UN: conflicting views on harm reduction

18 February 2008

Conflicting views and policies within the UN system on harm reduction have become a major concern. Consistency in messages is crucial especially where it concerns joint global programmes such as the efforts to slow down the HIV/AIDS epidemic; efforts in which harm reduction practices like needle exchange and substitution treatment play a pivotal role. 

The next day, Mr Costa wrote a mea culpa letter to Mr Charles [PDF document] making the required promises to secure continued US funding. "On the general issue of 'harm reduction', I share your concern. Under the guise of 'harm reduction', there are people working disingenuously to alter the world's opposition to drugs. These people can misuse our well-intentioned statements for their own agenda, and this we cannot allow. Accordingly, and as we discussed in our meeting, we are reviewing all our statements, both printed and electronic, and will be even more vigilant in the future." He made clear that UNODC maintains a strong opposition to heroin maintenance and drug injection or consumption rooms which in his view run counter to the three UN drug control conventions. On the issue of needle exchange, according to Costa, the linkages between injecting drug use and the HIV/AIDS pandemic fuel a controversy placing UNODC in a difficult position. "Nevertheless, and again taking our guidance from the conventions, CND and INCB, we neither endorse needle exchange as a solution for drug abuse, nor support public statements advocating such practices."

This position taken by Mr Costa under US pressure is in direct conflict with many statements made by other UN agencies on this issue as well with statements made by UNODC representatives or in UNODC documents in the recent past. More than ever, inconsistency reigns within the UN around an issue all 191 UN Member States have pledged to achieve in the Millennium Development Goals: Halt and begin to reverse the spread of HIV/AIDS.

The General Assembly Special Session in 2001 on HIV/AIDS adopted a Declaration of Commitment [PDF document] saying that "harm reduction efforts related to drug use," and "expanded access to essential commodities, including [... ] sterile injecting equipment" should be ensured by 2005. Both WHO and UNAIDS use the term harm reduction as a matter of course. "The United Nations fully endorses the fundamental principles of harm reduction," according to Catherine Hankins, associate director of UNAIDS in her opening address [PDF document] at the 13th International Conference on Drug Related Harm in Slovenia, 2002.

The International Narcotics Control Board (INCB) has been regularly out of tune with the rest of the UN community on the issue of harm reduction. INCB president Philip Emafo, for example, considered in an interview even needle exchange to be contrary to the conventions and condemned the harm reduction policy trend as a "crusade" to undermine them. UNODC legal experts (at the time under the name of UNDCP), however, argued in a confidential and authoritative memorandum to the INCB in 2002, Flexibility of Treaty Provisions as Regards Harm Reduction Approaches [PDF document] that most harm reduction measures are in fact acceptable under the conventions. According to the Legal Affairs Section "it could easily be argued that the Guiding Principles of Drug Demand Reduction provide a clear mandate for the institution of harm reduction policies that, respecting cultural and gender differences, provide for a more supportive environment for drug users."

On methadone substitution treatment the UNODC experts say that it "could hardly be perceived as contrary to the text or the spirit of the treaties. It is a commonly accepted addiction treatment, with several advantages and few drawbacks. Although results are mixed and dependent on many factors, its implementation along sound medical practice guidelines would not constitute a breach of treaty provisions." On needle- or syringe-exchange the document says that this is a "rather straightforward strategy to reduce the risk of contagion with communicable diseases to IV drug abusers [intravenous] who share needles or syringes. It has been introduced in many countries around the world, to help reduce the rate of intravenous transmission of HIV and other transmittable diseases." About drug-injection rooms, the legal advice given is that "even supplying a drug addict with the drug he depends on could be seen as a sort of rehabilitation and social reintegration, assuming that once his drug requirements are taken care of, he will not need to involve himself in criminal activities to finance his dependence" and that it "would be difficult to assert that, in establishing drug-injection rooms, it is the intent of Parties to actually incite to or induce the illicit use of drugs, or even more so, to associate with, aid, abet or facilitate the possession of drugs. [..] On the contrary, it seems clear that in such cases the intention of governments is to provide healthier conditions for IV drug abusers, thereby reducing their risk of infection with grave transmittable diseases and, at least in some cases, reaching out to them with counselling and other therapeutic options. Albeit how insufficient this may look from a demand reduction point of view, it would still fall far from the intent of committing an offence as foreseen in the 1988 Convention." Finally, addressing the remaining doubts about a potential tense legal footing of some treaty articles with harm reduction, the document states, refering to the HIV/AIDS crisis: "It could even be argued that the drug control treaties, as they stand, have been rendered out of synch with reality, since at the time they came into force they could not have possibly foreseen these new threats."

In 2004 the position of UNODC seemed to move towards closer harmony with other UN agencies, especially regarding the usefulness of harm reduction measures for the purpose of HIV/AIDS prevention. UNODC is co-sponsor of the Joint United Nations Programme on HIV/AIDS (UNAIDS), is the convening agency of the UNAIDS Inter-Agency Task Team (IATT) on injecting drug use and (since July 2004 for a one-year period) chair of the UNAIDS Committee of Co-sponsoring Organizations.

In his Report to the Commission on Narcotic Drugs (CND) [PDF document] in Vienna,15-22 March 2004, UNODC Executive Director Costa clarified the position of UNODC on the issue of risk reduction for HIV/AIDS prevention. "Twenty years of research into various aspects of HIV/AIDS among injecting drug users and the experience of numerous programmes and projects indicate that HIV/AIDS epidemics among injecting drug users can be prevented, stabilized and even reversed. [..] Taking into account that drug use is a chronically relapsing condition, policies governing HIV/AIDS prevention must follow pragmatic approaches and therefore must address high-risk behaviour first before striving to achieve long-term goals such as total abstinence from drugs. Effective programmes typically include a wide variety of measures, ranging from drug dependence treatment, including drug substitution treatment, outreach providing injecting drug users with information on risk reduction and referral to services, clean needles and syringes, and condoms [..]. Thus, those injecting drug users who cannot stop injecting can be provided with clean needles and syringes, those who can stop injecting but who are not ready for abstinence-oriented treatment can be offered substitution treatment and a variety of treatment and rehabilitation options can be made available to those who have been able to stop using drugs. [..] A comprehensive package of measures also usually includes treatment instead of punishment for persons convicted of minor drug offences, since incarceration usually increases the risk of HIV transmission. The scientific evidence and the experience with such programmes strongly indicate that the above-described package is effective in reducing the risk of HIV transmission among injecting drug users and the risk of HIV diffusion from infected drug users to the general population."

Mr Costa reiterated that position in his address to the Bangkok International AIDS conference in July 2004: "During the past decade, we have also learned that the HIV/AIDS epidemic among injecting drug users can be stopped - and even reversed - if drug users are provided, at an early stage and on a large scale, with comprehensive services such as outreach, provision of clean injecting equipment and a variety of treatment modalities, including substitution treatment. It is, however, a sad fact that less than five per cent, and in many high-risk areas, less than one per cent of all drug users have access to prevention and care services. In too many countries, drug users are simply incarcerated. This is not a solution; in fact, it contributes to the rapid increase in the number of people living with HIV/AIDS."

This gradually shifting UNODC position in the course of 2003/2004 towards the broader UN consensus on basic harm reduction practices forms the background to the current US pressure on tne agency. The combination of two resolutions seeking CND acceptance for basic harm reduction principles at March 2004 CND session, from Brazil on HIV/AIDS and the Pompidou Group on substitution treatment, plus Costa's position paper on HIV/AIDS quoted above and one on substitution treatment jointly by WHO/UNAIDS/UNODC was the prelude to the current crisis in UNODC-US relations. An angried US delegation made blunt statements during the session like that needle exchange programmes in fact might accelerate the spread of HIV instead of preventing it. Thereby denying the wisdom of their own top scientists. An analysis from the US Assistant Secretary for Health and Surgeon General, Dr David Satcher, on Evidence-Based Findings on the Efficacy of Syringe Exchange Programs had concluded that, "After reviewing all of the research to date, the senior scientists of the Department and I have unanimously agreed that there is conclusive scientific evidence that syringe exchange programs, as part of a comprehensive HIV prevention strategy, are an effective public health intervention that reduces the transmission of HIV and does not encourage the use of illegal drugs." As confirmed by the Leadership Statement on Injecting drug use and HIV/AIDS [PDF document] resulting from the XV International AIDS Conference in Bangkok in July 2004, saying: "There is overwhelming, high quality evidence of very effective, safe and cost effective harm reduction strategies to reduce the negative health and social consequences of drug injection. [..] Experience of numerous programs and projects in all regions of the world indicate that HIV/AIDS epidemics among injecting drug users can be prevented, stabilized and even reversed by timely and vigorous harm reduction strategies."

Meanwhile, harm reduction practices have been spreading rapidly over the planet, in all of Europe, in Canada, Australia, Brazil, Argentina, Uruguay, and China recently starting needle exchange programmes and announcing to open 1000 methadone substitution treatment clinics over the years to come, and countries like Iran, Pakistan and Vietnam talking openly about harm reduction. Lacking any evidence-base for their ideological crusade, the US government now resorts to political and funding pressure to try to turn the tide.

Below an extensive selection of quotes and links to key documents is listed providing an overview of the evidence-base for harm reduction, its level of acknowledgement worldwide and the positions of the various UN agencies. The inconsistencies illustrated by this body of statements and position papers will have to resolved and a key moment for that will be the next session of the UN Commission on Narcotic Drugs (CND) in Vienna, 7-14 March 2005. If the world takes US funding pressure as its main guiding principle, an effective implementation of strategies to reach stated key goals of the UN system may be seriously hampered.

The International Federation of Red Cross and Red Crescent Societies, made it very explicit in its Guidelines on harm reduction related to injecting drug use: "Forcing people who use drugs further underground and into situations where transmission of HIV/AIDS is more likely, and denying them access to life-saving treatment and prevention services is creating a public health disaster. This happens even though the evidence from scientific and medical research on best practices and cost benefit analyses is overwhelmingly in favour of harm reduction programming. This includes needle exchange, drug substitution treatment and condom distribution as part of the response to HIV/AIDS. The message is clear. It is time to be guided by the light of science, not by the darkness of ignorance and fear."