-based policy on illicit drugs.

Reports of police beating and associated harms among people who inject drugs in Bangkok, Thailand: a serial cross-sectional study

BackgroundThailand has for years attempted to address illicit drug use through aggressive drug law enforcement. Despite accounts of widespread violence by police against people who inject drugs (IDU), the impact of police violence has not been well investigated. In the wake of an intensified police crackdown in 2011, we sought to identify the prevalence and correlates of experiencing police beating among IDU in Bangkok.MethodsCommunity-recruited samples of IDU in Bangkok were surveyed between June 2009 and October 2011. Multivariate log-binomial regression was used to identify factors associated with reporting police beating.ResultsIn total, 639 unique IDU participated in this serial cross-sectional study, with 240 (37.6%) participants reporting that they had been beaten by police. In multivariate analyses, reports of police beating were associated with male gender (Adjusted Prevalence Ratio [APR] = 4.43), younger age (APR = 1.69), reporting barriers to accessing healthcare (APR = 1.23), and a history of incarceration (APR = 2.51), compulsory drug detention (APR = 1.22) and syringe sharing (APR = 1.44), and study enrolment in 2011 (APR = 1.27) (all p < 0.05). Participants most commonly reported police beating during the interrogation process.ConclusionsA high proportion of IDU in Bangkok reported having been beaten by the police. Experiencing police beating was independently associated with various indicators of drug-related harm. These findings suggest that the over-reliance on enforcement-based approaches is contributing to police-perpetrated abuses and the perpetuation of the HIV risk behaviour among Thai IDU.

In the name of treatment: ending abuses in compulsory drug detention centers

In some Asian countries—including Burma, Cambodia, China, Laos, Malaysia, Thailand and Vietnam—people who use illicit drugs or those suspected of drug use can be detained involuntarily for long periods for the ostensible purpose of treatment of drug dependence [1]. ‘Drug treatment centers’ are generally run by the police and, if they provide treatment at all, do not provide services that correspond to recognized good practices. Recent reports have brought to light a wide range of human rights abuses committed in these centers in the name of treatment [2–6]. It is urgent that the ‘treatment’ façade of these institutions be denounced and that researchers and health professionals join human rights advocates in advocating for the closure of these centers. ‘Drug treatment centers’ are better referred to as compulsory drug detention centers. People may be put into such centers without being properly charged or brought before a court or tribunal to answer charges or challenge the sentence of detention, as should happen in criminal proceedings [2–5]. Police crackdowns may swell the population of these centers. People have been detained based on one positive drug test and, in some places, even people who have no history of drug use have been detained [3]. In some cases people may be brought into the centers by family members made desperate by the absence of affordable treatment options. While practices in compulsory drug ‘treatment’ centers are largely shrouded in secrecy, the few investigative reports available underscore that ‘treatment’ is a cruel misnomer. Military-style drills and forced labor are more likely to be the order of the day than health-care activities [2–4,6]. Some centers have no trained health professionals as regular staff members. Not only is good-quality treatment largely absent, but human rights organizations have documented cruel, inhuman and degrading practices equivalent to torture in these centers. These include sexual assault, slave-like conditions of hard labor, severe beatings and caning, forced testing for human immunodeficiency virus (HIV) and other sexually transmitted diseases without test results or treatment being made available, electric shocks and grossly inadequate food and sanitation [3–5]. Reports of inhumane conditions in the centers inspired the former United Nations Special Rapporteur on Torture to assert that ‘it is clear that abuses—sometimes amounting to torture— are commonplace in drug treatment centers, both public and private’ [7]. In the countries where compulsory drug detention is practised, heroin is widely consumed. Some of these countries—notably China, Malaysia and Vietnam—have successfully established opioid maintenance therapy (with methadone or buprenorphine) as part of HIV control programmes [2,8]; yet reports from all these countries indicate that the number of people being detained without due process in compulsory detention centers far exceeds those admitted to out-patient methadone therapy. The World Health Organization (WHO) and the United Nations Office on Drugs and Crime (UNODC) in 2010 issued a set of principles meant to suggest international standards for the treatment of drug dependence [9]. These standards, long in coming, assert that compulsory detention related to treatment of drug dependence should be restricted to instances where less repressive measures have been exhausted, where the patient presents a potential danger to himself or others, and for very limited periods. Plainly, these principles are violated in compulsory drug detention centers. A 2010 UNODC discussion paper characterizes compulsory drug detention centers as: ‘in reality a type of low-security imprisonment’ [10]. This characterization misses an important distinction. Prisons are legitimate institutions in criminal justice systems. In functioning justice systems, people are sentenced to prison after a judicial proceeding, usually with the right to appeal a verdict or sentence. Drug detention centers, by contrast, do not serve legitimate criminal justice objectives or social objectives. Cheap labor provided by detainees may serve the economic interest of profiteers [4], but it does not justify the abuses of human rights and medical ethics entrenched in these centers. UNODC and the Global Fund to Fight AIDS, Tuberculosis and Malaria have supported training programs for drug detention centre staff in Vietnam [4], and Global Fund grants have supported HIV treatment in some centers in Vietnam and China. Recognizing an ethical quandary, Dr Michel Kazatchkine, the Global Fund executive director, called publicly for the closure of these EDITORIAL doi:10.1111/j.1360-0443.2011.03738.x

Vertical HIV Transmission Should Be Excluded from Criminal Prosecution

Abstract Prevention of mother-to-child transmission of HIV (PMTCT) is an important part of global and national responses to HIV and AIDS. In recent years, many countries have adopted laws to criminalise HIV transmission and exposure. Many of these laws are broadly written and have provisions that enable criminal prosecution of vertical transmission in some circumstances. Even if prosecutions have not yet materialised, the use of these laws against HIV-positive pregnant women could compound the stigma already faced by them and have a chilling effect on women’s utilisation of prevention of mother-to-child transmission programmes. Although criminal laws targeting HIV transmission have often been proposed and adopted with the intent of protecting women, such laws may disadvantage women instead. Criminal laws on HIV transmission and exposure should be reviewed and revised to ensure that vertical transmission is explicitly excluded as an object of criminal prosecution. Scaling up PMTCT services and ensuring that they are affordable, accessible, welcoming and of good quality is the most effective strategy for reducing vertical transmission of HIV and should be the primary strategy in all countries.

Lives to save: PEPFAR, HIV, and injecting drug use in Africa.

This article focuses on US Presidents Emergency Plan for AIDS Relief (PEPFAR) programme and the need for it to reach thousands of injecting drug users in PEPFAR countries in Africa many of whom have HIV. It states that the silver lining of Africa’s growing injection-driven HIV epidemic is that the measures that can stop it are cost effective well researched and easily brought to scale. Additionally PEPFAR has the rare opportunity to save many lives in Africa by the encouragement and funding of effective strategies for HIV prevention and treatment for drug users.

Reason and rights in global drug control policy

Among a number of compelling reasons for the international community to reconsider the “war on drugs,” the HIV/AIDS epidemic is the most urgent. The prevailing emphasis on law enforcement in drug policy has failed to produce its purported benefits, yet many countries insist on enforcing