Why is eastern Europe the only region in the world that still has a growing HIV epidemic?1 In one of the region’s countries, Russia, more than two thirds of all HIV infections, and 55% of the near 100 000 new infections reported last year, resulted from drug injection.2
Some 3.2 million people in eastern Europe inject drugs, and about 1.5 million of them are in Russia. In 2007 the number of newly reported HIV cases among Russian people who inject drugs (12 538) was similar to the number in the rest of eastern Europe (12 026). But since then the numbers have diverged hugely.3
Scaling up of harm reduction programmes in several countries coincided with a stabilising of HIV rates—and fewer than 7000 new cases outside Russia in 2014. In Russia, however, where access to sterile needles and syringes is low and opioid substitutes remain illegal and unavailable, the number of people who inject drugs newly infected with HIV climbed to nearly 22 500 in 2014.3
Criminalisation of drug use
The reasons for Russia’s high figures include the prohibition and effective criminalisation of drug use, repressive law enforcement, and stigma around drug use. These factors lead people to inject in unsafe conditions for fear of police and arrests and result in needle sharing and overdose.4
In 2015, the United Nations’ secretary general, Ban Ki-Moon, called for “careful rebalancing of the international policy on controlled drugs.”
“We must consider alternatives to criminalisation and incarceration of people who use drugs,” he said. “We should increase the focus on public health, prevention, treatment, and care.”5
The World Health Organization, the United Nations Office on Drugs and Crime, and UNAIDS jointly recommend a package of harm reduction interventions as best practice to reduce the risk of acquiring, and improve treatment of, HIV, hepatitis, and tuberculosis among people who inject drugs.6 Such strategies, which do not require prohibition of harmful behaviours, are key to reducing death and disease because drug dependency is characterised by people’s inability to abstain.
Comprehensive and compelling evidence shows that providing needles and syringes, opioid substitution therapy (methadone or buprenorphine), and antiretroviral therapy to people who inject drugs reduces HIV transmission, decreases mortality, promotes initiation and compliance with antiretroviral therapy, reduces long term drug dependency, reduces crime and public disorder, and improves quality of life.7 Good evidence now also supports recommending supervised injection sites, distribution of naloxone for opioid overdose, and medical prescription of heroin to dependent people.
Ignoring the evidence is harmful
Russia, however, is strongly prohibitionist and rejects all such policies. Accepting harm reduction, it says, would require implicit acceptance of people continuing to use drugs. Hence access to clean needles and antiretroviral therapy there is very low.
And treatment with methadone and buprenorphine is illegal because Russia views their medical use as effectively substituting one addiction for another, even though they are designated essential medicines by the World Health Organization.
In the past decade, Russia has expressed these views in all relevant international forums, including the UN General Assembly meetings on drugs and on HIV/AIDS this year, insisting on maintaining an uncompromising interpretation of the global UN treaties that prohibit drug misuse.
In neighbouring Ukraine, however, large scale peer outreach and needle exchange programmes and access to opioid substitutes have been accompanied by a fall in new HIV infections among people who inject drugs.3 A sudden ban on methadone within days of Crimea’s change in political status was followed by many deaths among drug dependent people within a few months.8
Russia adopted a new strategy against HIV/AIDS in October 2016, but it is not an evidence based and pragmatic approach focused on public health and does not include harm reduction. Resistance and outright opposition to strategies to minimise the health risks associated with injecting drug use, despite evidence of effectiveness and increasing international acceptance, rely on narratives that prioritise prohibition. Harm reduction has become a highly polarising issue and an example of how health is increasingly being politicised and how policy decisions can be disconnected from scientific evidence.
Competing interests: I have read and understood BMJ policy on declaration of interests and declare I am a member of the Global Commission on Drug Policy.